Endometriosis and the Gut Microbiome, A Powerful Connection

Did you know from the time symptoms appear, it takes an average of four to eleven years for women to be diagnosed with endometriosis?[1]

This delay in diagnosis is most likely due to a combination of factors, including:

1. Endometriosis symptoms are similar to those of many other conditions, making diagnosis difficult.
2. We don't have a biomarker or test that can definitively diagnose endometriosis, so it's usually confirmed with a laparoscopy — a potentially expensive surgical procedure.
3. Most doctors genuinely want to help their patients, but some are unfamiliar with the symptoms of endometriosis and may misdiagnose a woman with another hormone-related condition.

The more women who are aware of endometriosis symptoms, the better they will be able to advocate for themselves and receive proper treatment for the condition.

That’s why in today’s article, I’m going to break down what endometriosis is, the symptoms, causes, and how the gut microbiome has an impact. 

What is endometriosis?

Endometriosis, also known as "endo," is a common health issue in women. It gets its name from the word endometrium, which is the tissue that normally lines the uterus or womb. Endometriosis occurs when tissue similar to the uterine lining grows outside of your uterus and in other areas of your body where it does not belong.[2]

Endometriosis is most commonly found in the:[2]

• Ovaries (most common)
• Fallopian tubes
• Tissues that hold the uterus in place
• Outer surface of the uterus

Other locations for growths include the vagina, cervix, vulva, bowel, bladder, or rectum. Rarely endometriosis can appear in other parts of the body, such as the lungs, brain, and skin.[2]

(Image by clevelandclinic.org)

What are the symptoms of endometriosis?

Pain and infertility are the most common symptoms of endometriosis. In fact, infertility occurs in 90% of women with the condition.3 Endometriosis pain generally presents as:[4]

• Menstrual cramps that are painful and may extend into the abdomen (stomach) or lower back 
• Pain during or after sex

Other signs and symptoms may include:[4,5]

• Diarrhea or constipation during a menstrual period
• Fatigue or a lack of energy
• Heavy or irregular periods
• Pain with urination or bowel movements during a menstrual period
• Bleeding or spotting between menstrual periods
• Chronic pelvic pain
• Chronic lower back pain
• Uterine masses/cysts (endometrioma)
• Bloating

Everyone's experience with endometriosis is different. Women with endometriosis may experience some, all, or none of these symptoms. Severe pain or other symptoms are not always indicative of more severe endometriosis.

What causes endometriosis?

While there are numerous theories about the condition's potential causes, endometriosis is thought to be caused primarily by the backward movement of menstrual flow (retrograde menstruation).

We know that the female sex hormone, estrogen, is required by the body to produce endometrial tissue. Endometriosis patients have consistently high estrogen production, and excess estrogen contributes to the pain and inflammation associated with endometriosis.[6]

Additionally, oxidative stress, free radicals, inflammation, having too much estrogen and/or too little progesterone, genetics, epigenetics, and environment all appear to play a role in the development of endometriosis.[1]

Endometriosis can also be caused by the following factors:[5]

• Being under the age of 12 at the start of the period
• Menstrual cycles lasting less than 26 days
• Heavy menstrual flow
• Chemical exposure (since certain chemicals can mimic estrogen in the body).

How does the gut microbiome impact endometriosis?

Numerous studies have found a link between the gut microbiota and a variety of inflammatory diseases, as well as a connection between the gut microbiota and endometriosis.[7]

According to research, women with endometriosis have been shown to have decreased diversity of their gut bacteria compared to healthy women.[7] Additionally, dysbiosis (unbalanced bacteria in the GI tract), leaky gut, and chronic inflammation appear to be common with endometriosis.[8] 

Another study found that there was a depletion of protective microbes in the gut of women who had endometriosis confirmed by laparoscopy.[9] Furthermore, it was found that endometriosis patients have lower levels of beneficial Lactobacilli bacteria and higher levels of potentially pathogenic bacteria that cause inflammation. Endometriosis stage also influenced the microbiota.[9]

While some gut bacteria promote endometriosis, others protect against it by fermenting fiber to produce short-chain fatty acids as seen in a 2021 study.[10] Researchers discovered that altered gut microbiota promotes the growth of endometriotic lesions, and that feces from mice with endometriosis contained less short-chain fatty acid and n-butyrate than feces from mice without endometriosis.[10]

What hasn't been determined yet is which scenario arises first. Is it endometriosis that alters the microbes in and on our bodies? Or is it possible that changes in the microbiome contribute to the development or progression of endometriosis? This is an exciting area for future investigations!

We hope that this article helped you understand more about endometriosis and how the gut microbiome can have an impact! If you suspect you have endometriosis, talk with your doctor for more information. 

References: 

1. Tsamantioti, E. S., & Mahdy, H. (2022). Endometriosis
2. Endometriosis. Womenshealth.gov. Retrieved December 17, 2022.
3. Maroun, P., Cooper, M. J. W., Reid, G. D., & Keirse, M. J. N. C. (2009). Relevance of gastrointestinal symptoms in endometriosis. The Australian & New Zealand Journal of Obstetrics & Gynaecology, 49(4), 411–414. 
4. Endometriosis. Hopkinsmedicine.org. Retrieved December 17, 2022. 
5. Ruscio, M. (2022, February 14). Endometriosis symptoms: Gut connections and how to heal naturally. Dr. Michael Ruscio, DNM, DC.
6. Chantalat, E., Valera, M.-C., Vaysse, C., Noirrit, E., Rusidze, M., Weyl, A., Vergriete, K., Buscail, E., Lluel, P., Fontaine, C., Arnal, J.-F., & Lenfant, F. (2020). Estrogen receptors and endometriosis. International Journal of Molecular Sciences, 21(8).
7. Talwar, C., Singh, V., & Kommagani, R. (2022). The gut microbiota: a double-edged sword in endometriosis. Biology of Reproduction, 107(4), 881–901.
8. Svensson, A. (2021, March 3). Associations Between Endometriosis and Gut Microbiota. Nih.gov.
9. Jiang, I., Yong, P. J., Allaire, C., & Bedaiwy, M. A. (2021). Intricate connections between the Microbiota and endometriosis. International Journal of Molecular Sciences, 22(11), 5644.
10. Huang, L., Liu, B., Liu, Z., Feng, W., Liu, M., Wang, Y., Peng, D., Fu, X., Zhu, H., Cui, Z., Xie, L., & Ma, Y. (2021). Gut Microbiota exceeds cervical Microbiota for early diagnosis of endometriosis. Frontiers in Cellular and Infection Microbiology, 11, 788836.
11. Chadchan, S. B., Popli, P., Ambati, C. R., Tycksen, E., Han, S. J., Bulun, S. E., Putluri, N., Biest, S. W., & Kommagani, R. (2021). Gut microbiota-derived short-chain fatty acids protect against the progression of endometriosis. Life Science Alliance, 4(12), e202101224.