NUTRITIONAL THERAPY FOR PELVIC PAIN GUEST POST BY CERTIFIED WOMEN'S HEALTH AND NUTRITION COACH, SUSAN TESSMAN
“After years of working with thousands of women patients, I have found that no therapy can be fully effective without including beneficial dietary changes as part of the treatment plan." (1) Over 20 years ago those words in a book on endometriosis were my first introduction to the connection between food and pelvic pain. I had been diagnosed with uterine fibroids, ovarian cysts and advanced endometriosis earlier that year and was determined to try anything I could that might help to reduce the pain, and avoid having to undergo further surgery or deal with the emotional and physical side effects of hormonal treatments.
At that time there was much less access to information on complementary therapies for pelvic pain, but I learned as much as I could about a holistic approach for treating endometriosis and other pelvic pain issues that I developed. I followed specific dietary recommendations along with addressing other lifestyle factors like exercise, sleep, and mind-body practices and had regular treatment with pelvic floor physical therapy, acupuncture and massage therapy. It took trial and error to learn what worked best for my body, but I had great results in managing my health outcome.
Most of the time there’s not a magic bullet cure for pelvic pain - it takes an integrated and multi-disciplinary approach to support sustained healing. Whether you suffer with painful bladder syndrome, pelvic floor dysfunction, endometriosis, irritable bowel syndrome (IBS), vulvodynia, or other sources of chronic pelvic pain, nutrition can be used as an additional therapeutic tool to improve these conditions, and to heal co-existing health issues that can increase pelvic pain.
NUTRITION AND ROOT CAUSES OF PELVIC PAIN
When working with nutritional therapy for pelvic pain we want to consider what some of the root causes and triggers might be. It’s estimated that the breakdown of sources of chronic pelvic pain are approximately 37% gastro-intestinal, 31% from urologic causes, 20% reproductive system, and 12% musculoskeletal.
Studies have shown that chronic pelvic pain is frequently associated with systemic inflammation, including autoimmune diseases. (2)
A 2002 study reported in the Sept. 27th issue of Human Reproduction (3) concluded that hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma are all significantly more common in women with endometriosis than in women in the general USA population.
Vulvodynia is associated with other chronic comorbid pain conditions such as fibromyalgia, interstitial cystitis and irritable bowel syndrome, individually and in combination, and the presence of vulvodynia or any of the other comorbid pain conditions increases the likelihood that a woman will have one or more of the other chronic pain conditions. (4)
If you suffer with multiple health issues, nutritional therapy can not only address the pain symptoms, but can also support healing in other inter-related body systems that can be impacting your pelvic pain. The right nutritional shifts can correct digestive disorders, improve the healthy balance of gut microbiota and ability to absorb healing nutrients, bring hormones and blood sugar levels into better balance – all of which can impact pain levels, support your recovery from surgery and medical procedures, and help to down-regulate the nervous system so pain response is not as intense.
ELIMINATION DIETS TO DECREASE INFLAMMATION AND PAIN
To begin to address pelvic pain symptoms, a personalized elimination diet is an important tool. What exactly is an elimination diet and why do we use it?
Most people are familiar with food allergies and how potentially deadly they can be. A food allergy reaction occurs when your body recognizes a certain food as harmful and produces an immune response to that food, which can result in severe symptoms. Antibodies produced in the allergic response (most commonly IgE antibodies) will show up on a food allergy test. 8 food groups have been identified as causing 90% of all IgE food allergies in the U.S.: Milk, eggs, fish, shellfish, wheat, soy, peanuts, and tree nuts.
But many of these same foods also cause reactions that may not produce IgE antibodies, but do cause other immune responses, and these reactions are referred to as food sensitivities or intolerances. A common example of this would be having “lactose intolerance” where you’re lacking the enzyme needed to properly digest this milk sugar. These kind of responses are often delayed and not always as obvious to detect. Symptoms of food intolerances can include digestive problems like bloating, cramping, constipation, diarrhea; headaches; sinus problems; unexplained weight gain; fatigue; skin conditions; and increased pain anywhere in your body.
You can imagine if you’re eating poorly tolerated foods over and over again, and each time your body is having a reaction, that this can lead over time to a chronic state of low-grade inflammation, as the immune system is always being activated. And once inflammation is ongoing, it can also lead to developing even more food intolerances, so a very negative cycle of inflammation is set up, and symptoms increase.
Testing for allergies and food intolerances can be extremely helpful, but tests are not always completely accurate, and can be expensive, so using an elimination diet can be another effective method to help identify these possible food sensitivities. One of the main goals of using an elimination diet with pelvic pain conditions is to calm down and reduce the inflammation cycle and resulting pain and symptoms, and allow the body to rest and heal.
ELIMINATION DIET BASICS
The nutritional advice I followed over 20 years ago for my pain was to stop eating dairy, wheat and sugar (and processed foods in general) and focus on whole foods. I’ll admit it wasn’t a total breeze at first! Those three food groups are still considered top of the list to avoid to reduce many disease or pain states, including pelvic pain conditions. But in a full elimination diet protocol we include all of the main “allergenic” foods: dairy, gluten, corn, shellfish, soy, eggs, peanuts, tree nuts as well as alcohol and caffeine. Some people may also need to remove nightshades, citrus fruits and sometimes even non-gluten grains and/or legumes.
These foods are removed for 3 to 4 weeks, and at the end of that time you add back only one of the eliminated food groups at a time, eating 2-3 servings per day for 3 to 4 days, making note of any symptoms that arise and then breaking from that food to let the symptoms resolve. The following week you try reintroducing the next food. For those foods you identify as having a reaction to, it’s a good idea to then stay off of them for at least 3 to 6 months, if not longer, to allow for full healing before trying to introduce them again. Many people choose to permanently remove certain foods because they experience such improvements in their health.
When people first think about removing these foods from their diet, especially dairy, gluten and sugar, it can be overwhelming to say the least, because these foods have become such a huge part of the standard North American diet. It helped me stay motivated when I understood a little more of the “why” -
Dairy: Lactose is a sugar in cow’s milk, and casein is the protein found in cow’s milk. People can be sensitive to either or both. Many people who are gluten intolerant are also casein or lactose intolerant. Gluten can damage the part of the intestine that is responsible for producing the enzyme lactase, which is necessary for breaking down lactose. About 75% of adults worldwide are lactose intolerant, and don’t have the digestive enzymes needed to digest this milk sugar, and that means digestive distress. Dairy products are also a dietary source of arachidonic acid, the fat used by the body to produce “bad” prostaglandins, localized hormones which can increase pelvic pain, cramps, and inflammation.
Gluten: Gluten includes several related proteins found in wheat and other grains including spelt, kamut, triticale, barley and rye. It’s estimated that approximately 30 to 40% of the U.S. population has some sensitivity to gluten, in addition to those diagnosed with full blown autoimmune celiac disease. Non celiac gluten sensitivity can over time result in damage to the intestinal lining or mucosa, that then allows undigested food proteins to “leak” through the gut wall into the bloodstream, which can trigger pain, inflammation and autoimmune responses. Even among people who are not sensitive to gluten, eating it triggers the release of a protein produced in the small intestine called zonulin, which again can lead to damaged intestinal lining. Gluten expert Dr. Alessio Fasano has stated that nobody digests these proteins well, and because of this it tends to trigger an inflammatory response.
Gluten intolerance has also been linked to altered estrogen levels. In a 2012 study on women with severe painful endometriosis-related symptoms over 12 months, 75% of the over 200 participants reported statistically significant improvements in painful symptoms when eating gluten-free. (5)
Sugar: Sugar depletes the body’s B complex vitamins and minerals which can worsen muscle tension as well as nervous tension and anxiety. Lack of B vitamins can make it harder for the liver to handle estrogen (important with a number of pelvic pain conditions), and B6 in particular is required for production of good prostaglandins that have relaxant and anti-inflammatory effects. Too many simple carbohydrates and sugar can contribute to indigestion, leaky gut (damage to the lining of the gut), a suppressed immune system, and candida overgrowth. These all mean more inflammation, which can trigger increased pain or symptoms.
FOCUS ON ANTI-INFLAMMATORY FOODS
The good news is there are still lots of delicious, satisfying and nourishing foods left to eat – really! With the right guidance, you will find an elimination diet isn’t the imagined journey of utter deprivation, but leads to discovering and enjoying new foods, losing old cravings, and learning to easily make healthy substitutions. Foods that are well tolerated can be eaten again after only a few weeks.
A focus on choosing mostly whole, nutrient dense, organic foods when possible reduces exposure to toxic chemicals, pesticides and added hormones, so the best choices are:
A basic elimination diet is a great start to tackling your pelvic pain. There are growing resources available via books, group programs, and personal nutrition coaching to lead you through the process, but it’s always best to work with someone who understands pelvic pain conditions and can develop your personalized nutrition plan based on your particular genetic makeup, pelvic pain symptoms, and other health conditions and treatments you’re undergoing, especially in working to identify any personal food sensitivities and recommendations that are outside of a basic elimination diet.
A few examples of how we would tailor a pelvic pain nutritional program would be to also test removing additional foods that are known to increase symptoms for specific conditions:
Resources
Cohan, Wendy, RN, The Better Bladder Book. 2011
Morrison, JA, Sullivan, J. A novel approach to treating endometriosis. Alternative & Complimentary Therapies, August 1999, p 225-229.
Petrelluzzi KF, Garcia MC, Petta CA, et al. “Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain.” Sep;11(5) (2008): 390-7. doi: 10.1080/10253890701840610.
Segersten, Alissa and Malterre, Tom, MS, CN, The Elimination Diet. 2015
BIO
Susan Tessman is a Certified Nutrition Coach, and Certified by the Integrative Women’s Health Institute as a Women’s Health and Nutrition Coach, with specialized training in chronic pelvic pain, hormone health and pre-conception health. She is dedicated to supporting women suffering with pelvic pain conditions, using a whole person approach that includes nutrition and lifestyle solutions. For more resources on endometriosis and pelvic pain please visit www.susantessman.com
At that time there was much less access to information on complementary therapies for pelvic pain, but I learned as much as I could about a holistic approach for treating endometriosis and other pelvic pain issues that I developed. I followed specific dietary recommendations along with addressing other lifestyle factors like exercise, sleep, and mind-body practices and had regular treatment with pelvic floor physical therapy, acupuncture and massage therapy. It took trial and error to learn what worked best for my body, but I had great results in managing my health outcome.
Most of the time there’s not a magic bullet cure for pelvic pain - it takes an integrated and multi-disciplinary approach to support sustained healing. Whether you suffer with painful bladder syndrome, pelvic floor dysfunction, endometriosis, irritable bowel syndrome (IBS), vulvodynia, or other sources of chronic pelvic pain, nutrition can be used as an additional therapeutic tool to improve these conditions, and to heal co-existing health issues that can increase pelvic pain.
NUTRITION AND ROOT CAUSES OF PELVIC PAIN
When working with nutritional therapy for pelvic pain we want to consider what some of the root causes and triggers might be. It’s estimated that the breakdown of sources of chronic pelvic pain are approximately 37% gastro-intestinal, 31% from urologic causes, 20% reproductive system, and 12% musculoskeletal.
Studies have shown that chronic pelvic pain is frequently associated with systemic inflammation, including autoimmune diseases. (2)
A 2002 study reported in the Sept. 27th issue of Human Reproduction (3) concluded that hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma are all significantly more common in women with endometriosis than in women in the general USA population.
Vulvodynia is associated with other chronic comorbid pain conditions such as fibromyalgia, interstitial cystitis and irritable bowel syndrome, individually and in combination, and the presence of vulvodynia or any of the other comorbid pain conditions increases the likelihood that a woman will have one or more of the other chronic pain conditions. (4)
If you suffer with multiple health issues, nutritional therapy can not only address the pain symptoms, but can also support healing in other inter-related body systems that can be impacting your pelvic pain. The right nutritional shifts can correct digestive disorders, improve the healthy balance of gut microbiota and ability to absorb healing nutrients, bring hormones and blood sugar levels into better balance – all of which can impact pain levels, support your recovery from surgery and medical procedures, and help to down-regulate the nervous system so pain response is not as intense.
ELIMINATION DIETS TO DECREASE INFLAMMATION AND PAIN
To begin to address pelvic pain symptoms, a personalized elimination diet is an important tool. What exactly is an elimination diet and why do we use it?
Most people are familiar with food allergies and how potentially deadly they can be. A food allergy reaction occurs when your body recognizes a certain food as harmful and produces an immune response to that food, which can result in severe symptoms. Antibodies produced in the allergic response (most commonly IgE antibodies) will show up on a food allergy test. 8 food groups have been identified as causing 90% of all IgE food allergies in the U.S.: Milk, eggs, fish, shellfish, wheat, soy, peanuts, and tree nuts.
But many of these same foods also cause reactions that may not produce IgE antibodies, but do cause other immune responses, and these reactions are referred to as food sensitivities or intolerances. A common example of this would be having “lactose intolerance” where you’re lacking the enzyme needed to properly digest this milk sugar. These kind of responses are often delayed and not always as obvious to detect. Symptoms of food intolerances can include digestive problems like bloating, cramping, constipation, diarrhea; headaches; sinus problems; unexplained weight gain; fatigue; skin conditions; and increased pain anywhere in your body.
You can imagine if you’re eating poorly tolerated foods over and over again, and each time your body is having a reaction, that this can lead over time to a chronic state of low-grade inflammation, as the immune system is always being activated. And once inflammation is ongoing, it can also lead to developing even more food intolerances, so a very negative cycle of inflammation is set up, and symptoms increase.
Testing for allergies and food intolerances can be extremely helpful, but tests are not always completely accurate, and can be expensive, so using an elimination diet can be another effective method to help identify these possible food sensitivities. One of the main goals of using an elimination diet with pelvic pain conditions is to calm down and reduce the inflammation cycle and resulting pain and symptoms, and allow the body to rest and heal.
ELIMINATION DIET BASICS
The nutritional advice I followed over 20 years ago for my pain was to stop eating dairy, wheat and sugar (and processed foods in general) and focus on whole foods. I’ll admit it wasn’t a total breeze at first! Those three food groups are still considered top of the list to avoid to reduce many disease or pain states, including pelvic pain conditions. But in a full elimination diet protocol we include all of the main “allergenic” foods: dairy, gluten, corn, shellfish, soy, eggs, peanuts, tree nuts as well as alcohol and caffeine. Some people may also need to remove nightshades, citrus fruits and sometimes even non-gluten grains and/or legumes.
These foods are removed for 3 to 4 weeks, and at the end of that time you add back only one of the eliminated food groups at a time, eating 2-3 servings per day for 3 to 4 days, making note of any symptoms that arise and then breaking from that food to let the symptoms resolve. The following week you try reintroducing the next food. For those foods you identify as having a reaction to, it’s a good idea to then stay off of them for at least 3 to 6 months, if not longer, to allow for full healing before trying to introduce them again. Many people choose to permanently remove certain foods because they experience such improvements in their health.
When people first think about removing these foods from their diet, especially dairy, gluten and sugar, it can be overwhelming to say the least, because these foods have become such a huge part of the standard North American diet. It helped me stay motivated when I understood a little more of the “why” -
Dairy: Lactose is a sugar in cow’s milk, and casein is the protein found in cow’s milk. People can be sensitive to either or both. Many people who are gluten intolerant are also casein or lactose intolerant. Gluten can damage the part of the intestine that is responsible for producing the enzyme lactase, which is necessary for breaking down lactose. About 75% of adults worldwide are lactose intolerant, and don’t have the digestive enzymes needed to digest this milk sugar, and that means digestive distress. Dairy products are also a dietary source of arachidonic acid, the fat used by the body to produce “bad” prostaglandins, localized hormones which can increase pelvic pain, cramps, and inflammation.
Gluten: Gluten includes several related proteins found in wheat and other grains including spelt, kamut, triticale, barley and rye. It’s estimated that approximately 30 to 40% of the U.S. population has some sensitivity to gluten, in addition to those diagnosed with full blown autoimmune celiac disease. Non celiac gluten sensitivity can over time result in damage to the intestinal lining or mucosa, that then allows undigested food proteins to “leak” through the gut wall into the bloodstream, which can trigger pain, inflammation and autoimmune responses. Even among people who are not sensitive to gluten, eating it triggers the release of a protein produced in the small intestine called zonulin, which again can lead to damaged intestinal lining. Gluten expert Dr. Alessio Fasano has stated that nobody digests these proteins well, and because of this it tends to trigger an inflammatory response.
Gluten intolerance has also been linked to altered estrogen levels. In a 2012 study on women with severe painful endometriosis-related symptoms over 12 months, 75% of the over 200 participants reported statistically significant improvements in painful symptoms when eating gluten-free. (5)
Sugar: Sugar depletes the body’s B complex vitamins and minerals which can worsen muscle tension as well as nervous tension and anxiety. Lack of B vitamins can make it harder for the liver to handle estrogen (important with a number of pelvic pain conditions), and B6 in particular is required for production of good prostaglandins that have relaxant and anti-inflammatory effects. Too many simple carbohydrates and sugar can contribute to indigestion, leaky gut (damage to the lining of the gut), a suppressed immune system, and candida overgrowth. These all mean more inflammation, which can trigger increased pain or symptoms.
FOCUS ON ANTI-INFLAMMATORY FOODS
The good news is there are still lots of delicious, satisfying and nourishing foods left to eat – really! With the right guidance, you will find an elimination diet isn’t the imagined journey of utter deprivation, but leads to discovering and enjoying new foods, losing old cravings, and learning to easily make healthy substitutions. Foods that are well tolerated can be eaten again after only a few weeks.
A focus on choosing mostly whole, nutrient dense, organic foods when possible reduces exposure to toxic chemicals, pesticides and added hormones, so the best choices are:
- free range, grass fed meats, wild game, and wild-caught salmon
- a wide variety and rainbow colors of veggies
- gluten free grains - quinoa, millet, amaranth, tapioca, rice, sorghum
- nuts and seeds - coconut, pine nuts, chia seeds, almonds, brazil nuts, walnuts, pecans, nut flours, and meals
- legumes
- whole fruits, especially berries
- healthy fats from olive oil, coconut oil, avocados, ghee, and nut oils
- fermented foods like water kefir, sauerkraut, kim chee, other fermented vegetables
- herbs and spices
- beverages - water, broths, un-caffeinated herbal teas, mineral water, diluted juices, vegetable juices, coconut and other non-dairy milks
- sweeteners (to be used sparingly!) - brown rice syrup, raw honey, stevia, fruit sweetener, blackstrap molasses
A basic elimination diet is a great start to tackling your pelvic pain. There are growing resources available via books, group programs, and personal nutrition coaching to lead you through the process, but it’s always best to work with someone who understands pelvic pain conditions and can develop your personalized nutrition plan based on your particular genetic makeup, pelvic pain symptoms, and other health conditions and treatments you’re undergoing, especially in working to identify any personal food sensitivities and recommendations that are outside of a basic elimination diet.
A few examples of how we would tailor a pelvic pain nutritional program would be to also test removing additional foods that are known to increase symptoms for specific conditions:
- for women with vulvodynia, avoiding foods that are high in oxalates may reduce symptoms. Some higher oxalate containing foods include spinach, soybeans, grains, legumes, potatoes, almonds, cashews, rhubarb, raspberries, chocolate
- for sufferers of interstitial cystitis/painful bladder syndrome avoiding foods like citrus juices, coffee, alcohol, and spicy foods that can cause bladder irritation may be very helpful
- in treating endometriosis, we emphasize the balancing of excess estrogen which can fuel the growth of the disease, by removing inflammatory foods and products that tend to imbalance estrogen levels, and emphasizing detoxifying veggies, fruits, fiber and supplements as part of a comprehensive approach to pain reduction and hormone balancing
- Lark, Susan M., M.D., Fibroid Tumors and Endometriosis Self Help Book. 1995
- J Reprod Med. 2005 Oct;50(10):745-758
- Human Reprod. 2002;17(10):2715-2724
- Reed BD, Harlow SD, Sen A, Edwards RM, Chen D, Haefner HK. Relationship Between Vulvodynia and Chronic Comorbid Pain Conditions. Obstetrics and gynecology. 2012;120(1):145-151. doi:10.1097/AOG.0b013e31825957cf.
- Marziali M, Venza M, Lazzaro S, et al. “Gluten- Free Diet: a new strategy for management of painful endometriosis related symptoms?” Minerva Chirurgica. Dec; 67(6) (2012): 499-504
Resources
Cohan, Wendy, RN, The Better Bladder Book. 2011
Morrison, JA, Sullivan, J. A novel approach to treating endometriosis. Alternative & Complimentary Therapies, August 1999, p 225-229.
Petrelluzzi KF, Garcia MC, Petta CA, et al. “Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain.” Sep;11(5) (2008): 390-7. doi: 10.1080/10253890701840610.
Segersten, Alissa and Malterre, Tom, MS, CN, The Elimination Diet. 2015
BIO
Susan Tessman is a Certified Nutrition Coach, and Certified by the Integrative Women’s Health Institute as a Women’s Health and Nutrition Coach, with specialized training in chronic pelvic pain, hormone health and pre-conception health. She is dedicated to supporting women suffering with pelvic pain conditions, using a whole person approach that includes nutrition and lifestyle solutions. For more resources on endometriosis and pelvic pain please visit www.susantessman.com
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