President/Executive Director, Dori Lynn Knoff, Research Program Associate, Endometriosis Association, International Headquarters, 8585 North 76th Place, Milwaukee, WI 53223, USA
Email: www.EndometriosisAssn.org
Sir,
After review of the article Selected Food Intake and Risk of Endometriosis by Parazzini et al. in the July 2004 issue of Human Reproduction, we have the following comments.
We're excited that specific scientific evidence now links an environmental factor such as food, and endometriosis. The findings reinforce the lifestyle changes which numerous women with endometriosis have reported as aiding them in their search for health, and reinforce the suggestions for prevention of endo in our most recent book (Endometriosis: The Complete Reference for Taking Charge of Your Health, by Mary Lou Ballweg and the Endometriosis Association).
The finding that high intakes of red meat and ham increase the risk for endometriosis is not surprising, though it is new. Red meat can contain high levels of dioxins and other endocrine disruptors. Research initiated by the Endometriosis Association and replicated worldwide has shown a strong link between exposure to dioxins and development of the disease.
Red meats may also contain high levels of other hormones (like DES in the past) that may cause hormonal effects as well. In addition, the fat content in meats may raise estrogen levels.
The finding that higher intakes of fruit and vegetables reduce risk for endometriosis also supports our dietary recommendations for women with endometriosis. Among other micro-nutrients, fruit and vegetables contain antioxidants, important in the function of the immune system and in fighting free radical damage. Work from Emory University has shown that free radical damage is clearly a problem in women with endometriosis. Fruits and vegetables also contain lots of fiber, which plays an important role in estrogen excretion and balance, and the control of intestinal flora.
The 1976 disaster in Seveso, Italy may also play a role in the risk for endometriosis in this region. This massive chemical accident released multiple chemicals into the environmentincluding dioxin. Because Seveso is close to Milan (one of the sites of patient recruitment and testing for this study), dioxin exposures from this spill may affect the number of cases of endometriosis in that region.
The lack of increased risk of endometriosis for those eating fish, milk or cheese is puzzling, however, in light of the potential dioxin exposure from these food sources. Also, depending upon what type of milk or cheese (low or high fat), the risk for consuming some dairy products may increase the risk for certain types of diseases.
Because we do not know the food chain in Italy, we are working with our leaders at the Italian Endometriosis Association to learn more about their agricultural and horticultural standards and practices.
There is one statement in the study that is extremely unfortunate and perhaps is simply a bad translation, or due to language barrier. That is the statement that the authors make in attempting to explain why diagnosis of endometriosis is more frequent among more educated women of higher social class in Italy. The authors state that this fact may reflect the greater attention such women pay to relatively minor health problems. Endometriosis is not a minor health problemany review of the data on the many symptoms and the level of disability shows clearly how disabling endometriosis can be, the chronicity of the disease, the many relationship and other quality of life stresses due to the disease, as well as the ability of the disease to interfere with work, education, and family life (Ballweg, 1995, 2003
, 2004a
,b
).
While Endometriosis Association groups all over the world have shown that women across all socioeconomic levels have endometriosis, they also show that the lower the socioeconomic level of the women, the greater the difficulty in obtaining an endometriosis diagnosis. Even among higher socioeconomic levels, there is a delay of almost 10 years in the US between onset of symptoms and diagnosis (Sinaii et al., 2002). Ultimately, three quarters of women are told the symptoms are normal, stress-related, or are dismissed as having psychological problems. It is not surprising that those with a higher level of education and more background understand that these symptoms are not normal, and also have greater financial and other resources which would more likely lead to a diagnosis and treatment.
We are thrilled to see the findings of this study in your journal and we hope to see more coverage of endometriosis-related findings in the future. Researchers interested in studying this and other topics related to endometriosis should watch for the Endometriosis Association's next round of funding which will be announced in the next few months.
References
Ballweg ML and the Endometriosis Association (1995) Endometriosis: A New Picture of the Disease is Emerging. In: The Endometriosis Sourcebook. Contemporary Books, Chicago, pp. 369375.
Ballweg ML (2003) Big Picture of Endometriosis Helps Provide Guidance on Approach to Teens: Comparative Historical Data Shows Endo Starting Younger, is More Severe. J Ped Adoles Gynecol 15 (Suppl 1), S21S26.
Ballweg ML (2004a) Impact of Endometriosis on Women's Health: Comparative Historical Data Show that the Earlier the Onset, the More Severe the Disease,. Clin Obstet Gynecol 18, 201218.
Ballweg ML and the Endometriosis Association (2004b) Research Reveals Disease is Starting Younger, Diagnosis is Delayed. In: Endometriosis: The Complete Reference for Taking Charge of Your Health. McGraw-Hill/Contemporary Books, New York, pp. 343360.
Sinaii N, Cleary SD, Ballweg ML et al. (2002) Fibromyalgia, Chronic Fatigue Syndrome and Atopic Diseases Among Women with Endometriosis: A Survey Analysis. Hum Reprod 17, 27152724.