Complementary therapies for endometriosis: what options are available and what does the scientific evidence say?
Endometriosis is a chronic, oestrogen-dependent inflammatory disease that affects approximately 10% of women of reproductive age. It is characterised by the presence of tissue similar to the endometrium outside the uterine cavity, which can cause pelvic pain, painful periods, pain during sexual intercourse, digestive or urinary symptoms, and infertility.
In recent years, our understanding of the disease has improved, and we now know that endometriosis is not simply a gynaecological condition, but a complex disease involving inflammatory processes, immune alterations, oxidative stress, angiogenesis, fibrosis, and even changes in pain perception at the level of the central nervous system.
The mainstays of medical treatment continue to be hormonal therapy —using medications such as progestogens, combined contraceptives, agonists and antagonists, among others— and surgery in specific cases where it is indicated. However, there is growing evidence that certain complementary therapies may help reduce inflammation and pain and improve quality of life.
It is important to emphasise that these interventions do not replace medical treatment, but rather form part of a comprehensive and individualised approach to patient care.
Diet and endometriosis: is there a specific diet?
There is currently no specific diet or definitive cure for endometriosis. However, several studies suggest that certain dietary patterns may modulate inflammation and oxidative stress, two mechanisms closely associated with the disease.
The dietary approach for endometriosis with the strongest scientific support is a pattern similar to the Mediterranean diet, characterised by a high intake of plant-based foods and healthy fats.
Several mechanisms could explain this potential benefit, including reduced production of pro-inflammatory prostaglandins, increased antioxidant intake, reduced oxidative stress and improvements in the gut microbiota.
Although the available evidence still has methodological limitations, maintaining a healthy dietary pattern is a widely accepted recommendation.
Supplementation: which supplements have the strongest evidence?
No supplement has been shown to be an effective treatment for endometriosis on its own. However, some compounds have shown promising results as an adjunct to conventional treatment.
Lactoferrin: one of the most promising molecules
Lactoferrin is a glycoprotein naturally present in various body fluids and is particularly abundant in colostrum and breast milk.
In recent years, it has attracted considerable interest due to its multiple immunomodulatory, anti-inflammatory, antioxidant, antimicrobial and anti-angiogenic properties. Experimental studies suggest that it may partially inhibit the proliferation of endometriotic cells, while also promoting intestinal iron absorption, an important consideration in patients with heavy menstrual bleeding.
Curcumin
Curcumin is the main active component of turmeric (Curcuma longa) and is probably the most extensively studied natural compound in endometriosis.
Experimental evidence has shown that it acts on multiple anti-inflammatory mechanisms, which could potentially lead to a reduction in pain and disease progression.
Its main limitation is its low bioavailability, which is why formulations with enhanced absorption are currently recommended.
N-acetylcysteine (NAC)
NAC is a potent antioxidant. Certain clinical studies have reported reductions in pain and clinical improvement in endometriosis with its use.
Alpha-lipoic acid
Alpha-lipoic acid is another potent antioxidant that may be particularly relevant for women with neuropathic pain or central sensitisation, as it also has certain neuroprotective properties. It is frequently used in combination with other antioxidants such as NAC.
Bromelain
Bromelain is an enzyme obtained from pineapple stems with anti-inflammatory and anti-oedematous properties. Although specific evidence regarding its use in endometriosis remains limited, some studies suggest a potential benefit for pelvic pain.
Zinc
Zinc is involved in numerous processes related to immune response and the regulation of oxidative stress. There is currently insufficient evidence to recommend routine zinc supplementation, although correcting a deficiency may be beneficial.
Microbiota and probiotics: a new area of research
One of the areas that has attracted the greatest interest in recent years is the microbiota, which plays a role in regulating the immune system, oestrogen metabolism (the estrobolome), intestinal barrier integrity and systemic inflammation.
Several studies have identified alterations in the bacterial composition of women with endometriosis compared with women without the disease, although a characteristic microbial pattern has not yet been established.
Probiotics could potentially help restore this balance and modulate inflammation. Among them, one of the most promising strains is Ligilactobacillus salivarius (formerly known as Lactobacillus salivarius).
Although the results are promising, higher-quality clinical studies are still needed before definitive recommendations can be established.
Physical exercise: much more than improving physical fitness
We now know that exercise is a valuable therapeutic tool in many chronic inflammatory diseases. In the case of chronic endometriosis, it may help improve different aspects related to pain and quality of life.
Regular physical activity can reduce systemic inflammation and oxidative stress, increase the release of endorphins, improve mood, reduce central sensitisation to pain and improve sleep quality.
Intense exercise is not necessary. In fact, many patients may benefit more from an adapted programme combining moderate aerobic exercise, strength training and mobility work, Pilates, yoga, breathing exercises or pelvic floor physiotherapy when indicated.
The key is consistency and adapting the intensity to each patient’s clinical circumstances.
Acupuncture
When considering acupuncture and endometriosis, one of its main applications as a complementary therapy is the management of chronic pelvic pain.
Its potential analgesic effect appears to be related to the release of endorphins, activation of inhibitory pain pathways, modulation of the autonomic nervous system and reduction of certain inflammatory mediators.
Systematic reviews suggest a reduction in the intensity of menstrual pain and an improvement in quality of life, although the level of evidence is moderate.
This technique, which originates from Traditional Chinese Medicine (TCM), may be considered a particularly interesting complementary option for patients who experience persistent pain despite conventional treatment.
TENS: transcutaneous electrical nerve stimulation
TENS (Transcutaneous Electrical Nerve Stimulation) involves the application of low-intensity electrical impulses through electrodes placed on the skin.
Its aim is to reduce pain perception through two main mechanisms: activation of the “gate control” theory of pain (Gate Control Theory) and stimulation of endorphin release.
Some studies have reported benefits particularly in dysmenorrhoea and chronic pelvic pain, as well as a reduction in analgesic use, although the quality of the evidence is moderate.
It is a safe, non-invasive technique with few side effects and can be used both in a clinical setting and at home after appropriate instruction.
Success rates of these therapies
The effectiveness of complementary therapies for endometriosis varies depending on the type of intervention, the symptoms being treated and the individual characteristics of each patient.
The available scientific evidence does not currently allow a single success rate to be established for these therapies. However, some studies have reported improvements in pain, quality of life and other symptoms associated with endometriosis.
| Complementary therapy | Main findings reported | Level of evidence / limitations |
|---|---|---|
| Dietary interventions | Mediterranean-style dietary patterns may help reduce inflammatory and oxidative processes associated with endometriosis. | Evidence remains limited and heterogeneous. |
| N-acetylcysteine (NAC) | Some clinical studies have reported reductions in pelvic pain and improvements in clinical symptoms. | Further controlled clinical trials are needed. |
| Probiotics | Certain strains have shown potential benefits in modulating inflammation and pain. | Preliminary evidence; larger clinical studies are required. |
| Physical exercise | Regular exercise may contribute to reducing pain and improving quality of life. | Evidence is favourable, although protocols vary considerably between studies. |
| Acupuncture | Systematic reviews report reductions in menstrual and pelvic pain in some patients. | Moderate-quality evidence; considerable heterogeneity between studies. |
| TENS | Improvements in chronic pelvic pain and dysmenorrhoea and reduced use of analgesics have been reported. | Moderate evidence and limited sample sizes. |
The response to these therapies can vary considerably from one patient to another, which is why each case should be assessed individually. This individual assessment is particularly important when, in addition to symptom control, there is a desire to conceive, as endometriosis can have implications for fertility and the chances of achieving pregnancy.
The team of endometriosis specialists at Instituto Bernabeu can provide guidance on the most appropriate therapeutic options according to each patient’s symptoms, medical history and individual characteristics.
References
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- Porpora MG, Brunelli R, Costa G, et al. A promise in the treatment of endometriosis: an observational cohort study on ovarian endometrioma reduction by N-acetylcysteine. Evidence-Based Complementary and Alternative Medicine. 2013.
- Signorile PG, Viceconte R, Baldi A. Novel dietary supplement association reduces symptoms in endometriosis patients. Journal of Cellular Physiology. 2018.
- Itoh H, Uchida M, Sashihara T, et al. Lactobacillus gasseri OLL2809 is effective especially on the menstrual pain and dysmenorrhea in endometriosis patients: randomized, double-blind, placebo-controlled study. Cytotechnology. 2011.
- Tennfjord MK, Gabrielsen R, Tellum T. Effect of physical activity and exercise on endometriosis-associated symptoms: a systematic review. BMC Women’s Health. 2021.
- Mira TAA, Buen MM, Borges MG, Yela DA, Benetti-Pinto CL. Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. International Journal of Gynecology & Obstetrics. 2018.
- Mira TAA, Yela DA, Podgaec S, Baracat EC, Benetti-Pinto CL. Hormonal treatment isolated versus hormonal treatment associated with electrotherapy for pelvic pain control in deep endometriosis: randomized clinical trial. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020.
- Giese N, Kwon K, Armour M. Acupuncture for endometriosis: a systematic review and meta-analysis. Integrative Medicine Research. 2023.
- Buggio L, Barbara G, Facchin F, Frattaruolo MP, Aimi G, Berlanda N. Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. International Journal of Women’s Health. 2017.
- Armour M, Sinclair J, Chalmers KJ, Smith CA. Self-management strategies amongst Australian women with endometriosis: a national online survey. BMC Complementary and Alternative Medicine. 2019.
Dr Silvia Gorgan, Co-director of the Endometriosis Unit at Instituto Bernabeu