Fibroids, Ovarian Cysts, and Endometrial Hyperplasia
Fibroids, Ovarian Cysts, and Endometrial Hyperplasia
What are Fibroids?
Uterine fibroids are benign growths found on your uterine muscle. The vast majority of the time fibroids do not cause symptoms or pain, and won’t even really be noticed unless found on an ultrasound. It’s fairly common to have fibroids after the age of 35, and this does not necessarily mean that these fibroids need to be treated or removed, especially if they are not painful for you. Fibroids, if they grow large enough, can cause pain by pressing on other pelvic organs such as the bladder.
If you google “symptoms of fibroids” the first thing that will pop up is “heavy menstrual bleeding” but here’s a reason why that’s not exactly accurate. Only about 10% of fibroids grow INSIDE the uterine cavity where they could cause heavy bleeding. This means that 90% of fibroids are growing inside the uterine muscle, and therefore do not produce excess endometrium. So why is heavy bleeding associated with fibroids? Because they both have the same *root* cause: estrogen excess. This means that your heavy bleeding is not caused by the existence of a fibroid, but rather by too much estrogen - whose job it is normally to proliferate uterine lining. Instead of making the right amount of uterine lining, excess estrogen instructs the body to make too much uterine lining. The effect of this is that you have a heavier than normal menstrual bleed when it comes time to release that lining. At the same time, excess estrogen is at the root of fibroid growth. It is common to see these two things happen at once, though the misconception lies in that fibroids generally are NOT the cause of the heavy menstrual bleeding. Sometimes this is referred to as endometrial hyperplasia, and is a concurrent condition to the fibroid, but not actually caused by it.
What is Endometrial Hyperplasia?
Endometrial hyperplasia is when the lining of the uterus grows too thick from too much estrogen relative to progesterone. It is not cancerous, however, if left untreated, it can lead to endometrial cancer later in life. The typical symptoms associated with endometrial hyperplasia include heavy bleeding and abnormal bleeding patterns. There are two types, without atypia (endometrial cells look normal) or with atypia (endometrial cells are abnormal and cancer risk is increased)
What are Ovarian Cysts?
Ovarian cysts are normal ovarian follicles that have overgrown from the presence of too much estrogen. Every ovulation starts in the ovarian follicle. An ovarian follicle is a small, fluid-filled sac in the ovary that contains one immature egg. There are thousands of follicles in the ovaries. The process starts with follicle recruitment, where the body picks a couple contender follicles to become the next mature egg, and they fill with fluid. As these follicles develop under the direction of the hormone estrogen, one will be selected as the dominant follicle and the other failed contenders will reabsorb. During ovulation, the mature egg is actually pushed out of the follicle and into the abdominal cavity, where the fallopian tubes scoop it up and send it on its way. The remnants of the burst follicle turn into a temporary endocrine organ called the corpus luteum, which secretes progesterone. This is the normal development of an ovarian follicle during the menstrual cycle.
However, with an ovarian “cyst” that ovarian follicle fails to burst on time to release the egg, and continues growing beyond its normal size. It’s like it’s stuck in the preovulatory phase for too long, growing between 2cm and 10 cm in size. Ovarian “cysts” are not necessarily painful or harmful, especially if they are small, and they may just be seen on an ultrasound. It is when they grow large enough that they start to impact the other pelvic organs, pushing against them, or causing bloating, nausea, pain, or irregular spotting. If a large ovarian cyst bursts, this can cause severe acute pain and give you the symptoms of an infection, like fever and vomiting. Most times, all that is recommended is pain medicine, and the immune system cleans up the rest on its own. In some cases the internal bleeding from the cyst can require immediate medical attention. To recap, ovarian cysts are actually normal ovarian follicles that have overgrown from the presence of too much estrogen. This makes it different from polycystic ovarian syndrome, which is a metabolic disorder with the side effect of keeping many ovarian follicles in an undeveloped state. Thus “polycystic” is also a misnomer, these are simply undeveloped ovarian follicles which fail to mature in the presence of too much estrogen.
The Path of Estrogen Metabolism
This leads us to discussing the path of estrogen metabolism.
Estrogen is a friendly hormone for us menstruators. It is something we want to make every cycle during the fertile window so that it can do its various jobs. It is primarily made in the ovaries, adrenal glands, and fat cells, and then travels through the blood stream to its various destinations. Estrogen is the Proliferator hormone and this is why it becomes a problem to have too much estrogen, instead of proliferating at the right time in the right amounts, your body is proliferating things when it shouldn’t, or to the size that it shouldn’t.
When I say estrogen metabolism, I’m talking about the normal removal process of estrogen from the body after its done its job. Some people call this “detoxification” but that word is pretty charged with a lot of connotations
So I like to say that it’s simply the process your body does to flush out estrogen its finished using, and then it will make more again in the future.
Step 1: Estrogen metabolism occurs in the liver. Your liver needs nutrients like B vitamins, magnesium, selenium and zinc, as well as protein, to do its job. It will attach a small molecule to active estrogen to inactivate it. Then it sends it to your gut to prepare to be excreted.
Step 2: This inactivated estrogen reaches your gut. When you have a healthy gut microbiome, they do all the work by assisting in estrogen removal, which is eventually physically excreted in your urine and stool. We call the microbiome which deals directly with estrogen the estrobolome.
So what can go wrong in this scenario?
1. If the liver is functionally impaired, this can lead to problems inactivating estrogen, leaving more estrogen circulating in its active form and impairing the rest of the process. Toxins that negatively effect the livers ability to detoxify estrogen include alcohol and endocrine disrupting chemicals as well as prescription drugs.
2. When you have an abundance of bad bacteria in your gut, they make an enzyme called beta-glucuronidase, which reactivates estrogen and sends it to recirculate through the body, resulting in estrogen excess. Maintaining a healthy gut microbiome is essential to excreting estrogen properly and making sure it doesn’t recirculate, a process called enterohepatic recirculation.
3. There is also the issue of hypersensitivity to estrogen, which occurs most often with iodine deficiency or chronic inflammation. Either of those issues should also be addressed if need be to deal with estrogen in excess.
4. Another cause of excess estrogen is hormonal birth control containing ethinylestradiol, a xenoestrogen that is stronger than the body’s own homemade estradiol which can damage the gut microbiome and impair estrogen metabolism.
5. Perimenopause, the time of transition before menopause, causes swings in estrogen, and this may be why it is more common to see fibroids above the age of 35.
6. Insulin resistance can also upregulate the type of estrogen called estrone, putting you at risk for uterine cancer later in life.
7. Estrogen stimulates the creation of more histamine while downregulating the enzyme that clears histamine. This becomes a vicious feedback cycle where more estrogen makes more histamine which makes more estrogen. And this is why dealing with histamine intolerance is another thing to pay attention to in this process of estrogen metabolism.
Putting it all together
At the root of all of this is prevention. We are trying to restabilize the normal path of estrogen metabolism so that estrogen can come in, do its job, and properly be excreted afterwards.
- Be gentle with your liver during the healing process and avoid alcohol, which can vastly increase your exposure to estrogen - Work on healing your gut by eating a gentle diet, dealing with gut permeability, histamine intolerance, or gut dysbiosis where bad bacteria are able to wreak havoc allowing estrogen to be reabsorbed in your body. Avoid antibiotics and pharmaceuticals if possible, which can damage healthy gut bacteria
- Avoid endocrine disruptive chemicals found in personal care and home products, plastics, pesticides, and even hormonal birth control, which is technically a xenoestrogen.
- Reduce inflammatory foods like sugar, gluten, Holstein conventional cows dairy, and other histamine containing foods to avoid the effects of insulin resistance and histamine intolerance
- Work with B-vitamins, calcium d-glucarate, selenium, and eat iodine rich foods.
- Take a probiotic containing lactobacillus casei
- Take magnesium and zinc to reduce inflammation
- Try micronized progesterone in the post-ovulatory phase to help counterbalance the effects of estrogen
I find the language that is used when my clients visit the doctor with concerns about ovarian cysts and fibroids is inadequate to actually explain to them what exactly is going on in their bodies. A combination of “wait and see what happens” and “just take the pill” is NOT acceptable! I think if the time was taken to explain to patients what are some of the root causes of estrogen excess that it would help them be able to construct a regimen that is right for them in a truly full bodied way. Shutting down ovulation and the menstrual cycle will not deal with estrogen. Ultimately, your body knows how to detoxify estrogen, in a healthy menstrual cycle it happens over and over again. If there is a problem in this pipeline of estrogen metabolism, it is imperative that you find out what it is and work to correct it. Leaving patients confused about what is causing these conditions is not helping them.