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Endometriosis is a widely encountered but poorly understood condition (as is the case with most hormonal disorders, such as PCOS.)  It affects, by some estimates, up to 20 percent of women of reproductive age,  and by more modest estimates, around 5-10 percent.  In either case this population comprises millions of women.

Moreover, no one is really sure how the endometriosis situation varies between countries–I have struggled for a while to dig up any information–but in general everyone seems to agree that endometriosis happens to everyone, but to Western, and, in particular, American, women the most.  And the most painfully.

Endometriosis is usually diagnosed in women through inspection of their infertility or their menstrual pain.  The reason this is the case is that endometriosis is the condition in which endometrial tissue grows in places outside of the endometrium.  Common locations include the ovaries, the fallopian tubes, and the abdominal cavity and bowels.    The fact that endometrial tissue may be found in important reproductive areas is in part why many women find out they have endometriosis when they have trouble conceiving children.  With tissue blocking a fallopian tube, sperm and eggs have a hard time communicating, and fetuses, growing.

Why endometriosis is painful  

Endometrial tissue can cause women pain first because they are abnormal tissue growth that can hinder normal physiological function.  And secondly, they grow over time.  Yet the most important reason endometriosis causes pain is that ectopic (misplaced) endometria act in the same way as the true endometrium does, just spread out throughout the entire body, wherever they are located.  

Endometrial tissue responds to hormonal changes in the blood in the same exact manner no matter where it is located in the body.  For this reason, ectopic (misplaced) endometria become inflamed, pulse, grow, and bleed throughout the course of a woman’s menstrual cycle.  This magnifies the pain of menstruation and distributes it wherever a woman might have endometrial tissue.  If a woman ordinarily has premenstrual cramps, but then the cramps occur also on her ovaries and in her intestines, she may be in for an increasing difficult menstrual cycle throughout her life.

How endometriosis happens

Medical professionals are not sure how these endometrial implants manage to escape the fallopian tubes and to plant themselves around the abdominals like mini-tumors.   Three seemingly less likely candidates are 1) Mullerianosis, in which the potential for cells to become endometrial is laid down in tracts during embryonic development and organogenesis.   In this theory, an endometriosis patient is made in the first 8-10 weeks of life.   2) Coelomic metaplasia, which asserts that some tissue types transform into others, perhaps triggered by inflammation, and 3) vasculogenesis, in which tissue grows de novo (or from new) via abnormal vascular growth.  Wikipedia et. al have plenty to say about these theories.

The emerging front-runner amongst these candidates, however, retrograde menstruation.  Retrograde menstruation is the phenomenon in which a woman’s monthly flow does not exit the body entirely smoothly southward via the vagina, but instead can flow “backwards” out the fallopian tubes and escape into the abdominal cavity.   From here, the tissue attaches itself to the lining of the abdominal cavity.  It then becomes a more or less permanent fixture.

But do all women with retrograde menstruation experience endometriosis?

No.  In fact, retrograde menstruation is pretty common, occurring in many women who experience no endometrial abnormalities.

So what has to be coupled with retrograde menstruation in order for endometriosis to occur?

This is where the Standard American Diet “triple threat” comes into play.  Immune system malfunction, hormone imbalance, and inflammation all appear to play significant roles.

The extent to which each factor impacts endometriosis is not clear, and certainly not all doctors are on board with this theory. Many medical professions believe that genetics are a dominant factor (they are at least important), or that one of the aforementioned developmental issues is the most important.  What is emerging from the literature, however, is the strong influence the varying factors of impaired immune system function, inflammation, and hormone imbalance have on endometrial development and pain.  The general idea is that impaired immune system function enables the tissue to implant itself, and inflammation and hormone imbalance exacerbate tissue growth, infertility, and pain.

Immune system dysfunction

Much of the endometrial research being conducted today is focusing on the possibility that in endometriosis patients, the immune system may not be able to cope with the cyclic onslaught of retrograde menstrual fluid.   It is common for menstrual flow to escape into the abdominal cavity.  But some women’s immune systems are capable of properly dismantling those tissues, while others are not.

The one overarching job of the immune system is to distinguish between “us” (inside our bodies) and “them” (intruders), and to kick the intruders’ asses.  One facet of this job that is less well known, however, is that the immune system also in a healthy body identifies tissue in the wrong location as “foreign” and attacks it.  The immune system works just as well locally as it does spread throughout the whole body.

That is, of course, unless the immune system has been down-regulated.   If the immune system has been impaired in any fashion, whether by stress, by micronutrient and vitamin deficiencies, or by an inflammatory diet, (one way in which inflammation plays a role) then it may not be strong enough to prevent the implantation of this tissue.  Especially because women in the modern world ovulate far and away more often than women have throughout history… so far as we can tell, anyway.  Since we are both pregnant and starving (presumably) less than ancient women.

In any case, the constant onslaught of reproductive tissue is just too much for some women’s impaired immune function to handle.

Might endometriosis be an autoimmune condition?  

Endometriosis may in fact be an autoimmune condition.  The jury is still far away from deciding whether or not it is a matter of impaired or of auto immunity.   One of the primary markers of autoimmunity is the presence of autoimmune antibodies.  In endometriosis, autoimmune antibodies are always present.   However, autoantibodies may also occur  in other conditions, such as cancer, massive tissue damage, and sometimes in healthy individuals.  It is not yet clear whether autoantibody formation in endometriosis is simply a natural response to chronic local tissue destruction, or a pathologic response leading to more generalized autoimmune dysfunction.

That being said, endometriosis fulfills most of the classification criteria for autoimmune disease.  These include polyclonal B cell activation, immunological abnormalities in T and B cell functions, increased apoptosis, tissue damage, and multi-organ involvement.

Yet despite these similarities, endometriosis appears to be, so far as reaserchers can tell, a condition in which the immune system is weak, and therefore endometriosis occurs, not so much that it is up-regulated and wreaking havoc destroying the body’s own tissues (as in the case in autoimmune diseases).  What then, gives?  Perhaps, in many women, autoimmune disease leads to impaired immunity, which leads to endometriosis.  This would explain the correlation that exists between autoimmunity and endometriosis, but it would allow for other factors, such as inflammation or plain old decreased immune activity, to also play causative roles.

Regardless, endometriosis is strongly associated with autoimmune diseases

Autoiummune diseases correlate fairly well with endometriosis, or at least some of them do.  And they may in fact be causative factors, as I just mentioned.   Autoimmune diseases which may be significantly associated with endometriosis include SLE, Hashimoto’s hypothyroidism, rheumatoid arthritis, Sjögren syndrome and multiple sclerosis. The best evidence exists for an association with inflammatory bowel diseases.


There are two ways in which inflammation impacts endometriosis.  First, in the genesis of endometriosis.  Here, inflammation may cause endometriosis by impairing the immune response.   Secondly, however, inflammation is what (coupled with hormones, discussed below) has the capacity to make endometriosis painful.  Just as in some women have painful periods and others do not, so the same phenomenon translates to the endometrial tissue that is located elsewhere in the abdomen.  If a woman has an up-regulated inflammatory response to her menstrual cycle, then her endometriosis will be painful.  If she does not, then her endometriosis can go unnoticed for years–even for her whole life.  It just doesn’t hurt her.  Inflammation partly explains why there is no statistical correlation between the extent of a woman’s ectopic endometrium and her pain level.   Some women have wicked ectopic endometria, but no pain because their inflammation levels are low.

So what is it about inflammation that is painful?  It is the prostagladins and other inflammatory markers that are produced in endometrial tissue at the time of menstruation.  These inflammatory molecules act locally.  This means that they create painful signals both in the endometrial tissue as well as in the surrounding tissues.  Hence why a phenomenon in such a specific place– ie, the endometrium– can hurt an entire abdomen.

When a woman has endometriosis, this inflammatory signalling and induction might be happening in various locations throughout her entire lower abdomen.


Hormones play an intricately linked role in the genesis of and pain generation within endometriosis.  Estrogen plays many roles throughout a woman’s body and in her cycle, yet one of the most important ones is to stimulate the thickening of the endometrium.  This is an important, normal process that happens in all women.  If estrogen levels are high, however, the endometrium grows very thick, and much larger than normal.  This provides  a) more tissue out of which ectopic endometria can be made, and 2) more tissue from which prostaglandins and other inflammatory markers can be released.   The more endometrial tissue a woman has, the more places pain can come from.  This is in fact the direct cause of most of the “normal” pain women experience with menstrual cramps…and therefore with endometriosis, too.

Estrogen dominance is caused by being overweight, possibly by consuming too many xeno- and phytoestrogens (though that is a complicated issue), and by systemic inflammation.  It can also be caused by having clinically low progesterone levels, since progesterone acts as a bit of a counterbalance to estrogen in the body.   Estrogen and progesterone need to be properly balanced in order for reproduction to proceed smoothly and painlessly.

See Danny Roddy’s view on estrogen as an inflammatory molecule (in excess.)

Endometriosis is usually treated with…

Surgery, birth control pills that raise progesterone levels, birth control pills that lower estrogen levels, or specific estrogen antagonistic medications.  Each of these fixes has its own problems, least of which is the fact that dosing with these kinds of hormones can lead to greater hormonal dysfunction further down the road.  Moreover, it does not get at the underlying cause, which is in many cases very serious.

Endometriosis might not go away entirely, but it can subside, and the pain can be minimized. 

Usually women who have painful endometriosis experience a soothing of their symptoms once they undergo menopause.  This is because their estrogen levels drop, and naturally.

There are other ways to naturally decrease estrogen levels.  Losing weight and decreasing stress are the two biggest factors.  Removing phytoestrogens, which include soy, flax, and all nuts and seeds, as well as xenoestrogens, such as BPA found in plastics, have also been implicated in throwing estrogen levels out of balance.

Yet there are even better ways to work with endometriosis.  And all of them, holistically, are enabled with a paleo diet.

Endometriosis probably– at least according to the majority of medical research and speculation– would not affect women’s health if they did not have compromised immune systems.  In endometriosis, it is unclear whether the women suffer autoimmunity, or if they just have the problem because their immune systems are functioning at a sub-optimal level.  In either case, a paleo diet mitigates the problem.

If endometriosis is autoimmune (a theory I am not sold on), an anti-inflammatory, gut-friendly diet should ameliorate its genesis and symptoms.  This means eliminating potential gut irritants such as wheat, dairy, legumes, and possibly nightshades and eggs from the diet.  Eliminating omega 6 vegetable fats should also be helpful.  A GAPS diet is appropriate in extreme cases.

If endometriosis is from impaired immunity (a theory I am more comfortable with), correcting gut imflammation in this case also goes a long way.  Having a vitamin-rich diet including many meats, organ meats, vegetables, and fruits, low in sugar and processed carbs, with plenty of stress reduction and sleep, with moderate exercise, and with vitamin D from sun exposure, should help boost immune function over time.   It is important to know that I am not promising a cure-all.  These problems can be complex hurdles to get over, and may take several months if not years of troubleshooting and patience and healing in order to get right.

So endometriosis will not necessarily go away.  Tissues might shrink, but they may be too far implanted to ever disappear.   But endometriosis can be mitigated, and with a diet and lifestyle focusing on nourishment, and whole, natural foods and activities.  The importance of stress cannot be under-emphasized, either.   Stress plays a large role in inflammation and in immune system functioning.  So moving forward with holistic healing–with stress-reduction, with love, with healthful foods and with a nourishing lifestyle–goes a very long way in propelling us forward into healthful, natural, kickass womanhood.


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