S2 E1: Nutrition for Endometriosis with Cindy Dabrowska, RD


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Amanda: Hey, this is Amanda, women’s health dietitian.
Emily: And I’m Emily, nutritional therapy practitioner.
Amanda: And this is the Are You Menstrual? podcast where we help you navigate the confusing world of women’s hormones and teach you how to have healthy periods.
Emily: Each week we will be diving into a different topic on women’s health and sharing our perspective using nutrition, female physiology, and metabolic health.
Amanda: Our goal is to help you wade through conflicting health information and empower you on your healing journey.
Emily: We hope you enjoy it.

Amanda: In this episode, we are discussing a heavily requested topic and that’s really nutrition for endometriosis. We’ve had quite a few people reach out. We covered PCOS, we’ve covered painful periods, all that kind of stuff, but endo is really a whole different animal and it’s very specific and that’s why I brought on Cindy Dabrowska to cover this topic with me.

Cindy is a registered dietitian, Master of Applied Nutrition and endo warrior and founder of The Supportive Endo RD. Her passion comes from supporting endo warriors who, much like herself, have said enough is enough to debilitating, life-altering symptoms of endometriosis. She has been blessed to support countless women in her nutrition counseling practice through a functional medicine root cause approach to endometriosis. And as a, as a registered dietitian and endo warrior herself, Cindy prides herself on being an ally, too, and a resource for the endometriosis community.

So really, our goal is to help you better understand what endometriosis is and then how you can make nutrition changes that are going to positively impact it. And I’m just so happy to have Cindy here with me to chat about this.

Cindy: Likewise. So happy to be with you, Amanda, I’m such a big fan of your podcast and the work that you do.

Amanda: I particularly like the way that you speak about endometriosis. I think it makes a difference because you yourself have it and it’s been, I’m guessing, like, a really big part of your own health journey. Do you want to talk a little bit more about what that’s been like for you? And I’m really curious, like, did you become a dietitian because you had endo or did it just so happen to work out that way?

Cindy: Yeah, I think in part I did become a dietitian to support people with endo. I have one of those journeys where I went to school for something else that I thought I would get into. And I had a change in my mindset and decided okay, what, what can I do as a career that will help people. And nutrition and healthy eating were always a big part in my household growing up. And it’s actually kind of funny to admit, but I didn’t even know what a dietitian was. But the word popped into my head and I started researching what is a dietitian, what does a dietitian do, and then the very next day, I was enrolled in the courses I needed to get into the dietetics program here in the GTA in Canada.

And when I got into my undergrad and my master’s degree, especially my master’s degree, we had a big clinical project. And endometriosis wasn’t on the list of conditions that we could present on. But I requested to present on this topic because despite the fact that there are so many, well, I don’t even know if you can say so many, but there are several options, you know, whether that’s hormone therapy, or, or surgery, or birth control for managing symptoms of endometriosis. I found that diet and lifestyle for me personally had been the most effective and I really wanted to bring that to other people in the community. Especially when I, when I got into my masters that’s when I decided, you know, yes, at some point in the future, or when I become a dietitian, I will launch a private practice in this space. And, and time and time again, I’m proved by my clients and patients that nutrition and lifestyle absolutely does make a huge difference in endo symptom management.

Amanda: When were you diagnosed? Like, tell us a bit, because that’s usually, like, a huge part of the journey for people that are dealing with endometriosis. Did you know when you were in college that you had it? Or did you suspect it?

Cindy: Yeah, so, you know, endo as you described it in your intro is, is a whole different animal, right? Like some, some people experience symptoms, you know, from their first period ever and then others might start experiencing symptoms only into their 30s or following an IVF cycle for example. So I’m one of those people that was symptomatic from my very first period at age 12. Absolutely debilitating periods, heavy to the point where I would faint or vomit from the pain. Pretty much any characteristic symptom of endometriosis that you may be familiar with I have lived with or maybe in part still live with. So, you know, the lower back pain, the cramping pain with ovulation, infertility. You know, and I am always mindful when I speak about the symptoms of endometriosis to not just talk about the physical symptoms, but also how it impacts us, you know, socially and mentally, right. There’s, there’s so much anxiety, depression in this space, you know, in people with endometriosis, and absolutely when you can’t see your friends or can’t see your family because you’re in pain or not feeling well, that will also impact your mental health. So I’m always mindful to mention that.

But anyway, so symptomatic since age 12. And then sadly, I was only diagnosed at 27. So 15 years of living with these symptoms before getting a diagnosis, which is absolutely heartbreaking, not just for me, but the fact that this is the norm. You know, it’s terrible, but this is the norm for people in the endometriosis community. So yeah, that’s, that’s my story. To this day, I still live with pain but it’s very much a manageable type of pain. Sometimes I don’t even have to take pain relieving medications. The one thing about managing endo with, with diet and lifestyle is you absolutely have to be very diligent, right? You have to be mindful of your choices. And as long as I’m doing that I can travel, I can, you know, enjoy social events, and live a relatively normal life, I would say.

Amanda: I’m really happy that you mentioned the mental, emotional aspect of endo. We do have a question about that towards the end. I think the physical symptoms are probably the most, they can feel the most pressing for people, because it’s, they’re debilitating and it impacts your quality of life. But living with those every single day or having them pop up certain times of your cycle, it can be very mentally challenging. And then having the, it’s a chronic illness really is what it is. And so living with that can be very challenging. I’m curious, did you push for the diagnosis? Were you like, I think I have this and then you finally were able to get it?

Cindy: I did push for the diagnosis. So, you know, again, this is another unfortunate thing about living with endo—a lot of people really have to prompt their, their doctors to dig deeper. And I was very, very fortunate, because it got to a point where the symptoms were getting so severe I…so they became severe, I started making changes to diet and lifestyle, because I didn’t really feel, excuse me, like, I was getting the support I needed from my healthcare team. So, you know, I had suspected that I had endo probably for about maybe five plus years before my actual diagnosis, because I started reading about it, researching about it, what it could be. I had a family friend who had endo as well. And basically what I did was I, you know, got online, I researched endometriosis specialists in my area, found one that was accepting new patients, requested a referral from my doctor. Luckily, she was open to sending a referral, which isn’t always the case for some people—their doctors are not open to doing this.

So I got the referral, got to see my surgeon. Shortly thereafter, I think my, my wait time between then and the referral was about one month. And then three months after the initial visit with him, I had my surgery. So it was a very short timeline from when I requested that referral to getting surgery. And that was a really interesting experience too. I had never had surgery before. I’ve never been under anesthesia. And you know what, despite the fact that my symptoms didn’t improve, you know, terribly from the surgery—like, I know some people get quite significant relief from the surgery—the one thing I’ll say did improve for me was pain with intercourse because I did have a big nodule of endo on my cervix. So that improved because that was removed. But despite the fact that I didn’t have, like, you know, significant improvements in pain, for example, it was priceless to know that I wasn’t crazy all these years and that I did in fact have endometriosis. That meant more to me than, than anything.

Amanda: I feel like just knowing what’s going on so that you can actually say, okay, this is what’s going on with me. Yes, obviously, we do need surgery to diagnose it, although, I know, like, some experts are using certain types of, like, more advanced ultrasounds now, but typically, it’s surgery, right? And then they, they’re doing, they’re exploring and then they’re typically going to do the excision and remove the lesions right then and there. But it can be really hard, you know, that recovery time, kind of depending on what you have going on, where the lesions are, are they on your bowel, you know, it’s pretty, it can be like pretty intense. And I think something that most people don’t realize. That’s interesting that you say that you didn’t have a ton of pain relief after, minus obviously, like, less pain with intercourse which is going to be beneficial. But I usually hear that people, a lot of my clients have done really well after, but then it’s like six months later, the symptoms are starting to come back, you know, unless you’re managing it with nutrition and lifestyle.

Cindy: Exactly. And unfortunately all the options that are available to us, they don’t address the full picture, right? Like, if you have, like, systemically if you’re producing a lot of these inflammatory chemicals, then cutting out some endometrial-like, tissue may not make the biggest impact. And then for others, it does make a big impact, right? So it’s very much an, an animal, like you described it—it’s hard to understand, it’s hard to address.

Amanda: And we need a lot more research on it. There’s just not enough out there. And a lot of women are struggling with this. It’s, it’s super undiagnosed, obviously easier to get a diagnosis now, because it’s somewhat more well known. But, you know, you could get that diagnosis, but you might not have a great, like, expert surgeon near you. I know so many people that travel across the country to go see a surgeon to get their excision surgery.

So before we get into the nutrition stuff, now that we’re kind of digging a little bit more into endometriosis, can you talk about the four hallmarks of endometriosis? And maybe just, like, what is it in case someone isn’t familiar.

Cindy: So endometriosis is a condition where tissue that is similar to that which lines the uterus grows outside, you know, in various parts of the body, on organs in the abdomen, it’s actually been found really everywhere in the body at this point. And it behaves similarly to that tissue of the, of the uterine lining, so it bleeds when we menstruate. And the problem is that it doesn’t have anywhere to go, right, because it’s now outside of the uterus, and it basically bleeds into the abdomen or wherever it is located. And that can form scar tissue, cause, you know, debilitating pain, impact fertility.

And in terms of the hallmarks, so we know that there’s a major immune system dysfunction piece with endometriosis. So what this means is that, you know, we’ve got a number of immune cells, the cells of the immune system. And basically, in short, with endometriosis, these immune cells are not doing what they’re meant to do in a normal healthy body. So, you know, for example, they may be clearing away some of the endometrial-like tissue, but they’re not functioning to the same degree as somebody who doesn’t have endometriosis, for example. So then you get this establishment of the endometrial-like tissue and then proliferation of the disease.

Then you’ve got the hormonal piece. So this is kind of, I guess, two, two-pronged—you’ve got estrogen dominance and you’ve got progesterone resistance. So estrogen dominance, we know that endometriosis is an estrogen-dependent condition. The tissue itself in some people can be a source of estrogen as well. So it’s almost like, like a self-sustaining disease in a sense. It’s, it’s, we also see a lot of genetic mutations in people with endometriosis that hinder things like methylation, for example, which then cause estrogen to build up and be a source of inflammation. And, you know, things like histamine, for example, which I think we’ll be talking about later on.

We also know that there’s this predisposition to higher aromatase activity. So aromatase is that enzyme that converts androgens like testosterone into estrogen. So we have a an upregulation, so more of this aromatase activity. So this is another source of estrogen in people with endometriosis. And then with progesterone resistance, you know, some people are producing sufficient amounts of progesterone, but those receptors are just not computing. They’re just not getting that signal, and so you end up with a lower amount of progesterone. So, you know, you can have hormonal imbalances in a number of different ways. You can have, you know, normal estrogen, low progesterone; you can have high estrogen, normal progesterone. And there’s another one but I’m losing my… what did I say? High estrogen, low progesterone; you can have normal estrogen, low progesterone; and then you can have normal progesterone, high estrogen. I think that’s, that’s, what I was saying. So, you know, and, and we know that progesterone is so important for, like, mental health and sleep quality and reducing anxiety, which are all things that people with endo are plagued by. And then those estrogen dominance symptoms, right, the heavy clotting, bleeding, inflammation, breast tenderness, trouble sleeping, bloating, like so many of these symptoms are associated with these hormonal imbalances.

And then with inflammation, I mean, at any time this tissue, this endometrial-like tissue prompts an immune response, you have inflammation because that’s a normal part of your immune response. It creates a little bit of inflammation. So it is this sort of cyclical inflammation that’s happening every time, you know, we menstruate or ovulate for example, in some people. And there’s a number of different sources of inflammation in people with endometriosis, whether directly or indirectly related to endo.

So, you know, we know that people with endo are predisposed to having a dysbiosis in the gut and imbalance between commensal and opportunistic strains. Or higher numbers of pathogens which can all be inflammatory. I previously already mentioned that we’re predisposed to genetic mutations that make things like methylation a lot harder. So if we’re not methylating properly, we’re going to get a buildup of estrogen. And that can act as a source of inflammation. You know, the low progesterone as well, the changes in cortisol, and cortisol helps us regulate inflammation. So a lot of the things that are kind of indirectly related to endo like poor sleep quality or irregular meals, all can impact the cortisol levels, which, in turn, will, will prevent regulating inflammation.

So I mean, there’s, there’s way more ways than that as well. And then we’ve got angiogenesis, so that formation of new blood vessels to endometrial-like tissue, that’s a big hallmark as well. So I don’t know what more to say about that. But there, the tissue comes in many different colors. When it’s red and bright, we know that it has, you know, vasculature or blood supply. So naturally, in order for it to get to that state, it does need to have blood vessel formation. So if we can stop that, and there are things that we can do through diet and supplementation that, that can slow, I guess, the formation of these blood vessels. So those are the four hallmarks.

Amanda: It’s just helpful for people to know, because when you think of endometriosis, especially if you haven’t, like, maybe you haven’t ever heard of someone with a more functional approach talk about it, right? Like, they’re not, they’re, they’re really treating it as a hormone issue, right? It’s, but it’s really, it’s so much more than that. Like, just how the immune system functions differently when you have endometriosis, and then how we don’t, it’s not just estrogen, we also have this progesterone resistance. And then all these triggers for inflammation that are much more likely to be happening genetically and also in your day-to-day life. I mean, it’s just, it’s pretty wild, when you’re laying it all out. And like, it really does all feed into each other. Which it’s, it’s like, it makes sense. But it can, I get that it can be hard for people to kind of wrap their heads around.

So the goal is just understanding, like, here’s what endometriosis is, here are the different hallmarks of what can be impacting the growth, how you’re feeling, your symptoms, pain, all those different things. And I think it’s important to know that if you want to address it nutrition, lifestyle-wise, right, because how are you going to…you can’t just address the hormone piece. We know, okay, like, we have to look at immune system and inflammation. And I feel like what comes with that is really digestion. That’s probably one of the biggest areas I focus on with women with endometriosis. And I’m really curious, like, what’s your take on how endometriosis impacts digestion. I know you talked a little bit about gut bacteria.

Cindy: I feel like this podcast is going to be either overwhelming or super informative for somebody who’s just beginning their journey with endo or maybe suspects endo. But there’s a, you know, a long list of ways that endometriosis impacts digestion. A couple of these I already mentioned, so dysbiosis, right, this imbalance in the gut. So there is research that exists that has been done on women with endometriosis showing that, you know, we’re predisposed to having higher numbers of inflammatory species, streptococcus, staphylococcus, E. coli, for example. So that might not mean anything to anybody listening to this, but higher numbers of these species that, you know, are irritating to the gut lining. They’re a source of inflammation, they can absolutely cause bloating. So, so that is one way.

We’re also, you know, when you’re not feeling well, when you’re nauseous, when you’re in pain, you are probably not going to be eating regular structured meals. You may, you know, have something in the morning and then you may take a long nap, whatever, whatever your day might look like. And we know there’s a mountain of research about this that, you know, irregular meals spaced, you know, too far apart, not well constructed…you know, this is a risk factor for things like SIBO, small intestinal bacterial overgrowth, or large intestinal bacterial overgrowth or low stomach acid or low pancreatic output. So this is another way that we’re predisposed to poor digestion with endometriosis.

So, as somebody who lives with endo, I know that this is something that’s really hard to accomplish sometimes. So I always just urge my clients and people in my community that, you know, if you can have even like the smallest thing, like some broth or, you know, something like a piece of fruit or some cheese or something, whatever it might be, to do that, right, because something is better than nothing. We’re also predisposed, I kind of alluded to this already, but predisposed to SIBO and things like LIBO and IBS. Although, you know, I have a different opinion about IBS. But you know, we’re predisposed to these things for a lot of the same reasons that I already mentioned with the irregular meals, right? If the motility is not functioning well, that’s going to be a big risk factor for SIBO. Surgery is a risk factor for SIBO. Surprisingly, I actually have a handful of clients who develop SIBO following their laparoscopy. So, you know, this is another thing.

And inflammation, like, if we’re inflamed, if we’re chronically inflamed, the body’s gonna adapt by diverting a lot of fuel to fueling that inflammatory response. So this may correspond to slow digestion and may correspond to, you know, progesterone deficiency, you know, deficiencies in other hormones. So if you’re not getting appropriate fuel to the digestive tract, this is going to impact things like stomach acid, it’s going to impact things like motility, you probably won’t even properly be absorbing the nutrition from your food, right? So you’re not getting the tools that your body needs to heal and to support healthy digestion and healthy hormone balance.

And you know, what, we’re not eating regular meals when we’re feeling nauseous, when we’re inflamed. We’re likely not getting in…. again, I think I’m repeating myself a little bit, but we’re not getting in cofactors and nutrients we need for things like stomach acid production or pancreatic output, right? And, and for anybody who doesn’t know what that means, your pancreas is, has so many roles, but one of those is producing our enzymes, right. So if you’re not producing enough of these enzymes, then you basically, you’re not properly breaking down your macronutrients—your carbohydrates, fats, and proteins. And then these things can contribute to a lot of bloating, loose stools, chronic constipation, undigested food in the stools, low stomach acid, and, you know, the list goes on. So I don’t know if that was a comprehensive list or not.

Amanda: And I mean, it’s like, we can’t cover everything in this episode. So please do not feel pressured to teach everyone everything about endo. We will, I’m sure that we’ll get questions and we can expand on certain topics and have you back on.

I think it’s just, I think the digestive piece is not highlighted enough. Because when you think about it, if you, if you’re going to your doctor, it’s, like, your options are sometimes surgery, sometimes they just recommend going on something like hormonal birth control or a hormonal IUD to manage it and digestion might not even be brought up to you. And then if you’ve been living with this your whole life, or at least since you’ve been menstruating, then you might not know that all these things aren’t normal with digestion. Like, I have a lot of clients that have lots of, like, the endo belly that bloat, right. And they’re also dealing with constipation. And they don’t know that, oh, it’s not normal to not have a bowel movement every day? Like I thought that was normal. And so even I think just bringing awareness to this and that, hey, if you have endometriosis, digestion is a huge thing that hopefully you’re paying attention to.

What are some things that you like to do to help your clients support their digestion?

Cindy: I’m finding in a lot of my clients that the stomach acid is very low, which makes a lot of sense to me logically because of the inflammation. So supporting that stomach acid whether you’re doing digestive bitters or you’re doing a stomach acid replacement. This, the stomach acid replacement I only do in very, very, like, severe cases. I have one client who is producing almost no stomach acid. It’s terrible, and she had recurrent SIBO for years and years and years. So finally we’ve got her on a good track. But that’s one thing that’s really important to, to assess and to address. And I find that even just the simple intervention makes a world of difference for the digestion and the bowel regularity and just absorbing nutrition from food.

The regular structured meals are so important, so getting a foundation in there. The thing with diet and endometriosis is it’s not just about getting in diversity and getting in…well yeah, basically diversity in your diet…it’s also about absorbing that diversity. Like, if you’re somebody with chronic loose stools, like, we need to address those loose stools because your, your food is running through you too quickly and you’re not absorbing this nutrition, right? It’s not, it’s not helping. I mean it may help a little bit if you increase the, the diversity in your diet, but ultimately we need to address those loose stools, we need to get you actually absorbing that nutrition properly.

You know, sometimes I do GI protocols so that might be, you know, if I’ve done testing with somebody and you have SIBO that, you know, involves some motility support, it involves some antimicrobials or overcrowding with, you know, a tailored probiotic regimen if somebody has large intestinal bacterial overgrowth, so that’s another way that we support digestion. I mean, hydration is super important for digestion.

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Amanda: I mean, I feel like even the hydration, some sort of digestive bitters, or some, some, like, stomach acid support like that. And then the regular meals, like, they’re small things, but they’re probably also things that—if you’re dealing with endometriosis—you could be struggling with, and maybe not necessarily putting a ton of emphasis on because you just don’t know that that’s the thing that’s gonna move the needle. And that’s why it’s, like, it’s so important to know, like, okay, so if, if this plays a huge role, like, think about it. If, if you have, the more digestive issues you have the more inflammation in your gut, the more stressed out your body is going to be, cortisol goes up, estrogen goes up, endo grows, right? Inflammation is going to drive the immune system. Everything’s kind of feeding into itself. So I love starting with digestion for people with endometriosis, because it’s one of those things where I’m like, this will probably get you feeling better the quickest. And it’s, like you said, we have to absorb the foods that we’re eating. We can eat the most beautiful nutrition foods, nutritious foods ever. And if we’re not absorbing them, like, it’s not necessarily going to help us long term.

And then of course, like, with a lot of I’m sure a lot of your clients, you have to go deeper. Like, I love GI map stool testing to look at deeper, some of those, like, types of bacteria and pathogens that you recommend. But a lot of people want to do the fancy stuff, right? They want to jump immediately to the crazy gut protocols, the super intense stuff, and they skip those foundational steps that I feel like are just so important.

Cindy: Yeah, absolutely agree. And I start with digestion as well. I feel like if you’re somebody who’s chronically constipated or having loose stools, I’ve seen it time and time again in my clients, that is an incredibly impactful intervention to getting you feeling better the fastest. I totally agree with that. And yeah, I love the, the GI map as well. I think, especially if you’re somebody who has taken, you know, antibiotics in high amounts at some point in your past, then it’s great to see if you’re missing some diversity in the gut. And then you can create a tailored approach.

Amanda: And knowing, like, a lot of people ask, like, what kind of probiotic should I take? Do I need a probiotic with endometriosis? Or even without it? So it’s like, and I know you have a really great Instagram post that you did on that. And it’s like, it depends. I hate, people hate the answer. They hate it. But for most things, when it comes to nutrition, it really does depend. So I love that you kind of address that. I’ll have to link that post in here that goes into that more, because you even had, you broke down, like, the different types of probiotics for different things. I think it’s eye opening for people to know, like, I shouldn’t just blindly take supplements because someone else with endo took it and it worked for them.

Cindy: Absolutely agree with that for sure. Probiotics, I mean, because we know that a big chunk of the immune system is located in the gut. It’s not a terrible choice of supplements to take, but why take it if you don’t need it. Like, if the diet is sufficient in dietary probiotics if it’s nice and varied in color and diversity in plant foods, then, you know, you may not need it. So yeah, I totally agree for sure.

Amanda: So I’m curious… Let’s go a little bit more into the nutrition piece, because with any health condition, whether it’s something like PCOS, endometriosis, like, like you mentioned SIBO, small intestinal bacterial overgrowth, thyroid issues…there’s always some, like, matching diet, right, that people are recommending or foods that you should avoid if you have x, y, and z. One thing with endo and I love, I, when I was like going through your website and obviously I follow you on Instagram so I know like your approach with this. But I really love that you specifically say that you don’t feel that women need to remove, you know, gluten, dairy, soy, red meat, alcohol, caffeine, sugar, all the things. I mean, if you have endo and you go online and do a Google search or go on Instagram, you’re gonna think you can’t eat anything. So what is your approach when it comes to foods like this? And how do you kind of work that through with your clients?

Cindy: You know, we’ve already alluded to this a number of times that endo is extremely complicated. So wouldn’t it be nice if we could just cut out a couple of foods? And you kno

Amanda Montalvo

Amanda Montalvo is a women's health dietitian who helps women find the root cause of hormone imbalances and regain healthy menstrual cycles.

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