Endometriosis, in which functioning ectopic endometrial glands and stroma are present outside the uterine cavity, affects 5% of American women of childbearing age. Extrapelvic manifestations develop primarily in the 35-to-40 age group. Usually accompanied by chronic or acute pelvic pain which may radiate to the buttocks and perianal region, endometriosis develops gradually. The condition is underdiagnosed (often mistaken for dysmenorrhea) and is present in 30% of infertile women.

While etiology remains uncertain, retrograde menstruation, genetic predisposition, and immune system involvement are widely accepted theories. Because ectopic endometrial implants respond to exogenous and endogenous hormones, medical treatment aims at suppressing estrogen production to bring about amenorrhea, which halts retrograde menstruation and promotes decidualization and atrophy of implants.

Endometriosis is "staged" as either:

• Mild—small, localized implants
• Moderate—larger, more extensive implants; scar tissue may be present
• Severe—large, widespread implants; extensive scar tissue

Etiology uncertain; three major theories are widely accepted:

• Immunoincompetence: increased macrophage, prostaglandin, and lymphokine action; decreased T- and NK-cell responsiveness. (Studies indicate that TCDD [dioxin], an environmental toxicant, alters the action of estrogen in reproductive organs and increases incidence of endometriosis.)
• Retrograde (or reflux) menstruation: transtubal dissemination of endometrial cells into pelvic cavity; lymphatic and/or vascular transportation to remote areas.
• Genetic predisposition/congenital defect: Cells intended to be part of the female reproductive system fail to migrate to the appropriate locations and become embedded in inappropriate locations. Under estrogen stimulation, they differentiate into functioning endometrial glands and stroma.

• Genetic predisposition (daughters of mothers having the disorder)
• Reproductive age

Endometriosis is asymptomatic in one-third of cases. Symptoms typically begin several years after onset of menses, progress as ectopic endometrial deposits increase, and subside after menopause. Most common symptoms include:

• Pelvic pain cycling with menses (not always related to severity of disorder)
• Dysmenorrhea
• Dyspareunia
• Infertility
• Pain with bladder/bowel function
• Intestinal pain
• Tenderness when affected areas are palpated

• Abortion (including complete, incomplete, threatened, septic)
• Crohn's disease
• Irritable bowel
• Appendicitis
• Bowel obstruction, irritable bowel syndrome
• Dysmenorrhea
• Ectopic pregnancy
• Gastric/peptic ulcers
• Ovarian cysts/torsion
• Pelvic inflammatory disease (PID)
• Urinary obstruction, urinary tract infection (UTI)

• Nonspecific pelvic/adnexal ovarian tenderness
• Nodular masses along uterosacral ligaments, posterior uterus
• Obliteration of cul-de-sac with fixed uterine retroversion (extensive disease)
• Ruptured ovarian endometriomas (acute abdomen)
• Adhesions/obstruction of rectum/GI tract

For differential diagnosis:

• CBC/differentials: PID
• Urinalysis: UTI
• Cervical gram stain/culture: PID
• Beta hCG: ectopic pregnancy

Cyclic bleeding of ectopic endometrial tissue produces lesions/implants which have been found in every extrapelvic organ system except the spleen, including lungs, CNS, kidneys, GI tract. Also found in rectum, bladder, vagina, cervix, vulva, thigh, and arm. Most frequently involved sites are:

• Ovaries
• Fallopian tubes
• Broad and uterosacral ligaments
• Bladder
• Area between the vagina and rectum
• External surface of the uterus
• Cul-de-sac

Ultrasound/MRI to detect pelvic masses (low sensitivity to detection of ectopic endometrial deposits, however).

• Medical history
• Physical examination (exclude life-threatening etiology of abdominal pain)
• Laparoscopy (essential for confirmation)
• CA 125 (ineffective for screening, however)

Appropriate and early diagnosis and aggressive treatment prevent significant complications and sequelae.

Drug therapy is intended for pain relief and hormone suppression.

• NSAIDs/narcotics
• Combined oral contraceptives
• Estrogen/progestin androgens—suppress FSH and LH and endogenous estrogen production
• Progestational agents—leuprolide acetate, norethindrone, megestrol acetate, hydroxyprogesterone, norethisterone, lynestrenol (may cause irregular vaginal bleeding, bloating, or depression)
• Danazol (synthetic 3-isoxazole derivative of 17-ethinyl-testosterone)—most frequent choice for hormone suppression; reduces size/extent of lesions with 80% to 90% symptom relief and 20% to 35% recurrence rate after treatment cessation (unsafe for developing fetus; common side effects synonymous with menopause)
• Gonadotropin-releasing hormone agonist (GnRHa)—induces amenorrhea (loss of bone mineral precludes long-term therapy). Nafarelin (Synarel), leuprolide (Lupron), goserelin acetate implant.

• Laparoscopic laser/electrocoagulating techniques—for destruction of implants, excision of ovarian endometriomas, and lysis of adhesions (10% to 50% recurrence rate within 12 months)
• Total hysterectomy/bilateral salpingo-oophorectomy—90% effective for pain relief (recommended only when essential and when childbearing is no longer desired)

Providing liver support is the backbone of alternative treatment of endometriosis. Enhancing the liver's ability to metabolize hormones may help restore normal hormone ratios. Endometriosis is best treated early and alternative therapies alone may not be sufficient to eradicate this condition.

• Eliminate all known food allergens. The most common allergens are dairy, wheat, citrus, corn, soy, and fish.
• Eliminate alcohol, caffeine, chocolate, refined foods, food additives, sugar, and saturated fats (meats and dairy products).
• Avoid exogenous estrogens found in estrogen-fed poultry and pesticide-sprayed fruits and vegetables. Eat only organic poultry and produce.
• Increase intake of whole grains, fresh vegetables, essential fatty acids (cold-water fish, nuts, and seeds), and vegetable proteins (legumes such as soy). Include liberal amounts of liver-supporting foods such as beets, carrots, onions, garlic, dark leafy greens, artichokes, apples, and lemons.
• Vitamin C (1,000 mg tid) decreases inflammation and supports immune function.
• Zinc (30 to 50 mg/day) and beta-carotene (50,000 to 100,000 IU/day) support immune function and enhance healing.
• Vitamin E (400 IU/day) is necessary for hormone production and is an antioxidant.
• Selenium (200 mcg/day) is needed for fatty acid metabolism.
• Iron supplementation may be necessary if bleeding is severe. Elemental iron (30 mg bid). Glycinate form is least constipating and 30% better absorbed than ferrous sulfate.
• Calcium (1,000 to 1,500 mg/day) and magnesium (200 mg bid to tid) are needed for hormone metabolism and to modulate inflammation.
• Essential fatty acids (1,000 to 1,500 mg bid) to support hormone production and decrease inflammation.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Chaste tree (Vitex agnus cactus) helps to normalize pituitary function and balance estrogen/progesterone ratios. This herb may need to be taken long term (12 to 18 months) for maximum effectiveness. Combine 2 parts of chaste tree with 1 part of two herbs from each of the following categories. Herbs are listed in order of preference. Drink 3 cups of tea/day or take 30 to 60 drops of tincture/day.

For liver support (include milk thistle with one other herb from this section): Milk thistle (Silybum marianum), dandelion root (Taraxacum officinale), vervain (Verbena officinalis), and/or blue flag (Iris versicolor) support the liver and may help restore hormone ratios. Use vervain with nervousness and anxiety; blue flag, for poor fat digestion and liver congestion; dandelion, for fluid retention.

For reducing pelvic congestion: Squaw vine (Mitchella repens), motherwort (Leonurus cardiaca), red root (Ceonothus americanus), red raspberry (Rubus idaeus). Red raspberry may be used alone and drunk as a tea (2 to 3 cups/day) throughout treatment.

Herbal therapy may also be used to treat acute pain during menstruation. Combine equal parts of the following herbs in a tea (¹/2 cup every three to four hours) or tincture (15 drops every 15 minutes for up to eight doses acutely or 30 to 60 drops tid to qid): black cohosh (Cimicifuga racemosa), wild yam (Dioscorea villosa), Jamaica dogwood (Piscidia piscipula), ginger root (Zingiber officinalis), cramp bark (Viburnum opulus), and valerian (Valeriana officinalis). In cases of excessive menstrual flow, substitute yarrow (Achillea millefolium) for ginger root.

For management of severe pain and extensive endometriosis, Turska's formula is the preferred combination and should only be used under physician supervision. The formula contains two parts of poke root (Phytolacca americana), and one part each of monkshood (Aconitum napellus), gelsemium (Gelsemium sempervirens), and white bryony (Bryonia alba). These herbs have anodyne properties and may help shrink endometrial tissue. They have toxic side effects and are used at very low doses (10 to 15 drops bid).

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Belladonna for menstruation with sensation of heaviness and heat in abdomen. Patient may be restless, thirstless, and sensitive to drafts.
• Calcarea phosphoricum for excessive and too frequent menses with violent backache.
• Chamomilla for heavy menses with dark clotted blood and labor-like pains. Patient may be irritable, thirsty, and oversensitive to pains that radiate to the thighs.
• Cimicifuga racemosa for profuse, dark, coagulated menstrual blood with unbearable pain radiating from hip to hip.

Do not perform these therapies during menstrual flow.

• Contrast sitz baths may relieve symptoms and promote circulation, reducing pelvic congestion. You will need two basins that can be comfortably sat in. Fill one basin with hot water, one with cold water. Sit in hot water for three minutes, then in cold water for one minute. Repeat this three times to complete one set. Do one to two sets per day, three to four days per week.
• Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to abdomen, cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results use three consecutive days. Adding a few drops of St. John's wort oil (Hypericum perforatum, four to six drops) may potentiate the pain-relieving effects. One or more essential oils (four to six drops) can be added to increase circulation and enhance relaxation. Essential oils to consider include clary sage, rose maroc, geranium, or nutmeg.
• Kegel excercises should be performed frequently, up to 100 times/day to improve pelvic tone.

Chinese herbal formulas may have profound effects on liver function and hormone balance. Acupuncture may resolve excesses and deficiencies associated with endometriosis.

Therapeutic massage not only increases the overall sense of well-being but it may help resolve pelvic congestion. To enhance the benefit of massage, add three to four drops of essential oils (see castor oil pack) to one tbsp. massage oil. Particular attention should be paid to the sacral area.

• Monitoring for side effects/effectiveness of treatment
• Track bone density during hormone treatment

Exercise, swimming, relaxation/meditation/visualization, yoga, polarity therapy, magnet therapy, reflexology, Schuessler tissue salts, and Kegel exercises may relieve symptoms of endometriosis.

• Infertility
• Chronic pelvic pain
• Infection from ruptured ovarian lesions
• Adhesions/obstructions
• Progression into infection/abscesses
• Drug therapy reactions

• Progressive after onset of menses
• Complete regression may be seen during pregnancy and following menopause

• Pregnancy is postponed during hormonal therapy.
• Danazol unsafe for developing fetus
• Although no definite cause-effect relationship, other disease is present in 30% of infertile women.
• Endometriosis often resolves during pregnancy because of sustained, increased progesterone and decreased estrogen levels. Treatment should be delayed until after breast-feeding has been discontinued.

Facts About Endometriosis. U.S. Department of Health and Human Services. National Institutes of Child Health and Human Development. NIH Publication no. 91-2413.

Hudson T, Lewin A, Gerson S, et al. Endometriosis (modality specific condition reviews) Protocol J Botan Med. 1996;1:30-46.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:112-114.

McQuade CA. Women's health workshop: endometriosis, fibroids, PMS and HRT. Medicines from the earth: exploring nature's pharmacy (official proceedings). Harvard, Mass: Gaia Research Institute; 1997:182-183.

Tureck RW. Endometriosis: diagnosis and initial treatment. Hospital Physician Obstetrics and Gynecology Board Review Manual. April 1997;3:1-8.