More Than Surgery- Emerging Research And Solutions for Endo
Endometriosis: Why Surgery Is Only One Piece of the Puzzle
For many women, endometriosis is far more than painful periods. It is a chronic inflammatory condition that can affect the reproductive system, gastrointestinal tract, bladder, pelvic nerves, immune function, and overall quality of life. While there is no single treatment that works for every woman, the current evidence suggests that a comprehensive approach addressing both the disease itself and the body's inflammatory response provides the best opportunity for long-term symptom improvement.
Excision Surgery: The Current Gold Standard
When endometriosis lesions are identified, laparoscopic excision surgery remains the surgical treatment with the strongest evidence for removing disease. Unlike ablation, which burns the surface of lesions, excision removes the lesions entirely and allows tissue to be sent for pathology confirmation. Multiple studies have demonstrated improved symptom relief and quality-of-life outcomes following excisional surgery, particularly for deep infiltrating disease and ovarian endometriomas. Recurrence rates also appear lower when disease is completely removed by experienced surgeons.
Excision surgery is not a cure, however. Endometriosis is a complex inflammatory condition, and many women require additional support before and after surgery to address hormone balance, nervous system regulation, gut health, and chronic inflammation.
The NaPro Technology Approach
Natural Procreative Technology (NaProTechnology) physicians take a different approach than conventional gynecology. Rather than suppressing the menstrual cycle, NaPro physicians aim to identify and address underlying causes contributing to symptoms.
Many NaPro physicians focus on:
Detailed cycle charting through the Creighton Model
Evaluation of progesterone production and timing
Identification of ovulatory dysfunction
Assessment of heavy menstrual bleeding
Fertility preservation
Collaboration with excision surgeons when indicated
The goal is not simply symptom suppression but restoration of healthy reproductive function whenever possible.
Nutrition: Lowering the Inflammatory Burden
Nutrition alone cannot remove endometriosis lesions, but it may significantly influence inflammation and symptom severity.
Many women report improvement by emphasizing:
Wild-caught salmon and/or omega-3-rich fish
Colorful vegetables and berries
High-quality protein at each meal
Adequate fiber
Extra virgin olive oil
Proper hydration
Common triggers reported by some women include:
Alcohol
Highly processed foods
Excess sugar
Ultra-processed seed oil-rich foods
Emerging research also suggests a connection between gut health and endometriosis symptoms, highlighting the importance of individualized dietary strategies.
Pelvic Floor Therapy: Often Overlooked
Years of pelvic pain can create secondary dysfunction within the pelvic floor muscles.
Depending on the individual's symptoms, pelvic floor therapy may include:
Down-Training
For women with muscle guarding, spasms, painful intercourse, urinary urgency, or chronic pelvic pain.
Manual Therapy
Hands-on treatment designed to release muscle tension, scar tissue restrictions, and connective tissue dysfunction.
Myofascial Release
Gentle techniques that address fascial restrictions throughout the pelvis, abdomen, hips, and low back.
Breathing and Core Retraining
Proper diaphragmatic breathing helps regulate pressure within the abdomen and improves pelvic floor coordination.
Post-Surgical Rehabilitation
Many women benefit from pelvic floor therapy after excision surgery to address scar tissue, mobility, and residual pain patterns.
Hormone Management
Endometriosis is often described as an estrogen-dependent condition, but the story is more complex.
Research suggests many women experience:
Progesterone resistance
Altered estrogen signaling within lesions
Chronic inflammation
Immune dysregulation
Hormone management may include:
Optimizing ovulation
Supporting healthy progesterone production
Addressing heavy menstrual bleeding
Evaluating thyroid function
Supporting iron stores in women with chronic blood loss
The goal is to create an environment less supportive of ongoing inflammation while preserving healthy hormonal function.
Gut Health and Endometriosis
Many women with endometriosis experience:
Bloating
Constipation
Diarrhea
Food sensitivities
IBS-like symptoms
The gut and reproductive systems communicate through immune signaling, inflammatory pathways, and hormone metabolism.
Supportive strategies may include:
Restoring microbial diversity
Improving bowel regularity
Supporting intestinal barrier integrity
Identifying food triggers
Addressing underlying inflammation
Nervous System Regulation
Chronic pain changes the nervous system.
Over time, pain pathways can become amplified, causing symptoms to persist even after lesions have been removed.
Helpful therapies may include:
Vagal nerve stimulation
Breathwork
Meditation
Gentle exercise
Walking
Strength training
Sleep optimization
Counseling and trauma-informed care when appropriate
Nervous System Based Chiropractic Care
The goal is not to imply symptoms are "in your head," but to recognize that the nervous system plays a significant role in pain perception.
N-Acetylcysteine (NAC): One of the Most Promising Supplements
Among supplements studied for endometriosis, NAC has some of the most encouraging clinical data.
Research has demonstrated that NAC may:
Reduce pelvic pain
Improve dysmenorrhea
Reduce endometrioma size
Lower CA-125 levels
Potentially improve fertility outcomes
Several studies have reported significant symptom improvement in women using NAC supplementation. Researchers have proposed that NAC may help regulate oxidative stress, inflammation, and cellular signaling involved in endometriosis progression.
Saffron: An Emerging Tool for Pain and Mood Support
Saffron is gaining attention for its effects on:
Menstrual pain
Pelvic pain
Mood regulation
Anxiety
PMDD-like symptoms
Current research suggests saffron may influence inflammatory pathways, neurotransmitter balance, and pain perception. While it is not a treatment for endometriosis itself, it may serve as a useful adjunct for symptom management.
Microdosed Tirzepatide: A Novel Approach to Metabolic and Inflammatory Support
At The Wellness Lounge, we are also exploring the role of microdosed tirzepatide as part of a comprehensive wellness strategy for select patients.
While tirzepatide is not approved as a treatment for endometriosis, its effects on:
Blood sugar regulation
Insulin resistance
Systemic inflammation
Weight management
Metabolic health
may indirectly support women who struggle with chronic inflammation and metabolic dysfunction alongside endometriosis.
This approach is individualized and intended to complement, not replace, evidence-based endometriosis care.
Off-Label Medications in Endometriosis Care
Because endometriosis is a complex inflammatory, immune, hormonal, and pain condition, many physicians utilize medications off-label to address specific symptoms or underlying mechanisms contributing to disease burden. "Off-label" simply means a medication is being used for a condition other than its original FDA-approved indication based on emerging evidence, clinical experience, and physician judgment.
Some examples include low-dose naltrexone (LDN), which may help regulate inflammation and immune signaling; metformin, which has been studied for its potential effects on inflammation and estrogen-related pathways; and certain antidepressants or neuromodulators that may be used to help manage chronic pelvic pain and central sensitization. Some physicians also utilize tranexamic acid to reduce heavy menstrual bleeding, helping to minimize blood loss and preserve iron stores in women experiencing significant menstrual bleeding.
Emerging areas of interest include the use of N-acetylcysteine (NAC), which has demonstrated promising effects on pain, inflammation, and endometrioma size, as well as metabolic therapies aimed at improving insulin sensitivity and reducing systemic inflammation. While many of these therapies are not considered first-line treatments, they may play a valuable role as part of an individualized treatment plan.
As with any medical intervention, off-label medication use should be discussed thoroughly with a qualified healthcare provider who can evaluate the potential benefits, risks, and appropriateness based on a patient's unique health history, symptoms, fertility goals, and treatment objective
Laboratory Evaluation for Women with Suspected Endometriosis
While laboratory testing cannot diagnose endometriosis, it can help identify common nutrient deficiencies, inflammatory patterns, hormonal imbalances, and metabolic dysfunction that frequently accompany the condition.
Iron Panel
Heavy menstrual bleeding is extremely common among women with endometriosis and adenomyosis.
Recommended tests:
CBC
Ferritin
Serum Iron
TIBC
Transferrin Saturation
Suggested functional ranges:
Ferritin: 50-100 ng/mL (many women report optimal energy above 75)
Iron Saturation: 25-40%
Hemoglobin: 13.0-15.0 g/dL
MCV: 85-95 fL
Low iron stores can contribute to:
Fatigue
Hair loss
Exercise intolerance
Brain fog
Restless legs
Poor progesterone production
Inflammatory Markers
Recommended tests:
hs-CRP
ESR
Suggested ranges:
hs-CRP: Less than 1.0 mg/L
ESR: Less than 15 mm/hr
While many women with endometriosis have normal inflammatory markers, elevations may indicate increased systemic inflammation.
Comprehensive Thyroid Panel
Thyroid dysfunction frequently overlaps with menstrual irregularities and fertility concerns.
Recommended tests:
TSH
Free T4
Free T3
TPO Antibodies
Thyroglobulin Antibodies
Suggested functional ranges:
TSH: 1.0-2.5 mIU/L
Free T3: Upper half of range
Free T4: Mid to upper range
Thyroid antibodies: Negative
Reproductive Hormones
Testing should be timed appropriately within the menstrual cycle.
Cycle Day 3:
Estradiol
FSH
LH
AMH (if fertility concerns exist)
Mid-Luteal Phase (approximately 5-7 days after ovulation):
Progesterone
Estradiol
Suggested functional ranges:
Mid-luteal progesterone: Above 10 ng/mL
Estradiol: Appropriate to cycle phase
FSH and LH balanced relative to age
Vitamin D
Recommended test:
25-OH Vitamin D
Suggested range:
50-80 ng/mL
Vitamin D plays a role in immune regulation, inflammatory signaling, and reproductive health.
Metabolic Assessment
Recommended tests:
Fasting Glucose
Fasting Insulin
Hemoglobin A1c
Suggested ranges:
Fasting Insulin: Less than 8 μIU/mL
Fasting Glucose: 75-90 mg/dL
A1c: Less than 5.3%
Emerging research suggests insulin resistance may contribute to inflammatory pathways and hormonal dysfunction.
Nutrient Status
Recommended tests:
Vitamin B12
Folate
RBC Magnesium
Zinc
Copper
Ceruloplasmin
Suggested ranges:
B12: 500-900 pg/mL
RBC Magnesium: Upper half of range
Zinc ratio approximately 1:1
Autoimmune Screening
Depending on symptoms:
ANA
Rheumatoid Factor
Anti-CCP
Celiac Panel
Many women with endometriosis also experience autoimmune or immune-mediated conditions.
Gastrointestinal Evaluation
For women with significant bloating, IBS symptoms, constipation, diarrhea, or food sensitivities:
Consider:
Comprehensive stool analysis
Celiac screening
H. pylori testing
Occult blood testing when indicated
Optional Advanced Testing
Some integrative providers may consider:
Homocysteine
Omega-3 Index
Oxidative stress markers
Organic Acids Testing
Mast Cell and Histamine Evaluation
Potential markers:
Plasma Histamine
DAO Activity
Tryptase
These tests may be particularly helpful for women experiencing:
Histamine intolerance
Chronic itching
Flushing
Migraines
Food sensitivities
Cyclic allergic-type symptoms
A Note About CA-125
CA-125 may be elevated in some women with endometriosis, particularly advanced disease, but it is not sensitive or specific enough to be used as a diagnostic test. It should never be used alone to rule endometriosis in or out.
The Bottom Line
Endometriosis is rarely solved by a single intervention. For many women, the best outcomes come from combining expert excision surgery with comprehensive support for hormones, nutrition, gut health, pelvic floor function, inflammation, and nervous system regulation.
The goal is not simply to suppress symptoms but to help women reclaim energy, reduce pain, preserve fertility, and improve quality of life.
References
Bignardi T, et al. Excisional versus ablative surgery for peritoneal endometriosis. Cochrane Review. 2019.
Mackenzie M, et al. Laparoscopic excision vs ablation outcomes in endometriosis. American Journal of Obstetrics and Gynecology. 2023.
Anastasi E, et al. Efficacy of N-Acetylcysteine on Endometriosis-Related Pain and Fertility. International Journal of Environmental Research and Public Health. 2023.
Porpora MG, et al. A Promise in the Treatment of Endometriosis: An Observational Cohort Study on NAC. 2013.
Goyal A, et al. Saffron Extract as an Emerging Novel Therapeutic Option for Women's Reproductive Health. 2024.
Mayo Clinic. Endometriosis: Symptoms and Causes. 2024.
Cleveland Clinic. Endometriosis: Causes, Symptoms, Diagnosis and Treatment. 2024.