A link has been identified between both endometriosis and irritable bowel syndrome (IBS).
Case features are similar between the two conditions, with Seaman et al. 2008 finding that women with endometriosis are 3.5x more likely to be diagnosed with IBS.
Please note that not every woman with endometriosis will have IBS (or vice versa), however the connection is worth considering.
My Clinical Experience with Endometriosis & IBS
Clinically speaking, I have noticed that almost (if not every) woman I see in clinic with endometriosis, also presents with some sort of digestive issue. It may be IBS or it may simply be written off as a bit of 'funny tummy'.
Funnily enough the term 'endo belly' has been coined for this very phenomenon! Demonstrating that digestive issues are indeed a predominant issue experienced by women with endometriosis.
How Can Naturopathy Help You?
As discussed below, it is evident that a breakdown in the integrity of the gut microbiota is implemented in both IBS and endometriosis. Therefore, it means that the health of your gut can directly impact those with IBS and/or endometriosis.
When working with either IBS or endometriosis (or both!) we need to figure out the exact cause behind your symptoms. Common factors contributing to poor gut health include: diet, lifestyle, stress, history of antibiotic use, nutrient deficiencies, hormonal imbalance, parasite infection, bacterial or overgrowth (e.g. candida), low stomach acid plus many more!
Naturopathic treatment protocols are centred upon addressing the root cause of your health concerns, then working to correct these issues using natural herbs, nutrients, diet changes and lifestyle modifications.
Many changes can be made for IBS and endometriosis severity; using naturopathic solutions that are tailored to suit your individual case presentation & needs.
What is Endometriosis?
Endometriosis affects 5-10% of reproductive aged women (2), with diagnosis being made via laparoscopy. (3) Ultrasound can aid with identification of lesions.(3) Endometriosis can result in dyspareunia, dysmenorrhea, low back pain and infertility (3)
Many women present with no symptoms, however the (2) main symptoms observed are (3):
Pain occurring in the place of endometrial tissue growth – often the pelvis – with pain usually peaking in a cyclical nature with the menstrual cycle. Women often experience painful intercourse too(3)
Sub-fertility or infertility – oftentimes this is when a diagnosis is made(3)
Current Medical Management of Endometriosis
Pharmacotherapy is centred upon pain management, (4,5) with most treatments focusing on the suppression of ovarian function.
These treatments are symptomatic and are not curative.(4,5) Combined oral contraceptives (OC) and progestins are often used for pain relief. (8,9) Gonadotropin-releasing agents are utilised when aforementioned treatment is ineffective, not tolerated or ineffective. (4,5) If dysmenorrhea (pain) is the main clinical complaint, with peritoneal implants or ovarian endometriomas <5cm; OC’s are recommended.(5) For severe deep dyspareunia & infiltrating lesions; progestogens are often preferred.(5)
What is Irritable Bowel Syndrome (IBS)?
• Rome Criteria IV is gold standard for diagnosis(15)
Recurrent abdominal pain, on average, at least 1 day/week in last 3 months, associated with two or more of the following criteria:
- Related to defecation
- Association with a change in frequency to stool
- Associated with a change in form (appearance) of stool.
• Pathophysiology not yet completely understood (16)
• 80% of those affected are female (17)
Medical Management of IBS
• Pharmaceutical management of IBS symptoms differs from patient to patient & each presentation must be evaluated by it’s own merit
• Current pharmaceutical interventions include: tricyclic antidepressants and chloride channel agonists/antagonists(18)
• 5-HT3 antagonists, 5-HT4 agonists and GCC agonists, antispasmodics, and alosetron were suggestive for the treatment of IBS (19). However, concerns for bias with GCC have been noted, meaning it should be used with caution.
• IBS treatments also note a high placebo effect response; ranging from 30-80%(20)
The IBS & Endometriosis Link
• Both IBS & endometriosis share some similar clinical features, namely chronic low-grade inflammation as the basis for disease chronicity(21,22,23)
• Key inflammatory markers present in both conditions include: mast cell activation, neuronal inflammation, dysbiosis and impaired intestinal permeability(21)
• Pelvic pain is often present in both conditions
Mast Cells in IBS & Endometriosis
• Mast cells contain many nociceptive substances; when broken these are released into interstitial fluid whereby they exert an effect
• Mast cells have been found to be high in both IBS (24,25) and endometriosis(26,27)
• Perpetuating chronic inflammation in both conditions
Neurogenic Inflammation (NI) in IBS & Endometriosis
• NI is largely responsible for pelvic pain(27)
• Calcitonin & substance-P play significant role in (NI); promoting the breakdown of mast cells(28,29,30)
• The presence of NI give rise to persistent low-grade chronic inflammation in both IBS & endometriosis(21)
• Modification to the microbiota has been implicated in many pathological conditions(21)
• IBS patients present with lower concentrations of Bacterioidetes and an increase of Fermicutes and Actinobacteria; when compared to a ’healthy’ control group(31,32)
• The severity of gastrointestinal symptoms is often relative to the level of dysbiosis (33)
• The endometrial composition in animal models have shown a decreased concentration of Lactobacilli, with an increase in Gram negative bacteria, in comparison to controls(21)
• Intestinal inflammation is often higher in those with endometriosis (34,35)
Intestinal Permeability in IBS & Endometriosis
• The integrity of intestinal junctions are dependent on substances found within the gut lining
• Some medications (NSAID’s) have a negative effect on the intestinal mucosa(36,37)a
• This can create permeability – resulting in IBS(38)
• Dysbiosis is associated with intestinal permeability, resulting in the translocation of LPS-endotoxins which have been implicated in endometriosis(39)
• The connection between intestinal disruption and endometriosis is significant because it opens up windows in regards to how we view & treat IBS and endometriosis
A note on NSAID’s…
• NSAID’s have been directly linked to intestinal permeability (36)
• This can result in the translocation of bacteria(40)
• Triggering an inflammatory cascade which may play a role in many diseases including IBS and endometriosis(41,42)
• NSAID’s should be prescribed judiciously given their potential implications in disease
A word on hormonal influence…
• Dysmenorrhea (painful periods) has been associated with IBS(1,43)
• It has also been noted that IBS symptoms improve post-menopause – further indicating a hormonal influence(44)
• Interestingly, GnRH intervention improves symptoms of both IBS and endometriosis(45, 46, 47,48)
• Demonstrating that altering hormonal function (in this case ovulation) has positive effects for a seemingly unrelated condition such as IBS.
Treatment of either/or IBS and/or endometriosis should take into consideration the aforementioned information
A well established link between the two exists in the literature
Further research into causal relationships needs to be conducted
This will allow greater understanding of the connection between the conditions & future treatment options
Current naturopathic treatment options work to decipher the root cause of an individual's problems (e.g. menstrual pain or upset tummy) and correct these issues
Sydney Naturopath -Hornsby Naturopath - Online Naturopath
This article is authored by Emma Clegg who is a qualified naturopath located in Sydney, Australia.
Emma has a special interest in all areas of female heath, gastrointestinal health and allergies.
Appointments are available from her clinic in Hornsby. Online consultations are also available from anywhere in the world.
Book your appointment now via email: firstname.lastname@example.org or phone: (02) 9476 6888 or 0435 609 957.
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