L.O.T.S OF INFORMATION (Your immune system, Candida and Endo)
Endometriosis and : Nutrition/Thyroid/Anti Candida/Osteoporosis/Trans Fatty Acids/Dioxins/HRT
NUTRITION
Adapted from :
Endometriosis : A key to Healing Through Nutrition - Dian Shepperson Mills MA & Michael Vernon PhD HCLD Sugar Busters : Dr Sam Andrews, Dr Morrison C Bethea, Dr Luis A Balart, H Leighton Steward
Digestion affects the reproductive system and how the changes in western diet over the last few hundred years has affected us in the rise of refined foods which are high in calories, but low in nutrition. Patterns of healthily eating have changed as our diet has drastically altered over the last 50 years and our bodies have not adapted to the changes.
There are immune system links related to the foods we eat. In nature oil molecules are shaped like a horseshoe. which fits with other bits to form a strong cell membrane to protect what is going on inside. This stops harmful chemicals entering and damaging the cells i.e. like what happens in endometriosis and breast cancers. These oils are crucial to health, i.e. extra virgin cold pressed olive oils, organic butter, vegetable oils such as sunflower, safflower and sesame which are labeled unrefined, unhydrogenated or cold pressed. Fresh nuts and seeds are also a good source of these CIS fatty acids. They aid metabolism in moderation and do not make you fat. Tans fatty acids from processed oils and foods don't form the horseshoe shape and therefore do not protect the cell, high trans fatty acids in body cells have a higher risk of breast cancer. They weaken the cells so that they cannot stop harmful chemicals entering the cell.
Heat changes cis oils into trans oils, so deep frying is not advised, and don't use the same oil twice for frying. Evening primrose and starflower oil in cheap packages and not cold pressed are almost as good as taking nothing, they have to be cold pressed to do any good.
"Nutrition is not an alternative approach like herbal medicine or homeopathy. It is essential to life. Eating is something we do every day. It sustains us and keeps us healthy, or it can make us unhealthy" "Nutrition is certainly very low on the list of doctors priorities, many of whom may have had only a few hours of lessons in nutrition and do not understand how nutrients can relate to body biochemistry. It is a rare doctor who shows any interest in your food intake".
" For example, the mucous membrane which lines the digestive tract is renewed rapidly every 72 hours, New tissue can be formed very quickly on damaged organs, given the right blocks of life".
Immune System Danger
Fluoride - Breaks off a portion of the Y shaped antibody, breaking the antibody in two and making it ineffective, causing immune system weakness and reproductive problems. This includes avoiding certain toothpaste's, mouth rinses, medications, aerosols, pesticides, herbicide, foods processed with fluoridated water, shampoo, deodorants etc. Look for those that are fluoride free.
Immune System Supplements
Selenium (yeast free)
Vitamins A C E
Echinacea (three week blocks only)
Coenzyme Q10
Zinc
Magnesium
B complex vitamins
Food Intolerances
"Some foods i.e. wheat and milk may be a problem if they are not digested correctly. The body becomes intolerant if large molecules pass through the mucosal barrier. Some of our white blood cells are thought to have a memory of three months, so avoiding a problem food for three months may solve the problem and then you can start to re-introduce the food gradually."
Why do food intolerances arise?
- Gut membrane is compromised by irritants as excess gluten from wheat, food additives, pesticides, drugs or filaments from yeast overgrowth. The protective mucous membrane is breached.
- Gut flora becomes imbalanced by onslaught of antibiotics or hormonal preparations.
Factors Influencing Nutrient Intake
Fresh healthy food is not much good if the digestive tract is not working properly.
For Healthy digestion
- time for food to be processed in the digestive tract
- liver function tests
- healthy gut flora
- fibre to excrete toxins and waste products
Constipation is triggered by wheat, eggs, bananas or dairy foods.
Some families are atopic, i.e. history of illnesses such as asthma, eczema, hay fever and arthritis. Most common food intolerances are cows milk products, (cheese, butter, yoghurt, cream), food preservatives and colourings, wheat (cakes, biscuits, pastries, pastas), chocolate, eggs, citrus fruits, and foods containing salicylates (e.g. apples, cherries, grapes, peaches, aubergine, broccoli, tea and coffee)
Natrual and Environmental Oestrogens
"Made from cholesterol in the ovaries, testes and adrenal glands in response to signals from the pituitary. They can also be made by every fat cell in the body, from where they are secreted into the blood and carried to the cells of the breasts and reproductive organs." Oestrogen's are responsible for cell growth in the breast, uterus, bone, liver and cardiovascular system. Some environmental synthetic chemicals such as pesticides, insecticides, and herbicides appear to mimic the role of oestrogen's in the body.
Control of oestrogen is a nutritional process which is disturbed by too much sugar, too little protein and incapacitated by lack of vitamin B complex. You can control oestrogen through diet and gentle exercise.
Dietary fibre increases secretion of excess oestrogen's from the body. The western diet rich in animal and trans fats elevates the levels of sex hormones produced in the body. Fats and fat cells store oestrogenic pesticides and cause a build up of free radicals, which can damage cell membranes, so a low fat diet is advisable. Avoiding bad saturated animal fats and trans oils, and eating mainly the good cold pressed cis oils is vital to health.
To aid excretion of oestrogen's.
- Unrefined wholegrain cereals, nuts, seeds, berries, and the pulse/legume vegetables (peas, beans and lentils). Fibre binds the oestrogen's and inhibits their reabsorption. Some fibres such as the lignins found in rye, other grains and seeds are changed by gut flora to form anti-oestrogenic compounds enterolactone and enterodiol, which are protective against cancers. Good quality fibre encourages a hormone known as serum hormone binding globulin (SHBG) which can be used as a marker for steroid hormone abnormalities. While the oestrogen is bound to the SHBG, it cannot exert any biological effect within the body. If the diet is low in fibre, the oestrogen's can have a biological effect.
- At least four vegetables, two fruits and a handful of nuts and seeds should be eaten each day with some wholegrain cereal. This speeds up the transit time of the food through the digestive tract. The best vegetables are all rich in vitamin B complex i.e. brussels, broccoli, cauliflower, kale, turnip, swede, radish, horseradish, mustard and cress. These speed up the body's degradation system, oestrogen is metabolised and ultimately excreted from the body.
- Other protective factors may be phyto oestrogen's from soya and high natural selenium in foods. Eating green leafy vegetables, a little soya protein and selenium rich seafoods helps the body protect itself.
Oestradiol causes tissue proliferation and uncontrolled levels of oestrogen. If the body goes into oestrogen dominance, it has been indicated for contributing to the serious problem of endometriosis and breast cancers. When this oestradiol form of oestrogen reaches the liver, enzymes which use B vitamins as co-factors, change this sex hormone to the less harmful oestriol. A healthy liver with plentiful supply of B vitamins can degrade oestradiol into oestriol which is important for optimum well-being. If the sum of Oestrone and oestradiol is greater than the oestriol in a 24 hr urine sample, women may be at greater risk of illness related to oestrogen excess. Your doctor can check levels with simple blood or saliva test.
Oestiol is the form in which oestrogen can be bound to fibre and excreted. Eating fish can be beneficial. Rich fish oils i.e. herring, mackerel, sardines, pilchards, salmon, trout, tuna has been shown to help women suffering from high circulating oestrogen levels. The fish must be from a clean source, low in pesticides.
- Xeno Oestrogen's - Those which our bodies metabolise from pesticides.
- Dioxins, PCB - Bad news - Even plastic wrappings leak into the food we eat daily.
- DES - used to prevent spontaneous abortion in pregnancy in the 60's and 70's
These mimic oestrogen and synthetic oestrogen's are soluble in ALL fats and oils so they can cross cell membranes into the nucleus and activate or repress gene expression. The body can alter these chemicals, possibly to even more potent forms in the body.
What contains dioxins in food
- Eating higher up the food chain - i.e. the fats in meat and dairy food contain the highest levels of dioxins so keep intake very low.
- Polluted lakes and rivers where fish are caught.
- Fruits and vegetables sprayed. Dioxins are even on the skins of organic vegetables. ALL fruits and vegetables MUST be peeled to remove the chemicals, washing does not work.
- Processed foods - i.e. cakes and biscuits contain contaminated fats so should be kept to a bare minimum. More control is available over pure ingredients cooked at home.
- Water from unpurified sources.
These alter the way genes are expressed.
What to Eat?
Easy - the freshest food available. Fresh fruits, vegetables, beans, peas, lentils, nuts and seeds and organic dairy foods. Organic meat which is hormone and antibiotic free and deep-sea fish. Cook from fresh often, avoid additives and flavour enhancers and preservative unless natural ones like vinegar and vitamin C. The soil association provides lists of suppliers who can deliver organic vegetables daily. 86 Colston St, Bristol BS1 5BB. Ideally, grow your own. Peel, scrubbing is not effective.
"Potatoes are for pigs and corn is for cattle". There is some truth in this saying of the French. They fatten animals just as they fatten us. Potatoes, beets, carrots and many other root vegetables are simply starch, a storage form of glucose. Once inside our digestive tracts, they are quickly converted to pure sugar. Their absorption is rapid, and the resulting insulin response is very significant. How many of us, for the sake of dieting, have not eaten a tender, juicy steak but instead have eaten a baked potato with all the fixings. If we scooped out a baked potato and filled the skin with sugar, would you eat it? That is what you do when you eat a baked potato, because it is quickly converted to sugar in your stomach.
Stock up with useful items i.e. balanced mineral salt, black pepper, spices and herbs. For wheat free, get rye crispbreads,, 100% rye bread, rye pasta, oatcakes, porridge oats, corn tortilla and tacos, corn pasta, rice pasta, lentil pasta, buckwheat pancakes, ricecakes, brown rice, millet, millet flakes, (pastry made from brown rice flour, ground almonds and marg in equal proportions)
Unflavoured crisps in moderation. Potato based pizza if you have to. Tuna, salmon, beans vegetable soups and tomatoes in tins. Sugar free jams, organic rice and corncrisps., yeast free vegetable stock powder. For dairy free - soya milks, rice dream or oat milks, soft soya cheeses, vegetable pates (carrot, mushroom, chestnut) or nut butters or black olive paste. Tofu, nut milks, soya yoghurt, ewes or goats milk and yoghurts, hummus, avocados and egg pate, tuna mackerel or crab pate.
Organic fruit and nut bars, dried apricots and carob bars for snacks. Nuts, seeds or sesame sticks. Wheat free museli. Tofutti.
Rules
- Eat two fresh fruits and four fresh vegetables daily, but preferably raw.
- Eat wholegrain cereals and unrefined foods.
- Drink at least a litre of fresh water daily.
- Use only cold pressed vegetable oils.
- Half your diet should consist of alkaline forming foods - i.e. vegetables, fruits, sprouted seeds, live yoghurt, almonds, brazil nuts and buckwheat. The other half should be acid forming i.e. grains, pulses, nuts, seeds, eggs, cheese, fish and poultry.
- Reduce sugar intake. - I.e. refined sugars. Causes fluid retention and stops other nutrients being absorbed.
- Avoid excess salt intake. Around 3g per day.
- Cut down tea, coffee, alcohol and tobacco.
- Avoid excess fatty foods e.g. beef, lamb and pork. Red meat supplies the pro-inflammatory series 2 prostaglandin's, so should be eaten in moderation. Game is often less fatty. Use white meat and fish. Avoid fried foods, and grill or bake instead. Steam vegetables. No dairy foods in excess. Balance dairy with lots of green leafy vegetables.
- Exercise gently regularly.
- Eat a high fibre diet. Wholegrain cereals,, nuts, seeds or fruits and vegetables, 30G (1oz) per day.
- Candida Albicans - If you suspect its grown, remove yeast for 2 - 3 months, refined sugars, wheat, fermented foods, dried fruits and dairy foods. The anti yeast foods which should be used frequently are garlic, onions, cabbage, broccoli, brussels, kale, watercress, mustard cress, cauliflower, turnips, cinnamon, olive oil, aloe vera juice and pau darco tea.
THYROID
The Role of the Thyroid
FROM : Endometriosis - A Key to Healing through Nutrition - Dian Shepperson Mills MA and Michael Vernon PhD HCLD
" The thyroid gland and its hormonal products play a vital role in our overall well-being. The major hormone produced by the thyroid is thyroxine, which is the hormone that controls the basal metabolic activity of the body. Thyroxine speeds up most of the metabolic reactions that take place in the cells of the body. "
" Thyroxine works with the other hormones of the body to enhance their biological actions."
"Oestrogen is an antagonistic hormone to thyroxine, so if we have oestrogen dominance, then thyroxine levels may also be low."
"When a person has low levels of thyroxine (hypothyroidism), the body slows up. An individual with hypothyroidism feels cold and becomes sluggish. But more important to our discussions in this book, hypothyroidism leads to infertility. Women with hypothyroidism nay not menstruate." " A normal menstrual cycle is dependent upon the presence of a properly functioning thyroid.
The thyroid gland also produces T3 (triidothyrine) and T4 (thyroxine). These hormones have to be finely balanced as imbalances can lead to abnormal heartbeats, hyperactivity and irritability. Very high levels can lead to hyperthyroid weight loss, low levels can lead to hypothyroid weight gain.".
"The pituitary gland produces thyroid - stimulating hormone (TSH). If the level of TSH is found to be normal when tested, the patient will not be suffering from hypothyroidism. The level of TSH will change before thyroid hormone levels fall and if you suspect you suffer from a sluggish thyroid, check with your GOP and ask for tests on T3, T4, TSH and antibodies to the thyroid. It is very important for women with endometriosis that all four tests are done, not just the first two. "
ANTI CANDIDA
FROM : Endometriosis - A Key to Healing through Nutrition - Dian Shepperson Mills MA and Michael Vernon PhD HCLD
"Candida albicans is a one celled yeast. We all have this yeast within our digestive tract, normally living in harmony with us. Only when it grows out of proportion can it become a problem. Symptoms from disrupted intestinal flora can include constipation and diarrhoea, or both; headaches: chronic fatigue; depression; dizziness; bloating; poor concentration; vaginal irritation; sugar and bread cravings; mood swings; PMS; digestive problems; and blurred vision. If you are experiencing these symptoms this may be an area to explore.
Three things can play havoc with the delicate balance of the intestinal flora, weakening the immune system so that it is less able to cope with yeast overgrowth;
1 A diet high in saturated and trans fats and refined sugars.
2 Prolonged use of antibiotics, the contraceptive pill and HRT, or exposure to toxic substances.
3 Prolonged stress."
(are you starting to see a connection here, immune system, endo is also probably related to that, trans fats and refined sugars, pill and HRT hormones, dioxins, stress caused by having endo)
"Candida albicans is a very aggressive yeast and if it sees a space for growth, it will proliferate. It can change from a one-celled yeast into a 'hyphal' form, spreading long filaments, which may puncture minute holes in the intestine wall, causing a 'leaky gut'."
"Candida can also upset the hormone balance as it has receptor sites in its cell membranes, which accept hormones; if progesterone binds to candida if fails to reach its destination. Acetaldehyde (breakdown product of alcohol produced by candida from sugar) reacts with the neurotransmitter dopamine to cause emotional disturbances like anxiety, spaced-out feelings and depression. Aldehydes cause suppression of T cell function, increased susceptibility to infection and inability of the immune system to respond efficiently to infections or allergens. "
(The diet I am on, no refined sugar, wholemeal pastas and breads, low dairy, the correct fats etc is supposed to help with this and I have had lots of success with it in the last three months relating to the intensity of pain that I suffer. )
"Important to reduce the foods feeling the yeast. i.e. sugars (sucrose, glucose, fructose, dextrose, maltose, honey, molasses). Refined sugars, yeasts, fermented foods, dried fruits, dairy foods (other than live yoghurt) should be removed from the diet for 2 or 3 months. "
" For the first month you can eat plenty of fresh vegetables, pulses, wholegrain cereals, meat and fish, nuts and seeds, which provide substantial meals. Avoiding snack type foods is important. The body craves nutrients from fresh meals: it needs solid wholefood meals, but many people replace wholesome dinners with sugar and wheat based snacks, which are nutritionally unsound. The following foods nave anti-yeast properties and should be used frequently: garlic, onions, cabbage, broccoli, brussels sprouts, kale, watercress, mustard cress, cauliflower, turnips, cinnamon, olive oil, and aloe vera juice. "
OSTEOPOROSIS
FROM : BBC Online News 24 8 99
Health: Medical notes
Osteoporosis: The facts
"Large holes inside bones cause them to become weak
" (Osteoporosis affects one in three women and one in 12 women, is responsible for 200,000 breaks per year in the UK and 40 deaths a day. It is often known as a silent illness, because many people do not know they have it until it is too late. Although it is thought of as a disease of old age, latest research suggests its roots lie in adolescence.)
"What is it?
Osteoporosis is a weakening of the bones that can lead to breaks which are difficult to heal - hence its alternative name, brittle bone disease.
Osteoporosis facts and figures
Bones are made up of a thick outer shell with a honeycomb mesh inside.
Osteoporosis occurs when the gaps in this honeycomb become bigger making the bone fragile and brittle causing them to break easily.
The wrists, hips and spine are particularly at risk.
What causes it?
During childhood and the teenage years the skeleton grows and develops, with the bones getting longer and the internal mesh becoming more dense until they achieve their greatest density when a person is in their late 20s.
A natural part of the ageing process is that bones get weaker in people over 30 and the honeycomb becomes less dense.
However, in some cases this occurs faster than in others leading to osteoporosis.
A poor diet in youth can also lay the foundations for the disease in later life.
Who gets it?
Women are particularly at risk because they have smaller more fragile bones to start off with.
Dr Nicola Keay on how the disease affects younger women This is complicated by the menopause during which the body stops producing oestrogen - a hormone essential for good bone health.
And because of the natural ageing process, the risk increases with age.
However, more and more research is indicating that the disease can affect younger people, with the National Osteoporosis Society reporting an increase in incidence of the disease among young women, particularly those who are underweight or who have suffered anorexia.
How can it be prevented?
Diet and exercise are the two key preventive measures.
Katy Jeffs on steps she has taken to avoid the disease The Chartered Society of Physiotherapy says skipping, jogging and aerobics are the best exercises to beat the disease.
A high calcium, well-balanced diet throughout life but especially while the body is still developing is recommended.
Dr Nicola Keay: "A balance is essential" Dr Nicola Keay, an osteoporosis researcher who has studied the effect of the disease on young women, said there were dangers in failing to find a balance.
"If you're doing too much exercise or don't eat enough, or if you don't do any exercise and eat lots of fast food, those extremes obviously aren't good," she said. "The message is to get a balance - do enough exercise, eat a reasonable diet and don't go on a crash diet at 10 or 12 worrying about being too fat because it's the worst thing you can do for your bones."
What is the treatment?
Gentle exercise can help those who are already suffering the disease but have not yet suffered any fractures to rebuild bone strength.
Drug treatments can help restore levels of oestrogen in those who have stopped producing it, or target it to where it is needed in people who have low levels of the hormone.
These therapies include including hormone replacement therapy, oestrogen derivatives and a new generation of drugs known as selective oestrogen receptor modulators.
Is there help?
The National Osteoporosis Society offers factsheets for sufferers.
They can be obtained by writing to The National Osteoporosis Society, PO Box 10, Radstock, Bath BA3 3YB, UK or by phoning 01761 471771.
TRANS FATTY ACIDS
FROM : Endometriosis - A Key to Healing through Nutrition - Dian Shepperson Mills MA and Michael Vernon PhD HCLD
I found the book above has quite good information on endometriosis and explains the value of the food we eat and how it affects oestrogen levels which we all know affects our endo and help with what is the best things to eat or not to eat as the case may be.
One interesting bit to me is Chapter 8 for how digestion affects the reproductive system and how the changes in western diet over the last few hundred years has affected us in the rise of refined foods which are high in calories, but low in nutrition. It also explains in patterns of healthily eating how our diet has drastically altered over the last 50 years and that our bodies have not adapted to the changes.
It explains the immune system link related to the foods we eat. In nature oil molecules are shaped like a horseshoe. which fits with other bits to form a strong cell membrane to protect what is going on inside. This stop harmful chemicals entering and damaging the cells i.e. like what happens in endometriosis. These oils are crucial to health, i.e. extra virgin cold pressed olive oils, organic butter, vegetable oils such as sunflower, safflower and sesame which are labelled unrefined, unhydrogenated or cold pressed. Fresh nuts and seeds are also a good source of these CIS fatty acids. They aid metabolism in moderation and do not make you fat.
Tans fatty acids from processed oils and foods don't form the horseshoe shape and therefore do not protect the cell, high trans fatty acids in body cells have about higher risk of breast cancer. They weaken the cells so that they cannot stop harmful chemicals entering the cell.
Heat changes cis oils into trans oils, so deep frying is not advised, and don't use the same oil twice for frying.
I was stunned to learn that evening primrose and starflower oil in cheap packages and not cold pressed are almost as good as taking nothing, they have to be cold pressed to do any good. That shocks me, I always thought I was doing the right thing by buying the stuff in bulk, cheaply.
There is a lot of food (pun) for thought here and if anyone is serious about nutrition to try and fight endo, this is a good place to start. I don't know them so no benefit in promoting the book, but you all know how much better I have been feeling since I severely cut back on dairy and refined sugar.
DIOXINS AND OESTROGEN
Hi all, thought you might find this interesting, I found it on a support list and it doesn't half put the dioxin theory into perspective for endo i.e. endometriosis is characteristic of oestrogen dominance ie oestrogen feeds the endometriosis.
QUOTE "Another major factor contributing to an imbalance between estrogen and progesterone is environmental in nature. We, in the industrialized world, now live immersed in a rising sea of petrochemical derivatives. Petrochemicals are everywhere. They are in our air, food and water. Our machines run a petrochemicals, millions of products including plastics (leaking xenoestrogens).....pesticides....are either made from petrochemicals or contain them. These organochlorine chemicals include pesticides, herbicides (such as DDT, DDE, dieldrin, atrazine, methoxychlor, hetachlor, kepone, etc.) as well as various plastics (polycarbonated plastics found in baby bottles and water jugs). These chemicals have an uncanny ability to mimic natural estrogen. As estrogen mimics, these compounds are highly fat soluble, non-biodegradable, accumulate in fat tissue of animals and humans and are difficult to excrete. They are given the name xeno-estrogens since, although they are foreign chemicals, they are taken up by the estrogen receptor sites in the body, seriously interfering with natural biochemical changes.
Mounting research in now revealing an alaring situation world wide created by the inudation of these hormone mimics worldwide.
Disturbing Changes Extremely disturbing events are being reported globally about other alarming changes happening in the environment.
In 1947, orthnithologists noticed that eagles in Florida had lost their drive to mate and nest. In th e1960's ranch minks that were fed fish from Lake Michigan failed to reproduce. In 1977, female gulls in California were nesting with females.
Not long ago, in Lake Apopka in Florida, wildlife biologists discovered that strange biological occurrences were happening to the alligators living there. In 1980, a toxic spill occurred dumping huge amounts of pesticide similar to DDT in to the lake. That event was almost forgotten until five years later, when it was discoverec that 90 percent of the alligators had disappeared. Most of those that reamined were incapable of reproducing or had no urge to mate. The males were born with deformed penishes that were 75 percent shorter than average. Further testing indicated that their testosterone levels were so low that they hormonally resembled females. Moreover, the females had abnormal ovaries and follicles described as "burned out".
To Add to this concern, recent reports show that strange hermaphroditic fish have been caught in Port Phillip Bay in Victoria, Australia.
Similarly, a major British study revealed that male fish downstream from sewage treatment plants are changing sex as a result of estrogen chemicals which are not removed from the treated effluent.
Dr. Ana Soto, an endocrinologist at Tufts University, had been experimenting with cancer cells taken from human breasts and then cultured. She found that they would grow when they were fed estrogens. As part of her experiment she quit feeding the cells estrogens. To her total amazement, however, the cancer cells continued to grow for four months even when no estrogens were fed to them.
Dr. Soto then realized that the manufacturer of the flasks she had been using had started to use a different plasticone that, when it becomes warm, releases minute quantities of the estrogen-like compound nonylphenol! Nonylphenols refer to a family of compounds that are used as surfactants (reducing the surface tension of water creating a bridge between two chemicals that don't normally mix) in pesticides as well as industrial and institutional cleaning products. Her tissue samples were being contaminated by the xeno-estrogens of the plastic flasks!
Good reading: Hormone Heresy What Women Must Know about their Hormones, By Sherril Sellman. " HRT
Taken from " HRT: Your Questions Answered" by Malcolm Whitehead & Val Godfree, which is aimed at the medical profession:
8.19 CAN A WOMAN WHO HAS ENDOMETRIOSIS TAKE HRT, AND WHAT IS THE RISK OF RECURRENCE?
This problem is fully discussed in Question 9.45. In summary, endometriotic tissue can respond to oestrogens, even if many years have elapsed between menopause and starting HRT. However, the possible risks of a recurrence of endometriosis must be balanced against the benefits of HRT. Often women with severe endometriosis have undergone a surgically induced menopause (bilateral oophorectomy), and thus are in special need of HRT to reduce their risk of future cardiovascular disease and osteoporosis. In women in whom all endometriotic tissue has been removed at surgery, the chances of recurrence appear lower than if endometriotic tissue had been left behind. However, even with apparent complete surgical removal of all endometriotic tissue, we have seen the disease reactivated with HRT. This may be because endometriosis can arise de novo from coelomic metaplasia; or because microscopic disease, not visible to the naked eye, remained after surgery.
In women with residual disease after surgery, it is often recommended that HRT be withheld for at least 9 months after surgery and then commenced. However, we have seen the disease reactivated in women starting HRT 10 years after menopause (see Question 9.45).
It is not possible to generalize further and each case has to be judged on its merits. We believe that endometriosis probably poses one of the most difficult treatment decisions. Primary care physicians should not hesitate to seek specialist advice if they are in any doubt as to whether or not to prescribe for these women.
8.20 WHAT IS THE BEST WAY TO PRESCRIBE HRT FOR PATIENTS WITH PREVIOUS ENDOMETRIOSIS?
The optimal treatment regimen is not known. In terms of overall stimulation by the oestrogen, there would not appear to be any differences between oral & non-oral routes at comparable doses. However, we would advise against using sustained release preparations, such as oestradiol implants, as first-line treatment. These can result in higher plasma oestradiol values and they cannot be discontinued quickly should symptoms indicative of recurrence develop (see Question 9.45).
Frequently, women with a history of severe endometriosis will have undergone hysterectomy and therefore, under normal circumstances, would not require progestons. However, the underlying pathophysiology of endometriosis is oestrogenic activation of ectopic endometrial tissue.
Progestons have an antimitotic, suppressant effect upon the endometrium, so, in theory, it may be advisable to add a progeston to the oestrogen in a continuous daily fashion. We stress that this strategy is hypothetical and confirmation data are not available.
9.45 WHAT EFFECT MAY HRT HAVE ON ENDOMETRIOSIS?
Endometriosis is an oestrogen-dependant condition & may be exacerbated by HRT or re-activated if dormant. Patients who have undergone total abdominal hysterectomy & bilateral salpingo oophorectomy with complete excision of all endometriotic tissue are currently believed to be at low risk from a recurrence if they take HRT. However, if excision of the endometriosis was incomplete then HRT can reactivate dormant disease.
We have a series of patients (data unpublished), some of whom had undergone hysterectomy & bilateral salpingo oophorectomy, in whom endometriosis has been re-activated by HRT in the following sites: the ovary, the adnexae and pelvic side-wall, the top of the vagina and the large bowel. In some, the passage of blood and/or mucus rectally was observed around the time of the withdrawl bleeding.
There was a suggestion that one patient had developed hydronephrosis due to the re- activated endometriosis causing ureteric obstruction. The renal enlargement resolved when HRT was withdrawn. We also observed a re- activation of endometriosis (requiring total abdominal hysterectomy & bilateral salpingo oophorectomy) in a woman first starting HRT 12 years after menopause. Thus, there seems to be no upper time limit after menopause when HRT can be prescribed safely, and comments that it is safe to administer oestrogens 3-5 years after hysterectomy/menopause have, we believe, no scientific basis.
Patients with a history of endometriosis, especially those with residual disease, should be advised to stop HRT if they develop symptoms or signs suggestive of re-activation. We stress that the incidence of re- activation is most probably low but no data are currently available as to the precise risk. Thus, patients in whom endometriosis may be re- activated should be closely supervised with more frequent pelvic examinations, perhaps every 6-12 months. Pelvic ultrasonography may be helpful if symptoms and signs suggestive of re-activation occur.