Women's Bodies, Women's Wisdom (41 page)

The pain associated with endometriosis clearly results from an in creased production of inflammatory chemicals such as cytokines and prostaglandins that are produced by the endometriosis lesions. Endometriosis lesions are also stimulated in part by the hormones of the female cycle, and the pain is worse at ovulation and during the premenstrual and menstrual times of the cycle. Since endometrial lesions are the same as the tissue inside the uterus, it is understandable that when a woman bleeds with her menstrual cycle, her endometriosis implants bleed microscopically inside her body, too. Some experts feel that the endometrial lesions also secrete some kind of chemical that re sults in bleeding from surrounding capillaries in the peritoneum (the Saran Wrap–like lining of the pelvic cavity, where endometriosis is found). Over time, this recurrent monthly bleeding into the pelvic cav ity is believed to cause painful cysts and adhesions that tend to flare up under the right circumstances.

The theory that makes the most sense to me is that endometriosis is a congenital condition that is present at birth.
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According to this the ory, endometriosis arises from embryonic female genital tissue that never made it to the inside of the uterus during development. This helps explain why endometriosis can run in families and why some girls have severe pelvic pain from endometriosis
as soon as
they start their periods. Yet in this theory all females have the capacity to develop endometriosis if embryonic cells in their pelvis get stimulated by the right set of circumstances.

Though most gynecologists have been taught that endometriosis is a progressive disease that gets worse over time, some studies, including Dr. Red-wine’s, show that endometriosis doesn’t spread or get worse over time (though its appearance changes) and won’t recur if all of it is removed surgically or if the conditions that stimulate it are no longer present.

When performing laparoscopies to diagnose the cause of pelvic pain, many gynecologists miss the diagnosis of endometriosis in its early stages because they were taught to look only for the characteristic black “powder burn” lesions. In fact, endometrial lesions come in a range of colors: clear, white, yellow, blue, and red. Many of these early lesions are very subtle and difficult to see without the proper equipment.
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The color of endometrial lesions may be related to blood leaking from nearby capillaries. Over time, the lesions progress from clear to black, depending upon the amount of scarring present. The older the woman with endometriosis, the greater her chances of having “classic” endometriosis with black “powder burn” lesions and “chocolate” cysts of the ovaries. (Endometriosis in the ovaries can result in large ovarian cysts filled with old blood. When these are operated on, the contents of the cysts look just like chocolate syrup.)

The Neuroendocrine-Immune Connection

The intimate interactions between our thoughts, emotions, and immunity hold the key to interpreting the message that endometriosis has for the individual woman as well as helping her heal it. Studies on the immune systems of women with symptomatic endometriosis show that these women often have antibodies against their own tissue, called au toantibodies. This means that at some deep level, the mind of their pelvis is rejecting aspects of itself.

The autoantibodies interfere with various processes of human reproduction, including sperm function, fertilization, and normal progression of pregnancy. Their presence may explain the association between infertility and endometriosis in those women who have both problems at the same time. Endometriosis has been clearly associated with decreased egg fertilization, decreased success rates for in vitro fer tilization (“test tube” fertilization), and increased miscarriages. The clinical experience of therapist Niravi Payne with women with infertility and endometriosis shows clearly that at an unconscious level, these women may have an ambivalence about becoming pregnant. Their minds may desire it, while their hearts aren’t sure. The presence of these abnormal autoantibodies in patients with endometriosis holds the key to understanding many characteristics of the disease that scientists have been unable to explain when they have looked at it as a structural prob-lem only, as if it were a tumor to be removed.
²⁰

Making antibodies against the body’s own tissue is characteristic of other autoimmune diseases that stymie conventional medical science and that cannot be “cured” in the conventional sense. The immune system is highly sensitive, and our survival depends upon its ability to rec ognize and distinguish self from nonself. A new body of research is documenting the intimate link between a healthy immune system and a healthy bacterial ecosystem in the places in our bodies that interface with the environment. These include the vagina, the mouth, the lungs, and also the entire surface of the gut. When the bacterial ecosystem bal ance is lost, then immune system function suffers. It is well documented, for example, that antibiotic usage destroys health-promoting bacteria in all those areas, leading to an overgrowth of yeast and mold. This yeast and mold has been shown to trigger allergic responses in the lungs when they are exposed to mold spores, which is one of the reasons why there is so much more asthma and allergies in children now than in the past. Children are put on too many antibiotics and there is an ever-increasing use of household disinfectants.
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The immune system imbal-ance that results could help explain the immune components of endometriosis. When a woman stops taking antibiotics, gets on a good probiotic to replenish her bowel and vaginal flora (normal bacterial life in this area), takes immune-enhancing supplements such as vitamin D (1,000 IU per day), and also follows a diet that halts cellular inflammation, the endometriosis pain often disappears in a few weeks.

Treatment

Women with symptomatic endometriosis do best with a comprehensive treatment program that fully supports their immune systems while they remain open to finding out what they need to change about their lives. My patients have healed endometriosis symptoms through a variety of treatments. Most important, many of them have come to a greater understanding of what they need to learn for true healing, not just masking of their physical symptoms.

Hormones

The most common treatment for endometriosis, once diag nosed, is hormonal therapy, in the form of birth control pills, synthetic progestin, danazol (Danocrine), or the GnRH (gonadotropin-releasing hormones) agonists, such as Synarel and Lupron. These drugs act on the pituitary gland to make a woman temporarily menopausal, thereby allowing the endometriosis to regress by stopping its cyclic hormonal stimulation.

All of these hormonal therapies change the amount of estrogen and other hormones in the system, so that endometriosis is not activated. When hormone levels are decreased, symptoms often disappear and the disease itself becomes inactive. Danazol and the GnRH agonists are also used to decrease the amount of endometriosis prior to surgery—in some cases so that surgical removal is easier. The problem with these approaches is that they don’t really cure the disease; they simply shut down the hormonal stimulation of it for a while. In addition, some women do not tolerate well the side effects of these treatments. Danazol is expensive—it costs about a dollar a dose—and it can have masculinizing side effects, such as hair growth and voice deepening. Most women gain some weight while they are on it. GnRH agonist therapy results in hot flashes, thinning of the vaginal tissue, and bone loss. Yet other women badly need these hormonal treatments as a respite from pain, even though the pain often recurs once the drug is discontinued.

I once saw a patient who had been on Synarel (a GnRH agonist) all summer. “It was so wonderful to go camping, water-skiing, and hang gliding and not have to worry about the pain,” she told me. “I felt just wonderful. I know I can’t stay on it forever, but I sure felt great.” She had been off it for two weeks when I saw her, and her pain was begin ning to recur. As we talked about her options, she said that when she was having the pain before she went on the drug, she would often get complete pain relief from a massage. She was surprised by that, but she felt that massage was too expensive and that dietary change was too difficult due to her schedule. Yet Synarel cost nearly $400 per month at that time.
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Once she thought it all through, however, she decided to try to change her schedule to eat better, and she became willing to try a few nondrug approaches for a trial period of three months. She knew that surgery was an option. When I last saw her, she was doing well with lifestyle changes.

Even though the menopausal symptoms associated with GnRH agonists are reversible once the drug is stopped, this type of therapy, if used longer than a few months, is not appropriate for everyone. I’d be particularly wary of using it in anyone who has had a problem with irregular periods or central nervous system disorders, since it has been associated with memory problems in some. The lifestyle of a pa tient who may need it is characterized by a very high-pressure job, long work hours, a lot of travel, almost no time to herself, and lack of desire or ability to change her career. Using drugs in this type of situation makes it easier for the woman to continue activities that may nonetheless be harming her at some level. I worry about her using the medication, but I also trust her process, knowing that she will learn something from whatever option she chooses. I also trust that what brought her to the doctor will eventually open her to learning about her body. The body is innately self-healing, and when there’s a genuine desire to be well, the patient almost always finds the modality that suits her best.

Natural progesterone often works very well to relieve endometriosis symptoms and is my first line of treatment following dietary improvement. The usual way is to use a 2 percent progesterone cream such as Emerita, one-quarter to one-half teaspoon on the skin twice a day. (See pages 132–133.) Natural progesterone helps counteract endometriosis by decreasing the effects of estrogen on the endometrial lesions. Natural progesterone is free from side effects and is very well tolerated. Use it on days ten to twenty-eight of each cycle; some women may need to use it daily. Sometimes the dose of progesterone needs to be increased beyond what is available in 2 percent progesterone cream. In these cases, a prescription transdermal cream can be compounded by a formulary pharmacist. (See Resources for how to locate one in your area.) Natural progesterone capsules taken orally are another choice; the usual dosage is 50 to 200 mg per day, taken on days ten to twenty-eight of each cycle. Progesterone vaginal gels are also available by pre-scription.

Surgery

Many women with severe endometriosis, having tried hormones and pain medication for years, often end up at a very young age with complete hysterectomies, including removal of their ovaries. I re gard this treatment as a last resort after trying other more benign alter natives.

More conservative surgery that removes only the endometriosis and preserves the pelvic organs can be very helpful. More and more gyne cologists are skilled at this pelviscopic surgery and have learned how to remove endometriosis without missing any lesions. If any endometrio sis is left behind after this conservative surgery, the pain is likely to re cur. Pelviscopic surgery, done correctly, has a pain recurrence rate of only about 10 percent. In these women, the pain is frequently associated not with endometriosis but with fibroids, adhesions, or adeno myosis. (See
chapter 5
.) A woman who intends to undergo surgery for endometrial pain must go to someone who is skilled in this form of treatment. (See
Resources
.)

Natural Healing Program for Endometriosis

See the Master Program for Optimal Hormonal Balance and Pelvic Health, chapter 5, pages 123–136.)

Women’s Stories

Doris: Learning from Endometriosis

Doris was forty-one when she first came to see me. She was a highly successful professional who spent lots of time traveling and working but had little time for herself and her personal, emotional needs. She had heavy periods that got worse at night and sometimes would soak through the sheets. She complained of fluid retention, bloating, and severe menstrual cramps. Her uterus was enlarged to ten-to-twelve-week-pregnancy size from fibroids. She had a history of infertility, several miscarriages, and an abortion. A laparoscopy by another physician had confirmed the presence of endometriosis as well as fibroids, and he felt that these were associated with her miscarriages. Her gynecologist had suggested a hysterectomy because he said that her periods would continue to be difficult and that she would eventually end up with the surgery anyway. She was not happy with this diagnosis, however, and came to see me about her al ternatives.

When I first saw her, she had a great deal of tenderness behind her uterus, which is very common in women with endometriosis. I asked her questions about her lifestyle, diet, miscarriages, abortion, exercise, and stress levels. I agreed that surgery was not something we needed to consider right then and suggested several alternative treatments. Among them were eliminating dairy products from her diet, applying castor oil packs to her lower abdomen, taking vitamin supplements, and reading about perfectionism, addiction, and whole foods. From what Doris had told me about herself, I felt that she needed to heal her feelings about her miscarriages and her abortion. She decided to follow my suggestions. To unlock her feelings about her fertility, she decided to write letters to the unborn potential beings who had been in her body. As she wrote me later, “Obviously they were still there in some form in my mind and had taken form as fibroids and maybe endometriosis in my body. The most incredible experience occurred af ter I wrote the letters. I had been remembering my dreams with great regularity through visualization techniques. One night in a dream, I was fully aware of my body, and I dreamed that thousands of white doves were flying out of my uterus. An unbelievable feeling of lightness came over me, and I awoke crying with joy.”