Dietary Approaches to Women’s Sexual and Reproductive Health

Abstract

Over the course of the reproductive life span, it is common for women to experience one or more of the most common gynecologic conditions, including sexual dysfunction, polycystic ovary syndrome, fibroids, endometriosis, and infertility. Although current management guidelines often turn to the established pharmaceutical approaches for each of these diagnoses, the scientific literature also supports an evidence-based approach rooted in the paradigm of food as medicine. Achieving healthy dietary patterns is a core goal of lifestyle medicine, and a plant-forward approach akin to the Mediterranean diet holds great promise for improving many chronic gynecologic diseases. Furthermore, creating an optimal preconception environment from a nutritional standpoint may facilitate epigenetic signaling, thus improving the health of future generations. This state-of-the-art review explores the literature connecting diet with sexual and reproductive health in premenopausal women.

‘A healthy and satisfying experience of sexuality is often an important component of overall well-being for women, associated with increased life satisfaction, higher perceived and objective health status, and even increased longevity.’

Introduction

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have both endorsed the notion of the menstrual cycle as the fifth vital sign. ¹ Although this framework appropriately positions reproductive health prominently as a marker of general health, lifestyle approaches to prevention and treatment of reproductive pathology remain underutilized. A comprehensive lifestyle medicine approach encompasses nutrition, physical activity, sufficient sleep, stress management, social connectedness, and avoiding toxic substances. ² Each of these components of a healthy lifestyle, though certainly interwoven, could easily be posited as having potential to affect gynecologic health. In this review, we will detail the power and promise of diet and culinary medicine as relates to sexual and reproductive health in reproductive-aged women.

The approach of lifestyle medicine focuses primarily on whole foods and dietary patterns rather than a granular approach delineating specific micronutrients. ² In the case of reproductive health, this approach works well because the connection with diet is mediated through factors such as cardiovascular and metabolic health, mood and mental health, and microbiome and inflammation. Each of these mediators has independently been researched in relation to certain dietary models. This article delves into available research on dietary patterns as well as specific foods and micronutrients when such research is available. Clinicians seeking to help their patients improve their sexual and reproductive health via lifestyle can utilize this review to not only understand certain disease states or pathology, but also to witness the continuum of food as medicine across the reproductive life span.

Sexual Health

Sexual health is defined by the World Health Organization as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.” ³ The factors influencing sexual health are vast and best conceptualized using a biopsychosocial approach, which recognizes the impact of physical and mental health, relationships, and cultural phenomena on sexual experience. ⁴ A healthy and satisfying experience of sexuality is often an important component of overall well-being for women, associated with increased life satisfaction, higher perceived and objective health status, and even increased longevity.^5-8

Unfortunately, sexual dysfunction is common. An estimated 43% of women, irrespective of age, report sexual problems, such as with desire, arousal, lubrication, orgasm, discomfort or pain, intimacy, and satisfaction.^9-12 Dysfunction is especially prevalent in women with chronic health problems, including metabolic syndrome, hypertension, dyslipidemia, coronary heart disease, diabetes, overweight and obese body mass indices (BMIs), anxiety, and depression.^7,13-20

On the whole, nutrition is known to play a significant role in cardiometabolic disease, suggesting one pathway through which diet influences sexual health. Although erectile dysfunction in men is a known and easily perceptible form of vascular compromise,^21-23 a similar female equivalent may take the form of vaginal dryness and impaired genital engorgement-mediated arousal.^23,24 Physiologically, healthy pelvic blood flow is necessary for vaginal lubrication. Normal blood pressure pushes a transudative fluid through capillaries, which ultimately coalesces at the vaginal surface epithelium.^25,26 This process relies on vessels being both patent and able to dilate effectively. Therefore, low atherosclerotic burden and sufficient nitric oxide (NO) activity are protective against sexual dysfunction. ²⁶ Atherosclerotic risk is minimized with a nutrient-dense diet whose foundation is plant-based foods. ²⁷ Meanwhile, NO can function best when inflammation is minimal.^26,28 A high-quality diet can be a source of antioxidants, and nitrate-rich foods can directly increase NO stores.^28,29 Diet can also indirectly support NO availability through preventing and ameliorating conditions associated with inflammatory and pro-oxidant activity, such as metabolic syndrome, obesity, and atherosclerosis.^26,30,31 Women should be educated on how maintenance of good cardiovascular health can support their sexual function, including helping avoid painful intercourse.

Among psychological factors affecting sexual health, mood is one factor that can be modified by diet. Positive mood has been associated with increased sexual desire and arousal and a happier, more positive experience of sexual activity. ³² Although more research is needed, dietary patterns rich in plants and unprocessed foods are linked to an increased sense of energy and decreased tension, anger, anxiety, and depression.^33-35 Proposed mechanisms are multiple and include blood glucose stability, anti-inflammatory properties, support of brain-derived neurotrophic factor expression, and other pathways through which nutrients can interact with serotonergic, dopaminergic, and noradrenergic systems. ³³ For women experiencing low mood and sexual dysfunction, increasing the relative consumption of whole foods and plants should be considered as a promising adjunctive therapeutic tool.

Although dietary composition affects sexual health in more general terms through the aforementioned associations between cardiovascular and psychological health and sexual function, research also highlights the effects of specific dietary patterns. The Mediterranean diet (MD) is the most widely studied in this context. Its emphasis on vegetables, fruits, nuts, whole grains, legumes, olive oil, and fish makes it high in antioxidants and low in saturated fat and refined carbohydrates. Multiple randomized controlled trials and cross-sectional studies have analyzed the long-term effect of the MD on reported sexual function. They find that adherence to a MD results in better sexual function in a dose-dependent manner, regardless of menopausal and metabolic syndrome status.^36-38

Other dietary approaches are less well studied. Diets high in whole foods and plants, or that reverse cardiometabolic disease, could mirror the benefits seen with the MD, but research gaps remain. Conversely, the Western diet is indirectly linked to sexual dysfunction. Its predominant components—processed foods, refined carbohydrates, sodium, and saturated fat–containing animal products—are extensively linked to metabolic syndrome, cardiovascular disease, and elevated BMI.^39-41 Of note, chronic caloric restriction in association with low body weight can negatively affect sexual desire and enjoyment. This likely stems from a combination of endocrine dysregulation as well as psychological factors. ⁴² A nutritionally adequate diet rich in whole foods and plants is supportive of health on multiple levels, including for promotion of optimal sexual function.

Specific dietary components also seem to be tied to sexual function. Decreasing sodium intake enhances the ability of vessels to dilate, with early evidence indicating direct impact on genital arousal.^26,43,44 As previously described, sufficient vessel dilation and engorgement are important preconditions for vaginal lubrication. Additionally, consumption of soy, a phytoestrogen, is shown to support increased vaginal blood flow, lubrication, and vaginal collagen content and decreased dyspareunia.^45-47 As a suppressor of free-radical generation, the benefits of soy plausibly include an anti-inflammatory effect that enhances NO activity.^45,48

Fruits such as apples, watermelon, and cacao have been linked to enhanced vascular and sexual health. Daily apple consumption is associated with improved vaginal lubrication and general sexual function. ⁴⁹ Apples are high in polyphenols, other antioxidants, and phytoestrogens, which together support an anti-inflammatory and antiatherosclerogenic environment. It can be expected that other fruits would perform similarly, though further research is needed to confirm. Watermelon in particular supports vascular health via an additional distinct mechanism. It is a rich source of citrulline, which the body readily converts to the NO precursor, arginine.^50-52 Chocolate, derived from the cacao bean, is rich in flavonoids and has been found to increase NO-mediated vasodilation, with promise for supporting sexual function.^53,54 Although more research is needed, these findings on individual foods offer support and further insight into how a plant-based dietary pattern can benefit female sexual health.

Meanwhile, evidence suggests that vitamin D and iron deficiencies are risk factors for sexual dysfunction, and resolution of these deficiencies may well be therapeutic.^55-58 Vitamin D receptors exist on the uterus and ovaries, where they can influence steroidogenesis and testosterone aromatization, with consequent effects on sex hormone levels.^59-61 In iron-deficiency anemia, fatigue is thought to mediate the relationship between deficiency and sexual dysfunction. ⁵⁷ Testing for vitamin D and iron deficiency may be considered as a relatively simple and low-cost addition to the workup for female sexual dysfunction.

In sum, sexual health is a key component of well-being, and growing evidence supports the role of diet in modulating sexual function. Practitioners should feel empowered to discuss with patients the supportive roles of cardiovascular and psychological health for sexual health in general and of plant-rich and nutrient-dense dietary choices in particular.

Polycystic Ovary Syndrome

Hyperandrogenic anovulation is common in women of reproductive age. Polycystic ovary syndrome (PCOS) is one of the most common hormonal disorders in young women and is characterized by a combination of hyperandrogenism (clinical or biochemical), oligo-ovulation or anovulation, and/or polycystic ovarian morphology on pelvic ultrasound.^62-65 Its etiology is considered multifactorial (ie, genetic, intrauterine exposures, environmental, metabolic factors), with insulin resistance as well as chronic low-grade inflammation playing key roles. ⁶⁶ For PCOS patients, therapeutic lifestyle changes, such as selecting a healthy dietary pattern, have been shown to improve insulin resistance and body composition, with associated improvements in fertility outcomes. ⁶⁷

Diet affects serum androgen levels. In 1 cross-sectional study, testosterone levels in women with PCOS were significantly lower in those who consumed more protein, complex carbohydrates, fiber, monounsaturated fats, and omega-3 polyunsaturated fats and who consumed fewer simple carbohydrates, saturated fats, and omega-6 polyunsaturated fats than in those who did not follow this high-quality dietary pattern. The testosterone levels were still significantly lower after adjusting for BMI and total energy intake. ⁶⁸ A case-control study conducted in India found that those consuming a vegetarian diet had both lower testosterone levels and decreased hirsutism. ⁶⁹ Finally, a systematic review of various dietary compositions in women with PCOS found that a high-carbohydrate diet predicted higher androgen levels. ⁷⁰

Dietary choices for women with PCOS also affect weight. A low-glycemic diet has been shown to result in greater insulin sensitivity and improved menstrual regularity, whereas a diet supplemented with monounsaturated fats predicted greater weight loss. ⁷⁰ Other studies have shown that an increase in daily plant protein ⁷¹ or a Dietary Approaches to Stop Hypertension (DASH) diet could both yield significant reduction in weight and BMI. ⁷² Notably, achieved weight loss in PCOS patients has also been found to positively affect psychological outcomes. Although the best dietary approach for this effect has not been resolved, it appears that weight loss in association with a low-glycemic and higher protein diet could hold special promise for positively affecting depressive symptoms, self-esteem, and quality of life related to decreased unwanted hair growth, weight, fertility, and menstrual problems. ⁷⁰

One proposed mechanism for the impact of diet on women with PCOS is through satiety signaling. A 3-day dietary diary study for assessing dietary composition of PCOS women compared with healthy controls found that in the PCOS group, the serum leptin concentration positively correlated significantly with the intake of total fat, total cholesterol, saturated fatty acids (SFA), and monounsaturated fatty acids (MUFA), whereas the serum ghrelin concentration correlated in an inverse manner with the intake of total fat, MUFA, and polyunsaturated fatty acids. In the control group, there was no correlation found between serum ghrelin concentrations and dietary macronutrients, but the serum leptin concentration was found to be inversely related to dietary protein intake. These results suggest that higher intake of dietary fats, particularly SFA, may be associated with higher insulin resistance, higher fasting leptin concentration, and lower fasting ghrelin levels and may affect energy balance in women with PCOS. The authors recommended further prospective research to assess if limiting food products high in fat, especially SFA, would benefit metabolic status in women with PCOS. ⁷³

Interestingly, however, the direction of causality in the relationship between diet and PCOS is not fully established. For example, an Iranian case-control study found that the prevalence of PCOS in those in the highest tertile Healthy Eating Index (HEI) score was significantly (50%) less than those in the lowest tertile HEI score. ⁷⁴ Whether poor dietary choices may be causative of PCOS or simply unmask an underlying pathophysiology, the conclusion remains that a healthy dietary pattern is particularly critical for women with PCOS.

Adding further complexity to PCOS research is the existence of a subset of women with “lean PCOS,” who exhibit normal BMIs but have findings consistent with PCOS, including elevated androgen levels and lower SHBG (sex hormone binding globulin) levels when compared with healthy controls. These women are more likely to have normal glucose and insulin levels than obese women with PCOS and lower risk of type 2 diabetes mellitus, impaired glucose tolerance, and endometrial hyperplasia. However, lean women with PCOS still tend to have higher insulin resistance than women without PCOS and may also display other adverse metabolic parameters, such as elevated liver enzyme γ-glutamyl transferase and higher low-density lipoprotein and total cholesterol levels. ⁷⁵ Because these adverse metabolic parameters serve as risk factors for future cardiometabolic disease, it is still necessary to address lean PCOS through therapeutic lifestyle behaviors, regardless of BMI. When counseling lean PCOS women about lifestyle and diet changes, the emphasis should be on incorporating healthy, whole or minimally processed foods and adequate daily servings of vegetables and fruits rather than calorie restriction.

In women with PCOS desiring fertility, a multicenter randomized-controlled trial demonstrated improved ovulation rate and a trend for higher live birth rate with ovulation induction when preceded by lifestyle modification with weight loss (through caloric restriction, exercise, behavioral modification, and weight loss medication) compared with immediate infertility treatment. ⁷⁶ Further research on live birth outcomes after lifestyle intervention in PCOS patients is limited. A systematic review of weight loss interventions for women with elevated BMI and infertility, with or without a PCOS diagnosis, found promising effects for diet and lifestyle changes resulting in weight loss. Overall, weight loss predicted greater rates of menstrual pattern regulation, success with assisted reproduction technologies, and even natural conception in many reviewed studies. ⁷⁷

In conclusion, multiple studies show that women with PCOS have significant improvements in BMI, body composition, androgen levels, cardiometabolic risk factors, fertility rates, depression scores, and quality of life through consuming a high-quality diet. Clinicians can recommend any nutritional pattern that incorporates healthy, minimally processed, fiber-rich foods (with calorie restriction if desired for weight loss) and emphasizes adequate high-quality protein intake while being low in saturated fats, refined high-glycemic-index carbohydrates, and sugar-sweetened beverages.

Gynecologic Conditions

The link between culinary medicine and gynecologic health is beginning to emerge based on recent research. From preclinical data on the microbiome and estrogen metabolism to direct links between dietary patterns and leiomyoma, endometriosis, ovarian senescence, and more, the ancient paradigm of “let food be thy medicine” is emerging as a novel therapeutic approach for women’s health.

Over the past decade, food has been identified as a primary determinant of the human microbiome, with disease states both positively and negatively correlated to changes in the microbiome resultant from dietary choices. In women’s health, one of the principal regulators of circulating estrogens is the gut microbiome, known as the estrabolome, in relation to estrogen metabolism. The estrabolome regulates estrogens through secretion of β-glucuronidases, enzymes that deconjugate estrogens into their active forms. ⁷⁸ Specifically, the gut microbiota, through β-glucuronidase activity, reactivates 2 distinct estrogen glucuronides, estrone-3-glucuronide and estradiol-17-glucuronide, to estrone and estradiol, respectively. ⁷⁹ When this process is impaired through dysbiosis of gut microbiota characterized by lower microbial diversity, the decrease in deconjugation results in a change in circulating estrogens. ⁸⁰ Furthermore, bacterial enzymes within the gastrointestinal tract have been postulated to be a contributing factor in hormone-driven cancers and leiomyoma. ⁷⁹ Dietary choices such as a whole food, plant-based diet including high fruit and vegetable intake, high fiber intake, omega-3 fatty acids, and fermented foods are all positively correlated with microbiome diversity and positively influence the estrabolome.

Examining the link between nutrition and leiomyoma, the evidence demonstrates a clear relationship. Controlling for age, education, menopausal status, BMI, parity, and smoking, a large trial showed an odds risk of 1.7 between leiomyomata and red meat intake. ⁸¹ Fatty acids were examined, with omega-3 fatty acids demonstrating an inverse relationship with uterine myomas (odds risk of 0.41) and trans-fatty acids associated with higher odds of clinical leiomyomata (odds risk of 3.33). ⁸² Vegetable and fruit intake, particularly green vegetables, were associated with lower risk of leiomyomata (0.5 odds risk); this was further studied in a prospective cohort of the Black Women’s Health study, showing an incidence rate ratio of 0.9 when comparing >4 versus <1 serving per day.^81,83,84 Indeed, recent research has begun to elucidate further phytonutrients prevalent in fruits and vegetables, including epigallocatechin gallate from green tea, berberine, curcumin (turmeric), resveratrol (berries, grapes, and red wine), fucoidans (seaweeds), indole-3-Carbinol (cruciferous vegetables), quercetin (citrus), sulforaphanes (cruciferous vegetables), anthocyanins (berries), and lycopene (tomatoes), as natural fibroid prevention. ⁸⁴ Besides the phyonutrients’ potential to beneficially influence immunomodulation, apoptosis, inflammation, and other biochemical processes related to uterine fibroids, all these whole plant foods are correlated with a healthy microbiome and increased fiber intake, further improving the binding and excretion of sex hormones. Whole food, plant-based vegetarians studied excreted 3 times more estrogen in feces, with 15% to 20% lower serum estradiol levels. ⁸⁵ Whole soy foods may be consumed without fear of aggravating uterine leiomyoma formation. ⁸⁶ Although these reports are based primarily on preclinical data, based on the available data, a whole food, plant-forward diet with avoidance of red meats, trans fats, and alcohol and emphasis on fiber rich foods should be encouraged.

Culinary medicine is also evolving as a novel approach to endometriosis prevention and treatment, with diet as a potentially modifiable risk factor. Evidence suggests that poorly nutritive diets result in changes to lipid metabolism, oxidative stress, and promotion of epigenetic abnormalities and may be involved in the genesis and progression of the disease. ⁸⁷ Despite this, nutrition modification for endometriosis has been insufficiently studied. ⁸⁸ Omega-3 fatty acids, fruits, vegetables, and whole grains have a protective effect to reduce the risk of endometriosis and possibly contribute to regression of the disease. ⁸⁸ The microbiome may be at play here as well; endometriosis sufferers share dysbiosis traits, including an increased presence of Proteobacteria, Enterobacteriaceae, Streptococcus species, and Escherichia coli across various microbiome sites. ⁸⁹ Similarly to uterine myomas, food can be used to positively influence the microbiome, with the direct potential for disease modulation. Risk factors that increase the risk of endometriosis include consumption of products rich in trans fats, consumption of fats generally, and consumption of beef and other kinds of red meat and alcohol. ⁹⁰ A whole food, plant-based diet may be a reasonable first approach for a woman with endometriosis, with particular emphasis on omega-3 fatty acids.

A paucity of data exists on the effects of diet on ovarian senescence. Whereas the early loss of ovarian reserve and subsequent menopause has long-reaching effects for a woman’s fertility and long-term risks of morbidity and mortality, little data exist to elucidate the data specifically on nutrition as a modifiable risk factor. A review of the available literature suggests that the age of natural menopause is positively correlated with fruit intake and, specifically, the phytonutrient β-cryptoxanthin, a carotenoid, when adjusted for risk factors for onset of menopause. ⁹¹ In the absence of further data, recommending a diet containing approximately 400 µg of β-cryptoxanthin per day from fruits, most notably citrus and stone fruit, could be a reasonable, low-risk suggestion for patients concerned about ovarian aging.

Fertility

When attempting pregnancy, whether just entering the preconception phase or struggling with infertility, dietary approaches can have a significant positive impact. Diet has been shown to optimize natural fertility, improve success of infertility treatment, and facilitate healthy epigenetic signaling during gestation. The link between diet and fertility is often overly simplified to the connection between body weight and ovulation, but there are additional mechanisms at play.

As relates to natural fertility, robust literature details the positive impact of a healthy preconception diet on length of time to pregnancy.^92,93 Multiple studies have linked improved fertility in women and men to healthy dietary models, including the US Dietary Guidelines, which recommends high consumption of whole grains, monounsaturated or polyunsaturated oils, vegetables, fruits, and fish. ⁹³ In the Nurses’ Health Study II, a large prospective cohort, women with the highest intake of a “fertility diet” composed of plant proteins, full-fat dairy, nonheme iron, and monounsaturated fats, with low intake of trans fats and animal proteins, had a 66% (95% CI: 52%, 77%) lower risk of infertility related to ovulatory disorders and a 27% (95% CI: 5%, 43%) lower risk of infertility from other causes, when compared with women with the lowest intake of this diet pattern, in a controlled analysis. ⁹⁴ Indeed, population attributable risk calculations based on this sample suggest that not following the “fertility diet” was the attributable factor in 46% of cases of infertility.

The MD has similarly been shown to have a beneficial impact on spontaneous fertility. In a Spanish study, those in the highest quartile of MD adherence, which similarly included high intake of vegetables, fish, and polyunsaturated oils, had 44% (95% CI: 35%, 95%) lower odds of seeking medical help for difficulty getting pregnant compared with women in the lowest quartile. ⁹⁵

In contrast, unhealthy dietary patterns consistently show a negative impact on fertility. In a study of 5598 women with low-risk singleton pregnancies, when compared with women who consumed fast food ≥4 times/wk, the reductions in median time to pregnancy by consuming fast food ≥2 to <4 times/wk, >0 to <2 times/wk, or no fast food were 11%, 21%, and 24% (P_trend < .001), respectively. ⁹⁶ When considering other common components of the typical Western diet, both trans fats and red meat have been implicated as having potential adverse effects on fertility.^93,97 There are limitations to this body of literature, with substantial methodological variability from study to study and 1 article even potentially linking MD to luteal phase defect ⁷ ; but in general, healthy diets have been consistently related to better fertility, with the opposite relation in unhealthy diets. ⁹³

The role of specific micronutrients in the preconception phase bears substantial potential consequence given the sensitive nature of embryogenesis. Folate is perhaps the nutrient most widely associated with the preconception phase. In a randomized controlled trial of subfertile women who took a multivitamin containing 400 µg of folic acid for 3 months, 26% had a pregnancy compared with 10% of women in the placebo group. ⁹⁸ Furthermore, folic acid seems to demonstrate a dose-response benefit even beyond the current recommended dose of 400 µg. ⁹⁹ Vitamins A, B6, B12, C, E, D, zinc, selenium, Coenzyme Q10, and various additional antioxidants are among the many micronutrients that have been investigated.^100,101 At this time, the data are mixed and most strongly support a healthy diet with the goal of avoiding gross micronutrient deficiencies. A typical Western diet lacks several important nutrients, including magnesium, iodine, calcium, and vitamin D.^102,103 It may well be through the impact of these micronutrient deficiencies, as well as proinflammatory states induced by animal products, that the impact on fertility is realized. Selecting a healthy dietary model that is plant forward and diverse, with supplementation via a prenatal multivitamin, appears a reasonable evidence-based approach given the extant literature.

When considering the importance of diet in the preconception phase, in many cases, weight may play a mediating role. BMIs in the overweight, obese, or underweight ranges are tied to infertility and recurrent miscarriage.^92,97,102 Abnormal BMI can affect oocyte maturation, ovulation, embryo quality, and implantation. Thus, choosing healthy dietary approaches that also assist in normalizing weight could confer multiple levels of benefit. Assisting those in the preconception phase to understand and adhere to these dietary models holds therapeutic promise. A large systematic review and meta-analysis of interventions to improve preconception lifestyle demonstrated an increase in natural pregnancy rate, even though such interventions varied widely from study to study. ¹⁰⁴

As seen in other realms of gynecologic health, diet also influences mood, and a healthy diet could affect fertility and the ability to persist through an infertility struggle by mitigating the burden of mental health disease. Both an MD and replete folate status have been shown to be protective against depression. Therefore, promoting healthy dietary patterns and higher folate intake among individuals experiencing infertility may improve their chances of achieving a pregnancy and concomitantly temper the psychological burden associated with their experience. ⁹⁷

Once women enter into infertility treatment, the literature continues to demonstrate a positive impact of healthy dietary choices, with trends that mirror those noted in natural fertility. In a study of 590 women undergoing in vitro fertilization (IVF), those with greater MD adherence had a greater yield of fertilized oocytes and embryos. ¹⁰⁵ In a Greek study, compared with women in the highest tertile of MD adherence, women in the lowest tertile had significantly lower rates of clinical pregnancy (29.1% vs 50.0%; P = .01) and live birth (26.6% vs 48.8%; P = .01). Among women <35 years old, increased MD score was associated with an ~2.7 times higher likelihood of achieving clinical pregnancy and live birth. ¹⁰⁶

Another study comparing a variety of dietary patterns found a positive impact for MD but an even stronger impact of a “profertility” diet focusing on higher intake of supplemental folic acid, vitamin B12, vitamin D, low- rather than high-pesticide residue produce, whole grains, dairy, soy foods, and seafood rather than other meats. ¹⁰⁷ Substituting fish for animal meat has also been shown to have benefit, with the odds ratios for live birth associated with increasing fish intake by 2 servings/wk being 1.54 (95% CI: 1.14, 2.07) when fish replaced any other meat, 1.50 (95% CI: 1.13, 1.98) when fish replaced any other protein-rich food, and 1.64 (95% CI: 1.14, 2.35) when fish replaced processed meat. ¹⁰⁸ Similar to its impact on time to pregnancy, fast food increases the risk of infertility. ⁹⁶

It bears noting that the literature is not entirely consistent, with an article investigating MD and IVF outcome in Italy showing no correlation. ¹⁰⁹ It may well be that the impact depends on baseline demographics, including rates of overweight and obesity, as well as typical food quality and eating patterns in a given patient population. BMI distribution within a study population is indeed an important confounder, and weight alone has been heavily studied in the IVF context and shown to play a substantial role. In a large retrospective cohort of 51 198 women undergoing their first IVF cycle, those with overweight or obese BMI experienced greater odds of cycle cancellation, fewer oocytes retrieved, fewer usable embryos, and lower rates of clinical pregnancy. ¹¹⁰ In the IVF context, underweight BMI does not seem to play a substantial role in outcomes. ¹¹¹

Although the data on dietary patterns and pregnancy loss are quite sparse, the extant literature has not revealed any clear connections. ¹¹² As the predominant cause of early pregnancy loss is embryonic aneuploidy, if diet can affect the continuation of a viable pregnancy, the connection may be challenging to prove. That said, given the role of healthy dietary models in achieving pregnancy and maintaining optimal health during gestation, it seems self-evident that continuation of such choices into pregnancy is optimal.

Healthy dietary choices during pregnancy have the power to influence fetal programming and the health of future generations. Data throughout the developed world demonstrate high rates of poor preconception lifestyle.^102,113 The need for more comprehensive and dedicated preconception care is great because studies have revealed the preponderance of poor nutrition, obesity, uncontrolled medical conditions, and suboptimal lifestyle, all of which contribute to maternal morbidity and mortality and also affect the future child’s health via epigenetics. ¹⁰² At this point, a robust body of literature has substantiated that fetal programming, likely set in place in the preconception phase, is connected to birthweight and subsequent lifelong risks of cardiometabolic disease. ¹¹⁴ Early intervention in the preconception phase, rather than initiation once pregnancy has been established, is critical to moving the needle on the intergenerational impact of poor diet and lifestyle.

Conclusion

Increasingly, women are interested in wellness and nonpharmaceutical methods of improving and maintaining sexual and reproductive health. Unfortunately, many clinicians are not well versed in the paradigm of food as medicine, nor do they have the infrastructure to provide sufficient counseling and ongoing support to combat the societal norms underpinning the typical Western diet. In this review, we have presented the case for dietary approaches to sexual, gynecologic, and reproductive health care in premenopausal women. It is worth noting that throughout all these phases of reproductive life, the general takeaway is constant—a plant-forward diet, favoring diverse nonanimal sources of protein and iron, high in monounsaturated and polyunsaturated fats and low in trans fats, whole grains, and fish, offers a multitude of health benefits. Although the literature varies in how such diets are measured or described, these general dietary principles consistently support mental and cardiometabolic health, which in turn reinforces reproductive health. As such, it is clear to see that, indeed, the menstrual cycle should serve as an important vital sign that speaks volumes about the overall health of women.

From a public health perspective, it is clear that substantive work is needed on the population level to help raise awareness in the general population about the reproductive health benefits of an optimal diet. Reorienting the health care system to prioritize wellness rather than treat chronic disease would also assist in this endeavor. In addressing these needs, it must be stated that health disparities cut across all aspects of this connection. Racial and ethnic minorities, particularly Hispanic and Black women, and those with lower income or educational attainment, face the greatest barriers to achieving lifestyle goals. Through lower awareness of the impact of diet, disparities in availability of high-quality food and preventive healthcare, and resultant discrepancies in rates of obesity, demographics ultimately play a large role in conferring access to a healthy diet in the United States.^97,115

In conclusion, ongoing research will undoubtedly continue to refine our understanding of the relationship between diet and sexual and reproductive health. In the meantime, enhanced emphasis on promoting healthy dietary patterns in the educational and health care systems and a deep-seated commitment to equalize access to these outcomes can perhaps offer all women a more comprehensive set of options for optimizing reproductive health across the life span.