What is Endometriosis?
Endometriosis (Endo = inside, metrio = uterus) is a complex, chronic condition where cells from the lining of the uterus (the endometrium) migrates to other parts of the body – most commonly the lower pelvis (including the ovaries, fallopian tubes, bladder and rectum) and abdomen. Once settled in position these cells can grow and multiply, spreading into patches and sticking to other organs in the area and causing significant pain.
As these patches originated from the uterus , no matter where they end up they still behave as if they are still in the uterus. The cells remain sensitive to and still respond to the hormonal changes that occur throughout the menstrual cycle. As the lining of the uterus is shed and bleeds at menstruation, these endometrial patches do too. The problem is that they are often fixed to other tissues in confined spaces so when they bleed there is no outlet. The blood accumulates locally, causing swelling and triggers an inflammatory reaction. This causes significant pain which is most often worse around the time of menstruation, although pain and discomfort can be experienced throughout the monthly cycle. Women may describe a tugging and dragging pain due to the ‘sticky’ nature of these patches – as the body tries to heal itself, it creates scar tissue. This is tough, inelastic tissue that can attach organs to each other; an adhesion.
There can be pain with ovulation, pain associated with adhesions, pain caused by inflammation in the pelvic cavity, pain during bowel movements and urination, during general bodily movement like exercise, pain from standing or walking, and pain with intercourse which over time can prove to be incredibly stressful, draining and debilitating.
Hormones have a lot to answer for when it comes to endometriosis. Oestrogen, produced by our ovaries stimulates growth and thickening of the endometrium prior to menstruation and so it is not really a surprise that oestrogen contributes to and worsens symptoms. Oestrogen can come from the following places:
- Endometrial cells
- Fat cells
So on top of the production by the ovaries, we have extra oestrogen made by the endometrial cells themselves and our fat cells. In addition to this, we may consume oestrogen-like substances in our diet which our body treats as such, just to top up our levels further. This certainly won’t help women who are sensitive to high levels. As you will see in a bit however, it is possible to reduce the intake of these dietary oestrogens through limiting our intake of certain foods.
Who does it affect?
The condition is estimated to affect around two million women in the UK, of all ethnicities. Most are diagnosed between the ages of 25 and 40 (NHS Choices, 2013). Many cases start during the teenage years however and many will remain undiagnosed, with symptoms being accepted as part of the normal menstrual cycle.
What are the causes? To be honest, we are not exactly sure! Here are a number of theories………….
The most commonly accepted theory is retrograde (backwards)menstruation. This is when the endometrial lining flows back up through the fallopian tubes and into the abdomen instead of leaving the body as a period. These cells settle on the lining of the abdomen and organs of the pelvis and grow. It appears most women have a certain amount of retrograde menstruation but the immune system can normally cope and remove this ‘debris’. Although it is not known how, endometrial cells are also believed to get into the bloodstream or lymphatic system (a fluid drainage system that also holds lots of immune cells). This theory could explain how, in very rare cases, the cells are found in remote places of the body such as the eyes or brain.
What we don’t know in women with endometriosis, is what triggers these cells to implant themselves in other parts of the body and why the immune system is unable to remove them. In other words, why do women with retrograde menstruation NOT get endometriosis? Other factors must be involved. Endometriosis stands as one of the most investigated gynaecological disorders so here are 3 other possible theories…………
Endometriosis is believed to be partly hereditary; 2 faulty genes have been identified so far which could be passed down through family members. Daughters or sisters of patients with endometriosis are at higher risk of developing endometriosis themselves because the genes may cause a hormone imbalance of change the way some cells work. It may be that cells actually change into a different type. This is a normal feature of certain cells in the body – many of which come from a common stem cell – and they help us repair and replace many of our body cells when they get worn out or damaged. It is thought that oestrogen may trigger this cell change and therefore might be responsible for the formation of endometrial cells and patches outside of the uterus. It might explain why women who have had a hysterectomy show signs of endometriosis? Endometriosis can affect women of every ethnicity, but is more common in Asian women than in white women. It is also less common in women of African-Caribbean origin.
Many women with endometriosis are found to have a poor immune system. However, this could be a ‘what comes first, the chicken or the egg?’theory – is the low immunity a result of the endometriosis or the endometriosis a result of the low immunity? We know there is some connection but to study this in women effectively is very difficult.
It is thought that endometriosis may in part be caused by exposure to certain toxins in the environment. Much focus has been on dioxins (toxic by-products of industrial processes) that can cause reproductive and developmental problems, damage the immune system and interfere with hormones. Dioxins are found throughout the world in the environment and they accumulate in the food chain, mainly in the fatty tissue of animals. According to the World Health organisation (2014), more than 90% of human exposure is through food, mainly meat and dairy products, fish and shellfish.
What can I do?
So based on what we do know about the menstrual cycle (particularly the hormones) and the possible causes of endometriosis, there are a number things we could do to our diet to improve overall health and perhaps reduce symptoms. I say perhaps because as of yet, there is no magic bullet. It may be that you notice no improvement at all in your symptoms but hopefully you will feel healthier and more energised. It may help to limit or avoid some foods, whilst increasing our consumption of others…….
The aims of improving your diet will be to:
- Help improve energy levels
- Boost your immune system
- Reduce inflammation which may help reduce symptoms
- Provide all the building blocks to help the body repair and heal itself
1. Eat more fibre (get your 5 a-day or more)
In the UK most people do not eat enough fibre (the average intake is just under 14g/day) which is some way off the recommended 18g per day; many other countries in Europe recommend more and it is likely we will be expected to increase our intake to around 30g/day. We should be aiming to consume more wholemeal breads and cereals, fruit and vegetables to reach our quota:
- 1 bowl high fibre cereal (bran-based) ~5g
- 1 slice wholemeal bread ~2-3g
- 1 piece of fruit ~2-4g
- 1 medium jacket potato (with skin) ~3-5g
- 80g portion of peas ~4g
Fibre provides a number of benefits:
- Fibre keeps you ‘regular’. It helps prevent constipation which may help with abdominal pain if you don’t need to strain when going to the toilet.
- Fibre helps to stabilise your blood sugar levels so you are less likely to nibble or crave unhealthy snacks. With fibre, you get a nice steady trickle of energy released over a long time (rather than floods of energy then nothing at all). This can help with appetite control, energy levels, weight and mood management.
- Fibrous foods, particularly fruit and veg make the blood more alkaline. This may help in reducing inflammation as more acidic foods (coffee, fizzy drinks, citrus fruits etc.) can increase inflammation and make symptoms worse.
- The bacteria in our gut feed on dietary fibre. Some of the products from these bacteria can help our immune system to function more effectively.
- Some plants contain phyto-oestrogens (phyto refers to plant). These bind weakly to and block the effects of oestrogen produced by our own body, helping to lessen its effects. There are some very mixed viewpoint on phyto-oestrogens and endometriosis.
What sort of fibre should we be having?
Ideally we should be having a mixture of soluble and insoluble fibre in our diet; eating more fruit and vegetables (with the skins on where possible) will help you on your way.
Soluble fibre is like a sponge and absorbs water. It becomes like jelly (making it easier to pass and helping prevent constipation) and is broken down by the bacteria in our bowel (they ferment it). So we have a nice relationship with our friendly (good) bacteria; we feed them fibre and in return they help us out. I’ll come back to them in a minute………….
Good sources of soluble fibre include:
Insoluble fibre does not absorb much water and is completely indigestible but it is this feature that gives ‘bulk’ to our stools and gives its laxative effect.
Good sources of insoluble fibre include
- wholemeal breads
- whole grain breakfast cereals
- dried fruit
- brown rice
When boosting your fibre intake, you should do it gradually (ideally over a couple of weeks) and you MUST increase your fluid intake too if you want to avoid getting bunged up and full of wind. Fibre is like a sponge, so to make the most of its properties and get all the benefits from it, you need to provide the liquid that will enable it to swell up.
2. Cut down on refined carbohydrates
Refined carbohydrates are the white bread, rice and pastas. The biscuits and cakes and pretty much all sweet and tasty puddings too. These foods are quickly broken causing a surge of sugar to be released into the bloodstream. You may get a quick buzz of energy initially, but this will be quickly followed by a crash in blood sugars and energy levels.
Not only will this make you ratty and tired but you will also crave more sweet things (food or drink) to curb your sugar and energy craving. It becomes a vicious cycle and does nothing for your energy levels.
Refined foods also have very little nutritional value so apart from providing energy and Calories, they don’t give us anything healthy. The refining process removes all the fibre and many of the vitamins and minerals from the foods so they don’t add any value to your diet at all.
In terms of energy levels it is important to say here that regular eating is essential. If you try to stick to just 3 meals a day, you should think about having a healthy fibre rich snack inbetween meals to keep your energy levels topped up. Breakfast is also hugely important to get your metabolism going at the beginning of the day (helping you get your body and brain going) and particularly if on medication; it is often advisable not to take these on an empty stomach. Finally, constant and significant pain is hugely draining on the body so eating regularly can also help you get the energy you need to cope with this a little better.
With any of these suggestions I am not saying you have to completely deprive yourself of all things nice but keep some of the ‘trigger’ foods as treats and boost your intake of the more healthy foods instead. Pick a day when you deserve you treat and you will appreciate it most. Perhaps stick a note or a picture of this week’s reward on your fridge and hold yourself to it!
It will depend on how strict you want to be with your diet and what you feel you can cope with.
3. Boost your friendly bacteria
Eating more soluble fibre, will help boost the numbers of friendly / good bacteria in your gut. In return, they provide us with some vitamins (B & K), keep harmful bacteria at bay and the by-products of their action can help us better manage our blood sugar levels.
More recently it has been found that the products from the bacterial action on soluble fibre could be anti-inflammatory so it could be important to boost your numbers of these bacteria.
Foods that will particularly help increase the numbers of good bacteria in our bowel include onions, garlic, leeks, asparagus, soya beans and honey. These are known as prebiotic foods
You can also buy prebiotic-containing foods too from the supermarket; look for prebiotic ‘live’ yoghurtand yoghurt drinks (e.g. Yakult, Danone Actimel or Muller Vitality), breakfast cereals and cereal bars (but do watch the sugar content of some of these).
Probiotics are the actual bacteria that we can consume to add to the existing populations that naturally live in our bowel. We can benefit from topping up these levels of bacteria, particularly if we are a bit run down, have had a bout of food poisoning, suffered from travellers’ diarrhoea or have been on a course of antibiotics (that wipe out both the bad and good bacteria). Basically a probiotic is the opposite of an antibiotic.
Regular intake of probiotics may increase the levels of good bacteria and improve digestive health, particularly in people with an illness. You can buy a good quality probiotic supplement from chemists or decent health food shops or just try to eat more probiotic containing foods.
Bifidobacteria are one of the good guys; ideally we want them to be present in the greatest numbers to keep our gut happy so look for a probiotic with a good amount of bifidobacteria if you can.
Some foods however are naturally rich in probiotics; especially fermented foods: cheese, yoghurt, fermented soy (miso soup), sauerkraut & pickles
4. Choose more polyunsaturated (good) fats
Research has shown that we should boost our intake of the healthy, polyunsaturated fats that we find in fish, seeds and nuts. Ideally we should be replacing unhealthy saturated fats we find in red meat, butter, cheese and processed foods with these healthier ones.
Not only great for heart health, omega-3 polyunsaturated fatty acids are some of the most effective natural anti-inflammatory agents available. The omega-3’s in fish oil are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which increases the production of anti-inflammatory chemicals in the body (P for prostaglandins). Omega-3 fats in seeds and nuts (α-Linolenic acid)are also beneficial for health. There are 2 types of prostaglandins in the body; the good ones and the bad ones. We want to be promoting more of the good ones (PE3) by eating more oily fish and stopping the production of the bad ones (PE2). The pro-inflammatory / bad prostaglandins are responsible for increasing the inflammation and worsening symptoms.
Good sources of omega 3 fats include:
- fresh tuna (not tinned)
- nuts & seeds (e.g. walnuts, brazil nuts, hazelnuts, sunflower seeds, pumpkin seeds and seed oils like walnut, sesame and pumpkin)
5. Cut the caffeine and alcohol
Alcohol and caffeine are both known to increase the amount of acid produced in the stomach, so potentially these acidic causing drinks could worsen symptoms.
Both alcohol and caffeine are stimulants too. They may make you feel more alert if you are struggling to get going in the day / evening, but in doing so you will eventually have to ‘come down’ again and the effects of too much caffeine can be much the same as those of anxiety. This up-down-up-down effect will affect your mood and energy levels and your sleep. You should think about having a ‘cut-off time’ in the day when you don’t have any more caffeine so it does not disturb your sleep. Many people also think a little alcoholic nightcap before bed will help you drop off but in fact it has completely the opposite effect. The quality of your sleep will be poor so you will most likely end up waking feeling more tired. As stimulants, they can also affect your gut – making everything rush through, they can add to abdominal pain, bloating and cause diarrhoea.
Alcohol is also full of empty calories -it provides no nutrients, despite what the labels of some alcoholic drinks might say. No amount of Guinness or Alcopop will provide useful amounts of vitamins or minerals – you will be much better off eating real food!
Caffeine is not only found in coffee, it is also found in tea, fizzy drinks (including diet versions), chocolate (although not much) and some pain medications. Coffee typically contains twice the amount of caffeine as tea (although it depends on how you like your tea – a good mug of ‘builder’s tea’ will contain nearly the same amount as an instant coffee) and cola drinks contain a little less than an average tea. Then there are all these caffeinated energy drinks that fill me with horror, plus they are loaded with sugar.
So opt for water, low sugar soft drinks, low fat milk, decaffeinated coffee or teas (including green teas). Teas are full of anti-oxidants which are great for helping protect the body and herbal teas (Rooibos, peppermint, chamomile) and can be soothing and relaxing to drink.
Just to add, if you decide to cut down on caffeine (whether coffee is your vice or its lots of coke / diet coke), do it gradually to avoid withdrawal effects. Going ‘cold turkey’ will more than likely mean you go have ton go back on it again. Allow yourself a good 3-4 weeks to cut down or remove it from your diet.
6. Watch your fat intake – go for green!
As body fat can release oestrogen into our body’s oestrogen ‘pool’ we need to be mindful of the amount of fat in our diet. Dietary fat is very energy dense. In other words a little goes a long way, so it does not take much to over consume and exceed our Calorie requirement. Women need around 2000 Calories a day, with no more than 35% of these Calories coming from fat. This equates to around no more than 75g fat a day.
When looking out for low-fat or reduced fat products, it is worth knowing they are NOT the same thing (the majority of people have no idea).
- A low-fat product contains less than 3% fat (<3g fat per 100g)
- A reduced fat or ‘lighter’ product contains 30% less fat than the standard product – this does NOT necessarily make it low-fat.
- Go for green when it comes to both fat and sugar content on the traffic light labels on some food packaging.
- A low sugar product contains less than 5g sugar per 100g)
What is the problem with some low-fat foods?
When removing fat from a product, it needs to be replaced with something else and there is no limit on how much of the other ingredient is added; often fat is replaced with sugar. The low-fat products often have more sugar in them than the full fat equivalent! So it is important to read the ingredients label carefully. Make no assumption the lower fat product is actually healthier; whether coming from fat or sugar, Calories are Calories. It doesn’t matter where they come from; the excess Calories we are consuming today from processed foods are contributing to weight gain.
Because of the complexity of endometriosis and the lack of understanding about what causes it, there is no golden rule card that will suit everybody. It’s really a matter of trial and error……….
- For which ever changes you decide to make, it is important to think what is going to work best for you. You are more likely to succeed by taking small steps rather than giant leaps and don’t go it alone – use your support network.
- You will need to be consistent, patient and realistic when you can – don’t change everything all at once and don’t put too much pressure on yourself.
- You might like to try keeping a food diary (alongside a pain diary) and revisit the changes you would like to make on a regular basis.