Affecting up to 10% of women aged 15-44, endometriosis is a condition where endometrial tissue grows outside of the uterus. It can cause painful menstruation and fertility issues. Locations of tissue growth can include the fallopian tubes, ovaries, uterine ligaments, bladder, the outside surface of the uterus, rectum, stomach, lining of the pelvic cavity, and more. Endometrial tissue growing in these areas does not shed during a menstrual cycle as healthy endometrial tissue inside the uterus does typically. Build up of the tissue can lead to inflammation, cysts, and scarring.
CC: Endometriosis, Breast Tenderness, Bloating, Gas, and Diarrhea:
Amanda was a 26-year-old female who had struggled with painful periods and gastrointestinal issues. Amanda had pain for years when she menstruated but was told it was normal and was given the birth control pill, which she hated. She took it for a few years and then discontinued it. Her periods were very painful and heavy, and she would experience nausea and lightheadedness and occasionally vomit. She felt the most pain in her abdomen, low back, and rectum. She finally found an ob/gyn who agreed to laparoscopic surgery. During surgery, they found and removed abnormal tissue around her ovaries and uterus but could not get to the rectum. Unfortunately, Amanda felt no relief from this. When she presented, her period was monthly, she had breast tenderness, clots, pain, and water retention, and her period was extremely heavy. At this point, her doctors didn't test her hormones, and she was told to go back onto birth control. This is what brought Amanda to functional medicine.
Simultaneously, she had struggled with Irritable Bowel Syndrome (IBS) since she was 12. She felt okay for a few years, but symptoms had recently returned. She would eat food and have to go to the bathroom immediately with diarrhea, regardless of what she ate. She felt she was bloated all of the time and had gas. She had eliminated gluten and dairy from her diet, which helped a little bit, but nothing substantial. When this started, Amanda had gotten married, bought a house, and was highly stressed at work. At the time, she was eating a mostly paleo diet. She had tried the Whole 30 diet in the past, where she felt good, but her symptoms did not improve.
Initial Lab Work
Labs showed low nutritional levels. Though considered "normal" based on the lab's reference range, B12 was functionally low. In my clinic, B12 levels are considered optimal when they are closer to 650+ pg/mL. Omega fatty acids were low in the lab work, and vitamin D was also functionally low. Both could be due to a lack of dietary intake or absorption.
Amanda's DUTCH test showed hormonal abnormalities. Her progesterone and testosterone were within normal levels. In phase 1 liver detox, estrone was low, estradiol was within appropriate levels, and estriol was extremely high. When comparing the three estrogen metabolite pathways, most estrogens favored the 16-OH-E1 pathway, although the preferred pathway is the 2-OH-E1 pathway. Estriol (E3) is commonly known as the "proliferating estrogen," meaning tissue likes to grow, which can be found in endometriosis. High levels may also be associated with fibrocystic breast tissues, PCOS, or fibroids. Most of the estrogen favoring the 16-OH-E1 pathway also aids in those conditions. Phase 3 liver detoxification, although not pictured on the DUTCH test, is associated with bowel movements. This is considered abnormal if a patient does not have regular bowel movements. Her cortisol was within normal values.
Labs were able to rule in/rule out other health concerns. Amanda tested negative for candida which helped differentiate the treatment approach for her gut concerns. Her thyroid, prolactin, and testosterone levels were all within normal limits, as well as autoimmune and inflammatory markers. Cholesterol markers were normal, which was extremely important to test as hormones are created from cholesterol.
The initial treatment plan started with addressing the gut. The microbiome maintains the integrity of the intestinal lining. This prevents bacteria from moving in/out of the gut, which is associated with a "leaky gut" and inflammation. Roughly 70%-80% of the immune system is in the gut, and that is also where most of our serotonin is produced. Dysbiosis is linked to endometriosis as endometriosis is linked to high levels of certain types of bacteria, such as Escherichia coli (E. Coli). This type of bacteria produces a toxin called lipopolysaccharide (LPS). LPS can migrate through the body. For example, it has been found in joints, which can contribute to joint pain. Regarding endometriosis, it has been theorized that LPS can move from the gut into the pelvic cavity, which promotes the progression of lesions. In essence, the gut microbiome can alter estrogen metabolism, increasing free circulating estrogen, leading to estrogen-like symptoms or "estrogen dominance."
Amanda was put on the low FODMAP diet with Biocidin (herbal blend) with an additional antimicrobial herb called Neem (100-300 mg 3x/day) for 4 weeks.
At the end of 4 weeks, she switched to a modified paleo diet that allowed more grains, and she discontinued Biocidin and Neem. Then, she started to take Spore Daily T and GI Core (glutamine, zinc, vitamin A, and various demulcent herbs) for 90 days. This was done to support gut integrity to treat leaky gut. Amanda was also given a B complex, Vitamin D (4,000 IU daily), and fish oil (2 g daily). She also started DimX (300 mg DIM, 60 mg glucoraphanin) to support proper phase 1 liver detoxification, pushing less estrogen down the 16-OH-E1 pathway and more estrogen down the 2-OH-E1 pathway. She also started Femguard + Balance which contains various B vitamins, calcium d-glucarate, chrysin, chaste berry, green tea extract, black cohosh, DIM, broccoli seed extract, and trans-resveratrol to reduce overall estrogen (2-4 capsules daily).
Follow Up 4 Weeks
At the 4-week follow-up, after completing the low FODMAP diet, Amanda felt substantially better. Bloating was 70% better. She had lost 5 pounds, and bowel movements were regular. She was having 1-2 well-formed bowel movements per day. Most importantly, she was not urgently running to the bathroom after each meal. She reported no gas and no abdominal pain. She had one menstrual cycle during this time and reported having ZERO pain. However, she did notice her period was 2-3 times heavier than usual. At this time, she added the probiotic, GI Core, DIMx, and the femguard+balance. Now that she had no pain during her cycle, she was able to notice that she had more breast tenderness than initially noticed. Her energy was great, no longer having the 2 pm "afternoon slump."
Lifestyle Interventions were discussed with Amanda. Another aspect of endometriosis and high estrogen is understanding how environmental toxicology plays a role. She was educated on xenoestrogens and ways to reduce plastics and the total toxin burden she was exposed to. This includes everything from makeup to deodorant, cleaning products, leftover storage containers, etc.
Three Month Follow Up
Amanda presented for her follow up, and her gut was still doing very well. After adding foods back into her diet, she knew her triggers: onion and garlic. Her cycle was not painful. Her breast tenderness improved by 80%, and the heaviness during her cycle was 70% better.
6 Month Follow Up
Leading up to the six-month follow-up, Amanda had slowly weaned herself off her hormone support supplements (as directed) to see what her cycle would do on its own. At this point, she was off most of her supplements besides those for nutritional support. Essentially, the patient's menstrual cycle was "perfect.” She has no pain, breast tenderness, or heaviness (only the first day of her cycle), and her mood was much better. Her gastrointestinal issues still subsided.
Amanda’s labs had normalized. The patient was so blown away by how she felt that she wanted updated hormonal levels to keep track of them. The DUTCH test did show some slight reduction in progesterone and testosterone, which can vary daily per person. Estrogen was improved. E3 was now on the lower end of normal, so it was positive that the patient was off of her supplements to avoid the continuation of lowering E3, which has other concerns. At this time, the patient would watch for any returning symptoms, and if symptoms returned, supplementation or more testing would be considered.
Endometriosis is a multifactorial condition. On average, it can take 4-11 years to get a diagnosis, and many women go undiagnosed their entire lives. A functional medicine approach for treating endometriosis involves getting to the condition's root cause. Factors to consider include gastrointestinal health, hormonal support, and total toxin load/xenoestrogen exposure reduction.