By Kiran Dhaliwal & Jessica Turton
Endometriosis is a challenging and complex condition with its causes still largely unknown. One in 10 (10%) women of reproductive age worldwide are currently affected by endometriosis, that’s approximately 200 million women.1 The treatment options are presently limited to laparoscopic surgery (to remove the endometrial tissue) or hormonal therapy (to reduce estrogen).2 However, there is an increasing amount of research linking dietary factors and nutrient intake with symptom management and slowing the progression of endometriosis.3 With more and more individuals seeking lifestyle therapies to manage chronic illness, the role of diet in endometriosis deserves further exploration. For now, let’s dive into what we do know.
What is Endometriosis?
Endometriosis (also known as endo) is an estrogen-dependant chronic inflammatory disease wherein the tissue that normally lines the uterus (the endometrium) starts growing in other parts of the body.1,2 It can affect the fallopian tubes, ovaries, bowel, and really any part of the body - although it most commonly affects the pelvic area.2 These endometrial tissues shed the same way the uterus does – like during a women’s period. Except this time, there’s no specified exit pathway in your body for the blood. This can cause severe inflammation in the body, resulting in excruciating pain and the formation of scar tissue in affected areas.1,2 Endometriosis is also a major cause of infertility in women.
Symptoms of Endometriosis
The symptoms of endo vary between women. For some, symptoms can occur at any time of the month. Whereas for others, endo symptoms are mostly apparent during their period.1
Symptoms can include:
Pelvic pain (heightened around menstrual cycle)
Heavy or irregular bleeding
Changes and/or painful bowel or urine movements
Fatigue or low energy
Low immune system
These symptoms can have an impact on relationships, physical and mental health and can lead to women needing to take time off from studying and work. Endometriosis can be a debilitating condition, significantly affecting one’s overall quality of life.
Dietary Management of Endometriosis
There is increasing evidence for dietary strategies that help to reduce inflammation and achieve a healthier balance of estrogen and other hormones in the body. So, let’s now empower ourselves with some key dietary strategies that might assist in improving endometriosis management.
#1 Dietary Fibre
Fibre is a type of carbohydrate that generally cannot be digested by the body. It is mostly found in plant foods, particularly in seeds, skins and stalks of fruits and vegetables. It can also be found in the outside layers of cereal grains. Increasing your fibre intake can aid in the process of excreting excess estrogen from the body as it leads to a decreased reabsorption of estrogen in the colon. In addition, fibre also binds to estrogen in the intestines which increases its faecal excretion.4
Choosing high-fibre foods that are also low in digestible carbohydrates (such as low sugar fruits, non-starchy veggies, nuts and seeds) is a useful strategy for achieving and/or maintaining stable blood glucose and insulin levels within a healthy range, which in turn, can help to minimise inflammation.5 This is important in endo due to insulin’s negative effect on endometrial cell proliferation and estrogen production.6
If needed, it is a good idea to increase your fibre intake gradually as part of a healthy diet that also has plenty of healthy fats and proteins, and drink plenty of fluids to prevent any unwanted digestive effects. With a few simple swaps, you can easily increase your fibre intake. For example, add some avocado to your lunch or dinner, fresh berries to yoghurt, and have nuts and seeds as a snack between meals.
#2 Dietary Fats
Long chain omega-3 fats (including EPA and DHA) are essential fats that have anti-inflammatory properties which can help to reduce endo-induced inflammation, pain and improve egg quality.7-9 Long-chain omega-3 fats are found in fish, seafood, seaweed/algae, free-range eggs and grass-fed red meat.
It is important to also consume lower amounts of trans fats, hydrogenated fats, and omega-6 fats which can contribute to inflammation.7,8 Food sources of these fats include cakes, cookies, desserts, pastries, some processed meats, margarines and deep-fried foods. Omega-6 fats are essential for human health, but too much of them in the diet can be problematic due to their inherent pro-inflammatory properties. Seed and vegetable oils (e.g., sunflower oil, canola oil, soybean oil, etc.) are very high in omega-6 fats. Even if you don’t use these oils at home, be aware that takeaways and restaurants commonly use seed and vegetable oils for cooking.
Antioxidants are natural substances which are found in both plant and animal foods. They essentially “fight” chemicals known as free radicals which threaten to cause more damage to the body through a process called oxidative stress.10 The number of free radicals in women living with endo are much greater than the general population.11 A study from the United States with 59 women showed that those who supplemented with antioxidant vitamins (Vitamin C & E) had a significant decrease in inflammatory markers and chronic pelvic pain.12 There was also a significant improvement in ‘everyday pain’ and pain associated with the menstrual cycle after antioxidant supplementation (p<0.005).12
In general, a food first approach is best because no one single antioxidant does everything. Therefore, consuming a nutrient-dense diet that is rich in essential proteins, fatty acids, vitamins and minerals is a good place to start. You might want to speak to a dietitian about how you can formulate a nutrient-dense diet to suit your individual needs and preferences. A healthcare professional can also help you understand whether nutritional supplements may be needed, as some of us have certain nutritional requirements that cannot be met with food alone.
Pesticides on fruits and vegetables contain dioxins which have been shown to be negatively associated with endometriosis. These pesticides not only affect hormonal pathways but decrease the amounts of antioxidants in fruit and vegetables.8 But does that mean we have to buy organic everything now? Not quite! Check out the "dirty dozen" and the "clean fifteen" food lists (https://natureshealthstore.com.au/2020-clean-fifteen-and-dirty-dozen/). These clearly outline the types of produce that typically contain the highest and lowest amounts of pesticides, respectively. If you’re eating from the dirty dozen list, you may want to opt for organic!
Evidence has shown the FODMAP approach can be effective in improving endometriosis symptoms. FODMAP stands for: fermentable oligosaccharides, disaccharides, monosaccharides & polyols.13 These are groups of carbohydrates that can ferment in the gut and cause uncomfortable symptoms such as bloating, gas, diarrhea, constipation, abdominal pain and/or significant discomfort. Many grains and cereals, fruits, vegetables, dairy products, legumes, nuts and sugar alcohols (sweeteners) are high in FODMAPs.13 Visit the Monash FODMAP website (https://www.monashfodmap.com/ ) for further information on which foods are high in FODMAPs. Some women living with endo may experience gut symptoms similar to IBS and may later be diagnosed with it or vice versa due to many overlapping symptoms. A recent study of New Zealand women facing both IBS and endometriosis showed >50% improvement in gut symptoms when they undertook the low FODMAP diet for 4 weeks.14 However, before you jump right into any kind of elimination diet, we recommend that you find yourself a savvy dietitian who can guide you through the most effective and appropriate approach.
The Bottom Line?
There are so many overlapping factors that can contribute to one’s management of endometriosis. Fortunately, we are learning more and more about the role of food and nutrition in specific chronic diseases, such as endometriosis – and it is an empowering area of research because what we put in our mouths is well within our control!
At the end of the day, food is needed to provide energy and essential nutrients to your body so that you can be healthy, strong and full of energy! That’s why we never recommend counting calories or restricting nutrient-dense whole foods. Instead, we teach individuals to identify and prioritise real foods that have been minimally processed and to consume these to satiety. If you are struggling with your diet – whether you have endometriosis or not - we highly recommend consulting with a qualified Accredited Practicing Dietitian (APD) to seek tailored advice. You can book an appointment with our team here: https://www.ellipsehealth.com.au/team
About our co-author: Kiran
Kiran is a recent graduate dietitian with a postgraduate degree in Masters of Nutrition and Dietetics. The recent knowledge gained at university in combination with her curious mind has allowed her to understand nutrition and the body as a whole. Her own personal health journey has fuelled her to empower others through nutritional knowledge and also to take charge to improve their own health. She enjoys going for brunch, moving her body and all things creative. You can find Kiran on Instagram @the.healthbean and LinkedIn.
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2. Barnard ND. Nutrition Guide for Clinicians. Physicians Committee for Responsible Medicine; 2018. [cited 2020 December 02]. Available from: https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342065/all/Endometriosis.
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10. Antioxidants: In Depth. Nccih.nih.gov. 2013 [cited 7 December 2020]. Available from: https://www.nccih.nih.gov/health/antioxidants-in-depth
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12. Santanam N, Kavtaradze N, Murphy A, Dominguez C, Parthasarathy S. Antioxidant Supplementation Reduces Endometriosis-Related Pelvic Pain in Humans. Obstetrical & Gynecological Survey. 2013;68(10):685-686.
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14. Moore J, Gibson P, Perry R, Burgell R. Endometriosis in patients with irritable bowel syndrome: Specific symptomatic and demographic profile, and response to the low FODMAP diet. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017;57(2):201-205.