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Like most of her friends, Sarah Hunter started menstruating in her early teens — but her periods were different from theirs. “They were always really heavy and irregular and very painful,” she recalls.

In her mid-20s, Hunter, now a family nurse practitioner in central Minnesota, went to see her doctor with a fever and intense pelvic pain. The doctor thought she might have pelvic inflammatory disease but couldn’t find evidence of an infection.

It would take another year before Hunter was diagnosed with endometriosis, at age 28.

The World Health Organization states that endometriosis affects as many as one in 10 women and girls globally, and studies show the condition affects up to half of all women who experience infertility (anyone with a uterus can be subject to endometriosis). This inflammatory condition is caused when tissue that resembles the uterine lining, known as the endometrium, starts to grow outside the uterine cavity.

Endometrial tissue can implant and grow on various organs, including the appendix, rectum, ovaries, intestines, leg nerves, and other parts of the pelvic region. In rare cases, implants have been found on the diaphragm, lungs, and kidneys.

Some estimates suggest that, on average, diagnosing endometriosis takes about 10 years from symptom onset.

The same hormonal changes that trigger the growth and shedding of the uterine lining to create a monthly period trigger these misplaced implants to grow and shed, or bleed. But unlike menstrual blood, the extrauterine endometrial tissue cannot exit the body. Trapped in the abdomen, it can cause severe pain, irritation, inflammation, adhesions, and scarring.

Many sufferers experience pain and other symptoms for years before discovering the cause. Some estimates suggest that, on average, diagnosing endometriosis takes about 10 years from symptom onset. “You can’t definitively diagnose endometriosis with a CT scan or an MRI,” Hunter notes. “The only definitive way to diagnose it is to do a laparoscopy,” in which a surgeon makes a small incision in the abdomen and inserts a camera to look at the reproductive organs.

Signs and Symptoms

The most common symptoms of endometriosis include intense menstrual cramping; long, heavy periods; bloating and constipation; urinary problems; painful sex; lower-back pain; and chronic fatigue.

It’s also possible to have endometriosis and be asymptomatic, notes Cindy Geyer, MD, a functional-medicine physician at the UltraWellness Center in Lenox, Mass. In these cases, infertility may be the first sign that anything is amiss.

For those who do experience pain, it’s often severe. “We’re talking about sometimes debilitating pain, where women might have a hard time functioning at work or need to go to the emergency room because of significant discomfort,” Geyer says. Even bowel movements can be intensely painful if there are implants on the intestines.

Endometriosis can sometimes fuse the back wall of the vagina to the front wall of the rectum, seriously disrupting sexual pleasure. Still, painful intercourse is just one of the ways the condition can challenge intimate relationships.

“Pain itself can contribute to depression, irritability, and mood challenges,” Geyer says. Add infertility, fatigue, and the side effects of medications often used to treat the condition, and it can have a devastating impact on quality of life.

Conventional Treatment

Birth control pills are among the most common treatments for endometriosis.

“Many women are put on powerful medications that suppress the whole hypothalamic-pituitary-ovarian axis. This completely shuts down ovarian cycling and functioning, which may give short-term relief but comes with side effects, like hot flashes and night sweats,” Geyer says. “You’re basically chemically inducing menopause.” Shutting down ovarian function also carries a risk of bone loss.

Excision surgery, in which endometrial implants are removed, can sometimes provide temporary relief from symptoms. However, some healthcare providers have warned recently that excision surgery — often performed multiple times on the same patient over time — could make endometriosis worse by creating nerve damage that can amplify pain sensitivity.

For those with endometriosis who do conceive — estimates suggest between 60 and 70 percent of women with endometriosis get pregnant without assistance — pregnancy can provide a reprieve. This is thanks to the high-progesterone, lower-estrogen hormonal environment it creates.

Unfortunately, the reprieve is typically short-lived. “Endometriosis tends to come back if we don’t address the underlying inflammation and root causes,” Geyer says.

Getting to the Root Causes

“Endometriosis is an immune and inflammatory problem that’s triggered by cyclic hormonal changes and worsened by chronic environmental-toxin exposure,” explains integrative-medicine physician and herbalist Aviva Romm, MD. While the exact causes of the condition remain unclear, these are some possible contributing factors.

Retrograde Menstruation

Among the possible causes of endometriosis, Geyer explains, a primary suspect is retrograde menstruation. “The cells of the endometrium, instead of flowing outward as in a menstrual period, flow backward up the fallopian tube and end up in the abdominal cavity. Once they’re there, they can take up residence and attach to the ovaries or other organs.”

Still, this condition alone can’t explain endometriosis. “Most women have some degree of retrograde menstruation,” Geyer says. “It’s actually normal.”

In most cases, the innate immune system recognizes the cells as a foreign presence in the abdomen, and it destroys them, she notes. “So, what is it that defines the 10 or 11 percent of women for whom those cells end up in the abdominal cavity and don’t get taken care of by the innate immune system?”

To answer that, Geyer says we need to look at “secondary imbalances that create an environment in which the cells attach, grow, proliferate, and cause a perpetuating cycle of inflammation and scarring.”

Hormonal Imbalance

Our sex hormones, adrenal hormones, and thyroid hormones interact in dynamic and complex ways. When considering hormonal conditions, it can be more useful to look at the balance — or imbalance — among hormones rather than at any single one in isolation. “In people with endometriosis, we tend to see less progesterone on board and more estrogen,” says integrative practitioner Marcelle Pick, OB-GYN, NP.

Endometriosis is considered an estrogen-related disease because that hormone acts as a sort of fertilizer for the growth of the errant cells. Many of the conventional treatments for the condition, such as birth control pills, aim to decrease the production of estrogen and increase progesterone, which helps thin both the lining of the uterus and endometrial lesions.

Yet endometrial implants can generate estrogen themselves, creating more fertilizer for their own growth. This is why birth control pills, hysterectomy, and even menopause don’t always reliably relieve the condition.

Estrogen metabolism and detoxification are key to reducing overall estrogen load. Genetics play a role here, as do environmental toxins, which increase the burden on the body’s detoxification system.


There’s evidence of a genetic component to endometriosis, though no single gene has been identified as the culprit. “Endometriosis is more common in first-degree relatives of women who’ve had endometriosis,” Geyer says. “There also seems to be an epigenetic component, in which the intrauterine environment can influence the baby’s future risk for endometriosis.” (Epigenetics describes the way our behaviors and environments affect our gene expression.)

Specifically, fetal exposure to endocrine-disrupting chemicals, such as dioxins, PCBs, phthalates, and bisphenol A (BPA), is suspected of contributing to increased risk.

“If we have genetic SNPs, we’re more prone to have poor methylation, or to have our bodies express estrogen in a more potent way,” Pick explains. (An SNP, or single nucleotide polymorphism, is a genomic variant at a single base position in the DNA.)

Particular genes can affect our ability to break down estrogen and other environmental toxins or increase progesterone resistance. (For more on how genetic variations can influence our health, see “What Are SNPs and Why Do They Matter?”)

Genes, however, are not destiny. Through diet and lifestyle, we’re able to reduce our toxic load and support our detoxification processes.

Environmental Toxins

Evidence suggests that increased exposure to environmental toxins called endocrine disruptors, which disrupt or mimic our natural hormones, could be contributing to the widespread development of endometriosis. Food packaging, personal-care products, and plastic water bottles frequently contain these hormone-disrupting chemicals, which “may stimulate endometriosis growth as a result of increased chronic inflammation, increased estrogen synthesis, and altered monthly thickening and shedding of the uterine wall,” explain Andrew Cook, MD, and Danielle Cook, MS, RD, CDE, in their book, The Endometriosis Health and Diet Program.

Evidence suggests that increased exposure to environmental toxins called endocrine disruptors, which disrupt or mimic our natural hormones, could be contributing to the widespread development of endometriosis.

BPA and phthalates fall into this category, and some studies have found that women with endometriosis had higher phthalate concentrations in their blood. “BPA has a similar structure to estrogen and can behave like estrogen; however, the body takes much longer to metabolize it,” the Cooks write. BPA can also disrupt estrogen signaling, exacerbating endometriosis symptoms.


An imbalanced microbiome and leaky gut can contribute to chronic inflammation, a risk factor for endometriosis. “We also now have studies indicating correlation between endometriosis and an imbalanced microbiome,” explains Pick. In addition to the microbiome of the intestines, she adds, “we also have a microbiome of the uterus that can be imbalanced.”

These microbial imbalances can disrupt normal immune function and may contribute to the development of endometriosis. Studies in mice have even shown successful endometriosis treatment using antibiotics that kill the overgrowth of hostile bacteria. Specifically, low levels of Lactobacillus bacteria have been linked to the disease, as have high levels of microbes related to bacterial vaginosis (Explore eight ways to balance your vagina’s pH level at “How to Support Your Vaginal Microbiome.”)

Certain bacteria even affect how the body metabolizes estrogen. “The microbiomes of the gut and uterus actually affect the entire physiology of the body, from hormonal balance to digestion,” notes Pick.


“More and more, we’re starting to look at endometriosis as an inflammatory cascade,” says Pick. The cascade begins with irritation and tissue damage and ends in fibrosis and scarring. Each stage adds more inflammation to the cycle, making it both a cause and an effect of endometriosis. Inflammation also contributes to the amount of pain women with endometriosis experience.

Food is a key factor. “We know that diet affects inflammation systemically, particularly a diet high in sugar and refined carbohydrates,” Geyer notes. Stress, poor sleep, and overall toxic load can also contribute to systemic inflammation.

This perspective offers a key entry point for treating endometriosis and relieving symptoms, Pick says. “Anything you can do to decrease that inflammatory cascade will help decrease pain and cramping.”


Stress can worsen endometriosis symptoms in several ways. “I don’t think that stress causes endometriosis, but it can certainly disrupt the health of the gut lining and increase inflammation,” Geyer explains.

Over time, chronic stress and pain can contribute to central sensitization, in which the central nervous system alters perception of pain. In these cases, “even a sensation such as light touch or cold temperature that ordinarily wouldn’t register as pain gets perceived as pain,” says Geyer. “Everything’s on hyperalert.”

Chronic stress can also lead to hormone dysregulation, in part by overworking the thyroid and adrenal glands. This sets the stage for the kind of hormonal imbalances that foster the growth of endometrial implants.

Dysregulated Immunity

Impaired immune surveillance and response may play a role too, mainly by allowing endometrial cells to grow outside the uterus. “One theory is that natural killer cells aren’t responding as they should and getting rid of endometrial cells,” Geyer explains. “And if there’s already inflammation inside the abdominal cavity, that creates an environment where those tissues are more likely to latch on and take up residence.”

The peritoneal fluid of patients with endometriosis has been shown to contain unusually high levels of the molecule galectin-3. “This molecule is produced by the immune system and is implicated in every single condition that involves fibrosis, such as nonalcoholic fatty liver disease and pulmonary fibrosis,” she notes.

Researchers speculate that galectin-3 not only hinders natural killer cells from detecting endometrial cells, but it allows the endometrial cells to become stickier, contributing to ongoing scarring. Drugs that target galectin-3 are currently in development.

A Whole-Person Approach to Healing

A functional approach to treating endometriosis “supports an optimal immune response, reduces inflammation and pain, promotes natural detoxification of environmental toxins, and helps to balance hormones,” Romm explains. These are the main pillars.

1) Use food as medicine.

An anti-inflammatory diet is the first critical step in healing from endometriosis. Eliminating inflammatory, ultraprocessed foods and emphasizing whole, fresh ones can help repair a leaky gut, balance the microbiome, and reduce inflammation — all of which can help reduce symptoms of endometriosis.

“Because so many people have a problem with dairy and gluten, I have people take those out immediately,” says Pick. Sugar, alcohol, refined carbohydrates, and excess saturated fats can also contribute to inflammation.

Omega-3s from fish, nuts, and seeds have an anti-inflammatory effect and help provide our immune system with what it needs to resolve inflammation once it starts,” Geyer notes. Bone broth, collagen, and fermented foods can help create a healthy intestinal barrier.

And a diverse array of plant-based, fiber-dense foods supports a balanced immune system and healthy hormone regulation. “Getting enough dietary or supplemental fiber is essential for reducing inflammation and overall body-toxin load and eliminating excess estrogen from your system,” says Romm. She recommends taking one to two tablespoons of freshly ground flaxseed daily in a smoothie or mixed into food.

Cruciferous vegetables, such as cauliflower, Brussels sprouts, broccoli, and broccoli sprouts, are superstars for supporting estrogen metabolism. Herbs and spices, including ginger, rosemary, and turmeric, also contain anti-inflammatory compounds. (Explore this simple five-step diet plan to help you fight inflammation.)

Plastics are a major source of estrogen-mimicking compounds called xenoestrogens, which can worsen endometriosis, so Romm suggests avoiding foods packaged in soft plastic wrap, as well as those that are stored in plastic. Avoid microwaving food in plastic because this leaches more of these compounds into the food.

2) Reduce stress.

Because endometriosis can be an intensely painful condition, it is also a stressful one — and chronic stress suppresses the innate immune system, Geyer notes. This includes the natural killer cells that typically recognize and eliminate errant endometrial cells.

Research on animals shows that stress increases the size and severity of endometrial lesions. This means it’s important to prioritize stress management when attempting to control symptoms.

Our bodies synthesize a variety of hormones from cholesterol, including estrogen, progesterone, and the stress hormone cortisol. “We can’t live without cortisol, but we can live without our sex hormones. So, if we have too much need for cortisol due to chronic stress, the body will make cortisol at the expense of our other hormones, causing tremendous hormonal dysregulation,” Pick explains.

Breath-based practices, mindfulness meditation, and guided imagery can help the body shift out of fight-or-flight mode and support the parasympathetic, or rest-and-digest, response. This can help lower inflammation, reduce pain, and ease the burden of chronic stress. Massage, pelvic-floor physical therapy, acupuncture, and myofascial-release techniques are other modalities that can help alleviate chronic pain.

A systematic review in the Journal of Psychosomatic Research found that mind–body interventions are useful — think yoga, mindfulness, relaxation training, cognitive behavioral therapy combined with physical therapy, and biofeedback. The study determined that these all “show promise in alleviating pain, anxiety, depression, stress, and fatigue in women with endometriosis.”

3) Supplement wisely.

Herbs and supplements can help soothe the effects of endometriosis in various ways, including by calming inflammation and repairing tissue damage. It’s always a good idea to work with a certified practitioner when adding herbs or supplements to your routine. These are some of the supplements experts recommend.

⋅ Modified citrus pectin (MCP) is a dietary fiber made from the pulp of citrus fruits. “This nutraceutical has the ability to block the activity of galectin-3,” Geyer says. Research on its effectiveness for endometriosis is thin, but because of MCP’s potential benefits and low risk profile, Geyer still recommends it.

“Not only can it block the activity of that molecule that’s driving scarring and adhesion, but it’s also a gentle chelator, so it can bind to heavy metals and other toxins we might be exposed to. And it’s a prebiotic, so it can support the growth of beneficial gut microbes.”

⋅ Anti-inflammatories, such as mushroom extracts, fish oil, curcumin, resveratrol, and green-tea extract, may help, Geyer says.

Romm adds bromelain (from pineapple), quercetin (found in apples, onions, and capers), ginger, and the herbal extract boswellia to the list. “Not only will inflammation be reduced, but these herbs also relieve pain over time,” notes Romm.

⋅ Antioxidants help prevent and reverse local tissue damage from inflammation, Romm adds. Resveratrol, N-acetylcysteine (NAC), pine bark, green tea, and curcumin are all powerful antioxidants available in supplement form.

A study published in 2013 found that women with endometriosis who took 600 mg of NAC three times a day on three consecutive days each week for three months saw a greater reduction in cysts and pain than a control group did, with results “better than those reported after hormonal treatments.”

While endometriosis can present real challenges, it’s important to know that “we have hope for treating it now, and years ago we really didn’t,” Pick says. She herself had surgery for endometriosis at age 19, which led to infertility. “If I’d known then what I know now, I could have avoided that. It’s empowering for me now to help people understand how to do things differently.”

Check out all of the content in our sexual health and well-being digital collection.

Illustration by: Neil Webb
Mo Perry

Mo Perry is an Experience Life contributing editor.

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