Endometriosis, a condition affecting roughly 190 million women and girls of reproductive age globally, is characterized by the presence of endometrial tissues outside the uterine lining, typically on the external surface of the uterus, the ovaries, fallopian tubes, abdominal wall, or intestines. This can lead to severe pelvic pain, dysmenorrhea, dyspareunia, fertility complications, fatigue, low back pain, bloating, constipation, and diarrhea. The prevalence of endometriosis in North America, Australia, and Europe is approximately 1% to 5% in women of reproductive age, with some suggesting the true figure is closer to 10%.
Understanding Endometriosis
Endometriosis occurs when the endometrium starts growing outside of the uterus where it does not belong. Individuals with endometriosis may experience life-impacting pain during periods, constipation, fatigue, abdominal bloating, infertility, and chronic pelvic pain. Various theories exist to explain the etiology of endometriosis, including the migration of endometrial tissues outward through the fallopian tubes. In the peritoneal cavity, endometrial tissue is associated with increased levels of prostaglandins, cytokines, and chemokines, all of which are markers of inflammation.
Endometriosis is a chronic condition that usually develops several years after menarche and generally wanes after menopause. Higher levels of estrogen circulating in the body can worsen the pain and inflammation associated with endometriosis.
Current Treatment Options
Current treatment options for endometriosis include over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) for acute endometriosis pain, but these agents have limited effectiveness and adverse outcomes that limit their use. Hormonal treatments, such as progestins, combined oral contraceptives, gonadotropin-releasing hormone agonists and antagonists, testosterone analogs, and aromatase inhibitors, aid in suppressing endogenous estrogen production. However, hormone-modulating therapies such as gonadotrophin-releasing hormones used to repress ovarian function are not recommended for patients who are pregnant or wishing to conceive.
Laparoscopic excision and ablation surgeries involve the removal of pathological lesions via cutting and cauterization. Excision is typically preferred over ablation as it is associated with better pain outcomes. Hysterectomy is effective in reducing pain and symptom recurrence in endometriosis but is major surgery and ends fertility.
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A Swiss study found that nearly half of endometriosis patients surveyed were dissatisfied with their medical support. This highlights the need for a more comprehensive and patient-centered approach to managing the condition.
The Role of Nutrition
The role for nutrition in endometriosis is suggested by the influence of diet on estrogenic activity and inflammatory processes. Certain foods play a vital role in helping the body fight against inflammation and bring better balance to estrogen. Current research regarding nutrition in the prevention and treatment of endometriosis suggests that following certain dietary patterns may reduce endometriosis symptoms in some individuals.
Fat Quality and Quantity
Fat quality and quantity appear to be modulating factors for endometriosis. Animal fats are a focus, as high consumption has previously been linked to other gynecologic diseases such as ovarian cancer. A 2010 prospective study found that the intake of palmitic acid (a saturated fatty acid derived mainly from meat and dairy products) and trans fat was associated with an increased risk of endometriosis, while total fat consumption did not confer the same risk. The NIH-AARP Diet and Health Study found that participants with the highest total fat intake had a 28% greater risk for ovarian cancer compared to those with the lowest intake; only animal-derived fats had a significant positive correlation.
Certain fats may play protective roles. Omega-3 fatty acids can calm inflammation from endometriosis. Good food sources of omega-3s include fatty fish, like salmon, sardines, and tuna, nuts and seeds, especially walnuts, chia seeds, and flaxseed, and plant oils, including flaxseed oil and canola oil. Monounsaturated fats also have anti-inflammatory powers. They’re found in avocadoes, nuts and seeds, olive oil, peanut butter, and safflower oil.
Fiber Intake
Because estrogens are key in the pathogenesis of endometriosis, dietary factors that modulate estrogen activity may be clinically important. Reducing dietary fat and increasing dietary fiber has been shown to reduce circulating estrogen concentrations by roughly 10 to 25 percent. Fiber can help your body eliminate excess estrogen because fiber helps you poop, and when you poop, it gives your body a chance to get rid of extra estrogen. Aim for about 35 grams of fiber each day.
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Some people can benefit from fiber supplements, but you can also up your intake by eating fiber-filled foods, like fruits and vegetables, focusing on the whole foods, not juice, which strips out the fiber, ground flaxseed, which is great to add to smoothies or home-baked foods, legumes, like beans, lentils, and chickpeas and whole grains, including whole-wheat pasta and brown rice. Increasing fiber intake gradually can help minimize bloating, gas, and other digestive discomforts, and drinking plenty of water can also help to minimize these side effects.
Meat Consumption
Two prospective studies demonstrated significant correlations between red meat consumption (both unprocessed and processed) and the risk of developing endometriosis. The Nurses' Health Study II showed that women consuming more than two servings of red meat per day had a 56% greater risk of endometriosis, compared with those consuming less than one serving of red meat per week. Increased poultry intake was also associated with higher risk of endometriosis, although risk estimates for specific intake categories were not significant. An Italian study reported increased odds of developing endometriosis associated with a higher intake of beef, other red meat, and ham.
Red meat consumption may be associated with higher levels of estradiol and estrone sulfate, and thereby with higher concentrations of steroids, inflammation, and the development of endometriosis. Furthermore, red meat consumption may promote expression of pro-inflammatory markers, which appear to be implicated in endometriosis pathogenesis and progression.
Plant-Based Diets
Because of the role of inflammation in endometriosis, and the fact that reducing dietary fat and increasing dietary fiber reduce circulating estrogen concentrations, the effects of plant-based diets on inflammation have been of clinical interest. An 8-week study of 100 participants with coronary artery disease published by the American Heart Association found that those following a strictly vegan diet experienced less inflammation than those following a diet including animal products. Plant-based diets are typically lower in fat and higher in fiber than ones including animal products.
In a randomized crossover trial in women with dysmenorrhea, a low-fat vegan diet was shown to increase plasma concentrations of sex-hormone binding globulin, which, in turn, would be expected to reduce estrogen activity. Observations from the Nurses' Health Study II, including 81,961 premenopausal women, suggested that low-Glycemic Index foods are associated with reduced risk of endometriosis. Plant-based foods contain increased amounts of polyphenols when compared to an omnivorous diet, which, when metabolized into bioactive compounds, can reduce inflammation. When comparing a plant-based diet to an omnivorous diet, the gut microbiome contains a larger number of anti-inflammatory compounds.
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Seaweed Consumption
Seaweed may have estrogen-modulating properties. A double-blind trial testing the effects of seaweed in healthy postmenopausal women found an inverse dose-response relationship between seaweed consumption and serum estradiol concentrations, i.e., the higher the seaweed consumption, the lower the estradiol concentrations, which may partly explain its protective effects for breast cancer and lower postmenopausal breast cancer incidence and mortality in Japan. Seaweed may also reduce estradiol concentrations in pre-menopausal women. A case study in three pre-menopausal women reported that intake of bladderwrack, an edible brown kelp, significantly increased the length of menstrual cycle and reduced estradiol levels.
Vitamin D
Vitamin D may play a role in the prevention and treatment of endometriosis. A 2020 meta-analysis found that low vitamin D levels were associated with increased risk of endometriosis diagnosis and increased severity of symptoms. In a randomized, placebo-controlled trial in women with endometriosis, 50,000 IU vitamin D every 2 weeks for 12 weeks reduced pelvic pain by 1.12 points on a self-reported scale. The best source is the sun, though it can also be obtained from mushrooms.
Antioxidants
Free radicals are generated through physiological processes and exposure to environmental factors and cause oxidative stress, which often results in cell damage or death, contributing to a wide range of pathologies. Conversely, antioxidants are molecules that combat free radicals and can be endogenously synthesized or exogenously consumed. Because of the role of inflammation in endometriosis, research studies have addressed the potential role of antioxidant intake.
A 2009 study from Mexico reported that women with endometriosis had a 30% lower intake of vitamin C and consumed 40% less vitamin E, compared with women who did not have endometriosis. Following 3 months on a high-antioxidant diet, women with endometriosis displayed higher peripheral concentrations of supplemented vitamins.
Other Important Nutrients
Magnesium can help ease muscle cramps, including menstrual cramps that can come with having endometriosis. Magnesium-rich foods include fruits, particularly bananas, papaya, avocados, and blackberries, leafy greens, like arugula, dark lettuce, kale, and spinach, legumes, like black beans and edamame, and nuts and seeds, especially almonds and pumpkin seeds.
Zinc helps regulate your menstrual cycles, which is important for hormonal balance, and can help your body ovulate (release an egg). That includes foods like poultry, like chicken or turkey, red meat, but limit this to two low-fat servings per week, shellfish, including oysters, crab, and lobster and eggs, but limit yourself to one a day. If you follow a vegetarian or vegan diet, ask a healthcare professional about good sources of zinc for you and whether you could benefit from a zinc supplement.
Foods to Limit or Avoid
Highly processed foods aren’t healthy for anyone, and if you have endometriosis, cutting back on your intake can help. Processed foods are the ones that come in a box or bag and have long lists of ingredients. They don’t have the vitamin and mineral content you’ll find in fresh foods. Instead, they tend to be chock-full of things that may worsen inflammation and stir up endometriosis symptoms, including ingredients like simple carbs, sugar, salt, saturated fats, preservatives and food dyes.
Some people with endometriosis find that certain foods or drinks make their symptoms worse. Common triggers for people with endometriosis can include things like alcohol, caffeine, gluten, dairy products and high-sugar foods. Keeping a food journal can help identify any triggering foods.
Soy and Endometriosis
While it is clear that soy plays a positive role in many different health outcomes, there have been queries over its action on endometriosis because soy contains phyto-oestrogens. However, studies have shown that phyto-oestrogens, although they look like oestrogen, do not act in the same way, and that much of the criticism previously levelled at soy is now debunked.
Dietary Recommendations for Managing Endometriosis
Based on the available evidence, the following dietary recommendations may be beneficial for managing endometriosis symptoms:
- Emphasize whole, natural foods: A diet that emphasizes lean protein, healthy fats, whole grains, and lots of fruits and vegetables can make a difference in how you feel.
- Follow a balanced, low-fat, plant-based diet: This can help reduce inflammation and lower estrogen levels.
- Increase your fiber intake: Aim for about 35 grams of fiber each day to help flush excess estrogen out of the body.
- Incorporate omega-3 fatty acids: Consume foods rich in omega-3 fatty acids to calm inflammation.
- Ensure adequate vitamin D intake: Pay attention to this important vitamin, as vitamin D deficiency is strongly connected to endometriosis.
- Consider seaweed consumption: Seaweed contains unique nutrients that manage oestrogen in ways currently not yet confirmed.
- Increase antioxidant intake: Consume foods rich in vitamins C and E, as they have both been found to significantly reduce the symptoms of endometriosis compared with a placebo.
- Limit red meat and processed foods: These foods may promote inflammation and increase the risk of endometriosis.
- Identify and eliminate food triggers: Keep a food journal to identify any foods or drinks that worsen your symptoms.
- Stay hydrated: Drinking plenty of water can help to minimize bloating, gas, and other digestive discomforts.
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