A Woman's Guide to a Healthy Stomach
Jacqueline Wolf
Why do my jeans fit only in the morning?Why am I always guzzling Pepto-Bismol before a big meeting? Could my PMS cramps mean something serious? Here, finally, are the answers to these questions, and hundreds more, about the nagging stomach problems that plague so many women.In this reassuring guide, Dr. Jacqueline Wolf, a leading expert in the field of GI health, explains the causes and cures for women’s most common digestive ailments (including bloating, constipation, diarrhea, acid reflux, IBS) and more serious, life-altering conditions like Crohn’s disease and endometriosis.This candid book deals with these sensitive issues in a down-to-earth way and eradicates the secrecy and shame surrounding these urgent problems once and for all.A Woman’s Guide to a Healthy Stomach includes: exercise and stress management tips the latest information on probiotics and prebiotics advice on knowing when to consult your doctor and what questions to ask and much more
A Woman’s Guide to a Healthy Stomach
A Woman’s Guide to a Healthy Stomach
Taking Control of your Digestive Health
Jacqueline L. Wolf, M.D.
To the Loves of My Life:
My husband, David,
and
My daughters, Laura and Rebecca
CONTENTS
Introduction
Chapter 1
How Uncouth: Stomach Shame
Chapter 2
Endometriosis and Feminine GI Troubles: Symptoms Every Woman Should Understand
Chapter 3
“Do These Pants Come with an Elastic Waist?” The Truth about Gas, Bloating and Irritable Bowel Syndrome
Chapter 4
When You Know Every Bathroom in Town: Diarrhea
Chapter 5
When You Just Can’t Go: Constipation
Chapter 6
Stinky Burps: Heartburn and Halitosis
Chapter 7
When It’s Really Bad: Time to Get Help
Chapter 8
Nine Months of This? Minimizing Stomach Problems During Pregnancy
Chapter 9
Eating Your Way to Health
Chapter 10
Doctors’ Visits and Medications
Appendix 1
Glossary
Appendix 2
GI Tests
Appendix 3
Resources
References
Acknowledgments
Introduction
“Part of the secret of a success in life is to eat what you like and let the food fight it out inside.”
—Mark Twain
This is a different kind of bathroom book. It’s a book about bowel function—blowing the lid (so to speak) off the secrecy and shame surrounding female digestive ailments once and for all. This is a reassuring guide for women by a woman. It explains the causes and cures for our most embarrassing, urgent and common stomach problems. Wondering what those PMS cramps might mean? Always guzzling Pepto-Bismol before a big meeting? Read on.
Stomach ailments might just be the last great taboo in American culture. Women are the ones who suffer (I’m not just saying this—statistics back me up), and yet we’re not whining about it! Seems silly, doesn’t it? Bowel function is a necessary fact of life. We all go. But how many times have you hunched in the office bathroom stall, waiting for the boss to comb her hair and wash her hands, before letting loose with a massive explosion? Or wondered if your bad breath was caused by the onions you had for lunch—or something more sinister, like acid reflux? You’re not going to cry about this over cocktails with your friends or coffee with your mother. No, it’s easy to think everyone else is clean and pure, while you’re the only woman alive with gas, acid, pain and cramping. But I’m here to tell you that your glamorous coworker with the designer clothes and perfect hair has stomach problems just like you, and it isn’t always pretty.
It’s during times like these, when things aren’t pretty, that our stomachs become the center of our universe. The stomach is where we feel stress, nervousness, anxiety, pain. Just ask Freud. Yet, strangely, there aren’t any books or websites that deal with stomach problems in a way that isn’t completely satirical (ratemypoo.com) or incredibly technical (I won’t bore you).
As a physician, I see this as a huge problem. Because when legitimate illnesses become shrouded in shame, they pose life-altering consequences for those who suffer from them. The repercussions range from the severe (undiagnosed ovarian cancer) to the annoying (planning out your driving route based on the nearest rest stop). By the time many patients reach my office, they’ve suffered alone for years, or they’ve been brushed off by doctors or told to take an over-the-counter medication.
Why? Bowel issues are hard to diagnose, thanks to symptoms that could really mean anything, and they’re tough to talk about. They involve bad smells and strange noises. You might have constant gas, but who wants to go to a doctor complaining of humiliating farting? You might get constipated during your period, but would this move you to get a GI referral? No, probably not. That’s where I come in. Consider this book your cheat sheet to bowel problems. This isn’t a substitute for a doctor’s visit—and please, if you have unusual symptoms, don’t hesitate to get checked out—but this is a jumping-off point for women who need answers.
Just as important, I think it’s helpful to recognize that men have it easier in this arena. (Sorry, guys.) As I’ve seen in my practice, stomach complaints are largely a “woman thing.” Like it or not, men are more apt to boast about farting or joke about bathroom escapades. Prostate exams are a rite of passage that men fret about—and joke about, too. You can’t turn on the TV without seeing a bronzed man in a hot tub singing the praises of Viagra. It’s okay for men to talk about and make light of their issues! Why not women?
I’m not sure why. But I do know that when it comes to the stomach, women are more prone to suffer quietly, with physical and emotional consequences. We also suffer from issues, like PMS and endometriosis, that just don’t affect men. And women are more likely than men to get gallbladder disease, autoimmune disease, irritable bowel syndrome (IBS) and constipation.
This shame and reluctance to seek help—or the tendency to seek it too late—have real-life repercussions. According to the National Institutes of Health, more than seventy million Americans suffer from digestive diseases. In 2004 more than 236,000 Americans died from digestive ailments. Over half of the deaths were due to cancer—colorectal cancer accounting for almost 40 percent of all cancer deaths. And in many of these cases, deaths could have been prevented if routine screening had been done and treatment had been sought at the outset of symptoms. In the United States, Canada and Northern Europe, women are more than twice as likely as men to seek the advice of physicians for changes in bowel function. In my gastroenterology practice at Beth Israel Deaconess Medical Center in Boston, 70 percent of my patients are women. And almost universally, these women feel alone and scared. There’s no road map, no resource to reassure them that they’re not imagining their problems or that they’re going to be okay.
Instead, symptoms mean fear: Could my bloating mean cancer? Could my endometriosis mean that I can’t get pregnant? I often find myself in the role of psychologist as much as gastroenterologist. And my message for the afflicted woman is this: you’re not alone!
Each chapter in this book touches on the physical, emotional and social consequences of women’s most common bowel conditions, from endometriosis to irritable bowel syndrome. In many cases, I highlight patients whose diagnoses are illuminating or particularly interesting (though for space’s sake, they are abridged here, and out of concern for privacy, their names, occupations and other possible identifiers have been changed). These women wanted to tell their stories so that other women might know that, yes, we’re all in this together. Indeed, while digestive dysfunction can point to serious problems, often it’s a common ailment with a clear-cut solution. How reassuring for the millions of women scouring the Internet in secrecy, running to the bathroom between appointments and avoiding social situations for fear of an eruption to know that there’s help. Each chapter also includes Q&As, designed to answer the most common questions I hear in my practice. You’ll also find advice on what to ask your doctor and which medications are worthwhile (and which ones aren’t), as well as nutrition tips.
So find a quiet corner—maybe your bathroom, even?—and start reading!
Chapter 1
How Uncouth: Stomach Shame
“For marriage to be a success, every woman and every man should have her and his own bathroom. The end.”
—Catherine Zeta-Jones
Why are stomach ailments shrouded in shame and embarrassment for women? We all have to cope with them at some point in our lives—a volcanic explosion after a Mexican dinner, a knot in the stomach before a big job interview or after fighting with a spouse. This is normal, and speaks to how acutely stress and discomfort resonate in our stomachs.
But, for some of us, our stomachs are the center of our very being. Many of us live with constant constipation, diarrhea, indigestion, cramping…without relief and without answers. Often, we suffer quietly—scouring the Internet to self-diagnose or bouncing from doctor to doctor, trying to figure out what’s going on. Even worse, many women simply figure that this is the way life has to be, and we don’t get the help we need. It doesn’t have to be this way!
Chances are, if you’re reading this book, you have stomach issues or care about someone who does. This chapter offers basic information about the digestive system and the way it affects our lives when it goes haywire. I’ll focus on an overview of common issues that I see in my practice every day and the typical effects these problems have on my patients’ lifestyles. In the discussion below, when I use the word stomach, it’s as a general term to describe any problem with the digestive tract below the chest (the abdomen or belly).
First things first: Bowel function is a fact of life, and it shouldn’t be humiliating. Everyone goes to the bathroom! And when we go normally, we don’t spend too much time thinking about it, right? However, when something goes wrong, it affects us deeply. For most of us, stomach function is a complete mystery, and we take it for granted when our digestive system works as it should. The flip side of this is that when it doesn’t, we tend to panic.
Part of the reason for this panic is that it’s socially unacceptable to talk about bowel problems. We have no problem moaning about a horrible headache or even PMS cramps, but if we’re going to the bathroom constantly—or not at all—there’s really no one to tell. This is ironic since children are often obsessed with excrement, both as a curiosity and as something that’s a little naughty and taboo. However, as we become “socialized,” we lose that obsession, or we just joke about it and brush it under the rug.
This isn’t a new phenomenon. In the eighteenth and nineteenth centuries, the health of the bowels was often equated with the health of the soul. Bad odors indicated that rot lurked inside. Better to cover up the odors with perfume and sprays! This stigma hasn’t evaporated with time. Bad breath, gas, belching—if we can produce such horrible smells and sounds, there must be something awry, possibly deep within our bodies. There’s a reason people load up on mouthwash, chewing gum, perfume and floral-scented bathroom sprays!
Yes, our odors are best kept hidden. Society has deemed it unladylike to smell bad. It has not always been that way, of course. Here, it’s instructive to examine the life cycle: Shortly after birth, a baby has its first bowel movement, beginning a lifetime “practice.” The mother (or father), who usually changes the diapers, is aware of the baby’s poops, gas and colic. She knows whether the baby’s elimination is effortless or distressing, and there’s no taboo in discussing this with the pediatrician. The toddler eventually becomes toilet trained. At this point, Mom and/or Dad have to be actively engaged in the elimination practices of their child, often spending hours in the bathroom, cajoling and pleading and teaching, plus many hours changing and washing sheets or clothes. We sit around with other parents and commiserate about our kids’ bathroom woes. We have no problem sharing gory details about their bathroom habits—but would you really tell your fellow playgroup moms about your own constipation, gas or diarrhea? Not exactly something you gossip about over lunch. I think that kids must sense our discomfort with our own guts and exploit that unease. When children don’t want to do something, they will often develop a gut ailment—abdominal pain, nausea or vomiting. It often takes an astute parent to recognize this action for what it is.
When then does “poop,” gas or abdominal pain become a taboo subject of conversation? Why are they considered dirty, disgusting and embarrassing? As we get older, the bathroom becomes an intensely private place for women. In high school, guys shower and use the bathroom en masse in the locker room. Women, of course, require privacy and closed doors. As we get older and enter romantic relationships, a double standard begins to emerge: It’s okay for your boyfriend or husband to joke or brag about his odors and noises, but it’s just not something women do. Remember on Sex and the City, when Carrie Bradshaw hid from Big after accidentally farting at his apartment? Or when Charlotte York exploded with diarrhea on the girls’ trip to Mexico and was mortified? Not pretty! These are lighthearted examples, but the core issue is troubling: Women do not like to discuss their stomach problems. And, as a result, they often suffer in silence for long periods of time.
In the United States, Canada and Northern Europe, women are more than twice as likely as men to ultimately seek the advice of physicians for changes in bowel function. Yet most women won’t talk about their fears until pushed. They don’t discuss them with their family members, significant others, friends or, in many cases, with their physicians; many women who come to see me skirt the reason for the visit until I pry it out, and once I do, I’m the first person they’ve told. Moreover, some stomach issues are woman-only problems, like endometriosis, ovarian cancer and that good ol’ standby, PMS. Also, women just seem more likely to react sensitively to the issues that stomach ailments cause. The gut can become the center of a woman’s life if she has belly pain, has too few or too many stools, has a hard time having a bowel movement, is worried about finding a toilet in time or has a problem with gas.
How can something so central to our well-being cause such embarrassment? The results of silence can be serious and life-altering: Some women I know won’t leave their homes until they feel it’s “safe” and they’ve done all they can do in the bathroom, lest they risk going to the bathroom in their underwear, or interrupting their commute or a work meeting to flee to the nearest toilet. Many wake up extra early and spend hours laboring in the bathroom, without anything to show for it except strained muscles. This may result in lateness to work, lost jobs, even depression and isolation. Many women are afraid to go out for dinner, to exercise or to travel. They fabricate elaborate excuses to stay home or just say they don’t feel well. More than anything, they feel alone.
So you feel less alone, here are some of the most common complaints and concerns I hear from my patients. Can you relate? Short, easy-to-follow solutions are suggested for each concern. I’ll address all these topics in detail in the book!
DR. WOLF’S TOP TEN MOST COMMON ISSUES:
1. “What if I can’t make it to a toilet in time?”
Are you one of those women who can’t go to the movies or the theater because you’re constantly scrambling for a restroom? Or when you’re on the highway, you’re always searching for a sign pointing to the next exit with a possible bathroom. So many women end up altering their social lives or reducing them to nothing because it’s just too embarrassing. Some of my patients have actually ranked public restrooms (note: hotels are usually safe bets) or highway rest stops because they so fear inopportune bowel explosions.
Try to use the bathroom before you leave the house. If you have frequent diarrhea associated with stress or IBS, you can take a half or a full dose of Imodium (loperamide) before you leave. (Check with your doctor if you have inflammatory bowel disease before taking loperamide.) If your bowel movement can be timed with your meals, eat earlier than usual, eat lighter than usual or delay eating until you get to your destination. If the diarrhea can be urgent and you can’t hold it, you could wear an adult diaper (e.g., Depend). You’re the only one who knows! It can give you security. Pack an extra set of underwear and clothing in your car, just in case.
2. “How can I go completely when my kids are banging at the door?”
I see countless mothers who suffer bowel issues yet can’t fully evacuate, because their kids need attention. Parents rarely have time enough for themselves as it is. It’s even tougher to be a mom when you’re constantly running for the bathroom or spending extended periods crouching on the toilet.
Try to carve out some time for yourself. Often you need to relax before you can completely relieve yourself of feces. While on the toilet, it sometimes helps to put your feet on a stool or phone books or to bend down in order to give the poop a straighter, more direct way out. It is best to go sit on the toilet when you have an urge. It usually doesn’t do any good to just sit down and wait.
3. “What if I fart while having sex?”
Not exactly the biggest aphrodisiac. Many women who suffer from gas, IBS and diarrhea often come to me with this fear.
Try to make this a nonissue. Avoid eating foods that cause gas several hours before you anticipate having sex. Go to the toilet before bed and see if you can eliminate gas or possibly stool. And relax. Don’t occupy your mind with this worry, or you really won’t enjoy the sex.
4. “How can I afford to buy all the supplements, vitamins and medications necessary to make my stomach feel normal again?”
Wander the aisles at any health food store, and you’ll see plenty of pricey supplements promising stomach serenity. Unfortunately, you could spend a small fortune trying to compose your own stomach-soothing cocktail, with dubious results. How do you know what’s worth it and what isn’t?
Become an informed consumer. Television ads and company information are almost certainly biased toward the product, and it’s often hard to assess the product’s potential usefulness and whether the potential benefit for you justifies its expense. And the advice dispensed by a friendly salesperson might be uninformed. Read newspapers, magazines or online media for new studies. Manipulating your diet and lifestyle changes are cheap and could have major positive effects on your health. Lose weight if you are overweight, exercise, stop smoking and eliminate foods that could be causing symptoms, as discussed in the following chapters. Vitamin D and calcium, if not obtained in food, are important supplements for good health. Generic medications in most instances are cheaper and just as good as name-brand medications. Starting with a cheaper medication over a more expensive one is advisable. Probiotics have many health benefits, as will be described. Insurance will not pay for them and they can be expensive. All claims made about probiotics are not always based on studies. If you have IBS and want to take a probiotic, be sure to take a probiotic that includes a bifidobacillus. Other suggestions are given in the chapter on diarrhea.
5. “How can I afford to eat healthfully?”
These days everyone wants to be Mario Batali, trotting through bustling markets for the freshest produce. It’s trendy, the food looks great, and you feel good about yourself after loading up your cart with shiny fruits and veggies, organic farmed fish and big bags of granola. But make a habit of shopping at fancy stores, and before long you’ve spent your entire shoe budget or mortgage payment. These delicacies might look pretty on the shelves—but buying them may not be the most money-wise thing to do. How can you eat well without breaking the bank?
Buy in bulk. Food is cheaper if you buy more than three pounds. Often joining a food co-op or a discount or wholesale market is cheaper. Specialty stores and organic food stores are more expensive. Think creatively. You can get much-needed protein from legumes and can add to them a small amount of meat and vegetables if you would like. Fish heads with the bones may be available from the fish market or store for a minimal cost. These can make a delicious soup. Many people don’t think about eating a turkey unless it’s Thanksgiving. However, turkeys are usually cheap and meaty and can stretch to feed many people. Buy items on sale and expand your palate. You might have to buy greens that you’ve never tried before—and you just might like them! You can freeze meat. Just make sure that you label it with the date and wrap it carefully. Check out the prices of frozen vegetables, as well as fresh vegetables. Make sure that you eat what is good for your condition.
6. “I’m always late for work because I can’t get off the toilet!”
So many women I know end up running for the subway because they’ve spent more time sitting on the toilet than putting on their clothes. There’s always that one last pitstop for the road—which sometimes turns into an hour of straining, grunting and pushing, to no avail. How many times can the “I was stuck in traffic” excuse hold up?
If the problem is that it takes you a certain amount of time after you wake up to finish your morning toiletry, wake up earlier. If the problem is that your cup of coffee sets you off, drink your coffee earlier, drink it on your way to work or wait until you get to work—whatever works. If the problem is that when you think of leaving home, you have to go to the bathroom, you should learn some biofeedback techniques. You may need to take an Imodium to get out. If you are taking fiber or a laxative during the day, try changing your intake schedule.
7. “I can’t go out to eat—everything makes me sick!”
What fun is going to a restaurant when the menu is a land mine? Some acidic foods cause heartburn; other foods cause major gas. And forget about alcohol. How can you enjoy dining out if you have to order a prune salad or a milk of magnesia cocktail?
Try to scope out the menu ahead of time. The Internet is great for that. Know what you can eat. Call ahead and discuss your food preferences or needs with the chef. Often he/she will be very accommodating. If no accommodation will be made, go somewhere else. You should also carry a card noting what you cannot eat; this can be slipped to the waiter. If you have allergies or celiac disease, you absolutely need to make sure the chef understands your forbidden foods. Some restaurants will list gluten-free choices. If you don’t think you can eat much at the restaurant, eat snacks at home before leaving and just order a few things (maybe just beverages) so that you can be social.
8. “My belly bloats up by the end of the day and I look seven months pregnant.”
Do you have to open your zipper to feel comfortable or wear elastic-banded pants or find a loose-fitting dress to hide your figure?
The first thing to do is to try to eliminate any foods that cause increased gas, as this may cause bloating. Reducing stress may help. Learn biofeedback or meditation techniques to control stress and to reduce the physical accompaniments to stress. It is not known if strengthening the abdominal muscles will help prevent increased bloating, but it is worth a try and healthy, too. Probiotics may help. If bloating continues, try wearing loose clothing. Elastic-waisted clothes can expand during the day and be hidden by beautiful oversize sweaters. Body shapers can help control the belly bloat as well as the bulge. Most times no one else will notice. Don’t broadcast your problem to your date or companion. Keep it to yourself.
9. “I can’t control the noises my stomach makes!”
You’re leading a board meeting, proudly giving a PowerPoint presentation, when suddenly your stomach erupts like Mount Vesuvius. Not the quickest route to a promotion. How do you rein it in?
This may require a course in biofeedback or a way that you find for controlling your emotions or stress. Sometimes there is nothing one can do. Everyone has had this problem at some time. Try to make light of it if you see someone staring at you. If your stomach makes loud noises when you’re hungry, have a low-calorie snack before you go into that important meeting. Try to figure out what causes the noises, and then try to reduce the precipitating factor.
10. “I can’t stop farting in public!”
You’re sitting in class or at a meeting when suddenly a noxious odor seeps from your body. You avert your eyes or stare suspiciously at that annoying guy from accounting, trying to pin the blame on him. We’ve all been there at one time or another. But for some women, this kind of deviousness is a way of life.
First try to reduce the foods that cause gas. Do you need to eliminate milk products, gas-forming vegetables or other foods? If, after changing your diet, you continue to have this problem, you may need to be evaluated with breath tests. Could you have a parasite? Does simethicone (Gas-X) or enteric-coated peppermint capsules (do not use if you have heartburn) help? If you still have gas after changing your diet, consider a diet that eliminates fructose, lactose and other carbohydrates that cause gas, or a specific carbohydrate diet, or consider trying probiotics. If flatulence persists, you could try purchasing carbon filter underwear, which is available online. This could help absorb the odor, although not the noise.
The following questions and answers will help you understand your digestive system:
What is normal digestive function?
Remember these four facts:
1 There’s a wide range of normal! Bowel movements can range anywhere from twice per day to three times per week. It’s about understanding what’s normal for you. If something feels off, don’t ignore it. Bowel movements are affected by where you are in your menstrual cycle. Due to hormonal changes, many women have diarrhea or loose stools during their period, and constipation leading up to it. Some women actually look forward to their periods to empty out their bowels, not just to reassure them that they aren’t pregnant.
2 Stool form varies from person to person and from event to event. No, it’s not always a firm, one-inch-wide and six-inch-long form with a curled end. It can depend on your diet and fluid intake. “Paperless” was the ideal state of the bowels described by Heinrich Böll in Group Portrait with Lady, in which the stool comes out in one complete piece and leaves no residue behind. However, not many people have this kind of stool.
3 Gas occurs in everyone! In fact, we all pass between a half quart (500 mL) to a quart and a half (1500 mL) per day if we’re normal. Some people make more gas than others. The amount depends on what you eat. It’s normal to pass gas ten to twenty times per day.
4 Check your meds! Medications, including herbs and over-the-counter medications, can sometimes cause constipation, diarrhea or heartburn. But remember: most people have heartburn at one time or another—40 to 50 percent of Americans monthly and about 10 to 20 percent weekly.
How soon after I eat should food be expelled from the body?
You should eliminate that delicious sushi feast or burrito dinner within three to five days.
As a woman, how does my digestive system differ from a man’s?
Well, we’re all human, and for men and women, the digestive tract is made up of the same parts. It is a hollow tube that travels from the mouth to the anus. When food is ingested, it migrates from the mouth through the esophagus into the stomach and then into the small intestine. The small intestine comprises the duodenum (which is short), followed by the jejunum and finally the ileum. Then, remaining food goes to the large intestine or colon. The small intestine is twenty to thirty feet long, while the colon is three to five feet in length.
But there are differences. A woman’s esophagus is shorter than a man’s regardless of her height. Also, a woman’s colon is often longer and “twistier” than a man’s. This could contribute to more constipation, although no one has looked at the association of the number of bowel movements with the length of the colon. (It definitely makes it harder to perform a colonoscopy on women!) Finally, what’s left of the food after its digestive tract travel is eliminated as waste.
Here’s a handy diagram:
Figure 1-1. The parts of the gastrointestinal (GI) tract with their locations are indicated. The food travels from the mouth through the esophagus, into the stomach and then out of the stomach into the small intestine. The small intestine is made up of (1) the duodenum, which is joined to the stomach in the upper right abdomen and then descends for a short distance before it heads across the belly to the left side, where it connects to the jejunum in the upper abdomen; (2) the jejunum; and (3) the ileum, which connects to the colon (large intestine) at the level of the cecum in the lower right side of the abdomen. There is no clear distinguishing characteristic marking the junction of the jejunum and the ileum. After the small intestine, the food travels into the colon at the level of the cecum. The main parts of the colon from cecum to rectum are indicated on the diagram. Bile is made in the liver, stored in the gallbladder and excreted into ducts. The common bile duct enters the small intestine in the duodenum. The pancreas makes digestive enzymes that are excreted into ducts, with the main duct entering the duodenum, usually with the common bile duct.
What does my digestive system do?
1 The saliva in the mouth moistens the food and starts the digestion process.
2 In the stomach, food gets mixed together, then broken down into smaller pieces, and digestion really starts in earnest with the help of acid and enzymes.
3 The small intestine breaks down the food substances with the help of more enzymes and proteins and absorbs nutrients and water into the body.
4 The large intestine (colon) takes out even more water to give you the stool form that we all know.
5 The intestines, particularly the colon, harbor helpful and harmful bacteria that produce nutrients and digest the food you eat.
6 The gut acts as a barrier to harmful substances and pathogens (organisms), keeping them out of the body.
7 The gut contributes to the immune response, making antibodies and fighting off disease.
8 The digestive system produces hormones and neurotransmitters that affect blood sugar, appetite and bowel function.
9 The digestive system eliminates indigestible substances as stool.
It’s disgusting to think that I have “germs” inside me. What do these bacteria do?
There are one hundred trillion bacteria in your body. A good number of these are in your digestive tract. Most times they’re working in perfect harmony with the body, helping to fight off bad bacteria and helping to digest your food. They make vitamins, as well as substances to help your body absorb the vitamins you ingest. But sometimes the ratio of good to bad bacteria becomes unbalanced, and symptoms or disease may become obvious. There is likely a healthy flora and it is unlikely to be the same in everyone. Lactobacilli and bifidobacteria are considered to be healthy bacteria.
What do bacteria have to do with weight gain and weight loss?
The more we learn about bacteria, the more we realize how much they influence our health. Take mice, for instance. Lean mice have different bacteria than obese mice, and it’s not just a result of the type of food the mice are eating. When obese mouse bacteria take up residence in a lean mouse, the lean mouse gains weight, even without eating any more food. There are two main kinds of bacteria that seem to change with obesity in mice. The obese mice have fewer Bacteroidetes and more Firmicutes. Human bacteria can take up residence in the intestines of mice that are raised without bacteria. When one group of mice colonized with human bacteria was fed a high-fat, high-sugar diet, typical for a Western diet, the mice gained weight and grew more Firmicutes and fewer Bacteroidetes. In mice fed a low-fat, plant-based diet, the bacteria ratios were reversed. The change in bacteria to a high concentration of Firmicutes could occur in less than one day when the mice fed a plant-based diet were switched to a high-fat, high-sugar diet. It appears the bacteria may be important in people, too. In obese twins, there are fewer Bacteroidetes and more Actinobacteria than in lean twins. The bacteria that are present in obese individuals are more efficient at extracting calories from carbohydrates. Limited studies show that weight reduction in adolescents results in a change of bacterial flora. Furthermore, studies show that after gastric bypass surgery, patients had a change in their bacteria.
The types of bacteria associated with obesity may even be present before obesity occurs. Why is this important? The bacteria extract calories from carbohydrates and fats, and they stimulate the body to absorb these substances into the body and lay down fat. My patients have often told me that they can’t lose weight, even though they are eating very little, or that they have even gained weight without overeating. These women were counting their calories, and they weren’t snacking. Could it be that their bacteria are responsible? Could their intestines just be more efficient in absorbing nutrients (i.e., calories)? Can changing the gut flora result in weight loss? I’m speculating, but I believe the answer is yes. Only future studies will show if I’m right.
I hear a lot about probiotics and prebiotics. What are they?
Probiotics are living organisms thought to have good effects on one’s health. They are similar to bacteria that are normally found in the intestines that do not cause disease and are often designated “good bacteria.” The most common probiotics currently in practice contain a combination of Lactobacillus, Bifidobacterium, Streptococcus and other bacteria, or the yeast Saccharomycetes boulardii. Probiotics are present in some foods such as yogurt, fermented and unfermented milk, some juices and soy beverages. A large variety of probiotics are sold as supplements in capsule and powder form. Studies showing the utility of probiotics for immune health and gastrointestinal diseases are limited. Further discussion of the utility of probiotics for different conditions can be found in later chapters. However, it’s important to keep in mind that no generalizations can be made regarding the effectiveness of an untested probiotic for a specific condition. Furthermore, it is unknown if a probiotic good for one person will be helpful for another.
Probiotics are often given to a person on antibiotics for protection against the development of Clostridia difficile bacterial infection. This infection occurs after the antibiotics kill off other gut bacteria that might keep the C. difficile in check.
Here’s an interesting tidbit: One study in pregnant women published in preliminary form suggests that probiotics may be helpful in preventing pregnant women from developing obesity twelve months after the end of pregnancy. Further studies are needed to confirm this finding.
Prebiotics, meanwhile, are nutrients for the healthy bacteria. These nutrients, typically complex carbohydrates, are not digested by your gut and provide the bacteria a food source. Common prebiotics are inulin and oligofructose.
What are the most common stomach ailments?
Food poisoning is a biggie. It seems there’s always a new scare out there: Don’t eat raw eggs or undercooked chicken unless you want a nasty case of Salmonella or Campylobacter. Is a little taste of batter safe when you make a cake? (How many of us remember joyfully eating cake batter or cookie dough as kids?) There are warnings for raw meat, but fruit and veggies must be safe, right? Not so fast. Along comes the chance of food poisoning from contaminated spinach and tomatoes!
We’ll all get food poisoning at one time or another. Other common ailments are heartburn (GERD), constipation and diarrhea, irritable bowel syndrome (IBS), and colorectal cancer. But don’t panic. For most stomach issues, there’s a logical and highly treatable explanation. In fact, about thirty-five million people have IBS, belly pain or discomfort with a combination of gas, bloating, diarrhea or constipation. I’ll discuss this more in Chapter 3.
How do I know when to seek help?
Many people endure months or years of gas, constipation, diarrhea and/or abdominal pain. They live with it. But when is it important to seek medical attention to make sure that nothing is seriously wrong? No one wants cancer, of course, but colon cancer is usually curable if caught early. Therefore, even if you feel well and have no belly problems and no family history of colorectal cancer, it’s important to do routine screening starting at age fifty (forty-five for African-Americans). And know the warning signs below that could indicate cancer or other GI problems.
WARNING SIGNS: CONSULT YOUR DOCTOR IF YOU HAVE ANY OF THESE SYMPTOMS
1. Rectal bleeding
Any rectal bleeding is abnormal and must be checked out. Although blood only on the toilet tissue when you wipe may just indicate a local cause, such as hemorrhoids, any blood should result in you seeking attention and being examined, usually via colonoscopy.
2. New onset of abdominal pain
There are many causes of abdominal pain, some of which require immediate attention. Usually, troublesome abdominal pain surfaces suddenly, with or without fever. However, it can be present for a long time under the radar before it becomes more frequent or severe.
3. Unintentional weight loss
4. Dehydration
Symptoms can include decreased urine production, thirst, dry mouth and eyes and dizziness.
5. New onset or worsening of diarrhea
Diarrhea springing from a virus or a bacterial infection often goes away on its own but sometimes requires further treatment if it is severe, with many watery stools (with or without abdominal pain), or if the symptoms persist for a long period of time. If the diarrhea continues for more than three days, consult your doctor.
6. Sudden change in the appearance of the stools or new and persistent constipation
Pencil-like or thin stools may indicate a narrowing in the colon.
7. The sensation that you have a mass, or a hard area, in the abdomen
8. Weakness and dizziness
This could indicate dehydration or anemia.
9. Prolonged fever
10. Repeated vomiting over a short period of time
11. Sudden onset of bloating that won’t go away
Bloating can be due to gas, fluid in the abdomen, stool or sometimes a mass. If there is a blockage in the bowels, the abdomen can bloat up behind it, which usually causes pain. If you feel unusually bloated, consult your doctor.
Other problems, such as joint pain or a rash, can often be associated with gastrointestinal issues.
REMEMBER: You know your body better than anyone else. If you feel that something is wrong, check in with your doctor. Don’t be afraid!
Chapter 2
Endometriosis and Feminine GI Troubles: Symptoms Every Woman Should Understand
“Man endures pain as an undeserved punishment; woman accepts it as a natural heritage.”
—Anonymous
We women tend to feel stress in our guts more so than men, and we talk about it less, tending to bottle up our stress. We also have unique stomach issues, too, that simply don’t affect guys. In this chapter I’ll talk about women-only issues like endometriosis and infertility (5 percent of women suffer from endometriosis, and 25 percent of sufferers are infertile), and touch on some other female-centric ailments. You’ll meet two of my patients, Marci and Susan, both of whom went through excruciating journeys to finally get proper treatment. Their cases are extreme but instructive: if one is properly armed, endometriosis is treatable, but it can be very hard to detect.
Women don’t usually come to me thinking that endometriosis could be causing their gastrointestinal symptoms. In fact, many times women have either never heard of endometriosis or have had it in the past, and they certainly don’t connect this problem with any gastrointestinal symptoms, thinking it’s a purely gynecological issue. I’m not a gynecologist, and I don’t treat women for endometriosis. However, I have seen many women with GI symptoms caused by endometriosis, often erroneously diagnosed as irritable bowel syndrome. Once I suspect the diagnosis, I can refer the woman to an expert who can decide what tests should be done and what treatment should be recommended for the problem.
When I tell women that they may have endometriosis, the women usually have a laundry list of questions. This is good. I find too many doctors who are not gynecologists know very little about endometriosis, and most gastroenterologists don’t even suspect it as a possible cause of symptoms. They often settle on a diagnosis before their patient has been properly heard. In order to understand what endometriosis is, it’s helpful to review the anatomy of the gynecological tract and normal menstruation. (See Figure 2-1).
Figure 2-1. Menstruation is monthly bleeding from the uterus. The menstrual cycle is considered to start with the first day of bleeding. The next cycle begins at the time of first bleeding with the subsequent period. During the first half of the cycle (follicular phase) an egg in the ovary matures and the wall of the uterus thickens. At about day fourteen the egg is released from the ovary (ovulation) and travels through the fallopian tube to the uterus. The uterus lining continues to thicken (luteal phase). Then, if no fertilization of the egg with sperm takes place, the lining of the uterus is shed and discharged through the cervix and vagina as your period. Oral contraceptive pills will interrupt the menstrual cycle, but when menstruation occurs, it is normal.
Here are some common questions I hear from my patients:
Several of my friends have endometriosis, and one of them is having trouble getting pregnant. What is it?
Endometriosis occurs when the cells that line the wall of the uterus—which a woman should pass with each menstrual period—end up growing outside the uterus instead. During normal menstruation the uterine lining cells exit through the vagina (see Figure 2-1). But almost every woman also has retrograde menstruation in which some of the uterine-lining cells travel out the fallopian tubes and into the pelvic cavity, thereby tracing the egg’s path in reverse from ovary to uterus (see Figure 2-2). This is called retrograde menstruation. When a person develops endometriosis these cells take up residence in the wrong places—sometimes even growing in and sticking to the bowel and other nearby organs—and can bleed with each period, causing pain and scarring. When this happens, a woman might get cyclical or constant abdominal pain. Usually, the endometriosis exists in the lower region of the pelvis, but it can creep onto other organs, too. (See Figure 2-3). Bowel endometriosis affects about one-third of women with endometriosis and can cause severe pain with bowel movements.
Figure 2-2. The menstrual cycle is the same as in normal menstruation. However, when the lining of the uterus is shed, it does not travel exclusively through the cervix and vagina. Some of the cells from the uterine lining travel upward, through the fallopian tubes and then out into the pelvis. This sets up the possibility for endometriosis to occur.
Figure 2-3. Endometriosis occurs when the cells of the lining of the uterus take up residence outside of the uterus. The endometriosis lesions can be different sizes and vary from clear to red to black. This drawing shows the common areas where endometriosis occurs and the close proximity of the bowel to the uterus, which explains how endometriosis might end up on the bowel. The sigmoid colon is behind the uterus (toward the spine) and the rectum is behind the vagina. The rectouterine fold, also known as the uterosacral ligament, connecting the uterus and the sacrum, part of the spinal column, is a common place for endometriosis. The broad ligament connects the uterus to the wall of the pelvis and is in a perfect location for implantation of the endometriosis.
Is endometriosis common?
Approximately 5 percent of all menstruating women and girls suffer from endometriosis. However, for women who are infertile and can’t get pregnant naturally, endometriosis can be the case 25 to 40 percent of the time! For teenage girls with very painful periods, endometriosis is the cause nearly 50 percent of the time.
If almost every woman has period cells that pass from the fallopian tubes, why don’t all of us who still menstruate have endometriosis?
Women who do get endometriosis have several things going on: First of all, the cells have to stick to a place where they can grow and attract more cells. These cells then have to form blood vessels within the clump or implant—not an easy feat! Genetics and environmental factors also play a part. How your body reacts to these misplaced cells strongly contributes to the damage the endometriosis may cause.
Interestingly, tall, thin women are more likely to have endometriosis than short, heavy women. Ahem! This does not mean you should gain weight to decrease your risk for endometriosis. Obesity, of course, has many negative effects on your health. Some studies have shown that caffeine and alcohol intake also increase the risk of endometriosis, while smoking and exercise reduce the risk. (Of course, I’m not going to endorse smoking, either.)
I feel bloated and crampy all the time. My doctor says it’s IBS. My coworker has endometriosis and told me I probably do, too, based on my symptoms. I’m starting to freak out. How do I know that I don’t?
Endometriosis can be tough to diagnose because several of the symptoms—like diarrhea and cramping—can mimic irritable bowel syndrome (IBS). Don’t settle for an IBS diagnosis, especially if you’re having trouble conceiving. Here are some symptoms of endometriosis:
The Big Ds
Dysmenorrhea—Otherwise known as debilitating menstrual cramps.
Dyspareunia—Painful sex.
Dyschezia—Painful bowel movements.
Dysuria—Painful or uncomfortable peeing.
PLUS:
Recurrent miscarriage—Particularly pregnancies that end within two to three months.
Nausea, vomiting and/or diarrhea—Particularly during PMS.
Unusually long or short menstrual periods—a normal period should last between three and five days.
What is the best way to diagnose endometriosis?
The best way to make the diagnosis is by a surgical procedure called a laparoscopy. In this procedure, a small cut is made under the belly button, infused carbon dioxide distends the belly and a scope is inserted. The gynecologist or surgeon looks around to identify any raised blue, red or clear areas that could be endometriosis and examines the ovaries for cysts. Often these areas can be treated, and scar tissue can be cut (released).
Surgery is not always needed for the diagnosis. Other tests can be done but might not be as good for detecting very small lesions or for identifying scar tissue. These tests include an MRI (magnetic resonance imaging) scan of the pelvis, which can identify pelvic endometriosis; a CT (computerized tomography) scan with air or contrast in the rectum; and an air-contrast barium enema (to detect endometriosis on the bowel). An endoscopic ultrasound, in which an ultrasound device on the end of a scope is inserted into the rectum, can take images of the surrounding area and often see if there is endometriosis in the bowel wall. Traditional ultrasounds, with the ultrasound probe placed on the abdominal wall or in the vagina, and colonoscopies aren’t particularly helpful for the diagnosis of endometriosis.
If endometriosis is so common, why is it so hard to pinpoint and diagnose?
The symptoms of endometriosis tend to mimic other issues. Women usually have different symptoms and may seek attention from a primary care physician, gastroenterologist or gynecologist. Abdominal or pelvic pain is a very common complaint. However, change in the bowels may also be a complaint. Endometriosis is not often the first thought for the internist or gastroenterologist.
Unfortunately, most doctors know very little about endometriosis. After all, isn’t pain the norm with the menstrual period? Suspicion of the diagnosis is really what’s needed to make a diagnosis. For more than forty-three hundred women reporting surgically diagnosed endometriosis who responded to a survey by the Endometriosis Association, the average time from the onset of symptoms until a woman sought medical attention was over four and a half years, and it took almost five years on average before the diagnosis was made. When symptoms started in adolescence, it took even longer before the correct diagnosis was made. And along the way, almost two-thirds of these women were told by one physician that nothing was wrong with them. Remarkably, 18 percent of women saw between five and nine physicians, and 5 percent saw ten or more physicians before endometriosis was diagnosed. Almost all of these women had pelvic pain and menstrual pain, and two-thirds experienced pain at ovulation.
Women often are totally accepting of having pain every month. But when is the pain not the norm?
Marci is a thirty-one-year-old lawyer who was referred to me for abdominal pain. For three months she had had an intermittent “pulling” pain deep in the pelvis, which seemed to come out of nowhere. This pain had grown more frequent, but she tried to ignore it—she had a frantic schedule, worked late all the time and just didn’t have time to deal with it. She was also constipated, with very infrequent pellet-shaped stools. She chalked this up to not eating regularly, scarfing down lunch at her desk and sometimes skipping dinner or doing takeout. Her most recent menstrual period, she told me, was more painful than normal. Her pelvic pain also had begun to shift to the left side of her abdomen. She’d been sent by her gynecologist for a pelvic ultrasound and vaginal ultrasound, where a probe was inserted into her vagina. The probe in the vagina reproduced the pain. A small cyst found on her right ovary—a common finding in a young woman, often due to follicle formation—was the only finding.
Her days followed a specific routine, centered around pain: Every morning she would wake up hoping that this would somehow be the day that she’d miraculously be pain free. But her relief would be short-lived. After an hour, once she was up and about, the pain would start and get progressively worse as the day wore on. The pain radiated down her left thigh and occasionally shot down her left leg, though her back was pain free. She even dreaded lying down to sleep, because she knew she’d only lie awake in pain. Her only other complaint was tiredness. But then again, who wouldn’t be tired given her lifestyle and lack of sleep? It was easy for her to make excuses.
Marci had suffered from colitis (an inflammation of the colon) five years ago, during law school, but a colonoscopy revealed that her colon had healed. She’d had a bout of appendicitis fifteen months ago, she told me, and her appendix was removed, which alleviated the sudden abdominal pain symptoms that she had at that time.
I reviewed her family history, and it was revealing: Her mother had endometriosis, and her mother’s aunt had endometriosis. A positive family history for endometriosis, especially in her mother, made me suspect that Marci had inherited it as well. (In fact, heredity plays a part in 18 percent of cases.) Plus, Marci was an only child, which made me think her mother had had a hard time getting pregnant due to her condition.
When Marci came to me, she was very distressed about her previous physician interactions.
“My gynecologist told me that I must be under stress since my affect was ‘flat,’” Marci said. “I told her that I was in quite a bit of pain and that it was definitely affecting my mood. She spent an hour asking me about the stress in my life, and then she told me I should go to a mind/body clinic! She said nothing was wrong with me.” Marci’s gynecologist brushed off her fears when Marci told her how hard it was for her to insert a tampon because of pain; her gynecologist also failed to biopsy her ovarian cyst. Clearly, by the time Marci reached my office, she was very frustrated—not to mention physically miserable.
My examination revealed only tenderness below the navel and on the left side of her belly. I examined her colon again by colonoscopy, and while I could see traces of her previous colitis, nothing could explain the pain that radiated down her leg. I also ordered an MRI for her spine, which was normal, and a pelvic MRI scan.
Once I got those results, I felt like we were getting somewhere: The pelvic MRI was abnormal, showing a small amount of free fluid in the pelvis and an area that suggested that there might be unexplained nodules. Her colon took some unusual sharp turns, which suggested that the colon could be stuck to adhesions (scar tissue). Adhesions are caused after surgery from inflammation (such as diverticulitis, “pouching” in the colon) or from the bleeding of the lesions of endometriosis. Taken together, my findings suggested the possibility of endometriosis.
The only way to be sure was to look in that area. This was done by a laparoscopy. (See above for a description of this procedure.) There it was—endometriosis with scar tissue, with involvement in her colon. Her lesions were cauterized (burned off), and she was started on Lupron (leuprolide) to reduce her estrogen levels.
Marci developed hot flashes due to a lack of estrogen. This was actually a good sign, as it meant there wasn’t enough estrogen to stimulate the endometriosis to grow back. (Menopausal women experience this all the time.)
However, estrogen can be protective, especially against osteoporosis (loss of calcium in the bones, which makes them brittle). Marci’s doctor thought that a low dose of estrogen could prevent osteoporosis without making her endometriosis rear its head yet again, as had been shown in studies. Therefore, her gynecologist prescribed an oral contraceptive pill. Unfortunately, within a week of starting the oral contraceptive, Marci began to suffer uterine bleeding. This was unexpected—Lupron should have stopped her periods entirely. (Marci’s treatment isn’t as strange as it might seem. Despite the fact that she did not have a period, her fertility wouldn’t be permanently affected; once she stopped Lupron, her proper menstrual cycle and, hence, her fertility would return.) Even though this bleeding was clearly out of the ordinary, Marci assumed all was well, and she continued on her treatment. (Think this is weird? It isn’t. I’ve had patients come to me after having ignored bleeding for years. Don’t make this mistake!)
After three months of treatment, the bleeding became constant, so heavy that Marci went through a tampon every hour. For two weeks she went through a box of tampons every day. Her pain also became progressively severe. It was impossible to ignore any longer. On the advice of her gynecologist, she stopped the oral contraceptive pill. The bleeding stopped within twenty-four hours. The pain lessened after a few weeks but then returned, shooting down her left leg. Ibuprofen didn’t help. The endometriosis was clearly back.
Now, five months after her first laparoscopy, an MRI scan showed a new lesion between her rectum and her spine on the left side. After she endured two months of exhaustion and increasing pain traveling down both legs, despite the Lupron, more laparoscopic surgery was considered.
She underwent another laparoscopy ten months after the first one, performed by a new gynecologist. Now she had endometriosis on the right ovary and additional endometriosis in her pelvis. Further evaluation showed new lesions in front of the spine and also between the rectum and bladder, which would certainly affect her bowels. She was told by the operating gynecologist that nothing else could be done for her—short of a hysterectomy with removal of the ovaries. At thirty-one, still hoping to start a family, she refused to accept this outcome.
At this point, it had been a year since she’d begun her journey. I had kept in touch with her via phone during her long saga. She now returned to my office for a GI follow-up. She told me her bowel movements were coming only once every three to four days, pelletlike and incomplete. Because constipation can accompany endometriosis, and especially given her new lesions, I thought the endometriosis was likely one reason why her stools were so odd. For the constipation, I recommended that she take Benefiber pills (guar) and add flaxseed (whole or ground), one to two tablespoons of each per day. I also started her on lactobacillus tablets. (A study in rhesus monkeys, which I talk about below, suggests that those with endometriosis had fewer lactobacilli. The benefits of lactobacillus supplements aren’t definitively known for humans.)
Most troubling, though, was the pain that resulted from her deep endometriosis. She couldn’t have intercourse or easily insert a tampon. I switched her to sulindac, a nonsteroidal drug, which I thought would work better than the ibuprofen.
Marci didn’t like the sulindac, because it made her dizzy, and so she returned to ibuprofen for pain, sometimes taking up to eleven tablets every day. The ibuprofen made her more constipated, though it did somewhat address her pain. When she decreased the amount of ibuprofen at my strong suggestion, her constipation improved. She decreased the ibuprofen and put up with her pain.
Over the next eight months, Marci continued to have constant pain in her pelvis, although she was able to make it through her busy day, through a delicate dance of medication management. The pain caused exhaustion; she told me she’d crawl into bed at the end of a long day, praying for a pain-free night’s sleep.
In spite of two surgeries, medical therapy and opinions from several surgeons, she continued to suffer. She had a choice: should she undergo hysterectomy, with the removal of the ovaries, which would likely take away all her symptoms? This is a difficult choice for a young woman, of course. Interestingly, if she did get pregnant in the future, the endometriosis would likely regress during pregnancy, though we don’t know why. (Getting pregnant in the first place, however, might be difficult without IVF [in vitro fertilization].)
Before resorting to hysterectomy, she was seen by another gynecologist, who found tenderness on the pelvic exam consistent with endometriosis. He referred her to a gynecological-oncological surgeon, who was very experienced in complicated surgeries as he specialized in cancer in the female organs. The best time to operate was thought to be when Marci was bleeding during her period, since the endometriosis lesions could be more easily identified as they would be active. Therefore, she stopped further doses of the Lupron and surgery was scheduled when her estrogen levels were at their peak, meaning the endometriosis would be at its most visible.
The surgery was a success. The visible endometriosis lesions were cauterized (ablated) or removed, and the scar tissue was cut (lysed). Now on continuous birth control pills, Marci has been almost pain free for over one year.
How is endometriosis treated?
The goal of the treatment is to reduce pain, improve the chances for pregnancy and reduce any associated side effects from the endometriosis. Estrogen is a major factor in stimulating the endometriosis to grow. Therefore, treatment is aimed at interfering with estrogen stimulation.
Endometriosis can be treated medically and surgically. Your doctor should discuss the treatments with you in detail, as every treatment has possible side effects. Here’s what he or she might suggest:
1 Oral contraceptive pills (cyclical or continuous).
2 Androgens: These are male hormones, like testosterone, which is the opposite of estrogen. A medication like Danazol increases testosterone and lowers estrogen. Beware—androgens can cause weight gain and masculinizing effects, like hair on your upper lip.
3 Gonadotropin-releasing hormones: These prevent the stimulation of the ovaries by your innate (natural) hormones and produce a low-estrogen environment. Lupron, leuprolide acetate, (given to Marci) is one such medication.
4 Progestins: Progestins stimulate progesterone receptors, helping to prevent ovulation and to lessen menstrual bleeding.
Are the symptoms the same for everyone?
The course of endometriosis varies from person to person. Marci’s odyssey was severe. In fact, one-quarter of women don’t have symptoms and might not even suspect a problem until they try to get pregnant and have trouble. Of those women with symptoms, pain can be mild or intense, like Marci’s. The pain can be cyclical, occurring in relation to the menstrual cycle (often before your period), or it can be constant.
In up to one-third of women, the intestinal tract (usually the surface of the small and large intestines) houses these rogue cells. When endometriosis involves the colon or the small intestine, 40 percent of women experience constipation; 33 percent, diarrhea; and 5 percent, both diarrhea and constipation. Rectal pain during a bowel movement can be severe, and bleeding from the rectum can occur. It’s little wonder that the diagnosis of irritable bowel syndrome is so often made in women who actually have endometriosis. A woman might even mistakenly be given the diagnosis of ulcerative colitis or Crohn’s disease when she has bleeding from her rectum due to endometriosis.
Where does this pain come from?
The pain brought on by endometriosis is due to a variety of causes.
1 Irritation of the nerves occurs. When the endometriosis grows, it acquires a nerve supply and irritation of the nerves can cause pain.
2 Blood is an irritant. When the endometrial tissue bleeds due to hormonal stimulation, the blood can cause all sorts of inflammatory cells to migrate into the affected area.
3 Inflammatory cells release compounds that can cause pain. These substances stimulate nerves or cause pain directly by inducing inflammation, just like when you get a bad cut that develops inflammation around it. There are medications that act directly against the formation of these substances. These include aspirin, ibuprofen (Motrin), naproxen (Naprosyn) and sulindac (Clinoril). We use them to prevent menstrual cramps and for other aches and pains.
Do women with endometriosis tend to get other illnesses more often than women without endometriosis?
According to a survey conducted in 1997 by the Endometriosis Association, many conditions are found to occur more frequently in women with endometriosis. The most common coexisting conditions are allergies and asthma. Women with endometriosis also have a high prevalence of hypothyroidism, fibromyalgia, chronic fatigue syndrome, rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s syndrome (dry eyes and mouth) and multiple sclerosis.
Is there a diet that I can follow that can help the endometriosis?
Maybe. The data suggest that diets may help, but there are few good studies. Here’s what I know.
In Japan a study showed that women who ate dietary soy isoflavones, which come from soybeans (tofu, for example), had fewer cases of advanced endometriosis, but the consumption of soy isoflavones did not affect the risk for early endometriosis. Soy isoflavones have estrogen-like activity but also can have weak antiestrogen properties. In this case, it was speculated that the antiestrogen properties decreased the risk for advanced endometriosis. Fish oil decreases the size of the endometriosis lesions in animals but hasn’t been shown to decrease the risk for endometriosis or the size of endometriosis lesions in women.
Do probiotics help?
I wish I could tell you definitively, but I can’t. The only evidence that suggests they might help is that the types of bacteria in the guts of monkeys with endometriosis are different from those in healthy monkeys. In monkeys with endometriosis, there are fewer lactobacilli. Whether or not endometriosis can be improved by taking probiotics containing lactobacilli just isn’t known.
Are there any alternative treatments that work for endometriosis?
As any woman with severe endometriosis will tell you, it’s worth trying anything! But there aren’t any solid trials evaluating alternative treatments. In a self-report of 1,160 women responding to an Endometriosis Association survey, many different treatments were highlighted, including whole medical systems and energy medicine (including acupuncture, traditional Chinese medicine, candidiasis treatment, homeopathy and naturopathy, ayerveda reiki), mind-body medicine, biologically based therapies (including ingestion of dietary supplements, diet-based treatment and ingestion of herbs), and manipulative and body-based therapies (including exercise, chiropractic manipulation and massage therapy).
Biologically based therapies (use of substances found in nature) (52 percent) and manipulative and body-based therapies (based on manipulation and movement of one or more parts of the body) (41 percent) were commonly used. The self-reported improvements were 74 percent for therapy with mind-body medicine (techniques to enhance the mind’s capacity to affect bodily function and symptoms) and 53–66 percent for therapy with many of the whole medical systems (complete systems of theory and practice), energy medicine (use of energy fields) and biologically based therapies. The manipulative and body-based therapies overall were reported to be less helpful, with 35 percent of women reporting improvement. However, without good studies, I can’t recommend the alternative therapies just yet.
I have endometriosis. Do I have to worry about getting cancer, too?
If you have symptoms that are unusual or bothersome, certainly get them checked out. You should also have the routine recommended screening tests for cancers, such as PAP smears, mammograms and colonoscopies. There are some differences in cancer rates for women who have had endometriosis. In a very large study from Sweden that looked at the rate of diagnosis of cancer after a hospitalization for endometriosis, the overall rate of cancer was not increased. However, some tumors were slightly more common, and one—cervical cancer—was less common. The cancers that had about a 25–37 percent increase in incidence were ovarian, endocrine, thyroid, brain and kidney cancer, and malignant melanoma. Colorectal cancer was not examined but may be slightly more prevalent. Breast cancer was barely increased, possibly due to the fact that we screen so vigilantly these days.
Lately I’ve been needing to pee—constantly. Judging by my sex life, I’m sure I’m not pregnant. My mother wants me to get tested for ovarian cancer, just in case. I had no idea constant urination was even a symptom! Could I have it?
Probably not. Frequent urination is more often a symptom of other problems. It could be a symptom of a urinary tract infection or diabetes mellitus, or it might be associated with irritable bowel syndrome or interstitial cystitis. Burning with urination also occurs in almost half of all women with endometriosis. It’s important to make sure that you don’t have an infection by getting a culture of your urine and to make sure you don’t have diabetes mellitus by having the sugar checked in your urine or blood. In the United States, females have a 1.4 percent lifetime chance of developing ovarian cancer. More than half of the deaths from ovarian cancer occur in women between the ages of fifty-five and seventy-four years. Still, it’s important to be aware of the symptoms. If something feels unusual for your body, please tell your doctor! Many symptoms overlap with gastrointestinal issues. See your doctor if the following symptoms are constant or worsening:
Bloating throughout the day, especially requiring a larger waist size on your pants
Pelvic or abdominal pain
Difficulty eating, feeling full quickly or weight loss
Urinary symptoms (urgency or frequency)
Frequent pain with intercourse
If I decide to get tested for ovarian cancer, what’s going to happen?
It’s important to remember that we want to rule out the zebras—or more unusual diagnoses—in the hopes of finding what we call horses, or more common ailments. Here’s what you can expect.
Pelvic exam: Your doctor will feel your cervix, uterus and ovaries. She may do a Pap smear, which evaluates for cervical and uterine cancers or changes in their cells, but not for ovarian cancer.
Pelvic ultrasound: This will take a “picture” of your ovaries and analyze what might account for that full, bloated feeling. It does not involve any radiation, just sound waves. Usually part of the test involves putting an ultrasound probe in the vagina, which may show the ovaries better. If there are growths, the ultrasound can’t always determine if these growths are likely to be cancer.
CT scan: This test uses X-rays to examine part of the body. It allows smaller problems to be detected. It visualizes the ovaries and uterus, as well as the bowel, lymph nodes and the spaces around them. A CT scan for ovarian cancer often includes an examination of the abdomen, as well as the pelvis. In that case, oral contrast is given to you to drink so that the bowel will stand out from the surrounding area. When the abdomen is examined, the liver, kidneys, spleen and pancreas are also seen. Often the radiologist doing the test will want to better visualize the blood vessels. This is done by an injection of dye into your arm. The dye contains iodine. So if you are allergic to iodine-containing substances, be sure and tell the doctor, as you will likely be allergic to the dye. Also, if you have any problems with kidney function, be sure to tell the doctor, as he or she might not want to do this part of the test.
MRI scan: This scan uses a magnetic field instead of X-rays to view the internal organs. It sees soft tissues very well. The best test is done with an enclosed scanner, where you’ll hear a lot of banging. (If you’re claustrophobic, speak up.) An injection of gadolinium (an element used as a contrast agent in MRI scans) is often done to see the blood vessels. Your kidney function should be confirmed as normal before you are given gadolinium, particularly if you have any problems that could affect the kidneys, like high blood pressure, diabetes mellitus, lupus, dehydration or kidney diseases.
Blood tests: A blood count (CBC) looking for anemia and liver function tests are commonly done. In fact, there is a blood test (CA-125) that had been touted to diagnose ovarian cancer. Unfortunately it is not a good screening test and has not been recommended as a routine screen in most people. CA-125 can be falsely high in someone who does not have ovarian cancer and falsely low in someone who does have ovarian cancer. On the other hand, CA-125 is often used to detect early recurrence of cancer in someone who had a high CA-125 with the original cancer and has had her ovarian cancer treated.
Laparoscopy: This is an even more precise test, in which a thin viewing tube (called a laparoscope) is placed through a small cut made in the abdomen. Using the scope as a guide, the surgeon takes a sample of fluid and tissue from the growth. These samples are then tested for cancer.
Every month around my period, I get bloated, I cramp and I have horrible diarrhea. I don’t mean to be a big baby, but how can I deal with it without letting it ruin my life?
Well, first remember that you’re not alone: about 85 percent of women suffer from some form of PMS each month, whether or not they have endometriosis. PMS, as defined by the American Congress of Obstetricians and Gynecologists, is “the cyclic occurrence of symptoms that are sufficiently severe to interfere with some aspects of life, and that appear with consistent and predictable relationship to the menses [menstrual period].” Only about 3 to 8 percent of women have severe symptoms. PMS symptoms may include upset stomach, bloating, constipation or diarrhea, appetite changes, mood disturbances, joint pain, headache and acne.
Changes in bowel habits during menstruation are reported by many women (34 percent in one study), and the symptoms are cyclical in almost 30 percent of women. At the time of menses, gastrointestinal complaints that women report are increased gas (14 percent), increased diarrhea (19 percent), and increased (11 percent) and decreased (16 percent) constipation.
One big tip—get enough calcium! A calcium supplement with vitamin D helps ease some symptoms of PMS. If you’re between the ages of eighteen and fifty, you need at least 1000 mg of calcium per day. If you’re older than fifty, you need 1200 mg. Eat plenty of fruits and vegetables, and get enough whole grains. Avoid alcohol and caffeine. They’ll exacerbate your troubles.
For the bloating, try enteric-coated peppermint capsules before meals, although if they cause heartburn, you should stop. Loperamide (Imodium, one half to two tablets) could help treat or prevent the diarrhea, though too much can cause constipation. Pepto-Bismol is also worth a try—two tablespoons or tablets up to four times per day. Remember your stool and tongue may turn dark or even black after using it, but this is a harmless side effect.
I’m going to have a hysterectomy, and I’m worried that it might affect my bowels. I am already somewhat constipated. Will I get worse?
Probably not. Chronic constipation after a hysterectomy, unless it is an extensive operation for cancer, is not common. One study reported less frequent bowel movements, more laxative use, harder stools and constipation after hysterectomy, but this was not statistically more significant than in women who have not had hysterectomies. In more recent studies, no increase in constipation occurred in women without GI symptoms who underwent a hysterectomy. Furthermore no increase of IBS occurred after a hysterectomy in women without GI symptoms before surgery. Overall, movement of the stool through the colon does not change as a woman gets older, but the signal to let you know the stool is waiting to come out does decrease with age, unfortunately.
Can endometriosis come back?
Unfortunately, the likelihood that endometriosis will return is high. Five years after a patient has stopped medications to treat endometriosis, the recurrence rate is over 20 percent. Endometriosis and the pain associated with it can even recur after a successful ablation (cautery) or hysterectomy. The recurrence rate after surgery is higher when the ovaries (even one) are left or the endometriosis was severe, in which case it recurs in 30 to 47 percent of women. Of over eleven hundred women who had endometriosis diagnosed by surgery and who responded to a 1998 Endometriosis Association survey, 42 percent underwent surgical procedures for endometriosis at least three times.
You always have to be aware that recurrence is a potential problem. A cure of the endometriosis can only be assured if all estrogen, which can stimulate the endometriosis, has been removed. This occurs if a woman has both of her ovaries removed or goes through menopause. However, if one ovary is left behind after endometriosis surgery to prevent a woman from getting hot flashes or other symptoms related to menopause, the endometriosis can continue to be stimulated.
This problem often goes unrecognized. Women are told that they had a hysterectomy and that should “cure” the endometriosis. Not always! They don’t know that a hysterectomy can involve removing only the uterus or removing the uterus with one or both ovaries. If you switch to a new physician, it’s important for him or her to know right away what kind of hysterectomy was performed.
One such blunder happened with Susan, a forty-one-year-old woman who came to me with abdominal pain and diarrhea. Susan was a tough lady: a survivor of child abuse, she acted largely as a single mother to her handicapped son and her daughter while her husband traveled on business. She also worked full-time in a doctor’s office. An avid athlete, she’d begun to curtail her activities because of her bowel problems, and her weight was fluctuating wildly. “I’m no use to anyone,” she cried on our first meeting. “I feel like I’m in the twilight zone.”
She was referred to me for a second opinion regarding her diagnosis of Crohn’s disease. (Crohn’s disease is a chronic inflammatory bowel disease. Crohn’s can affect any part of the GI tract, and symptoms vary by patient depending on where the inflammation occurs. Symptoms can include constipation, diarrhea, abdominal pain, vomiting, weight loss or weight gain, and gastrointestinal bleeding.)
When I met Susan, she was clearly at a low: She’d have just a sip of water, then suffer diarrhea. She was having six to ten yellow, watery bowel movements every day, in spite of taking Imodium daily. Plus, she often woke up with fevers, which caused headaches and confusion. She was still able to work as an office manager at the doctor’s office, but her weekends were consumed with sleep. Her eyes were inflamed, and her back was afflicted with arthritis. She also had hip, neck and leg pain, as well as sores in her mouth and a sore on her neck.
Susan had developed abdominal pain, rectal pressure and cysts in one of her ovaries after a hysterectomy for endometriosis a few years prior. She was treated with a large amount of Anaprox (a nonsteroidal anti-inflammatory drug like aspirin) for pain. She tried to tell doctors that the rectal pain reminded her of how she felt before her hysterectomy, but they brushed it off.
Shortly thereafter, Susan began to experience bloody diarrhea. She was admitted to her local hospital. A colonoscopy showed inflammation in her rectum at the end of her colon, and she was told that she had ulcerative colitis. She was treated with a steroid, prednisone, which has many possible side effects, such as diabetes, acne, and weight gain with short-term usage and bone loss and cataracts with long-term usage. Susan’s symptom complex of abdominal pain, rectal pressure or pain and frequent stools occurred almost monthly. She was taking up to nine medications per day and still having a minimum of six bowel movements every day, too. She was also seeing an array of doctors, including a rheumatologist and an ophthalmologist, for side effects brought on by the steroids. Her weight was also fluctuating between 110 pounds (without steroids) and 150 pounds (with steroids). The steroid was eventually tapered down and stopped, and Susan was changed to a nonsteroid compound. She did well for a while, until she developed diarrhea, a whopping twenty-five times per day. She was treated with steroids yet again, despite the fact that she didn’t even have colitis and had experienced side effects previously.
“I now have eye inflammation, arthritis and decreased calcium in my bones,” she told me at our meeting. “Both specialists, a rheumatologist and an ophthalmologist, say it’s from all the steroids and various other drugs. I am seeing a total of six doctors! Why can’t I get better? The steroids are killing me. Still, I take them, then taper. My weight is going up and down. My old GI doctor is insisting that I have to comply and take the drugs. I tried to ask if it was endometriosis, but he’s insisting it isn’t.”
Susan was somewhat lucky; thanks to her medical background, she knew what kinds of questions to ask. Still, she was seeing so many doctors and taking so many different medications that it was tough to get a clear picture of what was going on. And her doctor had overlooked the strong possibility of endometriosis, which I began to suspect.
I carefully considered her family history: a mother with breast cancer; two aunts with endometriosis, breast cancer, colon cancer and ovarian cancer; another with uterine cancer. Susan also had six older brothers, one of whom had Crohn’s disease and another who had adult-onset diabetes mellitus and obesity. Susan herself had suffered from irritable bowel syndrome as a teenager.
Her examination was normal, save for a dark, raised round area on her neck and slight tenderness on the lower left side of her belly. Her blood tests showed borderline anemia. A repeat colonoscopy and upper endoscopy with samples of the bowel lining were completely normal. She was also tested for gluten allergy and did not have it. A review of the original rectal biopsy, when she was first hospitalized with bloody diarrhea, was consistent with an episode of infection.
These findings suggested that Crohn’s disease was unlikely to be the cause of Susan’s symptoms. Further history revealed that Susan always developed diarrhea whenever she was given the antibiotic clindamycin; not surprisingly, she had received clindamycin before dental work in the past, possibly just before the bloody diarrhea. Prior to her hysterectomy, she experienced rectal pressure, and around her menstrual period she would have diarrhea lasting up to eight days. The rectal pressure and diarrhea both resolved after surgery.
Because I really didn’t think that she had Crohn’s disease, I stopped all her medications. Off all meds, Susan reported that her diarrhea occurred up to six times per day after eating, three to four days out of the month, and was usually controlled by Imodium—a definite reduction from her previous bouts.
An abdominal CT scan was done one month after her second appointment, after all the records had been reviewed and the endoscopic procedures completed. This showed only a 2-by-2.5-centimeter round mass in the pelvis, close to the abdominal wall, the exact location where Susan felt her lower abdominal pain and where an ovarian cyst was found in the past.
Endometriosis as the cause for all her inflammatory symptoms was very unusual. Yet because Susan didn’t appear to have Crohn’s disease and was doing well off all medications, and because the CT scan showed an abnormality where Susan complained of pain, I referred her to a gynecologist who specialized in endometriosis. He performed laparoscopic surgery, which revealed a hemorrhagic ovarian cyst and scar tissue. The doctor didn’t see endometriosis, though. He thought the pain was due to the ovarian cyst and the scar tissue. He drained the ovarian cyst and cut the adhesions. Her abdominal pain improved after surgery.
However, seven months post-surgery she began to develop severe left lower abdominal pain monthly with what she thought was ovulation. The pain was accompanied by sores in her mouth and fever. She continued to develop ovarian cysts, which would rupture. She had cramping abdominal pain at other times (different from the monthly ovulation pain), which she controlled with dicyclomine hydrochloride, an antispasmodic drug.
Her gynecologist started her on Loestrin, an oral contraceptive pill, to try to suppress ovulation. However, she could “feel” ovulation and did not think it had been suppressed, even though her diarrhea decreased. To treat the irritable bowel syndrome with which she had been diagnosed as a teen, she was started on the tricyclic antidepressant desipramine, which is helpful for decreasing abdominal pain and diarrhea.
But two years later she again developed severe lower left abdominal stabbing pain and fevers. Her blood pressure spiked to 146/96, and the Loestrin was stopped. (Hormones will increase your blood pressure at times.) A pelvic and abdominal exam showed tenderness on the left side, in the area of the ovary.
Susan’s gynecologist performed yet another laparoscopy. Endometriosis was buried in the adhesions that were found. At that time, because of all her symptoms, the gynecologist removed both ovaries and tubes. Now, more than two and a half years after surgery, she has had no further abdominal pain or diarrhea. “I’m cured,” Susan told me recently. “I have begun traveling again and exercising. I eat what I want when I want. I feel like a normal human being, and I’m a mom to my children.” She thanked me for listening to her when no one else would.
If your ovaries are left at the time of surgery, endometriosis can come back. Women should discuss having their ovaries removed with their gynecologist, because doctors will often leave an ovary to prevent the menopausal symptoms that can occur after the ovaries are removed. If you have already had the children that you would like to have, removal of both ovaries may be a good option.
Why did Susan have to suffer for so long? Why was she misdiagnosed? The doctors didn’t listen. Or, if they did, their preconceived notions did not allow them to ask the right questions and think outside the box. Perhaps they weren’t knowledgeable about some of the side effects of medications, or perhaps they weren’t knowledgeable about endometriosis. Either way, Susan was treated with the wrong medications—medications that caused a substantial number of side effects. Prednisone could have caused her osteopenia (bone loss), joint pain, weight gain, high blood pressure and possibly the skin infections. Her doctor almost put her on Remicade—a potent drug that suppresses an inflammatory substance called tumor necrosis factor.
Importantly, medications given to Susan by physicians played a major role in Susan’s gastrointestinal illnesses. The Clindamycin, an antibiotic, likely caused the bloody diarrhea by inducing a Clostridia difficile infection, which was responsible for the bloody diarrhea. Nonsteroidal anti-inflammatory medications (NSAIDs), like aspirin, ibuprofen and naproxen, can also cause colitis. It would appear that one physician did not know what another physician had done. Susan tried to ask the right questions. She was more knowledgeable than most women, since she worked in the medical field. However, she wasn’t calling the shots—her doctors were. And her questions were rebuffed.
For doctors, it’s an easy trap to fall into. Once a diagnosis is given, it is often difficult to get that diagnosis changed. It’s often easier to fit symptoms into that diagnosis if they seem to “mostly” fit rather than embark on an evaluation for a possible new diagnosis. When all the results don’t fit—like in Susan’s case—a new way of looking at the old and new problems has to happen. Susan tried to foster that way of thinking. However, the sicker she became and the more she was told she had to live with her problems, the more despondent and hopeless she grew. Some of her symptoms were not typical for endometriosis, and this led her doctors astray. Susan was misdiagnosed and on drugs she shouldn’t have been on, and that caused side effects. I was at least able to correct the Crohn’s misdiagnosis, take her off unnecessary drugs that could have caused substantial side effects and refer her to a doctor who could take care of her problem.
The moral of this story is be vigilant—you know your body best. If something feels wrong, say so. If you’re left with more questions than answers after a doctor’s visit, speak up. Get a second opinion.
WHAT YOU NEED TO KNOW ABOUT ENDOMETRIOSIS:
1. Endometriosis is a condition in which the lining of the uterus takes up residence outside of its proper location.
2. It is common in women.
3. It often mimics common gastrointestinal conditions, such as irritable bowel syndrome.
4. Many health-care providers are not adequately informed about endometriosis. Be your own advocate—ask whether you could have it.
5. It is difficult to diagnose with standard radiology tests and often requires an examination with a scope inside the pelvis or abdomen (laparoscopy).
6. There are both medical and surgical treatments for the condition, but recurrence is high if a woman still has her ovaries.
7. It is associated with an increased difficulty to conceive, but endometriosis seems to improve during pregnancy.
Chapter 3
“Do These Pants Come with an Elastic Waist?” The Truth about Gas, Bloating and Irritable Bowel Syndrome
“My philosophy on dating is just to fart right away.”
—Jenny McCarthy
This chapter chronicles what happens when we can’t fit into our pants, when gas escapes at inopportune times, when we have to beeline for the bathroom during an important meeting. We’ve all been there. But why does it happen? And, you’re asking, why does it happen to me? After all, body odor is repellent, bizarre and unpleasant—especially for women. She might be gorgeous, smart and hilarious, but if she smells strange, well…all bets are off. Men, on the other hand, are sometimes allowed to smell rugged and musky. Guys work out and smell “ripe,” and that’s okay, maybe even alluring. Not so for women. So pity the poor woman who does suffer from regular flatulence. This is a mortifying situation, leading to low self-esteem and isolation, or at least complete humiliation.
In this chapter we’ll meet Elizabeth, a thirty-seven-year-old art student who went to dozens of doctors in her quest to figure out why she was, in her words, a “gas factory.” Her story is representative of those of many women I see—IBS can destroy a woman’s life. By the time I met her, Elizabeth’s sex life was lousy, her self-esteem was shot, and she’d been spending money running from specialist to specialist, who prescribed everything from antidepressants to antispasmodic drugs, when indeed she had irritable bowel syndrome. She was beginning to think she was crazy.
Elizabeth hardly seemed like a crazy, smelly woman: fragile and birdlike, weighing just one hundred pounds, she was pursuing a graduate degree in sculpture, which had been consistently derailed thanks to her ongoing stomach issues. By the time I met her, she had quit school and couldn’t work. She told me that she had been “gassy” for as long as she could remember. She grew up in a traditional Asian home, where she suffered from frequent abdominal pain and the inability to control her gas. Her parents were mystified and ashamed—gassiness, in their opinion, was not an especially feminine trait. Her dad took to addressing her as “You, smelly girl!” and went so far as to tell her she mustn’t be a girl, since she passed so much gas. “No man will ever want you like this,” he told her.
Of course, this instilled a deep sense of unworthiness and translated into difficulty in intimate relationships. She spent her high school years isolating herself for fear of rejection. “I feel like my childhood and formative years were spent in the bathroom or in search of a bathroom,” she told me when we first met. She also experienced a great deal of pain on a daily basis, which prevented her from connecting emotionally and participating in activities with her peers. Elizabeth’s life, it seemed, had been defined by an ongoing waltz of pain and shame.
Elizabeth was seen by a physician, who brusquely told her to take a tranquilizer and see a psychiatrist. The psychiatrist helped her cope with some of her emotional baggage, but the sessions did nothing to relieve her symptoms. And what awful symptoms they were. She had severe, often debilitating pain and cramps in the abdomen and severe rectal spasms. These gave her the feeling that she needed to run to the bathroom to pass stool or gas, even if there was nothing to pass. She would end up in the bathroom all day, almost every day. This rendered her more or less housebound.
“Every day my main concern is, ‘Uh-oh, do I have to run to the bathroom? Can I leave the house for ten minutes?’ Wherever I go, I need to make sure I have easy access to a bathroom. At lectures I can hardly focus on what’s going on. I’m plotting my escape route. Or else I show up late because I’ve been in the bathroom,” she told me. At night she’d bolt awake with severe pain and rectal spasms, often spending hours on the toilet.
“I have trouble holding onto relationships because of this,” she said wryly. “But I have great relationships with every bathroom in town.” She did have a long-term boyfriend, but he was beginning to get fed up, too. It was hard for him to enjoy going anywhere with her when she was so clearly filled with dread about leaving the house. “I’m constantly preoccupied, and he’s angry,” she said. “My quality of life is in the gutter. My boyfriend is getting annoyed, and I’m not getting any sympathy from physicians. They think I’m exaggerating. It makes me not want to be around other people at all.” She had begun to feel completely desexualized and had stopped having sex entirely. I felt immense empathy for this young woman whose life had clearly ground to a halt.
When I first met her, she was being treated with the antispasmodic medications belladonna and phenobarbital. She said the belladonna and phenobarbital helped a little, but only if she was not under stress. Stress made all her symptoms worse. Without the belladonna, she felt like she was a gas factory. She had to belch or “fart,” or she would get a pressure in her stomach and lower belly. “I know how bad I must smell,” she admitted to me.
Elizabeth was also coping with heartburn, despite the fact that she wisely avoided coffee, onions, mint and other irritants. Even a few bites of a totally bland food, like pudding, would make her feel full and give her heartburn. I suspected IBS and supplemented her medications with Pepto-Bismol, and for her heartburn she was given a prescription for pantoprazole, a proton pump inhibitor that stops acid. With some relief, she left my office.
Over the next month her upper abdominal pain and heartburn improved. However, in spite of the belladonna and phenobarbital, she had rectal pain that occurred throughout the day, lasting up to two hours at a time, which was debilitating. This was affecting her ability to take classes. A few minutes into a lecture she’d feel like she had to run to the bathroom. On the toilet, she might or might not have a bowel movement, but in either case the lower abdominal pain would not go away. I increased her phenobarbital with belladonna to four times per day. Because she still had severe rectal spasms, I tried adding an additional antispasmodic, hyoscyamine sulfate, which she could take as needed.
Over the next six months, her medications were modified. The belladonna and phenobarbital were changed to a long-acting hyoscyamine (Levsin), which would not make her sleepy or tired. Elizabeth continued to improve, with fewer episodes of pain. But when she was in pain, it was severe—she would remain in bed, unable to walk. Tricyclic antidepressants have been shown to help IBS pain, so I suggested she use a tricyclic antidepressant, Elavil (amitriptyline), in a low dose at night. (Studies have also shown that when anxiety or depression is treated, IBS will improve.) With the addition of Ativan (lorazapam) and Lamictal (lamotrigine) by her psychiatrist, her abdominal pain improved even more, although she did have some constipation as a side effect of these medications.
Despite some constipation, her quality of life continued to get better. The intensity of her cramping was much less, and she was able to do more. She still suffered from abdominal tenderness, but it didn’t get any worse. I upped her Elavil even more, and her pain became more and more bearable. In the past she’d spend two hours on the toilet in the morning; this dwindled to just a half hour. Still, gas would return whenever she felt stressed, and she remained embarrassed about her odor, which she described to me as “silently fatal,” particularly when she drank milk. Suspecting bacterial overgrowth (too many bacteria in her small intestines, which can result in abdominal pain and gas), I put her on a short course of tetracycline in addition to her other meds. (Tetracycline has been the traditional first choice of antibiotics for bacterial overgrowth, although rifaximin has fewer side effects and has been shown to help reduce gas and bloating. Unfortunately rifaximin is expensive and is not usually covered by most insurance plans until tetracycline fails.) To try to change the resident bacteria with new ones, I started her on a probiotic once the antibiotics ran their course. She also started drinking soy milk instead of cow milk. Elizabeth remained on the combination of medication that was helpful for her IBS, heartburn and anxiety/depression.
Today she says she feels a million times better. “After seeing Dr. Wolf, my symptoms didn’t get better overnight, but at least emotionally, I felt that finally somebody was taking me seriously and not just writing me off as a hypochondriac. She started me on a set of medications to help me reduce my symptoms so that my daily life is not torture. My cramps used to be so bad, I’d break into a cold sweat. I couldn’t talk. I’d be balled up in the corner of the cardio area in the gym for hours. Now that’s not quality of life. But now it [the pain] is not that extreme. I feel a lot less embarrassed about being outside and being around people. I can function.” In fact, she’s now trying to finish her degree, and she hopes to get pregnant. “Instead of IBS managing me, I’m managing it,” she told me at our latest meeting.
What is IBS?
Irritable bowel syndrome (IBS) occurs in about 14 to 25 percent of women, although most people with symptoms do not consult a physician and suffer in silence, due to shame or being told that they’re overreacting. IBS also mimics many other issues, like endometriosis, so it’s difficult to pinpoint right away. Elizabeth had a particularly bad and chronic case of IBS. Women are twice as likely to get IBS as men, and many of these women have suffered abuse, just like Elizabeth had. Symptoms vary and are sometimes confused with those of inflammatory bowel disease (ulcerative colitis or Crohn’s disease), which is a physical disruption or abnormality in the intestines that causes inflammation or damage to the bowel. With IBD, an X-ray, colonoscopy, endoscopy and so forth will show an abnormality; but with IBS they won’t. IBS is a syndrome, not a disease.
The diagnosis of this syndrome is based on symptoms. There’s no study that determines IBS; rather, the absence of abnormal X-rays and colonoscopy tests points to an IBS diagnosis. The diagnostic criteria have changed over the years but have always consisted of recurring abdominal pain and a change of bowel function—constipation, diarrhea or alternating constipation with diarrhea. Ask yourself this: Have you had recurrent abdominal pain or discomfort for three or more days per month? Has this been going on for at least the past three months? Does going to the bathroom help? Have the stools changed in frequency or form? And what about gas? Have you got it? If you have pain with the stool changes, you might have IBS.
Who gets IBS?
Those with a low quality of life are more likely to be afflicted because IBS may have a negative impact on one’s overall well-being. Several psychological factors and childhood rearing practices have been reported to increase the risk of IBS. One study suggests that IBS in children is more common if the mother paid a lot of attention to complaints of illness and if children had many absences from school. A child with a parent or a twin with IBS is also more at risk for developing IBS due to genetic factors. Identical twins have a greater risk for developing IBS than nonidentical twins when one twin is diagnosed with the condition. The development of new onset IBS is associated with frequent visits to doctors, anxiety, sleep problems and somatic complaints (physical complaints, like aches, where the cause can’t be found). Sometimes IBS crops up in the wake of a viral or bacterial infection; in this case, diarrhea is more likely to occur than constipation.
Some gut infections are more likely to cause IBS than others. After an infection with Campylobacter jejuni, a bacterial infection that comes from food poisoning from eggs and poultry, the risk of developing IBS is as much as 13 percent. It occurs less after Salmonella infections. But if you get antibiotics for your Salmonella infection, your risk almost doubles to over 17 percent, according to one study, which is why Salmonella usually isn’t treated, except in the very young or elderly. Factors that increase the risk of developing IBS after an infection are being female, being younger than sixty, increased duration and (probably) intensity of the infection, psychological factors such as anxiety and depression, and smoking. Sometimes IBS is brought on by stress. Remember, your gut is hypersensitive and feels stress acutely. This is one way that it reacts.
What are the symptoms of IBS?
Without abdominal pain or discomfort, you don’t have IBS! The pain or discomfort has to recur at least three days per month for three months in a row and also has to persist for six months. Secondly, the pain or discomfort has to be relieved by a bowel movement or be associated with a change in stool frequency (for you), or a change in stool appearance or form. This can be an increased or decreased frequency of stool or such changes in the stool as watery or mushy, hard, incompletely evacuated or requiring straining to evacuate. Bloating, gas and frequent urination, as well as the urgent need to urinate, are associated with IBS. Fibromyalgia and depression are also common in those with IBS. IBS is divided into subtypes, which are usually treated differently. These are constipation, diarrhea, mixed pattern (alternating between diarrhea and constipation) and undetermined. The constipation subtype is much more common in women, while the diarrhea subtype occurs equally in men and women.
Many women will tell you, though, that gas is their worst and most humiliating symptom. It’s present in women with IBS 72 percent of the time.
My doctor asks me to describe my stool. I barely want to even look at it, let alone describe it!
Knowledge of the form your stool takes helps your doctor make an assessment about what might be happening in your intestines. A scale, dubbed the Bristol Stool Form Scale, has been developed just for this purpose. This scale helpfully describes seven major consistencies and shapes of stool, from little pieces (pebbles, rabbit droppings) to mush or liquid, so we doctors don’t have to grope for vivid descriptions! Type 1 and 2 are hard to pass and occur with constipation. Type 3 and 4 are normal in the sense that they are more easily passed. Type 5 and 6 are soft and may come out with more force, and type 7 is diarrhea. Be sure to tell your doctor if your stool is bloody, that is, if blood is present either on the toilet paper or in the toilet, or is mixed in with the stool.
Figure 3-1. This chart shows the different types of stool form. Types 1 and 2 are hard to pass and are seen with constipation. Types 3 and 4 are considered normal (and ideal, by some people). Types 5 and 6 tend toward diarrhea. Type 7 is definite diarrhea with liquid and no form.
Can I get tested for IBS?
First things first: All women over age fifty and African-Americans women over age forty-five should have a colonoscopy to make sure there are no polyps or cancer. No matter what her age, any woman with unexplained rectal bleeding should have a colonoscopy to make sure there are no polyps, cancer or inflammation. Sorry, though, there are no accurate blood tests to make the diagnosis of irritable bowel syndrome. However, new blood tests have been developed to identify markers of substances (biomarkers) in the blood that are associated with irritable bowel syndrome. If there is a high suspicion of IBS and the test panel is positive—the tests have good predictability. Conversely, if there is a low suspicion of IBS and the test panel is negative, again, the test has good reliability. But if IBS is suspected and the test panel is negative, well, you still might have it.
Unfortunately, there are large numbers of people having these tests who could be overlooked and who do have IBS, or who are incorrectly told they have IBS. The blood tests sometimes used for diagnosing IBS include ones that are useful in making the diagnosis of celiac disease and inflammatory bowel disease; people with IBS could be told they have one of these other conditions. Other tests—such as stool cultures; routine blood tests looking for anemia or high white blood cell counts, which could indicate an infection or an inflammatory process; X-rays; or endoscopic tests—are useful in ruling out other conditions. However, for most people under fifty, they’re not usually necessary. Celiac sprue (gluten allergy) (see Chapter 4) can be discounted by doing a blood test called tissue transglutaminase antibody.
If I’m diagnosed with irritable bowel syndrome how do I know that I got the right diagnosis?
You can’t be 100 percent sure. Warning signs that would require other diagnoses to be eliminated with testing are:
Onset of symptoms over age fifty
Rectal bleeding
New anemia
Unexplained weight loss
Worsening of IBS symptoms
Poor appetite
A family history of other diseases that affect the gastrointestinal tract
Vitamin deficiencies
Reassuringly, studies have shown that the diagnosis of IBS does not usually change. After six months to six years after the diagnosis was made, only 2–5 percent of irritable bowel syndrome patients were diagnosed with another GI disease. With long-term follow-up of IBS, on average two years, about 2–18 percent of people developed worse IBS, 30–50 percent of patients had no change in IBS symptoms and 12–38 percent of people had a complete disappearance of their symptoms, for reasons unknown. If your symptoms change, tell your doctor.
Why do women bloat?
A great question that is still only partially understood! Most women do not have excess or an increased amount of gas, even though it might feel that way when you’re squeezing into your favorite pair of jeans. The problem seems to be more that the gas doesn’t move out of the small intestine like it should. And when it’s there, watch out! Women with irritable bowel syndrome or other functional GI disorders feel it more. There is an increased sensitivity toward and awareness of what is happening inside the body.
However, not everyone who feels bloated actually has a larger belly. (In a study from Olmsted County, Minnesota, a quarter of the women studied reported they were bloated, but in actuality, only half of the bloated women had an increased circumference when measured!) Younger women are more likely to bloat than older women. Bloating is more common in the lower abdomen than the upper, unless someone has upper intestinal symptoms (like heartburn), whereby bloating can be anywhere in the abdomen or throughout the abdomen. With recurrent nausea, vomiting and pain (called dyspepsia), bloating is also more common in the upper abdomen. Men, meanwhile, are lucky. They bloat and distend only half as much as women. No wonder their pants fit better!
What about distension? Doesn’t that mean you have more gas?
Again, not necessarily. Sometimes your ab muscles just aren’t working right. The diaphragm comes down, the air and intestinal contents pool and the only way for the belly to go is out. Women can bloat if they get stressed. This may be due to a release of hormones or other substances that cause a change in the movement of the bowel or abdominal wall muscles, or just hypersensitivity. Another overlooked but likely cause of bloating is the bacteria in the bowel. The bacteria that are the normal inhabitants of the bowel are different in women with irritable bowel syndrome than those without it—one study shows decreased or absent species of lactobacilli in the intestines of patients with IBS. The fruits that are least likely to cause gas are white grapes, strawberries, blackberries, raspberries, pineapples and oranges. Fruits that are more likely to cause gas are prunes, pears, sweet cherries, peaches and apples. The bacteria in our guts break down the food products that get to the colon and can release rotten gas or compounds, like fatty acids, that could cause bloating.
What causes gas?
There’s no getting around it: Gas is often a by-product of what we eat. We share our body with bacteria; in fact, there are ten to one hundred times more bacteria than cells in our body. These bacteria also inhabit our bowels. When the carbohydrates and fat within our food aren’t broken down by the substances (enzymes) our bodies make and are not absorbed by the intestines into our bodies, the bacteria metabolize them and form gas as a by-product. For instance, if someone is missing the enzyme in the small intestine to break down lactose (the sugar in milk), she becomes lactose intolerant. The lactose travels down to the colon, and the bacteria break down the lactose and release hydrogen gas as a by-product. Fructose is poorly absorbed into the body unless it is accompanied by the sugar glucose. Therefore some fruits are more likely to cause gas than others. These fruits have less glucose than fructose. There are other poorly absorbed short-chain carbohydrates that will cause gas when broken down by bacteria. These are termed FODMAPs (Fermentable Oligo-, Di and Mono-saccharides and Polyols).
The oligosaccharides consist of fructans (wheat, onions, artichokes) that have long chains of fructose and galactans (legumes, cabbage, brussels sprouts). The disaccharides are lactose- (milk) containing foods. The mono-saccharides are fructose-rich foods (fruits). The polyols include sorbitol (added to low calorie foods). A more extensive list of the foods that may cause gas is found on pages 52–53.
Why do I feel stress—and, consequently, gas—so acutely in my stomach?
Strange as it seems, your gut has a brain. More than 95 percent of serotonin resides in the gut, and serotonin, coincidentally, helps modify mood. It is important for the movement of the gut and is a strong determinant of constipation, diarrhea and pain. But cortisol, the “fight or flight” hormone made in the adrenal gland, also causes increased movement in the gut and may be responsible for some of the increased gas when you’re stressed. People with IBS also have a lower threshold for pain in the gut.
One of the tests done to look at how sensitive one’s bowel is to noxious stimuli is to place a balloon in the rectum and distend it. If a balloon is distended in the rectum of an IBS patient, the tolerated volume of air in the balloon is less than that of a person without IBS. In IBS patients, when the balloon is distended in the rectum (ouch!) or if pain is anticipated, areas of the brain are activated. These can be seen on PET (positron-emission tomography) scans that examine blood flow. However, women’s and men’s brains light up in different places. In women, the limbic and paralimbic areas light up. These are areas that amplify pain. In men, areas that are more concerned with inhibiting pain (prefrontal cortex, insula, dorsal pons) light up. Men, too, experience intense pain; it just registers differently.
Why, oh why, does gas smell so disgusting?
Gas is actually a mixture of different gases. Only a minority cause odor (it’s true!). The culprit for the rotten egg smell exuded by some gaseous odors is hydrogen sulfide. Other compounds like methyl mercaptan and short-chain fatty acids, like skatoles, can also impart a noxious odor to our released gas. Ironically, skatoles in small amounts have a flowery smell and are found in several flowers and essential oils, such as orange blossoms and jasmine (though I don’t know of anyone who describes her gas as perfume-worthy). It’s the sulfur-containing compounds that impart most of the bad odor to the gas. Depending on the type of bacteria residing in your gut and what food you eat, different gases and therefore different odors will be released.
What foods are notorious bloat causers?
Bananas, prunes, legumes, pretzels, cabbage, beans and raisins are big culprits. And, of course, dairy products produce bloating in lactose-intolerant people. Sorbitol, the sugar often found in chewing gum, causes gas, too.
How can I relieve gas and bloating symptoms while driving, or in a meeting, if I can’t rush to a bathroom right away?
Whenever you’re in for a long haul, visit the bathroom beforehand. And avoid those aforementioned foods that are likely to cause gas and/or bloating. If the trip or meeting is long, take bathroom and walking breaks. I’m also a big fan of relaxation techniques, such as meditation. Is that dragon-lady boss or tailgating driver really worth getting upset about, at the expense of your health?
Why are some women gassier than others?
Some women simply swallow air when they get nervous or eat. Some women aren’t able to break down lactose. Still others have issues breaking down the sugar in fruits, called fructose. Some women also eat lots of beans and legumes, which have a nonabsorbable sugar known as raffinose, which is broken down by the resident gut bacteria that cause gas. Women like Elizabeth with irritable bowel syndrome often have gas and bloating—which is worse during the hormonal shifts around their periods.
What are some of the less common—and more severe—causes of distension?
Fluid in the belly, known as ascites, is one cause. This fluid can appear for a variety of reasons, from cancer to pancreatitis (inflammation of the pancreas) to cirrhosis (scarring of the liver). Abdominal masses and abdominal hernias are less common causes of bloating and distension. But bear in mind, all these issues are relatively uncommon and can often be detected on physical examination or with radiological tests.
Okay, so what foods should I avoid to reduce IBS and gas symptoms?
For IBS symptoms (abdominal pain, diarrhea), you should first try to eliminate “CAF” (caffeine, alcohol, fatty foods). If this doesn’t work and you still have IBS symptoms or gas, try eliminating lactose for one week (milk, ice cream, cheese products). Decrease your meal size and eat smaller amounts more frequently. If this doesn’t work, try decreasing fruits, followed by insoluble fiber. Red meats also seem to be poorly tolerated by some people with IBS symptoms. If all these things fail, sometimes a dietitian can help with an elimination diet.
Here are some commonly troublesome foods for causing gas:
Beans and lentils (humans don’t have the proper enzymes to break these tasty treats down. Sorry!)
Brussels sprouts
Carrots
Celery
Onions
Apricots
Bananas
Prunes
Raisins
Pretzels
Wheat germ
Beano, an over-the-counter preparation of the enzyme galactosidase, may help prevent the gas formed from the digestion of beans and peas. Women with bloating should avoid lactose and see if it makes a difference in bloating and gas. If it doesn’t, you could go back to lactose. Sometimes it is not just the lactose but the milk proteins that cause belly discomfort.
Warning! Foods with lactose:
Milk
Cream
Cheese
Butter
Yogurt
Ice cream
What if I change my diet? I’ll do anything! Give up ice cream! Throw away the wine! Will that help?
Many people report that diets for IBS and gas help. Unfortunately, not all diets help all people. One diet that helps one person may make another person worse. If allergy testing reveals food allergies, then elimination of food triggers may help symptoms. It is important for everyone to try to associate symptoms with a possible food that may have been eaten within the previous six hours (usually during the most recent meal). Keep a food diary! If there isn’t a pattern, and allergies aren’t found, there are certain things you can do to try to see if they help. Irritants to the gut, causing an increase in stimulation of gut movement and perhaps pain, are coffee, caffeine, alcohol, fatty and fried foods, and large meals in general.
As I mentioned before, some people get gas and pain from lactose, fructose or sorbitol. Insoluble fiber, mainly found in whole grains, raw vegetables and fruits, are often rough on the stomach. This may be due to the bacteria in the bowel eating up some of the fiber that gets to them or the stimulation of the bowel to have more contractions. However, it’s hard to predict which foods will be tolerated and which won’t.
I need help and I need it now. Can’t I just run down to the local drugstore?
For gas, a simple treatment, such as simethicone (Gas Relief, Gas-X), works wonders. To reduce spasms, try enteric-coated peppermint capsules, sold under the name Pepogest at nutrition stores and specialized health-food grocery stores. Charcoal also binds the gas, and you can buy it as CharcoCaps. Keep in mind that charcoal turns the stool black, so don’t be alarmed when that happens to you. Also, be sure not to take CharcoCaps with other medications, as it can bind up the medications so that they may not be absorbed effectively into your body. Pepto-Bismol may also be helpful to remove or decrease some of the foul odors.
Can’t I just wear a “filter” in my underwear, kind of like the filter in my air conditioner?
Panty liners and underwear designed to absorb odors are available on the Internet, and I think they work pretty well. One study tested how well different products worked. Carbon fiber briefs extract almost all the foul-smelling gases, while pads made of fabric-covered charcoal absorb 55 to 77 percent of sulfide gasses. Cushions with carbonized cloth might also help. Sexy they’re not, but then again, neither is a foul aroma.
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