Endometriosis: Diet and Lifestyle Changes that Work |Women's Health | Sara Gottfried MD

Endometriosis is an often undiagnosed problem that affects 10 to 15% of women.1 What happens with endometriosis is that the cells of the endometrium, or uterine lining, migrate and implant outside the uterus, usually on the ovaries or other pelvic organs, causing inflammation and sometimes extreme pain. This pain usually occurs during their period, although some women can experience pelvic pain at other times of the month.

In this article, we explore what are the causes and how diet and lifestyle changes can help endometriosis.

What Causes Endometriosis?

I’ve found in my work several root causes, dysestrogenism and progesterone resistance, and this has been confirmed recently by others.2 

  1. Dysestrogenism or estrogen dominance. This is when levels of estrogen are high. This can be due to a number of causes, including impaired estrogen metabolism. Estrogen starts as estradiol, but it can be broken down into estrone and metabolites. It’s crucial for your body to break down the estrogen in order to maintain balance. You must inactivate estrogen to maintain normal levels, and inactivation occurs mostly in the liver in two phases. If there is a problem with estrogen metabolism and breakdown, then instead of being excreted, estrogen can remain recirculating in the bloodstream and it becomes difficult for the body to regulate estrogen levels.
  2. Low progesterone or progesterone resistance. Estrogen and progesterone are in balance with one another but if progesterone is low, then estrogen dominates because the levels are relatively high compared to its partner hormone, progesterone. In one study, nearly half of the women with endometriosis had either low blood progesterone or a short luteal phase.3 Progesterone resistance seems to contribute to the development of endometriosis.4 Women with endometriosis don’t make enough progesterone receptors, particularly in the endometriosis growths, or cells become numb to progesterone.5 That makes it difficult to shut down estrogen activity, so estrogen levels rise, especially around the aberrant growths.6

How Do You Diagnose Endometriosis?

Even though approximately 1 in 10 women suffer with endometriosis, it can often take years for a diagnosis. There are several reasons for this. Often women assume the painful periods they have each month are normal and don’t think to bring it up to their doctor. Or, if they do, their pain can be dismissed as normal, that it is “part of being a woman.” Other factors leading to a late diagnosis may be due to the fact that endometriosis does not show up on routine ultrasound screening. A laparoscopy is the only way to be certain that someone has endometriosis, which is a cost-prohibitive procedure for some women.

How Can You Manage the Symptoms of Endometriosis?

Think first of gut function, even if you do not have gut symptoms. You may have small intestinal bacterial overgrowth (SIBO), which is common in endometriosis.7 Another common diagnosis that is conflated with endometriosis is irritable bowel syndrome, a condition with many causal factors and a high prevalence of SIBO.8

We don’t necessarily think of the gut when discussing endometriosis. But here’s why it is important. The endocrine system is the collection of organs responsible for your hormones. When people think of hormone production, they usually think of glands throughout the body like the thyroid, adrenals, and reproductive organs. But the gut microbiome may be the most important organ of the endocrine system. In fact, the gut microbiome may be more important than the other hormone-producing glands in your body. Your gut microbiome regulates your hormones carefully. When your gut microbiome is healthy, it does its job well. But when it is unhealthy, it throws your hormones out of tune and can cause all sorts of problems. As a result, in some women, estrogen can continue recirculating, leading to estrogen dominance.

Not only does your gut microbiome help create maintain estrogen balance overall, a specific group of microbes called the estrobolome reduces harmful side effects of more potent estrogen. Your estrobolome helps metabolize excess estrogen to keep it from causing problems. That’s great news because too much estrogen can worsen endometriosis symptoms and it can also lead to weight gain, cause mood issues, and potentially breast, endometrial, and prostate cancer.

How Can You Maintain a Healthy Gut?

Having a healthy gut is essential for hormone balance and in women with endometriosis, gut health is even more important. The main way to ensure that estrogen metabolites are excreted is to have a gut that is firing on all cylinders.

Feed it well with fresh veggies, including prebiotics. Prebiotics are a type of plant fiber that feeds the good bacteria in your gut. They include: asparagus, burdock root, Jerusalem artichoke, jicama, garlic, onion, leeks, unripe (green) bananas, flaxseeds, seaweed, konjac root (you can find this prebiotic source in shirataki noodles), and yacon root. Add green bananas, potatoes, and crackers made from yuca.

How Does Fiber Help Endometriosis?

The golden rule of estrogen is-use it and lose it. Effective estrogen metabolism relies on the body’s ability to excrete the excess estrogen and its metabolites. A healthy intake of fiber will ensure that estrogen metabolites are excreted from the body with regular bowel movements. I recommend that you consume 35 to 45 grams of fiber per day as part of a healthy food plan; most women only consume about 13 grams per day. Even with seven or more servings of fresh fruits and vegetables per day, most women need medicinal fiber, taken as a supplement. Psyllium is one example of a medicinal fiber. Others include psyllium, inulin and glucomannan and I recommend rotating through the different types.

What Other Diet and Lifestyle Changes Can Improve Endometriosis?

A diet that promotes gut health and strengthens estrogen metabolism is very important. Follow a plant-based diet, drastically reduce red meat intake and avoid CAFO meat at all costs. Alcohol can change the way a woman metabolizes estrogen so reduce or give up alcohol. Reduce sugar to a minimum as this impacts the health of the gut. If you are obese or overweight, weight loss will reduce your excess estrogen levels. Exercise helps estrogen metabolism and overall gut health but chronic cardio (hours on the treadmill, marathons) can raise cortisol levels.

What Role Does Stress Play in Endometriosis?

Stress can affect endometriosis in several ways. Firstly, high levels of stress have a negative impact on the gut. Excess cortisol, the major stress hormone, pokes holes in the gut wall which can lead to leaky gut and an increase of inflammation in the body, which in turn can exacerbate endometriosis symptoms. Furthermore, cortisol is a bully. Cortisol impacts all the other hormones and if stress is high and cortisol levels go up, other hormones can become imbalanced. High levels of stress rob the sex hormones to meet the high demand for stress hormones, leading to an imbalance of estrogen and progesterone.

What about Xenoestrogens? What Role Do They Play?

Xenoestrogens are synthetic chemicals that mimic estrogens. They are often found in many beauty and personal care products in the form of phthalates. There is a delicate balance between estrogen and progesterone in the female body, and phthalates disrupt it.

Which Supplements Help with Endometriosis?

There are several supplements available that improve estrogen metabolism as well as ones that reduce oxidative stress and inflammation.

Supplements That Reduce inflammation:
• N-Acetyl-L-Cysteine (NAC). Dose: approximately 900 mg once or twice per day.
• Curcumin
Melon (Cucumis melo)

Supplements That Resolve inflammation:
• Balanced omegas
o Fish oil (EFA, DHA). Dose: 3-6 grams per day.
o GLA from borage oil and/or evening primrose oil. Dose: 2 gram per day.
• Specialized proresolving mediators (SPMs), which in the United States are offered by multiple supplement manufacturers. The research behind them is from Harvard Medical School and the groundbreaking work of Charles Serhan, PhD.9 I suggest taking them with a baby aspirin in patients in whom it is safe (discuss with your healthcare practitioner).

Supplements That Improve Estrogen Metabolism:
• I use a product that contains flaxseed lignans, calcium D-glucarate, and zinc.
• Di-indole Methane (DIM) is the most potent promoter of 2-hydroxylase, the enzyme that helps to correct dysestrogenism by making more 2-hydroxy-estrone and 2-hydroxy-estradiol. In other words, DIM has been shown to favor the production of protective estrogens and reduce bad estrogens. Overall, DIM lowers excess estrogen. DIM occurs naturally in the Brassica, or cruciferous, vegetables, such as cabbage, broccoli, Brussels sprouts, and cauliflower. Unfortunately, you have to eat bushels of broccoli or Brussels sprouts to benefit your estrogen balance. You can ingest DIM in a capsule or tablet. The dosage is approximately 200 mg/day.

Is It Possible to Avoid Laparoscopic Surgery with Diet and Supplements?

I’ve seen patients use lifestyle changes, such as eating one pound of vegetables per day, correcting gut imbalances like SIBO, and supplements as listed, and successfully avoid laparoscopy.

Can You Get Pregnant with Endometriosis?

Yes, you can get pregnant with endometriosis but how difficult it will be depends on the severity and location of the endometrial lesions. Optimizing diet and lifestyle can improve endometriosis but fertility treatments, including hormonal therapy and/or laparoscopic surgery combined with IVF may still be necessary. Generally, the most effective window for conception is immediately after surgery, so it much be carefully planned and orchestrated.

Can Endometriosis Come Back after Hysterectomy?

If the ovaries were conserved, it is more likely that endometriosis will return. If ovaries were removed, I’ve had success using bioidentical estrogen together with bioidentical progesterone, but the decision is complex and needs to be customized to the individual woman. I do a thorough review of risks, benefits, and alternatives. Test multiple genes and biomarkers, and together we make a collaborative assessment. Generally, I am a fan in the right person, with safe and effective prescribing. I use progesterone even if the patient is post-hysterectomy in patients with a history of endometriosis.

Don’t Suffer in Silence

So many women suffer unnecessarily with endometriosis. While there is no cure for endometriosis, the painful, distressing symptoms can be reduced and managed with effective diet and lifestyle modifications. It is important to talk to your gynecologist about your symptoms but you don’t have to wait for a diagnosis to make the healthy changes discussed above. For more information about how to balance your hormones and manage endometriosis symptoms, pick up a copy of my book THE HORMONE CURE.

1.Mehedintu C, Plotogea MN, Ionescu S, Antonovici M. Endometriosis still a challenge. J Med Life. 2014 Sep 15;7(3):349-57. Epub 2014 Sep 25.

2. Marquardt RM, Kim TH, Shin JH, Jeong JW. Progesterone and Estrogen Signaling in the Endometrium: What Goes Wrong in Endometriosis? Int J Mol Sci. 2019 Aug 5;20(15):3822.

3. Zhang YW, Ji H, Han ML, et al. “Luteal function in patients with endometriosis.” Proceedings of the Chinese Academy of Medical Sciences Peking Union Medical College 4 (2) (1989): 96–101.)

4. Bulun SE, Cheng YH, Pavone ME, et al. “Estrogen receptor beta, estrogen receptor-alpha, and progesterone resistance in endometriosis.” Seminars in Reproductive Medicine 28 (1) (2010):36–43.

5. Marquardt RM, Kim TH, Shin JH, Jeong JW. Progesterone and Estrogen Signaling in the Endometrium: What Goes Wrong in Endometriosis? Int J Mol Sci. 2019 Aug 5;20(15):3822.

6. Bulun SE, Cheng YH, Yin P, et al. “Progesterone resistance in endometriosis: link to failure to metabolize estradiol.” Molecular and Cellular Endocrinology 248 (1–2) (2006): 94–103.

7. Mathias JR, Franklin R, Quast DC, Fraga N, Loftin CA, Yates L, Harrison V. Relation of endometriosis and neuromuscular disease of the gastrointestinal tract: new insights. Fertil Steril. 1998 Jul;70(1):81-8.

8. Ghoshal UC, Shukla R, Ghoshal U. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy. Gut Liver. 2017 Mar 15;11(2):196-208.

9. Serhan CN. Pro-resolving lipid mediators are leads for resolution physiology. Nature. 2014 Jun 5;510(7503):92-101; Serhan CN. Treating inflammation and infection in the 21st century: new hints from decoding resolution mediators and mechanisms. FASEB J. 2017 Apr;31(4):1273-1288; Serhan CN, Levy BD. Resolvins in inflammation: emergence of the pro-resolving superfamily of mediators. J Clin Invest. 2018 Jul 2;128(7):2657-2669.