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Nutrition for Endometriosis: A Dietitian’s Guide

Endometriosis

Endometriosis is a condition where tissue similar to the tissue that normally lines the inside of your uterus (the endometrium) grows outside your uterus. The condition affects roughly 1 in 10 women of childbearing age. It is often painful and comes with a host of symptoms that can impact quality of life. Instead of viewing nutrition as a solution for endometriosis, it makes sense to view it as something that can help to manage some of the symptoms.

Symptoms that are typically of relevance for endometriosis are:

  • Painful periods
  • Pain during sexual intercourse.
  • Pain with bowel movements or urination, particularly around the time of menstruation.
  • Heavy bleeding during a period, or sometimes even between periods.
  • Infertility.
  • Fatigue.
  • Intense cramping.
  • IBS – diarrhea, constipation, bloating and nausea. Often worse during periods.

There are far more impactful ways of managing endometriosis than solely focusing on nutrition. It is strongly encouraged to speak with your medical team about what options are available.

Since nutrition can help manage some of the symptoms though, it’s obviously worth not ignoring how it can help.

How Does Diet Help?

Healthy Food

Diet can mainly help through directly helping to manage IBS symptoms. It can also indirectly help manage other symptoms through mechanisms such as:
– Reducing inflammation
– Managing oestrogen levels
– Reducing the production of harmful tissue.

Anti-Inflammatory Diet

Anti-inflammatory foods

Endometriosis typically involves chronic inflammation which contributes to making symptoms worse.

Therefore, it makes sense both in theory and in practice to emphasise an anti-inflammatory style diet.

This means emphasising foods like healthy fats, wholegrains, fruits and vegetables.

One example of this is focusing on omega 3 intake.

Omega 3 consumption theoretically should directly reduce the formation of cystic lesions.

Individuals with higher than average omega 3 consumption are ~22% less likely to develop endometriosis.

At the other end of the spectrum, those with high trans fat intake (not as common in Australia as it is in other countries) are ~48% more likely to develop endometriosis.

Supplementing with omega 3 also appears to reduce pain in those with endometriosis.

In general, it also appears to be a good idea to emphasise foods that are high in antioxidants.

Those with endometriosis appear to have higher levels of reactive oxygen species that contribute to inflammation. Antioxidants quite literally counteract this.

It makes sense to increase intake of antioxidant-rich foods first (particularly fruits and vegetables). But supplementation studies also leave clues.

Vitamin C and E supplementation have been shown to reduce pelvic pain significantly. There also appears to be a mild benefit for period pain and cramps.

Oestrogen

High levels of oestrogen (or estrogen) are often linked with endometriosis. High oestrogen can affect symptoms such as fatigue, heavy periods and aggravated PMS. It also potentially contributes to the growth of tissue outside of the uterus.

High intake of fibre can reduce oestrogen resorption in the large intestine, which helps to reduce oestrogen levels overall.

Aiming for >25g of fibre per day appears to significantly reduce oestrogen levels in individuals where it was previously elevated.

This is even more reason to focus on foods like legumes, nuts, seeds, wholegrains, fruits and vegetables.

Red Meat

Red Meat with an emphasis on mince

Research on red meat is always difficult to interpret.

When looking at red meat as a factor in isolation, it appears as though decreasing red meat intake would be beneficial for managing endometriosis symptoms. Females with higher red meat intakes are more likely to develop endometriosis.

While a strong link has not been identified, there are even proposed mechanisms involving haem iron. These could potentially explain an increased risk of either developing endometriosis or making symptoms worse.

But this obviously presents another challenge for those who struggle with iron deficiency related to heavier bleeds related to their period. So that also needs to be factored into the management.

‘That being said, I’m not sure I would recommend reading too much into the need to limit/avoid red meat for endometriosis.

The reason I say it is difficult to interpret red meat research is a concept called “healthy user bias.”

Basically, those who engage in certain health-seeking behaviours often engage in other health-seeking behaviours.

It has been standard health advice for decades to limit red meat consumption.

Somebody who still chooses to consume red meat is also more likely to:
– Do less physical activity
– Smoke more, drink more
– Sleep less
– Eat less fruits/vegetables/fibre
– Eat more calories
– Do other behaviours not linked with positive health outcomes.

The study above linking higher red meat intake with endometriosis also identified that high red meat intake was associated with significantly higher BMI.

While increased BMI is not directly linked with endometriosis, I’m putting that idea out there to highlight this healthy user bias effect.

Those with higher red meat intakes in that study either were eating more total calories and/or exercising less. It is also safe to assume they likely had a lower antioxidant intake, lower fibre intake and other factors that are not linked with positive outcomes related to endometriosis.

All of that is worth mentioning. But I also do not think the link between red meat and endometriosis should be ignored either. I am just trying to add context.

Personally, I think a cautious approach should involve aiming for <455g of red meat per week, emphasising leaner options. This lines up with the Australian Dietary Guidelines position on the topic for general health anyway.

Gluten

Gluten is a fascinating one when it comes to endometriosis.

To the best of my knowledge, there is only two studies on gluten and endometriosis. Both of them have had extremely positive results.

One study with 207 participants showed that 75% of them had a decrease in pain after going gluten-free for 12 months.

I think it is always worthwhile being sceptical. But this study has also been repeated under similar circumstances with similarly impressive results. In the repeated study participants experienced an average drop in pain of 50% over a 3-month period.

I am personally not at a point where I am recommending a gluten-free diet to those with endometriosis. I think it would take a fair bit more information before I jump to that conclusion. But it is worth being aware that this research exists.

It is also worth being aware that fructans, which are found in wheat, are a FODMAP. This can contribute to IBS symptoms in some individuals.

Reducing/eliminating gluten also reduces the intake of fructans. This could lead to improvements by itself for some people, even if gluten was not the original issue.

If you choose to follow a gluten-free diet, it is still important to address gaps commonly associated with a gluten-free diet. Some of these gaps could include a reduced intake of fibre and certain B vitamins such as folate. 

Dairy

Bottles of Milk

Usually lumped in with the whole gluten conversation, a lot of people also include limiting/avoiding dairy intake.

One aspect people often mention is that they link dairy and inflammation. But when you actually look at the research on the topic, it is clear that on average dairy does NOT contribute to inflammation.

That does not mean there are not situations where dairy can contribute to inflammation, since those situations do still exist.

But it is important to be aware that on average it does not contribute to inflammation. This allows you to filter out poor advice based on the philosophy that dairy = increased inflammation.

Research specific to endometriosis highlights that those who consume 3 serves of dairy per day are 18% less likely to develop diagnosed endometriosis than those who have lower intakes. So clearly it is not really increasing the risk of endometriosis.

When it comes to managing symptoms though, it is worth being aware that lactose could play a role in IBS symptoms for some people. Reducing lactose could be beneficial under those circumstances.

It’s also important to be aware that not all dairy foods are high in lactose. If you want more information, it could be worth checking out our article on lactose intolerance.

Caffeine

Cup of coffee and coffee beans on wooden table

Coffee intake (which obviously is linked with caffeine intake) has not been shown to be a risk factor for endometriosis.

A lot of people link caffeine with increased inflammation. But on average caffeine appears to have mostly neutral impact on inflammation, whereas coffee reduces inflammation on average.

Beyond caffeine coffee is surprisingly rich in antioxidants and polyphenols which can have health benefits that are often overlooked.

From the IBS perspective though, caffeine can stimulate the bowels and trigger symptoms, particularly diarrhoea. This is not relevant for everybody, but it is worth being aware of. It is encouraged to pay attention to your own symptoms and identify whether or not decreased caffeine intake would be beneficial.

Managing IBS Symptoms

Endometrial tissue can grow in the large intestine and other nearby structures which can contribute to IBS symptoms. This can lead to a variety of symptoms including diarrhoea, bloating and constipation.

The low-FODMAP diet is one of the most effective options we have available for managing IBS symptoms, particularly bloating and diarrhoea. In general, it appears to significantly improve symptoms in around 50-80% of people without endometriosis.

List of high fodmap foods

While there is not as much endometriosis specific research available yet, there is some promising research out there.

One study highlighted that 72% of women with both IBS and endometriosis who undertook the low FODMAP diet for 4 weeks showed a >50% improvement in symptoms. Such a large percentage of people finding benefit is promising!

The low-FODMAP diet is difficult to do, particularly when it comes to re-introducing foods. Staying completely low-FODMAP is NOT a good long-term plan either, so re-introduction is important.

I have never seen somebody do it well without the guidance of a dietitian. I encourage booking in to see one either from Ideal Nutrition or from the Monash FODMAP directory.

Beyond FODMAPs though, there are plenty of other strategies that can be useful for managing IBS symptoms.

When it comes to constipation, there are some basic changes that can make a huge difference.

Focusing on consuming sufficient (but not too much) fibre is a good starting point. Consuming sufficient fluid also can help. And getting sufficient exercise can make a big difference too.

Other less commonly known tips that are surprisingly effective are:

  1. 5-10g of psyllium husk (or Metamucil) per day.
  2. 10-20g of flaxseed/linseed per day (start low and build up).
  3. 1-2x kiwi fruit per day.

If you want more info on those tips, I recommend reading my article on nutrition for constipation.

It is also worth playing around with fibre intake. Excessive fibre can cause just as many issues as inadequate fibre.

It is likely a good idea to slowly build up to at least 25g of fibre per day. But it would be wise to avoid going dramatically over that intake, unless there are minimal symptoms.

Supplements

I always encourage food first. But if you have tried to address all the relevant gaps in your diet, and it is not going to happen for a variety of reasons, supplementation can beneficial.

Omega 3 –

Supplementation with 1g of omega 3 per day has been shown to reduce pain associated with endometriosis.

If you have a high intake of fish, than omega 3 supplementation might be less relevant. This could be defined as >2x per week intake of fish with an emphasis on oily fish like salmon.

But that being said, 1g per day of fish oil is not a high dosage. And a lot of other research on omega 3 has highlighted additional benefits to having significantly higher dosages e.g. 2-3g+.

Who is to say having >1g of fish oil per day would not be even more beneficial? The research on that topic has not been done to the best of my knowledge.

What we do have evidence of though is that those with higher levels of Omega 3 in their blood have decreased risk of endometriosis.

Vitamin D –

Those with higher levels of vitamin D in their blood are less likely to develop endometriosis. They are also likely to experience less pain if they have diagnosed endometriosis.

In Australia, we are lucky. If you go see a bulk-billing GP you can get a blood test for vitamin D for free.

I encourage people to test vitamin D status. If you are either deficient or on the low end of the healthy range, it is likely worth supplementing.

A typical starting dosage is 1000IU per day. Often your doctor can recommend much higher dosages to address a deficiency quicker. I obviously do not recommend doing a high dosage without medical guidance, since that could cause more problems than it solves.

Vitamins C and E –

Antioxidant supplementation of vitamin C and vitamin E at dosages of 1000mg and 1200IU respectively have been shown to significantly reduce pelvic pain associated with endometriosis.

Personally, I would focus on aiming to eat foods that are high in those nutrients as a priority rather than supplementing. But it is worth being aware that supplementation has been shown to be beneficial.

Increasing intake of fruits and vegetables would be a great way to get high amounts of vitamin C.

An underrated way to get vitamin E is extra virgin olive oil (EVOO). In comparison to regular olive oil, EVOO is particularly high in polyphenols and antioxidants including vitamin E.

Curcumin

Curcumin has been shown to decrease pain, inflammation, and oxidative stress in endometriosis. It also appears to minimise the growth of endometrial lesions.

There is only a limited number of studies on curcumin and endometriosis, so I wouldn’t encourage getting overly excited. But it is definitely an option worth considering and keeping an eye on.

By itself, curcumin is typically not well absorbed. But there are some options that increase the absorption that some supplements use, such as paring it with black pepper extract.

A standard dosing protocol of curcumin would be around 500mg, 2-3x per day. There are a variety of dosages that are recommended though.

Pesticides on Fruit and Vegetables

Organic fruits and vegetables

As a general rule, choosing organic vs non-organic produce for overall health does not seem to be like that big of a difference.

That’s a debatable topic and I’m open to being disagreed with on that one. But that seems to be the general conclusion from large reviews that have been done on the topic.

One area that is interesting though is pesticide usage. Organic foods typically involve lower pesticide usage.

Pesticides on fruits and vegetables have been linked with increased risk of endometriosis. And there are potential mechanisms related to hormonal pathways and oxidative stress.

Now I would not exactly pinpoint this as a top priority. If you happen to have a lot of disposable income and are trying to minimise symptoms, it could make sense to emphasise organic produce over non-organic options when possible. Otherwise, it is best to just do the best you can.

Take Home Message

I have seen extremes at either end of the spectrum.

Some people act as if diet can completely solve endometriosis.

Meanwhile, at the other end of the spectrum, I have seen respected practitioners act as if diet makes zero difference.

As with most things, the answer is somewhere in the middle. Implementing some of the aspects mentioned in this post likely will be able to improve symptoms. And this could make the overall condition a little bit less unpleasant.

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