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Diet and Nutrition
Vitamin and Mineral Supplementation
Herbals
Acupuncture
Interferential Electro-Therapy

Ayurvedic Medicine

     Alternative Medicine is an area of healthcare that has been rapidly evolving over the past few years.  Some of the practices have been around for centuries, while others have become popular within the last few decades.  "Alternative medicine" encompasses a vast array of ideologies and treatment options, which include acupuncture, massage, herbal therapy, iridology, homeopathy, and chiropractic manipulation to name a few.   Alternative medicine utilizes the "whole body" approach to physical, mental and spiritual health.  Traditional (sometimes referred to by alternative healers as "western medicine") has been somewhat skeptical about these complementary treatments.  Whereas "western medicine" tends to focus on a "cure" for a disease process, alternative therapy practitioners focus their efforts on "healing" the physical, emotional, spiritual, and mental needs of a patient.  In alternative medicine, patients feel they have more of a participation in their healthcare and disease prevention, whereas in traditional medicine, they feel they have little influence on their state of health.
      Regardless if traditional healthcare providers consider complementary medicine a valid form of healthcare, or view it as quackery, it is imperative for these physicians to become familiar with the different therapies so that they can better serve their patients.  As of 2002, 36% of adults in the United States had used some form of complementary medicine in the 12 months with women using more than men.  Over the past ten years, the use of complementary medicine has significantly increased due to information technology such as the Web; people are reading more, and learning more about their health.   

DIET AND NUTRITION

    The plan of the purposed "endometriosis diet" is to relieve or prevent some of the disabling symptoms that occur with menstruation.  These symptoms range from intense cramping, backaches, fatigue, dysmenorrhea, dyspareunia, and menorrhagia.   The goal is to decrease estrogen levels, stabilize hormones, increase energy, alleviate painful cramps, and stabilize emotions.
    Endometriosis is an estrogen-sensitive condition, but the painful menstrual cramping that occurs is predominantly due to prostaglandin synthesis in the body.  Prostaglandins are naturally occurring fatty acids, which are derived from dietary phospholipids.  Through a complex series of pathways, the body can produce different types of prostaglandins: Prostaglandin E₁ (PGE₁), prostaglandin E₂ (PGE₂) and prostaglandin F_2a (PGF_2a).  Prostaglandin E₁ is also known as gamma-linolenic acid, or GLA, and is a conversion product of linolenic acid.   PGF_2a and PGE₂  are smooth muscle stimulants, and fuel uterine contraction.   PGE₂ is also a potent vasodilator and inhibits platelet aggregation, and therefore has been implicated as a cause of menorrhagia that can occur with endometriosis.  PGF_2a, can also stimulate other smooth muscle throughout the body, causing the sometimes-associated-symptoms of nausea, vomiting, or diarrhea.  
    The goal in alleviating cramping during menses is to 1). block the production of PGF_2a and PGE₂  2).  Stimulate the production of PGE₁; this can be achieved several ways.  First, the production of PGF_2a  can be blocked by taking nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen.  However, by changing the types of oils that are taken into the diet, the production of PGE₁ can be stimulated, which helps with uterine relaxation.  These oils are composed of omega-3 fatty acids, which lead to PGE₁  production.  Excellent sources of these omega-3 fatty acid producing oils (linolenic acid) are:

• Evening Primrose oil
• Safflower oil
• Walnut oil
• Flax seeds/oil

It is also important to decrease intake of those fatty acids that will stimulate PGF_2a production:  Saturated fats, butter, animal and organ meat, lard.
    In addition to decreasing "bad" fat intake, the diet should also consist of high fiber.  Not only does this help with good digestion, but it is also thought that a diet high in fiber can decrease total circulating estrogens (remember that estrogens stimulate prostaglandin production).  It is recommended to incorporate 25 grams per day of fiber.  Good sources of fiber include:

• Whole grains
• Beans
• Brown rice
• Vegetables and fruits
• Oatmeal
• Shredded wheat

It is also recommended to "modulate" estrogen levels by incorporate one to two servings per day of the following:

• Kale
• Collard greens
• Mustard greens
• Broccoli 
• Cabbage
• Turnips

It is advised to limit the consumption of refined and concentrated carbohydrates (sugar, white flour, fruit juices, dried fruit).  Alcohol, caffeine, and chocolate should also be avoided.  There has been convincing research on food and beverages with a high sugar content, and their relation to menstrual cramping and associated pain.

Take Home Message
         *Increase omega-3 fatty acids
         *Decrease meat and dairy
         *Increase fiber
            *Modulate estrogen          
            *Avoid sugars, caffeine, and alcohol
                                                  

VITAMINS AND MINERAL SUPPLEMENTATION
      Vitamins and minerals are an essential component of any diet.  It is important to keep in mind that before beginning any new supplements/vitamins that you first consult your doctor, especially if you have any heart, kidney, or liver problems.

• Calcium levels in menstruating women decrease 10-14 days before the onset of menstruation.  Deficiency may lead to headache, muscle cramps, or pelvic pain.  Excellent dietary sources of calcium are milk, dairy, green tea, or calcium gluconate supplements.  Calcium relies on vitamin D for its absorption in the small intestine, so it should be taken with a source of vitamin D.  It is important to note that certain foods containing oxalic acid (spinach, cocoa, rhubarb), phytic acid (brown grains), high fat diet, or inability to digest fat, may interfere with the absorption of calcium. 
  
  
• Phosphorus is an important mineral in bone formation and stabilization.  However, foods that are high in phosphorus are also high in fat (egg yolk, red meat, whole milk) and may exacerbate the symptoms of endometriosis.
  
  
• *Magnesium is a mineral that is believed to ease cramping at the time of menstruation.  A deficiency in magnesium may trigger muscle cramping, menstrual cramping, insomnia, and rapid heart rate.  Excellent sources of magnesium are soybeans, brussel sprouts, wheat germ, peanuts, and leafy green vegetables.
  
  
• *Zinc is essential for enzyme activity, helping cells to reproduce, and important for RNA and DNA in the body.  It is purposed that deficiencies in zinc affect the immune system and resistance to infection by weakening the white blood cells.  Women may develop headaches, become irritable, and depressed.  It is thought that supplementation with zinc will help women better cope emotionally with menstruation, and eliminate some of the irritability that can accompany a monthly cycle.  Also, it may boost the immune system.  Good sources include shellfish, organ meats, nuts, whole grain cereals.
  
  
• Women lose about 30mg of iron per menstrual period.  However, some women with endometriosis have very heavy periods, and may lose substantially more iron.  These women are at risk of iron deficiency anemia, which is characterized by weakness, extreme fatigue, and mental fog.  It may be recommended by your physician to increase iron intake above the recommended daily allowance to compensate for heavy bleeding.  When taking iron supplements, they should be divided with two meals for better absorption.  Dietary sources of iron include organ meats, egg yolk, dried apricots, and potatoes.
  
  
• Sodium retention is promoted by increases in blood estrogen levels.  It is advisable to limit sodium intake to 200mg per day (one teaspoon), and perhaps to 1/2 teaspoon premenstrually and during cycle.  Staying away from pickled foods, canned vegetables and soups, and carbonated drinks will help decrease fluid retention and edema during the menstrual cycle.
  
  
• *It has been proposed that selenium strengthens that immune system and slows the aging process.  Seafood, whole grain cereals, and garlic are all good sources of selenium. 
  
  
• Potassium is essential for muscle contraction, regulating heart rate, conduction of nerve impulses, and fluid balance in the body.  Many women may become deficient in potassium due to bouts of diarrhea during the menstrual cycle, and have bloating, weakness, and fatigue.  Some good sources of potassium are potassium gluconate supplements, bananas, apricots, oranges, peanuts, potatoes, and dark green leafy vegetables.
  
  
• *B vitamins (thiamine, riboflavin, pyridoxine, niacin, cobalamin, panthothenic acid, biotin, folic acid, choline, inositol, and PABA) are all involved in the breakdown of proteins, carbohydrates, and fats in the body.  Of importance are folic acid and B₁₂ (cobalamin), which are instrumental in RBC and their ability to transport oxygen to the tissue.  If there is a deficiency in either B₁₂ or folic acid, anemia may occur.  It is important to take a B-complex vitamin with meals, as a full stomach can offset the side effect of nausea.  Excellent sources for the B vitamins include dark leafy vegetables, whole grains, soybeans, oatmeal, lima beans, turkey, tuna, asparagus.  Overcooking, canning, long-term storage of vegetables can decrease the B vitamins in food, so they are best eaten when they are fresh.
  
  
• Vitamin C is instrumental in building and maintaining collagen within the body.  It is thought to stimulate the immune system to promote healing and provide resistance to disease.  Sources include brussel sprouts, green/red peppers, collard greens, and kale.  Fruit is also an excellent source of vitamin C, but contain bioflavinoids which may mimic estrogen effects on the body.  Decreasing fruit intake perimenstrually may help ward off painful cramping. 
   
  
• Vitamin A is found in yellow, red, orange, or dark green leafy vegetables.  It is proposed that it works as an immune system booster, and prevents night-blindness.  Vitamin A in high doses can be toxic, do not exceed the recommended daily allowances.  Interestingly, 1 1/2 ounces of parsley is equal to 4200units of vitamin A--an excellent source!
  
  
• *Vitamin E is thought to play a role in anti-aging, increasing oxygen carrying capacities, and immune system strengthening.  Excellent sources include wheat germ, whole grain, nuts, and rice germ.  If you are taking anticoagulant drugs you should not take vitamin E supplements.
  
  
• Vitamin K is essential in forming prothrombin, which helps in blood coagulation.  Dietary sources include cabbage, kale collard greens, and spinach.  Production of vitamin K is also dependant on bacteria that are present as part of the normal bowel flora.  Therefore, supplementing the diet with acidophilus may be useful in maintaining this bacteria.

* The above starred items are those vitamins and minerals that are considered instrumental in an endometriosis diet:  Vitamin E, zinc, selenium, B-complex vitamins, and magnesium.

To view the recommended daily allowances for vitamins and minerals, please click on the FDA Center for Food and Safety and Applied Nutrition website.

Take Home Message
          *B vitamins have reportedly improved emotional symptoms of endometriosis
          *When taken together, selenium and vitamin E have been reported to
             decrease inflammation associated with endometriosis
          *Zinc has been reported as boosting the immune system and helping 
            to create an emotional sense of well-being
          *Magnesium has been reported to ease cramping during menstruation

HERBALS
     A form of alternative medicine that is widely used today is herbal therapy.  Herbal therapy is used by practitioners to prevent and treat certain illnesses or diseases:  Endometriosis is no exception.  The goal of herbal therapy is to decrease the pain, improve circulation in the pelvis, facilitate removal of inflammatory substances,  and create hormone balance.  Although there is a plethora of herbals that can be used to "treat" endometriosis, only a few have been provided below.  Before beginning any new therapy, you should check with your physician as to possible side effects or drug interactions.

• Evening Primrose oil-Oenothera biennis is a North American wildflower that can be found growing along roadsides.  Modern interest has centered on the oil expressed from the plant's small dark seeds.  The seeds produce an oil that is rich in essential fatty acids:  65% linoleic acid and 10% gamma-linolenic acid.  As discussed in the nutrition section, these two fatty acids are precursors to the production of prostaglandin E₁, which is the anti-inflammatory prostaglandin.  This should not be used in those patients with a history of seizure disorder, as it has the potential to lower the seizure threshold.
  
• Hormone normalizer- Vitex agnus castus is fruit from a chaste tree.  It was used in medieval times to decrease sexual desire in men (specifically monks) therefore giving it the name chaste tree or monk's pepper.  Chaste tree berry extract is believed to have a dopaminergic effect on the anterior pituitary, causing a decrease in prolactin production.  This decrease in prolactin leads to increased progesterone production in the luteal phase of the menstrual cycle, reducing symptoms of PMS.  Similarly, this may be useful in endometriosis to relieve the cramping and discomfort associated with menstruation.  Concomitant use of vitex with oral contraceptives is not recommended due to decrease in contraceptive efficacy.
  
• Anti-spasmodic and nervine relaxant-Cimicifugae racemosae rhizoma is a preparation of black cohosh, which consists of fresh or dried rhizome with roots.  It is has a long history of traditional use among Native American peoples.  It is used to treat many types of pain, including dysmenorrhea.  One of the constituents of the drug is salicylic acid, which is better known as aspirin.  This may account for its anti-inflammatory and analgesic effects.  Use in pregnancy is contraindicated due to risk of spontaneous abortion.  
  
• Mild diuretic effect-Taraxacum, better known as Dandelion/tea has been used by some practitioners to relieve swelling and edema.  It is thought that there is "uterine obstruction" with endometriosis, and causing a diuresis will alleviate the congestion within the pelvis.
  
• Pain management/antispasmodic/GI discomfort-Dioscorea villosa is better known as wild yam or colic root.  Practitioners may use it to alleviate bowel  and cramping symptoms associated with endometriosis.   Similarly, Viburnum prunifolium (black haw) and Viburnum opulus (crampbark) are useful as pain relievers because they contain salicylic acid in potentially therapeutic doses and muscle relaxants.
  
• Tonifier/decongestant in body organs/pain management-Angelica sinensis, or Dong Quai, is recommended for dysmenorrhea, abdominal discomfort or pain, constipation, or anemia, all of which may occur in endometriosis.  The herbal contains significant amounts of vitamin B₁₂ and folic acid, which may explain its beneficial effects on anemia.  It also contains ferulic acid that has been reported to have anti-inflammatory and analgesic effects.  Caution should be used when taking dong quai with anticoagulants, and possibly, anti- platelet aggregating agents, as the risk for bleeding is increased.  

For additional information on herbal therapy, please click here.

ACUPUNCTURE
      Acupuncture is form of Chinese medicine that has been practiced for more than 4000 years.  It came to America in the 1970's when a west reporter in Beijing received acupuncture for post-operative pain after an appendectomy.   
      Chinese medicine is based on the principle of life force--qi or ch'i (pronounced chee)--that flows through the body via 14 invisible meridians, or channels.  A vital component of this life force is the yin and yang; in order for balance to occur, the yin and yang must be kept in harmony with one another.  
     Acupuncture has traditionally been used to relieve pain in sufferers of endometriosis.  However, Traditional Chinese Medicine views endometriosis as a problem of "blood stasis," or ch'i stagnation within the pelvis, not allowing the vital energy to move freely through the body.  By inserting tiny needles into specific trigger points--called acupoints--the yin and yang will achieve harmony, restoring a balanced ch'i flow to the lower abdomen.  Acupoints are points on the body where meridians surface, having run deep within the body tissues and organs.  A very fine, disposable needle is inserted into various acupoints anywhere from 1/4 to one inch deep, depending on skin and muscle thickness.  After insertion, the needles can be twirled or connected to an electric current to help stimulate the site.  Patients have described the insertion of the needle as a "mosquito bite," and perceive the stimulation as a tingling or aching sensation.  The needles are generally left in for about 20 minutes to one hour.  The effects from acupuncture are generally slow, becoming apparent after several treatments.  However, for acute pain that is associated with endometriosis, the effects may be felt within one treatment, requiring only a few visits .  Women with more chronic, persistent pain may benefit from long-term therapy.  Initially, treatments may start at 2-3 times per week, but as symptoms improve, therapy can be moved to weekly or monthly "maintenance doses."
     There is no clear cut evidence as to why acupuncture works, but the thousands of patients who have used it can testify that it does.  In the Western model of thinking, the insertion of the needles trigger local inflammation.  This inflammation cascade triggers the release of natural painkillers called endorphins.  It is hypothesized that these endorphins "blunt" the perception of pain.  Similarly, it is theorized that acupuncture may alter the body's output of inflammatory substances.  One of these such substances is prostaglandin--a well known instigator of pain in endometriosis.  It is important to mention that if a patient is on warfarin or heparin (anticoagulants), acupuncture could pose a significant risk of bleeding, and should not be used in combination. 

Take Home Message
        *Endometriosis is a result of blood stasis, or ch'i stagnation
        *Acupuncture involves insertion of needles at acupoints
        *Proposed to release endorphins (natural painkillers)
        *Alteration of the flow of body energy
        *Balance of yin and yang

INTERFERENTIAL ELECTRO-THERAPY
   Interferential electro-therapy is a therapeutic treatment to help alleviate pain.  Through electrical muscle stimulation, it is proposed that soft tissue injuries can be healed.   Small amounts of electrical impulses are induced into tissues, and intersect below the level of the skin.  In theory, this prompts the body to secrete natural pain killers, called endorphins, to ease pain.  Some practitioners believe interferential therapy increases blood flow and lymphatic flow in the injured tissue area.  This, in turn, increases the oxygenation and nutrients to the injured site.  Benefits from this therapy include:

• Decrease pain
• Decrease inflammation and swelling
• Accelerate healing
• Restore normal movement

When used in patients with endometriosis, two of the electro-therapy patches are placed on each side of the low back, and two are placed on each side in the pelvic region anteriorly.  The theory is that the electrical stimulation will "criss-cross" in the pelvis, promoting healing and relief of pain. 

AYURVEDIC MEDICINE

    Ayurveda is India's natural system of medicine that has been practiced for greater than 5,000 years.  It stresses prevention of disease, rejuvenation of bodies and extension of life span.  Through the use of Ayurveda, it is believed that not only can disease be prevented, but one can also live her life in balance and harmony and attain a better understanding of the world around her.

    Ayurveda promises an integrated approach towards preventing and treating illness via lifestyle modifications and natural therapy.  It is based on the idea that nature's elements, forces and principles are also seen in humans.  The mind and body not only influence each other, but they form the mind-body.  Symptoms and disease that are due to mental thoughts or feelings are of equal importance as symptoms and diseases of the physical body.  Both are due to imbalances and both are treated by restoring balance both physically and mentally.

    Endometriosis is an example of this imbalance.  To correct this imbalance, ayurvedic practitioners recommend reducing activities for the first three days of her cycle and establishing a regular routine.  This includes increasing the amount of rest the patient gets, practicing meditation, eating the correct diet and maintaining a biologic rhythm.  It is recommended to go to bed at 10pm and then rise at 6am.  It is during this time that the earthy's energy most complements human energy.  On the fourteenth or fifteenth day of a woman's cycle, the use of a laxative, castor oil or senna tea followed by a light diet is recommended.