Naturopathic knowledge and approaches to managing endometriosis: a cross-sectional survey of naturopaths with experience in endometriosis care

Introduction

Globally, endometriosis is estimated to affect 10% of reproductive-age women with symptoms presenting differently among individuals [1]. Endometriosis is defined as a chronic gynaecological disease that has multifactorial pathophysiology [2]. Although the pathogenesis for endometriosis is unclear, there are several dominant theories involving retrograde menstruation, coelomic metaplasia, genetics, inflammation, stem cells, and immune dysfunction [2, 3]. Symptoms of endometriosis can include dysmenorrhoea, menorrhagia, dyspareunia, dysuria, chronic pelvic pain, and infertility [4]. However, some women can be asymptomatic and disease severity (i.e. the extent of endometrial lesions) does not correlate to the presence or severity of symptoms [5]. The varying impacts of endometriosis can result in substantial negative implications on a woman’s quality of life involving their social life, relationships, employment, financial burden, education, and overall health and well-being [6]. The cost of endometriosis in Australia alone is estimated to be $9.7 billion annually [7]. Women with endometriosis often receive healthcare through pharmaceutical interventions and laparoscopic surgery [8, 9]. The effectiveness of pharmaceutical interventions can vary depending on the type of treatment and presentation of endometriosis. Some pharmaceutical treatments (e.g. oral contraceptive pill, GnRH analogues) show promise in providing endometriosis-associated pain relief and are well tolerated in symptomatic women [2]. After diagnosis, women can still experience disease progression [8] with reports of recurrence between 6 and 67% post laparoscopic surgery within an average of two to five years [10].

Women with endometriosis are known to seek care from various healthcare professions within conventional medicine [5, 11], allied health, and traditional and complementary medicine (T&CM) [5, 12, 13]. Research suggests that women with endometriosis need to have access to a multidisciplinary team for ongoing management [5], to improve long term clinical outcomes [14], and for access to pain management services [9]. As a healthcare service, T&CM professions such as naturopathy are utilised by reproductive-age women, particularly those with chronic diseases [13, 15], [16], [17]. Reasons for T&CM use by women with endometriosis can be due to medical dismissal, taking control of their symptoms and disease, dissatisfaction with standard care [12] or that some T&CM treatments provide better effectiveness compared to hormonal interventions [18]. Naturopathy, defined as a traditional medicine system is one T&CM profession [19, 20] that is utilised by women with endometriosis [13, 16, 21, 22]. Australian research suggests that naturopaths are one of the most common T&CM professions utilised by women with endometriosis, who are 1.5 times more likely to seek naturopathic care than those without endometriosis [13]. Australian prevalence data reports that 0.7–19.8% of women with endometriosis seek care from a naturopath [13, 16, 21, 22].

Reports of naturopathic treatments for endometriosis [23, 24] and the effectiveness of those naturopathic treatments are in their infancy [23], however, one study reported various naturopathic treatments and the perceived effectiveness by naturopathy users who sought care for endometriosis management [21]. The naturopathic approach to care is underpinned by a philosophical framework emphasising the treatment, prevention, and promotion of health through the application of therapeutic practises (such as herbal medicine, clinical nutritional medicine, dietary counselling, and lifestyle recommendations) [19, 20]. This approach provides individualised care that is suitable in chronic and complex diseases where a holistic approach is needed [25]. The utilisation of naturopathic therapeutic practises is applied to a patient-centred framework involving an integrative and multidisciplinary approach [26, 27], in conjunction with various forms of naturopathic knowledge.

The patient-centred framework delivered by naturopaths has potential to address areas of endometriosis care that are of importance to women. These areas could be addressed through naturopathy by using a hierarchy of therapeutics [28] that aligns to reducing endometriosis-associated pain, symptom management (particularly bothersome symptoms), improving quality of life, and supporting women’s satisfaction with treatment [29] through patient empowerment and self-management strategies, where appropriate. Further, this approach utilises naturopathic knowledge involving the application of traditional knowledge, scientific research, clinical intuition, and expertise delivered through evidence-based practice and adherence to the philosophical frameworks of the profession.

Currently, the Australian Endometriosis Clinical Practice Guideline recommends a multidisciplinary approach to ensure comprehensive care [9]. Research into multidisciplinary care and clinical management programs for endometriosis has investigated the role of conventional and allied healthcare [14, 30] in managing endometriosis. However, there has been little research exploring the naturopathic knowledge and approaches to endometriosis, despite the use of this profession by women with endometriosis [21, 22] and the acknowledgement of naturopathy as a healthcare service for women [9]. In direct response to these gaps, this study aims to explore the naturopathic knowledge and clinical approach including multidisciplinary involvement for endometriosis by naturopaths with experience in menstrual disorders.

Materials and methods

Results

Discussion

An important aspect to consider for this research is the different perspectives in healthcare from naturopaths compared to medical doctors. In the context of this study, some results may not align with contemporary medical knowledge of endometriosis. This relates to the differences in terminologies, definitions, and approaches between the two aforementioned healthcare professionals. While the differing views between naturopathy and conventional healthcare are known [32], this study adds to previous work by enhancing the understanding of the value and potential role and application of naturopathy in a complex disease like endometriosis.

The majority of naturopaths involved in this study identified inflammation and genetics as the causes of endometriosis. While the pathogenesis of endometriosis is unclear [2, 33], both inflammation and genetics are involved in the proposed pathogenesis theories [2]. Whether inflammation is the factor that perpetuates the disease is not yet known [2, 34]. However, increasing evidence suggests that endometriosis may be a systemic inflammatory disease due to notable increases in activated macrophages and inflammatory cytokines [2, 35]. Medical research does not define endometriosis to be caused by inflammation, however, inflammation is acknowledged as an essential aspect [2, 34]. Study participants stated their patient’s primary concern was symptoms that can be caused by inflammation, such as dysmenorrhoea and chronic pelvic pain [36]. To address these concerns, participants described aiming to reduce inflammation, as well as supporting gastrointestinal function and promoting oestrogen clearance. These three aspects of naturopathic care demonstrate that naturopaths may be addressing the philosophical principles Tolle causam (treat the cause) and Tolle totum (treat the whole person) by focussing on multiple factors in endometriosis pathophysiology. While the clinical naturopathic approach to endometriosis has complexities [25], the approach identified through our study highlights that naturopaths are targeting a key area of endometriosis pathophysiology in an attempt to achieve positive patient outcomes such as quality of life and reducing dysmenorrhoea. While this approach to care is important in endometriosis management, the efficacy and impact of the naturopathic approach in modulating inflammation-related symptoms are unclear.

Genetics was also considered a cause and risk of endometriosis by participants in our study. The inheritable nature of endometriosis has gained research attention as part of the potential cause of the disease [37, 38]. However, clear identification of genetic variations and inheritance patterns has yet to be fully established [2, 38]. Although, familial aggregation is known to be a high-risk factor for endometriosis [3]. Familial aggregation and linkage analysis studies have identified endometriosis in first-degree family members with continued prevalence in second and third-degree family members [39]. In Australia, naturopathic curriculum does not include in-depth training in genetics but does include the role of genetics in disease processes to understand an individual’s metabolic and physiologic risk [37, 40]. Identifying genetics as a cause and risk factor in endometriosis may be indicative of holism which is a focal point in naturopathic philosophy and principles. This holistic approach may present in clinical practice by addressing risk factors that may increase the likelihood of endometriosis such as environmental exposures (e.g. dioxin, polychlorinated biphenyls, diethylstilboestrol) [41]. Additionally, this approach may draw on features of precision medicine whereby naturopaths employ individualised treatments to support the philosophical underpinnings of their clinical care [42]. While consideration of genetics is important, naturopaths drawing on features of precision medicine may be innovative care within naturopathy. However, it could lead to the potential use or overuse of complex or ineffective treatments as an indiscriminate approach rather than resulting in a more conservative approach to endometriosis care. As this study did not collect data on genetic treatments or tests recommended by naturopaths, research focused on this topic is warranted.

Findings in this study suggest that naturopaths aim to support gastrointestinal function and the promotion of oestrogen clearance in endometriosis care. Interesting, both abdominal bloating and menorrhagia were reported as frequent presenting concerns by women with endometriosis. The gastrointestinal system is an important aspect of naturopathic care for reasons relating to its bi-directional function in endocrine, neural, and immunological bio-mechanisms [43]. Naturopaths have historically targeted the gastrointestinal system to improve immunological functioning, reduce inflammatory processes, balance regulatory systems, and optimise metabolic functioning [44]. Study participants may be targeting this biological system for various reasons. The rationale for addressing gastrointestinal involvement in endometriosis may relate to the immunomodulation and inflammatory process known within the microbiome [45] and addressing abdominal symptoms (such as bloating and irritable bowel syndrome) [46, 47]. From a naturopathic perspective supporting the gastrointestinal system may also promote oestrogen clearance by reducing the reabsorption of deconjugated oestrogen [48]. However, the effectiveness of this approach in endometriosis and symptom management is currently unknown.

Naturopaths in our study appear to attempt multidisciplinary care, by referring women with endometriosis to and receiving referrals from both practitioners within the conventional medicine and T&CM professions. Naturopaths reported referring to General Practitioners (GPs) primarily for a multidisciplinary approach to endometriosis care. GPs are well positioned to provide collaborative support for women with endometriosis with the use of prescribed pharmaceuticals and additional referrals, both of which are commonplace in endometriosis care [2, 49]. Referrals to T&CM professionals – acupuncturists/TCM practitioners – may be indicative of the supportive evidence for these practitioners in treating endometriosis, particularly pelvic pain, and dysmenorrhoea [50], [51], [52]. Likewise, the reported referrals from healthcare professionals (such as GPs and psychologists), indicate that these referrals to naturopaths were conducted to establish a multidisciplinary team approach to endometriosis care. This suggests that naturopaths may be a profession to consider for endometriosis multidisciplinary management.

Multidisciplinary care is an essential factor in ensuring adequate evaluation of endometriosis and improvement in patient outcomes [5, 14]. While the findings of referrals in our study are important, there is some evidence of poor communication between naturopathy and other health professionals [32]. Reasons for poor multidisciplinary collaboration between naturopaths and conventional healthcare professionals are often attributed to the differences between philosophical frameworks, negative professional perception of naturopathy, professional competition, and questionable validity of naturopathic care [32, 53]. The limited cross-communication between naturopathy and conventional healthcare professions often relies on the patient to pass knowledge between both healthcare professionals [54, 55]. Ensuring open and respectful communication between healthcare professionals is important in providing optimal care for individuals utilising these professions [15, 17]. Therefore, infrastructure improvement is needed to encourage cross healthcare collaborations to deliver safe and effective multidisciplinary care involving naturopaths for women with endometriosis.

Conclusions

Naturopathic knowledge and management of endometriosis targets known problematic areas of endometriosis that can have debilitating effects on women’s quality of life. Naturopathic care has the potential to align with important health outcomes for women with endometriosis however, further attention is needed to assess the effectiveness and continue to establish a multidisciplinary approach involving naturopathic care.