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Endometriosis and Pregnancy

September 7, 2020
endometriosis pregnancy naturopathic doctor toronto

Endometriosis is a condition where endometrial tissue grows outside of the uterus – commonly on the ovaries and rectum, but even as far as the lungs, brain, or sciatic nerve. This tissue often produces an inflammatory response resulting in symptoms like pain.

Back in the 20s, researchers believed that endometrial lesions regressed during pregnancy – and so doctors would sometimes tell their patients that pregnancy could be “curative” because the person was no longer ovulating or menstruating. However a decrease in symptoms isn’t the case for everyone. Studies show that people with endometriosis can still be affected by this condition.

Pain and Lesions

Only a few studies have evaluated pregnancy and endometriosis-related pain. While some lesions can regress, others can remain stable or increase. The only beneficial effect of endometriosis in pregnancy is that amenorrhea (no periods) decreases the risk of new lesion formation.

One study by Alberico noted an improvement of endometriosis-related pain symptoms, where after 2 years about 63% of women experienced an improvement in pain symptoms and an improvement in quality of life. That said, in this same study, 84% of women still experienced pain-related symptoms after pregnancy.

Pregnancy Loss

People with endometriosis had a greater risk of pregnancy loss – specifically miscarriage before 20 weeks and ectopic pregnancy. The risk of miscarriage was highest in women younger than 35 and was their first pregnancy. The risk of ectopic pregnancy was stronger for pregnancies in women without a history of infertility.

Gestational Diabetes

In the review by Farland, women with endometriosis had a 35% greater risk of gestational diabetes in pregnancy. This risk was highest in women younger than 35, no history of infertility, and in second or later pregnancies.

Gestational diabetes is the onset of carbohydrate intolerance in pregnancy, which is typically diagnosed after the 24th week of pregnancy. It affects 3-25% of pregnancies.

If gestational diabetes was not controlled, it may put pregnant people at risk for abnormal fetal growth, hypertensive disorders of pregnancy, difficult labor and vaginal delivery, and increased risk of cesarean section. Risks for the baby include low blood sugar, increased bilirubin, and possibly delayed lung maturity. Moreover, they’re also at risk for adult onset of metabolic disorders, diabetes, hypertension, obesity, cardiovascular disease, and shorter lifespan.

Hypertensive Disorders

The same review by Farland, women with endometriosis had a 30% greater risk of hypertensive disorders of pregnancy. The risk was highest in second or later pregnancies.

Hypertensive disorders of pregnancy are present in about 15% of pregnancies and include pre-existing high blood pressure, gestational hypertension, and preeclampsia.

Hypertension is defined as a diastolic rate above 90mmHg (based on 2 measurements), while severe hypertension is a blood pressure over 160/110 mmHg. Pre-existing high blood pressure occurs prior to pregnancy or before 20 weeks pregnant, while gestational hypertension is usually diagnosed at or after 20 weeks pregnant.

Preeclampsia is defined as the presence of one or more symptoms at or after 20 weeks of pregnancy with the involvement of other body systems. The main symptoms include: hypertension (greater than 140/90 mmHg taken at least twice, 4 hours apart) and protein in the urine. Other symptoms include visual complaints, headache, vomiting, and abdominal pain.

If left untreated, preeclampsia can lead to neurologic complications, such as seizures (eclampsia) and strokes, kidney injury, and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.

Preterm Birth

The review by Farland demonstrated that women with endometriosis had a 16% greater risk of preterm birth, specifically in second or later pregnancies. Preterm birth was defined as birth less than 37 weeks of gestation.

Low Birth Weight

Lastly, the review by Farland demonstrated that women with endometriosis had a 16% greater risk of low birth weight. Low birth weight was defined as birth weight less than 5.5 lbs (in a single pregnancy).

Final Thoughts

Overall, while new lesions are unlikely to develop during pregnancy, there’s limited knowledge about the impact of existing lesions and related symptoms during pregnancy or in the postpartum.

Furthermore, because there are some adverse pregnancy outcomes in people with endometriosis, it may be warranted to think about conditions like gestational diabetes and hypertension prior to the second trimester. Perhaps thinking about prevention may be worthwhile in the first trimester. Also, since pregnancy loss has been shown to be an adverse event in the first trimester, it may be worthwhile to talk to your healthcare provider prior to pregnancy to see if there’s anything that can be done to prevent this. However, miscarriage is more common than we think, and sometimes can be unavoidable.

At the end of the day, if you have endometriosis, don’t buy into the hype that you should become pregnant to decrease symptoms, and this isn’t the best advice. Choosing to expand your family should be done because you want to become a parent, not to improve your endometriosis symptoms.

If you have endometriosis and are looking to become pregnant or manage this condition during pregnancy, consider booking an appointment with a Naturopathic Doctor to complement obstetric or midwifery care.

References

Alberico, D., Somigliana, E., Bracco, B., Dhouha, D., Roberto, A., & Mosconi, P. et al. (2018). Potential benefits of pregnancy on endometriosis symptoms. European Journal Of Obstetrics & Gynecology And Reproductive Biology230, 182-187. https://doi.org/10.1016/j.ejogrb.2018.08.576

Denney, J., & Quinn, K. (2018). Gestational Diabetes. Obstetrics And Gynecology Clinics Of North America45(2), 299-314. https://doi.org/10.1016/j.ogc.2018.01.003

Farland, L., Prescott, J., Sasamoto, N., Tobias, D., Gaskins, A., & Stuart, J. et al. (2019). Endometriosis and Risk of Adverse Pregnancy Outcomes. Obstetrics & Gynecology134(3), 527-536. https://doi.org/10.1097/aog.0000000000003410

Leeners, B., & Farquhar, C. (2019). Benefits of pregnancy on endometriosis: can we dispel the myths?. Fertility And Sterility112(2), 226-227. https://doi.org/10.1016/j.fertnstert.2019.06.002

Leeners, B., Damaso, F., Ochsenbein-Kölble, N., & Farquhar, C. (2018). The effect of pregnancy on endometriosis—facts or fiction?. Human Reproduction Update24(3), 290-299. https://doi.org/10.1093/humupd/dmy004

Leone Roberti Maggiore, U., Ferrero, S., Mangili, G., Bergamini, A., Inversetti, A., & Giorgione, V. et al. (2015). A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes. Human Reproduction Update22(1), 70-103. https://doi.org/10.1093/humupd/dmv045

Shah, S., & Gupta, A. (2019). Hypertensive Disorders of Pregnancy. Cardiology Clinics37(3), 345-354. https://doi.org/10.1016/j.ccl.2019.04.008

Endometriosis in Teens

December 10, 2018
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It’s time to listen to your body. 

Especially if you’re experiencing period pain. 

You might’ve been told that period pain is normal. But that’s not exactly true. Period pain is a common symptom, but isn’t always normal.

Cramping in your lower pelvis or back is normal around the start of your period, but experiencing severe pain isn’t. If you feel a stabbing, burning, or throbbing pain that doesn’t go away with pain killers, and is causing you to miss school or work, and affecting your quality of life – you need to figure out what’s going on.

One of the emerging causes of period pain in teens is endometriosis. Endometriosis happens in about 10% of women who menstruate (likely more!). It was previously thought that teens didn’t have endometriosis because research only looked at older women who were having trouble getting pregnant.

What is endometriosis?

Endometriosis is a gynecologic disease that occurs when endometrial tissue grows outside your uterus. This tissue can grow anywhere in your body (it’s even been found on the lungs and brain), but it’s most commonly found on the ovaries, fallopian tubes, uterine surface, bowel and the lining of the pelvic cavity.

When you experience your monthly period, you also experience internal bleeding and ultimately scar tissue will form. Sounds great, right? #noway

Common endometriosis symptoms in adults

Some of the common symptoms associated with endometriosis are:

Other symptoms include:

How does endometriosis present in teens?

You might notice pain that doesn’t quite sync with your period (aka. noncyclic pelvic pain). Also, if your mom or sister have endometriosis, or if you have a history of atopic disease (ex. eczema, asthma) – you should be checked!

Endometrial lesions might be found between your ovaries, peritoneum, pouch of Douglas, uterosacral ligaments and rectovaginal septum. Typically, the lesions may present differently than they would in adults. Yours might be more red and clear. 

Because of these differences, this may contribute to your delay in diagnosis, and ultimately treatment. Obviously this lag may negatively impact your quality of life. 

Warning signs in teens

Pay attention to these signs:

  • Extended use of anti-inflammatory drugs (ex. NSAIDs)

  • Family history of endometriosis (ex. mom and sister)

  • Frequent absence from school during your period, and skipping exercise because of pain or a heavy flow

  • Birth control prescription before you turn 18 because of pain

How is endometriosis diagnosed?

You can’t diagnose endometriosis through a blood test. Instead, the gold standard of testing is a laparoscopic exam. This is considered a minimally-invasive surgery where small incisions are made in the abdomen to both confirm the presence of and remove endometrial lesions.

Doctors may suggest ultrasounds to see if you have endo, but that test can’t completely rule endo out. 

Conventional Treatment of Endometriosis

Unfortunately there’s no cure for endometriosis. But treatment should include controlling pain and preventing lesion progression. 

The first line treatment in endometriosis is birth control (usually a combined pill). This may actually be worthwhile to try if the pain is incredibly severe, and not responding to regular painkillers. Nevertheless, there are a few things to consider if you plan on taking birth control: 

A huge study in 2016 investigated different types of birth control and how they were associated with antidepressants and a diagnosis of depression. Researchers found that teens (between 15 to 19) are more sensitive to depressive symptoms and antidepressants than adults. This was seen in teens using the combined pill or progestin-only pill. The study did show that the incidence of depression and antidepressants use decreased with age. 

Teens with endometriosis report impaired physical and mental health quality of life. As well as physical pain, difficulty in participating in daily activities, physical activities, and social events. Therefore all of these factors must be considered when determining the best treatment route, or adjunctive supportive therapies. 

Naturopathic Treatment of Endometriosis

Once again there isn’t a cure for endometriosis, but you can do a couple of things to manage the pain and improve quality of life. There are some supplements that you can take, but it should really be done under the supervision of a health practitioner like a Naturopathic Doctor. 

You may want to consider:

  • FODMAPs diet or an anti-inflammatory diet

  • Curcumin

  • N-acetyl cysteine

  • EPA/DHA

  • Selenium

  • Vitamin E

Next Steps

If you’ve been experiencing any of the warning signs, it may be time to talk to your doctor about endometriosis. 

If you found this information helpful, I would encourage you to download my 
FREE EndoDiet meal guide and plan. It goes through everything we discussed: foods that are safe and that should be avoided, and a 7 day meal plan and preparation guide!

References

Dowlut-McElroy, T. and Strickland, J. (2017). Endometriosis in adolescents. Current Opinion in Obstetrics and Gynecology, 29(5), pp.306-309.

Gallagher, J., DiVasta, A., Vitonis, A., Sarda, V., Laufer, M. and Missmer, S. (2018). The Impact of Endometriosis on Quality of Life in Adolescents. Journal of Adolescent Health, 63(6), pp.766-772.

Reid, R., Steel, A., Wardle, J. and Adams, J. (2018). Naturopathic Medicine for the Management of Endometriosis, Dysmenorrhea, and Menorrhagia: A Content Analysis. The Journal of Alternative and Complementary Medicine.

Zannoni, L., Forno, S., Paradisi, R. and Seracchioli, R. (2016). Endometriosis in Adolescence: Practical Rules for an Earlier Diagnosis. Pediatric Annals, 45(9), pp.e332-e335.

Endometriosis and the FODMAPs Diet

June 9, 2018
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Women who live with endometriosis often report symptoms of abdominal bloating, diarrhea, constipation and of course pain. It’s been suggested that IBS (irritable bowel syndrome) may happen in about 90% (!!!) of women with endometriosis. Since almost all women are affected, it seems obvious that diet can play a huge role in pain and overall health, highlighting the need for an endometriosis diet. 

The above symptoms may happen because of the location of endometriosis (ie. near the sigmoid colon or rectovaginal space). Moreover, endo may affect nervous system function and lead to changes in sensitivity and movement in the GI space.

How is IBS Diagnosed?

IBS is often a diagnosis of exclusion –  aka. many conditions need to be ruled out before IBS can be ruled in. Nevertheless, IBS is diagnosed by the the Rome IV criteria. 

You may have IBS if you have recurrent abdominal pain on average at least one day/week in the last three months, associated with two or more of the following criteria:

  • related to defecation

  • associated with a change in frequency of stool

  • associated with a change in form (appearance) of stool

Endometriosis and FODMAPs

Because IBS is so common in women with endometriosis, focusing on nutrition and diet makes total sense. Ultimately, we want to see if certain foods are causing pain and bloating, and changes in stool formation. 

The FODMAP diet has a lot of research with respect to improving symptoms of IBS. Therefore, it should be considered for women with endometriosis as it may provide therapeutic benefit. 

FODMAP Diet for IBS and Endometriosis

If you’ve never heard of a FODMAP – that’s okay! It’s an acronym that refers to carbohydrates (ie. sugars) commonly found in food. Here’s what the letters mean:

  • Fermentable

  • Oligosaccharides

  • Disaccharides

  • Monosaccharides

  • And

  • Polyphenols

The Pathway of Food and Gut Bacteria

When we eat, food travels from our mouth down the esophagus, and enters the stomach where the carbs, protein and fats are digested. As it moves through the small intestine, the food will continue to break down into smaller nutrients which will end up being absorbed into the bloodstream. The leftovers will pass through the large intestine, which will remove fluid through absorption. The bacteria in the large intestine will digest any leftover bits of carbs and proteins.

If someone has IBS, then the above carbs (O, D and M) will NOT be properly digested and will move into the large intestine, where the gut bacteria will begin to ferment them. This may cause painful gas, bloating, diarrhea, and other undesirable symptoms.

Therefore when someone chooses to follow a FODMAP diet, they’re choosing foods that are low in fodmaps – PREVENTING fermentation by the bacteria. 

Understanding FODMAPs

Let’s talk about the FODMAPs acronym again – oligo, mono and di are saccharides (which is another name for sugar).

  • Oligo means a FEW sugars linked together – like cellulose and starch

  • Di means TWO sugars linked together – like lactose which is made up of glucose and galactose sugars (monosaccharides)

  • Mono which means ONE sugar like fructose/glucose/galactose

A note about fructose: fructose is only an issue if there’s NOT enough glucose to help with absorption. Which means that anything with high fructose corn syrup or foods that have excess fructose (ie. apples) should be AVOIDED if you’re on a FODMAPs diet.

Lastly, polyphenols are sugar alcohols – basically any sugar that has –ol at the endo of it, such as xylitol, mannitol, etc.

How does the diet work?

This diet is similar to an elimination diet, with 3 phases: 

Phase 1: Low FODMAP

Eating a low-FODMAP diet. You would accomplish this by going through the FODMAP list and designing your meals around foods that you can eat, and foods you should avoid. For instance, if you’re used to eating an apple at 11am (to obviously keep the doctor away), you’ll want to switch it up for an orange. 

To make sure you get all the FODMAPs out of your system, you’ll want to follow this for about 2-6 weeks.  

Phase 2: Challenge

This is where you introduce FODMAP rich foods back into your diet (although not all at once!) to determine which foods trigger symptoms. If you do experience symptoms once you re-introduce a particular food into your diet, it’s best to avoid introducing another for a few days to let your gut get back to baseline. 

Based on how many foods you’re introducing and which symptoms keep popping up, this may take about 6-8 weeks. It’s best to go through this phase with a Naturopathic Doctor’s help.  

Phase 3: Adaptation

Now that you’ve gone through re-introducing all the foods that may cause unwelcome symptoms, you’ll know which foods you can safely eat and which you should avoid. In the adaptation phase, you can also re-challenge foods that previously cause you pain to again determine if they’re safe or should be avoided – this is because tolerance may change as time progresses. 

Final Thoughts of the Endometriosis Diet & Additional Resources

Monash University has an easy to use app highlighting FODMAP foods, as well as a great blog that provides additional information and FODMAP-friendly recipes. One particular article that I like is eating out on a FODMAP diet – because it’s always a huge limitation for everyone 

If you found this information helpful, I would encourage you to download my FREE EndoDiet meal guide and plan. It goes through everything we discussed: foods that are safe and that should be avoided, and a 7 day meal plan and preparation guide!