Diet and Nutrition

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Diet and Nutrition

There is no one specific diet for endometriosis. No food, diet, or supplement will “cure” endometriosis, but it can help manage symptoms and is great for overall health and well-being. Your diet needs to be individualized to your specific needs, and it can take quite a bit of experimentation to find what works for you.

Some studies have found that a few things seem to help manage symptoms of endometriosis. Most of the strategies help to eliminate any food intolerances and influence inflammation and estrogen (Thomas & Natarajan, 2013). Some of the dietary strategies might include:

  • Gluten free diet (Marziali et al., 2012)
  • Low FODMAP diet (Moore et al., 2017)
  • Anti-inflammatory diet (Leonardi et al., 2020)
  • Fruits, vegetables (“preferably organic”), and whole grains (Ghonemy & El Sharkawy, 2017; Harris et al., 2018)
  • Antioxidants, such as vitamins A, C, D, and E as well as B vitamins (Darling et al., 2013; Ghonemy & El Sharkawy, 2017; Huijs & Nap, 2020; Thomas & Natarajan, 2013) [Caveat- one study stated that vitamins from vitamin rich food and not supplements were noted with the difference (Darling et al., 2013)]
  • Anti-inflammatories such as green tea, resveratrol, fish oil, healthy fatty acids (omega-3), N-acetylcysteine, quercitin, curcumin, parthenium, nicotinamide, 5‐methyltetrahydrofolate (Ghonemy & El Sharkawy, 2017; Huijs & Nap, 2020; Leonardi et al., 2020; Signorile, Viceconte, & Baldi, 2018)
  • High fiber diet (Thomas & Natarajan, 2013)
  • Rule out food intolerances and individualize your diet (Karlsson, Patel, & Premberg, 2020; Kronemyer, 2019; Leonardi et al., 2020)
  • “Balanced diet with adequate vitamins and minerals, reduction of alcohol, sugar, and caffeine intake, exclusion of fructose or lactose intolerance” (Halis, Mechsner, & Ebert, 2010)
  • The consumption of soy is controversial in endometriosis; however, Huijs & Nap (2020) note that “the amount of phytoestrogens present in soy is relatively low, making the effect of avoiding soy on suppressing endometriosis-related symptoms questionable”. They conclude that “there is insufficient evidence to advise women with endometriosis to avoid soy” (Huijs & Nap, 2020).

Karlsson, Patel, and Premberg (2020) summed it up best by stating that “participants experienced decreased symptoms and increased well-being after adopting an individually-adapted diet”; therefore, it may take some experimenting to find what works best for you as an individual.

*Interstitial cystitis is often called the “evil twin” of endometriosis and its symptoms can be greatly influenced by diet (see Interstitial Cystitis).

Links:

Studies:

“Results: Participants experienced an increase in well-being and a decrease in symptoms following their dietary and lifestyle changes. They also felt that the dietary changes led to increased energy levels and a deeper understanding of how they could affect their health by listening to their body’s reactions. The participants understood that they could influence their symptoms through lifestyle changes. Support from family and friends was important in implementing and sustaining the dietary changes. However, the participants stressed the lack of support from healthcare professionals. Conclusions: This study contributes to filling the knowledge gap about dietary strategies in endometriosis and lifestyle change as a method of alleviating suffering and increasing well-being. An important finding is that the participants experienced decreased symptoms and increased well-being after adopting an individually-adapted diet. Healthcare professionals should take their patients’ knowledge and experience into consideration, and allow patients to participate in their own care. Further research is necessary to give evidenced-based dietary advices in endometriosis.”

  • Mumford, S. L., Weck, J., Kannan, K., & Buck Louis, G. M. (2017). Urinary phytoestrogen concentrations are not associated with incident endometriosis in premenopausal women. The Journal of nutrition, 147(2), 227-234. Retrieved from https://academic.oup.com/jn/article/147/2/227/4630423 

“Despite endometriosis being an estrogen-dependent disease, we found no evidence that urinary phytoestrogens were associated with a higher risk of an endometriosis diagnosis in either a sample of premenopausal women or in a surgical sample.”

  • Jurkiewicz-Przondziono, J., Lemm, M., Kwiatkowska-Pamuła, A., Ziółko, E., & Wójtowicz, M. K. (2017). Influence of diet on the risk of developing endometriosis. Ginekologia Polska, 88(2), 96-102. doi: 10.5603/GP.a2017.0017

“Currently, there are no clear correlations between particular food products and the risk of endometriosis.”

“In order to gain more insight into the role of nutrients on symptoms in women with endometriosis a systematic review was carried out in which the effect of a nutrient or diet on endometriosis-related symptoms was investigated. PubMed and the Cochrane Database of Systematic Reviews were searched for relevant articles up to 1 March 2019. Search terms included endometriosis, diet, and 26 possible nutrients were identified after assessing available endometriosis diets in the literature and on the internet. Twelve studies were included. Study quality, including risk of bias, was assessed using GRADE criteria and all were of low to very low quality. Intake of additional fatty acids, antioxidants and a combination of vitamins and minerals may have a positive effect on endometriosis-associated symptoms. Future studies are necessary to gain evidence about which food products are effective and in which amounts.”

“Women with endometriosis suffered significantly more from diet-related comorbidities than the control group, such as for food intolerances (25.6% vs. 7.7%; P = 0.009) and allergies (57% vs. 31%; P < 0.001). Gastrointestinal symptoms, including constipation, flatulence, pyrosis, diarrhea or frequent defecation, were also higher in the endometriosis group (77% vs. 29%; P < 0.001). In addition, the nutrient intake of patients with endometriosis varied significantly from controls…the total intake of animal proteins was significantly lower among women with endometriosis compared to controls (P = 0.047). The endometriosis group also showed a decreased intake of vitamin C (P = 0.031), vitamin B12  (P = 0.008) and magnesium (P = 0.043) compared to controls. The lower intake of vitamin B12 in the endometriosis group could be attributed to a lower intake of animal protein in this group because the vitamin is mostly found in animal products. The endometriosis group also failed to attain the recommended daily intake of 300 μg folate. About 77% of the women in the endometriosis group said they suffered from gastrointestinal symptoms, namely constipation and flatulence, versus 29% in the control group (P < 0.001). Besides disease localization, therapeutic treatment like gynecological surgeries and medications may impact gastrointestinal symptoms.The current study found hysterectomy and ovariectomy impaired indigestion, in particular constipation, flatulence and diarrhea in the endometriosis group. The investigators also observed a significantly higher portion of celiac disease and gluten sensitivity in women with endometriosis compared to controls, “which may explain the positive effect of a gluten-free diet in the management of pelvic pain in these patients.” Initiating studies to assess the prevalence of food intolerance in relation to endometriosis might help manage pain and gastrointestinal symptoms, such as through dietary interventions. “Considering the described gastrointestinal symptoms and food intolerances, endometriosis patients probably have a different nutritional behavior compared to women without endometriosis,” the authors wrote. Organic acids, such as citric or sorbic acid, may benefit endometriosis because of their anti-oxidative and antimicrobial properties. These acids have also shown anti-inflammatory effects in animal experiments. Dietary supplementation of vitamin C or magnesium might also be part of nutritional therapy for endometriosis.” 

  • Marziali, M., Venza, M., Lazzaro, S., Lazzaro, A., Micossi, C., & Stolfi, V. M. (2012). Gluten-free diet: a new strategy for management of painful endometriosis related symptoms?. Minerva chirurgica, 67(6), 499-504. Retrieved from https://europepmc.org/article/med/23334113

“RESULTS: At 12 month follow-up, 156 patients (75%) reported statistically significant change in painful symptoms (P<0.005), 51 patients (25%) reported not improvement of symptoms. No patients reported worsening of pain. A considerable increase of scores for all domains of physical functioning, general health perception, vitality, social functioning, and mental health was observed in all patients (P<0.005). CONCLUSION: In our experience, painful symptoms of endometriosis decrease after 12 months of gluten free diet.”

  • Moore, J. S., Gibson, P. R., Perry, R. E., & Burgell, R. E. (2017). 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, 57(2), 201-205. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/ajo.12594 

“Of the 160 women who met Rome III criteria for IBS, 36% had concurrent endometriosis. The presence of dyspareunia (P  > 0.0001), referred pain (P  = 0.005), bowel symptoms exacerbated by menstruation (P  = 0.0004) and a family history of endometriosis (P  = 0.0003) were associated with concurrent endometriosis. Seventy two percent of these women reported a >50% improvement in bowel symptoms after four weeks of a low FODMAP diet compared with 49% in those with no known endometriosis (P  = 0.001, odds ratio 3.11, 95% CI, 1.5–6.2.  Conclusions: Women with concurrent endometriosis and IBS report a unique symptom phenotype. The low FODMAP diet appears effective in women with gut symptoms and endometriosis.”

“…chronic exposure to dietary high-fat intake has been linked to greater systemic inflammation and oxidative stress, both features of women with endometriosis. Here, we evaluated the effects of a high-fat diet (HFD) (45% fat kcal) on endometriosis progression using an immunocompetent mouse model where ectopic lesion incidence was induced in wild-type recipients by ip administration of endometrial fragments from transcription factor Krüppel-like factor 9-null donor mice. We show that HFD significantly increased ectopic lesion numbers in recipient mice with no significant weight gain and modifications in systemic ovarian steroid hormone and insulin levels, relative to control diet-fed (17% fat kcal) mice. HFD promotion of lesion establishment was associated with reductions in stromal estrogen receptor 1 isoform and progesterone receptor expression, increased F4/80-positive macrophage infiltration, higher stromal but not glandular epithelial proliferation, and enhanced expression of proinflammatory and prooxidative stress pathway genes. Lesion-bearing HFD-fed mice also displayed higher peritoneal fluid TNFα and elevated local and systemic redox status than control diet-fed counterparts. Our results suggest that HFD intake exacerbates endometriosis outcome in the absence of ovarian dysfunction and insulin resistance in mice and warrants further consideration with respect to clinical management of endometriosis progression and recurrence in nonobese patients.”

  • Buggio, L., Barbara, G., Facchin, F., Frattaruolo, M. P., Aimi, G., & Berlanda, N. (2017). Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. International Journal of Women’s Health, 9, 281. Retrieved  from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422563/ 

“Despite these premises, the role of diet on endometriosis risk remains elusive, eg, in a systematic review of the literature by Parazzini et al8 of eleven studies, the results were characterized by extreme variability, and strong or definitive information could not be provided.

“Several studies have focused on the relationship between endometriosis and fish oils/polyunsaturated fatty acids (PUFAs), because these nutrients have an anti-inflammatory profile and are able to reduce proinflammatory prostaglandin production. ω3 PUFAs can be found mostly in salmon, tuna, and halibut. A large study by Missmer et al9 on a population of 70,709 US women, 1,081 of whom with a diagnosis of endometriosis, revealed that high intake of long-chain ω3 fatty acids (FAs) and decreased consumption of trans unsaturated FAs reduced the risk of endometriosis. Instead, an increased risk was associated with animal-fat ingestion, particularly palmitic acid.9 The ω3 FA:ω6 FA ratio has been investigated in three studies. Missmer et al9 and Netsu et al12 demonstrated that a higher ratio reduced the risk of the disease; on the contrary, Khanaki et al13 found a positive correlation between the ratio and the severity of the disease. Savaris and do Amaral14 reported a lower consumption of PUFAs in women affected by the disease, resulting in an imbalanced formation of long-chain ω3 PUFAs. In an endometriosis rat model, Netsu et al12 found a significant reduction in the thickening of the active site for inflammation in endometriosis in rats fed with a diet supplemented with ω3 eicosapentaenoic acid. On the other hand, three other studies,15–17 did not reveal a significant association between intake of fish or other dietary fats and risk of endometriosis….The relationship between red meat and risk of endometriosis has been analyzed in three studies. An Italian case-control study17 found a significantly higher risk of the disease in women reporting higher meat and ham intake. A plausible explanation of the role of red meat in the pathogenesis of the disease could be represented by the high amount of fat contained in this nutrient, in particular ω6 FAs, implicated in the production of proinflammatory prostaglandins. However, this association was not replicated in other studies by Trabert et al16 or Heilier et al.15

“Two studies have investigated the relation between fruit and vegetable consumption and endometriosis risk.16,17 Parazzini et al17 found that intake of both these nutrients led to decreased risk; on the contrary, in the case-control study conducted by Trabert et al16 an increased number of servings/day of fruit was associated with an augmented risk of the disease, but no association appeared with vegetables. These results could be explained by the fact that nowadays the cultivation of fruit involves extensive use of pesticides and dioxins, both implicated in the production of reactive oxygen species, as well as in the reduction of the antioxidant properties of these categories of food.

“In order to evaluate the potential association between coffee/caffeine intake, Chiaffarino et al18 recently conducted a meta-analysis. Eight studies were included, six case-control and two cohort studies, with 1,047 endometriosis patients in total. The meta-analysis provided no evidence for an association between coffee/caffeine ingestion and risk of the disease. The consumption of caffeine has been extensively analyzed, due to its property to act on hepatic production of sex hormone binding globulin (SHBG), reducing testosterone bioavailability,19,20 as well as for its role in inhibiting aromatase, an enzyme involved in the conversion of androgens to estrogens.21

“The role of a gluten-free diet in the management of symptomatic endometriosis has also been evaluated in two Italian retrospective studies.22,23 The rationale of these studies was the potential proinflammatory role of gluten that could enhance the production of specific cytokines involved in the exacerbation of the disease. Both studies demonstrated an improvement in pain symptoms in women who followed a gluten-free diet. The possible role of gluten in the worsening of the disease is indeed intriguing; however, due to the scanty available evidence on this topic, further research is needed in order to confirm this hypothesis.”

  • Mathias, J. R., Franklin, R., Quast, D. C., Fraga, N., Loftin, C. A., Yates, L., & Harrison, V. (1998). Relation of endometriosis and neuromuscular disease of the gastrointestinal tract: new insights. Fertility and sterility, 70(1), 81-88. Retrieved from https://pubmed.ncbi.nlm.nih.gov/9660426/

“Treatment consisted of dietary changes, including reduction of glycemic carbohydrates, balancing with omega 9 oils, elimination of foods with caffeine and tyramine, and addition of omega 3 fatty acids, as well as drug therapy with clonazepam (0.25 mg 3 times per day). Result(s): All 50 women showed a characteristic motility change (ampulla of Vater-duodenal wall spasm, a seizure equivalent of the enteric nervous system). Forty of the women showed bacterial overgrowth. There was a significant reduction in the total symptom score after 8 weeks of treatment. Conclusion(s): This study suggests that endometriosis and gastrointestinal tract symptoms are a result of the dysfunction of hollow organs. Correction of the biochemical imbalance of the eicosanoid system and the hypersecretion of insulin that results from excessive intake of glycemic carbohydrates and lack of essential fatty acids significantly decreases symptoms in patients with endometriosis and associated neuromuscular disease of the gastrointestinal tract.”

References