Endo, PCOS + IBS

Have you heard about the relationship between some gynaecological conditions such as endometriosis or polycystic ovarian syndrome (PCOS) and IBS?

This week, our guest blogger is Briony Blake, an Australian Accredited Practising Dietitian from regional New South Wales. In this blog, you’ll learn about the different conditions and the extent to which they overlap - making an accurate diagnosis REALLY important.

Introducing Briony

My name is Briony Blake, I am an APD (accredited practising dietitian) working in private practice in regional NSW.

I see a lot of clients with polycystic ovarian syndrome (PCOS) and/or endometriosis. I also see a lot of clients with irritable bowel syndrome (IBS symptoms such as bloating, abdominal pain and bowel irregularities). I have been looking more closely at these seemingly separate but potentially intertwined health conditions and want to share with you what I have learned.

ENDOMETRIOSIS

Endometriosis occurs when endometrium tissue (endo: within, --metrium: refers to layers of the uterus) migrates outside of the uterus where it can cause pain, inflammation and adhesions around other pelvic organs.

Endometriosis is a progressive, chronic condition that can have enormous impacts on people’s lives and livelihoods.

It has historically been diagnosed through keyhole surgery called a laparoscopy that involves opening the abdomen to look for and remove endometrial tissue outside of the uterus however emerging evidence supports and encourages the use of medical imaging as a less invasive diagnostic tool.

Polycystic ovarian syndrome

PCOS is a hormonal condition that is diagnosed using the Rotterdam Criteria (see criteria ➡️ ). Due to the nature of PCOS, those with it are at a higher risk of developing metabolic conditions such as diabetes and cardiovascular disease. The severity of PCOS varies between individuals and much of the treatment options are lifestyle based.

These include :

1.   Dietary interventions

2. Individually tailored exercise programs

3. Promoting sleep

4. Reducing stress

5. Supplementation is an emerging area of PCOS, at current inositol is a supplement of particular interest to this population. As always discuss supplementation with your doctor.

Irritable Bowel Syndrome

IBS is diagnosed using the ROME IV criteria. When someone initially presents with IBS like symptoms such as abdominal pain and cramping and bowel irregularities it is important to conduct appropriate investigations to rule out the following, amongst other potential causes:

·      bacterial infections from pathogens such as H. pylori,  

·      auto-immune conditions such as coeliac disease, and

·      Inflammatory Bowel Disease which encompasses Crohn’s disease and ulcerative colitis.

Once these conditions have been ruled out, IBS is the catch all condition that is left. Unfortunately there is NO evidenced based test to diagnose food intolerances (food allergies are a different story).

I am pausing here to advise that any hair testing, skin testing or other tests that advertise their ability to diagnose food intolerances are not based on, nor supported by scientific evidence.

Okay back to it: this can be frustrating as what we are left with is elimination diets to try to ascertain which foods may be acting as triggers for an individual’s IBS. I would recommend this be undertaken with the help of a trained dietitian.

At present, Monash University’s FODMAP method is the most supported means of both reducing IBS symptoms and determining the root cause. To learn more about this you can head to this 2-min introductory blog or visit Monash’s website.

Who do these conditions effect?

1 in 10 menstruating Australians live with endometriosis and despite its prevalence it can take between 7-10 years for a diagnosis. People seeking support and medical advice for this condition often have to face many barriers and obstacles to access help.

5-10% of people with uteruses of reproductive age have PCOS - it is estimated that 70% of people living with PCOS are undiagnosed.

3-5% of Australians have IBS.

Why the crossover in symptoms?

While these conditions are distinct, there is emerging evidence to imply that they may be connected. One indication for their relationship is that people with endometriosis and/or PCOS are more likely to experience IBS than those without.

One hypothesis is that the hormonal imbalances associated with endometriosis and PCOS can contribute to IBS symptoms. Another possibility is that the pain associated with endometriosis and PCOS can cause stress and anxiety, which we know can lead to exacerbation of IBS symptoms

Another common feature of these conditions is what is called visceral hypersensitivity which means that the sensory nerves in the abdomen send pain signals more frequently and with less stimulation than people without these conditions.

This means that it can take LESS stimulation of the nerves in the abdomen to trigger a pain response. To read an interesting study about IBS involving balloons click here

Current help available for IBS Symptoms

Once other medical conditions have been ruled out, a low FODMAP method is suggested to manage symptoms and determine trigger foods that may need to be avoided to prevent flare ups.

IBS specific hypnotherapy and meditation may also be suggested to manage stress from both external sources and stress specific to IBS-like symptoms.

Due to the complex and often conflicting information about these topics it is important to seek help from a Doctor and/or Accredited Dietitian to guide and support you through some of these investigations.

Role of a dietitian

From a health professionals perspective it is SO important to have the support of a trained dietitian anytime you undertake any kind of food restriction- even if it is for investigative purposes to ensure that you aren’t susceptible to falling into disordered eating habits and that you are able to maintain a healthy relationship with food. I often see clients who have been stuck in “phase 1” of the fodmap method, they have cut out ALL fodmaps from their diet, have seen an improvement in their symptoms but are hesitant to retry these foods for fear of symptom relapse. While I understand that this is a natural response to IBS I want to iterate the importance of re-challenging fodmap containing foods to ensure that an individual is able to live a full life, eat socially with friends and family and to prevent any dietary deficiencies that restriction may lead to.

Some of the things that trained dietitians can guide you through include:

1. Fodmap/food intolerances elimination and re-challenging protocols

2. Practical planning for eating well when symptoms are flaring

3. Providing evidenced based advice around supplementation for PCOS, ENDO and IBS, there are SO many probiotics/vitamins/fibre supplements on the market and it’s important to know which the right ones are to save you time AND money

4. Advising on macronutrients (carbs, fats, proteins and fibres) and micronutrients (vitamins and minerals) to ensure your diet is well balanced and varied. 

Final take home message

All three of these conditions are still being researched to help us determine their causes, correlations, and best managements. If you are concerned that you may have any of these conditions the first step is finding a GP that you trust and are able to feel comfortable talking about your symptoms with. All these conditions are chronic and therefore are eligible for a Chronic Disease Management Plan which allows you access to 5 Medicare subsidised visits to allied health professionals per year. Be informed and empowered to ask for support when and where you need it.

If you are based in or around Melbourne and interested in taking part in a study looking into the correlations between endometriosis and IBS. Monash University are currently recruiting participants for a pilot research study.

Key papers and resources:

Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of endometriosis. Nature Reviews Endocrinology. 2019 Nov;15(11):666-82.

Cowan S, Lim S, Alycia C, Pirotta S, Thomson R, Gibson-Helm M, Blackmore R, Naderpoor N, Bennett C, Ee C, Rao V. Lifestyle management in polycystic ovary syndrome–beyond diet and physical activity. BMC Endocrine Disorders. 2023 Jan 16;23(1):14.

Lee SY, Koo YJ, Lee DH. Classification of endometriosis. Yeungnam University journal of medicine. 2021 Jan 31;38(1):10-8.

Lebovic DI, Mueller MD, Taylor RN. Immunobiology of endometriosis. Fertility and sterility. 2001 Jan 1;75(1):1-0.

Mathur R, Ko A, Hwang LJ, Low K, Azziz R, Pimentel M. Polycystic ovary syndrome is associated with an increased prevalence of irritable bowel syndrome. Digestive diseases and sciences. 2010 Apr;55:1085-9.

Yuan YZ, Tao RJ, Xu B, Sun J, Chen KM, Miao F, Zhang ZW, Xu JY. Functional brain imaging in irritable bowel syndrome with rectal balloon-distention by using fMRI. World journal of gastroenterology: WJG. 2003 Jun 6;9(6):1356.