These growths or cells, act exactly like those found inside the uterus. These growths will often bleed around your period, increasing their size of them, and causing the unwanted symptoms associated with Endometriosis.

Currently, one in nine women, or people born with biologically female organs, suffers from this debilitating condition. It is not rare. It needs far more information, funding, research and empathy.

Symptoms

It is important to know that symptoms will differ from person to person. However, there are a few that tend to present commonly. 

Some defining symptoms of Endometriosis include:

• Pain – this includes pain during periods, pain during or after sex, ovulation pain, and pain through the menstrual cycle
• Heavy bleeding – this occurs during periods, and prolonged and irregular bleeding through the menstrual cycle
• Bladder and bowel problems (changes in patterns) 
• Bloating and abdominal discomfort 
• Vaginal discomfort
• Fatigue 
• Reduced quality of life.

It is known that around three out of four (75%) people with Endometriosis have pelvic pain and painful periods.

There is no known cause of Endometriosis. Research is still being done to determine this, and if it can be prevented. However, there is a family link as those with a family member previously being diagnosed who are seven to ten times more at risk for it to develop.

When should I reach out for more help?

Heavy, prolonged, and painful periods are not normal. If your periods are stopping you from participating in school, work, or social activities, or if pain medication does not work you should reach out to your GP for further investigations.

Diagnosis

The number one, definitive way to diagnose is via a surgery known as a laparoscopy. This is performed by a gynaecologist. A laparoscopy is an operation, where a tube and a camera are inserted into the abdomen to see whether there is any present, and sometimes it can be removed in these situations.

Specialised pelvic ultrasounds are sometimes used to attempt to view the presence of Endometriosis, however, this is not always reliable, and can be difficult to see and diagnose. There is a great debate raging on this subject within online Endo communities, as some medical professionals use imaging to ‘rule out’ the diagnosis of Endometriosis.

Endometriosis is graded depending on severity. It is important to note that the severity of symptoms does not correspond to the severity. This staging also does not predict whether future fertility will be affected. The stages of are graded as: 

• Stage I – Minimal 
• Stage II – Mild 
• Stage III – Moderate 
• Stage IV – Severe

This is also paired with other terminology that describes Endometriosis such as 

• Superficial is where it appears on the surface or lining of the organ and does not deeply invade the tissues
• Deep-infiltrating is where lesions invade the tissues deeply.

Multi-pronged management of Endometriosis

There are four major categories that management often falls into: 

Hormone Therapy or medication 

Hormone therapy aims to reduce the growth of Endometriosis and stop bleeding, including menstrual bleeding. These therapies aim to manage the troublesome symptoms of pain and heavy bleeding. Common hormonal therapies include: 

• The combined oral contraceptive pill 
• Progestogens, which can be taken orally, via injection or the Mirena IUD (intrauterine device).
• Gonadotrophin releasing hormone (GnRH) agonists and antagonists, stops the menstrual cycle and can create a temporary chemical menopause. 

These all come with their own side effects and risks which should be discussed with your GP, or health provider. 

Surgery

Excision surgery (the removal of Endometriosis) is one of the main treatments. It is important that the Endometriosis is removed as completely, and as best as possible. Scarring because of incorrect removal can contribute to regrowth.

Many will go through multiple of these surgeries throughout their life.

Pain Management Strategies

The symptom that interferes with sufferers' lives most is severe chronic pelvic pain. There are a few medicinal pain management strategies that may be helpful, these include:

• Over the counter pain relief medication, such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs e.g. ibuprofen)
• Prescription Pain relief (e.g. Ponstan or Naproxen)
• Stronger pain relief such (e.g. Panadeine or Tramadol)
• Chronic Pain medications, that act on nerve pain and act as nerve/muscle relaxants (e.g. Amitriptyline or Pregabalin)

Natural therapies

The overload of appointments and medications can be overwhelming and some people with Endometriosis may like to use other management strategies. These are often referred to as non-pharmacological strategies. These may be used in combination with the above treatments. 

• Heat packs
• Stretching, yoga, pilates or gentle walks
• TENS machine
• Building your healthcare team - some other helpful professionals to include (apart from a GP and gynaecologist) might be a pelvic floor physiotherapist, dietitian, and psychologist/pain psychologist. 

Lifestyle changes are often used in conjunction with medical management, to optimise the quality of life for those who live with Endometriosis. Take a look at the Red Pages for Menstrual Products to see Australian brands.

Management of Endometriosis through diet

Diet is an important component in managing Endometriosis and can be considered another ‘tool in the toolbox’ for management strategies.

Endometriosis is an inflammatory condition. Through the assistance of diet, you can counteract the effects of inflammation, by following anti-inflammatory eating principles. 

Antioxidants protect our cells against damage and have anti-inflammatory effects on the body. It is all about adding as much to your diet as possible, not restriction or cutting out of whole food groups and nutrients.

Firstly, there is no single ‘Endometriosis diet’, what works for one person may not necessarily work for another. There is research to say that including certain nutrients can reduce symptoms such as pain development, severity, and pain frequency across all stages of the menstrual cycle. 

Which nutrients are key to include? 

Vitamin E
One study showed that supplementation of vitamin E and vitamin C reduced pelvic pain in those with Endometriosis (Kavtaradze et al, 2003). This included reduced pain with periods and pain during penetrative sex. 

Another study showed that supplementation with these two vitamins (which are antioxidants) reduced overall oxidative stress - a common issue contributing to inflammation (Amini et. al., 2021). Vitamin E is found in avocado, nuts and seeds, fish, extra virgin olive oil and olives.

Vitamin D
Research has found vitamin D deficiency is connected both to Endometriosis development and to its severity (Yarmolinskaya et al., 2021) Many people with Endometriosis are low in vitamin D. 

The research around vitamin D and its direct relationship to Endometriosis is still emerging. Vitamin D can be found in fortified eggs, small fish with bones, and of course from the sun.

Fibre
Fibre helps with the removal of excess estrogen in the body and having a high-fibre diet prevents estrogen from being re-absorbed. Fibre can be very useful for those who also experience bowel symptoms as part of their Endometriosis, or if they have an IBS (irritable bowel syndrome) diagnosis.

Magnesium
Magnesium is a nutrient that works by relaxing smooth muscles (i.e., the muscles in the uterus and bowel). Having magnesium in your diet, or as a supplement can reduce pain and cramping through all stages of the menstrual cycle. You can find magnesium in whole grains, leafy vegetables (green), legumes and nuts and seeds.

Omega-3 fatty acids
One of the non-negotiables when it comes to the management of Endometriosis is omega-3 fatty acids. Research has shown that omega-3 intake plays a role in reducing inflammatory markers in the body (Calder, 2003). It has also been shown that those who have a higher intake of omega-3 fatty acids are less likely to develop Endometriosis (Missmer, Chavarro, Malspeis, 2010). 

There has also been some research on the ratio of omega-3 and omega-6 fatty acids and its impact on Endometriosis development (Khanaki et al, 2012). Another study showed that an increased intake of omega-3 fatty acids contributed to lower pain intensity, lower pain duration and a decreased use of painkillers (Hansen & Knudsen, 2013). 

One study looked at the effectiveness of hormonal therapy versus diet versus a placebo group (no intervention) in managing pain. The study found that both the medical and diet groups had improved symptoms in three categories of painful periods, painful sexual intercourse and chronic abdominal pain regardless of menstruation (Sesti, Pietropolli & Capozzolo, 2007). 

Omega-3 fatty acids are most abundant in oily fish such as salmon, sardines, trout, and anchovies. Omega-3’s are also found in chia seeds, flaxseeds and walnuts.

Iron
Iron is a key nutrient to include for Endometriosis sufferers. A key symptom of Endometriosis is heavy bleeding during periods, and often through the cycle. Iron is important to include in the diet to replace these menstrual losses. 

Iron is abundant in red meat, poultry, legumes, and dark leafy green vegetables. Nutrients such as calcium and zinc can compete for absorption with iron, so it is important to consume iron with a source of vitamin C for peak absorption and for an antioxidant boost. Vitamin C is found in tomatoes, kiwifruit, capsicum, and citrus fruits.

It is important to explore all your management options for Endometriosis. Diet and nutrition are major contributors to Endometriosis management. Make sure you check in with a dietitian who has experience in the management of pelvic pain conditions to support you through implementing a sustainable eating pattern that works for you.

References

Amini L, Chekini R, Nateghi MR, Haghani H, Jamialahmadi T, Sathyapalan T, Sahebkar A. The Effect of Combined Vitamin C and Vitamin E Supplementation on Oxidative Stress Markers in Women with Endometriosis: A Randomized, Triple-Blind Placebo-Controlled Clinical Trial. Pain Res Manag. 2021 May 26;2021:5529741. doi: 10.1155/2021/5529741. PMID: 34122682; PMCID: PMC8172324.

Calder P C. N-3 polyunsaturated fatty acids and inflammation: from molecular biology to the clinic. Lipids. 2003;38:343–352.

Hansen S O, Knudsen U B. Endometriosis, dysmenorrhoea and diet. Eur J Obstet Gynecol Reprod Biol. 2013;169:162–171.

Jean Hailes for Women’s Health. Health Topics – Endometriosis. Accessed January 2023.
Available from https://www.jeanhailes.org.au/health-a-z/Endometriosis 

Kavtaradze, Nino et al (2003). Vitamin E and C supplementation reduces Endometriosis related pelvic pain. Fertility and Sterility, Volume 80, 221 – 222,
doi: https://doi.org/10.1016/S0015-0282(03)01504-8

Khanaki K, Nouri M, Ardekani A M. Evaluation of the relationship between Endometriosis and omega-3 and omega-6 polyunsaturated fatty acids. Iran Biomed J. 2012;16:38–43.

Missmer S A, Chavarro J E, Malspeis S. A prospective study of dietary fat consumption and Endometriosis risk. Hum Reprod Oxf Engl. 2010;25:1528–1535

Sesti F, Pietropolli A, Capozzolo T. Hormonal suppression treatment or dietary therapy versus placebo in the control of painful symptoms after conservative surgery for Endometriosis stage III–IV. A randomized comparative trial. Fertil Steril. 2007;88:1541–1547.

Yarmolinskaya M, Denisova A, Tkachenko N, Ivashenko T, Bespalova O, Tolibova G & Tral T. (2021) Vitamin D significance in pathogenesis of Endometriosis, Gynecological Endocrinology, 37:sup1, 40-43, DOI: 10.1080/09513590.2021.2006516