Counseling Sheet

Agatha M. Thrash, M.D.
Preventive Medicine

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Endometriosis is the condition caused by the presence of small portions of the lining tissue from the inside of the uterus called endometrium, in abnormal places such as on the outside of the uterus, in the floor of the pelvis, on the appendix, bladder, inside the abdomen, along the ligaments that hold the uterus and other pelvic structures in place, and in the fallopian tubes. It is a common disorder, being found in up to 20 percent of women, and is increasing in frequency.(3)

Symptoms

There are no typical symptoms of the disease, but the most distinctive symptom that can be found in the greatest number of women is that of painful menstrual periods, the pain being felt also in the rectum, lower sacrum, and the coccyx (tailbone). Even this sign is found in only about one third of patients. Pregnancy improves the symptoms. It is rare among black women; but up to 30 percent of white women suffer from this condition at one time or other.

Other symptoms of endometriosis include pain on sexual intercourse, painful menstruation (which develops many years or even decades after the onset of menstruation), low abdominal pain present any time of the month (but worse in the premenstrual and menstrual periods), backaches, pain on passing urine or bowel movements, constipation, and menstrual disturbances (the most common being excessive menstrual flow).(5, 4, 2)

Another major feature of the disease is that of the strong correlation between infertility and endometriosis. The pregnancy rate in women with endometriosis is about half that of women not having endometriosis.(1)

Causes

There are several theories as to the cause of endometriosis, by far the most widely accepted and plausible of all theories is that of the backward regurgitation of the menstrual flow out through the fallopian tubes and into the peritoneal cavity. In this way tiny fragments of the lining of the uterus, which are still living in the menstrual fluid, simply become implanted as seeds along the ligaments, ovaries, fallopian tubes, and floor of the pelvis. The great question is that of why the menstrual blood flows backward into the abdomen, rather than naturally out through the cervix to the outside.

Birth control pills stimulate endometriosis by preparing a fertile site for the transplant of endometrium to grow.

Although it has not been proven, I believe it may be that of sexual excitation during the menstrual period. During sexual excitation, there is encouragement of the spermatozoa to meet the ovum, and material inside the uterus and tubes more naturally flows backward toward the ovaries than forward toward the outside. Several features of the disease lend credence to this theory:

• The more common occurrence of the disease after sexual activity begins.
• The commonest site for the implants being the ovaries, apparently gaining access to a fertile field by means of the recently ruptured ovarian follicle.
• The great increase in incidence of the disease in modern times, since intercourse during menstruation no longer caries the taboos of former times.(4)

Other theories suggest that endometriosis a) develops in the prenatal period or early childhood, b) results from a backward flow along the lymphatics or blood vessels, and recently that of c) internal fetal monitoring during labor. The fetal monitor is a device that measures the heartbeat of the unborn baby. The measurement may be done externally or internally. It is only the internal fetal monitoring that has been associated with increased incidence of endometriosis.(7) It has been theorized that the development of vaginal tampons, a custom having its origin after about 1930, is the cause of the recent increase in endometriosis. Some investigators believe that the use of tampons encourages backflow of menstrual blood.(6)

Most physicians believe that imperative pelvic examinations done during menstrual periods should be quite gentle, any squeezing of the uterus being likely to cause the backflow of the blood and shed lining tissue into the tubes, where living particles could take hold and grow on the ovaries or other structures. No fertility tests involving sufflation of the tubes should be performed during the menstrual period. There is no evidence that the backward bending uterus, so-called "retroversion," is associated with an increased incidence of endometriosis.(3)‍

Treatment‍

Many patients require no treatment at all, as they tend to burn out endometriosis. This is the best way to treat the disease, but may take 3 to 5 years or more, but tends to get better as time goes by. In my opinion it is well worth a trial to treat the symptoms of endometriosis with home remedies and allow a woman to have the opportunity to burn out the symptoms on her own. Certainly, surgery and hormone administration should be reserved only for the incapacitating case of endometriosis. One would then have to balance the side effects of the treatment against the threatened destruction of the quality of life from the symptoms of the disease.(3) Endometriosis is automatically cured by menopause.

There are investigators who believe that one form of hormone administration is definitely contraindicated, causing endometriosis to worsen: that of the administration of birth control pills.(8) Since all of this class of hormone administration can be regarded as having many side effects, from weight gain to an increased incidence of cancer of the breast and uterus, it seems well to withhold the use of any kind of hormone.

I do not recommend surgery for endometriosis, as it often leaves some kind of disability, and frequently removes organs the patients would prefer not to have removed: ovaries, tubes, appendix, portions of bowel, etc. The patches of endometriosis always play themselves out; and with the proper treatment, the foci of endometrium can be tolerated until they eventually kill themselves by pressure after they form a cyst or by scarring.

A diet high in the plant sterols (plant hormones similar to animal hormones) has seemed to help many of our patients with endometriosis. This diet should emphasize the use of the following foods and herbs: apples, cherries, olives, plums, wheat germ, whole grains, carrots, peanuts, soybeans, all dried beans and peas, yams, bell peppers, eggplants, potatoes, tomatoes, parsley, sage, clover, alfalfa leaf tea, licorice root tea, sage, red raspberry leaf tea, food yeast, garlic, anise seed, coconut, and all nuts. Garlic has a good level of plant sterols (such as ergosterol, sitosterol, and phytosterol) and may be taken in as large quantity as the patient finds practicable.

One treatment routine includes a series of three fomentations (hot packs, wrung from hot water or heated in a microwave oven) taken each of the first three days of the menstrual period for twelve months. For some, this has resulted in complete clearing of symptoms. A hot water bottle or heating pad to the low abdomen or low back, or placed in the chair for the seat, may be remarkably helpful in reducing the pain and discomfort of endometriosis. If you are able to predict when the pain is to begin, you should put the heating pad to your back from the waist to the crease in the buttocks for one to two hours.

An ice bag used in the same areas suggested for the heating pad or hot water bottle is more effective for some women than heat.

We have found some relief for some individuals by putting a tampon impregnated with thick charcoal slurry made by one tablespoon of charcoal powder mixed with a few drops of water, until it is the consistency of soft ice cream. The tampon is placed against the cervix and left there for four hours. At the same time you should take a heaping tablespoonful of charcoal stirred in water and drunk with a straw every 30 minutes for two hours at the very onset of the pain, beginning within the first five minutes of experiencing pain.

While you lie face down, have someone standing over you massage, using firm pressure on the right of your spine from the waist to the end of the seat. Then back up again for 5 minutes. The outflow tracts to the pelvis are chiefly on the right side of the spine.

We recommend hot sitz baths in about four to six inches of water for 20 minutes, followed by a brisk rubdown with a coarse dry towel and approximately 30 minutes of rest in bed. A hot foot bath can be substituted for the hot sitz bath if it is not convenient to take a sitz bath.

A stretching exercise has been found of benefit by many women. It is done by measuring a line on the floor two feet from a wall. Stand with the tips of the toes on the line and heels on the floor (be sure to keep them on the floor during the entire exercise). Lean the whole body toward the wall, placing the hands at about shoulder height, until the chest touches the wall. Hold this position for ten seconds, push up straight for five seconds, and repeat three times. Turn to the side, putting the right outer edge of the foot on the line, and lean sideways toward the wall until the right hip touches the wall. Hold for ten seconds and repeat as at first. Turn with the left hip toward the wall, the left outer foot on the line, and lean into the wall touching the left hip to the wall, and continuing as for the other two exercises. These three stretching exercises should be done three times daily for three days, then once a day for 30 days, and then once a week for one year.

Another good exercise is that of walking up and down ten flights of stairs daily.

‍Botanical Remedies

One cup of the following tea three times daily, by itself is about 80 percent effective:

• 3 cups boiling water
• 3 teaspoons catnip tea
• 3 teaspoons red raspberry leaf
• 1 teaspoon alfalfa leaf
• 1 teaspoon black cohosh
• 1/4 teaspoon licorice powder

Other herbs that have estrogen and progesterone precursors are hops and ginseng. Use 1 teaspoon of each. (All ginsengs have a lot of saponins in them, which stimulate the nerves and cleanse the bowels.) Gently boil the cohosh, licorice, and ginseng for 30 minutes and pour it all up into a container with all the other herbs. Steep 30 minutes. Strain. Make fresh daily.

We recommend the usual treatments for pain, such as the herbal preparations (white willow bark, wild lettuce, and the anti-inflammatory herbs, such as licorice root). Roots, shoots, bark, flowers, and seeds need to be gently simmered for 20 to 25 minutes, whereas leaves need to be soaked in boiling water for 30 minutes, the leaves never being boiled.

Flaxseed oil should be tried. Use 1 to 2 teaspoons two to three times a day with meals.

A large comfrey or charcoal poultice covering the lower abdomen and pelvis at night is useful in pain relief.

‍References:‍

1) Gynecology, Principles and Practice, Second Edition, Kistner. Robert, M.D., Year Book Medical Publishers, Chicago, 1972.

2) Journal of Reproductive Medicine 19(5):301-306, November 1977.

3) Gynecology, Second Edition, Parsons, Langdon, M.D., W.B. Saunders Company, Philadelphia, 1978.

4) Novak's Textbook of Gynecology, Novak, Edmond R., et al.

5) Clinical Obstetrics and Gynecology 22(1):101-119, March 1979.

6) Family Practice News, June 1, 1978.

7) Clinical Obstetrics and Gynecology, 23(3):875-882, 1980.

8) American Journal of Obstetrics and Gynecology 135(2):279-280, September 15, 1979.