Is your abdominal discomfort caused by poor digestion, endometriosis, or both?

09-Oct-2021

It’s that “time of the month” again and you’re doubled over in pain. Each time the pain is at least an 8 out of 10 and the medications seem to be less effective than they used to be. Your frequent bloating and abdominal discomfort is getting out of hand. Is it PMS? Is it digestive issues? Could it be both?

Many women have painful periods, also called dysmenorrhea. The pain is most often menstrual cramps, which manifests as a throbbing, cramping pain in the lower abdomen. However, period pain that impacts daily functioning is not normal. In fact, the normalization of period pain can lead to women going undiagnosed for more serious conditions like endometriosis or uterine fibroids.

When it comes to pelvic pain, digestive issues are a top cause. There is a strong overlap between irritable bowel syndrome (IBS) and chronic pelvic pain. And, interestingly, women with endometriosis have at least a two-fold greater risk of having irritable bowel syndrome (IBS) [1]. Many women who have endometriosis in the bowel and other nearby structures often receive an IBS misdiagnosis.

IBS and Endometriosis

There are many similarities between IBS and endometriosis. Endometriosis is a chronic inflammatory disease characterized by the presence of endometrial tissue that grows outside the uterine cavity. One of the most common places it grows is in the space between the uterus and rectum, often resulting in IBS-like symptoms. Endometriosis is characterized by abdominal pain, painful periods, and many other symptoms like pain during intercourse [1]. IBS, on the other hand, is also characterized by abdomino-pelvic pain, altered bowel habits, and persistent inflammation at the microscopic and molecular level [2]. Both conditions have elevated proinflammatory cytokines and immune system imbalances.

So why does all this matter?

Because it’s really important that the correct diagnosis is made for a woman experiencing chronic, severe menstrual pain with or without concurrent digestive symptoms.

It takes an average of seven (7!) years to diagnose endometriosis. Patients are often told, “It is just PMS. Menstrual cramps are normal.” For those experiencing more predominant bowel symptoms, patients may be told, “Your pain is caused by IBS; eat more fibre” or “It’s just IBS. Learn to better manage your stress.”

Unfortunately, the consequences of misdiagnosing endometriosis can be problematic.

When it comes to endometriosis, the research shows early referral, diagnosis, identification of the disease, and treatment may mitigate pain, prevent disease progression and thus preserve fertility [3]. The consequences of not identifying and treating endometriosis include ovarian failure due to endometrial tissue invading the ovaries. As summarized by Carrilo et. al, patients affected with severe endometriosis “are at significant risk for ovarian tissue damage, which may lead to infertility, reduced response to ovarian stimulation, and occasionally, premature ovarian failure” [4].

It doesn’t stop there. Endometriosis tissue also has the ability to cause infertility in other ways, including adhesions, scarred fallopian tubes, inflammation of the pelvic structures, altered immune system functioning, changes in the hormonal environment of the eggs, impaired implantation of a pregnancy, and altered egg quality [5].

Imagine being told your whole adult life that your period pain was “normal” to only find out in your 30s that in fact, it may have caused infertility. How crushing.

Conclusion

It can be an issue when healthcare providers misdiagnose or mismanage women with chronic pelvic pain. The research shows that overall, there is dissatisfaction with treatment options, outcomes, health care provider empathy and compassion in patients with endometriosis [6]. Since endometriosis is a condition that can often present symptoms that mimic other conditions, the healthcare provider must have good diagnostic skills and be a chief advocate for the patient. Referral should be considered if pain is not controlled with simple analgesia or the diagnosis is suspected in a woman who is actively trying to conceive.

I help many patients with IBS and endometriosis in clinical practice and am always sharing resources with them. For those interested in finding out more about the diagnosis of endometriosis, check out the work of Dr. Mathew Leonardi, Gynecologic Surgeon and Ultrasound Expert, in Hamilton Ontario. He specializes in endometriosis and in utilizing ultrasound in the diagnosis and surgical management of endometriosis.

Dr. Dominique Vanier is a naturopathic doctor in Burlington, Ontario with a focus on digestive health and hormones. As a regulated health provider, she is registered to see patients in Ontario both virtually (online) and in person.

References:

[1] Chiaffarino F, Cipriani S, Ricci E, Mauri PA, Esposito G, Barretta M, Vercellini P, Parazzini F. Endometriosis and irritable bowel syndrome: a systematic review and meta-analysis. Arch Gynecol Obstet. 2021 Jan;303(1):17-25. doi: 10.1007/s00404-020-05797-8. Epub 2020 Sep 19. PMID: 32949284.

[2] Ng QX, Soh AYS, Loke W, Lim DY, Yeo WS. The role of inflammation in irritable bowel syndrome (IBS). J Inflamm Res. 2018;11:345-349. Published 2018 Sep 21. doi:10.2147/JIR.S174982

[3] Parasar P, Ozcan P, Terry KL. Endometriosis: Epidemiology, Diagnosis and Clinical Management. Curr Obstet Gynecol Rep. 2017;6(1):34-41. doi:10.1007/s13669-017-0187-1

[4] Carrillo L, Seidman DS, Cittadini E, Meirow D. The role of fertility preservation in patients with endometriosis. J Assist Reprod Genet. 2016;33(3):317-323. doi:10.1007/s10815-016-0646-z

[5] Bulletti C, Coccia ME, Battistoni S, Borini A. Endometriosis and infertility. J Assist Reprod Genet. 2010;27(8):441-447. doi:10.1007/s10815-010-9436-1

[6] Evans, S., Villegas, V., Dowding, C., Druitt, M., O’Hara, R., & Mikocka-Walus, A. (2021). Treatment use and satisfaction in Australian women with endometriosis: A mixed-methods study. Internal Medicine Journal. https://doi.org/10.1111/imj.15494