Do I Have Bowel Endometriosis or IBS?

Those of you who have been following Endo Strong since the days when it was called “Lovely & Lazy” will remember that I originally started blogging about IBS, not endometriosis. That’s because, like 10 percent of endo patients, I was originally diagnosed with and treated for IBS. The first year of my journey with chronic illness was valuable, in that it taught me everything I ever needed to know about maintaining a healthy gut. Gut health is equally as important in endometriosis as it is in IBS. However, I remain frustrated that my family and I spent hundreds, potentially thousands, of dollars on tests and treatments that didn’t bring me answers, before discovering that my problem was in a completely different set of organs.

Over the 1.5 years I spent searching for answers, I was diagnosed with IBS, referred for SIBO testing, and underwent a breath analysis for H. pylori (the bacterium responsible for most stomach ulcers). I had a CT scan, upper endoscopy, colonoscopy, and transvaginal ultrasound that each turned up nothing, save for a couple of harmless “functional” cysts on my ovaries. I tried eating vegan and low-FODMAP, yet nothing helped. It took me over a year to notice that my symptoms were correlated with my menstrual cycle. And knowing what I do know about endometriosis, I’m not surprised.

It takes patients an average of seven years to be diagnosed with endometriosis. I started getting my period at age 10. Over the years, my cramps only worsened. My doctor had to sign a note allowing me to keep Aleve in the school nurse’s office for my cramps starting when I was 13 years old. At 15, I vomited in the nurse’s office when I got period cramps. I thought I had a 24-hour stomach bug at the time, but it turns out it was the period pain that likely caused my nausea. Not long after, I nearly fainted when I started getting cramps in the middle of a statewide standardized test. You weren’t supposed to leave the room during the exam, but my teacher was so worried about my pale appearance that she permitted me to go to the bathroom when I admitted I had my period.

Yet when I asked my (male) primary care doctor to go on birth control pills for my period pain, I wasn’t questioned about the extent or severity of my cramps. I was simply written the script and left to deal with the consequences. The pill helped the pain somewhat, until my depression began to worsen and I was forced to stop them. Soon after, I had an IUD inserted, in what was the most painful medical procedure of my life. (I now know that I have a retroverted, retroflexed uterus, and they were trying to insert the IUD in the wrong direction.) My cramps lightened again, but I continued to have long, heavy periods that lasted eight to ten days. (A healthy period lasts anywhere from three to seven days.) But all of this was bearable until I began experiencing gastrointestinal symptoms alongside my period pain.

In college, I started having alternating bouts of constipation and diarrhea. Every day, I was bloated — often painfully so — leading me to work out obsessively in pursuit of a “flat stomach.” On a few occasions, I even noticed blood in my stool. After I did 23andme with my boyfriend for fun, I discovered I carried a number of genes that raised my risk for Inflammatory Bowel Disease (IBD). My mom’s uncle has Crohn’s disease, so I decided to see the school doctor to get tested for biomarkers. They tested my sedimentation rate, which was normal, and preliminarily diagnosed me with alternating-type IBS. I got a referral to Boston Medical Center for gastroenterology services, where they tested my stool for calprotectin levels and occult blood, and confirmed the diagnosis of IBS-A.

During that time, I was technically on the low-FODMAP diet, but I was so afraid to exacerbate my symptoms that I was frequently skipping meals (or surviving on coffee and an underripe banana from the campus Starbucks) to cope with them. It didn’t get really bad, however, until I spent winter break visiting David in Erie, Pennsylvania, where he was finishing medical school at the time. After eating at Panera Bread, I got such painful stomach cramps that we decided to go to the emergency room. There, I was written a script for Bentyl (an anti-spasmodic that’s over-prescribed for IBS) and basically told I was overreacting. Refusing to give up, I scheduled an appointment with a nurse practitioner, who tested me for H. pylori and sent me in for a CT scan. I originally felt good that she was taking me seriously, but when the CT turned up naught but a functional ovarian cyst, she wrote off my pain as related to the cyst and told me to come back only if I worsened. To be honest, I felt so terrible already that I couldn’t imagine getting any worse — so I gave up on my medical quest for the time-being, and resigned myself to a life of suffering.

It wasn’t until I moved to Cleveland to live with David after graduation that I decided to keep pushing for answers. I saw a gastroenterologist, who did an upper endoscopy and biopsy for celiac disease, which also came back negative. I then had a colonoscopy, which came back — you guessed it — negative, too. After that, the doctor decided that I definitely had IBS-C, and told me my problems would be solved with a daily dose of Miralax. About a month later, after failing to see improvement with the Miralax (and feeling skeptical of relying on laxatives long-term, which can make your bowels dependent on them), I came back to ask if there was anything else he could do. I overheard him complaining about me to the nurse in the back room, saying that I was “noncompliant” and needed to be urged to take my Miralax. Following that appointment, I left in tears, and refused to go back to his office ever again.

To be honest, I don’t even remember how I came to the conclusion that I needed to pursue an endometriosis diagnosis rather than accepting I had IBS. All I know is my IBS diagnosis never sat right with me; I always had a gut feeling that something deeper was wrong with me. I had read Dr. Tamer Seckin’s book The Doctor Will See You Now when it came out, wanting to understand more about the problems women face in healthcare, and found it interesting, though not applicable to my life at the time. I guess I figured that since I hadn’t had painful period cramps for years, thanks to hormonal treatments, there was no reason to find out if I had endometriosis or not.

Now, I believe that I was drawn to that book for a reason — because somewhere deep down, I think I always knew there was something wrong with my menstrual cycles. But once I became diligent about tracking my IBS symptoms, I knew this for certain, as I began to notice a pattern that correlated with my menstrual cycle. For the first time, it occurred to me that my symptoms might be reproductive, rather than digestive, in nature. I pushed for an appointment at Cleveland Clinic’s Center for Pelvic Pain and Endometriosis, and haven’t looked back since. Now, I’m eagerly awaiting a diagnostic laparoscopy, and most likely excision surgery, for suspected endo.

At my first appointment, my doctor scheduled me for an MRI because she suspected deep infiltrating endometriosis (DIE), a form of endometriosis that infiltrates deeper than 5 mm into the tissue it grows on. Thankfully, my MRI came up negative for DIE, but it remains possible that I have superficial endometriosis on my bowel, or in areas adjacent to my bowel, that could be responsible for my symptoms (for example, endometriosis of the uterosacral ligaments or cul-de-sac can cause constipation by pushing on the bowel). Because I have a retroverted, retroflexed uterus, it’s also possible that my uterus obscured the radiologist’s view of my pelvic cavity and missed potential DIE lesions in those areas.

If you have painful periods and have been diagnosed with IBS, parts of my story might sound eerily familiar to you. 80 percent of endometriosis patients have gastrointestinal symptoms like bloating or constipation, and 18 percent have involvement — whether deep or superficial — of the bowel wall. It’s not at all uncommon to be misdiagnosed with IBS when you actually have endometriosis. Alternatively, you can also have both. If your doctors identify IBS as the cause of your symptoms and don’t ask about your periods, they may miss the fact that you could also have endometriosis.

This brings me to the Golden Ticket of questions for endometriosis patients: do I have bowel endometriosis or IBS? Or do I have GI symptoms of endometriosis, in other locations besides the bowel, that mimic IBS? Ultimately, the only way to answer that question in your unique case is to pursue a diagnostic laparoscopic surgery. A trained minimally-invasive gynecologic surgeon can definitively tell you if you have bowel endometriosis, or endometriosis that could result in bowel symptoms. In the meantime, however, it helps to learn everything you can about bowel endometriosis, as well as how any type of endometriosis could potentially affect your bowel. In this post, I’ll answer those questions, as well as sharing some of the self-management tips that have helped me cope with GI symptoms while I am (eagerly) awaiting diagnostic laparoscopic surgery myself.

What is Bowel Endometriosis?

Bowel Endometriosis: Symptoms, Why It Is Misdiagnosed, and How to ...
Image Source: Everyday Health

Outside of the fallopian tubes and ovaries, the uterosacral ligaments (the ligaments that support the uterus) and the cul-de-sac, or pouch of Douglas (the space between the uterus and rectum), are the two most common sites of endometriosis. Half of all endometriosis cases have superficial rectovaginal involvement. In these cases, endometriosis affects the bowel, or spaces adjacent to the bowel (like the cul-de-sac), without infiltrating deeper than 5 mm into the tissue. The top layer of tissue involved in superficial endometriosis is called the peritoneum or peritonial lining, so you may also hear it referred to as peritoneal endometriosis. This type of bowel involvement cannot be seen via MRI, CT scans, or ultrasound, and can only be definitively diagnosed via laparoscopic surgery. Sometimes, it cannot even be seen by the naked eye, so your surgeon may need to take biopsies during laparoscopy.

By this definition, bowel involvement is very common in endometriosis. Serious bowel involvement, which can require a type of surgery called resection to treat (in which parts of the bowel with deep endometriosis are removed and the two ends of the remaining bowel are reattached to one another), is less common, though still prevalent. 1 in 5 cases of endometriosis present with deep involvement of the intestinal organs. Severe infiltration of the bowel exceeding 5 mm in depth can usually be seen via MRI, CT scans, or ultrasound prior to surgery. If your doctor suspects deep bowel involvement, they may refer you for pre-diagnostic imaging before surgery to help them better plan for your laparoscopy. Should they discover deep involvement of the bowel that could require a resection, you might have to undergo bowel prep before surgery or meet with a specialized surgeon who deals with bowel resection.

How Endometriosis Affects the Bowel

Whether your endometriosis is deeply infiltrating or confined to the peritoneum, it’s more likely than not that you will experience some degree of gastrointestinal symptoms with your endo. You may have heard of “endo belly,” which is painful bloating associated with endo flares. Many patients with endometriosis also present with painful bowel movements (especially during their menstrual periods), constipation, diarrhea, and abdominal pain. Some even have dyschezia, or blood in their stool, during their menstrual period. These symptoms can indicate bowel endometriosis, but they aren’t specific to bowel endo. In contrast, deep dyspareunia (pain during sex) is another, more specific symptom that may signify rectovaginal involvement.

The fact that endometriosis patients experience so many bowel symptoms explains why endo is so commonly confused with IBS. Most doctors won’t ask you if your symptoms are correlated with your menstrual periods. Instead, they’ll hear your symptoms and refer you to a gastroenterologist, who deals with the digestive system. The GI doc will then want to run diagnostic tests like an upper endoscopy or colonoscopy to check for conditions like celiac disease or IBD. When those tests don’t turn up results, they’ll probably give you a “diagnosis of exclusion,” such as IBS — when in reality, your symptoms could be due to a disease of the reproductive tract, rather than one of the digestive system.

Unfortunately, specialists like gastroenterologists spend so much time studying and dealing with the digestive tract that they aren’t taught to look for, or even to recognize, endometriosis. Even if your symptoms scream endometriosis, they might not think to ask you about your menstrual periods. Or, they may have been conditioned to believe that painful periods are “normal,” and think nothing of your menstrual symptoms. This is a common reason why you, like me, might get stuck with a diagnosis of IBS, only to find that IBS treatments — such as laxatives or the low-FODMAP diet — don’t work for you. Science supports this finding, too: patients with endometriosis are 3.5 times more likely to be diagnosed with IBS than patients without.

Coping with Bowel Symptoms

Even if your endometriosis isn’t on or near your bowel, you might still experience symptoms like painful bloating, constipation, diarrhea, or vomiting, especially in connection with your menstrual period. Sometimes, symptoms might be caused by period pain — I’ve both vomited and gotten diarrhea from intense cramps — while other times, they might be connected to the location of your endo.

Regardless, it’s important to remember that the severity of your symptoms might not correlate with the extent of your disease. Someone with Stage I or Stage II endometriosis could have debilitating symptoms, while someone with Stage IV endometriosis might have no symptoms at all.

Either way, you won’t know how severe your disease is, or where it is located, without laparoscopic surgery. The best plan for long-term management of endometriosis symptoms, including GI distress, is to make an appointment with a minimally invasive gynecologic surgeon.

Many hospitals are resuming elective surgeries (read: any procedure that is planned in advance, as opposed to a sudden emergency) after suspending them due to COVID-19. Still, you might find that there’s a backlog of people who are rescheduling their surgeries due to the coronavirus. As a result, you may not be able to get in for surgery as soon you would like.

I’m right there with you. We had to cancel my surgery date after moving to Rhode Island for my boyfriend’s medical residency, and getting in anywhere has been nearly impossible thanks to COVID. In the meantime, however, my primary concern — and probably yours, too — has been managing my symptoms so I don’t feel miserable while I’m awaiting the date of my surgery.

Remember all those things I learned about good gut health while following the IBS rabbit hole? This is the part where those things come in handy. When it comes to IBS, changes in diet and lifestyle are the only treatments available. That might not be true for endometriosis, but that doesn’t mean that diet and lifestyle changes can’t help you improve your gut health and manage your bowel symptoms, regardless of the actual location of your endo.

1. Medical Management of Symptoms

While surgery is the most effective long-term treatment, many endometriosis sufferers get temporary relief from certain medications, both prescription and over-the-counter. Not all patients with endometriosis respond to hormone therapy, but for those who do, you may find that your bowel symptoms improve as your pain does. Hormone therapy for endometriosis includes birth control methods like the pill and the IUD, as well as GnRH medications like Orlissa. GnRH medications put the body into artificial menopause, so you stop getting a menstrual period. As a result, you may find that the symptoms associated with your cycle due to endometriosis also improve. Some people are not comfortable with artificially pausing their menstrual cycle, however, and may not want to try hormone therapy. Others may have unpleasant side effects from hormone therapy, such as vaginal dryness or depression.

Over-the-counter (OTC) medications can also provide short-term relief for GI distress. Which medication you should take depends on your symptoms and what other medications you might be taking. For constipation, there are many types of laxatives you can try to help you get relief. These remedies are inexpensive and available at your local drugstore. Most are very safe for short-term use. There are also OTC medications available for diarrhea, gas, and bloating that may provide temporary relief in some endometriosis sufferers.

Treatments for Constipation

Short-term constipation can be due to the location of your endometriosis or due to food intolerances related to endo. When endo grows in such a way that it presses on or narrows the bowel wall, constipation is the result. In these patients (myself included!), constipation typically worsens during the menstrual period. These patients may get relief from hormone therapy. However, other short-term remedies for constipation are available OTC. These take the form of laxatives.

Different types of laxatives work differently. As an endo sufferer who suffers from cyclical constipation, I sometimes feel like I’ve tried them all! As a result, I know the pros and cons of each type of laxative. You should always talk to your doctor before beginning a course of laxatives, but this information can help you determine which type may be most appropriate for you:

Fiber supplements can relieve long-term constipation that is due to a lack of fiber in the diet. Many endo sufferers may find that high-fiber foods cause gas or bloating. As a result, they may not consume enough dietary fiber and can suffer from constipation. In these cases, fiber supplements may be most appropriate. Fiber supplements come in the form of soluble fiber, which must be accompanied by plenty of water, and insoluble fiber. These supplements add “bulk” to the stools to help them pass more easily. Brands include Citrucel, Metamucil, and Benefiber. Personally, I have had the best experience with Citrucel or psyllium husk fiber, but you may want to experiment to find which brand is best for you. Fiber supplements are generally the safest option for long-term use. However, you should note that they can make constipation worse if you don’t drink enough water with them.

Osmotic laxatives draw water from the intestines into the stool to soften it and help it pass more easily. As a result, thirst can be a side effect of osmotic laxatives. You should always take them with plenty of water to replenish the water lost from their use. Osmotic laxatives include Milk of Magnesia, magnesium citrate, and Miralax. Miralax is a colorless, tasteless powder that you can mix into any drink. Magnesium citrate is a carbonated saline solution that comes in a variety of flavors. Milk of Magnesia is a derivative of magnesium and comes in liquid format. I find it works best if you take it with a warm liquid, such as coffee or tea. Osmotic laxatives are generally considered safe, but should not be used long-term, as your bowels can become dependent on them to work properly. They usually work overnight.

Lubricant laxatives lubricate the digestive tract to help stool pass through the colon more easily. They make your stool more “slippery” to decrease its transit time. I like oral lubricant laxatives the best of any laxatives, because I find they are the most gentle. However, they are also available as suppositories. Examples of lubricant laxatives include mineral oil and glycerin. Mineral oil can be taken by mouth. It has a bit of an unpleasant taste (it tastes like soap to me) but generally works within 6-8 hours. Glycerin or mineral oil suppositories are inserted into the anus and work as quickly as 15 minutes.

Emollient laxatives mix fluid into stools to soften them, helping them pass more easily. They are also called stool softeners. Your doctor may prescribe them for use after giving birth, after surgery, or if you suffer from hemorrhoids. It can take a week or longer for stool softeners to become effective. As a result, they are not a good “quick fix” if you are suffering from acute constipation due to endometriosis. However, they can be helpful after excision surgery to remove endo implants.

Stimulant laxatives are a last resort. They stimulate the bowels by forcing them to contract. This causes an almost instantaneous bowel movement. However, they are far from gentle, and can cause intense cramping and severe diarrhea. Stimulant laxatives include Dulcolax (bisacodyl) and senna. Watch out for senna in “detox” or laxative teas — they may claim to help relieve constipation, but like any stimulant laxative, they can cause diarrhea and cramping. Stimulant laxatives are not safe for long-term use. Long-term use of stimulant laxatives can weaken the bowel’s ability to contract naturally, leaving you dependent on these laxatives anytime you need to “go.” The only time I would use stimulant laxatives is in bowel preparation prescribed by my doctor. Bowel prep is prescribed before colonoscopy to clear the colon and improve the doctor’s ability to see the intestinal walls. It is also prescribed to some patients having excision surgery, especially if bowel endometriosis is suspected. Bowel preparation before surgery reduces the risk that fecal matter will leak into the abdomen during bowel surgery, which can cause dangerous infections.

Treatments for Diarrhea

Like constipation, diarrhea has many links to endometriosis. Inflammation of the bowel wall in bowel endometriosis may cause chronic diarrhea. You can also get diarrhea from intense period cramps. Diarrhea linked to your menstrual cycle may be due to endometriosis. Food intolerances, which are common in patients with endo, can also cause acute episodes of diarrhea.

Nobody loves having diarrhea — but thankfully, there are two effective OTC medications, called anti-diarrheals, that can help. Loperamide (brand name: Imodium) slows transit time, or the time it takes for stool to pass through the colon, by absorbing water into the intestines. Its side effects include abdominal pain, nausea, and constipation. Bismuth subsalicylate (brand name: Pepto-Bismol) can treat both diarrhea and upset stomach by reducing inflammation. Side effects include black stool or tongue, and constipation.

Be wary of overusing anti-diarrheal medications, as they can cause chronic constipation. If you have chronic diarrhea that requires long-term use of anti-diarrheals, make sure to check in with your doctor. They may want to examine your intestines via colonoscopy or upper endoscopy to see if you have inflammatory bowel disease or celiac disease, which can also cause chronic, watery diarrhea.

Treatments for Gas and Bloating

“Endo belly” is one of the most widespread symptoms of endometriosis. It can be uncomfortable, embarrassing, and even painful. It also affects body image and confidence, which can then impact our relationships. Endo belly can also be accompanied by gas, which is equally unpleasant. In the long-term, only excision surgery will cure your endo belly — but there are some short-term OTC solutions to relieve extreme, painful cases of bloating or gas.

Simethicone (brand name: Gas-X) breaks up the bubbles in trapped wind and helps gas pass through the digestive tract more easily. It may cause you to pass more gas or “fart” more at first, but the process of passing gas can relieve bloating and abdominal pain related to trapped wind. Simethicone comes in chewable tablets, which are often flavored. They are generally safe and can provide some relief, though there is little clinical evidence behind them. Some people also swear by activated charcoal. Taken before or after a meal, charcoal pills could reduce symptoms. I have not tried it, but there is limited clinical evidence to support their use. It’s also important to note that charcoal pills can interfere with the absorption of medications and stain your teeth and clothes.

Probiotics are OTC supplements that come in pill or powder form. I’m a huge proponent of probiotics — and of all the OTC solutions for gas and bloating, they have the most evidence behind them. They contain live active cultures of beneficial bacteria found in a healthy digestive tract. This healthy bacteria lives in the gut to keep unhealthy bacteria in check. Gut dysbiosis, or an imbalance of healthy and unhealthy bacteria in the gut, is common in patients with endometriosis. (You might also hear this referred to as small intestinal bacterial overgrowth, or SIBO.) The medical community debates whether or not probiotic supplements are actually helpful. Opponents say you shouldn’t waste your money: these supplements are expensive and not worth it, given that very few of the bacteria are alive by the time the supplement reaches your gut, and that even fewer are able to colonize the intestines. However, there are also plenty of proponents, and plenty of research to say that probiotics can play an important role in reducing GI symptoms like gas and bloating.

There are many probiotics available on the market today. Don’t be fooled by advertising. Instead, check the label. Any good probiotic should contain strains of lactobacillus and bifidobacterium, the two most well-researched strains of healthy bacteria used in probiotics. Your supplement should also contain at least one billion CFUs (colony-forming units) of said bacteria. Probiotics consume the healthy prebiotic fiber found in fruits and vegetables. Therefore, you should eat plenty of these foods to help sustain the growth of probiotics so they are more likely to colonize your gut. Probiotic supplements are safe for long-term use and may even have additional health benefits, such as reducing anxiety and depression. There are many brands, but way back in college, my gastroenterologist back in Boston recommended Align to me. Of all the types I’ve tried, Align remains my favorite.

2. Home Remedies for GI Symptoms

Now, I’m not saying you should try any sketchy Pinterest remedies for constipation, diarrhea, or bloating caused by endometriosis — but there are some tried-and-true at-home remedies that can help soothe GI symptoms.

For example, have you ever heard someone say “coffee makes me poop?” It’s true: a cup of coffee can be an effective remedy for constipation. Basically, your intestines contract rhythmically in a process called peristalsis that helps move food and poop along the digestive tract. Coffee appears to speed this process. We still don’t really know why this is the case, but it isn’t because of the acidity, the temperature, or even the caffeine. While caffeinated coffee can produce stronger effects, as it speeds the contractions of the intestines even more than coffee itself, decaffeinated coffee has been found to have the same laxative properties. If you suffer from diarrhea, you may want to avoid coffee for its laxative effects.

When you have diarrhea, eating a bland diet can help soothe your intestines and make your stool more solid. Growing up, my mom swore by the BRAT diet whenever we were sick — bananas, rice, applesauce, and toast — and it always worked. You may feel tempeted to choose whole-grain rice or toast for the health benefits, but when you have diarrhea, white may be the better option. This is because processed white grains contain less fiber, as the manufacturing process removes the germ, which is the part of the grain with the most fiber. When you want to poop, fiber is your friend — but when you are already pooping too much, it may be time to cut back.

I also swear by the healing properties of tea for just about anything, but especially for GI upset. As I mentioned previously, I recommend steering clear of laxative teas including senna, since this is a stimulant laxative that can cause cramps and diarrhea. However, other types of tea are well-suited to different GI symptoms. Peppermint tea can help with bloating, while ginger tea can soothe the digestive tract if you are suffering from nausea or diarrhea. Additionally, dandelion root tea may act as a mild laxative. Green tea is also thought to have a generally positive effect on digestive health and reduces inflammation, which is great news for endometriosis sufferers.

3. Managing Symptoms with Diet

Research shows that food allergies and intolerances, for whatever reason, are more common in people suffering from endometriosis. We still don’t really know why this is the case, but some doctors have proposed that the bodies of people with endometriosis are just more sensitive than others. Inflammation also links the two, as it plays a role in both endometriosis and food allergies. If you have endometriosis, it’s worth asking yourself whether your GI symptoms could be due to an underlying food intolerance or allergy.

Keeping a food diary can help you identify if you might have a food intolerance or allergy. This printable template was designed for IBS sufferers, but is generic enough for use with endometriosis, too. (You’ll find the Bristol stool scale below for rating your bowel movements.) Notice the days when your symptoms are worse, and see if there are any commonalities between them. Common culprits include gluten, dairy, and fructose. While the low-FODMAP diet was originally created for IBS, some endo patients also seem to be intolerant to FODMAPS, too.

How to Read the Bristol Stool Chart - Poop Types 1-7 • Seed
Image Source: Seed

Both food intolerances and allergies can be treated by avoiding the food that causes a reaction. However, it’s important to know the difference between the two. Allergies, unlike food intolerances, can have a long-term effect on your health. For someone who is lactose intolerant, eating milk accidentally may cause a few hours of upset — while for someone with a milk allergy, eating milk could have serious consequences, or even put their life in danger. An allergist can perform testing if you are worried your intolerance might actually be an allergy. In this testing, a small amount of an allergen is injected under your skin and the allergist will check for swelling at the site of injection. Similarly, a gastroenterologist can do blood tests and biopsies of the small intestine (during an upper endoscopy) to check for celiac disease, in order to distinguish it from non-celiac gluten sensitivity.

4. Improving Gut Health to Manage Symptoms

Of all the causes of GI distress, among both endometriosis sufferers and non-endo sufferers, poor gut health may be the most common. We live in a culture that promotes poor gut health. Heavily processed, low-fiber foods like sweets and chips don’t provide the nutrients needed to support healthy bacteria in the gut — yet these foods form the bulk of the American diet. We also live in a capitalist culture where we are told we need to be constantly productive, fostering an environment laden with chronic stress that takes a toll on gut health. As I shared in an old tweet, I once overheard a girl at my high school say that she “didn’t have time to poop” because she was so busy. Like, what?! Are you okay?!?!

But as much as I like to kid, good gut health is no joke. Our microbiome, comprised of the healthy bacteria in our gut, isn’t only responsible for the digestive tract: it supports everything from good mental health to a strong immune system. Good gut health is good health, period — which is why, endometriosis or no, we all need to take better care of our digestive tracts. Unfortunately, there’s a lot of misinformation out there about the gut, especially since gut health has become one of the latest Goop fads. So, setting aside the turmeric lattes and vaginal steaming — how do you actually promote a healthy gut?

I hate to be the bearer of bad news, but the magazine covers have got it all wrong: there’s no quick-and-easy secret to improving your gut health. Instead, it all boils down to things you’ve probably heard before and just didn’t want to have to implement. And trust me, I get it: I get that most of us hate running and would rather die than give up cake and wine. But at the end of the day, you can’t cheat your way into good gut health. You have to reduce the processed foods, sugary snacks, and animal products in your diet, and focus on whole grains, fruits, and vegetables that feed the digestive tract with healthy prebiotic fiber. Get enough sleep, reduce your stress levels, and maybe exercise a few times a week. It really is that simple.

If you want to go above and beyond, consider taking a well-researched probiotic supplement and consuming fermented foods that are also rich in probiotics. Sauerkraut, kimchi, kombucha, and kefir are all examples of cultured foods and beverages that contain gut-healthy probiotics. But it’s important to know that none of that matters if you aren’t creating a gut-healthy environment by laying down the foundations of diet, exercise, sleep, and mental health. You can feed your body all the probiotics you want, but they won’t be able to survive in a digestive tract that is stressed, tired, out of shape, and malnourished. In order for probiotics to work, you have to create the ideal environment for healthy gut bacteria to thrive.

What I Eat in a Day with Endometriosis

Even before I had to start paying attention to what I eat for my endometriosis, I’ve always been obsessed with food. I’m constantly fascinated by new combinations of flavors and always looking for unique new ways to eat my veggies and whole grains. Cooking and baking are two of my favorite pastimes, and I love experimenting with new recipes — often using David as my guinea pig!

When I’m not blogging, reading, or pinning new recipes to my Pinterest boards, I’m usually cooking or eating something deliciously gluten- and dairy-free. Eliminating gluten and dairy for endometriosis was something that felt incredibly intimidating and restrictive to me at first, so I turned to a lot of “What I Eat in a Day” blog posts and YouTube videos for inspiration. Soon, I found that people were enjoying variations on a lot of the same foods I love and enjoy, without experiencing an endo flare afterwards. I decided to try the gluten- and dairy-free diet for myself.

What sold me on the gluten- and dairy-free diet for endo was the way it made me feel. I used to experience endo belly every. Single. Day. Not anymore! Eliminating gluten and dairy keeps my bloating at a minimum, which means my pants still fit at the end of the day and I’m comfortable enough to stay focused throughout the workday. I’m not saying this solution is going to work for every endo babe, but I do think it’s worth trying to identify if you have a food intolerance that could be contributing to your endometriosis symptoms.

My doctors advised me to try eliminating gluten and dairy — and I recommend you consult with your own doctors before making any dietary changes yourself! You never know if you might have a deficiency or complication that would make a gluten- or dairy-free diet dangerous for you, so turn to the experts who know the human body best. That being said, I want to be a part of showing people that gluten- and dairy-free doesn’t equal a death sentence. You can still enjoy delicious foods without experiencing an endo flare — here’s how I do it!

pasta dish on white ceramic bowl

Throughout the day: I am making a conscious effort to drink more water and water-based liquids, as opposed to running solely on coffee! As a result, I always keep the fridge well-stocked with lemon Polar Seltzer, lemon or raspberry Hint water, and Health Ade Pink Lady Apple kombucha to sip on throughout the day.

9:00 AM: I start every morning with cold brew coffee from Califia Farms, alongside a full breakfast. Breakfast is my FAVORITE meal of the day — I would eat bacon and eggs all day, every day if it wouldn’t kill me — so it’s naturally one that I never skip! Lately, I’ve been loving Simply Elizabeth’s Maple + Almond Butter granola on top of some vanilla almond milk yogurt, with a side of strawberries. I also like to fry an egg over-hard with gluten-free avocado toast (my favorite GF bread is Canyon Bakehouse), or even make a green smoothie with spinach, pineapple, mango, and almond milk.

11:30 AM: For lunch, I usually am throwing together a mix of frozen veggies with protein. A lot of the time, I eat vegan by coincidence, though one of my favorite animal proteins is chicken sausage. One of my favorite lunches is a chopped and seasoned sweet potato fried up with chicken sausage and kale in a bit of olive oil. Another is sauteed cauliflower rice (I like the blends from Cascadian Farm) with a side of black beans simmered with onions and spices. Something I used to eat more of that I haven’t had since moving is sushi — we had a great local grocery store with delicious, freshly-made veggie rolls back in Cleveland (which I would dip in gluten-free tamari sauce from home). Often, I top off lunch with a cookie, like Nothin’ But’s Granola Cookies or Emmy’s Chocolate Macaroons, for just a touch of something sweet.

3:00 PM: I’m typically hungry in the afternoons, so I reach for a snack. I keep things like GoGo Squeez cinnamon applesauce packets, Skinny Pop popcorn, and single-serve packs of gluten-free pretzels (which I eat with hummus) on hand for occasions like these. I also like to bake, so sometimes I snack on dessert; recently, I made a gluten-free, dairy-free strawberry shortcake that I ate with So Delicious Coconut Whip (mmmmm….). A lot of the time, this is when I hit my afternoon slump, so I might also treat myself to an iced coffee at Dunkin’ — a medium iced coffee with extra almond milk when I’m feeling healthy; a medium iced caramel swirl with extra almond milk if I need a pick-me-up on a bad day.

5:30 PM: The earlier I wake up, the sooner I find myself ready for dinner. Lately, I’ve been ready to eat around 5:30 or 6:00 PM most days, which is early for me! I start cooking when I get hungry, which takes me anywhere from 20 minutes to an hour. I love experimenting with new recipes — some of my current favorites are coconut curried lentils and spinach, rice cooker Spanish chickpeas and rice, and, for an easy meal, a concoction I created of Banza chickpea cavatappi, Rao’s tomato herb sauce, sauteed chicken sausage, and steamed broccoli. We also make baked chicken in a Greek marinade about once a week, which we keep in the fridge for making salads or Buddha bowls.

8:30 PM: Nighttime is when I start to get snacky! I don’t follow food rules, so I let myself eat when I’m hungry, as long as it’s not so close to bedtime that I’ll get a stomachache. If I need something sweet, I like So Delicious Cookie Dough Ice Cream made with coconut milk. Or, for something savory, I might pop a bag of Skinny Pop pocorn to share with David or eat some Garden Veggie Good Thins made from rice — which are now, thankfully, gluten-free! On cold days, I usually end my day with a cup of black tea and almond milk, but those days are getting fewer and farther between now that it’s summertime.

How to Start the Endo Diet on a Budget

Disclaimer: I am not a medical professional. As always, please consult with your doctor before making any dietary or lifestyle changes!

*Author’s Note: I usually use the term “people with periods” to talk about patients with endometriosis, in order to be as inclusive as possible. I don’t plan to stop doing this. I recognize that transgender and nonbinary folks also struggle with endo, and that speaking of endo in terms of “women” and “females” can be an incredibly dysphoric experience for them. That being said, I chose to use the term “womxn” in this context to emphasize the societal constraints and discrimination unique to those of us who present as female, while still maintaining an inclusive definition of the endometriosis community.

Having endo is expensive. We don’t often talk about it — probably because, as womxn,* we’re discouraged from talking about money (it’s not something that “good girls” do) — but between medical debt, copays, and prescription meds, the cost of having endometriosis is steep. And that doesn’t even take into consideration the lifestyle changes needed to manage endometriosis on a daily basis.

For me, freelancing has been one of the biggest gifts for my health. It allows me to take time off as needed for medical appointments, adjust my working hours when I’m fatigued or in pain, and gives me the flexibility to work more or less depending on how I feel. But freelancing is also incredibly unstable, especially compared to the salaried job I had before. Thanks to COVID-19, I’ve been struggling more than ever, between trying to pay my bills and stay healthy with an inflammatory disease.

Living on a limited budget, with me freelancing and David working as a medical resident, we try to cut costs wherever we can — but one of the places I’m not willing to compromise is my health. Eating a gluten-free, dairy-free diet for endometriosis sometimes means buying pricey supplements or substitutes. The way I see it, though, it also prevents me from making expensive emergency room visits, only to be told there’s nothing the doctors there can do for me.

Still, I recognize that not everyone has the privilege of paying steep price tags for better health. In college, when I cut ties with my dad, I experienced living on an incredibly limited budget firsthand. Thankfully, I received financial support from my mom, but admittedly, there were more than a few weeks when I couldn’t afford to grab a coffee or Chipotle with my friends because I needed to buy groceries or pay my credit card bills. At the same time, I was also incredibly stressed and always getting sick — I had recurrent vaginal infections; one time, I had strep throat for almost a month.

These two experiences have taught me a lot about managing my endometriosis through diet. Getting sick all the time taught me the importance of taking care of my health, by eating well, exercising, going to therapy, and taking my meds, while living on an extreme budget taught me how to save a quick buck on my grocery bills. As I incorporated the endo diet into my lifestyle, I valued the tangible changes this diet made in my everyday health and quality of life, while still looking for ways to save money where I could.

Anyone with endometriosis knows that endo doesn’t strike when it’s most convenient for us. Endo doesn’t care about our budgets or whatever else is going on in our lives at the time. It’s entirely up to us to look out for our physical health by making investments in proper nutrition to help us manage endo, while looking out for our financial health by cutting costs whenever possible. As I said before, our physical health is a necessary investment to make in our present and our future — and we need to value it, even as we work toward our financial goals.

That’s where this blog post comes into play. Whether you’re a college student struggling to keep up the endo diet on a budget or a freelancer like me reeling from lost income due to COVID-19, I’m here to help. Today, I’m sharing a few of the ways that I save money on the endo diet to help this lifestyle change feel less impossible and more realistic for your wallet.

Change how you look at your diet.

The gluten-free, dairy-free diet for endo can already feel overwhelming. So many of us grew up on a standard American diet of boxed mac ‘n’ cheese and delivery pizza. For a lot of us, eating gluten-free and dairy-free is outside our comfort zones.

When adopting a diet that’s different from what you’re used to, it’s important to keep motivation in mind. Especially when there’s a steep price tag associated with it, any lifestyle change requires you to know your “why.” Remembering your motivation in times when the going gets tough reminds you why you started this journey in the first place, and helps you combat the urge to quit.

For me, it helps to look at food as medicine. If your loved one just had a heart attack, you probably wouldn’t buy them a fast food burger and fries for dinner. In fact, one of the first lines of treatment for hypertension — a precursor to cardiovascular disease — is the DASH diet, which focuses on eating plant-based whole foods and minimizing added salt and sugar. So, why should endo be any different?

Treating your endo as if it’s not as serious as a heart attack, or as if the endo diet isn’t as important to maintaining your health as the DASH diet is to preventing heart disease, minimizes the challenges you go through on an everyday basis as a result of endo. As womxn in the healthcare system, we already face so much discrimination and disbelief. Don’t add yourself to the list of people trying to erase your symptoms or write off your pain as “normal” when it’s not.

My doctors recommended I try a gluten-free, dairy-free diet for my endo. The way I see it, this recommendation is the same as any of the prescriptions they’ve written me. I strive to take it just as seriously, and as a result, I’ve had excellent results in terms of the endo diet’s effect on my overall health, the severity of my pain, and my quality of life.

Treat meat as a side dish.

When I think of the traditional American diet, a quarter-pound cheeseburger is one of the first things that comes to mind. Meat is often the star of the show on the American dinner plate. While there’s no medical reason for you to cut out meat altogether — especially lean, white meats like chicken and turkey — on the endo diet, I’ve found that minimizing the amount of meat I consume helps me cut down my grocery bill and encourages me to eat more plant-based foods like fruits and veggies.

Beyond managing endometriosis, there are still compelling health benefits for eating a flexitarian diet. The term “blue zone” describes a geographical region of the world where people live longer, healthier lives than average. Some blue zones include Italy, Greece, and Japan. Researchers have found that one of the commonalities in these blue zones is that people in those regions eat a primarily plant-based diet, eating meat, on average, only five times per month. Eating less meat, therefore, appears to promote longevity and reduce chronic disease risk.

Processed and red meats in particular — staples of the typical American diet — are linked with chronic disease development and earlier mortality. That’s why when I do choose to splurge on meat, I opt for lean meats like chicken, turkey, or pork. While organic meat is more expensive, I think it’s worth buying organic meat less often, as opposed to conventionally farmed meat more frequently. When it comes to managing endo, buying organic meat minimizes your exposure to artificial hormones (which are often fed to factory farmed animals to “fatten them up” before slaughter) that can further disrupt your endocrine system.

Stock up on pantry staples.

Fruits, vegetables, whole grains, beans, legumes…. all of these foods are “safe” to consume on the endo diet, and safe for a limited budget. So, why do we think of a gluten-free, dairy-free diet as so expensive? I think it’s because we see lots of influencers in this space splurging on pricey alternatives to our favorite foods — think Daiya ‘pepperoni’ pizzas and Amy’s rice macaroni and cheeze. However, I’m of the opinion that it’s healthier to eat gluten and dairy that’s cooked from scratch than it is to rely on packaged foods.

If you’re going to adopt a gluten-free, dairy-free diet for endometriosis (such as the endo diet), replacing bread and cheese with processed alternatives won’t benefit your health or your wallet. Foods like French fries, corn pasta, soda, and margarine are all technically gluten- and dairy-free, but still have an inflammatory effect on your body that could lead to an endo flare. And, these expensive packaged foods use greenwashing to charge you extra for products marked with marketing language such as “organic,” “natural,” and “gluten-free.”

Some of the least processed and most affordable foods you can eat on the endo diet don’t require you to shop in a special section of the grocery store or buy a box with some bougie certification on it. I like to stock up on pantry staples like salt-free canned beans (garbanzo, black, and great northern are my favorites), canned tomatoes, canned artichoke hearts, raw cashews (which can be soaked to make creamy dairy-free sauces), and almond milk, in addition to fresh produce. Making your own endo-friendly substitutes for things like salad dressing, crackers, and cookies can also save you from paying the “natural” and “organic” tax at the grocery store.

Batch cook whenever possible.

On lazy days, I understand the urge to rely on frozen meals from the grocery store — but giving into that urge may be doing you more harm than good. Even when a frozen meal is marked “gluten-free,” “dairy-free,” and “organic,” you’re still potentially sacrificing nutrient content and exposing yourself to inflammatory ingredients by opting for a frozen option.

Marketing terms like “gluten-free,” “dairy-free,” and “organic,” aren’t heavily regulated and don’t prevent companies from loading their products with salt, sugar, and preservatives. Seeing these words on a label doesn’t even necessarily guarantee that a product is actually what it says it is, since companies basically only need to meet enough regulations when using these terms so as not to get sued for using them. You’re best off looking for product certifications from the USDA and independent organizations like the Gluten-Free Certification Organization and Vegan Action. However, for your wallet, these certifications can mean a huge markup on price tags, since the cost of certification is often high for manufacturers.

Still, I understand the need for convenience in this crazy world we live in — which is why I highly recommend saving a few go-to recipes that you can scale up to cook in batches. You can then freeze the leftovers to create your own frozen meals that are free of preservatives, yet still just as convenient as the “real thing.” While often associated with dieting and the “clean eating” movement (blergh), meal prepping is also a great way to ensure you have lazy meals available for busy weeknights. The blog Simply Taralynn has an awesome guide to gluten-free, dairy-free meal prep on a budget — I highly recommend you check it out!

Additionally, frozen fruits and veggies don’t compromise nutrient content, but will save you a quick buck compared with buying fresh. I always like to stock up on frozen veggies like zucchini noodles, cauliflower rice, broccoli, and kale, which can be turned into a quick and easy meal by simply adding a whole grain and a protein, as well as pineapple, mango, and spinach, to blend into my favorite green smoothie with a bit of almond milk for a speedy breakfast or snack.

The Best Packaged Foods for the Endo Diet

“Packaged foods” and “endo diet” seem like complete antonyms — after all, eating for endometriosis means focusing on plant-based whole foods and minimizing processed goods. But in the modern world, let’s face it: packaged foods are just a fact of life. For endometriosis, it’s important to eat whole foods like fruits, vegetables and whole grains, but sometimes, eating quickly or on-the-go takes priority over optimum health.

Even so, I don’t think eating packaged foods means resigning to symptoms. In today’s grocery stores, there are plenty of gluten-free, dairy-free packaged options with (mostly) whole ingredients that won’t trigger your endo. Still, it can be difficult to know where to find these foods if you aren’t used to eating on the endo diet. Skipping meals to manage symptoms is NOT an option, so it’s important to have go-to snacks and meals you can count on in a pinch.

To help you get started, I compiled this list of packaged and pre-made foods that are convenient and delicious, yet don’t trigger my endo symptoms. Remember: everyone is different, so you may still struggle with some of these foods even though I can tolerate them just fine. The best way to learn what does and doesn’t work for you is through trial and error. However, this list avoids common triggers for people with endometriosis, such as gluten and dairy, as a starting point for building a healthier, happier diet!

On-the-Go

Whether you’re road tripping or running errands all day, sometimes you don’t have the time to stop at home for a snack or meal as you’re rushing from point A to point B. That’s why I always make it a point to know where I can stop to get my fix without triggering symptoms when I’m running around. This shortlist of snacks can be found at almost any convenience store to tide you over until your next stop:

  • Banana + Justin’s nut butter. Admittedly, it can be tricky to find fresh produce at a truck stop or convenience store — but in my experience, bananas are pretty universal. To make this snack more substantial, add some protein with a packet of Justin’s nut butter (varieties include almond, peanut or chocolate hazelnut), which can be found at many gas stations.
  • Bob’s Red Mill oatmeal cup. Bob’s Red Mill makes many amazing gluten-free products, including their oatmeal cups, which are rich in fiber due to their inclusion of flax and chia seeds. Many gas stations have hot water for brewing tea or microwaves you can use to make your oatmeal free of charge.
  • Rice Chex or Cheerios with dairy-free milk. You can usually find individually packaged cereal cups in convenience stores. Mainstream cereals like Rice Chex and Honey Nut Cheerios happen to be gluten-free. Pair with an individual bottle of soy or almond milk to make it a substantial snack.
  • Larabar or The Gluten Free Bar. Bars can tide you over in a pinch when you just need something small to get you through a hunger pang. The Gluten Free Bar’s Dark Chocolate + Coconut and Larabar’s Coconut Chocolate Chip (sensing a theme here?) are my favorite flavors, but they come in varieties for every palate.
  • Boom Chicka Pop kettle corn. Popcorn is a healthy whole-grain snack that’s packed with fiber to keep you full — but finding packaged popcorn that doesn’t include butter or some suspicious cheese-flavored dust can be a challenge. Boom Chicka Pop’s kettle corn is the perfect balance of salty and sweet that makes snacktime a breeze on-the-go.
  • Mini rice cakes. Rice cakes are a must-have snack for anyone who is gluten-free. Skinny Pop and Quaker both make mini rice crisps in delicious dairy-free flavors, such as caramel and sea salt. If you’re lucky, you might even be able to find my old college favorite, mini rice cakes dipped in dark chocolate. Mmm!
  • Roasted unsalted nuts. Nuts are packed with protein and healthy fats to keep you full when you’re in a hurry. You can pick up a package of roasted unsalted (or low-sodium) almonds, cashews or peanuts at most convenience stores. (There’s nothing wrong with a little salt, but too much can leave you with a bad case of endo belly.) These to-go packs of nuts tend to be pre-portioned for perfect snacking.

Ready-Made Meals

Most days, I try to cook for myself, since eating frozen or delivered meals tends to make me painfully bloated. But as we all know, there is always the odd day out when we need a fast dinner before rushing toward our next commitment. In preparation for those days, I like to stock up on some of these ready-made gluten-free, dairy-free options that won’t make my endo flare:

  • Trader Joe’s Organic Acai Bowl. Trader Joe’s is a haven for all the endo babes out there. They make products that cater to every diet, and their organic acai bowl is no exception. This frozen meal makes the perfect breakfast or lunch and can be easily defrosted with a few seconds in the microwave. It even comes with strawberry slices and coconut granola on top for added fiber and crunch.
  • Daiya Meatless Pepperoni Pizza. Pizza may not be the healthiest choice, but sometimes you just need to devour something cheesy and delicious! Daiya’s Meatless Pepperoni Pizza is gluten-free and vegan to satisfy all your cravings without making you ill. I’m not actually vegan myself, but I’ll be the first to admit that Daiya’s meatless pepperoni and soy cheeze are spot-on imitations of the real thing.
  • Amy’s Rice Macaroni and Cheeze. Amy’s makes tons of delicious gluten-free frozen meals, but the rice macaroni and cheeze is a personal favorite. Mac ‘n’ cheese is my favorite comfort food, but often leaves me bloated with endo belly. This version uses rice noodles and Daiya’s vegan cheddar cheeze for a creamy, satsifying take on an old classic.
  • Dr. McDougall’s Pad Thai Noodle Soup. I discovered this quick and easy meal choice in college among our convenience store’s selection of ramen noodles. This vegan pad thai noodle soup is pre-packaged, fast and easy to make (just add boiling water and wait!) and tastes delicious. Better yet, it contains only a few simple ingredients that you can pronounce, so you can feel good about what you’re putting into your body.
  • Dr. Praeger’s Black Bean Quinoa Veggie Burger. There’s nothing better than throwing a veggie burger on the griddle at the end of a long day, am I right? Maybe I’m just weird, but there’s something so satisfying about Dr. Praeger’s black bean and quinoa burgers that’s even better than the real thing. This brand makes tons of veggie burgers for every taste, but I like these for their spicy kick. My pro-tip? Top with smashed avocado and lime for a taste of the Southwest!
  • Seeds of Change Quinoa and Brown Rice. I always keep Seeds of Change Organic Quinoa and Brown Rice packets in my cupboard for emergencies. When I really need to hustle, these cook in the microwave in just 90 seconds. With olive oil and garlic, they offer healthy fiber, fats and whole grains. Pair a serving of this with some salad or frozen veggies and you get a quick lunch or dinner that will hold you over whenever you’re in a rush.

Fast Food

For obvious reasons, fast food isn’t ideal on the endo diet — but as someone in eating disorder recovery, I firmly believe that eating fast food is always better than skipping a meal. Thankfully, options are improving at many mainstream fast food chains, making it easier than ever to order something that won’t trigger an endo flare. Here are some of my go-to orders at my favorite fast food restaurants when I’m running around on-the-go:

  • Starbucks: Iced Coconut Milk Cascara Latte and Blueberry Oatmeal. Almost any coffee choice can be customized at Starbucks to fit the endo diet, but the iced coconut milk cascara latte has become a recent favorite of mine. This drink is made with Starbucks’ blonde roast, poured over ice, with coconut milk and cascara sugar sprinkled on top. It’s lower in sugar than drinks containing flavored syrups, but still has that hint of sweetness I love! For snacking, the blueberry oatmeal is jam-packed with healthy fiber (and fats, if you add the nuts on top) to keep you full longer. Just skip the brown sugar packet — and if you need some extra sweetness, opt for the agave instead.
  • Chipotle: Brown Rice Chicken Burrito Bowl. I could practically write a love letter to Chipotle, but that’s a blog post for another time. Instead, let me tell you about my favorite burrito bowl to order at Chipotle. I always opt for brown rice to sneak in a serving of whole grains, then top with chicken, plenty of veggies and a heaping spoonful of guac. The fajita veggies, corn salsa, pico de gallo and romaine lettuce are all delicious, fresh options to add a little color to your bowl — and, of course, extra vitamins to your bod.
  • Panera: Chicken Tortilla Soup and Side Salad. Panera is best known for its bread and mac ‘n’ cheese, so you might not think of it as a gluten-free haven. However, their grain bowls and some of their soups are great options for eating GF on-the-go. The chicken tortilla soup makes a delicious dairy-free lunch or dinner on the go. Choose a You-Pick-Two combo with any side salad (minus the cheese) to sneak in extra veggies and keep yourself fuller for longer.
  • Shake Shack: Burger with Gluten-Free Bun. Shake Shack is a not-so-guilty pleasure of mine! When you’re gluten-free and dairy-free, this burger joint might not seem like your new favorite fast food restaurant, but unlike most, Shake Shack actually carries a gluten-free bun (rather than offering you a sad, wilted lettuce wrap for your patty). To keep it gluten- and dairy-free, skip the Shack Sauce and cheese and instead load up on lettuce, onion and tomato, adding ketchup or mustard if you need a little extra flavor.
  • Blaze Pizza: Gluten-Free Build-Your-Own Pizza with Daiya Cheeze. Blaze Pizza was a cult favorite on campus at Boston University. Even Lebron James owns stock in them! This fast-fired pizza chain is rapidly spreading around the U.S. — and if you’re lucky to have one nearby, it’s also a great place to eat gluten- and dairy-free. Blaze carries Daiya cheeze and a gluten-free crust. If avoiding dairy, choose spicy or regular red sauce and top with your favorite gluten-free meats and veggies for a hearty meal that doesn’t skimp on flavor. They’ll even do a glove-change for you if you have celiac or prefer to be extra-careful about your GF diet!
  • Sweetgreen: Build-Your-Own Salad or Warm Bowl. Of all the places I miss from my time in Boston, Sweetgreen might be my most beloved. This build-your-own salad place has locations around the Northeast, as well as the Pacific Coast. As you can imagine, it’s a wonderful place to load up on veggies and gluten-free whole grains. They even make a variety of flavorful dairy-free and vegan salad dressings in-house to add some extra zing to your salad or grain bowl. Just make sure you avoid options that might trigger a flare, such as cheese or the za’atar breadcrumbs, when building your bowl.
  • + BONUS: The Find Me Gluten-Free App! I wouldn’t want you to miss out on local fast casual options that carry gluten-free and dairy-free options — of which my home city, Cleveland, Ohio, has many! For that reason, I also suggest you download the Find Me Gluten-Free app. It’s free in the App Store and allows you to use location services to track down a gluten-free restaurant near you, as well as to view menu options and reviews from real-life gluten-free eaters. If you have celiac disease, I especially recommend downloading this app, as it allows you to view ratings on the restaurant’s risk of cross-contamination.

Supplements for a Gluten-Free, Dairy-Free Diet

Disclaimer: I am not a medical professional. Please consult your doctor before making any changes to your diet, medication or supplement routine!

Well, fam…. after about two months’ reprieve, I am officially back on the gluten-free bandwagon.

When I first found out I most likely had endometriosis — not, as previously diagnosed, IBS — I quit my low-FODMAP diet and started eating whatever I wanted. For the first few weeks, it was great. Then, I quickly learned that I could not, in fact, eat whatever I want with endometriosis if I wanted to minimize my symptoms and maximize my well-being.

Don’t get me wrong: I don’t have celiac disease and I will not harm my long-term health if I indulge in a slice of pizza or a bowl of cookie dough ice cream from time to time. (And I am happy to do so, even now.) But in terms of managing my symptoms on a day-to-day basis, I discovered that a gluten-free and now (mostly) dairy-free diet helps me feel my best the most consistently.

My doctor recommended the gluten-free diet to me because she has found a link between endometriosis and non-celiac gluten sensitivity in her patients. As for the dairy, I’ve long known I was lactose-intolerant, but my love for macaroni and cheese surpassed my disdain for bloating. Until very recently, I was content to keep eating dairy despite my gluten-free lifestyle — but after a bad flare-up, I decided to give ditching dairy another go , if only for my uterus’s sake.

The trial run of my gluten-free, dairy-free diet has gone well so far, so I’ve decided to make it a quasi-permanent lifestyle change — at least until we see how my laparascopy improves my endometriosis symptoms. However, adopting a gluten-free, dairy-free lifestyle has raised some concerns that I may not be getting all the nutrients I need. For example, while I drink coffee with almond milk creamer and have coconut milk yogurt once a day, in addition to the occasional feta, Parmesan or goat cheese garnish, I still suspect I’m only getting about half the calcium I need for strong, healthy bones.

That being said, I know a lot of women with endometriosis are in the same boat. Many of us follow the endo diet, which suggests you limit gluten and dairy, or have co-occurring food intolerances that lead us to swear off gluten and dairy. If you’re on a gluten-free, dairy-free diet, you may — like me — be wondering what supplements, if any, you need to take to maintain optimum levels of vitamins and minerals. So, I did my research, and now I’m here to share what I’ve learned with you all!

Vitamin and Mineral Deficiencies on a Gluten-Free, Dairy-Free Diet

Unfortunately, my research suggests that vitamin and mineral deficiencies on a gluten-free, dairy-free diet may be fairly common. The odds of deficiency largely depend on what you eat (especially the variety of your diet) as well as the reasons for being on a gluten-free, dairy-free diet.

Gluten-free diet and nutrient deficiencies: People adopt a gluten-free diet because they have a sensitivity to gluten, such as celiac disease or irritable bowel syndrome.The likelihood of nutrient deficiencies on a gluten-free diet depend on the cause of your intolerance to gluten.

The first type of gluten sensitivity is celiac disease, which is an autoimmune disorder in which gluten causes the small intestines to attack themselves. People who have celiac disease and don’t know it have been consuming gluten for years. This exposure to gluten damages the intestines, resulting in the uncomfortable symptoms of celiac disease (although some patients show no symptoms at all). The more damaged the intestines, the fewer vitamins they can absorb from your food, leading to deficiencies. After being on a gluten-free diet for a while, your intestines will eventually heal, reversing the damage and therefore the deficiencies. However, you may need to supplement your diet in the meantime to help your body absorb more nutrients than it is receiving from your food.

Non-celiac gluten sensitivity (NCGS) is the second type of gluten sensitivity. It is not an autoimmune disorder and does not compromise the absorption of vitamins and minerals through the intestines. Irritable bowel syndrome (IBS) is similar, in that it can cause an intolerance to gluten that does not result in malabsorption or damage to the intestines. Therefore, if a person with NCGS or IBS suffers from vitamin and mineral deficiencies, the cause is probably poor diet. Unfortunately, few gluten-free foods are enriched with the vitamins and minerals found in gluten-containing products, so anyone on a gluten-free diet can be at risk, whether they have celiac disease or NCGS.

For this reason, it’s recommended you NOT go on a gluten-free diet to lose weight or improve your health, despite what “wellness gurus” like Gwyneth Paltrow may say. If you do not have a true sensitivity to gluten, you’re placing yourself at risk of vitamin and mineral deficiencies for no reason, meaning you’re actually harming your overall health. However, there is a huge link between the gluten-free lifestyle and patients with endometriosis: endo patients are more likely to have autoimmune diseases like celiac disease, as well as to be diagnosed with intestinal disorders like food intolerances or IBS. It’s also thought by some that gluten is inflammatory, though there is very little clinical research to support the link between diet and endometriosis. As a result, a gluten-free diet may be appropriate for some patients with endometriosis.

Dairy-free diet and nutrient deficiencies: People adopt a dairy-free diet for many reasons. Some people do not consume any animal products because they are vegan. Others ditch dairy due to an allergy, due to lactose intolerance or due to a medical condition like acne or endometriosis.

Lactose intolerance is a deficiency in the enzyme lactase, which digests lactose, the main sugar found in milk and its byproducts. It can be genetic (especially in Asian-Americans) or can develop when we stop eating dairy for long periods of time. The body only produces lactase in order to digest our mother’s milk as infants. As a result, it will only continue to produce lactase if we continue to consume dairy. If we stop eating dairy for an extended period of time, our body may stop producing lactase — and may not produce it again, even if you choose to eat dairy in the future. This is how I became lactose-intolerant; I developed lactose intolerance after going vegan for six months.

Some people believe that dairy consumption contributes to other medical conditions, and may choose not to eat dairy even though they can digest it. This is especially true of patients with hormonal conditions like polycystic ovarian syndrome, infertility, acne and endometriosis. Many factory-farmed cows are fed hormones to help them grow faster, which are excreted in their milk. As a result, when we consume dairy products, we may be consuming excess hormones from our environment that contribute to symptoms like pain and acne. Other people believe that, like gluten, dairy may be an inflammatory food that contributes to the pain of endometriosis. They may also choose to avoid dairy in their diet.

In any case, the primary cause of vitamin and mineral deficiencies in a patient on a dairy-free diet is, well, diet. American law requires manufacturers to enrich dairy products with vitamin D. As you probably know from the “Got Milk?” campaigns you saw as a kid, dairy is also a good source of calcium, which is important for preventing osteoporosis in old age (especially in people assigned female at birth). Thus, if you choose not to eat these foods, whatever the reason, you may not get enough of the nutrients your body needs to stay happy and healthy.

The only way to know for sure if you are deficient in something is to get tested at your doctor’s office. This usually takes the form of some simple bloodwork. Still, you may be wondering what you can do to enrich your diet and prevent vitamin and mineral deficiencies before they can happen, Just for you, I’ve compiled a list of some of the more common deficiencies found in people on gluten-free, dairy-free diets. I’ll also include information about food and supplement sources of these nutrients to help you feel your healthiest on a gluten-free, dairy-free diet!

B-Vitamins

There are so many types of B vitamins that it can be difficult to keep track of them all. You’ve probably heard of vitamin B12, which is found primarily in animal products. It’s a common deficiency in people who don’t consume meat, eggs or dairy, such as vegans. But did you know that the vitamins that go by thiamin, riboflavin, niacin and folate are also versions of vitamin B?

Bread and cereal products in the United States are enriched with B vitamins as required by law, but many of their gluten-free counterparts are not. This is especially problematic in the case of folate, which women require a steady intake of as young adults in order to sustain a healthy pregnancy later in life.

Thankfully, there are many food sources of B-vitamins that contain neither gluten or dairy. Some gluten-free cereals like Rice Chex and Cheerios are enriched with vitamins and minerals, as are dairy-free products such as almond milk. If you eat meat on your gluten-free, dairy-free diet you shouldn’t need to worry about vitamin B12. (If you are vegan, it’s recommended that you take a supplement to meet your B12 needs.) Other forms of vitamin B, however, may be harder to find in nature. Here are some food sources of the various types of vitamin B:

  • Thiamin (B1): sunflower seeds, black beans, tuna, lentils
  • Riboflavin (B2): mushrooms, spinach, soybeans
  • Niacin (B3): mushrooms, avocado, broccoli, tuna, salmon, chicken breast
  • Pantothenic acid (B5): avocado, broccoli, kale, eggs, animal products
  • Biotin (B7): eggs, amonds, mushrooms, sweet potato, spinach
  • Folate (B9): green leafy vegetables, asparagus, beets, broccoli, lentils

If you are eating a variety of these foods and still don’t feel like you’re getting enough B-vitamins, if you have been told you are deficient or if you have another medical condition (such as depression) that could benefit from B-vitamin supplementation, you may want to try taking an over-the-counter B-vitamin complex. Nature Made products are affordable and gluten-free. For a more luxurious product, try Nordic Naturals.

Vitamin D

Vitamin D deficiencies are not uncommon in the U.S. population, even if you are consuming a diet rich in wheat and dairy products. In fact, Mercy Medical Center reports that as much as 42 percent of the American population may be vitamin D deficient.

There are very few food sources of vitamin D, making it difficult to get enough of this important fat-soluble micronutrient, even on a healthy and balanced diet. Fatty fish, such as salmon and sardines, contain some vitamin D. However, the best source of vitamin D is thought to be sunshine.

Sunshine helps the body produce its own vitamin D. When your body is exposed to sunlight, the sun’s UV-B rays trigger a process that converts cholesterol into vitamin D. Doctors suggest that 10 to 30 minutes of midday sunshine exposure (sans sunscreen) is enough to help the body synthesize vitamin D without elevating your skin cancer risk.

Certain factors put you at higher risk of a vitamin D deficiency. Americans who live in a northern climate — think New England, the Great Lakes region and the Pacific Northwest — may not be able to get enough vitamin D due to lower levels of sunlight in those regions. People on a gluten-free and/or dairy-free diet are also at higher risk of deficiencies, as many wheat and dairy products are enriched with vitamin D.

Lack of consumption, as this is called, is a common cause of vitamin D deficiency. However, patients with celiac disease may also experience malabsorption of vitamin D because their intestines are too damaged from gluten exposure to function properly.

A simple blood test is enough for your doctor to tell you if you are vitamin D deficient. Still, some medical professionals say that every adult should take a vitamin D supplement in the autumn and winter, when sunlight levels reach a natural low. Those with darker skin and/or those at risk of low vitamin D levels (such as people on a gluten-free, dairy-free diet) are recommended to take a vitamin D supplement year-round.

If a blood test finds you are deficient in vitamin D, your doctor may prescribe a megadose of vitamin D to be taken once per week for a defined period (for me, this was six months). After that time, you can take an over-the-counter supplement. Look for vitamin D3, which is most readily absorbed by the body in supplement form. I take Nature Made, but I’m also a fan of HUM Nutrition.

Calcium

Growing up in the United States, I was exposed to the “Got Milk?” campaign often as a kid, making it impossible to neglect the importance of calcium. Dairy is the most well-known food source of calcium — so if you’re on a dairy-free diet, you may worry about how to get enough of it. But contrary to those notorious milk-mustache ads, dairy is not the only food source of calcium.

Many bread products are enriched with calcium, including some gluten-free alternatives, as are many non-dairy milks and fruit juices. Soy products (which, I will note, aren’t ideal for patients with endometriosis due to their phytoestrogenic effects) like tofu, tempeh and edamame contain calcium, too, as do some dark leafy greens — think kale and bok choy.

Calcium is incredibly important for bone health, especially in women (who are at higher risk of osteoporosis as they age). Women under 50 need 1,000 mg of calcium per day, which can be difficult to get on a gluten-free and dairy-free diet, even by consuming all the food sources of calcium listed above. If you are a serious athlete, or don’t eat dairy, Mayo Clinic suggests monitoring calcium levels more closely than the average person.

Food sources of calcium are better absorbed than supplement forms, according to Johns Hopkins. Still, Harvard reports that there are few negative side effects associated with calcium supplements — and those that do exist are minor, such as heartburn and constipation. Hypercalcemia (a medical term for too much calcium in the bloodstream) is rare, even with calcium supplementation, but can cause more serious side effects, such as nausea, vomiting and neurological symptoms.

It’s up to you to weigh the pros and cons of taking calcium supplements on a gluten-free, dairy-free diet to determine if they are right for you. I recommend either having your calcium levels tested by a doctor or tracking your diet for a few days to see how much calcium you’re consuming on average before splurging on a supplement.

Caltrate gummies are an inexpensive and tasty way to get both vitamin D and calcium; they’re both gluten-free and dairy-free, but do contain some added sugar. If you are diabetic or prefer to avoid added sugar, you may want to opt for a pill or tablet instead — as you already know, I love the brand Nature Made!