Plant-Based Eating for Endometriosis and Adenomyosis
May 11, 2022
Following a plant-based eating pattern for endometriosis and adenomyosis is becoming increasingly popular. As more research emerges on this topic, it seems that diet and nutrition can have a significant impact on symptoms for these conditions.
This article outlines common symptoms of endometriosis and adenomyosis, dietary principles to manage symptoms, and covers some frequently asked questions.
What is endometriosis?
With an estimated 1 in 10 women of child-bearing age living with endometriosis, it is more than likely that if you do not suffer from it, someone you know does. Endometriosis (or endo as it is commonly referred to) is a chronic inflammatory condition in which tissue similar to endometrial tissue (the tissue which lines the uterus) starts to grow in other parts of the body.
This is usually within the ovaries, fallopian tubes, peritoneum (lining of the abdominal and pelvic cavities). This tissue acts very similarly to endometrial tissue because it also bleeds during a period.
However, unlike the bleeding associated with normal endometrial tissue shedding, this bleeding causes inflammation around the reproductive organs which can lead to the formation of scar tissue, cysts and painful adhesions.
Endo affects everyone differently, however, there are a few common symptoms you may experience. These include:
- Painful periods including before and after menstruation (this may present as abdominal, pelvic and/or back pain)
- Heavy bleeding during periods and/or bleeding between periods
- Irregular periods
- Pain during or after sex
- Pain with urination or bowel movements (particularly during menstruation)
- Fertility difficulties
- IBS symptoms such as constipation, diarrhoea, bloating and nausea (which often worsen during periods)
What is adenomyosis?
Often referred to as the sister condition of endometriosis, adenomyosis (or adeno) is a little bit different. In this condition, the endometrial tissue grows into the muscle wall of the uterus rather than just lining it. This causes many microscopic bleeds in the muscle during menstruation.
Symptoms of adenomyosis are pretty similar to that of endo and again will present differently from person to person. The most common symptoms experienced are:
- Heavy and/or painful periods (most common) – this pain may also radiate down the back of the legs
- Pain during or after sex
- Chronic pelvic pain even outside of the menstruation
Endometriosis and adenomyosis can be present in individuals alone, or some people may experience both. You can learn more about both conditions and find support on the QENDO website: https://www.qendo.org.au/learn
Whether you have one of these conditions or both, one thing they all have in common is that their symptoms can have significant impacts on your mental and physical health and overall quality of life.
So how can our diet and nutrition help?
The link between nutrition and endo/adeno is still quite a new concept. However, there is emerging research that whilst diet and nutrition can’t cure either of these conditions, it can have quite a significant impact on managing the severity of symptoms if you struggle with these.
As mentioned, endo/adeno affects everyone differently, so the dietary management tips that work for you will likely vary to what works for someone else.
Most of the research published so far has been targeted toward managing endo rather than adeno. However, these conditions have many similarities as inflammatory conditions, so many of the nutrition and lifestyle tips can be translated across.
Plant-based eating for endometriosis and adenomyosis – can it help?
At this stage, research into plant-based eating (specifically) for endometriosis and adenomyosis is too limited to provide conclusive recommendations.
Despite this, many of the management strategies that have been researched do lean towards promoting a more plant-based style of eating. These dietary strategies can be categorised into six key areas which we will explore further below.
1. Include Antioxidant-Rich Foods Daily
Both endometriosis and adenomyosis can be categorised as inflammatory conditions. As such, it makes sense that an anti-inflammatory style diet can be a beneficial strategy to help improve symptoms. An anti-inflammatory diet is one that is rich in many plant-based foods such as fruits, vegetables, whole grains, and nuts and seeds. In particular, it emphasises antioxidant-rich foods.
Antioxidants are naturally occurring chemicals that can be found in many of our plant-based foods and help fight inflammation. This is especially important for people living with endo or adeno as there is strong research that suggests inflammation plays a significant role in the development and progression of these conditions (2).
One study delved into the effects of vitamins E and C (these nutrients are also antioxidants) on endometriosis and found that supplementation with the two vitamins had many positive outcomes (3). These included an improvement in chronic pain for almost 50% of participants and decreases in menstrual pain and painful sex. The study also measured the participants’ inflammatory markers before and after supplementation and found a significant decrease. This suggests that a reduction in inflammation was likely a big factor in the positive results.
Other studies have found that eating antioxidant-rich plant-based foods may even decrease your risk of developing endometriosis. This can start just by incorporating green vegetables and 2 serves of fruit each day (4,5).
However, this doesn’t mean you need to start stocking up on expensive antioxidant supplements. We recommend starting with a food-first approach by loading up your diet with colourful fruits and veg each day. Alongside this, include vitamin E-rich healthy fats such as extra virgin olive oil, peanut butter and sesame seeds (including tahini).
2. Make Fibre Your New Best Friend
Fibre is contained in all our plant-based foods such as fruits and veg, whole grains, nuts and seeds, and legumes. It is essentially the part of the plant that our bodies are unable to properly digest. Instead, it serves other important functions such as feeding our gut bacteria for good gut health and helping to keep our bowels regular.
Beyond this, fibre also plays an important role in endometriosis management. Research has found that fibre is able to help us to remove excess oestrogen from the body through a process called ‘barrier protection’. This is where the fibre surrounds the oestrogen to stop our bodies from absorbing it and instead transports it out of our bodies through our bowels.
This is important for anyone struggling with endometriosis as having excess oestrogen in the body is linked to a worsening of symptoms (6). This is because whilst oestrogen is an important hormone when present at normal levels, high oestrogen levels can increase the growth (in number and size) of endometrial cells. It can also cause the formation of prostaglandins. These are often referred to as ‘fake’ hormones that can increase inflammation.
Research has found links between consuming more fibre-rich fruits and veg and reducing your risk of developing endometriosis (5).
A good place to start is aiming for at least 30g of fibre per day. You can achieve this by including fibre-rich plant foods in each meal, such as fruit, vegetables, whole grains (rolled oats, quinoa, grain bread, brown or wild rice, or barley), legumes or psyllium husk.
3. Choose More Low Glycaemic Index (GI) Foods
Glycaemic Index (GI) is a ranking system for carbohydrate-rich foods based on how they affect our blood glucose (i.e. blood sugar) levels after we eat them. The lower the GI of a food, the slower our blood sugar levels rise after we eat it.
On the other hand, high GI foods will raise our blood sugar levels quite quickly soon after they are eaten. When our blood sugar levels rise, our body produces a hormone called insulin to help draw the sugar from our blood into our cells for use or storage. This means that high GI foods cause an increased insulin response as there are more sugars in our blood to be transported.
How does this link to endometriosis?
Some research has found that the increased insulin response associated with eating high GI foods may be linked to an increase in the number of endometrial cells. This means that eating a lower-GI diet may help to slow the progression of endometriosis (7).
Some easy tips to lower the GI of your diet include:
- Swap white bread for multi grain or sourdough
- Switch white pasta for wholemeal or legume-based pasta
- Instead of white jasmine rice, use Basmati rice, wild rice or other whole grains such as quinoa, buckwheat, farro or pearl couscous
- Swap standard breakfast cereals for rolled oats
- Pair carbohydrate-rich foods (e.g. bread, pasta, rice, potato) with a source of healthy fats and/or protein such as avocado, nuts and seeds or tofu. This helps slow down digestion which can also help slow the insulin response after a meal
4. Include More Healthy Fats
There has also been quite a bit of research into how different types of fats can impact both endometriosis development and symptom severity. The easiest way to understand the impact of fats is to break them down into three main categories: saturated fats, trans fats and unsaturated fats.
As discussed previously, endometriosis is an inflammatory condition and thus, consuming a more anti-inflammatory diet can have positive benefits. The different types of fats in the diet can play a role in promoting or reducing inflammation.
Let’s start with the ‘not-so-beneficial’ fats, or the ones that we know can promote inflammation in the body. These include trans fats and saturated fats.
Trans fats are produced through high levels of processing. Fortunately, they aren’t too much of an issue in the Australian food industry. However, small amounts can be found in most commercially produced foods such as cakes, biscuits and pastries as well as fried foods.
Research has found that consuming foods containing trans fats increases inflammation in the body and one study found that women with a high trans fat intake were 48% more likely to be diagnosed with endometriosis (4). Bear in mind that this is a small sample size and only a single study, and that there are many factors that could contribute to the development of endometriosis.
The second type of ‘not so beneficial’ fat is saturated fat. Saturated fats can be found in most animal products such as meat, dairy, eggs, palm oil and coconut and its products (e.g. coconut milk and oil). One saturated fat in particular, palmitic acid, which is primarily found in red meat, has been linked to increased risk of developing endometriosis (4).
Processed meats such as sausages, ham and other cold cuts have also been suggested to increase the risk of developing endo. High consumption of red meat has also been linked to an increased level of steroids in the body which can encourage the maintenance of endometriosis (7, 8).
On the other hand, unsaturated fats have the opposite effect and can help to reduce inflammation in the body. Foods rich in unsaturated fats include avocado, olives and olive oil and nuts and seeds.
One type of unsaturated fat, omega-3 fats, is a superstar when it comes to endometriosis management and even prevention. Oily fish such as salmon and walnuts, chia, flax and hemp seeds are all rich sources of omega 3 fats.
Alongside anti-inflammatory properties, omega-3 fats can play a role in reducing prostaglandin production, which is known to increase endometrial and pelvic pain and can worsen symptoms (9). Research has found a link between having a high omega-3 intake and a reduced risk of developing endometriosis by around 22%.
Another staple food for any anti-inflammatory diet is extra virgin olive oil (aka EVOO) (4). A good source of unsaturated fats, EVOO is also a rich source of antioxidants and contains a component called oleocanthal. This compound has unique anti-inflammatory properties similar to ibuprofen (which is commonly used for management of pain in women with endo or adeno). It is also rich in vitamin E which may help to reduce pelvic pain during menstruation and intercourse (10).
The low FODMAP diet for endometriosis
Many people with endo may also struggle with a range of uncomfortable digestive symptoms such as gas, bloating, abdominal pain and bowel irregularities such as constipation or diarrhoea. This can be similar to the criteria for diagnosis of Irritable Bowel Syndrome (IBS).
Research has found that women with endo may be 3.5 times more likely to also be diagnosed with IBS (11). This means that following a low FODMAP diet may positively help with symptom management. One study of women with both endo and IBS found that with just 4 weeks of a low FODMAP diet, 72% of participants reported a 50% improvement in bowel symptoms (12).
What are FODMAPs?
FODMAP is an acronym for Fermentable, Oligosaccharides (fructans and galactooligosaccharides), Disaccharides (lactose), Monosaccharides (fructose), and Polyols (sorbitol, mannitol, maltitol, xylitol and isomalt). These are types of carbohydrates found in many common (and nutritious) foods such as fruit and veg, legumes, nuts and seeds, grains and dairy. However, they are not well digested by the body and are instead fermented by the gut bacteria in our intestines, creating gas as a byproduct.
While this is a very normal and healthy process, for some people, it can cause many uncomfortable IBS symptoms.
The phases of the low FODMAP diet
The low FODMAP diet has 3 phases. An elimination phase during which all high-FODMAP foods are restricted, followed by a re-introduction phase where each FODMAP is challenged to determine the type and amount of FODMAPs that you can tolerate without triggering symptoms. The final phase involves formulating an individualised diet based on your challenge results to ensure you have as much food variety as possible with minimal symptoms.
If the low FODMAP diet does not lead to symptom improvement within the first 2-4 weeks, it should be discontinued to trial other diet or lifestyle strategies.
The low FODMAP diet is designed to be followed with the guidance of an Accredited Practising Dietitian who is trained in this area. It is challenging to do it correctly, and there are risks involved including nutrient deficiencies or disruption to the balance of good gut bacteria from excluding a range of foods.
In many cases, other diet or lifestyle strategies can be effective, or someone may follow a ‘light’ version of the low FODMAP diet which can be an easier process.
Other considerations for managing gut symptoms
There are other dietary or lifestyle strategies outside of the low FODMAP diet that can be useful to help manage IBS symptoms. They may be much more simple, yet can make a huge impact. These include fibre and fat modification, fluid intake, caffeine consumption, stress management and mindful eating, amongst others.
There is a strong link between stress or anxiety and IBS symptoms due to the ‘gut-brain axis’, in which there is a two-way relationship between the brain and the gut. Meditation and breathing techniques could help, alongside apps such as Nerva that provide self-guided digital hypnotherapy.
In some cases, there may be pelvic floor dysfunction which can play a role in gut symptoms. Working with a pelvic floor physiotherapist can be very helpful.
IBS triggers are highly individualised and what might improve symptoms for one person may have no effect or even worsen symptoms for someone else. This is why working with a dietitian is highly recommended to find a suitable approach that’s tailored to you.
Do you need to go organic?
A question that commonly pops up when discussing the role of plant-based eating for endometriosis is ‘do I need to go organic?’
The reason why organic produce is often put on a pedestal is because it contains significantly fewer pesticides (or none). There is some research which suggests that the pesticides traditionally used in the cultivation of fruits and vegetables may reduce their antioxidant capacity (13). Additionally, a specific type of pesticide – organochlorines – may interfere with hormonal pathways related to the worsening of endometriosis symptoms. This may be reversed by choosing organic varieties (14).
However, despite some potential benefits, organic produce is often accompanied by a much higher price tag that can make it a less affordable choice for many people. This means that you may end up limiting the amount of fruit and veg in your diet on the basis that it just isn’t financially feasible.
No matter what, adding more fruit and veg into your diet is going to be beneficial regardless of whether it is organic or not. So, as a general rule, if you can afford the additional cost of buying some organic produce (particularly those where the skin is eaten), it may be worthwhile, however it isn’t the most important thing to focus on.
The bottom line
Whilst there is some promising evidence that supports the role of diet in managing endometriosis progression and symptom severity, the research is still in its infancy.
Some of the main factors to consider include increasing intake of fibre- and antioxidant-rich foods, choosing lower GI foods and eating more healthy fats. To manage gut symptoms, dietary and lifestyle strategies include the low FODMAP diet, pelvic floor physiotherapy and gut-directed hypnotherapy.
As endo and adeno affect everyone differently, you may need to try several of these strategies to determine what works for you.
Working with an experienced health professional such as a dietitian at the PNW clinic can help make this process easier. You are welcome to book a discovery call to learn more about the coaching process!
This article was co-written by PNW Clinic dietitians Georgia D’Andrea and Kiah Paetz.