Nutrients and practical dietary strategies to consider as part of your holistic treatment plan.

Overview and diagnostic criteria

Endometriosis is a highly prevalent, inflammatory gynaecological condition affecting the reproductive health of 11 per cent of women and people assigned female at birth in Australia [1]. The oestrogen-dependent condition involves the abnormal growth of tissue similar to endometrial tissue, which lines the inside of the uterus, elsewhere in the body; this most commonly occurs in the pelvis [2; 3]. Hormonal stimulation causes endometriosis lesions to grow, and bleed during menstruation; endometriomas (cysts) – prone to rupture – can also form [4]. Endometriosis can cause debilitating pain and infertility; as such, prompt diagnosis and intervention are necessary to avoid undue distress and limit disease progression [3; 5; 6].

Endometriosis may be suspected in individuals experiencing chronic pelvic pain, dysmenorrhea (painful menstruation), dyspareunia (painful sex), or period-related gastrointestinal or urinary pain, particularly during bowel movements and when urinating [1; 3-5]. However, laparoscopic surgery – and biopsy – is required to reach a definitive diagnosis [3].

Treatment

Medical treatment may involve pain relief medications such as paracetamol and ibuprofen, oestrogen regulation via hormonal treatments such as the combined oral contraceptive pill, and/or laparascopic surgery [3; 4]. The chosen treatment option will depend on personal priorities concerning pain management, management of side effects, and fertility preservation [3].

Alongside medical treatment, diet and lifestyle are integral to managing endometriosis and its symptoms [7; 8].

Nutritional management of endometriosis

Omega-3 fatty acids have been found to reduce the size and growth rate of endometriosis lesions, and suppress endometriosis-associated inflammation and pain [14-16]. Multiple studies also associate omega-3 deficiency with increased endometriosis risk [9-13].

• Omega-3 fatty acids are found in oily fish (e.g. salmon, ocean trout, mackerel) and walnuts [17].

Vitamins C and E are associated with reduced endometriosis-associated oxidative stress and inflammation [5; 7]. Both nutrients have been found to reduce inflammatory markers in the pelvis, as well as the severity of chronic pelvic pain, dysmenorrhea and dyspareunia [5; 7; 18]. Vitamin C may also help prevent endometrial cells implanting outside the uterus [16].

• Many fruits and vegetables, including strawberries, kiwi fruit, tomatoes, red capsicum and snow peas, are rich sources of vitamin C [17].

• Vitamin E is found in nuts and seeds (e.g. almonds, sesame seeds), extra virgin olive oil, and eggs [17].

Despite encouraging evidence, the nutritional management of endometriosis remains an emerging area requiring further exploration [7]. Currently, an antioxidant-rich Mediterranean dietary pattern – incidentally, rich in omega-3, vitamin C and vitamin E, among many other nutrients – is the preferred clinical nutritional intervention to improve endometriosis symptoms, whilst also delivering well-established, broader health benefits [7; 19].

Suggested nutritional interventions and practical dietary strategies

To help manage symptoms of endometriosis as part of your holistic treatment plan, consider:

1. Adopting a Mediterranean dietary pattern.

   Try:

   • Including one high-quality plant-based protein source per day [20].

   • Limiting red meat and increasing fish and seafood consumption [7; 20].

2. Increasing your intake of monounsaturated and polyunsaturated fatty acids, in place of saturated and trans fats.

   Try:

   • Including high-quality, nutrient-dense fats (e.g. avocado, extra virgin olive oil) daily [7; 20].

   • Enjoying at least one serving of oily fish weekly [7].

3. Increasing your intake of antioxidant-rich foods.

   Try:

   • Enjoying a diverse array of different-coloured fruits and vegetables daily [21].

   • Featuring vegetables and legumes in main dishes (rather than sides) [20].

Disclaimer. Always consult your health care practitioner for individualised dietary and health care advice.

References.

[1] Australian Institute of Health and Welfare [AIHW]. (2019). Endometriosis in Australia: Prevalence and hospitalisations. Retrieved September 12, 2022, from https://www.aihw.gov.au/getmedia/a4ba101d-cd6d-4567-a44f-f825047187b8/aihw-phe-%20247.pdf.aspx?inline=true
[2] Commonwealth of Australia. (2022). What we’re doing about endometriosis. Department of Health and Aged Care. Retrieved September 12, 2022, from https://www.health.gov.au/health-topics/chronic-conditions/what-were-doing-about-chronic-conditions/what-were-doing-about-endometriosis
[3] The Royal Australian and New Zealand College of Obstetricians and Gynaecologists [RANZCOG]. (2021). Australian clinical practice guideline for the diagnosis and management of endometriosis. Retrieved September 12, 2022, from http://ranzcog.edu.au/wp-content/uploads/2022/02/Endometriosis-clinical-practice-guideline.pdf
[4] Norris, T. L. (2019). Porth’s pathophysiology: Concepts of altered health states (10th ed.). Wolters Kluwer.
[5] Amini, L., Chekini, R., Nateghi, M. R., Haghani, H., Jamialahmadi, T., Sathyapalan, T., & Sahebkar, A. (2021). The effect of combined vitamin C and vitamin E supplementation on oxidative stress markers in women with endometriosis: A randomized, triple-blind placebo-controlled clinical trial. Pain Research & Management, 2021, 1-6. https://doi.org/10.1155/2021/5529741
[6] Saunders, P., & Horne, A. W. (2021). Endometriosis: Etiology, pathobiology, and therapeutic prospects. Cell, 184(11), 2807-2824. https://doi.org/10.1016/j.cell.2021.04.041
[7] Nirgianakis, K., Egger, K., Kalaitzopoulos, D. R., Lanz, S., Bally, L., & Mueller, M. D. (2022). Effectiveness of dietary interventions in the treatment of endometriosis: A systematic review. Reproductive Sciences, 29(1), 26-42. https://doi.org/10.1007/s43032-020-00418-w
[8] Smolarz, B., Szyłło, K., & Romanowicz, H. (2021). Endometriosis: Epidemiology, classification, pathogenesis, treatment and genetics (review of literature). International Journal of Molecular Sciences, 22(19), 1-29. https://doi.org/10.3390/ijms221910554
[9] Halpern, G., Schor, E., & Kopelman, A. (2015). Nutritional aspects related to endometriosis. Revista da Associacao Medica Brasileira, 61(6), 519-523. https://doi.org/10.1590/1806-9282.61.06.519
[10] Hopeman, M. M., Riley, J. K., Frolova, A. I., Jiang, H., & Jungheim, E. S. (2015). Serum polyunsaturated fatty acids and endometriosis. Reproductive Sciences, 22(9), 1083- 1087. https://doi.org/10.1177/1933719114565030
[11] Jurkiewicz-Przondziono, J., Lemm, M., Kwiatkowska-Pamuła, A., Ziółko, E., & Wójtowicz, M. K. (2017). Influence of diet on the risk of developing endometriosis. Ginekologia Polska, 88(2), 96-102. https://doi.org/10.5603/GP.a2017.0017
[12] Abokhrais, I. M., Denison, F. C., Whitaker, L., Saunders, P., Doust, A., Williams, L. J., & Horne, A. W. (2020). A two-arm parallel double-blind randomised controlled pilot trial of the efficacy of omega-3 polyunsaturated fatty acids for the treatment of women with endometriosis-associated pain (PurFECT1). PLoS One, 15(1), 1-13.https://doi.org/10.1371/journal.pone.0227695
[13] Signorile, P. G., Viceconte, R., & Baldi, A. (2018). Novel dietary supplement association reduces symptoms in endometriosis patients. Journal of Cellular Physiology, 233(8), 5920-5925. https://doi.org/10.1002/jcp.26401
[14] Akyol, A., Şimşek, M., İlhan, R., Can, B., Baspinar, M., Akyol, H. Gül, Gürsu, H. F., Kavak, B., & Akin, M. (2016). Efficacies of vitamin D and omega-3 polyunsaturated fatty acids on experimental endometriosis. Taiwanese Journal of Obstetrics and Gynecology, 55(6), 835-839. https://doi.org/10.1016/j.tjog.2015.06.018
[15] Attaman, J. A., Stanic, A. K., Kim, M., Lynch, M. P., Rueda, B. R., & Styer, A. K. (2014). The anti-inflammatory impact of omega-3 polyunsaturated fatty acids during the establishment of endometriosis-like lesions. American Journal of Reproductive Immunology, 72(4), 392-402. https://doi.org/10.1111/aji.12276
[16] Yalçin Bahat, P., Ayhan, I., Üreyen Özdemir, E., Inceboz, Ü., & Oral, E. (2022). Dietary supplements for treatment of endometriosis: A review. Acta Biomedica, 93(1), 1-12. https://doi.org/10.23750/abm.v93i1.11237
[17] Food Standards Australia and New Zealand [FSANZ]. (2021). Australian Food Composition Database. https://www.foodstandards.gov.au/science/monitoringnutrients/afcd/Pages/foodsearch.aspx
[18] Santanam, N., Kavtaradze, N., Murphy, A., Dominguez, C., & Parthasarathy, S. (2013). Antioxidant supplementation reduces endometriosis-related pelvic pain in humans. Translational Research: The Journal of Laboratory and Clinical Medicine, 161(3), 189- 195. https://doi.org/10.1016/j.trsl.2012.05.001
[19] Ott, J., Nouri, K., Hrebacka, D., Gutschelhofer, S., Huber, J. C., & Wenzl, R. (2012). Endometriosis and nutrition–recommending a Mediterranean diet decreases endometriosis-associated pain: An experimental observational study. The Journal of Aging Research and Clinical Practice, 1, 162-166. https://doi.org/10.1007/s43032-020-00418-w
[20] Wahlqvist, M. L. & Gallegos, D. (2020). Food and nutrition: Sustainable food and health systems (4th ed.). Allen & Unwin.
[21] Australian Government. (2015, July 23). Australian dietary guidelines 1 – 5. Eatforhealth.gov.au. Retrieved September 12, 2022, from https://www.eatforhealth.gov.au/guidelines/australian-dietary-guidelines-1-5