Endometriosis and Metabolic Health: Unraveling the Hidden Connection

Endometriosis is a chronic inflammatory condition that affects roughly 1 in 10 women of reproductive age.¹ The condition is characterized by the growth of endometrial-like tissue outside the uterus, pelvic pain, and problems with fertility. It triggers systemic inflammation that may disrupt many processes, including metabolism. Researchers have discovered a compelling link between endometriosis and metabolic health issues, such as insulin resistance, dyslipidemia, and metabolic syndrome. 

In this article, we’ll explore how endometriosis influences metabolic pathways, the role of hormones and the gut microbiome, and practical interventions to support women struggling to manage these conditions.

Understanding Endometriosis and Its Systemic Effects

Endometriosis occurs when tissue similar to the uterine lining grows on organs like the ovaries, fallopian tubes, or pelvic lining. These growths cause uncomfortable symptoms such as chronic pelvic pain, heavy menstrual bleeding, and infertility. Beyond these localized effects, its inflammatory nature impacts the whole body. The immune system’s response to ectopic endometrial tissue releases pro-inflammatory cytokines, such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), which can circulate systemically. This chronic low-grade inflammation may disrupt metabolic processes, including glucose regulation and lipid metabolism, increasing the risk for other diseases. Studies suggest that women with endometriosis are more likely to have insulin resistance and cardiovascular disease, suggesting the condition has systemic effects. 

The Link Between Endometriosis and Metabolic Syndrome

Metabolic syndrome is a cluster of conditions including insulin resistance, hypertension (high blood pressure), abnormal levels, and abdominal obesity. There is significant evidence that suggests metabolic syndrome has a significant overlap with endometriosis. Research indicates that women with endometriosis are more likely to exhibit characteristics of metabolic syndrome.²  Studies suggest that women with endometriosis have a higher prevalence of insulin resistance compared to controls, even when adjusted for several social factors including age, race, education level, family poverty to income ratio (PIR), smoking, age at menarche, number of pregnancies, menopause, female hormones use, and dyslipidemia drug use.² Similarly, dyslipidemia, marked by elevated triglycerides, high LDL (low density lipoprotein) and low HDL (high density lipoprotein) cholesterol, has been observed at higher rates in this population.³

Several mechanisms may drive this association. Chronic inflammation from endometriosis can impair insulin signaling, leading to insulin resistance. Insulin resistance leads to high levels of insulin circulating in the body, which increases androgen production. Excess androgens, like testosterone, often lead to a reduction in sex-hormone binding globulin (SHBG), freeing up estrogen and allowing it to act on endometrial tissue, resulting in excess growth.

Poor metabolic health and glucose dysregulation are linked to elevated levels of reactive oxygen species (ROS), which drive oxidative stress and inflammation. Oxidative stress may have a bidirectional relationship with endometriosis. Endometriotic cells thrive on high levels of inflammation, leading to increased tissue growth. On the other hand, the condition of endometriosis itself causes oxidative stress, damaging pancreatic beta cells, further worsening glucose dysregulation. 

Hormonal Imbalances and Estrogen Metabolism

As mentioned above, endometriosis is often characterized by estrogen dominance, where excessive or unopposed estrogen drives the growth of endometrial lesions. This hormonal imbalance can also impact metabolic health. Estrogen plays an important role in regulating insulin sensitivity and lipid metabolism. In excess, it can impair insulin signaling, contributing to insulin resistance. It can also alter lipid profiles, increasing cardiovascular risk.

Estrogen metabolism–the process by which the body breaks down and eliminates estrogen–is also disrupted in endometriosis. Increased activity of enzymes like aromatase, which converts androgens to estrogens, is common in endometrial lesions, leading to local estrogen overproduction. This perpetuates inflammation and creates a feedback loop that worsens metabolic dysfunction. Addressing estrogen metabolism through targeted interventions may benefit endometriosis symptoms and metabolic health.

The Role of the Gut Microbiome

The gut microbiome is increasingly recognized as having a key role in endometriosis and metabolic health. Dysbiosis, an imbalance in gut microbial composition, is common in women with endometriosis and may worsen systemic inflammation.⁴ Within the gut microbiome, specific microbes regulate the balance between active and inactive estrogen forms, influencing circulating estrogen levels.

In endometriosis, dysbiosis can disrupt the functioning of these estrogen-regulating microbes, leading to increased estrogen reabsorption into the bloodstream. This contributes to estrogen dominance. Elevated estrogen fuels inflammation and metabolic disturbances, such as insulin resistance and lipid imbalances. 

Gut dysbiosis also compromises the gut barrier, allowing inflammatory bacterial toxins like lipopolysaccharides (LPS) to enter the bloodstream.⁵ Research suggests modulating the gut microbiome through diet, probiotics, or prebiotics could mitigate endometriosis symptoms and metabolic dysfunction.⁵

Dietary and Lifestyle Interventions To Manage Endometriosis

Managing endometriosis and its metabolic consequences requires a multifaceted approach, including lifestyle and diet modifications. Evidence-based interventions can reduce inflammation, balance hormones, and improve metabolic markers. 

Anti-Inflammatory Diet

An anti-inflammatory diet rich in whole foods can help mitigate the systemic inflammation associated with endometriosis. An anti-inflammatory diet includes:

• Omega-3 fatty acids: Found in fatty fish, flaxseeds, and walnuts, these fats reduce inflammatory cytokines. Studies suggest that a higher omega-3 intake was associated with reduced endometriosis-related inflammation and pain.⁶
• Antioxidant-rich foods: A 2009 study reported that women with endometriosis had a 30% lower vitamin C intake and consumed 40% less vitamin E, compared with women who did not have endometriosis.⁶ Consuming a diet high in antioxidants from berries, leafy greens, and cruciferous vegetables like broccoli helps reduce inflammation related to oxidative stress. This can help improve metabolic health as well as endometriosis symptoms.
• Low-glycemic index (GI) foods: Low-GI foods are associated with a reduced risk of endometriosis.⁶ These foods have less of an impact on blood sugar and are beneficial for anyone trying to improve insulin sensitivity and manage blood sugar. Whole grains, legumes, and non-starchy vegetables help stabilize blood sugar.
• Limit processed foods: Higher intakes of processed foods are linked to dysbiosis, insulin resistance, and dyslipidemia. Reducing your intake of refined sugars, saturated and trans fats, and red meat can lower inflammation, improve metabolic health, and support a healthy gut microbiome. 

Regular Physical Activity

Exercise is an important part of managing endometriosis and its associated symptoms. Research suggests that regular exercise may positively impact the health of women with endometriosis; however, more research is needed. 

Moderate aerobic activities (brisk walking, swimming) help improve insulin sensitivity and reduce visceral fat. Strength training can also increase metabolism and support healthy hormone levels. Aim for at least 150 minutes of moderate-intensity exercise per week, tailored to individual pain levels and energy capacity.

Stress Management

Chronic stress can worsen endometriosis symptoms and metabolic dysfunction by elevating cortisol and inflammatory markers. Stress reduction techniques may help reduce stress and improve symptoms for endometriosis patients. Mind-body practices like yoga, meditation, and deep breathing can lower stress hormones and improve pain tolerance.⁸ Cognitive-behavioral therapy (CBT) may also help women cope with the emotional toll of chronic illness, indirectly supporting metabolic health.⁹

Gut Health Optimization

A healthy gut microbiome is important to health and well-being, especially regarding metabolic health and endometriosis. Incorporating fermented foods (e.g., yogurt, kefir, sauerkraut) and fiber-rich prebiotics (e.g., asparagus, onions, bananas) can support a healthy gut microbiome. Probiotic supplements, particularly those containing Lactobacillus and Bifidobacterium strains, may reduce inflammation and improve estrogen metabolism. You should consult a healthcare provider before starting new supplements to ensure they’re right for you. 

Emerging Research and Future Directions

Researchers are interested in the relationship between endometriosis and metabolic health. Current studies are exploring the role of specific gut microbial metabolites, such as short-chain fatty acids (SCFAs), in modulating inflammation and insulin sensitivity in endometriosis. Others are investigating the potential of anti-inflammatory compounds, like resveratrol and curcumin, to address both conditions simultaneously.

Advances in genomics and metabolomics may allow clinicians to tailor interventions based on an individual’s hormonal, microbial, and metabolic profiles. For example, identifying specific estrobolome dysbiosis patterns could guide targeted probiotic therapy. Integrative approaches combining conventional treatments (e.g., hormonal therapy) with lifestyle interventions are also gaining traction, emphasizing the need for holistic care.

Future research is needed to address gaps in understanding, such as the long-term metabolic consequences of endometriosis and the efficacy of dietary interventions in diverse populations. Large-scale, longitudinal studies are needed to establish causality and refine treatment protocols, ensuring women receive evidence-based care that addresses their reproductive and metabolic health.

The Bottom Line

Endometriosis is more than a reproductive disorder; it's systemic inflammation and hormonal imbalances that can significantly impact metabolic health, increasing the risk of insulin resistance, dyslipidemia, and metabolic syndrome. Anti-inflammatory diets, regular exercise, and stress management may help manage both conditions, improving quality of life and long-term health outcomes.

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