Gastro-intestinal Symptoms and Dietary Intolerance in Women Diagnosed with Endometriosis

Transcription

1 Gastro-intestinal Symptoms and Dietary Intolerance in Women Diagnosed with Endometriosis Muscat Baron Y., Dingli M., Camilleri Agius R., Calleja N, Brincat MP. Department of Obstetrics and Gynaecology, St. Luke s Hospital and Mater Dei Hospital, Malta. MALTA ENDOMETRIOSIS SUPPORT GROUP

2 Objective: To evaluate the occurrence of a. Gastro-intestinal symptoms and b. Dietary Intolerance in women with endometriosis. Rationale: Immunological Connection between Dietary Components and Pathogenesis of Endometriosis

3 In fifteen (15) of the women, the whole questionnaire was asked again by a different observer to validate the methodology. The correlation of the results obtained in the latter group, when comparing the results of the same questionnaire asked twice, was r = 0.84 Methods and Materials Fifty-seven (57) menstrual women who complained of gynaecological symptoms and / or complained of infertility underwent laparoscopy to reach a diagnosis. These women were recruited sequentially into the study so as to avoid bias (age range years). Prior to the laparoscopy, a questionnaire was set up so as to enquire on occurrence of gynaecological symptoms, dietary intolerance, gastrointestinal and general complaints in these women.

4 Characteristics of Patients recruited for this Study Number of Patients Age Laparoscopy Laparotomy No Endometriosis / Endometriosis /-10. 2* 21 2 *p < 0.05

5 Main Reason for Laparoscopy No Endometriosis Endometriosis Group Dysmenorrhoea/ Dysparuenia Ovarian Cyst 4 1 Infertility 10 8 Abdominal Pain 8 4 Total 34 23

6 Gynaecological history of women recruited in study. Menarche Regular cycles Irregular Cycles Duration Menstrual Cycle Duration in days No Endometriosis /- 7.4 Endometriosis /- 2.6** **p < 0.01

7 Upper Gastrointestinal Symptoms in both groups of women. Abdominal Pain Heartburn Indigestion Bloating Belching No Endometriosis Endometriosis 22 19* 14* 9 4 * p < 0.05

8 Heartburn in Endometriosis and Control Group Percentage of Patients Endometriosis p < 0.05 Control Grp

9 Lower Gastrointestinal Symptoms in both groups of women. Flatulence Constipation Diarrhea No Endometriosis Endometriosis * 2 Mucus In Stools * p < 0.05

10 Diarrhoea in Endometriosis and Control Group Percentage of Patients p < 0.05 Endometriosis Control Grp

11 Dietary Intolerance to various types of food. No. of Pts Bread Pizza Pasta Red Meat White Meat No Endometriosis Endometriosis Chicken Fish Dairy Products Milk Yoghurt Vegetables No Endometriosis N= Endometriosis N=

12 General Symptoms Number of Patients Wheezing Hypo thyroid Depression Numbness No Endometriosis N = Endometriosis N = * 8 *p < 0.05

13 Comparison of occurrence of events by category in both groups of women N Gastrointestinal Symptoms Dietary Intolerance Gynaecological Symptoms General Symptoms No Endometriosis Endometriosis p=ns p=ns p=ns p=ns

14 DISCUSSION 6-10% women have endometriosis. Prevalence rate of 20-50% in infertile women, 80% in women with chronic pelvic pain. Endometriosis was found during laparoscopy in 20-50% of asymptomatic women. Mounsey 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): Williams TJ, Pratt JH. Endometriosis in 1,000 consecutive celiotomies: incidence and management. Am J Obstet Gynecol. Oct ;129(3):245-50

15 DISCUSSION Initiation of Endometriosis retrograde menstrual flow as expounded by Sampson (1927). Following the retrograde menstrual flow a number of immunological mechanisms have been implicated. There is a substantial body of evidence to support that the alterations in both cellmediated and humoral immunity contribute to the pathogenesis of endometriosis. Ulukus M, Arici A. Immunology of Endometriosis, Minerva Ginecol 2005;57:

16 Cellular Immunity Decreased T cell cytotoxicity Decreased Natural Killer cell cytotoxicity Polymorphisms in killer cell Immunoglobulin -like receptors Oosterlynck 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: 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.

17 Increased levels of cytokines and growth factors Interleukin-8 (IL-8) Monocyte chemotactic protein-1 (MCP-1) Tumour necrosis factor alpha Ulukus 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;

18 Resistance of the Ectopic Endometrium against Immune Cells Elimination of Natural Killer cells Autoantibodies reactive with cellular proteins Suppression of natural killer cell zeta expression Eidukaite A, Siaurys A, Tamosiunas V Aberrant expression of CD 95 and CD 69 molecules among CD56 cells in women with endometriosis. 2006;55: 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:

19 Dietary proteins Gluten and Casein Similar cytokines and T cell reactivity High titers of antibodies Altered cell mediated responses Ferguson A. Mechanism in adverse reactions to food. The gastrointestinal tract. Allergy 1995;50: 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:

20 Coeliac Disease Harmful T cell-mediated immune response INTERLEUKINS IL-6, IL-8, IL-10, MCP-1 and macrophage-derived chemokine 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.

21 Lactose Intolerance Galectin-3 induces a human monocyte migration MCF-pl5-L dose-dependent Monocyte chemotactic activity TNF-alpha from macrophages 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.

22 Parazzini et al Missmer et al Low Risk Neutral Risk High Risk Green vegetables Fresh fruit Dairy Products Seafood Cereal Red Meat Unsaturated Fats, Beef Ham 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

23 Endometriosis Increased risk of Inflammatory bowel disease INFLAMMATORY BOWEL DISEASE ULCERATIVE COLITIS CROHN S DISEASE (SIR=1.5; 95% CI 1.4 to 1.7) (SIR=1.5; 95% CI 1.3 to 1.7) (SIR=1.6; 95% CI 1.3 to 2.0) Jess 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

24 CONCLUSION Immunological pathways associated with dietary intolerance may influence the initiation and progression of Endometriosis. The findings in this study may lend support to this hypothesis with the preponderance of gastrointestinal symptoms and dietary intolerance noted 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.

25 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!!!!!