February 20, 2024

Worldwide, millions of people who menstruate have endometriosis, a gynecological condition that can cause debilitating symptoms and severely impact a person’s quality of life, mental health, and productivity. Yet treatments for endometriosis remain limited, and many people continue to struggle with symptom management. Could dietary interventions help?

Endometriosis is a gynecological condition in which endometrial-type tissue — similar to the tissue lining the inside of the uterus — grows in other parts of the body.

While endometrial-like tissue most commonly affects other organs in the pelvic and abdominal areas — such as the fallopian tubes, bladder, and intestines — research shows that in some cases it is much more far-reaching, impacting the heart, lungs, and even brain. Some research suggests that endometriosis can affect every single organ in the human body.

This condition can cause long menstrual periods (longer than 7 days), heavy bleeding, excruciatingly painful cramps that may cause a person to faint, nausea and vomiting, pain during and after sex with vaginal penetration, fatigue, and spotting between periods, among several other symptoms.

For people who receive a diagnosis of endometriosis, there are relatively few treatment and management options, which are not effective for everyone, and which do not guarantee long-term relief even for those for whom they do work.

This has led medical doctors, researchers, and individuals with endometriosis alike to search for additional relief methods, and one of these is centered on nutrition.

In this month’s installment of the In Conversation podcast, we discuss why endometriosis can be so difficult to manage, and some of the ways in which dietary changes may help relieve symptoms such as pain and heavy bleeding. Our guests are Dr. Hana Kahleova and Hannah Alderson.

Dr. Kahleova is director of clinical research at the Physicians Committee for Responsible Medicine — a nonprofit organization headquartered in Washington, DC — and one of the authors of a recent review looking at nutrition as a factor in the risk for and management of endometriosis. The review appeared in the journal Frontiers in Nutrition in February 2023.

Alderson is a registered nutritionist with the British Association For Nutrition And Lifestyle Medicine (BANT) and founder of The Positive Method – The Path to Happier Hormones. Her precepts for well-being stem from her own long journey seeking a diagnosis and treatment for polycystic ovary syndrome (PCOS) and endometriosis, which she shared with us on the podcast.

You can listen to this month’s conversation in full below, or on your preferred streaming platform for podcasts:

According to data cited by the World Health Organization (WHO), around 190 million menstruating individuals around the world are affected by endometriosis, which can severely impact their quality of life.

The figure given by the WHO may be an underestimate of the real number of endometriosis cases, since this condition is underdiagnosed, and it can take up to 11 years for a person to receive the correct diagnosis.

Excruciating pain is one of the most common symptoms of endometriosis. Indeed, the pain can be so debilitating and unusual in nature that, according to a 2021 report based on data from Britain, both patients and doctors said that the currently used pain rating scale was “insufficient as a standalone tool for communicating endometriosis related pain.”

Alderson also noted that it took a long time for her to find a doctor who correctly diagnosed her endometriosis. She already had a diagnosis of PCOS, and had just had an intrauterine device (IUD) put in, when she started experiencing horrible pain, she told Medical News Today in the podcast.

For a while, she thought this was a side effect of the IUD, but doctors soon ruled that out. This was the start of a long and convoluted journey to obtain a correct diagnosis. Alderson described her debilitating pain and how difficult the diagnostic process was:

“[The pain is] hard to describe — [it] sort of [extends] from your ovaries to the top of your thighs, going down like scraping metal […] And so I [initially] thought it must be the coil [IUD], went [to the doctor], got it checked out, had a scan and [the conclusion] was like, ‘No, nothing’s wrong.’ I went to see my […] family doctor, and then they said [it] could be trapped wind. […] I was like, ‘I really don’t think it is.’ [I] went away, came back. […] And then it got to a point where I actually did think I was making it up in my head.”

It was only when Alderson started studying to become a nutritionist, learning more about gynecological health conditions, that she found more information about the realities of endometriosis and, through her own research, finally reached a specialist who was able to diagnose her condition correctly.

But once the person manages to obtain a correct diagnosis, that is often only the beginning of the even longer search for an effective treatment or symptom management plan.

Currently accepted treatment options are limited, as Dr. Kahleova pointed out:

“I mean, you have some painkillers, you know, most of the time they don’t work much [for people with endometriosis] […] Then you have laparoscopy, and are hoping that surgically removing the [endometrial-type] tissues will help. But oftentimes, it [the tissue] comes back. So [surgery is] not a solution, either. So it’s kind of like [a] painful journey, just to [obtain an] endometriosis […] diagnosis in the first place, and with the limited treatment options in the second [place].”

Excision surgery is the only way to remove growths of endometrial-like tissue from other organs, but the tissue can grow back, so repeated surgery may be required.

Doctors may suggest nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, for pain relief, but these are often ineffective in reducing the severe pain that characterizes endometriosis.

Sometimes, doctors may prescribe tranexamic acid, a drug that promotes blood clotting, to help reduce heavy bleeding during periods, but the results are not guaranteed, and the “fix” may often be temporary.

Other treatments prescribed for symptom management include hormone therapy, such as birth control pills, or the insertion of an IUD which releases a form of the hormone progesterone, both of which can improve or stop a person’s period altogether.

However, once again, the result is not guaranteed, and not all people with endometriosis respond to hormone therapy, which may be down to the type of endometrial-like tissue that they have.

According to a 2018 study from The Journal of Clinical Endocrinology and Metabolism, people with progesterone receptor (PR)-positive lesions tend to respond to progestin, one of the active ingredients in birth control pills, while those with PR-negative lesions have a lower response rate.

Cue the search for lifestyle factors that may play a role in the risk of endometriosis and, by extension, could be leveraged to help manage the condition. One of the lifestyle factors that researchers have investigated in relation to endometriosis in recent years is nutrition.

Our diets have the potential to influence every aspect of our health, so it perhaps comes as no surprise that researchers have been looking at the link between nutrition and endometriosis risk and management.

One review of the existing literature published in 2021 found that several dietary items were linked to a heightened risk of endometriosis, including:

  • trans fats, which are a result of the food manufacturing process, which are found in fried and ultra-processed foods, and which increase cholesterol levels, as well as the risk of many health conditions, including diabetes and heart disease
  • red meat, which may be linked to various health risks depending on the level of consumption
  • alcohol, which can also contribute to a wide range of other health issues.

Dr. Kahleova and her colleagues made similar observations in their review.

“[W]hen we look into the studies that have been conducted on diet and endometriosis, we see clear links. So. for example, we see that red meat consumption — both processed and unprocessed red meat — increases the risk of endometriosis,” said Dr. Kahleova, adding that “in the prevention and treatment of endometriosis, removing red meat from the diet is the number one dietary recommendation.”

She also noted that reducing dairy consumption might help. “[D]airy products […] increase the estrogen levels, and [they] also contain palmitic acid, which is one of the saturated fatty acids that makes the symptoms worse,” Dr. Kahleova explained.

In contrast, some studies have found a protective effect of dairy products — except butter — if the intake is of over 21 servings a week, though it is hard to know if relevant confounding factors are linked to such a high dairy consumption.

The 2021 review also found that, when it came to treating and managing endometriosis, polyunsaturated fatty acids — such as omega-3 and omega-6 fatty acids — “reduce[d] the proliferation of endometriosis lesions both in vivo and in vitro.”

Fish, seaweed, and nuts can all be good sources of omega-3, and both Dr. Kahleova and Alderson agreed that adding more of those to the diet can help.

“Seaweed has been actually found helpful in women with endometriosis,” Dr. Kahleova noted, “based on [the experience of] just a few women that were in a series of case studies. Only three women were a part of this super small case study series, and consuming seaweed increased the length of their [menstrual] cycle[s], and decreased the length of their periods, and also decreased the symptoms that are associated with painful periods.”

Alderson said that her own experience backed what some of these studies have shown.

“[I]n terms of my approach [to dietary interventions],” she told us, “red meat consumption is something I definitely didn’t do too much of. But I did eat a diet which was more pescatarian. So that would fit into that narrative [that omega-3 fatty acids help].”

She also advised that bringing in more vegetables, particularly cruciferous vegetables, legumes, and fruits rich in antioxidants and that are also a good source of fiber can help.

A qualitative interview study with 12 people with endometriosis aged 28–44 years, published in BMJ Open in 2020, also suggested that such dietary changes can help improve symptoms.

Most of the people interviewed had excluded gluten or decreased its consumption, as well as that of dairy products, and carbohydrate-rich foods. At the same time, the interviewees had increased their fruit, vegetable, and fish consumption, and added dietary supplements, including vitamins, minerals, omega-3, turmeric, and ginger.

The interviewees said that after making these dietary changes, their endometriosis-related pain either decreased or disappeared entirely. “Some participants also experienced a decrease in the amount of bleeding and the number of days of bleeding,” the study reports.

What is important, in Alderson’s view is, essentially, “to create an environment [within the body] where endometriosis wouldn’t be able to thrive so well.” However, she also added that this must come “alongside the incredible work the doctor could do” to treat this condition.

“Because there’s no way I could have solved my situation with diet alone,” she cautioned, “but definitely it’s helped.”

So what are the potential mechanisms behind the ways in which diet may interact with symptoms and characteristics of endometriosis?

According to Dr. Kahleova and her colleagues’ review, several different mechanisms may be at play, depending on the foods under discussion. In the review, they note that reducing dietary fat and increasing dietary fiber can reduce circulating estrogen in the body by 10–25%.

This could help with endometriosis symptoms because, according to existing research, people with endometriosis have increased estrogen levels compared to those without, so reducing concentrations of this hormone may be beneficial.

“Saturated fat has been shown to increase the risk of endometriosis,” Dr. Kahleova said in the podcast. “And […] I mentioned that increasing the omega-3s instead of the low-quality fat is definitely helpful. […] And also if you’re eating red meat, that means that you are not eating the foods or are eating less of the foods that may be actually helpful with your endometriosis.”

Dr. Kahleova and colleagues’ review also found that plant-based diets may be beneficial thanks to their anti-inflammatory potential, and research has repeatedly shown that inflammation plays a role in endometriosis.

Indeed, a new study published in March 2023 has found that endometriosis shares some of the genetic characteristics of other chronic pain and inflammatory conditions.

Dr. Kahleova and her colleagues also note that vitamin C appears to have the potential to reduce endometriosis symptoms thanks to its antioxidant properties.

One study showed that, for example, in women with endometriosis, when they were supplementing vitamin[s] C and E, not only did their antioxidant levels go up, but their symptoms were actually alleviated by the supplementation,” Dr. Kahleova noted in the podcast.

Not all existing studies are in agreement, however, about which foods may be linked to an increased risk of endometriosis, which may help improve symptoms, and why that may be.

Both Alderson and Dr. Kahleova made the same point, commenting on these discrepancies: In their view, this comes down to the limited number of studies on the link between diet and endometriosis.

More importantly, this comes in the context of already-insufficient research on endometriosis and other gynecological conditions, in general.

Funding is a core issue. According to a 2021 study, the National Institutes of Health (NIH) in the United States allocate “a disproportionate share of [their] resources to diseases that affect primarily men, at the expense of those that affect primarily women.”

“This is a topic where we urgently need research. We need more studies that will look into specific foods and dietary patterns [in endometriosis],” stressed Dr. Kahleova towards the end of the podcast.

Alderson was in full agreement. “[W]e need to have further deeper research [into endometriosis],” she said. “It is so complex [a condition], and it’s very different for [individual] women. I think the complexity of it does make it difficult [to understand].”

While nutritional interventions may indeed help individuals affected by endometriosis, there is a long road ahead when it comes to finding more effective treatments for all.

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