There was a time when I considered almost debilitating pain, constipation, and overwhelming fatigue around my period to be normal. I was told this was normal by many doctors starting at around the age of 17. The only treatment I received was a prescription for birth control and the option to “skip periods” if I so choose by skipping placebo pills. One doctor even told me that “none of the female gynecologists in Manhattan are getting their periods now a days, they know better!”

After going through the trials of infertility and finally getting a diagnosis of stage IV endometriosis, I think back on the days of writhing in pain on the bathroom floor and wonder why it wasn’t addressed sooner? The alarming statistic is that most women with endometriosis go undiagnosed for around 10 years! Ten years of pain, inflammation, and possible fertility issues. Once diagnosed, the options offered by conventional medicine are still very limited. Drugs that put you in a pseudo-menopausal state, ablation, and/or surgery are currently what doctors are offering up as treatments with no known cure in site. It’s estimated that 1 in 10 women in the US suffer from endometriosis, and this is likely a conservative number given how frequently the diagnosis is missed from the onset of puberty.

Is endometriosis an autoimmune disease?

The short answer: although endometriosis is not yet classified as an autoimmune disease, it seems to behave very much like one. Yet there’s a lot of controversy as to what causes endometriosis and how it should be classified. Where the debate lies seems to be how the person’s body and immune system react to the inflammatory lesions found throughout the body of endo patients. By investigating some of the key mechanisms, you can see why the line is a bit blurred.

• The first mechanism is estrogen dominance. This is where “down-regulation” comes into play, the idea of switching off lesions which are stimulated by excess estrogen. This can result in bone loss, possible diminished ovarian reserve, and other signs of premature aging. Endometrial lesions have also been found to be resistant to progesterone, and progesterone has been shown to slow the growth of these effected areas. Tricky, right? Both hormones have also been studied to either promote or reduce inflammation given their excess or shortage, particularly the type of inflammation that effects the immune system.
• Lower androgen exposure in the womb may cause epigenetic changes in hormones and the immune system. This is potentially due to the toxic burden we all now experience through our food supply and the world around us. Genetic changes like these are also seen in some of the world’s most prevalent autoimmune diseases.

Through the scope of functional medicine, treating endometriosis as an autoimmune disease may be an option for many as far as symptom relief (including improved fertility) and disease management.

A food as medicine approach to the management of endometriosis.

An anti-inflammatory elimination diet is often used in functional medicine to down-regulate the immune response to food. It can also reduce inflammation associated with some of the most common food sensitivities. With endometriosis, we also want to focus on reducing the toxic load from food and food packaging that can increase your estrogen load. These toxins are known as xenoestrogens such as BPA, phthalates, and pesticides. Let’s explore each component of the ideal diet further:

• Major foods associated with immune dysfunction include gluten and foods with a similar protein structure to gluten. These can “mimic” gluten in the body, otherwise known as cross-reactive foods. Cross-reactive foods include grains, dairy, soy, and eggs. Soy can be controversial to remove on a hormone-balancing diet because it contains a high concentration of isoflavones, a type of plant estrogen (phytoestrogen) that is similar in function to human estrogen but with much weaker effects. Soy isoflavones can bind to estrogen receptors in the body and cause either weak estrogenic or anti-estrogenic activity. For some, the addition of quality, organic soy may be beneficial for its anti-estrogenic properties, but due to the common immune response to soy, we often remove and possibly reintroduce once symptoms have improved. Animal based saturated fats can also be an issue for endometriosis sufferers. That doesn’t necessarily mean you cannot have beef on an anti-inflammatory diet. Make sure to choose organic, grass-fed, leaner cuts meat and well sourced lean proteins like organic poultry without the skin, wild caught fatty fish (particularly fish high in omega-3 fatty acids like salmon and sardines), and US caught shellfish.
• Anti-inflammatory fats such as fatty fish, avocado, olive oil, nuts and seeds have also been shown to help lower inflammation. Nuts can be controversial on an immune regulating diet, so consider them a rotational food. The benefits seem to outweigh the immune compromising potential for most individuals.
• Fiber is very important for any anti-inflammatory diet. In the case of endometriosis, fiber can bind to excess hormones and toxins for removal. Beans and legumes can be controversial on an immune regulating diet because of substances known as “anti-nutrients” such as lectins or oxalates, but for many, the beneficial fiber outweighs the potential for immune dysfunction. Deanna Minich has studied and written extensively on the topic of anti-nutrients and has created a free guide that outlines risks, benefits, and cooking methods that optimize digestion and lower the inflammation associated with anti-nutrients.
• Some studies have shown better pain management for endo patients on a low-FODMAP diet. This is likely because some patients have dysbiosis and motility issues (particularly when endometrial lesions are found around the bowels). However, high FODMAP foods are some of the richest in detoxifying sulfur-rich nutrients. If you find you don’t tolerate foods in the high fiber, cruciferous, or allium families, consider rotation. This is where bio-individuality and health status play a part in designing an anti-inflammatory diet and you may need to investigate this further with a nutritionist or functional medicine doctor.
• High fiber, low starch vegetables should make up the bulk of an anti-inflammatory, immune balancing diet! Nutrient dense leafy greens, rich color from radishes, sweet potatoes, beets and squashes, detoxifying bitters like arugula and Bok choy, cruciferous vegetables like cauliflower and cabbage, and allium vegetables such as leeks and garlic are at the top of the list as well as antioxidant rich, low glycemic fruits like berries.
• Caffeine is a bit controversial as some studies show it may exacerbate endometriosis by increasing estrogen. On the other hand, organic decaffeinated green tea is high in antioxidants and may be especially beneficial for those with endometriosis.
• Keeping your blood sugar steady and your weight in a healthy range is also important for keeping inflammation in check. Extreme excess weight increases the risk of estrogen dominance. Removing gluten and grains from your diet even as a trial can have a positive effect on insulin resistance. For your starches, choose low to moderate amounts of starchy vegetables and low glycemic fruit mentioned above. Always be sure to pair these foods with healthy fat and/or protein.

Variety is key!

Remember, variety is key when trying to regulate both inflammation and your body’s immune responses. What triggers one person may not for someone else, and elimination diets are a great way to expose these triggers! Once you experience improvement with your symptoms, you may want to consider reintroduction. Some people may need to avoid certain foods long-term, while others won’t create a problem. Work with a nutritionist to introduce foods strategically and remember, rotation and variety are key to keeping your immune system in check. While there may be no clearly defined cure for endometriosis, symptom management and improvement can be accomplished by looking at the body and treating it as a whole. This includes the gut, the immune system, and addressing any other underlying causes of inflammation such as underlying infections and food triggers that could be affecting the body’s ability to heal and maintain homeostasis.