Endometriosis Awareness Month 2013 – Part II

Dietary advice is everywhere these days and the number of myriad ways in which people can shove or not shove foodstuffs down their gob seems to be steadily growing every year. For example Wikipedia lists some of the many, many diets you could go on for various reasons. Being bombarded with so much information regarding what we stuff in our mouths does create a lot of confusion though. Sometimes we will hear that a certain food is good for us, whilst simultaneously being told that same food is bad for us, usually by people with different agendas to push.

If all the general advice we get isn’t confusing enough, we also get regular updates about what foods are supposedly good for certain medical conditions (regardless of whether it is true or not). Endometriosis is no exception to this and there are a number of ‘endo diets’ out there you can follow. Some women find adhering to these diets helps their symptoms, which is fantastic news, however some women find it makes no difference. So it seems to be the case that there isn’t a ‘quick fix’ diet solution that will suit the needs of all endo sufferers and it may be a case of trying lots of things before you find something that works for you. But if you do find something that works, it will definitely be worth it.

One of the problems that compounds the issue of diet and endometriosis is that there has been very little proper, scientific research done examining the effect of different foodstuffs on endometriosis. That said, there have been a few articles published recently examining the role diet plays in endometriosis.

Firstly, there was a study from Italy looking at the effect of a gluten-free diet on the pain symptoms of women with endometriosis. I know some women with endo find that reducing or eliminating gluten from their diet helps relieve their pain symptoms. This study seems to very much confirm this as 75% of patients reported a significant change for the better in their pain symptoms - very encouraging results. However I can’t get full access to the paper so I can’t see whether this study was properly controlled. What do I mean by controlled? Well, in order to eliminate false conclusions from being drawn, studies like this have to take into account any factors that could swing the results away from the true values. Let’s consider the study above, what are the factors that could possibly interfere with the results? Were the women also taking any kind of medical therapy that may also change their pain levels? Did any of the women have surgery during the time of the study? Did any of the women have a gluten intolerance that they either did or didn’t know of or other conditions like IBS or Crohns?  How was the patient’s diet monitored to ensure it was definitely gluten free over the 12 months?

Like I said, I don’t have access to the full version of this article so the authors may well have taken all the above factors into consideration and if you want to try a gluten free diet for yourself, by all means give it a try. However, next time you read a magazine or newspaper article giving details about a supposed ‘miracle diet’, think about how well the study was conducted and whether the people conducting the study did it right.

Next up is a study from the US looking at dietary and health records of 70,556 US women over a 14 year period, so it was quite a large study. What they found was that women who developed endometriosis consumed less dairy products than other women. This finding was in agreement with another, smaller US study published in 2011 which had a similar result. However, these two studies are in conflict with an Italian study in 2004 that found dairy product consumption didn’t significantly vary between women with and without endometriosis. Remember when I said it can get very confusing. And again we have issue with what conclusions can be drawn from these results. Some might claim this information shows dairy products are protective against endo, because women who don’t have endo consume more dairy products. Of course another way of looking at it could be that women with endo may be more likely to have a dairy (or lactose) intolerance, which there is some circumstantial evidence to support, hence why they consume less dairy products. 

"well do you want the milk or not, I've got stuff to do y'know" Image courtesy of FreeDigitalPhotos.net

What we really could do with is a review of all the information published on the relationship between diet and endometriosis, which then gives the results from a pool of data. Conveniently that is the final study I’ll be looking at in this blog post. So this review examined the results of eleven different studies into the connection between dietary factors and endometriosis. What they concluded, from all the information that is worth examining, was that women with endometriosis may benefit from eating more vegetables and less red meat and trans fats. Oh, not exactly a radical breakthrough in our dietary intake paradigm, its good advice for, well, anyone really but not exactly giving us anything concrete and specific about endometriosis.

But that, in effect was the other conclusion of the review. There simply isn’t enough robust evidence at the moment to support a link between any specific dietary component and the risk of endometriosis. This isn’t surprising either when you think about it; every woman’s disease is different and every woman’s dietary needs are different, some may have tolerances and intolerances that others don’t, so trying to say one thing with make a difference across the board just isn’t going to be true.

Fortunately a lot of women with endometriosis do find modifying their diet can help reduce their symptoms, unfortunately though it may involve a bit of a trial and error.  Just don’t try anything extreme, for example the Breatharian diet (in fact a good rule is, if a diet has a silly sounding name, just avoid it) and if in doubt consult a doctor or dietician. 

Fat of the land

Talk of endometriosis and the role of diet is bound to crop up sooner or later. Some women have found that changes to their diet can help reduce the symptoms of endometriosis, some women find that certain foods make their symptoms worse, particularly if they have bowel symptoms.

Some studies have found that women who consume higher levels of fish oil experience less pain symptoms, although it could be that higher fish consumption is merely an indicator of a healthier lifestyle overall. Other studies agree that a diet high in green vegetables and fruit is associated with a decreased risk of endometriosis, whereas a diet high in red meat was found to increase the risk of developing endometriosis. Again though, these dietary factors are probably related to overall lifestyle health.

Recently a study from the Harvard Medical School found that consumption of certain types of fats was associated with an increased risk in endometriosis. This study used data from the Nurses’ Health Study II cohort, a very large repository of information on 116,607 registered female nurses in the US. Information has been collected from 1989 to 2001 and includes data on illness, environmental and lifestyle factors, so it’s a great source of information about the relationship between risk factors and illness. The aforementioned study looked at data on the 1199 cases of laparoscopically confirmed endometriosis and compared it with data from a food frequency questionnaire. This is what they found.

Total fat intake was not associated with any significant increased risk for developing endometriosis

There was a suggestion that animal fat intake may lead to an increased risk of developing endometriosis, which agrees with the studies mentioned previously that suggested increased consumption of red meat increases the risk of developing endometriosis. Although, intakes of the main components of animal fats i.e. saturated fat and monounsaturated fat were not associated with an increased risk of endometriosis.

Intake of trans-unsaturated fats was associated with a higher risk of endometriosis, with the risk becoming higher if protein intake was also increased.

Intake of long chain omega-3 fatty acids was associated with a decreased risk of endometriosis.

In this prospective study of US nurses the main sources of the seemingly protective long chain omega-3 fatty acids were salad dressing, tuna and dark fish. The major sources of trans-unsaturated fats were fried foods, margarine and crackers.
These results appear to show that a diet high in trans-fats increases the risk of developing endometriosis. However, it may be (and I’m probably sounding like a stuck record now) that a person who has a diet high in trans-fats, does not have a healthy lifestyle compared to someone who eats a lot of omega-3 containing foods. Therefore, the people who eat a lot of omega-3 are not necessarily at a decreased risk of endometriosis because they eat omega-3, but because their lifestyle is healthier overall. You may very well ask “if endometriosis is a disease you are born with, does diet really make that much difference?” Well it could be that having a consistently healthy lifestyle from an early age somehow suppresses the disease much in the same way as a healthy lifestyle can stave off cancer in those with a family history of the disease.

And, if nothing else, it’s another good reason to get trans-fats out of your diet, because although they taste delicious, they’ll make you fat and prone to heart attacks.

A Weighty Issue

Despite the fact every conceivable media outlet for the last fifty years has been forcing the notion down our collective throats that being thin is the most important thing in the universe, when it comes to endometriosis being thin is apparently not the preferred body model of choice. There have been several studies that suggest women with a lower BMI are more at risk of developing endometriosis than those with a higher BMI.

BMI, I should clarify, stands for Body Mass Index, essentially a ratio of weight to height that is often (mistakenly) used as a measure of overall health, but more on that later. Having a BMI of:
Less than 18 means you are underweight
Between 18 and 25 means you are of normal size
Between 25 and 30 means you are overweight
Over 30 means you are obese
Over 40 means you are morbidly obese
Anything over 50 and you will probably receive a personal visit from Richard Simmons.

Firstly, a Korean study, published only a year ago, looked at women with minimal and mild endometriosis and women with advanced endometriosis. It turned out that women with advanced endometriosis had a significantly lower BMI than those with minimal/mild disease. You may think then that being thin is bad, but looking at the details, that is not necessarily the case. The average BMI for women in this study with minimal disease was 23.0, the average BMI for women with severe disease was 21.4. Both of these groups of women fell well within the ‘normal’ BMI bracket meaning that neither group could be considered under or over weight. Also this particular study did not include a control group (i.e. a group of disease free women) to compare with women with endometriosis, which widens the margin for error.

Another study, this time from Italy in 2005, looked at the differences in BMI between women with and without surgically confirmed endometriosis. This study concluded, much like the Korean study, that women with endometriosis were significantly taller and weighed less than controls. So does this mean that women with endometriosis are spindly giants, wandering the countryside like elfin goddesses? Well not quite, sorry. The average height for women in the control group was 162.4cm (about 5 foot 4), the average height for the women with endometriosis was 164.5cm (about 5 foot 5). The average weight of the control group was 58.8Kg (129.4 pounds), the average weight of women with endo was 57.2Kg (125.8 pounds). Not that much different I think you’ll agree. But I did say the results were significantly different. The trouble is I meant mathematically significant, which is simply the product of several very long statistical calculations that may not appear significant in general terms. Confusing? Yes, but also necessary.

The next two studies both come from the USA, albeit one from May 2010 and one from Nov 2005. These two studies again both concluded that women with endometriosis tended to be slimmer and taller than controls (although not by much in real terms). However, these studies concluded that having a leaner body shape during adolescence and young adulthood increased the likelihood of developing endometriosis regardless of adult body habitus and menstrual characteristics. So does that mean we should all force feed pies to our children? Well, no because as one author points out “That women diagnosed with endometriosis may have a consistently lean physique during adolescence and young adulthood lends support to the suggestion of there being an in utero or early childhood origin for endometriosis”. Meaning that being thin during early life and having endometriosis go hand in hand. Essentially being thin doesn’t cause endometriosis, endometriosis causes you to be thin (when you’re young anyway). Why might this be the case? Perhaps the genetic or causes for endometriosis, whatever they may be, bring along other changes such as changes to metabolism which may lead to leaner body shape during childhood.

You’ll notice that most of these studies use BMI as a measure for weight. Therefore, you may think having a high BMI means you're fat. However that is simply not the case (up to a point). A body builder, for example, may have the same BMI as an obese person, because BMI is not an accurate measure of body fat, it is only a ratio of height to weight. So it should be worth noting next time you read a story connecting endometriosis to body weight whether they use BMI or body fat as a variable, it could make all the difference.

Although it would appear changing your diet cannot stop you from developing endometriosis, some changes may result in symptomatic relief. For more information on diet and endometriosis I recommend you check out Dian Mills’ book ‘A Key to Healing through Nutrition’.

Trial and Error

I’ve noticed at the time of writing this that there seems to be a bit of buzz going round the internet concerning Chinese herbal medicine (CHM) for the treatment of endometriosis. In particular there are some less than credible sources suggesting that CHM is better than conventional medicine for treating endometriosis related symptoms. The report on the NaturalNews.com website is perhaps one of the worst offenders, starting as they do the title “Vitamins and Chinese Herbs Prove More Effective than Drugs for Endometriosis”. A bold statement I think you’ll agree, so you’d expect they have some serious evidence to back up their claim, well let’s see.

But before I go into the report, I’d like to take a bit of time to show you a few things from that same NaturalNews.com website. They have some cartoons on this website, fair enough I like cartoons I draw them myself, so let’s see what they’ve drawn. Well take a look at this one and this one if you would like to see the true face of this website. They compare the use of chemotherapy to the gassing of the Jews during the holocaust. I am literally stunned (Oh and they lazily recycled that one from this one about mental health medication). This is just so you know what sort of people we’re dealing with here, so let’s move onto their article on endometriosis before I rupture something.

The article starts off by reporting on a recent publication from the Cochrane Database of Systematic Reviews. The Cochrane group is a large group of people from a wide variety of backgrounds who take in large amounts of studies on a particular subject (including a large amount of studies on drug effectiveness) and thoroughly review the evidence for and against, in an unbiased and methodological manner. It is for this reason that a Cochrane review is thought by many, including myself, to be a definitive source of accurate information. In this instance the Cochrane group have reviewed the evidence for the use of CHM for the treatment of endometriosis, the abstract from which you can find here. NaturalNews.com reports that “Chinese herbs were found to relieve post-surgical symptoms more effectively than the conventional hormone-based drug therapies, with a nearly 96% success rate of complete symptom relief, as compared to only 10% with danazol. The herbs caused virtually no side effects, while a significant number taking hormone medication suffered increased period pain and irregular periods, acne, fatigue, weight gain and evidence of liver damage.” I’m not sure where they are getting those statistics, because there is nothing like that on the Cochrane review.

If you would like to hear what the review actually said, here it is. The review only focussed on two clinical trials of CHM for endometriosis treatment and even these had major flaws in them. For example, although the trials were randomised, neither of them was placebo controlled or double blind, which leaves huge gaps for errors to creep in. Just in case you aren’t familiar with clinical trials here is the criteria a clinical trial has to fulfil in order to be deemed accurate and unbiased.

Large sample size: This means that the more patients you enrol to test a new medicine the better, and more accurate your conclusions will be.

It has be placebo controlled: This means that the people trying the medicine are divided into two groups, one group gets the real medicine, the other group gets a dummy medicine (placebo). This is to make sure any effects people get from the medicine aren’t just random effects you could get from a placebo.

It has to be randomised: This means that patients are randomly assigned to the real medicine or placebo group. This is to stop doctors selecting the patients they think will respond best to the real medicine.

It has to be double blind: This means that neither the doctors nor the patients know whether they are getting the real medicine or the placebo.

These are not just arbitrary rules dreamed up one day by some guy in his garden shed either. These criteria are the result of hundreds of years of clinical trial and error and much personal suffering.

So let’s move on to what these CHM trials found, I’ll quote directly from the abstract so as not to put any personal spin on things “There was no evidence of a significant difference in rates of symptomatic relief between CHM and gestrinone administered subsequent to laparoscopic surgery”.

Ok so what about the effect on fertility, NaturalNews.com claimed “Women taking the Chinese herbal treatments were also 10% more likely to become pregnant following surgery than those taking prescription medication”.

This is what the Cochrane review actually said “There was no significant difference between the CHM and gestrinone groups with regard to the total pregnancy rate”.

And here is what the Cochrane review said about the effects of CHM compared to Danazol “Oral plus enema administration of CHM showed a greater reduction in average dysmenorrhoea pain scores than did danazol”. So there is some positive news about the effect of CHM, however we must remember that these trials were neither placebo controlled nor double blind, so can we really take them seriously?

Naturalnews.com doesn’t stop at CHM either, so neither shall I. They go on to report on the use of Pycnogenol, an extract from the French maritime pine bark for the treatment of endometriosis. NaturalNews.com proudly states “Pcynogenol, was found to decrease symptoms of endometriosis by 33% when used for nearly a year after surgery. In the study, patients took 30 mg capsules of Pycnogel twice daily for 48 weeks immediately after morning and evening meals. The treatment was found to have reduced all symptoms from severe to moderate within four weeks”. That is a direct copy and paste from the website, by the way its spelt ‘Pycnogenol’.

Here is a link to the abstract from the paper they are referencing, which compared the use of Pycnogenol with a Gn-RHa (leuprorelin). There is no mention of Pycnogenol decreasing symptoms by 33% or being effective after 4 weeks. This is what the paper does say though “Treatment with Pycnogenol slowly but steadily reduced the symptom scores. Treatment with Gn-RHa reduced the scores more efficiently; however, 24 weeks after the end of treatment, the scores suggested a recurrence of signs”. Not a very convincing incitement to use Pycnogenol I think you’ll agree.

NaturalNews.com goes on the talk about the use of vitamins for the treatment of endometriosis. They say “Vitamin combinations have also been shown to be an effective therapy for endometriosis. Also in 2007, Italian researchers enrolled 234 women to assess the effectiveness of nutrition versus drug treatment for six months after surgery.Both the nutritional treatment, which included vitamins (B6, A, C and E), minerals (calcium, magnesium, selenium, zinc and iron), omega-3 and omega-6 fatty acids, as well as probiotic bacteria preparations, and the drug treatment were found to be effective in reducing menstrual pain, pelvic pain and pain during sexual intercourse. However, only the drug treatment was found to increase the risk of bone thinning and menopausal symptoms.”

Again here is a link to the article they are referencing, which compared the use of hormone therapy, dietary therapy or placebo therapy for postoperative symptoms. This is what they found “Patients treated with postoperative hormonal suppression therapy showed less visual analogue scale scores for dysmenorrhoea than patients of the other groups. Hormonal suppression therapy and dietary supplementation were equally effective in reducing nonmenstrual pelvic pain. Surgery plus placebo showed significative decrease in dyspareunia scores. Postoperative medical and dietary therapy allowed a better quality of life than placebo”. Look back at the quote from NaturalNews.com, especially the part where they mention dietary therapy and hormonal therapy were equally as good at reducing menstrual pain. Then re-read the second sentence from the quote directly above, notice anything innacurate? Also notice that in no instance was dietary therapy alone better than hormone therapy. Another very interesting point is the comparative cost of both hormonal and dietary therapy. Take into consideration that the hormone therapy is just one tablet a day, whereas dietary therapy consists of tablets and pills for vitamins, minerals, fish oils and pro-biotic bacteria. Guess which one costs you more. Oh and NaturalNews.com kindly provides you with links to its affiliates who sell books on vitamins and nutritional supplements for you to buy, how kind.

I should probably point out that I am in no way against the use of Chinese herbal medicine or other natural medicines, if you have tried it and it works for you, that’s fantastic. What I am against is people or organisations manipulating or fabricating information in order to garnish support for their own twisted propaganda or to increase their own profits. Something that conventional and alternative medicine is both guilty of. Because when ideological one-upmanship and profiteering takes precedent over patient wellbeing do you know who loses out? You, the sufferer, that’s who.