1 Dietary Intolerance and Gastro-intestinal Symptoms in Women Diagnosed with Endometriosis Muscat Baron Y., Dingli M., Camilleri Agius R., Calleja N, Brincat M Department of Obstetrics and Gynaecology, St. Luke’s Hospital and Mater Dei Hospital, Malta. MALTA ENDOMETRIOSIS SUPPORT GROUP
2 Content of Lecture Role of the Paleolithic Dietary EvolutionObjective and Methods Upper and Lower Gastrointestinal Symptoms Dietary Intolerance in Women with Endometriosis Cross-over between the Immunology of Endometriosis and Dietary Intolerance Endometriosis in relation to Ovarian Cancer and Inflammatory Bowel Disease
3 The Hunter-Gatherer
4 Evolution of Wheat (triticum aestivium) Holocene 10,000 B.C.Matsuoka Y. Evolution of polyploid triticum wheats under cultivation: the role of domestication, natural hybridization and allopolyploid speciation in their diversification. Plant Cell Physiol. 2011;52(5):
5 Introduction of Dairy Products in Human DietFarming including domestication of animals for meat and milk 4000 B.C. Farming including domestication of animals for meat 7000 B.C. Central East Europe South East Europe North West Europe Fertile Crescent
6 Alcock J, Franklin ML, Kuzawa CWAlcock J, Franklin ML, Kuzawa CW. Nutrient signaling: evolutionary origins of the immune-modulating effects of dietary fat. Q Rev Biol Sep;87(3): Dietary impact on Immune System vis a vis onset and propagation of Endometriosis?
7 Objective: To evaluate the occurrence ofGastro-intestinal symptoms and b. Dietary Intolerance in women with endometriosis. Rationale: Immunological Connection between Dietary Components and Pathogenesis of Endometriosis
8 Methods and Materials
9 Characteristics of Patients recruited for this StudyNumber of Patients Age Laparoscopy Laparotomy No Endometriosis 34 44.6 +/-9.2 32 2 Endometriosis 23 39+/-10.2* 21 *p < 0.05
10 Main Reason for LaparoscopyNo Endometriosis Endometriosis Group Dysmenorrhoea/ Dysparuenia 12 10 Ovarian Cyst 4 1 Infertility 8 Abdominal Pain Total 34 23
11 Gynaecological history of women recruited in study.Menarche Regular cycles Irregular Cycles Duration Menstrual Cycle Duration in days No Endometriosis 12.2 27 5 5.8 30.4+/- 7.4 Endometriosis 12.4 20 2 4.7 26.2+/- 2.6** **p < 0.01
12 Figure 2. Upper and Lower Gastrointestinal Symptoms in Endometriosis Group (53%) versus Control Group (31%) (Muscat Baron et al 2012).
13 Upper Gastrointestinal Symptoms inboth groups of women. Abdominal Pain Heartburn Indigestion Bloating Belching No Endometriosis 23 9 5 13 6 Endometriosis 22 19* 14* 4 * p < 0.05
14 Figure 3. Heartburn in Endometriosis Group( 82%) versus Control Group ( 26%) ( Muscat Baron et al 2011).
15 Figure 4. Dyspepsia in Endometriosis Group (61%) versus Control Group (14%) Muscat Baron et al 2011
16 Lower Gastrointestinal Symptoms in both groups of women.Flatulence Constipation Diarrhea Mucus In Stools No Endometriosis 14 5 Endometriosis 9 18 10* 2 * p < 0.05
17 Figure 13. Constipation in Endometriosis Group ( 78%) versus Control Group (41%) ( Muscat Baron et al 2011).
18 Figure 14. Figure 10. Diarrhoea in Endometriosis Group ( 43%) versus Control Group (14%) ( Muscat Baron et al 2011).
19 Dietary Intolerance to various types of food.No. of Pts Bread Pizza Pasta Red Meat White No Endometriosis 34 7 3 2 Endometriosis 23 10 5 Chicken Fish Dairy Products Milk Yoghurt Vegetables No Endometriosis N=34 1 4 8 N= 23 9 11
20 Figure 7. Dietary Intolerance to All Foodstuffs in Endometriosis Group (26%) versus Control Group(14%) ( Muscat Baron et al 2011).
21 Intolerance to Wheat Products in Endometriosis Group (43%) versus Control Group (26%) ( Muscat Baron et al 2011).
22 Figure 9. Intolerance to Dairy Products in Endometriosis Group (43.8%) versus Control Group (14.7%) ( Muscat Baron et al 2011).
23 General Symptoms Number of Patients 9 4 7 14 2 13* 8 *p < 0.05Wheezing Hypo thyroid Psychotropic Treatment Numbness No Endometriosis N = 34 9 4 7 14 Endometriosis N = 23 2 13* 8 *p < 0.05
24 Mounsey AL, Wilgus A, Slawson DCMounsey AL, Wilgus A, Slawson DC. Diagnosis and management of endometriosis. Am Fam Physician Aug 15;74(4): Carter JE. Combined hysteroscopic and laparoscopic findings in patients with chronic pelvic pain. J Am Assoc Gynecol Laparosc. Nov 1994;2(1):43-7. Verkauf BS. Incidence, symptoms, and signs of endometriosis in fertile and infertile women. J Fla Med Assoc. Sep 1987;74(9):671-5. Williams TJ, Pratt JH. Endometriosis in 1,000 consecutive celiotomies: incidence and management. Am J Obstet Gynecol. Oct ;129(3):245-50
25 DISCUSSION Initiation of Endometriosis retrograde menstrual flow as expounded by Sampson (1927). Fallopian Tube Retrograde Menstrual Flow through Fallopian Tubes Uterus Endometrial cavity Normal Menstruation Ulukus M, Arici A. Immunology of Endometriosis, Minerva Ginecol 2005;57:
26 DISCUSSION Anteverted uterus Ovarian Endometriosis Alterations in both cell-mediated and humoral immunity contribute to the pathogenesis of peritoneal endometriosis Endometriotic spots posterior to uterus and Pouch of Douglas Bladder Cervix Ulukus M, Arici A. Immunology of Endometriosis, Minerva Ginecol 2005;57:
27 Oosterlynck D, Cornille F, Waer M, Vandeputte M, Koninckx POosterlynck D, Cornille F, Waer M, Vandeputte M, Koninckx P. Women with endometriosis show a defect in natural killer activity resulting in a decreased cytotoxicity to autologous endometrium. Fertil Steril 1991;56:45-51. Kitawaki J, Xu B, Ishihara H, Fukui M et al . Association of killer cell immunoglobulin- like receptor genotypes with susceptibility to endometriosis. Am J Reprod Immunol 2007;58:481-6.
28 Ulukus M, Ulukus E, Tavmergen Goker E Tavmegen E, Zheng W, Arici AUlukus M, Ulukus E, Tavmergen Goker E Tavmegen E, Zheng W, Arici A. Expression of interlueken-8 and monocyte chemotactic protein 1 in women with endometriosis. Fertil Steril 2008;1. Agic A, Diali S, Wolfler M, Halis G, Diedrich K, Hornung D. Combination of CCR1, mRNA, MCP1 and CA125 measurements in peripheral blood as a diagnostic test for endometriosis. Reprod Sci 2008;15: Calhaz –Jorge C, Costa A, Barata M et al Tumour necrosis factor alpha concentartions in peritoneal fluid of infertile woen with minimal or mild endometriosis are lower in women with red lesionsonly than in women without red lesions. Hum Reprod 2000;
29 Eidukaite A, Siaurys A, Tamosiunas V Aberrant expression of CD 95 and CD 69 molecules among CD56 cells in women with endometriosis. 2006;55:276-81 Bohler H, Gercel-Taylor C, Lessey B, Taylor D. Endometriosis markers: immunologic alterations as diagnostic indicators for endometriosis. Reprod Sci. 2007;14: Galandrini R, Porpora M, Stoppacciaro A, et al. Increased frequency of human leukocyte antigen-E inhibitory receptor CD94/NKG2A- expressing peritoneal natural killer cells in patients with endometriosis. Fertil Steril 2008;89:
30 Ferguson A. Mechanism in adverse reactions to foodFerguson A. Mechanism in adverse reactions to food. The gastrointestinal tract. Allergy 1995;50: 32-8. Grose R, Thompson F, Cummins A. Deficiency of 6B11+invariant NK T-cells in celiac disease. Digestive Disease 2007;53: Grose R, Thompson F, Cummins A. Deficiency of invariant NK T-cells in celiac disease. Gut 2008;53:
31 Palova-Jelinkova L, Rozkova D, PecharovaB et al Gliadin fragments induce phenotypic and functional maturation of human dendritic cells. J Immunol 2005;175; Sano H, Hsu D, Yu L, Apgar J et al Human galectin-3 is a novel chemoattractant for monocytes and macrophages. J Immunol 2000;165: Yamanaka T, Saita N, Kawano O et al. Isolation of a lactose-binding protein wth monocyte/ macrophage chemotactic activity. Biological and physicochemical characteristics. Int Arch Allergy Immunol 2000;122:66-75.
32 Sano H, Hsu D, Yu L, Apgar J et al Human galectin-3 is a novel chemoattractant for monocytes and macrophages. J Immunol 2000;165: Yamanaka T, Saita N, Kawano O et al. Isolation of a lactose-binding protein wth monocyte/ macrophage chemotactic activity. Biological and physicochemical characteristics. Int Arch Allergy Immunol 2000;122:66-75.
33 Parazzini F, Chiaffarino F, Surace M, Chatenoud L, Cipriani S, Chiantera V, Benzi G, Fedele L. Selected food intake and risk of endometriosis. Hum Reprod Aug;19(8): Epub 2004 Missmer S, Chavarro J, Malspeis S, Bertone-Johnson E, Hornstein M, Spiegelman D, Barbieri R. Willet W, Hankinson S. A prospective study of dietary fat consumption and endometriosis risk. Hum Reprod 2010 Jun;25(6): Epub 2010
34 Jess T, Frisch M, Tore K, Bo JK, Pedersen V, Nielsen MJess T, Frisch M, Tore K, Bo JK, Pedersen V, Nielsen M. Increased risk of inflammatory bowel disease in women with endometriosis: a nationwide Danish cohort study. Gut Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case-control study – Part 2 Seaman H, Ballard K, Wright J, De Vries, S. BJOG
35 Pierce et al The Lancet Oncology, Early Online Publication, 2012 doi:10.1016/S1470-2045(11)70404-1
36 CONCLUSION Immunological pathways associated with dietary intolerance may influence the initiation and progression of Endometriosis. Study findings suggest preponderance of gastro- intestinal symptoms and dietary intolerance in the women with endometriosis. Dietary modification to diminish the onset of endometriosis or attenuate its effects may need to be tailored to the woman’s pattern of gastro-intestinal response to various foodstuffs.
37 E-mail to Malta Endo Support Group“Since our last meeting my life changed. The following day I decided to completely change my diet, stopped all red meat, dairy products and wheat (which used to be a big part of my diet). After a week I had my usual, ugly and painful period of just one and a half day. I simply thought that all was as always. In fact after all the spring clean ;o) I have had normal, healthy, periods. I haven't had such good periods for a decade!! I found the solution for my pain. These last few months I had no sign of endo and I am sooooooo HAPPY!!!!!”
38 'Let food be your medicine and medicine be your food' Hippocrates (460 BC)
39 Thank you