Author: Min Geraets | BNatMed | Naturopath & Medical Herbalist
Endometriosis is a common inflammatory condition affecting many women. It is characterised by the growth of tissue similar to the uterine lining (endometrium) outside the uterus.1 In New Zealand, approximately one in ten women are affected. This is consistent with the global estimates that it affects roughly 190 million people.2 Symptoms often include dysmenorrhoea (painful periods), chronic pelvic pain, dyspareunia (painful sex), and subfertility or infertility. Some individuals, however, may be asymptomatic, with diagnosis occurring incidentally during investigations or surgery for unrelated conditions.3
The condition commonly affects the pelvic peritoneum, pelvic ligaments, ovaries and bowel. Rarely, endometrial-like tissue can develop outside the pelvis, such as in surgical scars, the umbilicus, and very rarely, in the lungs. When this tissue infiltrates the muscular wall of the uterus (myometrium), it is termed adenomyosis.3
The American Society for Reproductive Medicine classifies endometriosis from stage I (minimal) to stage IV (severe) based on lesion depth, organ involvement and the extent of adhesions3:
- Stage I (minimal): superficial implants, scant adhesions.
- Stage II (mild): more extensive than stage I, limited infiltration, minimal adhesions.
- Stage III (moderate): widespread implants, ovarian endometriomas, moderate adhesions and scarring.
- Stage IV (severe): deep infiltration, multiple organ involvement, significant anatomical distortion and dense adhesions.
The exact cause of endometriosis remains uncertain, but research supports a multifactorial origin involving genetic, immune, hormonal, environmental and epigenetic factors.3 Genetic studies indicate some individuals have increased susceptibility, while immune research has identified changes in the pelvic environment, including overactive immune cells, reduced natural killer cell activity and heightened local inflammation. These processes create a pro-inflammatory environment that promotes lesion implantation, angiogenesis and resistance to normal cell death.4
Diagnosis
Diagnosing endometriosis can be challenging. In New Zealand, it takes on average 9.7 years to receive an official diagnosis.5 Delays are typically due to non-specific symptoms, normal early investigation findings and the tendency to normalise severe menstrual pain. This highlights the importance of taking menstrual pain seriously and considering endometriosis early in the diagnostic process.
Early diagnosis allows for early intervention. This enables better symptom management, which can prevent disease progression and long-term health complications. An early diagnosis often affords early treatment, which is shown to improve quality of life and minimise the long-term burden of endometriosis.6
Symptoms frequently overlap with other pelvic conditions and imaging has limitations. While transvaginal ultrasound can detect ovarian endometriomas, it often fails to identify superficial peritoneal lesions. Therefore, laparoscopy, ideally combined with histological verification, remains the gold standard for diagnosing endometriosis.3
Prevention
While there is no current method to prevent endometriosis, naturopathic care may support risk reduction and early intervention by addressing key drivers such as inflammation, oestrogen clearance, immune function and environmental exposures. Preventative strategies include an anti-inflammatory diet, optimising oestrogen metabolism through gut and liver support, minimising exposure to endocrine-disrupting chemicals and promoting regular physical activity. Stress regulation, adequate rest and nervous system support are also important, as chronic stress disrupts inflammatory and hormonal pathways.7,24 Providing education on the menstrual cycle and its symptoms can help identify risk sooner and support long-term health.
Endometriosis comorbidities
Emerging research has demonstrated a strong association between endometriosis and autoimmune disease. These include rheumatoid arthritis, coeliac disease, multiple sclerosis, lupus erythematosus, Hashimoto’s disease, Grave’s disease, Sjögren’s syndrome and ankylosing spondylitis. The research indicates that individuals with endometriosis have a significantly increased risk (30-80%) of developing an autoimmune condition. Shared mechanisms, including immune dysregulation, genetic predisposition and chronic inflammation, are believed to drive this co-occurrence.8,9 This association underscores the importance of addressing the immune component of endometriosis. Focusing solely on hormone regulation or reducing lesion size ignores a considerable driver of both disease progression and long-term health risks, including autoimmune disease.
Herbal medicine and endometriosis
Growing evidence suggests certain herbal medicines may serve as valuable adjuncts in managing endometriosis. This is primarily due to their anti-inflammatory, antioxidant, anti-angiogenic and hormone-modulating effects.10,11 A recent systematic review reported that medicinal plants and their active compounds may help manage endometriosis by relieving pain, improving fertility outcomes, reducing recurrence rates and enhancing overall quality of life. These effects likely occur via anti-inflammatory and anti-oestrogenic activity, antioxidant action, and reduced tissue adhesions. Promising plants identified include Viburnum opulus, Silybum marianum, and Curcuma longa, along with bioactive compounds including silymarin, curcumin, and naringenin.11
Traditional herbal medicine highlights several plants with mechanisms that may support endometriosis management through anti-inflammatory, anti-proliferative, hormone-modulating, antispasmodic and analgesic actions:
Hormonal regulation
- Chaste tree (Vitex agnus-castus) modulates reproductive hormones, indirectly increasing progesterone levels relative to oestrogen, thus supporting menstrual regulation.12
- Rosemary (Rosmarinus officinalis) is 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.13
Inflammation
- Lady’s mantle (Alchemilla vulgaris) is a uterine tonic and astringent for menorrhagia. It also displays significant anti-inflammatory activity.14
- Turmeric (Curcuma longa) inhibits pro-inflammatory mediators (TNF-α, IL-6 & IL-8) and supresses endometrial cell proliferation by decreasing levels of oestradiol. These actions are mediated by its active constituent, curcumin.15
- Kawakawa (Macropiper excelsum) has been clinically shown to inhibit several pro-inflammatory cytokines including NO, IL-6 and IL-10, while exerting anti-inflammatory effects by reducing the synthesis of TNF-α. These actions are mediated by bio actives myristicin, elemicin, piperine and isovetexin.16
Pain relief and muscle cramping
- Ginger (Zingiber officinale) reduces menstrual pain by antagonising cyclooxygenase and lipoxygenase, therefore inhibiting prostaglandin synthesis. Gingerol is the primary active constituent driving this mechanism.17,18
- Corydalis (Corydalis yanhusuo) modulates central pain pathways (dopamine D1 receptor) to provide analgesia. It also induces apoptosis, which is critical for maintaining cellular homeostasis in endometriosis.19
- Dong quai (Angelica sinensis) relaxes vascular smooth muscle, as well as uterine and intestinal smooth muscle, which supports its role in alleviating endometriosis symptoms. It is a uterine tonic that encourages blood circulation to relieve pelvic congestion.20
- Kohekohe (Dysoxylum spectabile) is a muscle relaxant and anti-inflammatory that eases uterine tension and alleviates muscle cramping. It encourages healthy blood flow within the uterus to relieve uterine congestion and reduce menstrual discomfort.21
- Crampbark (Viburnum opulus) exhibits antispasmodic, anti-inflammatory and analgesic effects through constituents scopoletin and salicylates.20
Other
- Thuja (Thuja occidentalis) has significant antiproliferative effects and may be effective at reducing endometrial fibroids and lesions.22
- Milk thistle (Silybum marianum) offers significant antioxidant and anti-angiogenic benefits via silymarin.11
- Paeony (Paeonia lactiflora) reduces lesion size, angiogenic and inflammatory markers, and may improve implantation rates, with paeoniflorin as its active compound.23
Although direct human trials for many herbs are limited, their mechanisms of action provide evidence for adjunct use alongside conventional therapies, with careful monitoring for herb-drug interactions and client suitability.
Management of endometriosis
Management should be individualised, considering pain severity, fertility goals, lesion type, disease stage and overall quality of life. There are multiple areas to focus on for management, these include dietary, lifestyle and nutrient-specific strategies:
· Dietary modifications: Dietary changes have the highest self-reported ratings for the ability to reduce pelvic pain and gastrointestinal symptoms. Evidence suggests that dietary changes can improve endometriosis symptoms through underlying mechanisms including inflammation, oestrogen pathways and the microbiome.15 Focusing on anti-inflammatory foods is recommended widely, due to the systemic inflammation that occurs in endometriosis. These include oily fish, leafy green vegetables, dark-coloured fruits, nuts and seeds, whole grains, legumes and extra-virgin olive oil.15,24
· Modulating the microbiome: The microbiome is an emerging key player in endometriosis pathology. Nourishing the gut with prebiotic and probiotic rich foods can support a healthy microbiome and regulate inflammatory processes.15 Prebiotic foods include onions, garlic, leeks, asparagus and bananas, while probiotic rich foods include kefir, sauerkraut, miso and yogurt.
· Regular exercise: A recent systematic review and meta-analysis discovered physical activity can alleviate pain, enhance emotional wellbeing and improve pelvic floor dysfunction associated with endometriosis.25
· Stress management and mind–body approaches: There is growing evidence to support mind–body practices for endometriosis management. Research has revealed endometriosis to be genetically correlated with various trauma-related situations, with the strongest evidence linked to post-traumatic stress disorder and adverse childhood experiences.26 For clients that this applies to, having access to a multi-disciplinary care team including a psychologist or psychotherapist is vital. Practices such as yoga, mindfulness and breathing techniques offer adjunct benefit. By activating the parasympathetic nervous system to improve pain perception, reduce stress, lower inflammation and increase emotional resilience.27
· Adequate sleep and rest: Restorative sleep works to regulate the immune system and promotes the release of anti-inflammatory mediators28, directly mitigating systemic inflammation associated with endometriosis. Sleep deprivation lowers pain thresholds and can amplify neural sensitivity to pain signals; improved sleep quality correlates with reduced pain scores.29
· Nutritional supplements: Targeted nutrient therapy can alleviate endometriosis symptoms and modify the disease process through multiple mechanisms. Vitamin D decreases inflammation, enhances immunity, inhibits angiogenesis and significantly reduces pelvic pain.15 N-acetylcysteine (NAC) is the precursor to glutathione, the body’s primary endogenous antioxidant. NAC exerts antiproliferative and antioxidant effects on endometrial tissues and is clinically supported to reduce endometrial pain.30 Palmitoylethanolamide (PEA) is a biologically active lipid that stimulates cannabinoid-2 receptors to produce analgesic and anti-inflammatory effects. PEA has been clinically shown to significantly improve pelvic pain, dyspareunia, dysmenorrhea and dyschezia associated with endometriosis.31 Omega-3 fatty acids, particularly EPA and DHA, are potent anti-inflammatories that inhibit prostaglandin and leukotriene synthesis, thus reducing pelvic pain and lesion size.15
· Liver support and hormone metabolism: The liver plays a key role in metabolising oestrogen and detoxifying inflammatory byproducts. Cruciferous vegetables contain indole-3-carbinol (I3C) and di-indoyl-methane (DIM) which support liver function and hormone metabolism by inducing oestrogen detoxification.24
A holistic approach that includes multidisciplinary support is most effective for improving health outcomes and quality of life for individuals living with endometriosis.
Key takeaways
- Endometriosis is a systemic, inflammatory and immune-mediated condition, not solely a hormonal disorder. Effective naturopathic care must address inflammation, immune dysregulation, oxidative stress and oestrogen metabolism, alongside symptom relief.
- Early recognition and validation of menstrual pain are critical. Naturopaths are well-positioned to identify red flags early, advocate for timely referral and support clients through their diagnostic journeys.
- Individualised, person-centred care is essential. Treatment should be guided by disease stage, symptom burden, fertility goals, comorbidities and psychosocial context.
- Herbal medicine offers valuable adjunct support. With evidence-informed actions including anti-inflammatory, antioxidant, analgesic, immune-modulating, anti-proliferative, anti-spasmodic and hormone-modulating effects.
- Diet, microbiome support and lifestyle interventions are foundational. Anti-inflammatory nutrition, optimising gut health, regular movement, restorative sleep and stress regulation significantly influence pain, disease progression and quality of life.
- Immune and liver support should not be overlooked. Addressing immune dysfunction and supporting hepatic oestrogen clearance are central to reducing disease drivers and long-term comorbidity risk.
- Mind-body and trauma-informed approaches enhance outcomes. Given the links between endometriosis, chronic stress and trauma, collaboration with mental health professionals and inclusion of nervous system regulation strategies is vital.
References
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