EP.371/ Study Spotlight: Can Lowering Gluten Intake Improve Pain and Quality of Life with Endometriosis?

Podcast

14 Nov

Today we’re continuing with our Study Spotlight Series on the study Dietary Modification and Supplement Use For Endometriosis Pain.

For those who need a recap of this study, go to episode 365.

Today we’re looking at the dietary intervention of removing gluten. The study found that out of those who tried reducing or eliminating gluten, 45% experienced a reduction in pain.

So, remember that there are limitations to this study. There is the possible placebo effect, where these patients may have expected to feel better from removing gluten and so they therefore did. There’s also a lot of variables - for example, did some people swap gluten for a lot of processed, gluten free products that could actually spike blood sugar, raise inflammation and even negatively affect the gut microbiome. And in contrast, were there some who instead swapped gluten for more whole food carbohydrates, such as more grains, beans and root veggies, as an example. We also don’t know how long these participants followed the gluten free diet, it could have a been a week for some, and a month for others and so on. There are also other variables that could have made a difference for each individual - for example, because of the high risk of celiac disease in the endo population, there’s a chance that some of these participants had undiagnosed coeliac disease and therefore felt improvements from removing it, others may also have IBS, and therefore have improvements from that (which I’ll talk about more later) and some may also have non-coeliac gluten sensitivity or a wheat sensitivity. So you can see why for some, the intervention could be more effective than others.

But are there any other studies on gluten and endo? Not many, but we do have some.

The most recent study we have (aside from the one we’re actually talking about today) is a qualitative interview study. This study interviewed 12 endometriosis patients who had made dietary changes, these patients removed or lowered gluten, dairy and increased fruit, vegetables and fish. The patients reported a decrease or entire disappearance in pain, and improvements in gut health, with patients reporting more normalised bowel habits, a calmer gut, and a reduction in swelling and gas. They also reported better energy levels, better sleep, shared that they could do more normal day to day tasks, they felt healthier overall and more “normal”, had better mental health, took less sick days from work and also had a reduction in allergic type symptoms like nasal congestion and rashes.

Now, some limitations we should be aware of is that the study was small, it was an interview study rather than a double blind study where there is a control group and participants don’t know whether they’re trying the treatment or a placebo, and these participants also made other changes aside from lowering gluten, like increasing fruits and vegetables. That doesn’t mean that lowering gluten didn’t help, we just need to consider all these factors and that other things may have played a role too.

A 2012 study looked at 207 endo patients with severe pain symptoms. The participants were assessed for their symptoms and put on a gluten free diet for 12 months, and afterwards, they were reassessed. The researchers found that 75% experienced a significant improvement in pain, with 25% reporting no improvements. However, all patients reported improvements in mental health, physical functioning, social functioning, vitality and general perception of health.

A limitation of this study however, is that there was no control group, which is what we want for a good quality study, so that we can compare how those who didn’t follow the gluten free diet responded. Without this, we can’t be sure whether some of this was related to the placebo effect.

And finally, we also have a study from 2011. This study assigned some of the participants to a gluten free diet for 1-3 months, and others were not assigned to a gluten free diet. Following the avoidance of gluten, the patients symptom scores were reassessed and it was found that those who followed the gluten free diet had a 50% reduction in pain and had a greater improvement in wellbeing than those who did not remove gluten.

Now, despite these positive studies, a recent 2024 paper concluded that there was not enough evidence to recommend a gluten free diet for endometriosis, and actually recommended against it, because it’s expensive, can be hard to do due to availability of gluten free foods, can limit quality of life due to restriction, and may negatively affect the gut microbiome because in some cases and studies, those who follow a gluten free diet end up eating less fibre and less quality foods.

A September 2023 narrative review also concluded similarly, detailing that there was not enough evidence from these studies or high quality studies, and that placebo effects could have influenced the findings. They also referenced that a gluten free diet may cause an impaired quality diet and quality of life.

Both of these papers also reference The Nurses Health Study II, which is an extremely large cohort of 116,430 participants that looks at risk factors for the most prevalent chronic diseases in women. This study found that there was “little to no evidence” on gluten and endometriosis risk or symptoms. However, it’s worth noting that despite its size, the Nurses Health Study also does have its own limitations because it is an observational study that relies on participants memories and ability to accurately self-report, and just like the study we’re looking at today “Dietary Modification and Supplement Use For Endometriosis Pain”, there are many variables because it’s not a randomised, double-blind, controlled study where the variables are tightly managed. That doesn’t mean that the conclusions aren’t accurate, but we should be aware of the limitations.

Now, despite there being no definitive link, and despite the limitations, the general trend we’re seeing in research that has been done and that I certainly see in my clients, is that some of us may benefit from reducing or removing gluten from our diet.

So why may that be? Here’s my theories on why lowering gluten could help for some of us…

Celiac disease

Research has identified an association between endometriosis and coeliac disease. Coeliac disease patients were found to be almost twice as likely to develop endo in research and studies have found that people with endometriosis are significantly more likely to develop coeliac disease.

To add to that, coeliac disease is a co-condition of small intestine bacterial overgrowth, which is a condition where normal bacteria which should be found in the large intestine, are growing in the small intestine. And SIBO is at present, estimated to affect up to 80% of people with endometriosis.

Now, many people think that you would know about it if you had coeliac disease, but actually, in the UK, only 30% of people with coeliac disease have been diagnosed, and it is estimated that 500,000 people are walking around with undiagnosed coeliac disease, and in America, 83% of people with coeliac disease are undiagnosed.

So, it’s possible that some of the participants in the studies and just within the endo population generally, have coeliac disease, and so removing gluten can improve quality of life, pelvic and abdominal pain, bloating, IBS symptoms, mental health, etc.

IBS

People with endo are three times more likely to also have IBS in contrast to those without endo.

And as we just discussed, there’s also an association with endometriosis and SIBO, yet emerging research is indicating 60-70% of IBS cases are caused by SIBO. So, whether we have IBS or SIBO, or maybe both, is currently to be debated, but what is clear is that the low FODMAP diet can be effective for reducing the symptoms of IBS, and in some cases, SIBO too.

Its effectiveness for IBS varies in the studies, but it can be as high as 75% or even 85%, but in others, closer to 50%.

However, it also seems to be an effective treatment for people with endo and gastrointestinal symptoms.

For example, in a study from May 2025, 60% of people with endometriosis and gut symptoms saw improvements after 28 days on a low FODMAP diet. Those who saw improvements reported an increase in quality of life and a reduction in bloating, abdominal pain and improvements in stool form. They also scored better on the Endometriosis Health Profile Questionnaire.

Then, another study from April 2025, found that after following a low FODMAP diet, 65% of people with endometriosis saw a reduction in chronic pelvic pain and significant improvements in sex, work, emotional wellbeing, self-image, and sense of control. Constipation and bloating also improved, with 53% reporting less bloating.

And lastly, in 2017, in a study of people with endometriosis and IBS, 72% saw a 50% or higher improvement in bowel symptoms — compared to 49% of those with IBS alone.

So why does this matter with gluten? Because wheat contains fructans and galacto-oligosaccharides (GOS), types of FODMAPs. So, it’s possible that the removal of these or at least the reduction, could have improved endometriosis pain due to the positive effects on IBS/SIBO.

IBS is also associated with microbiome disturbances, which could further aggravate endometriosis based on the research we have behind microbiome alterations and endometriosis development, so calming IBS could help improve the microbiome and intestinal inflammation, possibly leading to improvements in endo pain due to the microbiome connections. Though it’s worth mentioning that long-term use of the low FODMAP diet can negatively affect the gut microbiome.

Leaky gut and LPS

Which leads me onto the general effects of gluten on the gut. Gluten contains a protein called gliadin, and research has shown that even in people without coeliac disease, gliadin triggers an increase in zonulin, which weakens the intestinal barrier. Over time, this can cause leaky gut. The research indicates that this reaction is more likely or more pronounced in those with non-coeliac gluten reactivity, those with wheat sensitivity, autoimmunity and IBS, as well as those who carry the HLA-DQ2 and/or -DQ8 genes.

For those of you who don’t know what I mean by leaky gut, it’s when the intestinal lining that keeps the content of your intestines sealed up, starts to weaken - the tight junctions between cells, which are normally only wide enough for the absorption of nutrients, start to open up, and this allows for small food particles, bacteria, etc. to leak out. Now, when we get leaky gut, what can happen is bacterial and LPS translocation, which basically means, the movement of bacteria and LPS from the gut, through the gut barrier, and out into the blood stream and local area, like the pelvis. Leaky gut has been shown to be a leading cause of LPS translocation.

LPS stands for lipopolysaccharides, and they are released from gram-negative bacteria, and trigger an inflammatory reaction from our immune systems when they leak out of the gut. And here’s the thing. LPS have been found in elevated levels in the gut, menstrual fluid, blood serum and peritoneal fluid (fluid in the pelvic area) of people with endo, and in the endo lesions themselves, and they contribute to the inflammatory cascade that triggers endo growth and symptoms. In fact, a recent 2025 review investigating the connection between the gut and endometriosis growth, discussed the importance of a healthy gut barrier to prevent the translocation of lipopolysaccharides into the blood stream and triggering the processes that contribute to endo growth.

Intestinal inflammation

Now let’s talk about inflammation induced by amylase-trypsin inhibitors (otherwise known as ATIs for short). Whilst gliadin is a gluten protein, ATIs are wheat proteins. Research has shown that ATIs can trigger an inflammatory immune response, activating toll-like receptor 4 (TLR4), leading to intestinal inflammation and an in increase in pro-inflammatory cytokines and chemokines, including IL-8 and TNF-α, and CCL-2, all of which are elevated in endo patients and involved in endo development.

Now, whilst to my knowledge, there’s no current research connecting ATIs and endometriosis specifically, we can see how elevating these inflammatory pathways more than they already are, could be problematic in those of us with endo.

So, those are my theories.

Now, the idea of this series is to kind of take a 360 degree look at each intervention from this study. And that’s what we’re doing here. We’ve four studies now showing that people are reporting improvements in pain with gluten reduction, yet it’s clear that there needs to be better quality studies and more research.

So what does that mean for us?

Ultimately, it’s up to you. The researchers who recommend against a gluten free diet have valid points - it can be expensive if you’re looking to replace all your gluten products with gluten free versions, and it can be limiting, for example, if you’re someone who eats out all the time, and it can reduce your diet quality and as a result, possibly affect your microbiome health, if you end up swapping gluten products like wholewheat bread and pasta for heavily processed gluten free versions that include a lot of gums, additives and so on.

But whilst these are absolutely valid points and the poor diet and gut microbiome affects are based on research, my personal opinion is that I sort of think that takes a bit of a narrow-minded, and pessimistic view that in a way, assumes that we’re incapable of making healthy choices or aren’t open to being educated. For example, if you rely heavily on let’s say, gluten-based cereal for breakfast and bread for lunch and pasta for dinner - rather than just swapping for heavily processed versions that are poor quality, often tasteless and expensive, you could swap to overnight oats for breakfast or oatmeal, which is affordable, a whole food and rich in prebiotics for gut health. You could swap your lunch time sandwich for a hearty salad made with whole grains like brown rice, which again, is a high quality whole food which is relatively inexpensive. And finally, your carbohydrate at dinner could be potatoes, which once again, is a whole food and contains beneficial nutrients for gut health, especially if you’re using reheated potatoes (because they contain resistant starch), or you could opt for something like lentil pasta, which no, is not a whole food (just like regular pasta isn’t a whole food), and is a bit more expensive than some pastas (though not all, some fancy pastas are not cheap!) but does contain high amounts of protein and fibre per serve, and lentils are very beneficial for the gut due to being prebiotic.

So actually, with education and awareness, we can make affordable, quality changes that can enhance health. I think unfortunately, in the Western diet, we end up relying heavily on gluten based products to get fibre because we don’t eat enough fruit, veggies, beans, whole grains, etc. and so I think conventional medicine, dieticians, researchers, etc. have observed that once people remove gluten, the fibre intake goes down because they’re replacing it with low fibre gluten free foods and weren’t eating much fibre beforehand.

And I mean, let’s look at the alternative option as well…

If we decided against trying to reduce gluten, because the researchers have concluded there’s not enough evidence to try it - what if it was the tool to make a difference? I am pretty sure, and in fact, there’s research on this, that endo significantly reduces one’s quality of life. Perhaps more than say, trying a gluten free diet for one month? And look, maybe for you, actually, going gluten free would affect your quality of life more than endo currently does - and that’s why these are all options and that it comes down to each individual. It has to be about what’s realistic and sustainable and suitable for you.

But what if it did significantly improve your endo symptoms? For you, would it be worth lowering gluten for those benefits? Literally only you can decide that, based on the life you lead, your culture, your personal diet preferences and so on.

Now, it’s also worth remembering that you don’t have to go entirely gluten free. Just like we explored with alcohol, you may find that you feel significant improvements or improvements you’re happy with, with going gluten free with your week day meals that you cook at home or eat at work, but that eating out at the weekend, you can eat some gluten and still benefit from the overall reduction. That might be the sweet spot for you that enables you to not feel so restricted and doesn’t reduce your quality of life, and yet also see improvements in pain from.

And also, it’s worth pointing out that in the study from 2025 on gluten removal in endo patients, these women actually reported that they had a better quality of life and were able to be more social and felt more normal, not less - despite there being connotations that going gluten free would mean you have to be less sociable because not all resultants etc. offer gluten free options. So just something to consider there.

So, whilst we can’t draw any definitive conclusions, my personal opinion, as someone with endo, and who has now worked with hundreds, if not thousands of endo clients, is that if it’s not triggering for you, and you want to try reducing your gluten intake, that it could be worth giving it a go. Ideally, do it with the guidance of a nutritional practitioner who can support you to do it in a healthy, unrestrictive way that doesn’t reduce your diet quality, fibre intake or quality of life.

And as I mentioned with alcohol, when we perform elimination diets, the standard protocol is one month, to observe results from, but we can see from the studies on endo patients, that some of these were done for longer, such as three months to a year, so you might want to give it more time before you draw any conclusions.

Now, if you want more personalised and tailored support, you can reach out to me to set up a one off coaching session, or you can of course sign up to my longer coaching programme which is six to twelve months. I’ve linked to my coaching options in the show notes, but you can also just email me directly on hello@thisendolife.com

And if you do want some more guidance but not one to one support, my Nutrition Masterclass could be a good option for you, which covers gluten and trialing an elimination diet.

Okay, that’s it for this week!

I’ll see you next week.

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References

Study Spotlight

https://www.theendobellycoach.com/podcast/new-endo-survey-study-review

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831953

Gluten and endo research

https://pmc.ncbi.nlm.nih.gov/articles/PMC7044830/

https://pmc.ncbi.nlm.nih.gov/articles/PMC12299565/#B89-medicina-61-01264

https://pubmed.ncbi.nlm.nih.gov/23334113/

https://www.fertstert.org/article/S0015-0282(11)01637-2/fulltext

https://pmc.ncbi.nlm.nih.gov/articles/PMC12299565/#B89-medicina-61-01264

https://pubmed.ncbi.nlm.nih.gov/39040659/

https://www.researchgate.net/publication/373663256_Diet_associations_in_endometriosis_a_critical_narrative_assessment_with_special_reference_to_gluten

Coeliac disease and endo

https://pubmed.ncbi.nlm.nih.gov/21840904/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601386/

https://www.siboinfo.com/associated-diseases.html

https://pubmed.ncbi.nlm.nih.gov/9660426/

https://www.coeliac.org.uk/information-and-support/coeliac-disease/coeliac-disease-faqs/

https://www.coeliac.org.uk/information-and-support/coeliac-disease/about-coeliac-disease/myths-about-coeliac-disease/?&&type=rfst&set=true#cookie-widget

https://www.beyondceliac.org/fast-facts-about-celiac-disease-infographic/

IBS

https://pmc.ncbi.nlm.nih.gov/articles/PMC9357916/

https://pmc.ncbi.nlm.nih.gov/articles/PMC11668458/

https://pubmed.ncbi.nlm.nih.gov/18715239/

https://pubmed.ncbi.nlm.nih.gov/28303579/

https://pubmed.ncbi.nlm.nih.gov/18715239/

https://www.youtube.com/watch?v=Sv8LjTgpmP0

https://www.ibssmart.com/sibo-symptoms-and-diagnosis

https://www.nature.com/articles/s41598-022-05933-1

https://www.msjonline.org/index.php/ijrms/article/view/15048

https://www.monashfodmap.com/about-fodmap-and-ibs/

https://pmc.ncbi.nlm.nih.gov/articles/PMC4918736/

https://pubmed.ncbi.nlm.nih.gov/28303579/

https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-025-03715-1

https://pmc.ncbi.nlm.nih.gov/articles/PMC12107219/

https://gut.bmj.com/content/71/9/1821

https://ift.onlinelibrary.wiley.com/doi/10.1111/1750-3841.70072

https://www.sciencedirect.com/science/article/pii/S2475299122121001#bib22

https://pmc.ncbi.nlm.nih.gov/articles/PMC10095554/

https://pmc.ncbi.nlm.nih.gov/articles/PMC9962481/

https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2024.1363455/full

Gliadin and intestinal permeability

https://pubmed.ncbi.nlm.nih.gov/16635908/

https://pubmed.ncbi.nlm.nih.gov/28123927/

https://pubmed.ncbi.nlm.nih.gov/30785904/

https://www.sciencedirect.com/science/article/pii/S2475299122121001#bib22

https://www.mdpi.com/2072-6643/7/3/1565#:~:text=5.,blind, placebo-controlled studies.

https://pubmed.ncbi.nlm.nih.gov/29202198/

https://pubmed.ncbi.nlm.nih.gov/16099460/

https://academic.oup.com/nutritionreviews/article-abstract/75/12/1046/4675264?redirectedFrom=fulltext&login=false

LPS translocation, leaky gut and endo

https://pmc.ncbi.nlm.nih.gov/articles/PMC7033038/

https://pmc.ncbi.nlm.nih.gov/articles/PMC12277312/

https://pmc.ncbi.nlm.nih.gov/articles/PMC9729346/

https://pmc.ncbi.nlm.nih.gov/articles/PMC12277312/

https://pmc.ncbi.nlm.nih.gov/articles/PMC10888589/

https://www.researchgate.net/publication/332701068_Lipopolysaccharide_promotes_early_endometrial-peritoneal_interactions_in_a_mouse_model_of_endometriosis

https://www.sciencedirect.com/science/article/pii/S0015028204012944

https://pubmed.ncbi.nlm.nih.gov/22109896/

https://bmcgastroenterol.biomedcentral.com/articles/10.1186/s12876-014-0189-7

https://integrativewomenshealthinstitute.com/leaky-gut-and-pelvic-pain/

https://pubmed.ncbi.nlm.nih.gov/19517230/

https://pubmed.ncbi.nlm.nih.gov/30430944/

https://pubmed.ncbi.nlm.nih.gov/29692669/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519769/

https://pubmed.ncbi.nlm.nih.gov/9660426/

https://genomemedicine.biomedcentral.com/articles/10.1186/s13073-016-0303-2

ATIs and inflammatory pathways

https://www.sciencedirect.com/science/article/pii/S2475299122121001#bib22