Endometriosis affects one in eight women and can have devastating effects. It impacts all age groups with varying consequences and is not restricted to the reproductive tract. Severe endometriosis can cause bowel obstruction or perforation, ureteral stricture, renal failure and hemothorax, not to mention debilitating pain.
Despite these serious, and sometimes life-threatening sequelae, it is a disease with no cure. Medical and surgical management options exist to help alleviate symptoms, but there is no definitive treatment.
Nutrition is an important, and often overlooked, factor that may have the potential to significantly improve patients’ overall well-being and reproductive health. Identifying modifiable risk factors that could alter the manifestation or progression of this disease would dramatically improve quality of life.
There are several challenges in understanding the complex relationship between nutrition and reproductive health, including the heterogeneity of study populations, difficulty in assessing and controlling dietary intake and incomplete data regarding clinical outcomes. There are, however, some evidence-based recommendations that have been derived from well-designed and valid clinical studies.1
Folic acid is well known to be an important nutrient in the prevention of neural tube defects, however some studies have shown that supplementation at higher doses before and during pregnancy may also increase the likelihood of successful pregnancy.1 Evidence from the same study also suggests that increasing intake of omega-3 polyunsaturated fatty acids and lowering intake of trans fats is associated with a shorter time-to-pregnancy and better assisted reproductive technology (ART) outcomes.1
Other studies have demonstrated the benefits of omega-3 polyunsaturated fatty acids in improving symptoms of dysmenorrhea (menstrual cramps) in young women, possibly because prostaglandins derived from marine polyunsaturated fatty acids are thought to be less inflammatory than those derived from meat products.2, 3, 4 In fact, one reported risk factor for dysmenorrhea is a lower consumption of fish, eggs and fruit.5 This information may help encourage patients to better adhere with the 2015 Dietary Guidelines for Americans, which recommends whole grains, fish, fruits, vegetables and olive oils.6 Other diet-related factors that have been positively correlated with dysmenorrhea include skipping meals, specifically breakfast, and vitamin B1 and magnesium deficiencies.7, 8
With regard to specific pathologies, such as endometriosis, understanding the etiology of the disease may provide insight to diet-based risk reduction. Endometriosis begins on a cellular level, driven by hormones and cytokines.9 It is a chronic inflammatory disease, characterized by endome trial glands and stroma outside the uterine cavity.10 Thus, diet and lifestyle modifications that influence inflammation, estrogen activity, menstruation and prostaglandin metabolism may impact a person’s risk of developing endometriosis.10 This disease is commonly associated with significant pelvic pain and impaired fertility, so it is important to appropriately counsel patients on modifiable risk factors to optimize both their quality of life and reproductive health.
When comparing women with and without endometriosis, a statistically significant reduction in risk was found in patients with higher intake of green vegetables and fresh fruit. Conversely, higher intake of beef, other red meat and ham was associated with an increased risk of endometriosis.10,11
The importance of healthy fat intake is again noted in endometriosis-specific research. Data suggests women in the highest quintile of long-chain omega-3 fatty acid consumption are less likely to be diagnosed with endometriosis compared with those in the lowest quintile. Similarly, those in the highest quintile of trans-unsaturated fat intake are significantly more likely to be diagnosed with endometriosis.12
While some study results are conflicting, it seems reasonable to postulate that vitamins D, A, C, E and those in the B group are also associated with a decreased risk of endometriosis, possibly due to their role as antioxidants.11 Interestingly, providing these vitamins, via dietary supplements, does not necessarily influence the occurrence of endometriosis, which may indicate there are other factors present in food that are the risk modifiers.11
Though it is well known that nutrition can impact reproductive health, the exact nature of this relationship is poorly understood. There are many variables that make it difficult to design studies that would allow for a clear correlation between specific food items and disease processes.
However, the available data supports many of our recommendations to patients and reinforces the importance of a healthy diet.
Emphasizing the consumption of a plant-based diet rich in omega-3 polyunsaturated fatty acids should be a part of patient counseling; it may improve reproductive outcomes and will contribute to the overall health of our population.
Summary of Recommendations to Reduce Risk of Endometriosis
• Increase folic acid intake
• Increase consumption of omega-3 polyunsaturated fatty acids
• Increase intake of green vegetables and fresh fruit
• Eat foods rich in antioxidants, vitamins and magnesium
• Decrease dietary trans fats
• Decrease consumption of beef, red meats and ham • Do not skip meals (particularly breakfast)
Jurkiewicz-Przondziono J, et al. Influence of diet on the risk of developing endometriosis. Ginekol Polska 2017;88, 2:96-102.
Millen BE, et al. The 2015 Dietary Guidelines Advisory Committee scientific report: development and major conclusions. Adv Nutr 2016;7:438– 44.
Nezhat C, et al. (1995). Endometriosis: Advanced management and surgical techniques. Springer-Verlag; New York, NY.
Parazzini F, et al. Selected food intake and risk of endometriosis. Human Reprod 2004;19, 8:1755-1759.
1. Chavarro JE & Schlaff WD. Introduction: Impact of nutrition on reproduction: an overview. Fertil Steril 2018;110:557–9. American Society for Reproductive Medicine.
2. Fujiwara T & Nakata R. Current problems of food intake in young women in Japan: Their influence on female reproductive function. Reprod Med Biol 2004; 3: 107–114.
3. Deutch B. Menstrual pain in Danish women correlated with low n-3 polyunsaturated fatty acid intake. Eur J Clin Nutr 1995; 40: 508–516.
4. Harel Z, et al. Supplementation with omega-3 polyunsaturated fatty acids in the management of dysmenorrhea in adolescents. Am J Obstet Gynecol 1996; 174: 1335–1338.
5. Balbi C, et al. Influence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol 2000; 91: 143– 148.
6. Millen BE, et al. The 2015 Dietary Guidelines Advisory Committee scientific report: development and major conclusions. Adv Nutr 2016;7:438– 44.
7. Fujiwara T. Skipping breakfast is associated with dysmenorrhea in young women in Japan. Int J Food Sci Nutr 2003; 54: 505–509.
8. Wilson ML, Murphy PA. Herbal and dietary therapies for primary and secondary dysmenorrhea. Cochrane Database Sys Rev 2001; 3: CD002124.
9. Nezhat C, et al. (1995). Endometriosis: Advanced management and surgical techniques. Springer-Verlag; New York, NY, x.
10. Jurkiewicz-Przondziono J, et al. Influence of diet on the risk of developing endometriosis. Ginekol Polska 2017;88, 2:96-102.
11. Parazzini F, et al. Selected food intake and risk of endometriosis. Human Reprod 2004;19, 8:1755-1759.
12. Missmer S, et al. A prospective study of dietary fat consumption and endometriosis risk. Human Reprod 2010;25, 6:1528-1535.