Sometimes there are specific, identifiable causes of menstrual pain. One of the most common is endometriosis, in which some of the lining cells from the inside of the uterus end up in the wrong place. They are attached to the ovaries, intestinal tract, bladder, or elsewhere. And just as the cells inside the uterus swell and are shed each month, these misplaced cells do exactly the same thing. They swell and bleed, causing pain and infertility.
More than 5 million women in North America have been diagnosed with endometriosis, which is about 10 percent of women in their reproductive years.1 It runs in families to a degree, but genetic factors are not strong. If you have endometriosis, there is about a four to five percent chance that your mother or a sister will also have had it.2 After menopause, endometriosis is rare, except in women who take supplemental estrogens as part of hormone "replacement" therapy.
Endometriosis starts with cells that are wandering in the wrong direction. Normally, the uterine lining cells pass downward and out of the body during menstruation. But sometimes these cells slip through the fallopian tubes that lead to the abdominal cavity. From there, they can end up virtually anywhere.
This happens to some extent in all women, but the immune system spots these out-of-place cells and calls in white blood cells to eliminate them. If they somehow evade your immune defenses and attach in your abdominal cavity, the result is endometriosis. Occasional microscopic clumps occur in women with no symptoms at all. If they are more than minimal, the inflammation and pain can be severe and nearly disabling.3-5
The only way to diagnose it is by making a small incision below the navel and actually looking into the abdominal cavity with a slim tube called laparoscope. Doctors who have not done this sometimes dismiss the pain or misdiagnose it. The Endometriosis Association, based in Milwaukee, reports that 70 percent of women diagnosed with the condition were first told by their doctors that there was no physical reason for their pain. Among black women, 40 percent were told that their pain was caused by a sexually transmitted disease.
Do Foods Cause Endometriosis?
Certain foods appear to make endometriosis more likely. According to researchers at the Harvard School of Public Health, women who have two or more cups of caffeinated coffee (or four cans of cola) per day were found to be twice as likely to develop endometriosis as other women. The reason why caffeine has this effect is unknown.6
Foods tainted with certain chemicals appear to encourage the implantation of cells in the abdomen. Polychorinated biphenyls (PCBs) were commonly used in electrical equipment, hydraulic fluid and carbonless carbon paper, and organochlorine pesticides have been commonly used in agriculture. In 1992, German researchers found that women with high blood levels of PCBs had a higher prevalence of endometriosis.7
These chemicals presumably do their dirty work by impairing your immune defenses against abnormal cells. Indeed, the natural killer cells and other white blood cells that are supposed to maintain a constant look-out for any abnormal cells have been shown to be weakened in women with endometriosis.4 In addition, some organochlorines mimic the effects of estrogens.1,8
These toxins tend to accumulate in animal fat, and the major route of human exposure is through food, particularly fish. They also show up in meats and dairy products.1 Chickens, cattle, pigs, and other animals are fed grains treated with pesticides and sometimes contaminated with other organochlorines, and they tend to concentrate these compounds in their muscle tissues and milk. While there may also be organochlorine pesticide residues on non-organic fruits or vegetables, they are less concentrated and are easier to remove. Organic produce is grown without chemical pesticides.
To measure the concentration of organochlorines in a woman's body, researchers sometimes check samples of breast milk. Breast tissue is a natural target for chemicals that dissolve into fat, and, in fact, during breast-feeding, a woman can excrete up to half of all the dioxin she has accumulated in her body tissues.8 Unfortunately, the recipient of these chemicals is the nursing baby.1
A vegetarian diet has obvious advantages. By avoiding fish, other meats, and cow's milk, you avoid the foods that harbor most organochlorines. Indeed, researchers have found that vegetarian women have much lower levels of pollutants in their breast milk, compared to other women.9 The earlier in life that a plant-based diet is begun, the better.
Happily, bans on some of these compounds have caused exposures to decrease since the 1970s, although the amount in your body drops only very slowly.
Foods as a Treatment for Endometriosis
Some women with endometriosis improve spontaneously, although most find that their symptoms continue or gradually worsen. Medical treatments rely on anti-inflammatory pain-killers and hormone treatments designed to shrink endometrial tissues: danazol, gestrinone, GnRH agonist analogs, progesterone derivatives, and progesterone-estrogen combinations.
Surgical treatments include removing cell clumps, severing pain nerves, and even hysterectomy, sometimes with removal of the ovaries. Surgery to remove endometrial cells has about the same effectiveness as drug treatments, but both are usually temporary measures, as they do not reliably eliminate all of the troublesome cells.10,11
The dietary treatment is based on the fact that, whatever causes endometriosis to start, it is estrogen that keeps it going. Without estrogen, the clumps of cells do not grow each month; they soon wither away.
That means that the dietary approach that reduces estrogens can also be used for endometriosis. In my discussions with gynecologists who have tried this approach, it is clear that, for some patients at least, it can make a big difference.
Ronald Burmeister, M.D., a gynecologist in Rockford, Illinois, describes the case of a 24-year-old woman who had had terrible menstrual pain every month since her periods began. She had had laparoscopic surgery twice, but her pain continued. She had tried birth control pills, but they caused depression and other side effects. Hormone-blocking medications were helpful, but the medicine was very expensive and, in any case, could only be prescribed for six months without an increased risk of osteoporosis. After it was stopped, her pain returned. A progesterone derivative helped some but did not abolish the pain. One of her doctors recommended hysterectomy, but she wanted to avoid such a drastic solution.
Dr. Burmeister suggested trying a hormone-balancing diet. Using low-fat, purely vegetarian foods, which are known to reduce estrogen levels in the blood, she could reduce her hormone shifts, and, unlike medicines or a hysterectomy, it would not interfere with her efforts to get pregnant. He gave her a set of recipes and recommended several books for further information.
Within three months she was noticeably better, and at six months her pain was gone. She stopped the progesterone derivative, and set about seeing if she could become pregnant.
Based on this success, Dr. Burmeister made the same recommendation in three other cases, and found that it was helpful in reducing pain. One patient reported that if she deviated at all from the diet, by having some dairy products or a bit of chicken, her pain came right back, just as skipping one or two pills can make a prescription fail.
No one has yet done a clinical study on the use of a low-fat, vegetarian diet for endometriosis. That should change, because, unlike hormone treatments, it does not interfere with efforts to conceive. It is also cheap and safe, and it brings many other health benefits, too,
Aerobic exercise also helps. Women who run, jog, or work out for two hours per week have only half the risk of endometriosis, compared to other women. The reason, presumably, is the well-established ability of exercise to reduce hormone activity. In fact, women who exercise very strenuously and consistently sometimes miss periods altogether.3 Exercise also strengthens the immune system, making you better able to eliminate errant cells.
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2. Moen MH, Magnus P. The familial risk of endometriosis. Acta Obstet Gynecol Scand 1993;72:560-4.
3. Mangtani P, Booth M. Epidemiology of endometriosis. J Epidem Comm Health 1993;47:84-8.
4. Dmowski WP. Immunological aspects of endometriosis. Int J Gynecol Obstet 1995;50 (Suppl 1):S3-10.
5. Balasch J, Creus M, Fabregues F, et al. Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study. Human Repro 1996;11:387-91.
6. Grodstein F, Goldman MB, Ryan L, Cramer DW. Relation of female infertility to consumption of caffeinated beverages. Am J Epidemiol 1993;137:1353-60.
7. Holloway M. An epidemic ignored: endometriosis linked to dioxin and immunologic dysfunction. Sci Am 1994;270:24-6.
8. Koninckx PK, Braet P, Kennedy SH, Barlow DH. Dioxin pollution and endometriosis in Belgium. Human Reproduction 1994;9:1001-2.
9. Hergenrather J, Hlady G, Wallace B, Savage E. Pollutants in breast milk of vegetarians. N Engl J Med 1981;304:792.
10. Dawood MY. Considerations in selecting appropriate medical therapy for endometriosis. Int J Gynecol Obstet 1993;40(suppl):S29-S42.
11. Revelli A, Modotti M, Ansaldi C, Massobrio M. Recurrent endometriosis: a review of biological and clinical aspects. Obstet Gynecol Survey 1995;50:747-54.