Endometriosis: the role of diet & supplements

March is Endometriosis Action Month, raising awareness and demanding change for greater care, research, treatment and management options. 

This year the focus is on busting the myths and highlighting the real impact of living with endometriosis which affects not only physical health, but also mental health, relationships, work and finances. 

As someone who has endometriosis, has had 4 surgeries including a hysterectomy and endometrial-like tissue removed from the diaphragm (near the ribcage), this is a topic which is close to my heart. 

Endometriosis affects 176 million women worldwide. In the UK, it’s affecting 1 in 10 women of reproductive age, making it the second most common gynaecological condition. Despite increasing awareness, it still takes, on average 8 years from onset of symptoms to get a diagnosis, which is a shocking statistic. 

What is Endometriosis?

Endometriosis is a chronic inflammatory condition where cells similar to those that line the uterus are found in other parts of the body such as within the pelvic cavity (including the ovaries, fallopian tubes, and bowel). It can also be found elsewhere including the bladder, diaphragm, lungs and even the brain.

These endometrial-like cells react to the monthly menstrual cycle similarly to those within the womb, which means they build up and then break down and bleed. As the blood is unable to leave the body as a period does, this creates localised inflammation and can result in adhesions and scarring that causes significant pain, and in some cases infertility. 

The cause of endometriosis remains unknown. This means there’s no way of knowing if we can prevent it. It is thought that there’s a combination of factors that may lead to developing the condition, including genetics and environmental toxins, and possibly even a history of childhood trauma or immune system dysfunction. For more information on causes of endometriosis, you can read this article.

What are the symptoms?

Common symptoms of endometriosis include:

• painful periods
• pelvic and back pain
• painful intercourse
• pain when pooping
• abdominal bloating
• nausea
• constipation and/or diarrhoea
• fatigue 

The condition can also lead to relationship problems, depression, isolation and affect someone’s work and social life. 

Getting the right help is of the utmost importance.

There’s often an overlap between endometriosis and Irritable Bowel Syndrome (IBS) and this can lead to doctors missing the diagnosis for many years. IBS is a disorder of the gut-brain interaction, and the persistent symptoms of endometriosis including chronic stress and the mental drain that comes with this condition, could even be a trigger for developing IBS. 

If you suspect endometriosis it’s important that you see your doctor and ask for a referral to a gynaecologist. It can be helpful to have kept a calendar of your menstrual cycle and symptoms to present to your doctor to support your case and to discuss with them. 

What is the treatment?

There’s unfortunately no known cure so far, and so current treatment plans aim to improve the quality of life for those women living with the condition which may be via surgical removal(s) of affected tissue as well as hormone therapy and pain relief. 

Women should ideally be seen by an endometriosis specialist gynaecologist and have access to a multidisciplinary team (MDT) for a collaborative approach to treatment. This includes access to a clinical nurse specialist, pain consultant and psychological support. Also within that team women should have access to a colorectal surgeon, urologist and fertility services where necessary. Hopefully one day that team will also include a specialist dietitian!

Can diet help with endometriosis?

There’s no diet that can cure endometriosis, so please be wary of anyone pushing intense or restrictive diet plans. 

A diet rich in plants can help reduce endometriosis-associated pain as many of our plant foods contain plant chemicals called polyphenols which have antioxidant (protective) and anti-inflammatory properties. There’s different categories of polyphenols, but without getting too technical, if you’re including plenty of colourful foods in your week (eat the rainbow) then you’re likely getting a variety of these beneficial properties. Please note that we don’t currently recommend polyphenol supplements, and some may in fact be harmful. 

My top foods to include in the diet to help reduce inflammation:

1. Extra virgin olive oil (be very generous – think 30-50mls per day!)
2. Oily fish e.g. salmon, sardines, mackerel, trout, seabass
3. Nuts e.g. brazil nuts, almonds, walnuts
4. Seeds e.g. pumpkin, sunflower, sesame, chia
5. Cruciferous vegetables e.g. broccoli, cauliflower, kale, cabbage, kohlrabi
6. Soy foods e.g. tofu, tempeh, edamame beans
7. Berries e.g. strawberries, blueberries, raspberries
8. Red grapes
9. Citrus fruits e.g. oranges, lemons, kiwifruit
10. Green tea

Our dietary pattern is also important. Ideally we want to eat three regular meals a day.  Prolonged periods of fasting can increase the body’s circulating stress hormones which can increase inflammation. 

There is evidence that a low FODMAP diet may improve the digestive symptoms endometriosis sufferers experience. This is a type of temporary restrictive diet sometimes used in the treatment of IBS. It should only ever be carried out under the guidance of a FODMAP-trained dietitian as is extremely restrictive to begin with. The low FODMAP diet is not intended to be a long-term diet as the long term restriction can negatively impact our gut microbiome (the trillions of microbes living within our large intestine). A dietitian will guide someone through reintroducing those foods taken out whilst managing symptoms. 

Supplements for endometriosis

When it comes to supplements, the evidence isn’t conclusive. Where possible, I recommend obtaining nutrients through food instead of expensive supplement regimes however some supplements may be of benefit. Supplement recommendations should be tailored to the individual ideally based on lab results of vitamin/mineral levels to guide choices and doses. 

It is also important to discuss supplements with your doctor and/or pharmacist before starting in case of any drug-interactions. 

• Omega 3

This is important, especially if you don’t eat oily fish. Omega-3 provides anti-inflammatory benefits, and can help improve your omega 3:6 ratio which is important to consider when thinking about overall inflammation. We can arrange private testing for this in the clinic. 

• NAC (N-Acetyl Cysteine)

Scientific studies support the use of this supplement to help reduce inflammation, pain as well as decrease abnormal cell growth. 

• Vitamin D

This fat soluble vitamin plays an important role in the immune system, and optimising levels is important. You can read more about vitamin D in this article. 

• Magnesium

Choosing a gentle blend supplement can help with muscle relaxation, improved sleep, as well as softening stools.

• Melatonin

This is a neurohormone synthesised and released at night which may play a role in inhibiting the development and progression of endometriosis. Melatonin supplements aren’t widely available in the UK, although some sleep support products do contain them and may be beneficial. You can get 20% off this product (which also includes CBD which is beneficial in endometriosis) with the discount code GLN20. 

• Zinc

Another one that plays an important role within the immune system. Studies show that zinc levels may be lower in those with endometriosis. 

• Curcumin

Curcumin is the main compound found within turmeric which has anti-inflammatory properties. 

• Fibre supplements 

Fibres such as psyllium, flaxseed, chia or PHGG (partially hydrolysed guar gum) can be useful for those who have bloating and irregular stool habits which are common alongside endometriosis. Opening our bowels regularly can help flush out excess oestrogen which is important when considering endometriosis. 

• Probiotics

The evidence isn’t conclusive, but studies suggest that those with endometriosis may have lower levels of certain strains of bacteria within their gut microbiome. This means  a probiotic supplement (containing Lactobacillus acidophilus) could be helpful. This should be tailored to the individual and discussed with your dietitian. In some cases, the benefits of a probiotic are only seen whilst taking it (i.e. benefits cease when the supplement stops). So before starting a probiotic it should be considered whether it is something an individual can afford or wishes to take for the long term if necessary. 

Other lifestyle strategies for endometriosis

Nutrition is not the only thing that can support reducing inflammation. Exercise, sleep quality and quantity, and relaxation techniques are also important to consider to treat endometriosis holistically. 

Many complementary therapies including transcutaneous electrical nerve stimulation, osteopathy, massage, acupuncture, herbalism and Chinese medicine are used by endometriosis sufferers to reduce pain, improve mood and increase quality of life. There isn’t conclusive evidence to recommend all of these approaches, but anecdotal and observational evidence shows that some of these may be of benefit. 

Key recommendations:

• Try to get some daylight in the morning. This can help regulate your inner body clock and improve sleep at night. Better sleep can reduce inflammatory markers. 

• Techniques such as breathing exercises, mindfulness can help induce that “rest and digest” state which can not only improve digestion but can turn off that stress response which we know is associated with inflammation if over prolonged periods of time. 

• Exercise of some form can be beneficial not only for overall fitness and mental health support, but also in reducing inflammation. Whether it’s walking, yoga or high intensity cardio, keep active if you can. 

Summary

Nutrition can play an important role in the management of endometriosis symptoms, especially when combined with other lifestyle changes. A dietitian will be able to provide bespoke advice based on individual needs. 
If you’re interested in getting involved in Endometriosis Action Month take a look at EndometriosisUK (IG: @endometriosis.uk) which is the UK’s largest charity supporting those affected by endometriosis.