A gluten-free diet for endometriosis patients lacks evidence to recommend it

Abstract

Endometriosis, an estrogen-dependent chronic disease that is characterized by the presence of endometrium-like tissue outside the uterus, is often associated with symptoms like dysmenorrhea, dysuria, dyschezia, chronic pelvic pain and infertility. Women diagnosed with endometriosis can also report gastro-intestinal symptoms, including bloating, constipation or diarrhea and abdominal cramping, that can be associated with Irritable Bowel Syndrome (IBS) and can result in misdiagnosing endometriosis as IBS at first. Treatment usually involves hormonal therapy, pain management, surgery and/or assisted reproductive techniques in case of infertility. Nonetheless, these treatment methods can be insufficient in alleviating symptoms, or can cause unacceptable side effects leading to non-compliance. Therefore, women often apply self-management strategies including dietary interventions. One of the diets frequently suggested as a tool to manage endometriosis-related symptoms on social media and patient forums, is a gluten-free diet. While a gluten-free diet has been proven effective in managing non-celiac wheat sensitivity or celiac disease, its effectiveness for endometriosis remains uncertain. The Nurses’ Health study II found it unlikely that gluten intake was a strong factor in endometriosis etiology and symptomatology. The most frequently cited and sole published intervention study, to our knowledge, on the efficacy of a gluten-free diet for endometriosis has several important limiting factors, including the absence of a control group. Additionally, gluten consumption is highly susceptible to a placebo- and nocebo effect, where women might experience symptom relief when eliminating gluten, and return of symptoms when they consume gluten again, solely because they believe gluten are bad for them. Despite the inverse association between BMI and endometriosis and between a gluten-free diet and increased BMI, this is an association and no causality was proven. Other factors should be taken into account. Finally, a gluten-free diet is expensive with a limited availability, has a great impact on Quality of Life and without proper dietary guidance may adversely affect the gastro-intestinal microbiome. Therefore, a scientifically substantiated advice regarding the use of a gluten-free diet for endometriosis-related symptoms is currently not available and a gluten-free diet should therefore be discouraged unless there is an additional diagnosis of non-celiac wheat sensitivity or celiac disease.