EP.325/ Dairy and Endo Pain: Can It Help, or Can It Worsen?
In this penultimate instalment on our dairy series, I’m going to cover the effects of dairy on pain, and what to be aware of when managing endo. And yes - it’s not straight forward!
A1 casein inflammation
In our first episode on dairy and endo, we discussed A1 casein, but for those who haven’t listened to that episode, let’s cover it again.
A1 casein is a type of milk protein which research suggests some people find triggers intestinal inflammation and gut issues. The data on humans is emerging, and whilst it’s true for a number of people, not everyone will have this inflammatory reaction to A1 casein.
However, if you do experience inflammatory reactions to A1 casein, this can trigger a systemic full body inflammatory response with regular exposure, in a few ways.
First let’s look at how this chronic exposure could affect leaky gut.
You have an army of immune cells waiting on the other side of your gut lining, they are waiting for any potential pathogens like viruses or bacteria that might escape through the gut wall, where they will then attack with an inflammatory immune reaction. In a healthy gut, the gaps between the cells of your intestinal lining are very tight, and this is to prevent pathogens, food and irritants from passing through into the blood stream, but they are wide enough to allow for nutrients to pass through.
When your gut becomes irritated and inflamed on a regular basis, this can weaken the tight gaps between cells in your intestinal lining, and as they widen, they can allow for food particles, bacteria, etc. to pass through. This triggers the immune system on the other side of your gut to react, causing inflammation, which can spread throughout the body or locally in the pelvic area via the blood stream, which is just on the other side of your intestinal lining. I’ve linked to a helpful video by Dr Jessica Drummond on how this reaction can spread.
Remember, when our body releases an inflammatory immune reaction, it’s releasing pain causing immune chemicals like prostaglandins and histamines, so the more of those we are making, the more pain we can experience.
But what’s particularly relevant here is that leaky gut is one of the key causes of lipopolysaccharide translocation. Lipopolysaccharides are toxins that come off certain types of bacteria, and translocation is their movement from the gut to other places in the body. LPS have been found in higher levels and in the pelvic area of people with endo, and they trigger certain inflammatory pathways that further endo growth and pain.
Now the inflammatory reaction to A1 casein doesn’t end there. In people who do struggle with this reaction, emerging research suggests that A1 is broken down into beta-casomorphin-7, a type of peptide. BCM-7 triggers what’s called a T-cell mediated immune response, and this type of immune response releases inflammatory cytokines. These guys then go on to make inflammatory prostaglandins, and also trigger mast cells to release histamines.
Inflammatory prostaglandins are the absolute key drivers of endometriosis pain and period pain, and people with endo and dysmenorrhea have been shown to have too high levels of these.
Histamines are inflammatory by nature and cause pain, as well as swelling and other symptoms. They cause the uterine lining to contract during menstruation, which can (as we all know) be painful when happening in excess, they also further stimulate more prostaglandin production and can enhance their effects, and they can also sensitise nerves, making us feel more pain. Mast cells are higher in the endometriosis tissue and are implicated in the development and symptoms of the disease.
Now not everyone is reactive to A1 casein, but if you are, A2 dairy types are often better tolerated. This comes from sheep and goat’s dairy, as well as Guernsey and Jersey cows. So, you may find simply swapping from regular cow’s dairy to A2 types of dairy is enough to move the needle on your pain.
How would you know if A1 casein is a problem for you? The gold standard would be to do either a full elimination diet, or a partial, where you just remove all dairy for four weeks, and then introduce each type of dairy one by one, to test your tolerance. Alternatively, you could remove all A1 dairy for a few cycles, and eat only A2 sources, and observe if your period pain improves.
Lactose
Now let’s look at what else might be influencing your pain when it comes to dairy. As I just mentioned, if your gut is constantly being irritated by something, such as lactose, then this could trigger chronic low grade inflammation and leaky gut, which can cause an increase in those inflammatory immune chemicals I was just mentioning and allow for LPS to escape into the pelvic area.
For those of you who are not sure if lactose is a problem, you can get tested with your doctor, and you could also trial yourself on low lactose dairy products such as hard cheeses and 24 hour fermented yoghurt. You can also work with a practitioner on an elimination diet, to identify how much lactose you can tolerate.
Histamines
Next up let’s look at histamines. Now I know we just covered those under A1 dairy, but there are a few other things for us to consider. If you’re not sensitive to A1 dairy, but you do have a problem digesting histamine rich foods, then high histamine dairy such as aged and fermented dairy products, regardless whether they’re A1 or A2, may not be the best option for you, or you may need to reduce the amount you eat of them leading up to your period.
Histamine issues are quite common within the endo population, and essentially, we can be more reactive to histamines, allergens that trigger histamine production and we may have a hard time breaking down histamines. Remember I mentioned earlier that histamines can increase pain and inflammation, and high levels worsen period pain.
People who have difficulty breaking down histamine from food are often low in levels of the digestive enzyme DAO, which breaks down histamine. You can try supplementing with DAO, to boost your levels and to see if it helps you to tolerate these foods or lowers your endo pain over time.
Again, an elimination diet would likely help you here, to identify if histamines are a problem for you. The issue with a low histamine diet is that it’s very restrictive. My first suggestion would be to try A2 casein dairy only, for a few months first, and see if that helps reduce your endo and period pain, if you don’t find relief, then consider removing all dairy as part of an elimination diet, and see if that helps, before reintroducing specific dairy foods like high histamine ones, over time, to judge your reaction.
Arachidonic acid
Finally, let’s talk about arachidonic acid. Arachidonic acid is a type of omega 6 fatty acid found in dairy foods, eggs, fish and meat. Arachidonic acid is the precursor to inflammatory prostaglandins, meaning it helps to make these, it’s also crucial for other processes in the body. You need enough inflammatory prostaglandins to fight infections, wounds, etc. but if you eat a diet low in omega 3 fatty acids, which make our anti-inflammatory prostaglandins, and you eat a diet high in omega 6 foods and arachidonic acid, then this imbalance can allow for an excessive production of inflammatory prostaglandins and lower levels of anti-inflammatory ones (though the research is still evolving here and shows conflicting evidence). Consuming enough omega 3 sources from fatty fish, chia seeds, algae, walnuts and flax seeds can help to counteract this imbalance. Research has shown a correlation with a high intake of omega 6 rich foods and a low intake of omega 3 rich foods with endometriosis and pain, and research suggests that endo risk, symptoms and prostaglandin levels can be modulated with re-establishing healthy omega 3 levels.
So are there any benefits of dairy for pain?
Actually, there are, providing it agrees with you personally.
Menstrual pain reduction
Dairy contains both calcium and vitamin D, these nutrients are both essential to managing and lowering period pain. In fact, research has shown less period pain in those who ate more dairy, than less and showed associations with less menstrual pain with diets that contain fruit, veggies, dairy, legumes and whole grains.
Low levels of calcium causes more uterine contractions and so research has shown improvements in pain with both calcium supplements and a higher intake of dairy.
Low vitamin D levels are associated with endo, multiple menstrual disorders and chronic pain conditions. Additionally, supplementing with vitamin D has been shown to significantly reduce pain with dysmenorrhea.
Now of course, this all sounds great, but just remember that when it comes to managing endo, it’s about tailoring to your body’s personal needs. Whilst a higher consumption of dairy has been shown in various studies to lower pain, if you have any of the above issues like a A1 sensitivity, histamine intolerance, lactose intolerance, etc. then it could worsen your pain, so you need to work out how much dairy you can consume and which types, for your own unique body, if you want to include it in your diet.
Fermented dairy may lower systemic inflammation
The other positive of dairy is that in some research, dairy has been associated with lower inflammatory markers and inflammatory disease risk, though a recent meta-analysis has concluded that whilst fermented dairy can lower some markers of inflammation, not all markers reduce.
Research has also shown an improvement in the microbiome with fermented dairy products, and we know that microbiome dysbiosis, which is common in endo, is a driver of intestinal inflammation and intestinal permeability, so improving the microbiome could have an indirect beneficial affect on pain. Additionally, improving the microbiome also increases our levels of short chain fatty acids, which are often low in people with endo and play a major role in modulating inflammation. I’ve linked to my episode on short chain fatty acids in the show notes.
Finally, whilst we don’t have specific studies on dairy, research does show that probiotics foods help to support gut barrier integrity - meaning they help heal leaky gut, so if you do tolerate dairy and you’re not sensitive to it, fermented dairy products could help prevent leaky gut, which as we learned about earlier, can further inflammation.
So, to summarise, just like dairy and hormones, and dairy and gut health - the impact it can have on your pain levels, really depends on your personal body. Now I will say that clinically, myself and my colleagues do see improvements in endo pain with a modulation of dairy intake, so for example, swapping A1 for A2, or reducing milk consumption but still eating yoghurt, so if you’ve tried a lot of approaches for your endo pain and you’re not getting relief, perhaps this is the time to consider whether diary is an issue for you.
So that’s the final deep dive into this dairy topic. I am going to do a short episode summarising the top lines from all three episodes that cover the pros and cons of diary, and what to consider when making the right choice for you.
I hope this episode has been insightful and helpful!
Shownotes
A1 casein
https://pmc.ncbi.nlm.nih.gov/articles/PMC5593102/
https://www.youtube.com/watch?v=JirAKjC_Kh0
https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2024.1501596/full
https://pmc.ncbi.nlm.nih.gov/articles/PMC7033038/
https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2024.1363455/full
https://pmc.ncbi.nlm.nih.gov/articles/PMC5593102/
https://www.tandfonline.com/doi/10.3109/09513590.2011.588753
https://www.clinsurggroup.us/articles/JGRO-10-226.pdf
https://pubmed.ncbi.nlm.nih.gov/6790261/
https://pubmed.ncbi.nlm.nih.gov/3488529
https://www.sciencedirect.com/science/article/abs/pii/S1130862119303158
https://www.sciencedirect.com/science/article/pii/S0021925818953226
https://www.sciencedirect.com/science/article/pii/S0015028206014373
https://pmc.ncbi.nlm.nih.gov/articles/PMC9396281
Lactose
https://www.theendobellycoach.com/podcast/endo-belly-dairy
https://pmc.ncbi.nlm.nih.gov/articles/PMC2835780/
https://pmc.ncbi.nlm.nih.gov/articles/PMC9101724/
https://academic.oup.com/rheumatology/article-abstract/47/8/1223/1785625
https://www.jacionline.org/article/0091-6749(91)90180-V/pdf
https://onlinelibrary.wiley.com/doi/full/10.1111/apt.12306
https://pmc.ncbi.nlm.nih.gov/articles/PMC9101724/
Histamines
https://www.sciencedirect.com/science/article/pii/S0021925818953226
https://www.sciencedirect.com/science/article/pii/S0015028206014373
https://pmc.ncbi.nlm.nih.gov/articles/PMC9396281
https://my.clevelandclinic.org/health/articles/24854-histamine
https://integrativewomenshealthinstitute.com/histamine-intolerance-autoimmunity-and-endometriosis/
Arachidonic acid
https://lipidworld.biomedcentral.com/articles/10.1186/s12944-019-1039-y
https://pubmed.ncbi.nlm.nih.gov/29610056/
https://www.mdpi.com/2075-1729/13/3/654
https://www.clinsurggroup.us/articles/JGRO-10-226.pdf
Menstrual pain reduction
https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1447-0756.2009.01159.x
https://www.mdpi.com/2072-6643/16/1/69
https://pmc.ncbi.nlm.nih.gov/articles/PMC7834752
https://www.ajog.org/article/S0002-9378(34)90970-4/abstract
https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1447-0756.2009.01159.x
https://pmc.ncbi.nlm.nih.gov/articles/PMC10786361
https://pmc.ncbi.nlm.nih.gov/articles/PMC4427945/
https://pubmed.ncbi.nlm.nih.gov/29447494/
Lowered inflammation
https://zoe.com/learn/podcast-is-dairy-good-or-bad-for-you
https://link.springer.com/article/10.1007/s00394-016-1341-7
https://www.nmcd-journal.com/article/S0939-4753(22)00502-6/fulltext
https://pmc.ncbi.nlm.nih.gov/articles/PMC7524346/
https://pmc.ncbi.nlm.nih.gov/articles/PMC9962481/
https://pmc.ncbi.nlm.nih.gov/articles/PMC6722800
https://www.theendobellycoach.com/podcast/endometriosis-short-chain-fatty-acids?rq=short
https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2024.1501596/full
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Produced by Chris Robson