Endometriosis

Question 1

Endometriosis

Answer 1

Endometriosis = the presence of endometrial-like tissue outside the uterus
* Endometrial tissue locates in
the pelvis (e.g., ovaries, fallopian tubes, rectum, Pouch of Douglas). Extra-pelvic deposits can occur (e.g., lungs) but are rare.
* Tissue responds to the natural
hormonal cycle causing it to grow,
break down and bleed. The blood has no outlet, leading to inflammation, pain, and the formation of scar tissue and adhesions

Question 2

Endometriosis: Signs and symptoms

Answer 2

• Dysmenorrhoea, heavy menstrual bleeding and deep dyspareunia.
• Chronic pelvic pain (minimum of 6 months) and lower back pain.
• Period-related or cyclical GI
  (e.g., painful bowel movements) / urinary symptoms (e.g., dysuria).
• Migraines, anxiety and depression.
  Complications:
• Infertility, endometriomas (ovarian cysts containing blood and endometriosis-like tissue), bowel obstruction, ovarian cancer.

Question 3

Endometriosis, oestrogen and histamine

Answer 3

• Endometriosis is often associated with a high O:P ratio.
• Oestradiol (E2) is central to the endometrial tissue growth.
• Mast cells contain oestrogen and progesterone receptors. Oestrogen triggers histamine degranulation, but histamine itself is also able to induce ovarian E2 synthesis (a two-way process).
• High histamine drives inflammation and angiogenesis, and hence endometriosis proliferation.
• Progesterone has an inhibitory effect
  on histamine secretion following mast cell
  binding but is overridden by oestrogen

Question 4

Endometriosis theories

Answer 4

• Immune dysfunction — an inability to recognise and destroy endometrial tissue outside the uterus. Inflammatory mediators, cytokines, macrophages, T-lymphocytes, and TNF are elevated.
• Metaplasia — cells found in the pelvic and abdominal area change into endometrial-like cells.
• Retrograde menstruation — sloughed endometrial cells flow back from uterine cavity but has now been generally disregarded.
• Surgical scar implantation — following surgery, endometrial cells may attach to a surgical incision
• Endometrial cell transport — cells transported via the lymphatics

Question 5

Endometriosis: Causes and risk factors

Answer 5

• Prolonged oestrogen exposure (e.g., early menarche, nulliparity and OCP).
• Low birth weight, prematurity and formula feeding.
• Obesity (increased inflammatory cytokine and aromatase activity).
• Poor oestrogen detoxification and clearance.
• Environmental toxin exposure —
  (e.g., PCBs, organochlorines, dioxins) such as that consumed via food (plastic packaging, non-organic produce, larger fish, dairy).
• Emotional trauma, incl. childhood abuse
• Microbial infections — endometriosis can result from a triggering infection such as a virus (e.g., EBV, CMV, HSV), bacteria (e.g., E.coli) or parasite.
  – Intestinal dysbiosis can also lower DAO activity — increasing histamine levels.
  – A compromised mucosal barrier can also increase
  LPS leakage, contributing to immune-overactivity/inflammation.
• High consumption of fats (trans / saturated), red meats and alcohol. Low vegetables / fibre, low omega-3, selenium and vit. D.