Endometriosis is often described as a condition of painful periods. For the women living with it, that description barely scratches the surface. Pain that reaches well beyond the period, a bone-deep exhaustion, gut symptoms, painful sex, fertility worries and years of not being believed are, sadly, a very common story in my clinic.
Our understanding of endometriosis has shifted considerably in recent years. It is now recognised as a chronic inflammatory condition that involves the immune system, hormones, the gut and the nervous system, not just the pelvis. I find this genuinely hopeful, because every one of those systems is influenced by how we eat, sleep, move, breathe and live. Nutrition and lifestyle don't replace medical care, but in my experience they can make a real and lasting difference to how women with endometriosis feel day to day.
In this article I'll explain what endometriosis is, why it affects so much more than the pelvis, why the fatigue and pain deserve far more attention than they usually get, and what I've found most helpful in practice, including what to make of the recent interest in creatine.
What is endometriosis?
Endometriosis is a chronic condition in which tissue similar to the lining of the womb grows elsewhere in the body, most often on the ovaries, the lining of the pelvis, the bladder and the bowel. Like the womb lining, this tissue responds to the menstrual cycle, but it has no way to leave the body. The result is inflammation, pain and, over time, scar tissue and adhesions that can bind organs together.
It affects around one in ten women, roughly 1.5 million in the UK and an estimated 176 million worldwide [1]. Symptoms commonly include painful periods, pelvic pain at other times of the month, pain during or after sex, painful bowel movements or urination, heavy periods, fatigue and difficulty conceiving. One of the most confusing features is that the amount of endometriosis found doesn't reliably match the severity of symptoms: some women with extensive disease have little pain, while others with small areas experience severe pain.
Why diagnosis takes so long
In the UK, the average time from first seeing a GP with symptoms to receiving a diagnosis is now 9 years and 4 months, up from 8 years in 2020, and around 11 years for women from ethnically diverse communities [1]. Nearly four in ten women visit their GP ten or more times before endometriosis is even suspected. Scans can identify some forms of endometriosis, but a normal scan doesn't rule it out, and a definitive diagnosis may still require keyhole surgery (laparoscopy).
If you recognise these symptoms and haven't been taken seriously, keeping a pain and symptom diary and asking your GP directly whether endometriosis could be the cause can help move things forward.
More than a gynaecological condition
In 2021, a landmark review in The Lancet argued that the traditional definition of endometriosis as a pelvic disease is outdated, and that it should be understood as a chronic, systemic condition. The authors described effects on metabolism in the liver and fat tissue, inflammation throughout the body, and changes in the brain that contribute to heightened pain sensitivity and mood disorders [2]. Several threads run through this whole-body picture.
Inflammation and the immune system
Endometriosis lesions create an inflammatory environment in the pelvis, and the immune system plays a central role in whether they take hold and grow. Immune cells called macrophages, whose normal job includes clearing away debris, appear to help lesions establish a blood supply and may even encourage nerve growth into them, contributing to pain [3]. Much of this work comes from animal models, but it is reshaping how researchers think about the disease, and it becomes relevant again when we come to creatine.
Hormones
Endometriosis is driven by oestrogen, which fuels the growth of lesions. Lesions can produce some oestrogen locally, and they also tend to respond poorly to progesterone, the hormone that would normally help calm and stabilise endometrial tissue [2]. This is why many medical treatments work by lowering oestrogen or providing a progestogen.
The nervous system and pain
Long-standing pain changes how the nervous system processes pain signals, which helps explain why pain doesn't always match the extent of disease [2]. This is one of the most important, and most hopeful, parts of the picture, so I'll come back to it in detail below.
The gut
Bowel symptoms such as bloating, pain, constipation or diarrhoea are very common, and endometriosis is frequently misdiagnosed as irritable bowel syndrome (IBS) for years. In one clinic, more than a third of women diagnosed with IBS turned out to also have endometriosis [4]. The two can coexist, and gut symptoms deserve attention in their own right.
The exhaustion is real
If you have endometriosis and feel exhausted much of the time, you are not imagining it and you are not being lazy. In a study of more than 1,100 women, frequent fatigue affected just over half of those with endometriosis compared with around one in five women without it, and the difference remained even after accounting for pain, poor sleep, depression and work stress [5]. Yet fatigue is rarely asked about in appointments.
Why inflammation makes you so tired
Endometriosis creates a steady stream of inflammatory messengers called cytokines, such as interleukin-6 (IL-6), interleukin-1 and tumour necrosis factor (TNF). These don't stay in the pelvis. They signal to the brain, partly via the vagus nerve, and switch on what scientists call "sickness behaviour": the same protective programme that makes you want to curl up under a duvet when you have flu [6]. It brings fatigue, low mood, brain fog, a loss of motivation and a heightened sensitivity to pain. It is a sensible response to a short-term infection. When the inflammation never fully switches off, it becomes a constant, draining backdrop to life. Many women I work with describe it as feeling permanently "fluey", and this is very likely why.
Other things that stack on top
Inflammation is rarely the only factor. In clinic, I almost always find several contributors layered together:
Low iron, often from heavy periods, which is worth checking (ferritin is the most useful marker - please do not supplement iron without first checking your levels)
Disrupted sleep, because pain wakes you or stops you dropping off, and poor sleep then lowers pain tolerance the next day
The constant stress of being in pain, which I'll come to next
Blood sugar swings, particularly when appetite is low or meals are skipped on bad days
Gut symptoms, which can affect how well nutrients are absorbed
Low mood, which is both a cause and a consequence of exhaustion
The encouraging part is that several of these are very treatable. Checking for the straightforward causes first (iron, vitamin D, B12 and thyroid function) and then working on inflammation, blood sugar and sleep can make a meaningful difference to energy, even when the endometriosis itself is still there.
Pain, the nervous system and the stress of living with it
When the nervous system turns the volume up
Pain isn't simply a signal travelling from the pelvis to the brain. The nervous system constantly interprets and adjusts those signals, and when pain goes on for months or years, it can become sensitised: it starts amplifying signals, so that the same input produces more pain than before. This is known as central sensitisation, and it is well documented in endometriosis [7]. It helps explain why pain can spread to other areas, why some women still have significant pain after lesions have been surgically removed, and why the amount of disease found doesn't reliably predict how much someone hurts.
Chronic pain is a chronic stressor
This is something I think is badly underestimated. Living with pain day after day is a profound physical stressor, quite apart from the emotional toll of not being believed, missing work or cancelling plans. Pain activates the body's stress response, and chronic activation of that system feeds inflammation. Inflammation in turn sensitises nerves, and the result can be a self-reinforcing cycle of pain, stress and inflammation [8, 9]. Researchers studying this link have suggested that relieving stress should help calm inflammation and, in turn, reduce pain [9].
So when women with endometriosis are told to "try to relax" or "have a nice bath", it can feel dismissive, because it so badly underplays what their nervous system is dealing with. Supporting the nervous system needs to be taken as seriously as any other part of care.
The hopeful part: neuroplasticity
The same capacity for change that allows the nervous system to become sensitised also allows it to settle. This is neuroplasticity, and it is one of the areas I find most rewarding in my work with clients. Gently and consistently giving the nervous system new experiences of safety can, over time, help turn the volume back down.
In practice, that can include:
Breathwork, particularly slow breathing with a longer out-breath, which engages the calming branch of the nervous system
Meditation and mindfulness, which change our relationship with pain sensations rather than trying to fight them
Somatic approaches, which help rebuild a sense of safety in the body through gentle awareness and movement
Yoga and gentle, regular movement, adapted to how the body feels on any given day
Pacing, so that good days don't routinely lead to crashes
The research here is still young, but a systematic review of psychological and mind-body approaches in endometriosis found that they show promise for reducing pain, anxiety, depression, stress and fatigue [10]. In my experience, this work is often the missing piece for women who have tried everything else, and it combines beautifully with nutritional support. I've explored this in more depth on my Healthily podcast.
A personal note
I know some of this from personal experience. I lived with tummy aches and excruciating period pain from my teens, along with a fatigue that had me sleeping for two or three hours most Saturday afternoons. Even though I worked in nutrition and had learned about endometriosis in my training, it simply didn't occur to me that my own symptoms might be serious. I had got so used to living with pain that it barely registered. By the time I was diagnosed, the pain was constant. Surgery, together with targeted changes to how I ate to manage inflammation, transformed my day-to-day life, and I've never needed those afternoon sleeps since. Everyone's experience is different, and mine hasn't been without its challenges, but it's a big part of why I take women's pain and fatigue so seriously, and why I know how much nutrition can help.
Where nutrition fits: what I see in clinic
Many women with endometriosis tell me that food is one of the few things that feels within their control. That matters. Over many years of working with women with endometriosis, I've seen nutritional changes make a genuine difference to energy, gut symptoms, the intensity of flares and how resilient women feel overall. The research is still catching up, and I'll be clear about where the evidence is strong and where it comes from clinical experience, but I'm in no doubt that this is worthwhile work.
An anti-inflammatory foundation
Large population studies consistently find that diets higher in red and processed meat and trans fats are associated with a higher risk of endometriosis, while diets rich in fruit, green leafy vegetables and omega-3 fats are associated with a lower risk [11, 12]. Given how central inflammation is to endometriosis, this is the foundation I build on with almost every client:
A broadly Mediterranean pattern, rich in vegetables, fruit, pulses, wholegrains, nuts, seeds and olive oil
Oily fish a couple of times a week, for omega-3 fats
Less red and processed meat, and fewer ultra-processed foods
Plenty of fibre and plant diversity, introduced gradually, to support the gut microbiome and the body's normal clearance of oestrogen
Steady blood sugar, through regular meals with protein, which helps both energy and mood
Eating enough, because restriction worsens fatigue and makes pain harder to cope with
Food reactivity: something I see often
This is an area where my clinical experience runs ahead of the published research, so I want to be honest about both. For many of the women with endometriosis I've worked with, I suspect food reactions are playing a part in their symptoms. Certain foods seem to trigger flares of bloating, pain or fatigue, and identifying and addressing them can make a real difference.
Exactly why this happens isn't yet clear, but there are some plausible explanations:
The gut microbiome. Research has found differences in the gut bacteria of women with endometriosis, and the microbiome influences inflammation, immune function and oestrogen metabolism [13]
Intestinal permeability. Changes in the gut lining's barrier function are being investigated in endometriosis and may allow more inflammatory triggers to reach the immune system [14]
Mast cells and histamine. Mast cells are immune cells that release histamine and other inflammatory chemicals. They are more numerous and more active in endometriosis lesions, where oestrogen can activate them, and they appear to play an important role in driving pain sensitivity [15]. Some women notice that histamine-rich foods or alcohol worsen their symptoms, which fits with this picture, though it hasn't been formally studied
What I don't recommend is cutting out long lists of foods on the strength of a generic "endo diet". Women with endometriosis often end up on very restricted diets, which can create nutritional gaps and a stressful relationship with food. Instead, I take an individual approach: tracking symptoms carefully, testing one change at a time for a limited period, and always reintroducing foods to see what genuinely makes a difference.
My view on the low FODMAP diet
You may have been told to try a low FODMAP diet, and there is some evidence for it: in one study, 72% of women with both endometriosis and IBS reported their bowel symptoms improved by more than half after four weeks [4]. Used well, for the right person, it can be helpful.
On balance, though, I'm not a big fan of it for most people. It restricts many of the fibres that feed a healthy gut microbiome, it is easy to stay on far longer than intended, and I regularly meet women who have become anxious about food as a result. If it is going to help, it usually starts helping within a week or two, so I use it, if at all, as a short-term, guided tool with a clear plan for reintroduction. More often, I find that working on the mechanics of digestion, the gut-brain connection and nervous system regulation brings more lasting relief. I've written about this in more detail in The low FODMAP diet: powerful tool or unhelpful trap?
Nutrition as part of the whole picture
No diet has been shown to cure endometriosis, and anyone who promises that is overselling. But approached thoughtfully, and alongside medical care and nervous system support, nutrition can be a powerful ally in reducing inflammation, steadying energy and helping you feel more like yourself again.
A note on creatine
You may have seen recent headlines linking creatine, now a very popular supplement among women, to endometriosis. Two studies from one research group found that creatine encouraged endometriosis lesions in mice and in laboratory cell experiments [16, 17], but this hasn't been tested in women taking supplements, and the research has some important limitations [18]. Until we know more, I'd suggest discussing creatine with your doctor or practitioner before starting it if you have endometriosis. I've looked at the research in more detail in Creatine and endometriosis: what the research really says.
Seeing the whole picture
The bottom line is that endometriosis is a whole-body condition, and that means there are many ways to support it. Inflammation, the gut, the nervous system, energy and the daily stress of living with pain are all things that can be worked with, and when they are, women often feel very differently.
You deserve good medical care, and you also deserve support for everything that sits around it: The exhaustion, the gut symptoms, the pain that wears you down, and the confusion of conflicting advice. In my experience, bringing those pieces together is where real change happens.
Want support with endometriosis?
If you have endometriosis and would like help with nutrition alongside your medical care, particularly with gut symptoms, energy or feeling overwhelmed by conflicting advice, my Hormone Insights & Support Service is designed to help. You can also book a session with me here.
And if you'd like more articles like this one, grounded in the science without the overwhelm, my free newsletter goes out every fortnight.
References and further reading
Endometriosis UK. The State of Endometriosis Care in the UK. 2026.
Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet. 2021;397(10276):839–852.
Bacci M et al. Macrophages are alternatively activated in patients with endometriosis and required for growth and vascularization of lesions in a mouse model of disease. Am J Pathol. 2009; and Forster R, Sarginson A, Velichkova A, et al. Macrophage-derived IGF-1 and endometriosis-associated pain. FASEB J. 2019.
Moore JS, Gibson PR, Perry RE, Burgell RE. Endometriosis in patients with irritable bowel syndrome: specific symptomatic and demographic profile, and response to the low FODMAP diet. Aust N Z J Obstet Gynaecol. 2017;57(2):201–205.
Ramin-Wright A, Kohl Schwartz AS, Geraedts K, et al. Fatigue – a symptom in endometriosis. Hum Reprod. 2018;33(8):1459–1465.
Arnett SV, Clark IA. Inflammatory fatigue and sickness behaviour: lessons for the diagnosis and management of chronic fatigue syndrome. J Affect Disord. 2012;141(2–3):130–142.
Zheng P et al. Research on central sensitization of endometriosis-associated pain: a systematic review of the literature. J Pain Res. 2019;12.
Mokhtari T, Irandoost E, Sheikhbahaei F. Stress, pain, anxiety, and depression in endometriosis: targeting glial activation and inflammation. Int Immunopharmacol. 2024;132.
Appleyard CB et al. The link between stress and endometriosis: from animal models to the clinical scenario. Reprod Sci. 2020;(9):1675-1686
Evans S, Fernandez S, Olive L, Payne LA, Mikocka-Walus A. Psychological and mind-body interventions for endometriosis: a systematic review. J Psychosom Res. 2019.
Role of macronutrients, dairy products, fruits and vegetables in occurrence and progression of endometriosis: a summary of current evidence in a systematic review. Facts Views Vis ObGyn. 2024;16(4):409–428.
Food groups and nutrients consumption and risk of endometriosis: a systematic review and meta-analysis of observational studies. Nutr J. 2022.
Guo C, Zhang C. Role of the gut microbiota in the pathogenesis of endometriosis: a review. Front Microbiol. 2024;15:1363455.
Arab A et al. Gut microbiota and endometriosis: exploring the relationship and therapeutic implications. 2023.
Wang J et al. Unravelling the intricate link: mast cells and estrogen-induced pain sensitization in endometriosis. Int J Biol Sci. 2025.
Chen SM, et al. Creatine promotes endometriosis by inducing ferroptosis resistance via suppression of PrP. Adv Sci. 2024.
Chen SM, Liu YK, Ma XQ, Wei CY, Li MQ, Zhu XY. Creatine promotes endometriosis progression by inducing M2 polarization of peritoneal macrophages. Reproduction. 2025;169(3):e240278.
Machado M. Reassessing the proposed creatine–PrP axis in endometriosis: methodological and mechanistic considerations. Adv Sci. 2026;13(44):e21907.
