Endometriosis, a condition affecting millions that can be very painful, is not just about reproductive health—it's also deeply intertwined with gut health. Patients with endometriosis are more likely to experience irritable bowel syndrome or IBS and suffer from gastrointestinal symptoms.
Understanding the link between endometriosis and IBS is crucial in managing endometriosis symptoms and improving quality of life. Gut health is paramount to hormone health and this is no exception in endometriosis patients.
In this article, I'll explain the gut-endometriosis connection and offer tips for nurturing your gut in order to support your reproductive health.
For example, we'll explore the importance of eating a balanced diet, such as one rich in fiber and anti-inflammatory foods, and I'll explain why taking probiotics can help good bacteria thrive inside your gut. Both of these steps in turn help to manage inflammation, which you'll come to learn drives many of the symptoms of endometriosis, including pelvic pain.
Endometriosis Digestive Symptoms
Patients with an endometriosis diagnosis often report symptoms that overlap with gut-related issues, especially bloating (sometimes called “endo belly”) and gastrointestinal discomfort that mimics IBS or inflammatory bowel disease1, such as abdominal pain, pain with bowel movements, and indigestion.
In fact, the overlap between endometriosis and (gastrointestinal) GI issues can sometimes make the diagnosis of endo more challenging. Doctors may mistake endo for digestive issues such as food intolerances or IBS, which can delay diagnosis and treatment.
Here are some ways in which the symptoms of endometriosis and gut-related issues can be very similar:
- Endometriosis Diarrhea: Prostaglandins are the hormone-like chemicals responsible for uterine contraction and can also bowel cramps during periods. The uterine lining or endometrial tissue and endometriosis implants both release these with menstruation and can contribute to endometriosis diarrhea. It is via prostaglandins that endometriosis can cause diarrhea.
- Abdominal Pain: Both endometriosis and gastrointestinal disorders like IBS can cause significant abdominal pain. Some people report this as stomach pain, but often, in the case of endometriosis, the abdominal pain is predominantly in the low abdomen. In endometriosis, pain often correlates with the menstrual cycle, but it can also be chronic and resemble the cramping and discomfort associated with gut disorders. In some cases, severe pain may be debilitating.
- Bloating: Bloating is a common symptom among those with endo and with GI conditions. Women with endometriosis may experience a phenomenon known as “endo belly,” which can cause significant and sometimes sudden abdominal distension, similar to the bloating seen with SIBO or food sensitivities and intolerances. Some women with endometriosis even report dealing with new food intolerances, which may be due to inflammation exacerbating their gastrointestinal tract symptoms.
- Irregular Bowel Habits: Changes in bowel habits, such as constipation or diarrhea, can occur in endometriosis, particularly if endometrial-like tissue is present on or near the intestines. These symptoms are also hallmark signs of IBS. Endometriosis lesions can be present on the bowel wall, in the rectum, or in the intestines in what is known as bowel endometriosis.
- Painful Bowel Movements: Endometriosis can lead to painful bowel movements, especially if the disease involves the bowel area. This symptom can be confused with the discomfort associated with IBS or inflammatory bowel disease (IBD).
- Gastrointestinal Distress: Nausea, indigestion, and even vomiting can be present in both conditions. For women with endometriosis, these symptoms may be particularly pronounced during their periods.
The type of endometriosis may also play a role in how the digestive and pain symptoms are present. Endometriosis in patients with severe disease can present with pronounced pain.
Bowl complications and digestive pain can be a sign of severe endometriosis and shouldn't be ignored. Additionally, digestive symptoms may be more pronounced then reproductive symptoms.
Why the Gut is a Central Player in Endometriosis
Let's start by establishing some basic facts about endometriosis, which will make it easier to comprehend how your gut can contribute to this condition if you're someone who has endometriosis.
Endometriosis is an estrogen-dependent, inflammatory condition2. It develops when tissue similar to the uterus lining, called the endometrium, starts to grow outside the uterus. This endometrium-like tissue is similar to what is found in the lining of the uterus in that it responds to hormones and can bleed, but has its own distinct features that make it unique.
Typically, endometriosis symptoms include pain (sometimes which is debilitating), changes in menstruation (often heavier periods and cramps), inflammation, and in some cases, fertility problems including trouble getting pregnant.
Now, you might wonder, what does this have to do with gut health?
Well, your gut is home to trillions of tiny organisms, including bacteria and yeast, that make up your gut microbiome. This microbiome helps digest food, absorbs nutrients, and fights off pathogens. In fact, most of your immune system is located inside your gut.
The microbes in your gut and your immune cells are in constant communication, which is why your gut lining is considered “ground zero” for your immune system. Beyond this, your gut even affects your mood, appetite, and energy levels.Also importantly, your gut helps to modulate estrogen levels3. You'll recall that an imbalance in estrogen contributes to endometriosis lesion growths and pain.
In people with endometriosis, researchers have found4 that their gut microbiomes seem to be different from those without endometriosis. This doesn't mean gut bacteria necessarily cause endometriosis, but there could be a connection between the two. One study concluded5, “findings indicate that the gut microbiota may be altered in endometriosis patients.”
When the ratio of “good” to “bad” bacteria in your gut is off (called gut dysbiosis), it can lead to worsened inflammation, changes in how the gut functions, and gastrointestinal symptoms. The inflammation that results from endometriosis can affect the gut, while at the same time, the changes in the gut can influence inflammation in the body.
In other words, it's a two-way relationship, meaning that if your gut isn't healthy, it can make the symptoms of endometriosis worse, and if endometriosis causes inflammation, it can negatively affect gut health.
If you have endometriosis, you can see why keeping your gut microbiome in good shape can help manage your symptoms.
Related: Gut Health and Hormones: Why is a Healthy Gut Microbiome is Important for Hormone Balance
Specific Ways Gut Dysfunction And Endometriosis Are Linked
To expand on my points above, let's examine why the gut's role in endometriosis is significant and multifaceted.
The gut is a hub for hormonal balance and immune system regulation—both of which are major contributing factors to the development of endometriosis.
In terms of how to keep endometriosis symptoms under control, here's why the endometriosis-gut health link needs to be a focal point:
Your Gut Helps Determine Hormonal Balance:
Endometriosis is fueled by estrogen, and your gut directly influences estrogen levels. A healthy gut helps to break down and eliminate excess estrogen, mitigating one of the primary aggravators of endometriosis (high estrogen levels).
Your Gut is Responsible for Many Immune Responses:
A balanced gut microbiome supports a healthy immune system. For example, your gut lining is where many immune cells are created, plus the microbes in your gut essentially “teach” immune cells what to attack in your body and what to leave alone.
When your microbiome is healthy and does its job well, this lowers the risk of you experiencing immune responses targeted at your body's own tissues (autoimmune responses). Since endometriosis may have autoimmune components6, in which the body attacks itself, maintaining a well-functioning gut may help defend against endo's development
Your Gut Lining Can Be a Major Source of Inflammation:
Gut dysbiosis, or an imbalance in gut microbes, can exacerbate endometriosis symptoms by ramping up inflammation. Some gut bacteria produce substances that can calm down the immune system and reduce inflammation, while others might trigger more inflammation.
If the balance of these bacteria is off, it can lead to chronic inflammation, which is linked to many diseases including endometriosis. Endometriosis in itself is considered an inflammatory disease.Moreover, a leaky gut (also called intestinal permeability) allows toxins and undigested food particles to enter the bloodstream, potentially triggering an inflammatory response that can worsen endometriosis and autoimmune symptoms.
IBS or Endometriosis: The Difference and Similarities in Symptoms
Perhaps the most frustrating part of IBS and endometriosis is that some studies7 have demonstrated no differences between endometriosis and IBS symptom presentation. People with IBS are more likely to experience painful periods, as are those with endometriosis. And people with endometriosis are more likely to experience IBS-like symptoms. It's important to understand that while the symptoms of endometriosis can look like IBS, it doesn't necessarily mean that IBS is present.
If you've been diagnosed with IBS and experience the symptoms of endometriosis, it's important to speak to your doctor about exploring a diagnosis of endometriosis.
Common Symptoms of Endometriosis:
- Pelvic pain during period, ovulation, or the weeks leading up to your period
- Heavy bleeding, with or without clots
- Bleeding between menstrual periods
- Pain during intercourse
- Bladder symptoms (eg pain with urination, difficulty urinating)
- Difficult or painful bowel movements
- Abdominal cramping, burning, or aching sensation
- Nausea, vomiting, and/or diarrhea during your period or with abdominal pain
- Infertility
Common Symptoms of IBS:
- Incomplete bowel movements or feeling like you need to go again
- Bloating
- Constipation, diarrhea, or both
- Abdominal pain & cramping
- Digestive symptoms triggered by food or stress
Related: Can menstrual cycles make IBS symptoms worse?
How to Improve Endometriosis-Gut Health
Now that you know how your gut and endo are linked, here are strategies that focus on improving gastrointestinal/gut function and thereby helping to decrease the risk for endometriosis:
Make Dietary Adjustments:
Embrace an anti-inflammatory diet that's rich in fiber to support gut flora and ensure regular estrogen elimination. Foods like leafy greens, cruciferous vegetables, berries, soaked legumes, nuts, seeds, and 100% whole grains (preferably soaked and sprouted to support digestion) are all great sources of fiber. Check out this free meal plan and recipe guide to help you get started.
In general, aim to eat whole foods that are minimally processed, especially those with anti-inflammatory effects. Incorporate fatty fish like salmon, turmeric, ginger, bone broth, and olive oil into your diet for a boost in antioxidants and omega-3s that can fight inflammation.
Consume Probiotics and Prebiotics:
Add more probiotics and prebiotics to your diet and supplement routine to foster a healthy gut environment. This will boost the ratio of “friendly” microbes living in your gut, which can help keep inflammation in check and improve the gut's role in hormone regulation.
Keep in mind that if you have Small Intestinal Bacterial Overgrowth (SIBO) that certain probiotics or prebiotics may be aggravating. Follow what works best for your body.
Probiotic foods include:
- Yogurt (look for “live and active cultures” on the label)
- Kefir (a fermented milk drink)
- Sauerkraut (fermented cabbage)
- Kimchi (spicy fermented cabbage, Korean)
- Miso (a Japanese seasoning made by fermenting soybeans)
- Tempeh (fermented soybeans)
- Pickles (in brine, not vinegar, as vinegar kills bacteria)
- Some aged, fermented cheeses
Prebiotics (which “feed” probiotics) are found in foods such as:
- Garlic
- Onions
- Leeks
- Asparagus
- Bananas (especially when they're a little underripe)
- Chicory root
- Jerusalem artichokes (also known as sunchokes)
- Dandelion greens
- Whole oats
- Apples (with the skin on)
- Flaxseeds
- Seaweed
Aside from eating the foods above, a probiotic supplement can also boost your intake of beneficial microbes. For example, my Women’s Probiotic, is made with a blend of probiotics, prebiotics, and antioxidants that can specifically support healthy hormones and a balanced microbiome (including gut and vaginal microbiomes). The prebiotic it contains is unique in that it tends to be non-aggravating for people with SIBO. Remember, for women, the microbiome is directly tied to your estrobolome, as it influences your hormones. This product contains prebiotics to help the probiotics thrive more easily, plus antioxidants to generally support your gut.
Address Leaky Gut:
Strategies to heal the gut lining—such as avoiding inflammatory foods and common allergens, taking L-glutamine and magnesium supplements, and regularly consuming bone broth—can be beneficial for restoring endometriosis gut health.
While birth control pills are a common and sometimes effective way to manage endometriosis, they can contribute to intestinal hyperpermeability or leaky gut in some people. If you are using oral contraceptive pills, be sure to be incorporating diet and lifestyle practices that support gut health.
Keep in mind that leaky gut may be difficult to treat, however, it can often be improved if you generally improve your diet and lifestyle consistently over a period of time.
Related: What is Leaky Gut?
Support Liver Function:
Your liver is responsible for filtering toxins, aiding in digestion, and helping to regulate hormone metabolism. Here are lifestyle changes and practices that can help support liver function:
- Maintain a Healthy Diet: Eat plenty of fiber from sources like fruits, vegetables, whole grains, nuts, and seeds. Include liver-friendly foods like garlic, leafy green vegetables, berries, and grapes. Limit high-calorie meals, refined carbohydrates, and saturated fats.
- Stay Hydrated: Drink plenty of water throughout the day to help the liver flush out toxins.
- Limit Alcohol and Avoid Toxins: Alcohol can damage liver cells and lead to inflammation and scarring. Limiting or avoiding alcohol can reduce the liver's detoxification burden.
- Avoid Smoking: Smoking can harm the liver and add to the workload of detoxification processes.
- Exercise Regularly: Regular physical activity can help burn triglycerides for fuel and can also reduce liver fat.
- Use Medications Wisely: Take prescription and over-the-counter drugs only when necessary and in recommended doses. Don’t mix medications and alcohol, and talk to your doctor before mixing herbal supplements or prescription or nonprescription drugs.
- Consider Liver-Healthy Supplements: Some evidence suggests that milk thistle, turmeric, and other natural supplements can support liver health. You'll find a complete liver support protocol in our Paleo Detox.
- Manage Other Health Conditions: Properly managing conditions like obesity, diabetes, hypertension, and high cholesterol can reduce the risk of developing liver disease.
Be Aware of Environmental Toxins:
Limit exposure to endocrine disruptors that can affect both your hormonal balance and gut health.
Opt for organic produce as often as possible, use organic personal and household products, and avoid drinking and eating from plastic containers when possible.
Avoid inhaling or touching toxins found in some cleaning and aerosol products, insecticides, chemicals, and additives.
Related: How endocrine disrupting chemicals cause hormone imbalance
Manage Stress:
Chronic stress is known to worsen inflammation, plus it can impair gut health and may exacerbate endometriosis symptoms. Techniques that help you feel calm, such as yoga and meditation, are often helpful.
Getting enough exercise and general movement/physical activity, plus getting adequate sleep, also helps manage stress and its effects on the gut. Other ways to unwind include spending time outdoors, socializing, reading, taking warm baths, and journaling.
Collaborate With Your Health Provider:
For a condition as complex as endometriosis, a multidisciplinary approach is key. Collaborate with healthcare providers who understand the nuances of endometriosis and gut health.
Your team may include gastroenterologists, functional medicine doctors, naturopathic medical doctors, dietitians, and endometriosis specialists who can provide a tailored plan for managing your symptoms.
Can Probiotics Help Manage Endometriosis?
As I mentioned above, probiotics, which are beneficial bacteria, can potentially help manage endometriosis through several mechanisms. In addition, they can offer support in resolving gastrointestinal symptoms like bloating, gas, belching, and diarrhea. Here are some of the benefits of adding probiotics to your daily diet and supplement routine:
- Help Promote a Normal Response to Inflammation: Since endometriosis is characterized by chronic inflammation, probiotics may help reduce the inflammatory processes associated with the condition and support a healthy immune system.
- May Aid In Estrogen Metabolism: Probiotics play a role in the estrobolome8, the collection of bacteria in the gut that helps metabolize estrogens. Proper metabolism and excretion of estrogen can help lower the levels of circulating estrogen, which is often implicated in the progression of endometriosis.
- Support Gut Barrier Integrity: Probiotics can help to support and strengthen the gut barrier, potentially reducing the likelihood of leaky gut syndrome, which can contribute to systemic inflammation and may exacerbate endometriosis symptoms.
- May Assist In Modulating Pain: Some strains of probiotics have been shown to influence pain perception by interacting with the gut-brain axis. This could potentially help in managing the chronic pain associated with endometriosis.
- Can Help Enhance Digestive Health: Probiotics can improve overall digestive health, which can be beneficial for individuals with endometriosis who often experience gastrointestinal symptoms like bloating, constipation, and IBS-like symptoms.
Look for a probiotic that contains a SIBO-friendly prebiotic, as well as Lactobacillus strains, which specifically support female reproductive health. This Women's Probiotic contains all of these, plus spore-based organisms to help with managing dysbiosis and has the added benefit of supporting those with IBS or IBS-like gastrointestinal symptoms.
It's important to note that while probiotics can be a supportive part of managing endometriosis, they are not a cure. It's recommended to consult with a healthcare provider to tailor a probiotic regimen that's right for you as part of a comprehensive approach to managing the condition.
Final Thoughts on the Endometriosis Gut Health Link
The endometriosis gut health connection is undeniable. By taking proactive steps to support your gut and digestive system, you'll be better able to manage inflammation, as well as your endometriosis symptoms and overall well-being. Endometriosis and IBS can occur concomitantly, but endometriosis symptoms may also look like IBS. This is why working with a qualified practitioner to get the correct diagnosis of endometriosis or irritable bowel syndrome is important in healing.
Remember, while dietary and lifestyle changes are powerful, they should be part of a comprehensive treatment plan, ideally that you follow in collaboration with a healthcare provider.
References
- https://pubmed.ncbi.nlm.nih.gov/35878972/ ↩︎
- https://pubmed.ncbi.nlm.nih.gov/34718567/ ↩︎
- https://pubmed.ncbi.nlm.nih.gov/28778332/ ↩︎
- https://pubmed.ncbi.nlm.nih.gov/36506023/ ↩︎
- https://pubmed.ncbi.nlm.nih.gov/33660232/ ↩︎
- https://pubmed.ncbi.nlm.nih.gov/35878972/ ↩︎
- https://bmcgastroenterol.biomedcentral.com/articles/10.1186/s12876-023-02861-w ↩︎
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017946/ ↩︎
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