Initial presentation
The client, a 28-year-old female presents with fatigue, headaches, dysmenorrhoea, heavy menstrual bleeding, and bloating and abdominal pain prior to menstruation. She was diagnosed with endometriosis via laparoscopy two years ago. Her liver enzyme GGT was raised to 75 U/L in recent blood work.
The client experiences intermittent digestive issues including bloating and constipation. She frequently uses paracetamol for pain and currently supplements with iron bisglycinate for mild iron-deficiency anaemia. No known allergies.
High dietary intake of refined carbohydrates and dairy, with limited fruits and vegetables. Her alcohol intake is 2 glasses of wine 3x weekly. She drinks 1.5L of water daily and reports feeling chronically stressed from work. She values physical activity and does high-intensity interval training (HIIT) 4x weekly.
Naturopathic assessment
28-year-old female with diagnosed endometriosis presents with elevated GGT, fatigue, headaches, dysmenorrhea, menorrhagia, and pre-menstrual bloating and abdominal pain. Likely caused by liver dysfunction, oestrogen dominance, systemic inflammation, nutrient deficiencies and gut dysbiosis.
Key factors considered
- Liver dysfunction – The liver is critical for oestrogen metabolism. High alcohol intake, regular paracetamol use, limited vegetable intake and oestrogen dominance can overburden liver detoxification pathways.
- Inflammation – Chronic inflammation associated with endometriosis can contribute to liver dysfunction by increasing the liver’s inflammatory burden and impairing its detoxification capacity.
- Hormone dysfunction – Chronic oestrogen recycling due to poor liver and gut clearance, further fuelling endometriosis progression.
- Gut dysbiosis – Low dietary fibre intake, regular alcohol consumption and consistent paracetamol use are known to disrupt gut microbiota. Gut dysbiosis disrupts immune function, elevating proinflammatory cytokines and altering immune cell response, which contribute to the pathogenesis of endometriosis.
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Nervous system dysregulation – Chronic stress is associated with increased pain sensitivity and inflammation, and disruptions to hormone signalling.
Herbal medicine
Rosemary (Rosmarinus officinalis) – Clinically shown to modify oestrogen metabolism towards a less proliferative path by inducing CYP1A1 and inhibiting CYP3A4 enzymes. Therefore, reducing excessive oestrogen activity on uterine tissue. Rosemary has potent antioxidant and hepatoprotective effects and is indicated for headaches.
Milk thistle (Silybum marianum) – A hepatoprotective herb with an affinity for enhancing liver detoxification pathways and oestrogen metabolism. Silymarin displayed clinical benefit for increasing hepatic glutathione and supporting hepatocyte regeneration.
Kohekohe (Dysoxylum spectabile) – A powerful NZ native used in Rongoa Māori to support womb health. Anti-inflammatory and muscle relaxant actions work to soothe menstrual cramping and pain. Traditionally used to ease heavy menstrual bleeding due to its astringent and haemostatic activity.
Lady’s Mantle (Alchemilla vulgaris) – Traditionally used to relieve heavy menstrual bleeding and dysmenorrhoea. Also, displays significant anti-inflammatory activity.
Jamaican dogwood (Piscidia piscipula) – Indicated for pain associated with the uterus. Reduces inflammation and eases muscle spasms and cramps.
Corydalis (Corydalis ambigua) – Analgesic and spasmolytic actions work to alleviate menstrual pain and relax muscle spasms.
Crampbark (Viburnum opulus) – Beneficial in alleviating uterine pain and dysmenorrhoea. Spasmolytic action works to reduce smooth and skeletal muscle cramping.
Ginger (Zingiber officinale) – As a circulatory stimulant ginger encourages the movement of stagnant blood, while relieving menstrual pain and cramping. Ginger also has significant anti-inflammatory effects.
Herbal formula for liver support and oestrogen metabolism – 200 mL
Rosemary (Rosmarinus officinalis) 1:2 – 60 mL
Milk thistle (Silybum marianum) 1:1 – 40 mL
Kohekohe (Dysoxylum spectabile) 1:2 – 50 mL
Lady’s Mantle (Alchemilla vulgaris) 1:2 – 50 mL
Dosage: 7.5 mL twice daily (BD).
Herbal formula for pain and inflammation – 200 mL
Jamaican dogwood (Piscidia piscipula) 1:2 – 70 mL
Corydalis (Corydalis ambigua) 1:2 – 70 mL
Crampbark (Viburnum opulus) 1:2 – 50 mL
Ginger (Zingiber officinale) 1:2 – 10 mL
Dosage: 5 mL up to 3x daily, two days prior to bleed and throughout menstruation.
Additional recommendations
Dietary modifications
- Consume two servings of cruciferous vegetables daily – Cruciferous indoles including indole-3-carbinol (I3C) and di-indoyl-methane (DIM) are found in broccoli, kale, bok choy, cabbage, brussel sprouts, cauliflower, garlic and radishes. These compounds induce oestrogen detoxification through the liver.
- Reduce alcohol intake – Alcohol drives systemic inflammation, and frequent consumption overloads the liver. The strain alcohol places on the liver is likely to exacerbate symptoms of endometriosis.
- Increase hydration – When the body is adequately hydrated, blood travels easily throughout the body. Allowing wastes, toxins and oestrogen to be processed by the liver and eliminated through urine, sweat and stool.
- Increase anti-inflammatory food intake – As endometriosis is a chronic inflammatory condition, consumption of anti-inflammatory foods should be prioritised. These include oily fish, walnuts, hemp seeds, chia seeds, turmeric, ginger and cold-pressed olive oil.
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Increase daily fibre intake – Lack of dietary fibre is associated with bowel irregularity. Once oestrogen has been processed by the liver, it must be released from the body via the gastrointestinal tract. If there is not enough dietary fibre to support excretion, oestrogen is recycled by the body, leading to a worsening of endometriosis symptoms.
Lifestyle modifications
- Minimise exposure to endocrine-disrupting chemicals (EDCs) – EDCs are found in plastics, fragrances, cosmetics, cleaning products and pesticides. They may contribute to the pathogenesis of endometriosis by mimicking hormonal signalling, altering immune function and inducing oxidative stress.
- Incorporate low-intensity physical activity into exercise routine – Low intensity exercise including yoga, Pilates and walking stimulates the release of anti-inflammatory mediators, which can reduce endometrial pain. Regular physical activity supports liver detoxification by stimulating blood and lymphatic circulation. Helping to transport wastes to the liver for processing and removal.
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Implement daily stress management practices – As stress exacerbates pain sensitivity and inflammation, recommending practices such as deep breathing, yoga Nidra or mindfulness meditation is beneficial for symptom management.
Supplements
- N-acetylcysteine (NAC) – The precursor to glutathione, the body’s primary endogenous antioxidant. NAC exerts antiproliferative and antioxidant effects on endometrial tissue and has been clinically proven to reduce endometrial pain.
- Omega-3 fatty acids – A potent anti-inflammatory supplement. Omega-3’s eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) inhibit prostaglandin and leukotriene synthesis, reducing inflammation and pelvic pain.
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Strain-specific probiotics – Gut dysbiosis is associated with systemic inflammation and immune dysfunction, which are cornerstones of endometriosis. Clinical studies have revealed probiotic strains Lactobacillus gasseri, Lactobacillus acidophilus, Lactobacillus plantarum and Lactobacillus fermentum improve endometrial pain and regression. A healthy gut microbiome can secrete β-glucuronidase which promotes the degradation of oestrogen.
Follow up
After four weeks of following the wellness plan, the client reported improvements in several areas. Her fatigue has reduced, with increased energy levels particularly in the afternoons, and her headaches have become less frequent. Menstrual pain and cramping were milder this cycle, and she reported needing less paracetamol than before. While bloating still occurs, it has lessened in intensity and duration.
The client implemented several dietary changes, including reducing alcohol intake to one glass per week and increasing her intake of cruciferous vegetables and fibre. She has also incorporated daily stress management practices, including guided breathing and yoga twice weekly. Compliance with both herbal formulas has been consistent, and she was advised to continue with both formulas for three months before reassessing. The client was referred to her GP to retest liver functioning within 3 months.
New Zealand GGT reference intervals
| Liver function test | Sex | Interval | Units |
| GGT | Adult female | <50 | U/L |
| GGT | Adult male | <60 | U/L |