RAMB Novembro/Dezembro 2015

alpern

520

ssoc

ras

2015; 61(6):519-523

Despite the difficulties and disagreements among au-

thors, the objective of this study was to assess recent ev-

idence on nutrition and eating habits in relation to en-

dometriosis.

ethods

The largest medical information databases (Medline-

Pubmed, Lilacs and Cochrane Library) were searched for

the keywords “endometriosis” AND “nutrition” OR “diet”

AND “oxidative stress” OR “inflammation” OR “Omega”

OR “fatty acids” OR “antioxidants” OR “epigenetics” OR

“n-acetylcysteine” OR “vitamin D” OR “resveratrol”, over

the last 10 years.

Of the 113 articles retrieved, 31 were selected in Eng-

lish, French or Spanish based on title and abstract. By

reading the abstracts and articles, we selected 21 articles

deemed most relevant to this review. Articles related to

molecular biology and case reports, which would not have

practical applicability, were excluded.

We analyzed 10 case-control studies, 2 prospective

studies, 1 randomized prospective study, 1 cohort study,

6 review articles, 2 communications and 2 book chapters.

athophysiology

and

nutrition

In the typical lesions of the disease, the cells grow, differ-

entiate out of the uterus, and retain their ability to re-

spond to hormonal proliferative stimuli. Furthermore,

excess estrogen stimulates the formation of large amounts

of prostaglandins (from the even series), promoting in-

flammation and, consequently, a painful stimulus.

7,8

During the progression of the disease, changes occur

resulting in abnormal immunological antigen-antibody

reactions, contributing to the increase of pro-inflamma-

tory agents.

Women with endometriosis have a higher

concentration of lipid peroxidation markers in the blood

and peritoneal fluid, which promotes cell adhesion and

activation of macrophages. These, in turn, release reac-

tive oxygen and nitrogen species, leading to oxidative

stress.

Nutrient (folic acid, vitamin B12, zinc and choline) de-

ficiency may interfere with DNA methylation, resulting in

epigenetic abnormalities, given that it alters the expression

or silencing of certain

CpG

(cytosine-phosphate-guanine)

genes. In endometriosis, CpG hypomethylation can lead

to overexpression of steroidogenic factor 1 (SF1) or estro-

gen receptor

(ER-

), with a consequent increase in the

levels of estradiol and prostaglandin E2 (PGE2), favoring

inflammation and cell growth.

Furthermore, the change

in methylation of five-week embryos may predispose them

to the development of endometriosis in adulthood.

Various types of food demonstrate the ability to in-

terfere in these stages of the pathophysiology. Among

those that decrease the risk of developing the disease, we

cite vegetables, legumes and whole grains, rich in nutri-

ents (folate, methionine, vitamin B6, vitamins A, C and

E) that act on the genome by changing the gene expres-

sion and influencing DNA methylation. Diets deficient

in these nutrients show alterations in lipid metabolism,

oxidative stress and epigenetic abnormalities.

Although controversial, in 2011, Trabert et al. found

that the higher consumption of fruits (2 servings or more

versus

one serving or less a day), the greater the risk of de-

veloping the disease (RR=1.5, 95CI 1.2-2.3, p= 0.04). With

regard to vegetables, the authors found no association.

This data can be justified considering that currently pes-

ticides (organochlorines, organophosphates, bipyridines)

and dioxins are used in the cultivation of fruit – these

pesticides generate reactive oxygen species and reduce

the antioxidant capacity of fruits and vegetables, an ef-

fect that may be reversed through the consumption of

organic fruit. In addition to interfering in the antioxi-

dant capacity of fruits, organochlorine interferes with

hormonal pathways, acting on estrogen and androgen

receptors.

5,10

It is noteworthy that the presence of organochlorine

and pesticides in fruits should not contraindicate their

consumption. This is merely a warning for prescribers

and consumers, who should prefer organic ingredients

and, whenever possible, remove the skin from foods that

are usually contaminated.

In addition to being a source of nutrient antioxidants,

fruits and vegetables favor the increase of estrogen excre-

tion, contributing to hormonal regulation,

as these

foods contain a significant amount of fiber and nutrients.

Nutrients such as calcium, zinc, selenium, vitamin C,

vitamin E and bioactive compounds in foods (such as

phytochemicals – carotenoids, flavonoids, indoles, iso-

thiocyanates) influence health, interfering with process-

es closely related to the pathophysiology of endometrio-

sis, as well as hormonal balance, cell signaling, control of

cell growth, apoptosis and so on.

Polyphenols (anthocyanins, hydroxybenzoic acids, fla-

vones, isoflavones, lignans, resveratrol) are compounds

present in foods that have the ability to modulate the ac-

tivity of enzymes, as well as strong antioxidant properties.

Resveratrol, a polyphenol found in the skin of dark

grapes and

jabuticaba

(

Myrciaria cauliflora

, also known as

Brazilian grape) has demonstrated antineoplastic, anti-

inflammatory and antioxidant action. The administra-

tion of 10mg/kg/day of resveratrol in a rat model (compared