Digestive problems and pain cause most women with endometriosis to turn to various exclusion regimes. With a notable efficiency, which can however vary according to the period of the cycle. For nutritionists who are familiar with this condition, the diet must remain as diversified as possible, make room for foods with an anti-inflammatory action and contain a minimum of toxins.

which diet to adopt?

Preventing illness through food
Digestive problems and pain cause most women with endometriosis to turn to various exclusion regimes. With a notable efficiency, which can however vary according to the period of the cycle. For nutritionists who are well acquainted with this condition, the diet must remain as diverse as possible, make room for foods with an anti-inflammatory action and contain a minimum of toxins.

Affecting up to 10% of women childbearing age, endometriosis is said to have genetic, hormonal, immune and environmental causes. For the past ten years, researchers have been interested in the links between the disease and lifestyle, and more particularly diet. The majority of affected women complain of food intolerance or digestive upset that may be related to irritable bowel syndrome. If there are not yet official dietary recommendations for the management of this condition, first dietetic workshops are set up in hospitals within endometriosis reference centers and as part of dedicated spa treatments (gynecology treatments). Round tables are also organized on the subject by the association.

Minimize digestive disorders
Several recent studies show that more than half of women with endometriosis are also affected by irritable bowel syndrome. These two affections have certain mechanisms in common, among others that of an inflammatory state of the organism – in particular at the level of nerve ramifications located in the digestive tract (which explains the pain felt), abnormalities of the intestinal microbiota ( intestinal flora) and increased permeability of the intestinal mucosa favoring food intolerance.

Abdominal pain, bloating, constipation, diarrhea (sometimes alternately), can also be due to compressions of the digestive tract by adhesions (fibrous tissue) specific to endometriosis. In addition, the intensity of digestive symptoms can vary depending on the period of the menstrual cycle … which is irregular. Fortunately, certain dietary measures can provide relief.

Eat calmly
Endometriosis or not, taking your time to eat aids digestion. Sit down, cut small bites, chew well. Also, avoid overly large meals, even if it means splitting them up: for example, shift the dessert for main meals by an hour or two. Do not drink too much during meals and moderate soft drinks, which can reinforce bloating, as well as alcohol and sources of caffeine (maximum 3 cups daily of coffee or tea), which will irritate the digestive mucous membranes. Limit fat The more fatty a meal, the longer and more difficult it is to digest. Fats heated to high temperatures are particularly indigestible. Better to limit fried foods (potatoes, donuts, spring rolls, fish) and dishes in sauce. Prefer cooking methods using little or no fat: steam, foil, smothered and add at the end of cooking a reasonable portion of raw fat: 1 knob of butter or 1 teaspoon of cream or 1 fillet of oil. Also moderate very fatty foods: cold meats, certain meats (mutton, lamb, ribs or pork loin, rib steak, etc.), cheeses, crisps, aperitif cookies, pastries, pastries, etc.

Eliminate hard fibers Fiber is important because it helps regulate intestinal transit and improve the balance of the gut microbiota (by nourishing certain beneficial bacteria). However, some of them, cellulose, lignin, can be irritating. They are present in pulses, nuts (almonds, nuts, hazelnuts, etc.), whole grain products (wholemeal or bran bread, brown rice, etc.), certain vegetables such as cabbage, salsify, green leek, onion, celery. Other fibers, mainly pectin, are softer. They are found in bananas, citrus fruits, carrots, zucchini, eggplant, endive, beets, asparagus tips … Good to know: whatever the fruit or vegetable, its fibers are better tolerated in cooked form. As for white bread, if it is less rich in fiber, it can cause bloating when it is very fresh (its starch is then less easily digested by digestive enzymes): toasting improves its digestibility.

Test the diet without “fodmaps” Fodmaps (fermentable oligo-, di-, mono-saccharides and polyols) are sugars that can be fermented in the large intestine and cause bloating, abdominal pain and diarrhea. The diet without fodmaps relieves irritable bowel syndrome in more than 50% of cases. It has recently been tested in women with endometriosis and has been shown to be effective in almost three-quarters of them (72%) 6. In practice, we start by eliminating all the fodmaps: lactose (milk, white cheeses, fresh cheeses and dessert creams), fructose (fruits and sweet products), fructans (pulses, garlic, onion, wheat, rye, industrial products) and polyols (candy, chewing gum and “no added sugar” chocolates). Then, we very gradually reintroduce the fodmaps, category by category and food by food, so as to identify which foods really cause digestive disorders.

Test the gluten-free diet Gluten is a protein found in wheat, oats, barley and rye, as well as all derived foods: bread, pasta, semolina, flour, pastries, pizza … The gluten-free diet has been tested in women suffering from endometriosis and reduced abdominal pain in 75% of them7. The physiological hypothesis resides in gluten, it is a large molecule difficult to digest, capable of passing as is through the intestinal mucosa when the permeability of the latter is increased -activating the passage of inflammatory mechanisms-. Eliminating gluten-free cereals means falling back on amaranth, corn, rice, millet, quinoa, buckwheat and all other starchy foods: potatoes, sweet potatoes, pulses, etc. Gluten-free products on the market , breads, flours, cookies … come in addition, but their composition often leaves something to be desired: many are poor in proteins, fibers or micronutrients and enriched with undesirable sugars or fats.

According to dietitian-nutritionist Chinedu Davidson, who has been running endometriosis workshops for three years at Paris Saint-Joseph hospital, a strict gluten-free diet is not necessarily necessary. “Some women tolerate sourdough bread (made from wheat flour) or spelled, whose gluten is more accessible to digestive enzymes.” The dietician reminds us that gluten sensitivity can only be temporary and that it is wise to regularly try to reintroduce deleted foods. All in all, excluding foods that are sources of hard fiber, fodmaps or gluten can provide significant relief. But, Isabelle Phung insists on the importance of adapting the diet to everyone’s tolerance. “It remains preferable to diversify your diet as much as possible”. A study conducted in Germany and published in 2019 indicates that due to multiple exclusions, women suffering from endometriosis more often lack certain amino acids (constituents of proteins), vitamins C and B12, magnesium8. In addition, several scientific publications show that a diet low in fiber promotes an imbalance of the intestinal microbiota, which would promote pain and inflammation.

Focus on protective foods
Several reviews of existing studies published recently highlight the links between eating habits and the risk of developing endometriosis. Certain foods or nutrients seem to have a protective effect. Omega 3, especially EPA and DHA Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), found in seafood and fish (especially fats) have a proven anti-inflammatory effect in the body. These fats are also one of the essential fatty acids. To reach the recommended intake, count 2 fish per week, favoring small fatty fish, herring, mackerel or sardines, less at risk of pollution than large ones. In addition, season or cook with walnut or rapeseed oil, rich in alpha-linolenic acid (ALA), the body of which transforms part into EPA and DHA. Also think of nuts, flax seeds, chia or hemp.

Fruits and vegetables
These foods are rich in carotenoids (pigments), vitamins C and E, polyphenols, antioxidant and sometimes anti-inflammatory compounds (polyphenols). Their fibers help reduce the blood level of estrogens, hormones involved in endometriosis and improve the balance of the intestinal microbiota10,12. It is desirable to consume at least the five classically recommended fruits or vegetables, alternating raw vegetables and raw fruits, richer in micronutrients (vitamin C, for example, is altered by heat) and cooked fruits and vegetables, sweeter for intestines. Possibly raise them with spices with proven anti-inflammatory properties, turmeric, ginger, cinnamon or with carminative virtues (which help eliminate gases) or anti-spasmodic, cumin, cardamom, fennel seeds.

Dairy products
Their protective effect is found in a cohort of 70,550 American nurses followed for 14 years, as well as in a review of several studies published in 2017,12,13. Yogurts and other fermented milks, uncooked cheeses, provide living ferments, some of which help enrich the intestinal microbiota with beneficial bacteria (Lactobacillus, Bifidus). The immunomodulatory role of vitamin D (cheeses, whole milk or enriched milk products) is also mentioned. The consumption of these foods is recommended 2 to 3 times a day. Yogurts and mature cheeses are well tolerated in case of lactose intolerance.

Limit foods that promote inflammation Observational studies also find foods or nutrients that could promote the development of endometriosis.

Trans fatty acids
These fats have a pro-inflammatory effect. They are mainly found in industrial foods counting among their ingredients “oils or partially hydrogenated fats”: for example, sandwich breads, pastries, chocolate bars, pastry, cookies. They can form when frying food if the temperature exceeds 180°C. They are also naturally present in the meat and milk of ruminants: prefer lean meats and dairy products (skimmed or semi-skimmed milk, ordinary yogurts, white cheeses with a maximum of 3% lipids) helps limit their intake.

Red meats In these studies, the term “red meat” includes all meats, beef, veal, lamb, mutton, pork, … except poultry. These foods are rich in well-absorbed iron, the excess of which has a pro-inflammatory effect on the intestine. They contain saturated fat, which would also promote inflammation via an unfavorable impact on the intestinal microbiota. Their cooking at high temperature, grill, barbecue … induces the formation of compounds that can worsen inflammation10,12,14. In the context of recent recommendations for the prevention of cancer and cardiovascular disease, the Agence Santé Publique France advises limiting the consumption of meat to 500 g (the equivalent of 3 medium steaks) per week and deli meats to 25 g ( just under 1 thin slice of ham) per day 15. Studies show that marinating meats (or fish) before grilling them in olive oil, lemon, herbs or spices decreases the risk of toxic compounds forming16. The ideal is to equip yourself with an electric grill that can be set at a maximum temperature of 180 ° C, or even use a stove or grill just long enough to sear the food and finish cooking in the oven on low temperature (at 100 ° C).

Omega 6
Although not mentioned in endometriosis studies, these excess fats also have a pro-inflammatory effect. Since they are present in many foods such as meats or eggs, it is best to avoid cooking with the fatty substances that are the richest: sunflower, corn or grape seed oils. And limit industrial products prepared with sunflower oil: ready meals, sauces, certain crisps … Foods with a high glycemic index and sugary products These foods are also not cited in the studies. However, the former, refined cereal foods or products that have undergone “aggressive” industrial treatments, sliced ​​bread, rusks, most breakfast cereals, “express” rice, mashed potato flakes, sugary drinks, etc. are increasing blood sugar (blood sugar) quickly and strongly when they are concentrated in carbohydrates, which results in a large production of insulin, a hormone whose excess promotes inflammation. The second (sugar, honey, candy, chocolate bars, ice cream, pastries, etc.) have an average glycemic index (or high) and are generally poor in protective micronutrients. It is therefore better to moderate their consumption.

Be careful with endocrine disruptors Some of these compounds, ubiquitous in everyday life and sometimes food, could interfere with estrogens and thus promote the development of endometriosis. This is suggested, for example, by laboratory work on female mice which have been exposed to bisphenol A and bisphenol AF. Eat organic if possible Still authorized by the regulations, certain pesticides are currently on the hot seat. In addition to their likely deleterious health effects, some are among the endocrine disruptors. The analyzes regularly carried out by the Directorate General for Consumption, Competition and the Fight against Fraud (DGCCRF) and the European Food Safety Authority (EFSA) confirm that organic products provide less pesticide residues than products from conventional agriculture. When you cannot buy organically, wash and peel the fruits and vegetables systematically before eating them, these gestures make it possible to eliminate some of the pesticide residues.

Reheat food in glass containers Certain components of plastics, phthalates, styrene, bisphenols … are now classified as endocrine disruptors. Avoid reheating food in a plastic box, in contact with cling film or packaged in fat-resistant boxes (like those used in fast food). Or use a plastic steamer with polycarbonate (identified by the number 7 in a triangular logo). Limit industrial foods rich in additives Although authorized by regulations, certain additives are currently the subject of alerts by certain researchers. Certain preservatives (E310, E320) could be counted among the endocrine disruptors and certain emulsifiers (E433, E466) could alter intestinal permeability and thus promote inflammation. Even if their deleterious effects have yet to be confirmed, it is prudent to limit their consumption by favoring as much as possible home cooking or lightly processed industrial products (and without additives), such as natural preserves or uncooked frozen foods.

In Conclusion
Food undoubtedly helps to minimize digestive disorders and pain. But, reminds Isabelle Phung, we must not neglect the interest of physical activity, alternative medicine of the acupuncture or osteopathy type or even various relaxation techniques: meditation, sophrology, hypnosis… Each one to find the activities and the anti-stress solutions that “succeed”.

By Dco

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