Is Endometriosis an Autoimmune Disease?

Endometriosis isn’t simply painful cramps, for 6.5 million American women, endometriosis can range from a variety of symptoms including debilitating pelvic pain, heavy periods, nausea, vomiting, bowel irregularities, and infertility, to name a few. Unfortunately, although endometriosis impacts an estimated 11% of all American women, there is still so much we need to understand about the disease including diagnosis, causes and even treatment options. And on top of everything, determining the prevalence of endometriosis in the general population is challenging because some women are asymptomatic, and even those with symptoms can have varied and nonspecific presentations making it hard for patients to even be evaluated for endometriosis. And if that wasn’t enough, definitive diagnosis typically requires surgery making it even more challenging. Although there is still so much we need to learn, researchers have recently theorized that abnormalities in the immune system could be the cause of endometriosis. So what do researchers know and how would this help patients suffering from endometriosis improve their treatment options?

What is Endometriosis?

The endometrium is the inner lining of the uterus. This is something all women have and each month, the endometrium will thicken and renew itself in preparation for pregnancy. If an embryo does not implant, the endometrium sheds, leading to your period. Unfortunately, in patients with endometriosis, their endometrium can grow outside of the uterine cavity where it does not belong. Some of the most common places endometrial tissue will grow includes; the ovaries, fallopian tubes, posterior cul-de-sac (space between the uterus and rectum), anterior cul-de-sac (the space between the uterus and bladder), the bowels, and even as far as the nasal cavity, in rare cases. Unlike normal endometrial tissue, endometriosis lesions contain endometrial glands and stroma and when they implant on tissues where they do not belong they often cause fibrous tissue, blood and cysts to form. Since endometrial tissue is influenced by hormones, each time a woman begins her period, the endometrial tissue will be stimulated. Not only do women with endometriosis experience the cramping of their uterus during shedding, but if the endometrial tissue has traveled to distant locations, it will also cause pain and can contribute to the heavy menstrual bleeding and debilitating pain.

Is Surgery My Only Option for Diagnosing Endometriosis?

Unfortunately at this time, laparoscopy surgery is the only way to receive a definitive diagnosis for endometriosis. Most lab values will be “normal” in patients with endometriosis and even when lab values, like CA 125 levels are elevated, they are not specific enough to diagnose a patient with endometriosis.

Risk Factors Associated with Endometriosis

Although the cause of endometriosis is still unknown, there are a few factors that appear to increase your risk of developing endometriosis including:

Nulliparity (not having children)
Prolonged exposure to endogenous estrogen, like starting your period before the ages of 11-13.
Late onset of menopause
Shorter menstrual cycles (defined as ≤27 days)
exposure to diethylstilbestrol in utero , a synthetic form of the estrogen that was prescribed to pregnant women between 1940 and 1971 to prevent miscarriages (was banned in 1971 and is no longer in use)
High consumption of trans unsaturated fats
Exposure to severe physical and/or sexual abuse in childhood or adolescence
Race may also be a risk factor, as the prevalence of endometriosis has been reported as being higher in White and Asian women compared to Black and Hispanic women.

Factors that appear to reduce your risk of endometriosis include:

Having birthed multiple children
Extended intervals of lactation
Late menarche (initial onset of your period after age 14)
Increased consumption of long-chain omega-3 fatty acids.

Genetic Factors Associated with Endometriosis

Although endometriosis is not cancer, researchers have found when analyzing exome sequencing of nonmalignant deep endometriosis lesions 79% of lesions had somatic gene mutations and 26% of the lesions had mutations in the known cancer driven genes ARID1A, PIK3CA, KRAS, and PPP2R1A. The presence of cancer driver mutations in nonmalignant cells may partly explain the aggressive nature of deeply invasive lesions in patients with endometriosis.

Endometriosis and Inflammation is There a Link?

Although more research is needed to fully understand why endometriosis causes inflammation, researchers have established that symptoms associated with endometriosis are most likely caused by inflammation. The theory is that estrogen acts as a neuromodulator that selectively repulses the sympathetic axon (nerve pathways) and elicits pain felt by the central nervous system. Reducing inflammation seems to be an important part of treatment for endometriosis and is likely the reason why high consumption of long-chain omega-3 fatty acids (anti-inflammatory agents) has been so helpful for patients in our clinic. Long-chain fatty acids are found in sources such as fatty fish like salmon, sardines, herring, and trout, or by taking a complete omega-3 fish oil (including both EPA and DHA).

Is Endometriosis an Autoimmune Condition?

Although researchers have not classified endometriosis as an autoimmune condition just yet, many researchers have found a strong correlation between abnormal immune system responses and endometriosis. It is still uncertain if endometriosis is an autoimmune disease itself, or if having an autoimmune disease increases your risk of developing endometriosis.

In a small 2019 trial that studied 298 women, researchers found a significant correlation between endometriosis and autoimmune thyroiditis (Hashimoto’s Thyroiditis), finding that 80 women with endometriosis in the study had autoimmune thyroiditis versus 14 women in the control group. Although researchers were not sure if the autoimmune thyroiditis caused the endometriosis or vice versa, there is speculation that abnormal immune function may make it easier for the immune system to miss the movement of endometrial tissue outside of the uterine cavity.

A few other studies, also indicated a similar phenomena between endometriosis and other autoimmune conditions including systemic lupus erythematosus, rheumatoid arthritis, celiac disease, multiple sclerosis and inflammatory bowel disease.

If Autoimmune Disease Does Impact Endometriosis, What Can We Do?

Although there is still significant research needed to truly understand why those with endometriosis seem to have impaired immune function, in our medical clinic, we have found that addressing a few key areas can dramatically improve symptoms experienced by patients with endometriosis and in some cases has even reversed symptoms entirely and reduced the need for additional surgery.

#1) Whole Body Approach

One of the secrets to our patient’s success is taking a comprehensive approach to their health. This generally does not happen during your ten minute appointment with your doctor and should instead involve a comprehensive evaluation of not only your symptoms but also your diet, lifestyle, environmental exposures, nutrient status, comprehensive testing and so much. This is why our initial assessments take a full 60 minutes and involve a detailed history that allows us to better screen our patients for autoimmune conditions. So often, patients with endometriosis come to our office telling us they recently were told their labs looked “normal” and their thyroid was functioning well, when in fact, when we took a more comprehensive look, their thyroid antibodies were >1200! Autoimmune thyroid disease is extremely common and it impacts women 5 to 7 times more often than men, which means in our clinic evaluating for autoimmune related conditions like Hashimoto’s Thyroiditis, is a must. Addressing Hashimoto's thyroiditis with a combination of diet, lifestyle, and sometimes pharmaceutical interventions has not only helped our patients feel more energy and reduce their thyroid antibodies, but it has lowered their pain related to endometriosis!

#2) Food is Truly Medicine

If there is one aspect to medicine we have found most helpful for patients suffering from endometriosis, it would have to be the power of food. And when I say food as medicine, I am not talking about reducing your caloric intake but instead focusing on providing your body with nutrient dense foods that not only stabilize your blood sugar and reduce inflammation but also improve symptoms of endometriosis. Reducing artificial sweeteners and processed foods is an absolute must but also adding in foods including dark leafy greens, anti-inflammatory oils, like coconut and avocado oil as well as high quality omega-3 rich fats and high quality proteins has been extremely beneficial for our patients.

#3) Your Environment Matters

When it comes to endometriosis, we know optimal hormone balance is important which is why in our clinic, reducing your exposure to endocrine disrupting chemicals is an absolute must. Endocrine disrupting chemicals are chemicals that are commonly found in our beauty products and home cleaning products that have been documented to mimic or interfere with the production of our endocrine (hormone) system. Although we would think that if there was enough evidence to show an ingredient was harmful to our health that it would be banned from use but, unfortunately many endocrine disrupting chemicals are still widely available in most products we own. One way you can work on reducing your exposure to endocrine disrupting chemicals is to visit the EWG Skin Deep beauty database which allows you to find clean and safe alternatives to some of your most toxic products.

#4) Daily Movement

The modern world has provided many amazing advances to our society but unfortunately one of the major disadvantages of our modern life is that most of us sit behind a computer screen for the majority of our day. Sedentary living has not only been associated with negative health factors comparable to smoking, but it can contribute to stagnate blood flow and inflammation. Since inflammation is directly linked to endometriosis, adding in at least 15-20 minutes of exercise every day is something we truly believe helps our patients fight the symptoms of endometriosis.

About the Author: Meet Dr. ZenAlissia Zenhausern- Pfeiffer, NMD, FABNE, (commonly known by her patients as Dr. Zen), is a licensed naturopathic doctor board certified in naturopathic endocrinology and the founder of NMD Wellness of Scottsdale, a premier naturopathic medical practice that focuses on helping women to take a proactive approach to their hormone and fertility health. Dr. Zen has been featured as a lead expert in Forbes, Shape Magazine, and Instyle and is deeply passionate about bridging the gap between traditional and natural medicine in the world of fertility. She works with a variety of hormone related issues including PCOS, endometriosis and unexplained infertility. Her goal is to help more women get back into the driver’s seat of their own health to make lasting transformational changes to their health to bring more cute and adorable babies into this world. Read More About Dr. Zen...