Endometriosis is a common disease that affects up to 10% of reproductive women––190 million women––globally. With endometriosis, tissue similar to the lining of the uterus, known as the endometrium, grows outside the uterus where it shouldn’t be, causing pain and infertility.
Symptoms of endometriosis can include the following:
Cramping around menstruation
Heavy bleeding during or between periods
Pain during and/or after sex
Painful bowel movements
Chronic pelvic pain
Lower back pain
In many cases, it can take 4-11 years from the first sign of symptoms to a confirmed diagnosis with an invasive laparoscopic surgery, which is the gold standard for diagnosing endometriosis.
Conventional Treatment of Endometriosis
Conventional treatments include:
Gonadotropin-releasing hormone (GnRH)
Danazol (a pharmaceutical drug)
Laparoscopic surgery to try to remove or destroy endometrial tissue
There is no cure for endometriosis.
What Causes Endometriosis?
The exact cause of endometriosis is not known, but there are many theories, with the most common being retrograde menstruation, in which menstrual blood flows back through the fallopian tubes into the pelvic cavity, rather than leaving the body through the vagina.
This can result in endometrial-like cells being deposited outside the uterus, where they implant themselves and begin to grow, leading to endometriosis.
Looking Deeper Into Endometriosis
Beyond retrograde menstruation––of which 90% of women experience, but only a small percentage will progress to endometriosis––what else could be contributing to the development of endometriosis?
In functional medicine, we always look at the whole body to evaluate how every system is functioning in order to understand why dysfunction may be occurring.
A Functional Medicine Approach To Treating Endometriosis
With endometriosis, it’s very likely there’s more at play than just retrograde menstruation, including issues with gut health, the microbiome, intestinal permeability, bacterial contamination, the estrobolome, hormonal imbalances, estrogen metabolism, immune dysregulation, autoimmunity, endocrine-disrupting chemicals, environmental chemicals and pollutants, toxin overload, inflammatory diet, nutrient deficiencies, systemic inflammation, stress and more.
As we have known since the time of Hippocrates, all disease begins in the gut.
Studies have confirmed that the gut microbiota is indeed altered in patients with endometriosis. Microbial diversity was found to differ significantly between healthy controls and patients with endometriosis.
Healing the gut is the foundation upon which all health is built and there is no exception in the case of patients with endometriosis. Restoring healthy balance, diversity and abundance to the gut microbiome should be a primary consideration for all endometriosis patients.
One study found patients with endometriosis had abnormal intestinal permeability, indicating a possible pathogenesis for endometriosis.
Intestinal permeability (aka leaky gut) occurs when tight junctions in the lining of our intestinal tract become hyperpermeable, allowing toxins, pathogens, large molecules and food particles into the bloodstream that should not be there, causing an inflammatory immune response.
Addressing all the factors that can contribute to intestinal permeability, including viral and bacterial infections, antibiotics and other medications, toxins, stress, inflammation, food intolerances, and imbalances in gut bacteria, plus healing the abnormal permeability, should be explored for all endometriosis patients.
Supplementation with L-Glutamine, as well as supporting cofactors like deglycyrrhizinated licorice root, slippery elm bark, aloe vera, marshmallow root and MSM can help to support intestinal permeability.
A 2018 paper proposed a new concept in endometriosis, called the “bacterial contamination hypothesis”. High levels of bacterial endotoxins and lipopolysaccharides, like Escherichea coli, were found in the menstrual blood and peritoneal fluid of women with endometriosis.
These findings suggested that the contamination of menstrual blood with E. coli in women with endometriosis could be a constant source of bacterial endotoxin in the peritoneal fluid due to periodic retrograde menstrual flow and that this cyclic event could initiate the growth of endometriosis.
Bacteria making their way into the uterus and peritoneal lining then contribute to the inflammatory effects of endometriosis. Endometrial samples have been found to be colonized with microbes.
Treatment with gonadotropin-releasing hormone (GnRHa), which is commonly used in women with endometriosis as an estrogen-suppressing agent, was actually found to further worsen intrauterine microbial colonization, leading to the occurrence of endometritis in women with endometriosis.
Study authors proposed that the use of intravaginal or oral probiotics and/or antibiotics could offer some protection and prevention against subclinical vaginal or uterine infection.
Based on this recommendation, implementing vaginal and oral probiotics and antimicrobials could be an effective aspect of a patient’s treatment plan, depending on symptoms and state of the vaginal and gut microbiomes.
The estrobolome is a collection of gut bacteria capable of metabolizing and modulating the body's circulating estrogen.
Overgrowths of gut bacteria producing beta-glucuronidase can exacerbate endometriosis by leading to increased levels of circulating estrogen.
Estrogen drives endometriosis, so addressing these types of gut imbalances that adversely influence systemic estrogen levels within the estrobolome is a necessary part of any treatment for patients with endometriosis.
Vaginal dysbiosis, such as a decrease in Lactobacilli and an increase in pathogenic gram-negative bacteria, may also play a role in endometriosis, making the vaginal flora an essential microbiome to consider, as well, when treating a patient’s systemic microbiome.
Endometriosis is driven by high levels of circulating estrogen, which can both trigger and exacerbate symptoms.
Putting the body in position to effectively eliminate excess estrogen by optimizing liver and gut function is an essential aspect of treating the hormonal side of endometriosis.
Supplements such as I3C (Indole-3-carbinol), DIM (Diindolylmethane) and Calcium-D-Glucarate can be particularly supportive in the regulation of estrogen metabolism.
These compounds can also be attained through diet and are found in high amounts in cruciferous vegetables, like Brussels sprouts, broccoli, cabbage, cauliflower and kale. The fiber in these foods also naturally supports hormone and toxin clearance from the body.
I3C helps bind to excess estrogen, supporting the safe excretion and avoidance of reabsorption and recirculation of estrogens back into the body.
DIM helps prevent the adverse effects of estrogen on cells, and supports estrogen metabolism by increasing the beneficial 2-hydroxy estrogens, while reducing the undesirable 4-hydroxy and 16-hydroxy types, which are associated with various cancers, particularly breast cancer.
Calcium-D-Glucarate helps remove toxins and excess hormones from the body by inhibiting beta-glucuronidase, which produces active, unbound estrogen capable of binding to estrogen receptors and influencing estrogen-dependent processes in the body.
While there may be a genetic component to endometriosis to some extent, there is a significantly stronger epigenetic component, to be sure.
This can begin as early as the intrauterine environment where a baby develops, if they are exposed to hormone-disrupting chemicals, such as phthalates, dioxins, PCBs and bisphenol A, which are everywhere in our environment.
These xenobiotics and xenoestrogens act like hormones in the body and can strongly influence the potential development of many diseases, including endometriosis.
It’s essential to do everything in our power to limit exposure to the endless bombardment of toxins and chemicals our bodies face every day.
Evaluating and addressing possible exposures from personal care products, make-up, home cleaning products, off-gassing furniture and home goods, food storage containers, drinking containers, food chemicals, fragrances, pesticides, environmental toxins, pollutants and more are a few places we can make a difference.
Additionally, considering some level of air filtration to support the home environment is recommended. Americans, on average, spend approximately 90 percent of their time indoors, where the concentrations of some pollutants are often two to five times higher than typical outdoor concentrations.
A meta-analysis of multiple studies found an association between endometriosis and autoimmune diseases.
These included autoimmune thyroiditis, systemic lupus erythematosus, Sjögren’s syndrome, rheumatoid arthritis, celiac disease, multiple sclerosis and inflammatory bowel disease.
A separate case-control study additionally found that endometriosis is more severe in patients who are also affected by autoimmune disturbances.
While the connection between autoimmune disease and endometriosis may not be entirely clear at this time, the underlying link of inflammation is certainly significant and should be a central focus in the treatment of both autoimmune disease and endometriosis.
Galectin-3––a protein that is part of the immune system and has been linked to endometriosis––can fuel cellular growth, inflammation and scarring. A 2019 study proposed the use of Gal-3 inhibitors in the treatment of endometriosis.
Modified citrus pectin, a natural complex polysaccharide obtained from the peel and pulp of citrus fruits, can block the activity of galectin 3, which in turn could slow down endometrial fibrosis.
Addressing the many factors contributing to immune dysregulation and systemic inflammation is essential in both the treatment of endometriosis and any autoimmune disease. In doing so, we are able to support the immune system in returning to a balanced response, as a regulated immune system should be neither overactive, nor underactive.
Utilizing Functional Medicine Lab Testing
Treating the patient holistically by evaluating all the systems of the body is essential to uncovering all the various underlying mechanisms contributing to the presentation of endometriosis.
While the signs and symptoms of endometriosis may be generally localized to the reproductive organs and pelvis, recognizing the interconnectedness of every physiological process in the body is at the foundation of a functional medicine work-up exploring the causes of endometriosis in each individual.
Here are some of the tests that are likely to be included to support the treatment of endometriosis:
A full hormone panel that includes an evaluation of estrogen metabolism and cortisol.
A comprehensive stool analysis to evaluate gut health, the microbiome, intestinal permeability, beta-glucuronidase, infections, inflammation and much more.
Organic acids testing to evaluate micronutrient status of essential vitamins, minerals, amino acids, fatty acids and plant-based antioxidants, as well as cellular functions like mitochondria, and accumulation of toxic environmental pollutants and heavy metals.
A comprehensive functional blood chemistry panel with CBC, metabolic panel, inflammatory markers like CRP-hs, liver and kidney function, lipid panel, iron panel, thyroid panel, homocysteine, HA1C, CA125 and more.
Environmental toxin and chemical exposure testing to evaluate toxic burden in the body.
Genetic testing to evaluate methylation status (MTHFR, COMT), as well as inflammation and oxidative stress (TNF-alpha).
Supplemental Support For Endometriosis
The best approach to supplementation is always a customized protocol tailored to each patient based on extensive functional lab testing.
Every patient will have their own unique set of imbalances that must be addressed in an individualized way to achieve the most effective outcome possible.
Only after comprehensive micronutrient testing is completed can we target specific deficiencies in a truly precise and therapeutic way, focusing on the essential nutrients that need the most support with measured, high-dose treatment.
Here are some general supplements that may be of benefit to those with endometriosis:
Berberine has a long list of health benefits, including reducing inflammation, healing intestinal permeability, regulating immune function and acting as an antimicrobial. All of these actions address potential underlying contributors to endometriosis.
Turmeric is one of the most potent anti-inflammatory compounds in existence. Turmeric can reduce the size of endometriosis lesions and will block the stimulating effects of estrogen that exacerbate symptoms of endometriosis.
NAC (N-acetylcysteine) is the supplemental form of the amino acid cysteine, which is a precursor to the body’s master antioxidant, glutathione. In this way, NAC significantly contributes to the fight against systemic inflammation. A clinical trial involving 47 Italian women taking NAC for the treatment of endometriosis resulted in 24 participants either canceling scheduled laparoscopy procedures due to the disappearance of endometriomas, significant pain reduction or successful pregnancy. The study authors concluded NAC is more effective than hormone therapy for endometriosis and without side effects.
Zinc is a mineral commonly deficient in women with endometriosis that supports immune regulation, reduces pain and inflammation and can repair intestinal permeability. One study found dietary intake of zinc in women without endometriosis was higher compared to women who have endometriosis.
Omega-3 fatty acids have been found in test tube study to inhibit endometrial cell survival and help prevent the implantation of endometrial cells from occurring. One study found women with high consumption of omega-3 fatty acid were 22% less likely to have endometriosis, compared to women who consumed the lowest amounts. Omega-3 fatty acids are well-known for their anti-inflammatory effects and can help decrease pain associated with endometriosis.
Vitamin D has been shown to significantly reduce the inflammatory responses in endometriosis, specifically interleukin 1β and tumor necrotizing factor-α, and also results in fewer endometrial stromal cells and reduced DNA synthesis. Patients with significantly lower vitamin D levels were found to have severe endometriosis, compared to patients with normal vitamin D levels, who were found to have mild endometriosis. Vitamin D has also been found to inhibit proliferation, invasion, and pro-inflammatory cytokine production in endometriosis and reduced production of interleukin 6 and other inflammatory cytokines that stimulate adhesion of endometrial cells to the peritoneal cavity. Vitamin D supplementation was found in clinical study to significantly reduce dysmenorrhea pain in comparison to the non-supplementation placebo group, likely due to decreased levels of pro-inflammatory cytokines and decreased biological activity of prostaglandins.
Vitamin A plays a central role in immune system and gut health functions, both essential in the management of endometriosis. Vitamin A also helps in the maintenance of mucus membranes found in the reproductive organs, pelvis and digestive tract, where endometriosis tends to proliferate. Vitamin A additionally helps to support the clearance and metabolism of estrogen, which is a key driver of endometriosis. A study looking at the effects of retinoic acid, a vitamin A metabolite, found it has the potential to suppress endometriosis development. All of this makes vitamin A an important addition to the treatment of endometriosis.
B-vitamins support antioxidant activity and contribute anti-inflammatory effects; assist liver enzymes with the removal of toxins and estrogen; strengthen the lining of the uterus; support metabolic activity, anti-stress hormones and adrenal function; are required for the formation of hormones and neurotransmitters; alleviate bloating and PMS; increase immune function, systemic oxygenation, nerve health and overall energy production.
Magnesium is reduced by up to 50% during a woman’s menstruation, and more than half the population is already deficient in magnesium overall, creating a strong need for additional intake. Magnesium helps reduce cramping and pain associated with endometriosis. Magnesium relaxes smooth muscle, which can influence the retrograde menstruation associated with endometriosis. High magnesium intake may be associated with lower levels of inflammatory markers, including interleukin-6 and tumor necrosis factor α-R2. A 2013 study looking at magnesium’s effects on endometriosis observed a generally decreased risk of endometriosis with increased magnesium intake.
Iron plays a delicate, paradoxical role in women with endometriosis that must be approached with specificity and balance. Women with endometriosis are at higher risk of developing iron-deficient anemia than the general population, yet at the same time high levels of iron in the peritoneal cavity during menstruation have been implicated in the pathogenesis of endometriosis, as ferroptosis induced by iron overload promotes fibrosis in ovarian endometriosis and is related to the development of endometrial stromal cells. Iron also may become overloaded in endometriosis peritoneal fluid, leading to harmful effects on early embryo development and contributing to infertility. One study found that increased iron concentration present in the peritoneal fluid of women with endometriosis accelerated lipid peroxidation of spermatozoa, resulting in a detrimental action on the acrosome reaction, which plays an essential role during fertilization by making spermatozoa able to penetrate the zona and capable of fusing with the egg plasma membrane. In other words, iron overload in the peritoneal fluid can contribute to the development of endometriosis, and in women who already have endometriosis, this peritoneal fluid overloaded with iron essentially acts as a spermicide, preventing pregnancy, while also promoting fibrosis.
Vitamin E is a fat-soluble antioxidant that has been found in study to be lower in patients with endometriosis. In fact, an overall reduction of antioxidants in women with endometriosis may be an underlying mechanism that correlates with the severity of the disease. One study found a significant reduction in chronic pelvic pain, dysmenorrhea, dyspareunia (painful intercourse) and inflammatory markers in peritoneal fluid in patients with endometriosis who received antioxidant therapy with combined vitamin C. In another study, after six-month therapy with combined vitamin E and C, oxidative stress levels were found to be significantly lower in both plasma and peritoneal fluid. For patients with severe endometriosis and associated infertility, supplementation with vitamin E and other antioxidants is recommended.
Resveratrol has been extensively studied for its role in the treatment of endometriosis and has been found to have beneficial antioxidant, anti-inflammatory and antiangiogenic effects in patients with endometriosis. One study found resveratrol induced apoptosis (cell death) in endometriotic stromal cells. Based on its proapoptotic, anti-inflammatory, antioxidant, and antiangiogenic effects, resveratrol is recommended for patients with endometriosis.
ECGC is a compound found in the highest amounts in green tea. While it has not been studied in humans for endometriosis, non-human studies have found ECGC has significantly beneficial effects on endometrial cells, including suppression of estrogen activity, reduction of endometriosis implants, inhibition of cell proliferation, reduction of vascularization, increased apoptosis (cell death) and decreased lesion size and weight.
Vitamin C may prevent endometriotic implant and reduce implant size due to its anti-inflammatory and antiangiogenic effects. Vitamin C has also been found to significantly reduce the volume and weight of endometriotic cysts in a dose-dependent manner.
Alpha-lipoic acid has been found in study to lower endometrial implant volumes and decrease the appearance of endometrial tissue upon microscopic evaluation. Alpha-lipoic acid also significantly releives pain symptoms associated with endometriosis, including dyspareunia, dysmenorrhea and chronic pelvic pain, as well as improves quality of life and sexual function.
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Supporting Endometriosis With Diet & Lifestyle
Breastfeeding is beneficial to both mother and child in the avoidance of developing endometriosis.
Not only is breastfeeding beneficial to the microbiome and immune system of newborns––which will help them prevent ever developing endometriosis––one study found that women who nursed their babies for one year reduced their own risk of developing endometriosis by 32 percent, as well, over mothers who nursed their baby for less than one month.
Following a nutrient-dense, anti-inflammatory, organic, whole foods diet is a first-line therapeutic and the foundation upon which all treatment is built when working to lower the systemic inflammation that contributes to endometriosis, autoimmune disease and nearly every single other chronic inflammatory condition and disease of the modern age.
A literature review analyzing the evidence on nutritional aspects related to the pathogenesis and progression of endometriosis found that diets deficient in nutrients lead to changes in lipid metabolism, oxidative stress and epigenetic abnormalities that may be involved in the development and progression of endometriosis.
A 2012 study found that 75% of women with endometriosis who transitioned to a gluten-free diet reported significantly improved symptoms twelve months later.
In addition to the complete removal of gluten, avoidance of grains, conventional dairy, caffeine, sugar, alcohol, processed and packaged food, food chemicals and industrial seed oils is necessary to allow the body to begin healing itself.
Focusing on only the most nutrient-dense foods is the best path forward in providing the body with the vitamins, minerals, amino acids, fatty acids and phytonutrients it requires to function at a healthy, optimal level. These include organ meats, shellfish, fatty fish, animal proteins, organic vegetables, herbs, spices, nuts and seeds.
Sourcing is essential, so be sure to always buy organic and choose wild-caught fish and grass-fed/grass-finished meats from pasture-raised animals on regenerative farms.
Reducing overall stress is an integral part of putting the body in position to begin to heal itself. It is widely known that chronic stress is involved in a long list of adverse physiological effects in the body, which then contribute to the development and acceleration of disease––and endometriosis is no exception.
Endometriosis itself is a significant source of stress for any woman living with it, both the physical aspects associated with pain and suffering, as well as the emotional and psychological impacts of uncertainty surrounding endometriosis and its long-term implications.
Stress management is a broad topic and solutions will always vary by every patient, as each of us find stress relief from different activities and approaches.
Finding whatever works best for the individual is key, whether it be meditation, breath work, time spent in nature, community, friendships, exercise, sports, yoga, play, acupuncture, therapy, massage, energy work, walking, rest, hot baths, sauna, boundary setting, infrared-light therapy, reading, cooking, hobbies and so much more.
The key is to find outlets that truly lighten the load of accumulating stress, which can be unavoidable to some extent in modern day life.
The issue of stress cannot be simply brushed aside or dismissed; it must be earnestly addressed, and actionable solutions need to be consistently implemented to help mitigate the exacerbating effects stress has on endometriosis.
Exercise is a natural analgesic due to its release of endorphins, which can help mitigate the painful symptoms associated with endometriosis.
These same endorphins can also help relieve anxiety and depression, as well as improve overall mood, which is useful given the emotional challenges associated with endometriosis.
Endometriosis is also associated with pelvic floor dysfunction, and exercise can help strengthen the pelvic floor, relieving pelvic and lower back pain.
There are specific pelvic floor exercises that should be implemented if you suffer from pelvic pain, including kegel exercises, happy baby pose and heel slides.
Overall, low to moderate impact workouts are recommended for those with endometriosis, such as swimming, walking, cycling, yoga, pilates, strength training and tai chi.
Listening to your body is always best; it’s better not to push through pain or fatigue, so remember to be gentle and forgiving with yourself.
Sleep issues can contribute to endometriosis in a variety of ways, including increased inflammation, hormonal imbalances, increased pain signaling, fatigue, depression and anxiety.
Sleep is not just the passive action of lying unconscious on a mattress for eight hours. It is a time for deep repair work, the detoxification and healing of every organ, system and cell in the body.
When we do not prioritize our sleep, we rob our body of its built-in ability to heal itself and prevent the development or worsening of disease.
A few ways to put your body in position for optimal sleep include regular exercise, avoidance of blue light and electronic screens in the evenings, daily exposure to morning and midday sunlight, removal of all electronics from the bedroom, turning off wifi throughout the home during sleep, low bedroom temperature around 68 degrees, blackout curtains and/or an eye mask to prevent any light disruption, use of white noise devices or fans, ear plugs if surrounding noise is an issue and taking a hot epsom salt bath before bed to relax the body,
Supplementing with magnesium before bed or the use of other natural sleep compounds like valerian root, GABA, L-theanine, 5-HTP, chamomile, hops, passion flower, skullcap, jujube, melatonin, and Chinese herbal sleep formulas like An Mien Pian.
Treating Endometriosis With Eastern Medicine
There are more than a dozen Chinese herbal formulas that may be specifically effective in the treatment of endometriosis, including:
Quyu Jiedu Xiaozheng Tang
Shao Fu Zhu Yu Tang
Di Dang Tang
Ge Xia Zhu Yu Tang
Gui Zhi Fu Ling Wan
Huo Luo Xiao Ling Dan
Shen Tong Zhu Yu Tang
Sheng Hua Tang
Shao Tong Zhu Yu Tang
Xue Fu Zhu Yu Tang
Shi Xiao San
Yang He Tang
Xiao Chai Hu Tang
Qu Yi Kang
Yi Wei Ning
Yi Wei San
Huo Xue Xiao Yi Tang
Choosing the best formula for you will always depend on each individual patient’s presentation.
Working with a licensed herbalist is the best way to determine what herbal formula may help you the most, based on your clinical signs, symptoms and presentation.
Acupuncture is a natural, safe, non-invasive, non-toxic solution to treat the symptoms of endometriosis, while also addressing the underlying imbalances behind the mechanisms of action leading to endometriosis.
Many clinical studies into acupuncture’s beneficial effects on endometriosis have found efficacy in pain reduction, including a Harvard Medical School study that found a 62% reduction in chronic pelvic pain associated with endometriosis after four weeks of acupuncture treatment.
Many studies have found significant positive results with the combination of acupuncture and Chinese herbal medicine.
One study utilizing lab markers to evaluate efficacy in endometriosis patients found that after treatment with acupuncture and Chinese medicine, the levels of serum CA125, PGE2, and PGF2α (markers associated with endometriosis) were lower, while serum beta-Endorphin level (a substance produced in the brain that blocks the sensation of pain) was higher than before.
One study of 48 patients experiencing endometriosis-associated dysmenorrhea treated with acupuncture and Chinese herbs (Quyu Jiedu Xiaozheng Tang) indicated a total curative effect of 92.0%.
Another clinical observation of 58 endometriosis patients treated with Chinese herbs (Shao Fu Zhu Yu Tang) and acupuncture for three months resulted in the disappearance of dysmenorrhea symptoms in all patients.
A study involving 53 endometriosis patients treated with acupuncture and Chinese medicine resulted in a total effective rate of 87.09% and a pregnancy rate of 40%. The acupuncture points used in this study included Zigong, SP6, LV5, LV3, RN4 and ST29.
Another clinical observation of endometriosis patients showed that after treatment with acupuncture and Chinese herbal medicine, the total effective rate was 100%.
Chinese Herbal Medicine Enema
Several studies have found benefit from therapeutic treatment of endometriosis with Chinese herbal medicine enemas, particularly on reducing endometriotic lesions.
One study treated 64 patients using Chinese herbal medicine enema with a total clinical effective rate of 93.8%.
The study authors treated 51 cases of endometriosis-associated infertility patients who were randomized into two treatment groups, with one group receiving Chinese herbal medicine enema and the other group receiving Danazol treatment (a common endometriosis drug) for nine months.
Results showed that the pregnancy rate was 42.4% for those treated with Chinese herbal medicine enema and 27.8% for those treated with Danazol drug treatment after 26 months.
Chinese herbal medicine enemas can improve bioavailability of the herbs, prevent digestive enzymes from damaging the herbs, mitigate effects on the liver and other organs, and reduce stimulatory actions on the alimentary canal.
As you can see, a functional medicine approach to the treatment of endometriosis is quite comprehensive. The mechanisms of action behind its pathogenesis are complex and still being investigated.
Addressing each patient’s underlying dysfunctions, as identified through signs, symptoms and functional lab work, helps put the body in position to heal itself.
In this way, balance can be restored, leading to improved physiological function, decreased chronic pain, regained fertility and a better quality of life.