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Endometriosis, PCOS and Fibroids – How Nutrition and Physical Therapy Can Help

Now that we’ve got an idea of what a “normal” hormonal profile looks like, let’s take a look at what can go wrong. Today I’m going to be talking a bit about PCOS, uterine fibroids, adenomyosis and endometriosis.

Let’s start with Polycystic Ovarian Syndrome (PCOS for short). The main symptom of PCOS is irregular, long periods. PCOS is not clearly defined from a clinical standpoint. However, it involves the following three issues (according to the Rotterdam Criteria):

  • Problems with ovulation
    • Women with PCOS typically do not ovulate because they don’t have enough progesterone and/or estrogen.
  • Androgen (male hormone) excess
    • The three main androgens are testosterone, androstenedione and hydroepiandrosterone. Literature has demonstrated a correlation between insulin resistance and increased testosterone levels. This is a self-perpetuating cycle, because insulin resistance normally is related to being overweight and this insulin resistance leads to increased testosterone, which leads to further weight gain. High androgen levels can cause facial hair, body hair, cystic acne, or male-pattern hair loss.
  • Cystic ovaries
    • Why does this happen? Insulin resistance can lead to thickening of the ovarian walls (forming cysts), which impairs their ability to release eggs. Let me clarify that the name polycystic ovarian syndrome is misleading, because it implies that there are multiple cysts; however, many women with PCOS may not have any cysts on their ovaries!

PCOS is the most common hormonal disorder in young women and can affect up to 10% of all women throughout their lifetime. PCOS is one of the most common causes of infertility, as the ovary’s ability to release an egg is impaired. Now, here’s the thing: PCOS can develop for a variety of reasons. As I’ve already discussed, insulin resistance can lead to increased testosterone levels. But, women may develop PCOS in response to low estrogen and progesterone, rather than an excess of androgens. This can certainly be the case for women who have been on oral contraceptive pills for extended periods, as well as those who are over-exercising or under-eating. Think about it: your body is NOT concerned with fertility when it perceives a threat (significant dietary restrictions are perceived as famine!). Androgen excess comes from both the ovary AND the adrenal gland, so high stress levels and inadequate food (especially carbs) can certainly contribute to this!

How is PCOS diagnosed? Well, it doesn’t have a clinical test, because it is a cluster of symptoms. Therefore, it cannot be diagnosed with ultrasound! Instead, your provider would go off your subjective report based upon the Rotterdam Criteria or the Androgen Excess Society Criteria, which states that diagnosis should require that other reasons for high androgen levels should be ruled out (e.g. use of some psychiatric meds that cause androgen excess, high prolactin, hypothyroidism or adrenal disease).

PCOS obviously has a lot of conventional treatments, including hormonal birth control, Spironolactone (a drug that suppresses androgens and has some serious side effects), and Metformin (a diabetes drug). But, as a nutrition therapy practitioner, I encourage people to take a long hard look at their diet and lifestyle. What could have contributed to this? If your stress levels are through the roof or you are working out and really limiting your carb intake, you would benefit from increasing your carb intake (I recommend at least ~100g/day), supplementation with magnesium and zinc, and adequate sleep. We often see elevated dehydroepiandrosterone sulfate (DHEAS), a hormone made by the adrenal glands in women with PCOS. Elevated DHEAS levels are often related to adrenal dysfunction, but also can be due to elevated prolactin levels (e.g. when you’re breastfeeding). On the other hand, if you are someone that eats a lot of sugar and finds themselves constantly hungry, you would benefit from limiting your intake of refined carbohydrates and starting to regulate your blood sugar levels, which will also help to ward off diabetes and cardiovascular disease.

Anyone dealing with PCOS would benefit from supplementation of zinc, which is known to reduce inflammation and helps with adrenal regulation. Zinc deficiency is also correlated with greater risk of PCOS. Alpha-lipoid acid is a fatty acid found in liver and dark leafy greens; it works to improve your insulin sensitivity. Additionally, ensure adequate magnesium and vitamin D to improve insulin sensitivity. I also urge everyone to look at their environmental exposure do you have to endocrine-disruptors, like BPA’s (come back next week for discussion about this).

Uterine fibroids are another pain-generator for women. They are relatively common, especially in women over the age of 35. Fibroids are growths in the muscle wall of the uterus that are caused by excess estrogen. For this reason, fibroids often occur with heavy periods, although they do not cause or contribute to heavy bleeding. These fibroids are benign, but they can cause pain. They are typically benign and may exist without any symptoms. Fibroids are typically only removed (via surgery) if they are particularly large and pain-generating. Fibroids will shrink after menopause as estrogen levels drop and they are not correlated with cancer.

Lifestyle changes can help to prevent further growth of fibroids. These changes include alcohol reduction (recall that alcohol affects your liver’s ability to detoxify estrogen), maintenance of healthy body weight (also recall that adiposity is correlated with estrone release) and limiting your exposure to phytoestrogens (a group of foods that exert an estrogen-like effect, most notably, soy).

Adenomyosis is the condition in which your uterine lining (endometrium) grows into the muscle wall of the uterus. This causes significant pain and heavy periods. Adenomyosis is most common in women over 35 years old, but it can occur throughout the lifespan. While this is not a hormonal imbalance, the pain associated with it may be mitigated with dietary changes. I encourage women to limit their alcohol intake and adopt an anti-inflammatory diet, which often involves removing gluten and dairy from the diet. I also suggest supplementing with turmeric, cinnamon and zinc.

Endometriosis is a common (1 in 10 women are affected) condition in which the endometrium (tissue similar to that of the uterine lining) grows outside of the uterus. These growths are referred to as endometrial lesions, and they can affect the pelvic and abdominal organs (e.g. uterus, fallopian tubes, bladder, bowel and other gastrointestinal organs). We now know that adhesions form; these adhesions are essentially connective tissue bands that bind organs together and contribute to pain. The primary symptom of endometriosis is severe pelvic pain. Women with endometriosis may experience pain associated with menses, ovulation, or independent of the menstrual cycle. They also can experience bladder symptoms, bowel symptoms, nausea/vomiting, headaches, fever and infertility. Endometriosis is diagnosed with laparoscopic surgery. It’s important to note that ultrasound does not detect endometrial lesions. However, surgery is a rather drastic means by which to diagnose this condition. So, if if women have subjective reports that indicate endometriosis, women often are started on drugs that suppress estrogen (e.g. OCP, Depo-Provera, and Lupron).

There is no consensus about the underlying cause of endometriosis, but some providers hold that this condition is involved with immune dysfunction or may even be autoimmune in nature. There also seems to be a genetic component.  Although endometriosis is not a hormone problem, per se, it is worthwhile to promote hormone balance through diet and lifestyle, as estrogen does stimulate the growth of endometrial lesions. It’s also important to consider ways to decrease overall inflammation levels. That said, I suggest that patients try to remove cow’s dairy from their diet, as most conventionally-raised dairy may contain hormones and can often be inflammatory. I also encourage patients to assess effects of removing gluten from their diet to limit inflammation. Ensuring the integrity of the intestinal wall is also necessary, as leaky gut can lead to release of inflammatory cytokines. Exercise helps to clear excess estrogen. Regular  exercise and consumption of dark, leafy greens help to support liver function and assist with removal of excess estrogen. Supplementation with zinc is beneficial for its anti-inflammatory effect and support of immune function. Similarly, selenium can help to reduce inflammation and is correlated with decreased risk of endometriosis. Turmeric can also be effective in reducing the size of endometrial lesions. Ensure adequate omega-3 fatty acid intake, which also helps to reduce inflammation. Finally, I recommend supplementation with glutathione, again for its anti-inflammatory properties.

Now, I want to switch gears and address these issues from the perspective of a pelvic PT. What all of these conditions have in common is that they can cause discomfort, which in turn leads to compensation and guarding through our pelvic floor muscle. Think about what happens when you cut your hand – you make a fist to try to protect the area. This is essentially what happens in the pelvic floor. This muscle tension can perpetuate pain and can also cause secondary symptoms, like urinary urgency, frequency, difficulty emptying the bowel or bladder and pain with sex. Seeing a pelvic PT can help you to learn how to get in touch with your pelvic floor and finally get it to relax!  While pelvic PT’s cannot treat any of the above conditions, they certainly can help to reduce and manage symptoms associated with these conditions.  

Bottom line? A lot can go wrong with our reproductive system, and effective treatment is complex and multi-factorial! But, we don’t have to settle for conventional treatments. See a functional medicine doctor, naturopath or holistic nutritionist to identify lifestyle changes you can make to help you live more comfortably. And, see a pelvic PT to assess your pelvic floor muscle and eliminate muscle tension in this area, which will also facilitate your ability to manage symptoms of PCOS, fibroids, adenomyosis and endometriosis.

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