Holistic approaches to managing endometriosis pain

Endometriosis: A Complex Systemic Disease

Endometriosis is is not simply a “menstruation disease.” It is a complex, systemic condition in which tissue similar to the endometrial lining of the uterus grows outside the uterus, affecting multiple systems throughout the body. These include the endocrine, immune, reproductive, gastrointestinal, urinary, and nervous systems.

The condition is characterized by lesions—known as implants, nodules, or endometriomas (also called chocolate cysts)—that respond to monthly hormonal fluctuations, particularly estrogen and progesterone. During the follicular phase of the menstrual cycle, rising estrogen levels can cause this misplaced tissue to grow, often resulting in severe pain.

Endometriosis is associated with both immune and hormonal disruptions. As the disease progresses, it causes inflammation, which may lead to adhesions, scarring, internal bleeding, bowel or urinary dysfunction, constipation, painful intercourse, and infertility. The physical pain can be intense and may contribute to psychological distress, making endometriosis a debilitating condition for many individuals.

Causes of Endometriosis

The exact cause of endometriosis remains unknown, but several theories have been proposed:

• Retrograde menstruation: This theory suggests that endometrial tissue flows backward through the fallopian tubes into the pelvic cavity, where it implants on other organs.
• Genetic factors: Endometriosis is more common in families with a history of the condition, suggesting a genetic predisposition. Alterations in detoxification enzymes, hormone metabolism, and tumor suppressor genes may contribute.
• Embryonic cell transformation: Müllerian duct remnant cells from embryonic development may be stimulated by estrogen during puberty to transform into endometrial-like cells.
• Immune system dysregulation: Endometriosis is increasingly considered an autoimmune-related condition. Immune cells such as neutrophils, macrophages, NK cells, and dendritic cells may promote angiogenesis, growth, and invasion of endometriotic cells. These cells secrete cytokines and defensins, which influence the disease environment. Immune checkpoint inhibitors, which regulate immune responses, show altered levels in patients with endometriosis compared to healthy individuals.

Co-Factors That May Contribute to Endometriosis

• Early menarche (before age 12)
• Short menstrual cycles (less than 21 days)
• Prolonged menstrual bleeding (more than 7 days)
• Use of intrauterine devices (IUDs)
• Altered estrogen metabolism due to poor gut health
• Exposure to environmental toxinshttps://pmc.ncbi.nlm.nih.gov/articles/PMC2867352/ such as dioxins, POPs, and PCBs, which may affect estrogen production and promote chronic inflammation
• Dietary factors, including low omega-3 intake, high saturated fat consumption, low magnesium levels, and excessive caffeine and alcohol intake

Endometriosis and the Endocrine System

Endometriosis is an estrogen-dependent condition. During the follicular phase of the menstrual cycle, rising estrogen levels cause misplaced endometrial tissue to grow and thicken, leading to bleeding and pain outside the uterus.

Women with endometriosis often exhibit:

• Altered estrogen metabolism
• Reduced progesterone sensitivity in endometrial tissues
• Local estrogen production by endometrial lesions, contributing to hormonal imbalance (high estrogen-to-progesterone ratio)

Endometriosis and Reproductive Health

Endometrial cells can appear on the ovaries, fallopian tubes, bowel, bladder, peritoneal tissue, ligaments, and other abdominal structures. In rare cases, they may even affect the nasal and respiratory passages, causing nosebleeds or pink frothy sputum during menstruation.

• Ovarian endometriomas can impair ovarian function and reduce ovarian reserve.
• Lesions on the fallopian tubes may cause adhesions, scarring, inflammation, and blockages.
• Pelvic inflammation can negatively impact fertility.

Endometriosis and the Immune System

Misplaced endometrial tissue responds to hormonal changes and bleeds during menstruation, triggering local inflammation. This bleeding increases the production of inflammatory cytokines, which activate immune responses.

Endometriosis is associated with systemic immune dysfunction, where immune cells such as macrophages, natural killer cells, and lymphocytes fail to function properly and cannot effectively eliminate ectopic endometrial tissue.

Endometriosis and the Nervous System

Endometrial lesions and chronic inflammation can irritate pelvic nerves, causing persistent pain that worsens during menstruation. Nerve irritation may result in sharp, shooting, or electric shock-like pain radiating to the lower back, legs, and buttocks, mimicking conditions like sciatica.

Chronic pain may also alter the central nervous system, increasing sensitivity to pain signals.

Endometriosis and the Gastrointestinal System

Endometrial tissue on the intestines can lead to symptoms such as bloating, abdominal pain, diarrhea, constipation, nausea, and painful bowel movements—especially during menstruation.

Many women with endometriosis are misdiagnosed with IBS or IBD, though both conditions can co-exist with endometriosis. Gut health is especially important in managing symptoms.

Estrogen Metabolism and Gut Health

Estrogen is primarily metabolized in the liver via Cytochrome P450, producing various metabolites such as:

• 2-hydroxyestrone
• 16-alpha-hydroxyestrone (potent)
• 4-hydroxyestradiol (potentially harmful)

Poor liver function can impair estrogen metabolism, contributing to hormonal imbalance.

The estrobolome—a collection of gut microbiota—releases an enzyme called beta-glucuronidase (β-glucuronidase), which deconjugates estrogen and converts it into its biologically active form. This form is then reabsorbed into the body.

If gut dysbiosis (an imbalance in gut bacteria) occurs, it can lead to estrogen dominance, promoting lesion formation and worsening symptoms.

Studies show that multiple bacterial genera—including Bacteroides, Bifidobacterium, Escherichia coli, and Lactobacillus—produce β-glucuronidase. Patients with endometriosis often have significantly higher levels of Escherichia coli, contributing to elevated free estrogen.

Additionally, an increased presence of gram-negative bacteria such as E. coli can trigger inflammation, tissue remodeling, fibrosis, adhesion formation, and infertility.

Endomitosis and urinary system 

Endometrial tissue can also be grown on bladder and ureter causing urinary urgency, painful urination, blockage of kidney pain.

Holistic approach to Endomitosis

• Anti-inflammatory diet/Mediterranean diet: low in red meat, dairy, sugar, simple carbs. Diet high in fiber, fish, legumes and beans (if tolerated), vegetable and healthy fats.
• Dietary fatty acids: increase omega-3 fatty acids and reduce trans fats. Based on the available evidence, omega 3 may reduce the inflammatory response in patients with endometriosis, specifically by decreasing levels of pro-inflammatory cytokines, such as TNF-alpha, IL-6 and IL-1, indicating potential anti-inflammatory properties that warrant further investigation.
• Other supplements with Anti-inflammatory properties are curcumin, adaptogens, and medicinal mushrooms.
• Vitamin D enhances the function of immune cells, modulate immune response and reduce production of pro-inflammatory cytokines.
• Avoiding caffeine and alcohol may be possible risk-reducing factors.
• Gluten free diet may decrease painful symptoms of endometriosis.
• Increasing dietary fiber can help optimize the gut microbiome and support healthy estrogen levels. Aim to consume 25–30 grams of fiber per day. One of the best fiber sources for individuals with endometriosis is flaxseed. Flaxseed contains phytoestrogens—a weaker form of estrogen—that bind to estrogen receptors, thereby preventing stronger estrogen from exerting its effects on the body. Additionally, flaxseed supports the elimination of excess estrogen.
• Enhance detoxification with Brassicacae, Sulphur-containing vegetables, phytochemicals, phytoestrogen-containing plants. These Sulphur containing vegetables help with liver detoxification of estrogen.
• Feed your Flora: Eat variety of plant-based foods in different colors, this ensure you are getting variety of micronutrients, phytochemicals, fibers and starches that are important for gut health. Eat fermented foods, 2021 study showing that feeding people a diet high in fermented food increased the healthy diversity of their gut microbiome and lowered their overall levels of inflammation. High-fiber diets have also been shown to support a healthy gut microbiome. Healthy gut microbiome including estrobolome ensures estrogen metabolism
• Help liver detoxication of estrogen by taking supplements such as DIM, milk thistle or I3C. In vivo,  DIM significantly reduced endometriotic tissue viability by 25%. In another study I3C, the DIM precursor, and found it to be effective in decreasing endometroid heterotopias and endometriosis-induced pain. The authors highlighted that I3C has been shown to regulate the metabolism of estrogen by restoring the physiological ratio of 16-alpha and 2-hydroxymetabolites, normalizing hormone-sensitive tissue cell division in the female reproductive system. They also explain that I3C is prone to being converted into DIM in the stomach, and DIM exhibits its own clinically relevant properties.
• N-acetylcysteine (NAC): in an observational cohort study for endometriosis treatment, the NAC treated group experienced a mean decrease in cyst diameter and reduction in pain, and a complete disappearance in cysts in some women.
• Devil’s claw: Historically it has been used for its anti-inflammatory and analgesic effects and potentially can be helpful for endometriosis

 Acupuncture and Chinese Herbal Medicine for Endomitosis:

In Chinese Medicine, endometriosis is a complex disorder with both excess and deficiency pattern. The excess pattern of endometriosis includes qi and blood stasis with stasis of heat or cold and underlying deficiencies of kid yin and yang, spleen qi deficiency, blood deficiency.

Studies have shown that Acupuncture is effective in treating pain associated with endometriosis with results lasting up to 24 weeks after cessation of treatments.

Chinese Herbal Medicine is very effective in treating endometriosis by reducing inflammation, improving pelvic blood circulation, addressing the gut microbiome and immunity. The TCM herbalist will make appropriate differential diagnosis for the patient specific pattern of endometriosis and prescribe appropriate Herbal formula and or modification of a formula based on your specific condition.  along with dietary and life style recommendations.

Most commonly Herbal formulas

A large review involving 12,788 women with endometriosis in multiple Taiwanese hospitals who have taken Chinese herbal formula based on their differential diagnosis have shown improvement in their endometriosis symptoms.

Gui Zhi fu ling wan: anti-tumor, anti-inflammatory, analgesic and hemodynamic improvement.

Shao fu zhu yu tang: In a study, this formula significantly reduced the size of ectopic lesions in rats with endometriosis, inhibited cell proliferation, increased cell apoptosis, and reduced micro-vessel density and HIF-1α expression.

Wen jing tang:  prevents and treats endometriosis by reduction of inflammation through the inhibition of the HIF1 signaling pathway.