Tuesday 24 September 2019

Endometriosis: can your diet help?

Endometriosis affects 176 million women worldwide yet there is no cure, no known cause and treatment is limited. Our resident dietitian Orla Walsh looks at how food affects the condition

It is thought around 150,000 women in Ireland suffer with the condition
It is thought around 150,000 women in Ireland suffer with the condition

Endometriosis is a painful disorder that can take years to diagnosis - causing many to suffer a life of pain and debilitation and sometimes infertility. Some statistics suggest it afflicts about 10pc of women, most of which are diagnosed between 25 and 40 years. Unfortunately there is no cure and symptoms are traditionally treated with pain medication, hormone drugs or surgery.

So what is endometriosis? It occurs when pieces of the womb lining, or endometrium, are found outside the womb. They can grow in the fallopian tubes, ovaries, bladder, bowel, vagina or rectum. This endometriosis cells behave in the same way as it does in the womb. It grows during the menstrual cycle in response to the hormone cycle and breaks away when there's no pregnancy. When it grows outside the womb, it is trapped and cannot leave the body. Some women experience no symptoms, for others it is very painful. A common symptom is pain, especially in the lower stomach area, pelvis or lower back. Sometimes it's diagnosed when someone is trying to become pregnant without success as it impacts fertility.

* More common symptoms

* Painful periods

* Heavy periods

* Pain in the lower abdomen, pelvis or lower back

* Bleeding between periods

* Fertility challenges

* Pain during sex

Other symptoms you may have

* Bleeding from your rectum

* Blockages within the bowel

* Discomfort when passing urine

* Coughing blood (depending on situation of endometriosis)

* Endometriosis and your diet

Tackling the topic of diet and endometriosis is challenging as the literature is scarce. In 2006 a systematic review of the literature was limited to four trials of which two were on animals. Since then a literature review on the topic uncovered a further 16 studies. There are many reasons for this. Endometriosis needs to be diagnosed by laproscopy, which is invasive. On a whole the awareness of this condition is poor, with too many women going undiagnosed. This coupled with treatment options and recurrence rates mean that studies are more challenging to conduct. Nevertheless, this is not to say that diet has no impact on endometriosis. In fact, some women have very positive experiences and results when treating their endometriosis with tailored nutrition.

* Is your fat intake important?

In 2013 a systematic search for trials investigating a relationship between diet and endometriosis was undertaken. This is the largest study available investigating the link between diet and endometriosis risk and the first prospective study to identify a modifiable risk factor for the condition. This study suggested that the total amount of fat in the diet did not matter, but the type of fat eaten did. Women who ate the highest amount omega-3 fats were 22pc less likely to be diagnosed with endometriosis, while those who ate the most trans fats had a 48pc increased risk. Interestingly in the study, the highest contributor of omega-3 fats was mayonnaise and salad dressing, followed by oily fish, such as salmon and mackerel. Trans fats are artificially produced through hydrogenation, which turns liquid vegetable oil into solid fat. The major sources of trans fats in this study were from fried restaurant foods, margarine and crackers.

Interestingly a different systematic search found that intake of fish oil seemed to have a positive effect on pain symptoms showing the role of fat extending beyond risk.

* Foods to eat: Oily fish like mackerel, salmon, sardines and fresh tuna.

* Foods to avoid: Processed foods and fried foods.


There are a few studies that have reported that there is a decreased risk of developing endometriosis when the consumption of dairy products is high. One study reported that women who ate or drank more than three servings of total dairy foods each day were 18pc less likely to be diagnosed with endometriosis than those reporting two servings per day. As many women don't meet their dairy intake requirements each day, this is a change many may need to make.

* Foods to eat: Milk, yoghurt and cheese.

* Vitamin D

Vitamin D has been associated with many different conditions and diseases making it one of the more widely discussed micronutrients. Women with the highest vitamin D levels were shown to have a 24pc lower risk of endometriosis than women in the lowest levels.

Interestingly, several observational studies reported a better outcome for women receiving in-vitro fertilization when they had sufficient vitamin D levels within their body. This is mainly attributed to the positive impact vitamin D has on the endometrium. In a rodent study, it showed that vitamin D treatment improved. However, in more than one human study a high vitamin D intake was shown to be protective against endometriosis.

* Foods to eat: Oily fish, eggs and mushrooms.

* High antioxidant diet

Oxidative stress has been identified in women with endometriosis. A Food Frequency Questionnaire was used to evaluate the diets of 83 women with endometriosis and another 80 women without endometriosis. Those with endometriosis were then split into two groups with one group then guided on following an antioxidant diet for four months. The high antioxidant diet guaranteed the intake of 150pc of the suggested daily intake of vitamin A, 660pc of the recommended daily intake of vitamin C and 133pc of the RDI of vitamin E. Oxidative stress and antioxidant markers were determined every month. It was reported that women with endometriosis had lower antioxidant intakes overall. Nevertheless after two months on a higher antioxidant diet there was an increase in the vitamin concentrations and antioxidant enzyme activity, as well as a decrease in oxidative stress markers. Follow on research is required to see if this results in meaningful symptoms improvements for women with endometriosis.

* Foods to eat: Nuts, seeds, herbs, spices and berries.

* does reducing caffine help?

The internet is awash with guidance on endometriosis that is not backed up with research. A common suggestion for those with endometriosis is to reduce caffeine intake. A meta-analysis was conducted in 2014 to see if there was a link between endometriosis and caffeine. There were eight studies included with a total of 1,407 women with endometriosis. They reported no evidence for an association between coffee or caffeine and the risk of endometriosis.

* Supplements

A systematic review published in 2016 which included 27 trials investigated to see whether there was a relationship between any supplements and dysmenorrhoea. Although 27 trials sounds like a lot of research this only involved 3101 women. Interestingly 22 studies were conducted in Iran. The review reported that there was no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking.

* Supplements to take: No evidence for any supplements, to date.

* Gluten free diet

Pelvic pain affects four to 39pc of women and is the reason for 10-40pc of all outpatient visits to a gynaecologist. A retrospective study was undertaken to see if following a gluten-free diet had any impact on endometriosis-related pain and quality of life. Two hundred seven women with severe endometriosis-related pain enlisted in this study. After one year on a gluten-free diet the majority (75p ) of women reported statistically significant improvements in pain. None of the women reported worsening of pain. Other improvements were noted too including general health perception, vitality, social functioning and mental health. Therefore, a gluten free diet is worth considering for women with painful endometriosis.

* Foods to eat: Potatoes, rice, quinoa, sweet potato, parsnip, squash and pumpkin.

* Foods to avoid: Wheat, barley and rye.

* Low FODMAP diet

Women with endometriosis are frequently misdiagnosed with irritable bowel syndrome (IBS). Part of the reasons for this is that visceral hypersensitivity is seen in both conditions. A retrospective study which included 160 women with IBS, 36pc had concurrent endometriosis, showed that pain during sex, referred pain, bowel symptoms that worsened during menstruation and a family history of endometriosis were associated with concurrent endometriosis. After one month on a Low FODMAP diet, 72pc of women reported at least a 50pc improvement in bowel symptoms suggesting that the low FODMAP diet appears effective in women with gut symptoms and endometriosis.

* Foods to eat: Bananas, kiwi, orange, cucumber, tomatoes, peppers, courgette, spinach, lettuce, chives, carrots, lemon and lime.

Foods to avoid: Onions, garlic, apples, pears, celery, cauliflower, and peaches.

* Reducing reoccurrence with breast feeding

Women who breastfed for longer periods of time had significantly lower risk of being diagnosed with endometriosis. A study found that for every three additional months that mothers breastfed with each pregnancy, there was an 8pc drop in risk of endometriosis. For those women who were able to exclusively breastfed there was a 14pc drop for every three additional months per pregnancy. When the researchers looked across a woman's reproductive lifespan, women who breastfed exclusively for 18 months or more across all pregnancies had a nearly 30pc lower risk of being diagnosed with endometriosis. Part of this decreased risk may be due to the temporary absence of periods that naturally occurs when a woman is breastfeeding. However this was unlikely to be the only reason for the protection against developing endometriosis.

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