Published July 26, 2023 Endometriosis is a complex, debilitating, and often misunderstood condition that affects roughly 10% of women worldwide. But what exactly is it? Endometriosis is a painful condition where the tissue that is similar to the lining of the uterus tissue grows in other parts of the body, leading to symptoms like extreme period cramps, leg, hip and sciatic pain, heavy bleeding, GI discomfort like bloating, infertility and much more. While the exact causes of endometriosis remain unclear, several factors have been identified as potential contributors, from estrogen dominance to gut inflammation to stress. There’s emerging evidence suggesting that endometriosis may occur more commonly in those with autoimmune disease, which further leads me – as a holistic practitioner – to look towards the gut health piece, as intestinal permeability and altered gut microbiota (dysbiosis) are major players in the pathogenesis of autoimmunity. (1,2) Let’s break down the big picture of potential causes and contributors (that often co-occur alongside one another to create the ‘perfect storm’) and explore some strategies you can use to target each and every one of these factors in order to support symptoms holistically. 1. Estrogen Dominance One significant factor seen in the presentation of endometriosis is estrogen dominance. Estrogen stimulates endometrial growth, period – which is why an overabundance of this hormone leads to the painful tissue growth that occurs outside of the uterus. Estrogen dominance is a hormonal imbalance that occurs when levels of estrogen in the body are higher than they should be (either alone in the context of normal progesterone, or in comparison to low levels of progesterone) and “dominate” the delicate estrogen:progesterone ratio. For some women, estrogen itself is simply too high, even though their progesterone levels are just fine. For others, estrogen is in the normal range, but it is still “dominant” as their progesterone levels are far too low. It’s important to know where you fall within this framework so that you may either: (a) support your body in its metabolism and detoxification of estrogen and/or limit your exposure to “xenoestrogens,” or (b) support your body in making more progesterone, whether by eating and supplementing nutrients known to support progesterone production (like Vitamin C and B6), or by managing stress via lifestyle and adaptogenic botanicals that free up the body’s resources so that normal progesterone production can resume. A functional lab test, such as the Dutch Test, can give you a full picture of your estrogen and progesterone levels via urine sample, which is far more comprehensive and accurate than a traditional blood test where levels often falsely appear ‘normal.’ WHAT CONTRIBUTES TO ESTROGEN DOMINANCE? External factors, like exposures to the “xenoestrogens” mentioned above, can contribute to estrogen dominance. These xenoestrogens, or ‘false estrogens’ are not true hormones but rather estrogen mimicking compounds which are not produced by our body. These compounds mimic the structure or function of our very own human estradiol (E2) and bind to our estrogen receptors with varying degrees of strength. We’re usually exposed to them through our air, water, or food supply, and the major players include pesticides, heavy metals, and especially plastics. Food packaged in plastic or water sitting in plastic for long periods of time pose the greatest risk, and are most important to avoid. While it may be challenging to avoid all sources of xenoestrogens, being mindful of product choices, such as using organic tampons and minimizing exposure to environmental toxins, can help reduce the overall estrogen load. Internal factors related to estrogen dominance include sluggish liver detoxification, which can stem from inadequate intake of protein, fiber, and essential micronutrients required for phase II detoxification. Because part of the liver’s job is metabolizing and excreting excess estrogen (via bile, then ultimately the bowels), it needs adequate amounts of highly specific nutrients and amino acids to be able to properly perform this important function. Nutrients and amino acids required for healthy phase II liver detoxification include glycine, glutamine, choline and inositol (found in protein such as meat, bone broth, egg yolks, and foods like blueberries and cantaloupe). Cruciferous vegetable intake is also key, as they contain sulfur metabolites that fuel our liver’s sulfation pathway. Adequate protein intake in general cannot be stressed enough, as this is where we get the majority of amino acids that not only help the liver with phase II estrogen metabolism, but also help the liver make its master antioxidant, glutathione. Certain herbs can also support phase II liver detoxification, such as Milk Thistle, Dandelion Root and Burdock Root. Once the liver is supported with adequate nutrients for detoxification, there must be enough fiber consumed in one’s diet to ensure any estrogen released thanks to the liver and gallbladder via bile, has something to bind to in order to be safely escorted out of the body through the bowels. If there’s not enough fiber present in the digestive tract, and bile containing estrogen (and other toxins) is released into the intestines, those toxins will have nothing to cling onto and ultimately be reabsorbed through the intestinal wall, only to add an extra load to the liver and be processed once again. Alternatively, if fiber intake is adequate (at least 25g/day for women), toxins and hormones like estrogen released via bile have something to cling onto and essentially ‘ride’ out of the body through bowel movements. Fiber and liver detox-supporting herbs and nutrients go hand in hand, and when implemented together, make a world of difference. Ultimately, supporting the liver’s vital estrogen-metabolizing function through a nutrient-rich, fiber and protein-rich diet, plus incorporating liver-supporting herbs like Milk Thistle and Dandelion Root can help promote proper hormone elimination. 2. Gut Inflammation & Immune Dysregulation Another potential contributor when it comes to endometriosis is gut inflammation and altered gut microbiota (referred to as dysbiosis, an overgrowth of pathogenic bacteria and a disruption or lack of richness and diversity when it comes to healthy, beneficial bacteria). Altered gut microbiota and the often-resulting increased intestinal permeability can lead to systemic inflammation and immune dysregulation (seen in autoimmune disease), not to mention hormone dysregulation. Research shows that a disrupted microbiome is involved in the onset and continuing progression of endometriosis. Women with endometriosis have higher amounts of dysbiosis overall as well as bacterial overgrowth in the gut microbiome. An imbalanced gut microbiome and increased intestinal permeability (leaky gut) may result in the migration of harmful substances into the bloodstream, triggering an immune response and promoting immune-mediated inflammation, including the increased inflammatory cytokine levels and abnormal cell-mediated pathways seen in endometriosis (3). Endometriosis is considered to be related to autoimmune disorders because its characteristics are similar to those of autoimmune diseases, including the cytokine abnormalities mentioned above. Further, research has found that the diversity of the gut microbiota in patients with endometriosis is significantly decreased, whereas the ratio of Firmicutes/Bacteroidetes is increased – an unhealthy shift away from optimal microbiome balance. Because gut bacteria diversity and richness is such an important overall indicator of health and longevity, the decrease in gut diversity seen in those suffering from endometriosis is a clue and point of concern. (4) Another clue is that women with endometriosis also have much higher rates of IBS, suggesting an important connection between endometriosis and a disrupted microbiome. Lastly, the gut dysbiosis observed in endometriosis directly relates to the estrogen dominance piece, as bacterial overgrowths can actually recirculate estrogen within the gut, promoting cell proliferation in estrogen-sensitive tissues such as the breasts, endometrium, cervix, and ovaries. This is because unwanted microbes within the segment of the microbiome that influences the metabolism of estrogen (called the estrobolome) produce something called beta-glucuronidase. This enzyme, made by bacteria in high amounts when out of balance, alters estrogens into more active forms, which have a stronger affinity for estrogen receptors. The more beta-glucuronidase that the microbes in your gut produce, the less estrogen is excreted out of the body (which ultimately gets recirculated, binds to receptors, and contributes to tissue proliferation). Thus, addressing gut health and restoring balance within the microbiota through a balanced diet, prebiotics, probiotics, and targeted protocols to treat potential gut infections like SIBO may be an important step in managing endometriosis symptoms. 3. Stress Stress, both that which is “perceived” (how we mentally interpret stressors in our lives, aka why something feels huge to one person but no big deal to another), and internal stress which is experienced within our biochemistry (elevated cortisol, or blood sugar dysregulation due to an imbalanced diet) may play a crucial role in endometriosis. Perceived and internal stress trigger the hypothalamus-pituitary-adrenal-ovarian-thyroid (HPAOT) axis, which can disrupt hormonal balance on that O, or ovarian level. When the brain or hypothalamus perceives stress, our adrenals produce more cortisol, our hormones go out of whack, and our thyroid function is down-regulated. High cortisol levels resulting from chronic activation of this axis can contribute to elevated estrogen levels, worsening the symptoms of endometriosis. To address stress, implementing stress management techniques such as regular exercise, adequate sleep, and engaging in activities that promote relaxation such as breathwork and meditation can be extremely helpful. Aside from lifestyle changes, for those who have been under high levels of stress for long periods of time and feel utterly burnt out, “adaptogens” are the main tools that herbalists use to reduce flight-or-flight mode, restore resilience, and support healthy regulation of the HPA axis. Adaptogenic herbs include roots like Aswagandha, Eleuthero Root, and even Holy Basil (although many dispute whether or not this is a true adaptogen). Adaptogens help to generate a greater sense of resilience and help us to adapt to the stress in our lives by supporting both nervous system and hormone balance. 4. “Cold” Invading the Womb & Gut: A TCM Perspective If we were to take a Traditional Chinese Medicine (TCM) approach to endometriosis, practitioners may consider the concept of excess “cold” in the womb and gut. “Cold” is seen as one of the 6 evils in TCM that can invade the body and contribute to illness. Excess cold can stagnate, slow and constrict your Qi (energy/digestion/metabolism). In TCM, a “cold” reproductive system is a piece of the puzzle when it comes to womens’ reproductive health issues, especially symptoms that arise around menstruation. When we think of the word “cold,” we think of frigidity, contraction, and stiffness. That is exactly how TCM views a reproductive system that doesn’t have enough warming “yang” energy to smoothly release free-flowing blood each month. When the body is too ‘cold,’ blood vessels become constricted, creating congestion and stagnation (which can manifest as clots, painful cramps, and even cysts or growths). ‘Yang energy’ is the heat of the body, which would move and circulate not only our menstrual blood, but also our hormones. To counteract this cold energy, warming foods like ginger and incorporating cooked meals while limiting raw foods can be beneficial. 4 Tips for Supporting Endometriosis Naturally Patients who have more advanced endometriosis (stage 3-4), pain that does not resolve with a variety of treatments or dietary changes, tissue growth that has already spread to various parts of the body, or are trying to conceive may need surgery in order to address the existing tissue proliferation. Laparoscopy is the most common surgery doctors use to treat endometriosis. However, for those in the earlier stages (and even for those in later stages who are seeking surgical treatment), the tips below can be helpful, root-cause-focused strategies to utilize in tandem with conventional medical solutions. Increase Fiber Intake: Foods rich in fiber, such as legumes (beans), flaxseeds and chia seeds, all aid in eliminating excess hormones from the body through the stool. When enough fiber is present in the gut, toxins and estrogen released through bile have something to latch onto and can be safely excreted, reducing excessive estrogen levels. Including these fiber sources in your diet is one of the easiest and quickest things you can do to reduce estrogen dominance. These fiber-rich foods also increase gut microbiota diversity and feed healthier gut bacteria over time. One of our favorite ways to sneak a solid dose of fiber into meals or as a snack is Olivia’s High-Fiber Chia Pudding linked here. Additional helpful dietary strategies include: Eating more fermented foods such as sauerkraut and kimchi to help rebalance the gut microbiota and increase bacterial diversity.In addition to eating your probiotics, take a probiotic that contains Lactobacillus strains. Lactobacillus acidophilus, for example, can help crowd out the bacteria that produce beta-glucuronidase and ultimately reduce estrogen recirculation. Our probiotic formula is rich in Lactobacillus strains, as well as enzymes and prebiotic fiber that promote a healthier gut environment.Consume prebiotic foods such as asparagus and plantains (green bananas) that are rich in fructo-oligosaccharides or inulin. These foods feed your good bacteria, increase your gut diversity, and again – help crowd out the ‘bad guys.’Bump up the cruciferous veggies such as broccoli, cauliflower, cabbage, and kale. The liver’s phase II detoxification pathway called the ‘sulfation’ pathway requires sulfur-rich foods in order to function properly and metabolize various toxins and hormones. And of course, these foods are also rich in fiber for our beneficial gut bacteria. Herbal Liver Support: As we talked about, the liver is responsible for metabolizing and detoxifying excess hormones like estrogen from the body. Many women with endometriosis are estrogen dominant, meaning they have excess estrogen levels in relation to progesterone. Liver-supporting herbs like Milk Thistle and Dandelion Root found in Liver Juice can be supportive for both phase I and phase II detox pathways. Limiting your exposure to xenoestrogens found in things like plastics and pesticides is also important to reduce the burden on your liver. Pro Tip: Take your liver-supporting herbs, such as Liver Juice, 30 minutes after eating a healthy serving of fiber-rich foods. Because herbs like Dandelion Root activate our detoxification pathways and prompt bile release, the timing works out to your advantage. With fiber readily available in your intestines, the bile will readily have something to bind to! Stress Management: Stress exacerbates inflammation and disrupts that HPAOT axis (O is for Ovaries), so integrating stress management techniques can make a big difference when it comes to endo symptoms. In this podcast episode, Julie Tracy shares meditations and “body-scan” exercises to help you relax into your body and restore balance within your nervous system. There are also an array of herbs to lean on for stress support including adaptogens and nervines. We have an entire category of stress-supporting formulas within our apothecary, which you can find here. Gut Health: As mentioned, emerging research suggests that a disrupted microbiome is involved in the onset and continuing progression of endometriosis. Women with endometriosis have higher amounts of dysbiosis overall as well as bacterial overgrowth in the gut microbiome. And it makes sense – the portion of our gut microbiome called the ‘estrobolome’ influences hormones, specifically estrogen, contributing to the altered metabolism and recirculation of estrogen if dysbiosis is present. Focus on maintaining a healthy estrobolome by consuming probiotic-rich, fiber-rich, and antioxidant-rich foods. Avoid food triggers that result in gut inflammation for you (dairy is a common one, so pay attention to your body’s cues). You can also follow the tips within this blog post to increase your gut bacteria diversity and restore balance to your microbiome, as well as explore our gut-supporting formulas here. Working with a practitioner who can perform a functional “GI map” in order to test you for SIBO and other intestinal overgrowths is key if any digestive symptoms are present, so that they may create a comprehensive gut-balancing program that’s tailored to you involving either botanicals, antibiotics, or both. By addressing these potential contributing factors, you can take proactive steps toward improving your quality of life and symptoms. Working closely with healthcare professionals who specialize in endometriosis and consider a holistic approach is key when it comes to optimizing well-being and supporting long-term relief from symptoms. They can help you put these steps into action, and dig deeper for your individual root causes and solutions.