Is Endometriosis an Autoimmune Disease?
Way back, as early as 1987, researchers observed that a large percentage of endometriosis patients had “abnormal polyclonal B cell activation”, “a classic characteristic of autoimmune disease.”1 Similarly, B-cell-derived autoantibodies were detected in adenomyosis patients a few years later.2 More recently, HLA-G, a gene prevalent in several autoimmune diseases,3 was found in a significant number of patients with adenomyosis.4 And even as recent as this year, researchers are talking about using autoantibodies as a less invasive way to diagnose endometriosis.5 6 So here’s the question: is endometriosis an autoimmune disease?
What is autoimmune disease, anyway?
Autoimmune disease is defined by an over active immune system that, often in the process of attacking foreign invaders, ends up also attacking its own bodily tissues. In the case of celiac disease, for instance, the body attacks the finger-like villi of the small intestine after being exposed to gluten. In Hashimoto’s, antibodies attack the cells of the butterfly-shaped thyroid gland, inhibiting its hormone production, while in Graves’ disease, antibodies stimulate the thyroid to produce too much hormone.
In rheumatoid arthritis, the immune system attacks the lining of the joints, and in Type 1 diabetes, the immune system attacks insulin-producing cells in the pancreas. Both multiple sclerosis and lupus are more widespread, non-organ-specific autoimmune disorders, where nerve cells or tissues, respectively, are attacked throughout the entire body.
Conventional medicine has not yet identified what causes autoimmunity, except in the case of celiac disease, where gluten is identified, indirectly, as the culprit.
Where there’s one autoimmune disease, there are often more
It used to be said that autoimmune disease came in pairs. That is, if you had one, you likely had or would develop another. Take any autoimmune disease, search Pubmed for its co-morbidities, and you may be surprised about what you find. Or, you might already know, because you, yourself, have more than one autoimmune disorder.
For instance celiac disease and thyroid disease often run together.7 The same is true for Type 1 diabetes and thyroid disease.8 Guess what else is co-morbid with thyroid disease. Yep. Endometriosis. That’s why I mentioned in my last post, my top three tips for healing endometriosis, to include a check on your thyroid when testing your hormone levels.
Besides thyroid disease, endometriosis is also associated with lupus, Sjögern’s syndrome, rheumatoid arthritis, celiac disease, multiple sclerosis, and inflammatory bowel disease,9 among others. Its now well known that where there’s one autoimmune disease, there are often more, and sometimes even more than two.
But why do you never hear about our immune system attacking the endometrium?
When I asked our Facebook group if their doctor ever told them their endo or adeno was an autoimmune disease, most said no. Several were surprised. Others weren’t surprised, because they’re a smart group of women and were able to deduce it based on research into their other health issues. A few debated the idea, which is always welcome in the group (if done respectfully), because we never hear anything about our own immune systems attacking the endometrium.
But increased antibodies to estradiol (estrogen),10 have been found in endometriosis, as well as antibodies to the ovarian antiMüllerian hormone11, suggesting the body is indeed “attacking” its own reproductive tissues. But, more importantly, autoantibodies to the endometrium, itself, have been found in endometriosis. 12 13 14 10
In fact, as Eisenberg et al., say:
Endometriosis fulfills most of the classification criteria for autoimmune disease, including polyclonal B cell activation, immunological abnormalities in T and B cell functions, increased apoptosis, tissue damage, and multi-organ involvement. There is also…an increased likelihood of other autoimmune disease… 15
So honestly, what is there to debate?
Its true, some of the other autoantibodies, such as those derived from B cells, identified early on, or the antibodies to estradiol, are not specific to endometriosis. Both can also be found in lupus, for instance,16 17 as well as breast cancer.18 But does that matter? I already mentioned that where there’s one autoimmune disorder, there are more, so it’s probable more than one autoimmune response is happening at the same time. That doesn’t negate the fact that researchers have identified endometrial specific auto-antigens in both the endometrium as well as ectopic lesions.13
So why the hesitancy to declare endometriosis an autoimmune disorder?19 Is it because doing so would imply that autoimmunity is the cause of the endometrial lesions? It is certainly possible that heightened inflammation is triggered by the ectopic lesions, in the immune system’s failed attempt to ward them off, leading to an imbalanced, dysregulated immune system response. Indeed, “endometriosis is considered a chronic inflammatory disorder.”20 (Just like other autoimmune diseases). Or, As Lara Briden says, “Immune dysfunction is at the heart of what is going on… [its] what prevents the immune system from clearing up endometrial lesions. It’s also what promotes the growth and invasion of those lesions.”
So do the endometrial lesions create an inflammatory environment that causes autoimmunity? Or does autoimmunity cause an inflammatory environment that allows for the development and growth of endometrial lesions? Which came first, the chicken or the egg? (And does it matter?) By the way, Zhang et al. do a great job reviewing what immune regulating cells are involved in the pathogenesis of endometriosis, in case you want to geek out on that.
Maybe we’re asking the wrong question. Maybe instead of looking at organ-specific autoimmunity and treating each organ separately, as conventional medicine does, maybe we should consider autoimmunity a disease of the whole system. Either way, endometriosis and adenomyosis have a clear autoimmune component, which is highly overlooked and rarely discussed with patients.
If you were told your endometriosis was an autoimmune disease, would you treat it differently?
In the meantime, while we’re waiting for conventional medicine to classify endometriosis as an autoimmune disease (or not), it can’t hurt to treat it as though it was one.
Conventional medicine traditionally treats autoimmune disease by suppressing or modifying the immune response. While this might work temporarily, there are many side effects associated with these heavy drugs. Besides, an under-active immune system will make you vulnerable to all kinds of new infections and disorders, leaving you “immunocompromised” in the long-run. This is not the same thing as having autoimmunity. When you are immunocompromised, you never get out of the cycle of disease.
But if you manage your autoimmunity properly, you can have a robust immune system. For instance, I have Graves’ disease, a thyroid disorder whose autoimmune component gets activated whenever I am exposed to gluten or excessive stress. But since I strictly avoid gluten and work to minimize stress every day, my autoimmunity is mostly in remission, and I rarely get plagued by colds or flu or other viral infections. (Taking zinc during flu season helps, too).
How to reverse autoimmune disease, naturally
Rather than stop your immune system from doing what it was designed to do, protect you from outside invaders, a better approach is to avoid whatever is triggering your overactive immune system. If, as Dr. Fasano says, “the continuous stimulation by nonself-antigens (environmental triggers),” is at the root of what’s causing autoimmunity, then “the autoimmune response can theoretically be stopped and perhaps reversed.”21
He goes on to explain how gluten causes “leaky gut,” aka “intestinal permeability.” Normally a healthy intestine shuffles unwanted food particles, toxins and other antigens through to the colon where they can be excreted. But in leaky gut, gaps develop in the normally tight junctions of the intestines, allowing antigens to permeate, enter the blood stream, and elicit an inflammatory immune response. This doesn’t just happen in celiac disease. Intestinal permeability has been shown to occur in several other autoimmune diseases as well.
That’s why I recommend a paleo diet for treating endometriosis (as mentioned in my last post). Certainly, if you have autoimmunity you should strictly avoid gluten, but often going gluten-free is not enough. I like the paleo diet because it avoids other top inflammatory foods in addition to gluten, especially, dairy, sugar and soy. The paleo diet is also favored by functional doctors who specialize in autoimmunity. (I will delve more into the science behind the paleo and similar diets another day.)
Once your gut has been compromised, it’s vulnerable to invasion by unwelcome bacteria. That’s why many people with autoimmune disease and endometriosis often have Small Intestinal Bacterial Overgrowth (SIBO). You can take a breath test to determine whether or not you have it, and if you do you should adopt a low-sugar diet that will starve those bacteria, such as a low FODMAPs diet or candida diet.
You should also work with your functional doctor to eradicate the foreign bodies in your gut, because SIBO can also contribute to leaky gut, leaving you in a vicious cycle. SIBO is notoriously hard to treat, and while I am normally leery of antibiotics, this is one case where they may be necessary. If you are leery of them, too, you could start with herbal antibiotics and see how that goes. For more information on how to cure SIBO, please visit Dr. Siebecker’s blog. She also has a SIBO center in Portland, Oregon.
You should also work on repairing the lining of your intestines. Your functional doctor should be able to recommend supplements such as l-glutamine, quercetin, berberine or BPC-157, all known to help repair the gut. Zinc can also help strengthen the gut lining, and, as I already hinted, it’s a powerful immune booster, at the same time.
Turmeric is beneficial for reducing inflammation, but it shouldn’t be relied on indefinitely. Work to reduce the sources of inflammation so you won’t need to keep supplementing with it, otherwise you may develop a resistance to it.
Finally, if you’ve been following me in our Facbook group for any amount of time, you won’t be surprised to hear me say, minimize your stress. As I mentioned in my last post, cortisol competes with progesterone, making you more susceptible to estrogen dominance, and hence, endo and adeno.
But stress (cortisol) is not just related to endometriosis. Try another Pubmed search for “[insert disease name] and stress,” and you may be surprised by just how many chronic diseases are associated with it. This is because during extended periods of stress, you release chronic amounts of cortisol, which, if you never recover from, will lead to immune system dysregulation.22 And if you take only one thing away from this post, immune system dysregulation (whether “auto” immune or not), is a major factor in endometriosis and other autoimmune disorders.
Find the causes of your stress and your inflammation, avoid them where possible, and you should already begin feeling better.
Stay tuned for more specifics over the weeks to come. But for now, please check out the websites of these two well-known functional medicine doctors, Dr. Amy Myers and Dr. Terry Wahls for more information on how to treat and even reverse your autoimmunity. They’re both brilliant ladies who were able to overcome their own autoimmune diseases, when, as Dr. Myers says, “conventional medicine failed” them.