The connection between Endometriosis and the gut

If you have endometriosis then you probably know from experience that endometriosis and digestive issues go hand it hand. I wanted to shed light on the endometriosis-gut connection, and how healing the gut (our digestive organ) can have downstream benefits of relieving endometriosis.

Endometriosis is a condition where tissue similar to the endometrium (lining of the uterus) grows outside of the uterus. This tissue usually proliferates in and around the pelvic region and can attach to the ovaries, fallopian tubes, bowel and bladder. Common symptoms of endometriosis include chronic pelvic pain, period pain, pain on intercourse and impaired fertility.

Endometriosis also commonly presents with digestive issues like bloating, abdominal pain and constipation and/or diarrhoea (1). The association between endometriosis and digestive issues is so strong that some researchers have suggested that all females with irritable bowel syndrome (IBS) should be screened for endometriosis (1).

Research also demonstrates that females with endometriosis are more likely to experience gut conditions like IBS, inflammatory bowel disease, coeliac disease and intolerance to FODMAPs, highlighting the clear connection between endometriosis and the digestive system (1,2,3).

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How does endometriosis impact the gut?

If you look at the diagram below you will notice the gut and the uterus are neighbours. Endometriosis is associated with uncontrolled inflammation in the pelvic region - which is the release of warning signals that can ultimately cause irritation, damage and pain (1). As the gut borders the pelvic region, these warning signals can travel to the bowel region and have the same detrimental impact. Endometrial lesions can even be found attached to the gut. This adds another layer of complexity as the gut may start to adhere to other pelvic organs. Damage to the gut can impair its ability to breakdown food, resulting in digestive upset and even food intolerances (3). Adhesions on the gut can disrupts bowel motility - i.e. the movement of contents through the gut required for defecation - resulting in altered bowel habits like diarrhoea and/ or constipation (1).

image from https://www.everydayhealth.com/endometriosis/bowel-endometriosis/

How does the gut microbiome impact endometriosis?

The gut is home to our micro-biome, a community of trillions of bacteria, viruses and fungi that usually live peacefully on a layer of mucous on our gut lining. Studies have revealed that females with endometriosis are more likely to have an imbalance in this microbial community, having increased amounts of ‘bad bacteria’ like E.coli (4, 5). Having too many ‘bad bugs’ can break up the gut lining, causing a ‘leaky gut’ with holes that allow the passage of contents from the gut (like food and bacterial toxins) into the pelvic region (4). Indeed, females with endometriosis are found to have high levels of a gut-derived bacterial toxin known as lipopolysaccharide (LPS) in the pelvic region. LPS can exacerbate endometriosis by stimulating the growth of endometrial lesions (1,5). For this reason, aiming to repair or ‘tighten’ the gut lining whilst eliminating potentially ‘bad’ gut bugs may be an important aspect of endometriosis treatment.

Besides an imbalance in gut microbes, other factors that can cause a ‘leaky gut’ include stress, alcohol, gluten intake and the use of non-steroidal anti-inflammatories like ibuprofen (1). Healing the gut therefore involves limiting these factors.

The gut microbiome and oestrogen

Endometriosis is considered an ‘oestrogen dependent condition’, meaning that the hormone oestrogen can stimulate the growth of endometrial lesions (1).

Oestrogen is a really important hormone that helps support the menstrual cycle, mood, bone strength and cardiovascular health. However, we don’t want oestrogen levels to be too high. Once oestrogen has worked its magic the body removes it by packaging it up with bile and sending it out through the stool. An overgrowth of ‘bad’ gut microbes can cause increased activity of an enzyme known as ‘beta glucoronisase’ which separates oestrogen from bile, causing it to be recirculated in the body. This can potentially raise oestrogen levels which may further stimulate the growth of endometrial lesions (6).

Measurement of beta-glucoronidase activity can be measured by functional gut testing, and treated by healing the gut lining, rebalancing the gut micrbiome and potentially through supplements that can block its activity.

Putting it altogether

Research strongly supports a two-way relationship between gut health and endometriosis. For this reason, investigating and treating gut health for females with endometriosis can be an integral part of holistic treatment. Everyone’s endometriosis journey is different, which is why having a thorough assessment with a holistic practitioner is a great way to identify your personal underlying triggers and needs.


References

1. Viganò, D., Zara, F., & Usai, P. (2018). Irritable bowel syndrome and endometriosis: New insights for old diseases. Digestive and Liver Disease, 50(3), 213–219.

2. Stephansson, O., Falconer, H., & Ludvigsson, J. F. (2011). Risk of endometriosis in 11 000 women with celiac disease. Human Reproduction, 26(10), 2896–2901. doi:10.1093/humrep/der263 

3. Moore, J. S., Gibson, P. R., Perry, R. E., & Burgell, R. E. (2017). Endometriosis in patients with irritable bowel syndrome: Specific symptomatic and demographic profile, and response to the low FODMAP diet. Australian and New Zealand Journal of Obstetrics and Gynaecology, 57(2), 201–205. doi:10.1111/ajo.12594

4. Koninckx, P. R., Ussia, A., Tahlak, M., Adamyan, L., Wattiez, A., Martin, D. C., & Gomel, V. (2019). Infection as a potential cofactor in the genetic-epigenetic pathophysiology of endometriosis: a systematic review. Facts, views & vision in ObGyn, 11(3), 209–216.

5. Khan, K. N., Kitajima, M., Hiraki, K., Yamaguchi, N., Katamine, S., Matsuyama, T., … Masuzaki, H. (2010). Escherichia coli contamination of menstrual blood and effect of bacterial endotoxin on endometriosis. Fertility and Sterility, 94(7), 2860–2863.e3. doi:10.1016/j.fertnstert.2010.04.053

6. Ervin, S. M., Li, H., Lim, L., Roberts, L. R., Liang, X., Mani, S., & Redinbo, M. R. (2019). Gut microbiome–derived β-glucuronidases are components of the estrobolome that reactivate estrogens. Journal of Biological Chemistry, jbc.RA119.010950. doi:10.1074/jbc.ra119.010950