The ketogenic diet is based on an eating plan that sharply restricts carbohydrates and emphasizes the high consumption of healthy fats and protein. The standard ketogenic diet contains 75 percent fat, 20 percent protein, and only 5 percent carbohydrates. The goal is to get the body into a state of ongoing ketosis, where ketone bodies, not glucose, are burned for fuel. The diet is a highly effective approach to weight loss and also has other significant health benefits. In particular, the ketogenic diet can be beneficial for normalizing blood sugar and metabolic syndrome by reducing insulin resistance.
The keto diet works well for men, who generally go into and maintain ketosis with little difficulty. For women, however, the ketogenic diet can be a challenge. Even close adherence to the diet can fail to produce ketosis and weight loss. In fact, for some women, the keto diet can lead to weight gain.
Why the difference in response between the sexes? It’s estrogen. The presence of normal amounts of estrogen in premenopausal women seems to limit or even block ketosis. A recent study using mouse models confirms this. Male and female mice were fed a ketogenic diet for 15 weeks. At the end of the trial, the researchers found that male mice on the keto diet maintained blood glucose control and lost body weight. Female mice, however, gained weight, and tests showed poor blood glucose levels. When female mice had their ovaries removed to eliminate estrogen in their bodies and were placed on a ketogenic diet, they lost body fat. They maintained blood glucose control, similar to their male counterparts.
[Sex Differences in the Response of C57BL/6 Mice to Ketogenic Diets
Jesse Cochran, Paul V. Taufalele, Kevin D. Lin, Yuan Zhang, E. Dale Abel Diabetes Jul 2018, 67 (Supplement 1) 1884-P; DOI: 10.2337/db18-1884-P]
By the logic of the mouse model, the only women who can follow the keto diet successfully are those who have had their ovaries removed, or at least are in post-menopause. That’s not very helpful for all the other women, but it does give us a clue about how estrogen affects ketosis and what we can do about it.
Many women between the ages of 15 and 50 experience estrogen dominance—they have more circulating estrogen than its counterpart hormone, progesterone. The cause is usually excess estrogen, though a lack of progesterone can also create an imbalance. But what causes the excess estrogen? Genetics plays a role, but the most common causes are poor diet high in processed foods and low in fiber and micronutrients, chronic stress, poor liver function, inadequate sleep, exogenous estrogen supplementation, and a sedentary lifestyle. Of increasing concern are environmental toxins, particularly endocrine disrupters that mimic or interfere with the body’s hormones. These toxins surround us all the time—they’re found in plastic bottles and containers, flame retardants, food packaging, cosmetics, pesticides, among many other sources.
[Lauretta R, Sansone A, Sansone M, Romanelli F, Appetecchia M. Endocrine Disrupting Chemicals: Effects on Endocrine Glands. Front Endocrinol (Lausanne). 2019;10:178. Published 2019 Mar 21. doi:10.3389/fendo.2019.00178]
Correcting Estrogen Imbalance
Regardless of the cause, estrogen dominance can cause weight gain and problems with blood sugar control. Until the imbalance is corrected, getting into ketosis will be challenging.
Patients who have been diagnosed with premenstrual syndrome (PMS), endometriosis, polycystic ovary syndrome (PCOS), uterine fibroids, and other estrogen-sensitive conditions experience estrogen dominance. Other symptoms, often not medically diagnosed or even recognized, can include:
- Irregular periods
- Low thyroid function
- Decreased libido
- Weight gain
- Brain fog
- Irritability, anxiety, depression
Because estrogen dominance is so prevalent, I recommend an estrogen detoxification protocol to many of my female patients. The protocol can help restore a better estrogen/progesterone balance, reduce undesirable estrogen breakdown metabolites, and help the liver move to more efficient estrogen metabolism. Balanced estrogen metabolism is a necessity for success in following the ketogenic diet.
Estrogen is processed in the liver for elimination following phase I and phase II detoxification pathways. In that sense, an estrogen detox is similar to liver detoxification, with some modifications.
Estrogen is the collective name for a group of female hormones: estrone, estradiol, and estriol.
- Estradiol is produced in the ovaries; it’s the dominant form of the hormone. Estradiol affects libido and fertility; it protects women against heart disease, osteoporosis, and cancer. Levels of estradiol begin to drop when a woman reaches her mid-30s; by the time she reaches menopause, estradiol production ceases.
- Estriol is the form of estrogen produced during pregnancy.
- Estrone is produced in the ovaries and is also produced by fat tissue. It’s sometimes called the menopause estrogen because it continues to be produced in fat tissue and from endogenous testosterone, even
after the ovaries have stopped producing estradiol. Estrone is often blamed for weight gain as women enter perimenopause and menopause years.
When estradiol is hydroxylated in the liver during Phase I detoxification, it converts to three different estrone metabolites that vary considerably in their biological activity. One metabolite is generally considered to be “good” estrogen because it has only weak estrogenic activity. The other two estrone metabolites are “bad” because they are much more active—and are potentially carcinogenic. When the estrone metabolites are methylated in Phase II detoxification, however, they become less harmful.
The estrogen detoxification protocol aims to help the liver metabolize estradiol and estrone more efficiently and minimize the time the “bad” metabolites have to circulate and cause damage.
The protocol I recommend supports detoxification and methylation by making sure the body has the needed cofactors to help eliminate estrogens. It begins with a high-fiber diet rich in cruciferous vegetables such as broccoli and cabbage. High fiber alone has a positive effect on estrogen metabolism,
[Rose DP, Goldman M, Connolly JM, Strong LE. High-fiber diet reduces serum estrogen concentrations in premenopausal women. Am J Clin Nutr. 1991;54(3):520‐525. doi:10.1093/ajcn/54.3.520], while the indoles in cruciferous vegetables help shift estrogen metabolism away from “bad” estrones. [Fowke JH, Longcope C, Hebert JR. Brassica vegetable consumption shifts estrogen metabolism in healthy postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2000;9(8):773‐779.]
These vegetables are also a good dietary source of diindolylmethane (DIM), a compound that is shown to positively affect estrogen metabolism. For those who find that cruciferous vegetables are hard to digest, supplements containing DIM are an option as well.
[Dalessandri KM, Firestone GL, Fitch MD, Bradlow HL, Bjeldanes LF. Pilot study: effect of 3,3′-diindolylmethane supplements on urinary hormone metabolites in postmenopausal women with a history of early-stage breast cancer. Nutr Cancer. 2004;50(2):161‐167. doi:10.1207/s15327914nc5002_5]
I also strongly encourage all my female patients to get regular physical activity as a way to normalize their estrogen metabolism. [Smith AJ, Phipps WR, Thomas W, Schmitz KH, Kurzer MS. The effects of aerobic exercise on estrogen metabolism in healthy premenopausal women. Cancer Epidemiol Biomarkers Prev. 2013;22(5):756‐764. doi:10.1158/1055-9965.EPI-12- 1325]
The typical estrogen detox program lasts for 28 days before the implementation of the keto diet. I prescribe to a 3-step approach, as depicted below.
Step 1: Initial clearing. During the first four days, patients gradually eliminate dairy, gluten, and high carb sugary and processed foods. They’re replaced with high-quality protein, good fats, and at least five half-cup servings a day of cruciferous vegetables. During the detox, patients avoid caffeine, alcohol, and soda. Instead, they drink lots of pure alkaline water. I also recommend a daily green drink and a daily detox supplement shake. The green drink provides vitamins, minerals, and phytonutrients. The shake provides a wide range of natural micronutrients, cofactors, fatty acids, and amino acids the liver needs for the detoxification pathways to function efficiently.
Step 2: Estrogen detoxification. For days 5 through 28, patients continue with a diet that gradually gets closer to the full ketogenic diet. Good fats are slowly increased to 75 percent of the diet as a high-quality protein is gradually reduced to 20 percent of the diet. High consumption of cruciferous vegetables continues, as do the green drinks and detox shakes.
Step 3: Full keto diet. At the completion of the estrogen detox period, the full ketogenic diet begins. A greater variety of low-carb foods, such as leafy greens, berries, nuts, and seeds, should now be added. The green drink and detox shake are discontinued, and supplemental support for Phase I and Phase II for continuing estrogen detoxification is added.
By following the estrogen detox program for 28 days before going to the full keto diet, my female patients achieve much better results.
Keto Tips for Women
Even after an estrogen detox program, however, some women will have trouble getting into ketosis and staying there. The solution is supplementation with ketone salts, also known as exogenous ketones. These supplements contain ketones in the form of beta-hydroxybutyrate bound to a salt such as sodium, potassium, calcium, or magnesium. Ketone salts are beneficial for inducing ketosis and for relieving many of the discomforts from keto flu.
[Harvey CJDC, Schofield GM, Williden M. The use of nutritional supplements to induce ketosis and reduce symptoms associated with keto-induction: a narrative review. PeerJ. 2018;6:e4488. Published 2018 Mar 16. doi:10.7717/peerj.4488]
Women following the keto diet may run low on magnesium, iron, and calcium, micronutrients they need to maintain bone strength, and avoid osteopenia and osteoporosis later in life. I recommend daily supplements to be sure of getting an adequate supply. Oral magnesium bisglycinate supplements are easily absorbed and less likely to cause nausea or diarrhea.
Because the keto diet restricts carbohydrates, it is relatively low in dietary fiber from fruits and vegetables. The lack of fiber may cause constipation, especially when beginning the diet. Women, in general, are more likely to experience constipation, and they are also more likely to become constipated on the keto diet than men. The solution is to add more dietary fiber from low-carb fruits, vegetables, nuts, and seeds. Good choices include all leafy greens, cruciferous vegetables, artichoke, celery, avocado, fresh berries, chia seeds, flax seeds, hemp seeds, walnuts, and almonds.
I strongly recommend unrestricted daily amounts of leafy greens such as lettuce, spinach, and kale for all my patients on the keto diet. They add almost nothing to the daily carbohydrate grams limit while providing dietary fiber and also a range of vitamins, minerals, and phytonutrients. Fiber sources other than leafy greens are slightly higher in carbs but should still be included in small portions for their vitamins, minerals, and phytonutrients. Incorporating plenty of low-carb vegetables, fruits, nuts, and seeds to the keto diet also adds flavors and textures that add to the needed food variety for patient success.
The goal of adding low-carb plant foods is to increase fiber intake to at least 25 grams a day—more than the average American gets on a daily basis—and preferably more. This isn’t difficult to do while still maintaining ketosis. An ounce of almonds (about eight nuts), for example, contains about 3.5 grams of fiber, 6 grams of protein, and 14 grams of fat. An ounce of chia seeds (about three tablespoons) has about 10 grams of fiber, 4 grams of protein, and 9 grams of fat.
As they adapt to a diet extremely low in carbohydrates, my female patients seem to feel the effects of “keto flu” more than men do. The symptoms of keto flu—headache, muscle aches, nausea, dizziness, constipation, and others—usually dissipates within the first week. To help the body adapt faster, I urge all my patients to stay fully hydrated and maintain proper levels of electrolytes. Adding salt to food and making sure to include ketofriendly vegetables in the diet helps prevent electrolyte imbalance. As mentioned previously, keto salt supplements can attenuate the effects of the keto flu expeditiously.
Women also seem to have more difficulty staying in ketosis than men. I’ve found that my female patients are responsive to adding medium-chain triglyceride (MCT) oil to their diet. MCT oil converts quickly to ketone bodies and helps maintain ketosis.
Clean vs. Dirty Keto
Clean keto is a critical factor in helping women succeed with the diet. Clean keto and “dirty” keto both follow the same macronutrient proportions of fat, protein, and carbohydrates. Dirty keto, however, allows the macronutrients to come from any indiscriminate source, including dairy foods, processed meats, and fast food and pays little attention to the small but essential carbohydrate component. It leads to high consumption of lowquality fat, salt, and food additives and preservatives.
Clean keto sticks to healthy sources of the macronutrients, such as wildcaught salmon, organic eggs, pastured meat, cold-pressed organic vegetable oils, and avocados. Clean keto also encourages the consumption of low-carb vegetables, berries, seeds, and nuts to make sure the diet contains enough micronutrients, vitamins, and minerals.
Weight loss will occur with both approaches, at least initially. In the long run, dirty keto will stall weight loss and cause inflammation, often resulting in an unhealthy outcome. In women, dirty keto may cause deficiencies in calcium and other vital nutrients that lead right back to estrogen dominance and abandoning the ketogenic approach as just another failed diet.
In summary, women who adhere to an estrogen detoxification program before and during the (clean) keto diet are able to attain their weight loss and health goals successfully.