Nutrition Strategies for the Management of Endometriosis

Endometriosis is a common condition that can greatly affect a person’s quality of life. While research and support for endometriosis remain limited, there are some nutrition strategies that have the potential to help alleviate symptoms.

I’m a registered dietitian that focuses on irritable bowel syndrome (IBS) and endometriosis. In my years of practice, I’ve supported many people living with one or both of these conditions. I’ve seen in my work, and personally, how much impact these can have on people’s lives. In this post, we’ll review the symptoms, diagnosis, treatments, and nutrition strategies for the management of endometriosis. My hope is that this post will offer more clarity in the options available for endometriosis, as well as increase the awareness of this common condition.

What is Endometriosis?

Endometriosis is a common inflammatory condition in which tissue similar to the lining of the uterus grows outside of the uterus, around other organs. It usually affects organs inside the pelvis, such as the ovaries and fallopian tubes, but may also affect other organs, like the bladder, bowels and lungs. Just like the tissue in the uterus, it responds to changes in hormones throughout the menstrual cycle. The tissues thicken and bleeding occurs, leading to inflammation and painful symptoms.

Endometriosis Symptoms:

Many symptoms may be associated with endometriosis. Everyone’s experience will be different and you may not experience every one of the symptoms below.

Painful periods (dysmenorrhea)
Heavy menstrual bleeding (menorrhagia)
Painful sexual intercourse (deep dyspareunia)
Chronic pelvic pain
Lower back pain
Constipation, painful bowel movements, difficulty having a bowel movement
Pain or discomfort when urinating
Bloating
Diarrhea
Fatigue
Infertility

Note that the severity of symptoms is not a clear indicator of the severity of the condition. Some people with stage 4 endometriosis may have few or mild symptoms, while some with stage 1 endometriosis may have severe symptoms.

How is Endometriosis Diagnosed?

For many reasons, endometriosis can take a long time to diagnose. Diagnostic time will vary per region, but can take over 7-12 years from the onset of symptoms to the time of diagnosis. This is due to to a variety of factors, including a lack of awareness of the condition, non-specific symptoms that can lead to a misdiagnosis (often IBS), dismissal of pain, normalization of period pain, lack of non-invasive tests, and more.

Nevertheless, if you suspect you have endometriosis, it’s important to talk to your doctor as a prompt diagnosis can help improve quality of life and reduce disease progression. Your doctor may refer you for further testing, which may include:

Physical examination: This can include an internal pelvic exam or external abdominal exam. Note that this form of examination can’t exclude endometriosis.
Ultrasound: This can include a trans-abdominal ultrasound and intravaginal ultrasound. The findings will depend on the expertise of the person doing the scan and may lead to negative findings, despite having endometriosis. For this reason, an ultrasound can’t exclude endometriosis.
MRI: Your doctor may refer you for an MRI if an ultrasound is negative. This test also can’t exclude endometriosis.
Laparoscopy: This has been the gold standard for diagnosing endometriosis, though more guidelines now recommend making a clinical diagnosis based on symptoms and imaging. A laparoscopy is a surgical procedure where a camera is inserted through a small incision to assess internal organs and identify endometriosis. Endometriosis tissue can also be removed during this procedure.

Endometriosis Treatment and Management

Medication: This can include medication for pain management (NSAIDs, paracetamol), hormone treatments (combined hormonal contraceptives, progesterone (IUD, implant, etc.), and gonadotrophin-releasing hormone (GnRH)).
Surgery: Laparoscopy can be used to remove endometriosis tissue. This can help reduce symptoms, but does not cure endometriosis and symptoms often come back eventually.
Pelvic floor physiotherapy: Some people find pelvic floor physiotherapy to be helpful with pelvic pain symptoms and support with exercise. It can also help with constipation symptoms in those with pelvic floor dysfunction.
Nutrition: Nutrition can help to alleviate some symptoms of endometriosis through its effects on inflammation and digestive symptom management.
Other: Working with a therapist for support with mental health can be helpful when living with a chronic condition. Other strategies can also help with endometriosis symptoms, including heat, rest, exercise, breathing exercises, massage, stretching or yoga.

The Connection Between IBS and Endometriosis:

Endometriosis and irritable bowel syndrome (IBS) have many similarities and overlapping symptoms, which can often lead to a misdiagnosis.

Gastrointestinal symptoms affect 75-98% of people with endometriosis. This can include constipation, diarrhea, urgency, gas, bloating/distension, abdominal pain, and pain with bowel movements. Visceral hypersensitivity, which is an increased perception of pain from normal digestive sensations, appears to be present in both IBS and endometriosis. One study showed that almost 80% of women diagnosed with IBS actually had endometriosis on laparoscopy. Another study showed that 36% of women with IBS had coexisting endometriosis.

Due to the overlapping symptoms, the risk of misdiagnosis, and the increased risk of endometriosis in women with IBS, it’s important for doctors to be aware of endometriosis red flags in people presenting with digestive symptoms. This includes worsening symptoms around someone’s period, painful and/or heavy menstrual bleeding, pain during intercourse, a family history of endometriosis, and more.

Nutrition Strategies for the Management of Endometriosis

Many diets are proposed online to help with endometriosis. This includes the restriction of gluten, dairy, red meat, caffeine, soy, alcohol, ultra-processed foods, and more. However, there is limited research to support most of these diets for endometriosis.

Thankfully, we do have some evidence-based strategies that can offer symptom relief, especially for those living with digestive symptoms related to endometriosis.

Anti-Inflammatory Diet

This is an eating pattern that focuses on anti-inflammatory foods, such as fruits, vegetables, legumes, nuts, seeds, whole grains, and healthy fats, while limiting “inflammatory foods” like ultra-processed foods, refined carbs and sugars, red and processed meat, saturated and trans fats, and excessive alcohol. Note that some sources online will label gluten and dairy as “inflammatory”. This has not been shown in research.

Limited research supports the use of an anti-inflammatory diet for endometriosis management. While more research is needed for its effects on endometriosis, this eating pattern is in line with general healthy eating guidelines and will offer a variety of health benefits.

Many eating patterns can fall under the anti-inflammatory description, including the Mediterranean diet and plant-based diets. One study showed that a Mediterranean diet improved the general well-being of those living with endometriosis and helped reduce symptoms. Note that the Mediterranean diet reflects systemic racism and biased research and is not the only eating pattern offering many health benefits. An anti-inflammatory eating pattern can be adapted to reflect your own preferences and cultural foods.

Can the Low FODMAP Diet Help Manage Endometriosis Symptoms?

Research shows that a low FODMAP diet has benefits for those with endometriosis and gut symptoms. As we previously discussed, the majority of people with endometriosis suffer from digestive symptoms similar to those in IBS.

What is a low FODMAP Diet?

The Low FODMAP diet temporarily reduces the consumption of FODMAPs (short-chain carbohydrates that are poorly absorbed and can increase digestive symptoms). These include lactose (dairy), fructose (some fruits, honey), fructan (wheat, onions, garlic), GOS (beans, lentils) and polyols (some fruits, vegetables). These are reduced for 2-6 weeks before strategically reintroducing each category, one by one, to look for triggers.

Note that the low FODMAP is a temporary elimination diet and is not meant for long-term use. It’s important to follow this diet with the guidance of an experienced dietitian.

Supplements for Endometriosis

Some supplements may be helpful in the management of endometriosis. Vitamins C and E have been shown to reduce endometriosis symptoms and may be worth a try. Vitamin D supplementation can be helpful for those living in areas with limited sunlight. Iron deficiency is also common in those with endometriosis due to heavy periods and may need supplementation. Supplement needs are very personal and will depend on your diet and blood work results. I recommend working with a dietitian and with your doctor to review supplements that would be a good fit for you. It’s also important not to overdo it when it comes to supplements. Make sure not to exceed the upper limit for any given nutrient.

Conclusion

There’s a lot that remains to be seen when it comes to nutrition for endometriosis management, but an anti-inflammatory diet and low FODMAP diet can be considered based on your own needs and preferences. I highly recommend working with a dietitian when making diet changes, especially when food restrictions are involved. If you have IBS symptoms and suspect endometriosis, I encourage you to talk to your doctor to review available testing and treatment options.

If you live with IBS and/or endometriosis and are looking for dietitian support, I would be happy to help! I offer virtual nutrition counselling to those living in British Columbia, New Brunswick, and Nova Scotia. I also offer in-person support at CAYA Health Centre in Vancouver. You can learn more about my approach, training, and availability here. I also offer 15-minute complimentary consults if you want to review your goals and make sure we’re a good fit.

This information is intended for educational purposes only and is not meant to replace individualized nutrition or medical advice.