Saint Louis University School of Medicine Department of Obstetrics, Gynecology, and Women’s Health Center for Endometriosis
Patrick Yeung, Jr. MD Rose Catanzaro MS, RDN, LDN 1031 Bellevue Ave, Suite 400 St. Louis, MO 63117 314-977-7455
Table of Contents
Overview of Endometriosis …..3-4
What should your diet be composed of? ……5
Breakdown of Food Groups……6-8
Organic or not? ……9
Hidden hormones in Your Food …..10
Which Fats are the Most Anti-inflammatory? …..11
Omegas by the Mouth…..12
Omega-3 Supplementation …..13
Elimination Diet and Endometriosis …..14
Implementing the Endo Elimination Diet …..15-16
Dairy Foods …..17
Gluten Foods …18-21
Added Sugars …22
The Basics of a Healthy Well Balanced Diet …25
Food Intake Log and Symptom Diary …28
Overview of Endometriosis
Endometriosis is a painful, chronic disease where tissue that normally lines the uterus grows outside of the uterus. Such areas of growth include the abdomen on the ovaries and fallopian tube as well as the bladder, bowel, vagina, cervix, and the area between the vagina and rectum. The misplaced tissue builds up, breaks down, and sheds like the tissue that lines the uterus during menstrual cycles. However, the misplaced tissue has no way of exiting the body which results in internal bleeding, inflammation, bowel problems, infertility, scar tissue formation, and adhesions.
Painful urination before periods
Painful bowel movements during
Pain with sex
Pain before and during periods
due to severe cramping, heavy menstrual flow, and periods
lasting > 7 days
About 1 in 10 women in the U.S. have endometriosis. About 176 million women worldwide have endometriosis. Symptoms usually occur during reproductive age (12-60 years old) but most women are often undiagnosed.
Overview of Endometriosis
There is no identified cause for endometriosis. Theories related to genetics suggest that it may be carried in genes so some families may be more predisposed to it than others. Another theory has found it to be present at fetal development and activated during puberty. A retrograde menstruation theory suggests that menstrual tissue can back up into the fallopian tube, implant in the abdomen, and grow which can lead to the development of endometriosis. Lastly, there has been a link between the body’s inflammatory response and endometriosis but the mechanism behind this theory is not well understood.
To confirm diagnosis, a laparoscopy is performed which will show the location, size, and extent of the growths. The gold standard for treatment is laparoscopic excision surgery to remove the growths. However, there is no cure for endometriosis.
What should your diet be composed of?
Alcohol, caffeine & sweets 1-2 svg/week
(Dairy-free if necessary) 3 svg/day
(Gluten-free if necessary) 3-5 svg/day
Healthy cold-pressed oils (Extra virgin, canola flaxseed, nut- based oils), 2-4 svg/day
Fish, seafood 3-5 svg/week
Vegetables 4-5 svg/day
Nuts and seeds 1-2 svg/ day
Lean meat, poultry, eggs 3-5 svg/week
Beans, legumes 2-4 svg/week
Fruits 1-2 svg/day
How much? 4-5 servings per day minimum (one serving = 2 cups salad greens, 1⁄2 cup vegetables cooked)
Healthy Sources: Dark leafy greens (spinach, collard greens, kale, Swiss card), cruciferous vegetables (broccoli, cabbage, Brussels sprouts, bok choy, cauliflower), carrots, beets, onion, peas, squashes, washed raw salad greens
Why? Vegetables are rich in flavonoids and carotenoids with antioxidant and anti-inflammatory properties. Aim for a plate that’s colorful in vegetables to get a wide variety of vitamins, including A, E, and C as studies have shown these vitamins to be lower in endometriosis patients.
How much? 1-2 servings per day (one serving = 1 medium size piece of fruit, 1⁄2 cup chopped fruit, 1⁄4 cup dried fruit)
Healthy Sources: Raspberries, blueberries, strawberries, peaches, nectarines, oranges, pink grapefruit, red grapes, plums, pomegranates, blackberries, cherries, apples, and pears all have lower glycemic index.
Why? Fruits are rich in flavonoids and carotenoids with antioxidant and anti-inflammatory properties. Aim for variety in color to get a wide variety of nutrients, including A, E, and C.
When possible, choose organic for reduced pesticide residue that have been associated with hormone imbalances.
Fish and Seafood
How much? 3-5 servings per week (one serving = 4 oz. of fish or seafood)
Healthy Sources: Wild Alaskan salmon, herring, sardines, and black cod
Why? Fish is rich in Omega-3s which are anti-inflammatory. Choose higher fat, deep-sea fish as they have greater intakes of Omega-3s.
Lean Meat, Poultry, Eggs
How much? 3-5 servings per week (one serving = 3 oz. of poultry or skinless meat)
Healthy Sources: High quality skinless poultry, turkey, grass-fed lean meats, free-range eggs
Why? Lean meats are lower in saturated fat to better control cholesterol levels.
Beans and Legumes
How much? 2-4 servings per week (one serving = 1⁄2 cup cooked beans or legumes)
Healthy Sources: Black beans, chickpeas, black-eyed peas, and lentils
Why? Beans are rich in folic acid, magnesium, and potassium and
soluble fiber. They are a low-glycemic-load foods to stabilize blood sugars.
How much? 1-2 servings per week (one serving = 3 oz. of cooked meat)
Sources: Beef, steak, pork, veal
Why? Limit these types of foods as red meats are shown to be pro-
inflammatory and cause hormone imbalances. Choose grass-fed or organic meats.
Cold-Pressed Vegetable Oils
How much? 2-4 servings a day (one serving= 1 teaspoon of oil)
Healthy Sources: Extra virgin olive oil, vegetable oil, canola oil,
flaxseed oils, nut-based oils
Why? Oils are high in Omega-3s and antioxidants which are anti-
inflammatory. They are also rich in monounsaturated fats that raise good cholesterol (HDLs) and lower bad cholesterol (LDLs).
Expelled cold-pressed oil is best since it is not chemically treated and heated at lower temperatures to extract the oil. When cooking with oil, use lower temperatures as higher temperatures increases the production of trans fat.
Where to use? Drizzle cold-pressed oils on salads, over vegetables for roasting or sautéing, or even popcorn! Mix organic butter with a cold- pressed oil for a healthier spread.
Nuts and Seeds
How much? 1-2 servings a day (one serving = 2 walnuts, 1 tablespoon of flaxseed, 1 oz. of avocado, 1 tbsp. of peanut butter)
Healthy Sources: Almonds, walnuts, ground flaxseed, pecans, hemp seeds, avocado, natural peanut butter, chia seeds
Why? Nuts and seeds are high in Omega-3s which are anti- inflammatory. They are excellent sources of B-vitamins in addition to phosphorous.
How much? 3-5 servings a day (one serving = 1⁄2 cup cooked grains)
Healthy Sources: Brown rice, basmati rice, wild rice, buckwheat,
quinoa, steel-cut oats, gluten-free noodles or pasta
Why? Whole grains have added B-vitamins with added fiber to
promote a healthy digestive tract and reduce spikes in blood sugar that promote inflammation.
Low-fat Dairy or Dairy Alternatives
How much? 3 servings a day (1 ounce of cheese, 8 ounce serving of milk/dairy-free milk, 1 cup of yogurt)
Healthy Sources: Low-fat cheeses (Swiss, mozzarella, parmesan), fat- free yogurt, cottage cheese, skim or 1% milk. You can find dairy-free options of these foods as healthy dairy alternatives.
Why? Vitamin D has been shown to reduce pro-inflammatory cytokines that contribute to possible inflammation associated with endometriosis. Choose organic dairy products to reduce the amount of hormones added to your foods.
Alcohol, Caffeine, Processed Foods, and Sweets
How much? 1-2 servings per week, sparingly
Sources: Processed foods, fried foods, fast-food, caffeine in sodas or
sugary sweetened beverages, alcohol
Why? These types of foods have no nutritional value and added sugar
which can prevent other vital nutrients from being absorbed. Caffeine and alcohol have been thought to impair ovarian function, aggravate PMS symptoms, and negatively affect infertility. Sweets are pro- inflammatory and should be limited.
What to eat instead? Healthier sweet substitutes can include small servings of dark chocolate, dried fruit, frozen yogurt, and fruit sorbet.
How much? 8-8 oz. glasses of water, half a gallon (64 oz.)
Sources: Pure water, or drinks that are mostly water, such as tea or
sparkling water with lemon.
Why? Water is vital for overall proper functioning of the body and
removes metabolic waste products.
Organic or not?
Research has shown that pesticides like organochlorines, organophosphates, bipyridines have been associated with decreased antioxidant capacity of fruits and vegetables. In addition, organochlorines have been shown to negatively affect hormonal pathways.
Foods on the “Dirty Dozen” list have the greatest amount of pesticides while foods on the “Clean Fifteen” list have the least amount. In order to consume a wide variety of fruits and vegetables for optimal nutrition, choose organic produce when purchasing fruits and vegetables from the Dirty Dozen list to reduce pesticide exposure.
Hidden Hormones in Your Food
Dairy and meat products have added hormones that may be linked with hormone imbalances in patients with endometriosis. However, the nutrients from these foods, such as protein, Vitamin D, calcium, and iron are important components of a well-balanced diet.
To reduce the amount of hormones in your foods, choose organic milk or dairy-free milk and grass-fed beef.
What constitutes organic? Below are the USDA organic regulations:
Managed without antibiotics, added growth hormones, mammalian or avian byproducts, or other prohibited feed ingredients (e.g., urea, manure, or arsenic compounds)
Livestock that is allowed year-round access to the outdoors for grazing
Raised on certified organic land Fed 100% certified organic feed
Managed in a way that conserves natural resources and biodiversity
Which fats are the most anti-inflammatory?
Flaxseed has the highest Omega-3 concentration followed by canola and soybean oil.
The goal is to consume and use fats that have lower saturated fat and a higher Omega-3 to Omega-6 ratio to reduce rates of inflammation associated with endometriosis.
Omegas by the Mouthful
Check out the foods listed below to see which are the best sources of Omega-3s to help reduce inflammation.
Salmon, Atlantic, farmed Salmon, Chinook, cooked Mackeral, Atlantic Salmon, Atlantic, wild Shrimp Tuna, blue fin Tuna, yellow fin Cod, pacific Lobster Flounder or sole
Omega 3 DHA or EPA
Percentage of Omega-6s vs. Omega-3s
0% 50% 100%
Foods with a longer red line have larger amounts of Omega-3s.
Beef, lean, grain-fed Chicken, dark met, with skin
Egg Yolk Egg White Bacon Chicken, white meat, skinless Beef, grass fed, lean Lamb, high fat Venison Lamb, lean
Omega 3 DHA or EPA
0% 50% 100%
Percentage of Omega-6s vs. Omega-3s
Fish has a greater amount of Omega-3s compared to other sources of meat. The goal is to consume a variety of seafood and add in lean lamb, grass-fed beef, and skinless white meat chicken as good protein sources with larger amounts of Omega-3s and lower fat intake.
Assorted Meat & Protein Foods
Assorted Fish and Seafood
Omega 3 Supplementation
Past research has shown that Omega 3 supplementation in the form of EPA & DHA can improve rates of fertility and reduce oxidative stress as a cause of inflammation.
Omega-3 supplementation is increasingly being prescribed to patients with endometriosis. Discuss with your doctor if this is right for you.
A feasibility study was conducted on different fish oil supplements to compare their costs and benefits. The ProOmega liquid form is the best deal as it will last the longest for a total of 48 days compared to the others that range from 20-30 days.
Elimination Diet and Endometriosis
To help manage painful symptoms like abdominal pain, nausea, and cramping that can be associated with endometriosis, certain foods can be eliminated from the diet that worsen these symptoms. Research has shown that a gluten free diet can lead to dramatic pelvic pain reduction in women suffering with endometriosis. These may include:
- Dairy contains a sugar called lactose that may be difficult for some women to breakdown and digest, causing cramping, diarrhea, and pain.
- Gluten is a protein found in grains and wheat products which has been shown to cause diarrhea, abdominal pain, and bloating in women with gluten sensitivity. Gluten can cause malabsorption of vitamins and minerals that regulate hormones. Gluten, also can cause inflammation and induce autoimmune reactions that attack hormones and hormone receptors.
- Added sugars in processed foods, such as packaged or prepared foods, soft drinks and baked goods, can increase inflammation.
If you experience any of these symptoms, you may be a great candidate for the Endo Elimination Diet. Discuss with your doctor and dietitian to make the best plan for your health moving forward.
The Endo Elimination Diet
The goal of an elimination diet is to remove all foods that could be linked to making your symptoms worse. There are two phases in an elimination diet.
- Phase 1- Elimination: Over the course of 2 weeks, you will remove all dairy, gluten, and added sugars and consume only the foods approved on pages 4-5.
- Phase 2 – Challenge: Over the course of 4 weeks, you will slowly reintroduce these foods back into the diet. You will track your symptoms and discuss them with your doctor and dietitian to see which foods your body can tolerate.
How to be successful at following this diet?
- Learn more about endometriosis before starting the Endo Diet.
These books have been recommended by the Endometriosis Association as great reads to provide a more comprehensive overview of endometriosis.
Endometriosis: The Compete Reference for Taking Charge of Your Health by Mary Lou Ballweg and Endometriosis Association
Endometriosis: A Key to Healing Through Nutrition by Dian
Shepperson Mills, M.A., and Michael Vernon, Ph.D, HCLD
The Endometriosis Sourcebook: The Definitive Guide to Current
Treatment Options, the Latest Research, Common Myths about the Disease, and Coping Strategies-both Physical and Emotional by Mary Lou Ballweg and Endometriosis Association
The Anti-Inflammation Diet and Recipe Book by Jessica K. Black
- Record your current symptoms before starting the elimination diet. This is an essential step to help you identify what changes occur in your symptoms when eliminating foods from your diet. Have a notebook handy to write the symptoms. Keep this notebook with you at all times when eating to record how you react to certain foods, before, during, and after the elimination diet. This will help the doctor and dietitian better determine what the cause of your GI symptoms.
Plan your meals. Following the Endo Elimination diet can be difficult because you are eliminating foods that might be staples in your everyday diet. Therefore, plan your meals ahead of time to ensure that you can successfully follow the diet. Go grocery shopping and purchase foods on the approved foods list before starting your diet. Try out these food blogs for fresh, innovative Endo diet recipes to get you started!
o Foodie 4 Healing o ENDODIET
o Jessica Murnane
Jump right in! Follow the elimination phase for 2 weeks eating only the foods from the approved food lists. (See Endometriosis Food and Symptom Diary at the end of this booklet)
Dairy Foods to Avoid. Dairy-free Alternatives to Consume
Cow’s milk. Almond, coconut, soy, lactose-free milks
Yogurt (all types). Lactose-free yogurt
Cheese (all types). Dairy-free cheese, nutritional yeast
Cottage chees. Dairy-free cottage cheese
Sour cream. Soy sour cream, nutty sour cream
Butter. Olive oil, vegetable oil, canola oil, nut oils, etc.
Margarine. Dairy-free margarine
Condensed milk. Cream of coconut, dairy free milk powder
Cream cheese. Coconut cream, low fat soy cream
Coffee creamers. Dairy-free coffee creamers, soy creamers
Ice cream. Dairy-free ice cream
Whipped cream. Low fat soy cream
Chocolate. Baking chips and bars from dairy-free brands
These are good brands to try Enjoy Life Foods, Pascha Organic Chocolate, Taza Chocolate, Scharffen Berger Baking Chocolate
For more recipes, grocery lists, and helpful tips on going dairy- free, visit godairyfree.org!
Gluten foods to Avoid on Elimination Diet
Foods with Gluten to Avoid. Gluten-free Foods to Consume
Pastas (raviolis, dumplings, couscous, gnocchi). Gluten-free pasta
Noodles (ramen, udon, soba). Rice products
Breads and pastries. Gluten-free breads, bagels, muffins, rolls
Crackers (pretzels, goldfish, graham crackers). Gluten-free crackers
Baked goods (cakes, cookies, pie crusts, brownies). Gluten-free pastries
Cereal and granola (corn flakes, rice puffs, oats). Gluten-free cereals
Pancakes and waffles Gluten-freepancakes, waffles
Oatmeal. Gluten-free oats
Breading and coating mixes Breading made with ground up flax
Croutons (stuffing, dressings). Dressings made with flax
Sauces and gravies (soy sauce, cream sauces). Sauces made with rice
Flour tortillas. Gluten-free tortillas
Beer, malt beverage. Gluten-free beers
Wheat flour as an ingredient, “wheat free” does not mean gluten free
Nut flours, gluten-free flours (rice, soy, corn, potato, bean)
For more recipes, grocery lists, and tips to eating gluten-free, visit glutenfreeliving.com!
Watch out for Hidden Gluten! Some foods may contain hidden gluten. These may include:
Energy bars/granola bars – some bars may contain wheat as an ingredient, and most use oats that are not gluten- free
French fries – be careful of batter containing wheat flour or cross-contamination from fryers
Potato chips – some potato chip seasonings may contain malt vinegar or wheat starch
Processed lunch meats
Candy and candy bars
Soup – pay special attention to cream-based soups, which
have flour as a thickener. Many soups also contain barley
Multi-grain or “artisan” tortilla chips or tortillas that are
not entirely corn-based may contain a wheat-based
Salad dressings and marinades – may contain malt
vinegar, soy sauce, flour
Brown rice syrup – may be made with barley enzymes
Meat substitutes made with seitan (wheat gluten) such as
vegetarian burgers, vegetarian sausage, imitation bacon, imitation seafood (Note: tofu is gluten-free, but be cautious of soy sauce marinades and cross-contamination when eating out, especially when the tofu is fried)
Cheesecake filling – some recipes include wheat flour
Eggs served at restaurants – some restaurants put
pancake batter in their scrambled eggs and omelets, but on their own, eggs are naturally gluten-free.
Watch out for Hidden Gluten!
Some products may contain hidden gluten. These include:
Lipstick, lipgloss, lipbalm
Herb or nutritional supplements
Drugs, over-the-counter medications
Vitamin and mineral supplements
The following ingredients are often code for gluten:
Avena sativa Cyclodextrin
Fermented grain extract
Hydrolyzed malt extract
Hydrolyzed vegetable protein
Maltodextrin Phytosphingosine extract
Samino peptide complex
Tocopherol/vitamin E Yeast extract
Natural flavoring, caramel color
Brown rice syrup
Modified food starch
Hydrolyzed vegetable protein (HVP)
Hydrolyzed soy protein
Read Your Labels for Gluten!
To make sure you are not accidently ingesting gluten, be sure to read the label on all your food products before purchasing.
Look for the words “wheat, barley, rye and oats” to identify if a food contains gluten.
If in doubt about a food, go without consuming it just to be sure!
Added Sugar Foods to Avoid on Elimination Diet
Added Sugar Foods to Avoid. Foods to Consume
Regular soft drinks, energy drinks. Unsweetened tea, water
Juice, fruit punch. 100% freshly squeezed juice
Candy, cakes, cookies, pies, cobblers. Sugar-free cookies,candy
Sweet rolls, pastries, and donuts. Sugar-free rolls
Dairy desserts, such as ice cream. Frozen yogurt, plain Greek yogurt
Reading the label on processed foods can help identify added sugars. The different names for sugar include:
Confectioner’s powdered sugar
High-fructose corn syrup (HFCS)
Nectars (e.g., peach nectar, pear
White granulated sugar
The Challenge Phase
During this phase, you will introduce one challenge food at a time. Start with small portions on the first day of the challenge and record any symptoms in your notebook. The challenge phase will last 3-4 weeks, depending on the severity of your symptoms.
Week 1: Dairy Challenge
Day 1: Smaller portions Day 2: Larger portions Record in journal
Week 2: Gluten Challenge
Day 1: Smaller portions Day 2: Larger portions Record in journal
Week 3: Added Sugar Challenge
Day 1: Smaller portions Day 2: Larger portions Record in journal
Interpret your results: Look at the symptoms recorded in your journal. What foods triggered your symptoms and in what amounts? What foods were safe for you to eat? Discuss with your dietitian about how to evaluate your symptoms moving forward.
Change your diet: Avoid foods that trigger your symptoms during the challenge phases. Focus on consuming a well balanced diet without triggering your symptoms.
The Basics of a Healthy, Well Balanced Diet
Since there is no specified cause for endometriosis, it is important to adhere to a diet that focuses on variety and balance for optimal nutrition. The focus should be on consuming a diet balanced in all five groups, including fruits, vegetables, dairy, protein, and grains.
Aim for half of your plate to be filled with a variety of colorful fruits and vegetables. These are high in vitamins and antioxidants to reduce inflammation.
Make half your grains whole grains.
Vary your protein by adding in plant-based protein like
beans and legumes to lower red meat consumption.
Look for food and drink sources that are lower in
saturated fat, sodium, and added sugars.
Choose low-fat or fat-free dairy.
Incorporate healthy fats like Omega 3’s found in avocado,
fish, nuts, and olive oil to reduce inflammation.
Get active at least 30 minutes a day which has been
shown to reduce ovarian stimulation and estrogen production.
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A special thank you to Anne Cameron MS, RDN for her dedication and assistance in development of this booklet.
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