Dietary Practices of Women with Endometriosis: A Cross-Sectional Survey

Dietary and Nutritional Interventions for the Management of Endometriosis

Endometriosis is a chronic, complex, systemic inflammatory condition that impacts approximately 190 million girls and women worldwide, significantly impacting their quality of life. The effective management of endometriosis requires a multi-disciplinary and holistic approach, one that includes surgical and medical management, such as a laparoscopy and a chronic medical management plan, as well as dietary, nutritional, and lifestyle adjunct interventions, such as pelvic pain physiotherapy and acupuncture. There is growing evidence to support the role of dietary and nutritional interventions in the adjunct management of endometriosis-related pain and gastrointestinal symptoms. However, the implementation of these interventions is often not regulated, as patients with endometriosis often adopt self-management strategies. Diet and nutrition can modulate key players integral to the pathophysiology of endometriosis, such as, but not limited to, inflammation, estrogen, and the microbiome. However, it is unclear as to whether diet plays a role in the prevention or the onset of endometriosis. In this review, we discuss three key players in the pathogenesis of endometriosis-inflammation, estrogen, and the microbiome-and we summarize how diet and nutrition can influence their mechanisms, and consequently, the progression and manifestation of endometriosis. There is a major need for evidence-based, non-invasive adjunct management of this debilitating disease, and diet and nutritional interventions may be suitable.

Eating for Optimization: Unraveling the Dietary Patterns and Nutritional Strategies in Endometriosis Management

Endometriosis is a chronic gynecological disorder affecting millions of women worldwide, causing chronic pelvic pain, dyspareunia, dysmenorrhea, and infertility, and severely impacting their quality of life. Treatment primarily involves hormonal therapies and surgical excision, but high recurrence rates and the economic burden are substantial. With these challenges, significant discussion surrounds the potential role of dietary patterns in managing endometriosis, making it necessary to bridge this critical gap. This review investigates the current scientific evidence on the dietary patterns (eg, Mediterranean, vegetarian, anti-inflammatory, low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [low-FODMAP], and Western-style diets) associated with endometriosis and provides a concise, yet thorough, overview on the subject. In addition, antioxidants, microbiota, and artificial intelligence (AI) and their potential roles were also evaluated as future directions. An electronic-based search was performed in MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, Scopus, and Web of Science. The current data on the topic indicate that a diet based on the Mediterranean and anti-inflammatory diet pattern, rich in dietary fiber, omega-3 fatty acids, plant-based protein, and vitamins and minerals, has a positive influence on endometriosis, yielding a promising improvement in patient symptoms. Preclinical investigations and clinical trials indicate that dietary antioxidants and gut microbiota modulation present potential new approaches in managing endometriosis. Also, AI may offer a promising avenue to explore how dietary components interact with endometriosis. Ultimately, considering genetic and lifestyle factors, a healthy, balanced, personalized approach to diet may offer valuable insights on the role of diet as a means of symptom improvement, facilitating the utilization of nutrition for the management of endometriosis.

Endometriosis: recent advances that could accelerate diagnosis and improve care

Endometriosis is a common disorder associated with pain, gastrointestinal and urinary symptoms, infertility, and fatigue. It is defined by the presence of endometrial-like lesions found predominantly in the pelvis. Mechanisms that contribute to disease aetiology include changes in hormonal, inflammatory, and pain pathways. In this article, we focus on recent developments in imaging technologies, on our improved understanding of mechanisms contributing to infertility, on drug therapies that are in clinical trials, and on insights from studies on the gut that offer potential to support self-management strategies. We postulate that improvements in the quality of life of patients will be accelerated by reframing endometriosis as a multi-system disorder and learning from treatments targeting symptoms shared between endometriosis, neuroinflammatory, and gastrointestinal disorders.

Evolution, adaptation, and new applications of the FODMAP diet

The FODMAP diet has been a treatment of irritable bowel syndrome (IBS) for many years. Rigorous scientific evaluation and clinical application of the FODMAP diet have generated deep understanding regarding clinical efficacy, mechanisms of action, and potential adverse effects of this dietary approach. In turn, this knowledge has allowed fine-tuning of the diet to optimize treatment benefits and minimize risks, in the form of the traditional three-phase diet; the FODMAP-gentle approach, which is a less restrictive iteration; and a proposed FODMAP-modified, Mediterranean-style diet which endeavours to optimise both gastrointestinal symptoms and other health parameters. Furthermore, recognition that IBS-like symptoms feature in other conditions has seen the FODMAP diet tested in non-IBS populations, including in older adults with diarrhea and women with endometriosis. These areas represent new frontiers for the FODMAP diet and a space to watch as future research evaluates the validity of these novel clinical applications.

The feasibility of an anti-inflammatory diet in endometriosis: barriers and facilitators perceived by endometriosis patients

RESEARCH QUESTION

What is the feasibility of an anti-inflammatory diet in women diagnosed with endometriosis?

DESIGN

Qualitative study using semi-structured focus groups and individual interviews among patients with endometriosis. Transcripts of the focus groups and interviews were thematically analysed using ATLAS.ti 9. To identify and structure the ideas and views from the focus groups and interviews, two behavioural change models were used. The Capability Opportunity Motivation Behaviour (COM-B) model and domains of the Theoretical Domains Framework (TDF) helped to identify factors that make adherence to an anti-inflammatory diet more or less feasible for women with endometriosis.

RESULTS

The study population consisted of 23 patients with endometriosis. Numerous perceived barriers and facilitators were identified from all COM-B components and 13 out of 15 TDF domains. Knowledge and social influences were the most prominent TDF domains. Key barriers were eating with others; disbelief in a patients' own capability regarding specific dietary guidelines; concerns about taste; lack of knowledge on how to follow the diet; lack of noticeable beneficial effect; and lack of intention to follow the diet to full extent. Key facilitators were receiving social support; general confidence in a participant's own capabilities; knowing how and why to follow the diet; noticing beneficial effect; and belief that the diet would alleviate symptoms.

CONCLUSION

Provision of knowledge, stimulating social support and enhancing self-efficacy should be emphasized. Overall, an anti-inflammatory diet in endometriosis patients, especially when identified barriers and facilitators are addressed in an intervention, is feasible.

How Can Selected Dietary Ingredients Influence the Development and Progression of Endometriosis?

Endometriosis is a chronic, hormone-dependent disease characterized by the presence of endometrial tissue in ectopic locations. Since the treatment options for this disease are still limited, and the cure rate is unsatisfactory, the search for ways to treat symptoms and modify the course of the disease is of key importance in improving the quality of life of patients with endometriosis. So far, the literature has shown that nutrition can influence endometriosis through hormonal modification and altering the inflammatory or oxidative response. Since the importance of nutrition in this disease is still a subject of scientific research, we aimed to summarize the current knowledge on the role of dietary modifications in endometriosis. Our review showed that nutrients with anti-inflammatory and antioxidant properties, including most vitamins and several trace elements, may influence the pathogenesis of endometriosis and can be considered as the nutrients preventing the development of endometriosis. However, despite the many discoveries described in this review, further interdisciplinary research on this topic seems to be extremely important, as in the future, it may result in the development of personalized therapies supporting the treatment of endometriosis.

Comprehensive endometriosis care: a modern multimodal approach for the treatment of pelvic pain and endometriosis

Endometriosis is a prevalent gynecological disease, leading to chronic pain and inflammation, affecting 1 in 10 individuals presumed female at birth. The diagnostic journey is often arduous, marked by neglect of the right diagnosis and prolonged wait times, significantly compromising the quality of life among those affected. This review provides a nuanced exploration of endometriosis-associated pain management, encompassing medical, surgical, and holistic approaches, all guided by accurate and refined diagnostics. Our paramount goal is to empower physicians as key figures in confronting this intricate challenge with a patient-centric approach, ultimately aiming to improve treatment and quality of life. Acknowledging each patient's unique needs, we emphasize the importance of tailoring a spectrum of options informed by current literature and insights gleaned from our experience in a high-volume tertiary endometriosis center. It is imperative to recognize endometriosis as a complex and chronic disease, often occurring with co-morbid conditions and nuanced complexities, necessitating a long-term personalized multimodal approach for each case. In addition, incorporating principles such as patient autonomy, profound respect for diverse experiences, and practical education on treatment choices is pivotal in enhancing treatment outcomes and overall patient satisfaction.

The effect of dietary interventions on pain and quality of life in women diagnosed with endometriosis: a prospective study with control group

STUDY QUESTION

What is the influence of dietary interventions, namely the low fermentable oligo-, di-, mono-saccharides, and polyols (Low FODMAP) diet and endometriosis diet, on endometriosis-related pain and quality of life (QoL) compared to a control group?

SUMMARY ANSWER

After adhering to a dietary intervention for 6 months, women with endometriosis reported less pain and an improved QoL compared to baseline whereas, compared to the control group, they reported less bloating and a better QoL in 3 of 11 domains.

WHAT IS KNOWN ALREADY

Standard endometriosis treatment can be insufficient or may be accompanied by unacceptable side effects. This has resulted in an increasing interest in self-management strategies, including the appliance of the Low FODMAP diet and the endometriosis diet (an experience-based avoidance diet, developed by women with endometriosis). The Low FODMAP diet has previously been found effective in reducing endometriosis-related pain symptoms, whereas only limited studies are available on the efficacy of the endometriosis diet. A survey study recently found the endometriosis diet effective in improving QoL but currently no guidelines on use of the diet exist.

STUDY DESIGN, SIZE, DURATION

A prospective one-center pilot study was performed between April 2021 and December 2022. Participants could choose between adherence to a diet-the Low FODMAP diet or endometriosis diet-or no diet (control group). Women adhering to a diet received extensive guidance from a dietician in training. The follow-up period was 6 months for all three groups. For all outcomes, women adhering to the diets were compared to their baseline situation and to the control group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included women diagnosed with endometriosis (surgically and/or by radiologic imaging) who reported pain scores ≥3 cm on the visual analogue score (0-10 cm) for dysmenorrhea, deep dyspareunia, and/or chronic pelvic pain. The primary endpoint focused on pain reduction for all pain symptoms, including dysuria, bloating, and tiredness. Secondary endpoints, assessed via questionnaires, focused on QoL, gastro-intestinal health, and diet adherence.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 62 participants were included in the low FODMAP diet (n = 22), endometriosis diet (n = 21), and control group (n = 19). Compared to their baseline pain scores, participants adhering to a diet reported less pain in four of six symptoms (range P < 0.001 to P = 0.012) and better scores in 6 of 11 QoL domains (range P < 0.001 to P = 0.023) after 6 months. Compared to the control group, analyzed longitudinally over the 6-month follow-up period, participants applying a diet reported significant less bloating (P = 0.049), and better scores in 3 of 11 QoL domains (range P = 0.002 to P = 0.035).

LIMITATIONS, REASONS FOR CAUTION

No sample size was calculated since efficacy data were lacking in the literature. In order to optimize dietary adherence, randomization was not applied, possibly resulting in selection bias.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that women could benefit from adherence to a dietary intervention, since we found lower pain scores and better QoL after 6 months. However, caution is implied since this is a pilot study, no sample size was calculated, and data on long-term effects (>6 months) are lacking. The results of this pilot study underline the importance of further research and the drawing up of guidelines.

STUDY FUNDING/COMPETING INTEREST(S)

A.v.H. reports receiving a travel grant from Merck outside the scope of this study. J.W., S.V., J.T., and B.D.B. have no conflicts of interest to report. A.d.V. reports having received KP-register points for internship guidance of J.W., performing paid consultations with endometriosis patients outside the study and receiving reimbursements for educational lectures at the local hospital (Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands). A.S. reports having received expenses for travel and hotel costs as an invited speaker from ESHRE. This was outside the scope of this study. M.v.W. reports that she is a Co-Ed of Cochrane Gynecology and Fertility. V.M. reports receiving travel and speaker's fees from Guerbet and research grants from Guerbet, Merck and Ferring. The department of reproductive medicine (V.M.) of the Amsterdam UMC, location VUmc, has received several research and educational grants from Guerbet, Merck and Ferring not related to the submitted work.

TRIAL REGISTRATION NUMBER

N/A.

Self-managed dietary changes and functional gut symptoms in endometriosis: A qualitative interview study

Objective

Endometriosis is a chronic gynaecological condition, often causing gastrointestinal symptoms and misdiagnosed as irritable bowel syndrome (IBS). Endometriosis guidelines do not formally endorse dietary changes and little is known about how they are self-managed. The objective of this study is to understand nutritional practices and management of gut symptoms in people with endometriosis.

Study design

Participants were recruited as part of a larger survey study via endometriosis support groups on social media. Eligibility criteria were: a self-reported physician-led diagnosis of endometriosis, over 18 years old and residing in the United Kingdom (UK). Semi-structured interviews were undertaken virtually via Zoom using a predefined interview guide. All interviews were transcribed and analysed using thematic analysis.

Results

10 people with endometriosis were interviewed. All had made individual dietary changes to manage their gut-related endometriosis symptoms. Dietary changes were made based on advice from social media support, books, websites or professionals other than dietitians. Changes included the restriction and exclusion of multiple essential food groups, including dairy, grains (primarily gluten), vegetables, fruits, and animal products. These changes impacted participants' weight, nutritional status and relationship with food. Four strong themes were identified: 1) impact of pain 2) severe and unpredictable gut symptoms 3) dietary changes and their impact 4) seeking support for dietetic intervention. A common thread underlying and linking these four main themes was the feeling of being dismissed, care being delayed and lack of support. Overall the long delay waiting for a diagnosis, surgery and, at times, the re-occurrence of symptoms post-surgery led to unsupported trial and error with modifiable lifestyle factors, including diet.

Conclusion

Overall, participants demonstrated some patterns of restrictive eating behaviour and wanted more professional support to help manage their endometriosis-related gut symptoms. This highlights the need for dietitians to be involved in endometriosis care to help alleviate gut symptoms, whilst ensuring nutritional adequacy and offering weight management support where required.

Nutritional practices and dietetic provision in the endometriosis population, with a focus on functional gut symptoms

BACKGROUND

Endometriosis is a common condition causing chronic pain, fatigue and gut symptoms. Research suggests that dietary changes may improve symptoms; however, evidence is lacking. The present study aimed to investigate the nutritional practices and needs of individuals with endometriosis (IWE) and the management of endometriosis by dietitians in the UK, focusing on gut symptoms.

METHODS

Two online questionnaires were distributed via social media: a survey of dietitians working with IWE and functional gut symptoms and a survey of IWE.

RESULTS

All respondents to the dietitian survey (n = 21) used the low fermentable oligosaccharides disaccharides monosaccharides and polyols (FODMAP) diet in IWE, with the majority 69.3% (n = 14), reporting positive adherence and patient benefit. Dietitians recommended more training (85.7%, n = 18) and resources (81%, n = 17) for IWE. Of those who completed the IWE questionnaire (n = 1385), 38.5% (n = 533) had coexisting irritable bowel syndrome. Only 24.1% (n = 330) had satisfactory relief of gut symptoms. The most common symptoms were tiredness, bloating and abdominal pain, experienced by 85.5% (n = 1163), 75.3% (n = 1025) and 67.3% (n = 917), respectively. Some 52.2% (n = 723) had tried dietary modifications to relieve their gut symptoms; 36.7% (n = 500) ate a restricted diet at present; 13.5% (n = 184) experienced recent unintentional weight loss and 29.8% (n = 407) a decreased appetite Some 13.2% (n = 183) had seen a dietitian regarding their gut symptoms. Of those who had not seen a dietitian, 57.7% (n = 693) would find it useful to.

CONCLUSIONS

Gut symptoms and dietary restriction are very common in IWE; however, dietetic input is not. More research on the role of nutrition and dietetics in the management of endometriosis is recommended.

Identification of early symptoms of endometriosis through the analysis of online social networks: A social media study

Objective

Endometriosis is a complex full-body inflammation disease with an average time to diagnosis of 7-10 years. Social networks give opportunity to patient to openly discuss about their condition, share experiences, and seek advice. Thus, data from social media may provide insightful data about patient's experience. This study aimed at applying a text-mining approach to online social networks in order to identify early signs associated with endometriosis.

Methods

An automated exploration technique of online forums was performed to extract posts. After a cleaning step of the built corpus, we retrieved all symptoms evoked by women, and connected them to the MedDRA dictionary. Then, temporal markers allowed targeting only the earliest symptoms. The latter were those evoked near a marker of precocity. A co-occurrence approach was further applied to better account for the context of evocations.

Results

Results were visualised using the graph-oriented database Neo4j. We collected 7148 discussions threads and 78,905 posts from 10 French forums. We extracted 41 groups of contextualised symptoms, including 20 groups of early symptoms associated with endometriosis. Among these groups of early symptoms, 13 were found to portray already known signs of endometriosis. The remaining 7 clusters of early symptoms were limb oedema, muscle pain, neuralgia, haematuria, vaginal itching, altered general condition (i.e. dizziness, fatigue, nausea) and hot flush.

Conclusion

We pointed out some additional symptoms of endometriosis qualified as early symptoms, which can serve as a screening tool for prevention and/or treatment purpose. The present findings offer an opportunity for further exploration of early biological processes triggering this disease.

Lessons from implementing the Australian National Action Plan for Endometriosis

Abstract

Endometriosis is a common yet under-recognised chronic disease with one in nine (more than 830,000) women and those assigned female at birth diagnosed with endometriosis by the age of 44 years in Australia. In 2018, Australia was the first country to develop a roadmap and blueprint to tackle endometriosis in a nationwide, coordinated manner. This blueprint is outlined in the National Action Plan for Endometriosis (NAPE), created from a partnership between government, endometriosis experts and advocacy groups. The NAPE aims to improve patient outcomes in the areas of awareness and education, clinical management and care and research. As researchers and clinicians are working to improve the lives of those with endometriosis, we discuss our experiences since the launch of the plan to highlight areas of consideration by other countries when developing research priorities and clinical plans. Historically, major barriers for those with endometriosis have been twofold; first, obtaining a diagnosis and secondly, effective symptom management post-diagnosis. In recent years, there have been calls to move away from the historically accepted 'gold-standard' surgical diagnosis and single-provider specialist care. As there are currently no reliable biomarkers for endometriosis diagnosis, specialist endometriosis scans and MRI incorporating artificial intelligence offer a novel method of visualisation and promising affordable non-invasive diagnostic tool incorporating well-established technologies. The recognised challenges of ongoing pain and symptom management, a holistic interdisciplinary care approach and access to a chronic disease management plan, could lead to improved patient outcomes while reducing healthcare costs.

Lay summary

Endometriosis is a chronic disease where tissue like the lining of the uterus is found in other locations around the body. For the 830,000 people living with endometriosis in Australia, this often results in an immense burden on all aspects of daily life. In 2018, Australia was the first country to introduce a roadmap and blueprint to tackle endometriosis in a nationwide coordinated manner with the National Action Plan for Endometriosis. This plan was created as a partnership between government, endometriosis experts and advocacy groups. There are several other countries who are now considering similar plans to address the burden of endometriosis. As researchers and clinicians are working to improve the lives of those with endometriosis, we share our experiences and discuss areas that should be considered when developing these national plans, including diagnostic pathways without the need for surgery, and building new centres of expertise in Endometriosis and Pelvic Pain.