The Best Diet for Endometriosis and Adenomyosis
One of the first questions new women ask when they join our Facebook Group is, what’s the best diet for endometriosis and/or adenomyosis? Should you go vegan or paleo? Low fat or low carb? Or is there an official “endo” diet? And what’s the deal with soy?
There’s no simple, one-size-fits-all diet for endometriosis. Instead, the answer lies somewhere in the intersection of circles on the Venn diagram, with added personal modifications, specific to your genetic makeup, blood type epigenetic changes due to your environment, and current stage of your disease. But by taking a look at the most common diets medical practitioners, bloggers and nutritionists recommend, I aim to get you a good baseline from which to design the diet that is best for you.
The Mediterranean Diet
If you Google “best diet for endometriosis,” one of the first options that comes up is the “Mediterranean” diet. On the surface, it looks like a good place to start, and indeed for “normal” people (by that, I mean free of endo or adeno), it has “been associated with better women’s health outcomes, including lower risk of [cardiovascular disease] and cancer and the prevention and treatment of obesity.” 1 This is because, instead of highly processed foods, it is comprised of whole foods such as fresh fruits and vegetables, poultry and seafood, and even meat and wine on occasion. It also has a good balance of omega-3 to omega-6 fatty acids, which helps to keep inflammation at bay.
We should all be eating less processed foods and more whole foods, while keeping our omegas in balance. We all should be spending more time at the table together with our family, too, as is also Mediterranean tradition. Spending quality time with your loved ones provides nurturance beyond the plate.
But is the Mediterranean diet strict enough for women with endometriosis? Because the diet is simply modeled after the way people in the Mediterranean have traditionally eaten for decades, there is no strict avoidance of any one food in particular. But olive oil is the main fat, so trans fats from industrial seed oils, aka partially hydrogenated oils—the bad kind of fats, are generally not consumed.
However, there is also a reliance on whole grains in the Mediterranean diet and gluten is a known inflammatory food. 2 3 Due to the association of endometriosis with autoimmune disease and thus, inflammation, gluten should be avoided at all costs. Indeed, removing it from the diet has been shown to decrease painful symptoms of endometriosis,4 5 as well as benefit other non-celiac autoimmune conditions.6 Please be sure to remove all traces of gluten, rather than go low-gluten, because it only takes a tiny particle of it to cause an inflammatory reaction.
The Paleo Diet
The paleo diet is the next best diet choice for endometriosis, as it does eliminate gluten. But it doesn’t stop there. The same inflammatory properties that are associated with gluten have also been associated with other grains, which is why eliminating all grains is often a better choice than just gluten, especially for people with chronic disease and/or gluten sensitivity. Eliminating gluten and grains can also decrease intestinal permeability (leaky gut).
The paleo diet also eliminates dairy. Unless its organic (and even then, the contents of milk can be questionable), most dairy products are full of hormones and antibiotics. Avoiding hormones is an important part of healing from endometriosis naturally. In addition, milk from Holstein cows contain the inflammatory protein A1 casein that can be problematic for some. If that’s the case for you, you might be able to tolerate goat’s and sheep’s dairy which contains the protein A2 casein. But even then, up to 75% of people lose the ability to digest lactose (the sugar in milk) by adulthood, so unless you’re of Northern European or New Zealand descent,7 you might feel better giving up dairy altogether.
The paleo diet also avoids legumes. According to paleo diet researchers, legumes contain protease inhibitors, making them difficult to digest. They also have inflammatory lectins that can cause leptin and insulin resistance leading to metabolic syndrome, as well as phytates that “bind to minerals like zinc, calcium, iron and magnesium and make them unavailable for you.”
So What’s the Deal with Soy?
Speaking of legumes, soy, the most notorious of them, raises a lot of eyebrows. Besides most soy being genetically modified so that it’s able to withstand high amounts of the herbicide Round-up (bad for you and also the environment), soy also contains goitrogens that can interfere with proper thyroid functioning.8 This is particularly important for women with autoimmune thyroid disease, a common co-morbidity in endometriosis.
Many people are also concerned about soy’s estrogenic activity, but there are other staunch defenders of soy, claiming their phytoestrogens are actually beneficial to women with endometriosis. We could probably talk for days about this, which is why I’m reserving the discussion on soy, phytoestrogens and endometriosis for another blog post. For now, I think Rietjens et al. sum it up best: the beneficial health effects of soy are “not so obvious that they clearly outweigh the possible health risks.”9 In particular, they point out risks to thyroid and brain function as well as the possible development of uterine cancer. Another blogger, took the time to list 170 references on the negative effects of soy.
So until we know more about soy’s estrogenic effects on our bodies, its probably best to avoid soy. The only exception I would make, is if you come from a culture where soy has been eaten for generations. If that’s the case, the soy is likely fermented, or if unfermented, in small portions, and your body is accustomed to digesting it. As long as you’re sure soy doesn’t bother you, I see no reason to avoid it. You know, better than anyone, what’s best for your body.
The “Endo” Diet
Currently, there is no agreed upon, official “endo diet,” which means everyone’s definition of it may differ slightly. Some people also call the endo diet, the anti-inflammatory diet, which I like better. But what is or isn’t inflammatory is also sometimes up for debate. Red meat—yes or no? Fat? Carbs? However, most agree that gluten, dairy and trans-fats are inflammatory, as well as refined carbs and sugar.
The Autoimmune Protocol (AIP)
A few women in our Facebook group have also referred to the endo/anti-inflammatory diet as the Autoimmune Protocol (AIP), which is a modified version of the paleo diet. In addition to the inflammatory foods already avoided in the paleo diet, the AIP also avoids seeds and nuts, eggs, and even nightshades (eggplant, peppers, tomato, potatoes). It also specifically emphasizes removing food additives, although a whole foods diet like the Mediterranean or paleo diet shouldn’t include those anyway.
In addition, alcohol is also avoided because it is known to irritate the gut, as well as non-steroidal anti-inflammatory drugs (NSAIDs), such as Advil, Motrin and Aleve, because they are known to cause intestinal permeability. And coffee is restricted—not necessarily due to the caffeine, although caffeine can increase cortisol, which can compete with progesterone, but because you might “cross-react” to coffee. That is, a molecule of coffee looks enough like one of gluten, that the body might cause an immune response to it.
The AIP diet has helped many women reverse their symptoms of autoimmunity, including Dr. Amy Myers and Dr. Terry Wahls, both brilliant medical doctors. Its worth looking into, if you so far haven’t been able to get your symptoms under control.
Carbohydrate Restricted Diets
Special Carbohydrate Diet (SCD)
Because women with endometriosis are twice as likely to also suffer from irritable bowel syndrome (IBS),10 another diet you could consider is the Specific Carbohydrates Diet. It avoids starchy vegetables such as potatoes, plantains, and yams, as well as even natural sugars like maple syrup and molasses. According to cookbook author, Danielle Walker, The SCD diet is “based on the theory that eliminating complex carbohydrates (those carbohydrates that require minimal digestion are still allowed) can reduce inflammation, restore a healthy gut ecosystem, and make eating enjoyable once again for people with gastrointestinal disorders.” By the way, I love her cookbook, Against All Grain, which is paleo plus SCD, but you don’t have to be on the SCD diet to enjoy it.
Another diet to consider is one that eliminates “short-chain” carbohydrates. These are found in a variety of fruits and vegetables that have been found to ferment too quickly in the gut in some people. They’re called Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols, or FODMAPs for short.
The low FODMAPs diet does not necessarily exclude gluten, dairy or soy, on its own, but depending on your body, you could follow one of the diets above, then include the restriction of FODMAPs as well. The list of foods to avoid is long, meant to be done in stages, and can be a bit confusing, because it isn’t about complete avoidance in most cases, but rather limiting the total amount of FODMAPs per meal. So it is generally advised to work with a dietitian on this one. But it should be noted that 72% of women with endometriosis “reported a >50% improvement in bowel symptoms after four weeks of a low FODMAP diet compared with 49% in those with no known endometriosis.”11
But as the designers of the low FODMAPs diet point out, there is still a quarter of IBS sufferers who do not heal on the low FODMAPs diet. If you are one of them, there may be other gut issues that you need to address, such as SIBO or Candida. I will save that for another post. In the meantime, a ketogenic diet, or very low carb diet, is one that relies on getting its majority of calories from fat, rather than carbs, while keeping protein moderate. A traditional ketogenic diet doesn’t restrict specific carbs, but instead the amount of carbs. So technically, one could have a tiny bit of bread (gluten) with each meal, and for “normal” people that would be ok. But if you have endo or adeno and you want to try a keto diet, you should probably do a paleo diet with a high-fat to low-carb macronutrient ratio.
But Aren’t Fats Bad For Us?
For decades we’ve been told the answer to obesity and cardiovascular disease is to lower your fat consumption. But decades of low-fat consumption has not changed the trajectory of the obesity epidemic. And what happens when you lower fat? You often increase carbs. In addition to increasing your waistline, you could be increasing trouble with your gut, especially if you are consuming too many of the wrong kind of carbs. Still, I see many advocate for a low-fat diet for endometriosis, referencing studies from the 1980s and ’90s, when the low-fat craze was at its peak. Unfortunately the studies were not well designed, so cannot be considered conclusive.
For instance, in one study, a low-fat, high-fiber diet was said to decrease some estrogen activity,12 but unfortunately the fiber component of the diet was not extracted from the fat component during the time that subjects were on the diet. So how are we to know whether it was more fiber that caused the decrease or less fat?
Some women have found relief by eating cruciferous vegetables or taking the supplement, DIM, a compound produced by the digestion of cruciferous vegetables. And certainly, fiber helps move food through the digestive tract, taking with it unwanted particles, such as excess estrogen. So be sure when you do consume carbs, you include good sources of fiber. Personally, I love raw carrots, straight from the farmer, or wilted spinach with pine nuts and olive oil. But don’t choose these if you have a nickel sensitivity (see below)! Also, see this link about how to include fiber in your low FODMAPs diet. On the other hand, its also possible to get too much fiber, so don’t overdo it!
While there are still only a handful of more modern studies on dietary fat and endometriosis, they do come to some consensus. Missmer et al. say that “total fat consumption was not associated with endometriosis risk,”13 but they also agree with others in that Omega-3 fatty acids are likely beneficial, while (manmade) trans fats are likely harmful.14 15 16 Even animal fat is likely ok, and perhaps even good for you. Please read Chris Kresser’s article that does a great job breaking down the differences between dietary fats and which ones to avoid. Also, please check out my post comparing different percentages of fat, carbs and protein in popular diets.
One of the reasons people can’t stick with a low-fat, gluten-free diet, is that they never feel satiated. Increase your fat intake, and I promise, you will.
The carnivore diet is one of the latest to hit the nutrition world. And while it may sound crazy (I once thought the same about the paleo diet), if you are someone still having issues with carbs, you might find relief taking all of them out. Several women in our Facebook group have. While I’m not sure this diet is sustainable for the long term, it might be a good way to reset your body, then slowly bring back one carb at a time until you identify which ones cause you inflammation. Please see Dr. Axe’s article for more on the carnivore diet.
While, not restrictive of only carbs, per se, there is another restrictive diet you could consider, if you are still not feeling well on any of the above diets. Research has shown that nickel can bind to estrogen receptors (ERs) and higher concentrations of it have been found in endometrial tissue from patients with endometriosis.17 Thus, a nickel sensitivity may contribute to IBS-like symptoms in women with endometriosis.
Nickel is actually present in almost all foods, but found in higher concentration in beans, whole wheat flour, soy, corn, onion, and garlic, which may explain why going paleo and low-FODMAPs has made people feel better. But nickel is also found in higher concentrations in tomato, green leafy vegetables, raw carrots, shellfish, nuts, canned food, tea, and (no!) chocolate. It might be a difficult diet to follow, but after three months on it, those participants who remained in the study showed a “statistically significant decrease in intensity” of “all 15 gastrointestinal symptoms” asked about in the study questionnaire. Here’s the complete list of foods (and cooking utensils) they were asked to avoid.
What About Going Vegan?
There are many who believe going vegan is actually the best diet for endometriosis. However, there’s little scientific evidence to back this up. The problem with studies that associate a higher consumption of meat with endometriosis,18 19 or the opposite,20 is that they often rely on epidemiological studies. As with other epidemiological studies on diet and its effects on disease, instead of isolating specific foods from others and accounting for a multitude of conditions, or putting test subjects on a specific diet and comparing to a control diet over time, they use questionnaires and rely on a person’s memory of what they ate in the past. Sometimes months or even years into the past. Can you see how, this is not a reliable method of testing the effects of specific foods?
As Helbig et al. point out in their literature review, the three case-control studies that have addressed the link between eating red meat and the risk of developing endometriosis “revealed divergent results.”21 One study showed an increased risk associated with the consumption of red meat, but two did not.
Still, some people swear by the vegan diet for endometriosis. Maybe because, like several of the other diets already mentioned, it avoids dairy and, like the Autoimmune Protocol, eggs. That, in and of itself, could be a huge contribution to why some people feel better on it. But the problem with a plant-based diet is that its low or non-existent in some essential nutrients. It avoids most of things on the AIP diet that are considered beneficial, such as bone broth and organ meats, and it does not avoid gluten, sugar or soy. Of course, you could do a modified vegan diet that is also gluten, sugar and soy-free. But then you’re running out of options on what to eat.
However, if you come from a culture that doesn’t eat meat, I wouldn’t suggest suddenly adding it to your diet. Your body might be accustomed to living without it. But you might want to look at specific foods in your diet that are listed in this post to see if any of them could be causing you inflammation.
I do also appreciate the ethical concerns over eating meat (especially factory farmed), so if that’s why you choose to go vegan, be sure to follow the other guidelines already listed on what to avoid, and what to include in your diet. On the other hand, if you’re considering adding meat back into your diet, you might want to supplement with apple cider vinegar, or HCL (betaine) supplements, because if you’ve been off meat for a while, you may have trouble digesting it again at first.
But isn’t red meat supposed to be inflammatory?
Chris Kresser, Founder of the Institute for Functional and Evolutionary Medicine, does a good job getting into the nitty gritty of whether or not red meat should be avoided. Rather than recreate his review of the literature, I’ll let you read his work on your own time. But if you just want to skip to the end, here’s his conclusion: “there’s no good evidence that red meat is more inflammatory than other meats, and [there’s] some evidence indicating that it’s less inflammatory.” (And no, Chris Kresser isn’t “pimping” for the meat industry as some claim!).
However, like dairy, if the meat you’re consuming is not organic, then it most likely has added hormones and antibiotics and comes from animals who are cooped up in cages without ever getting to see the sun or graze in a field. Factory farmed meat is not only unhealthy, its cruel. So please choose your meat wisely. Personally, I order from Butcher Box or shop at Whole Foods, and support local farms when I can.
Personalizing Your Diet
Congratulations on making it this far through the post! I know it’s a lot of information (and I’m sure we could talk about so much more), but I wanted you to be informed about your diet choice, rather than follow blindly from popular advice. So as a little gift for giving me your attention all this time, I’ve prepared a dietary cheat sheet for you. Please read below the embed for instructions on how to use it.
I suggest starting with a Paleo Diet for 6 weeks (Stage 1). It’s more restrictive than the Mediterranean Diet but not as restrictive as the rest of them.
Then after 6 weeks, you have three choices (Stage 2): a) If you’re still not feeling better, you can try the Autoimmune Protocol (AIP) for another six weeks; b) if you are feeling better, and you’re managing the diet, you can stick with it indefinitely; or c) if you’re feeling better, you could alternatively experiment with adding some foods back into your diet, such as rice or garbanzo beans or goat’s dairy, but only one at time.
Stage 3 is a basically a repeat of Stage 2: a) if you’re certain the AIP diet isn’t working for you, you could try the SCD diet for another six weeks; b) if you’re feeling better, and you’re managing the diet, you can stick with it indefinitely; or c) if you’re feeling better, you can alternatively experiment with adding some foods back into your diet, such eggs, nuts and seeds, or nightshades.
In Stage 4, you either stay where you are, re-introduce foods, or swap out the SCD diet for either low Nickel or low FODMAPs diet for another 6 weeks. Both of these diets are highly restrictive, and the list of foods to avoid is sadly so long, especially for FODMAPs, that I didn’t include them in the PDF above. It’s probably best to work with a registered dietitian or nutritionist, for the low FODMAPs diet, anyway. This book, The Complete Low-FODMAP Diet, is also very helpful.
Along the way, keep a food and symptom log. Post the chart on your refrigerator and cross off foods from the “avoid” list if you believe you can handle them, or add foods to the avoid list if you need to.
Heather’s Adenomyosis Diet
By the way, in case you’re curious: I have personally been on a paleo diet for nearly ten years and have eaten low FODMAPs since about 2014. I ate ketogenic (very low carb) for about two and half years, between 2014 and 2016, but then decided I needed more carbs in my life, due to my thyroid condition, and semi-active lifestyle. So I now still eat fairly low-carb, but not too low carb (I don’t know if I’m in ketosis or not these days).
I have also been able to add some FODMAPs back into my life, as well as some non-paleo foods like green peas and hummus (garbanzo beans), rice in sushi, and organic blue corn chips with my guacamole, on occasion. And I enjoy dark chocolate from time to time, an almond milk cappuccino once a week (or more if I’m meeting a friend over coffee), and clear alcohol (rum or tequila) or wine (very dry) on the weekends.
Even with the avoidance of a lot of foods, I feel I have a fairly rich diet. But most importantly, keeping with my diet has kept me completely adenomyosis-symptom free since 2017, a year after I was diagnosed with it. I hope you will be able to say the same soon enough.
If you have more questions about diet, please leave a comment below.