EP.137/ Bloating Before Your Period with Endo: The Oestrogen and Gut Connection
Recently I polled my Instagram to find out just how many of you are suffering with PMS on top of your endo symptoms and the results were pretty staggering!
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Unfortunately, Instagram didn’t keep the number of votes so I don’t know how many people actually took part in this pole, but the percentage of people who did and who suffer PMS was 86%.
I know from past experience that the week leading up to your period and the week of your period, can often be when endo really rears its head for a lot of us, so adding PMS symptoms as well is of course not what we want!
I went on to poll your symptoms specifically and there was not one symptom that fell beneath the 50% mark, with most of them being around 70-90%, so you guys are dealing with a lot of symptoms.
I was originally going to do one podcast episode dedicated to PMS and endo, but after I saw these stats, I felt like it really would be too much to take on in one show and that some of these symptoms that you guys really scored high on deserve more focused attention.
So today, I’m talking about bloating before your period and why it happens. I chose this one to start with because this was the highest score, with 94% of you suffering with it.
So let’s dive in.
Now of course, when it comes to bloating, you know that I’m always going to talk about SIBO, which is small intestine bacterial overgrowth and research estimates that up to 80% of endo patients also have SIBO and that SIBO may even play a role in the development of endo. But, today I am not going to talk about SIBO. If you have bloating all the time, or most of the time, I really do recommend you also listen to my podcast episodes on SIBO, as that may be worsening the bloating you’re getting around your period. But if your bloating is mainly around your period or it’s at least worse around your period, then this episode is for you.
So other than SIBO and gut health infections or more serious gut health conditions, let’s look at some of the two of the key causes of bloating around your period.
1. Number one is hormonal imbalances, mainly oestrogen excess or oestrogen dominance and/or low progesterone.
So to be clear, excess oestrogen is a hormonal imbalance where we have too much oestrogen in the body, whereas oestrogen dominance is when our levels of oestrogen dominate over progesterone.
So in a normal healthy cycle, oestrogen should be higher in the first half during the menstrual phase and the follicular phase. It actually starts off at its lowest point on Day 1 of your cycle but it will begin to build. After ovulation, progesterone is higher than oestrogen, but what happens with oestrogen dominance is that oestrogen is higher than progesterone throughout the luteal phase, which is that second half of your cycle after ovulation.
This can occur in four ways:
· Progesterone is too low but oestrogen is normal so naturally oestrogen dominates.
· Progesterone is normal but oestrogen is in excess.
· Progesterone is low and oestrogen is in excess.
· Progesterone is low and oestrogen is low, but progesterone is lower.
Two of the most common symptoms of these hormonal imbalances are water retention and bloating. Why? Because progesterone and oestrogen actually play a role in fluid regulation, fluid retention and sodium (that’s salt, essentially) retention in our body! There are actually oestrogen and progesterone receptors in parts of the body that affect fluid regulation, such as the kidneys.
Research has found that in healthy participants, when they’ve isolated progesterone and oestrogen, separately, and administered them in normal doses, fluid regulation and sodium retention were acutely affected. So for example, the hormone that triggers the kidneys to recirculate water back into the body rather than excreted in urine was higher. However, in normal healthy participants the effects of these changes were minimal so fluid retention wasn’t dramatically increased.
But of course, we’re then left to wonder what happens when hormone levels aren’t normal and are in fact higher, like with oestrogen.
So, when they isolated normal levels of oestrogen in these studies, they found there was a small increase in water retention, which was because oestrogen encouraged the kidneys to recirculate water rather than excreting it.
However, despite higher levels in the hormone responsible for this process, which is called arginine vasopressin, the kidneys were not responding as expected, meaning there wasn’t as much water retention as they would have expected there to be given the levels of arginine vasopressin. This has left scientists wondering whether oestrogen has the ability to make the kidneys less sensitive to this hormone, which has actually been shown to increase in the second half of the cycle. So basically, the effects aren’t that dramatic and they’re still trying to work out why because giving these findings, they should be.
Now sodium retention does increase with oestrogen and so scientists believe that the small change in water retention that they observed, was really down to the higher levels of salt in the body, rather than the higher levels of arginine vasopressin, which didn’t seem to create a huge change in the kidneys. And higher sodium levels increase the amount of fluid that surrounds our cells, so that would explain why we feel extra puffy and swollen.
Additionally, oestrogen increases the amount of plasma in our body, which is a clear liquid fluid that makes up the bulk of our blood. This results in swelling in the body and alterations in where fluid is distributed. Progesterone has also been found to do the same thing, but this result hasn’t been consistent across studies.
So, if progesterone can increase swelling potentially, and very slightly in healthy adults, and oestrogen can increase it too, again, slightly, then you can see why having normal levels of progesterone and higher levels of oestrogen could result in excess swelling around the body water retention and ultimately, bloating.
So if we’re able to bring our hormones into balance, we may see some normal small increases in swelling and bloating as we enter the second half of our cycle, especially if this research on progesterone increasing plasma fluid is accurate, but we shouldn’t be experiencing dramatic bloating and noticeable swelling.
This leads me to my next cause.
2. Number two is your gut health.
If you listen to my podcast you’ll know already that gut health problems cause symptoms like bloating, especially problems like candida, SIBO and fungal overgrowth.
Even if you don’t have an infection, parasite or one of these problems, general gut dysbiosis can cause bloating. Gut dysbiosis is when the bacteria that live in your gut, become out of balance and this imbalance creates an inflammatory environment, excess fermentation which results in gas and bloating, and symptoms like IBS.
These issues can be worsened by the changes that happen to the gut during the lead up to menstruation. When progesterone rises in the second phase of your menstrual cycle, it actually slows down digestion – this is why you may experience constipation before your period or at least slower, sluggish bowels. This is because progesterone is a muscle relaxant, it actually helps to loosen muscles and ligaments during pregnancy to allow your pelvis to expand.
So yes, naturally and normally, your bowel movements might be a little slower in the second half of your cycle or you may just notice that your food doesn’t seem to go down as quickly after a meal, creating some degree of bloating or fullness. But these changes shouldn’t be to the point where you can hardly go to the toilet in the second half of your cycle or that your bloating is painful, your belly is really extended so you look six months pregnant or you can no longer wear the clothes you wear in the first half of your cycle.
If that’s happening, we need to look at your gut. If you have dysbiosis or a condition like SIBO, you’re going to be having more fermentation anyway, so that means you’re going to be more bloated generally. Now if we slow down the transit of food through your gut, of course, this gives the bacteria and archaea even more time to munch on the food, creating even more gas! Then, because you have slower peristalsis, which is the movement that pushes food and waste through your intestines, it’s going to take gas longer to exit. So essentially, you have more food and gas hanging around in your gut for longer, so it’s no wonder that you feel bloated!
On top of this, if you have gut dysbiosis, SIBO or another gut condition, your gut microbiome may have higher levels of an enzyme known as beta-glucuronidase. This is an enzyme that helps to regulate oestrogen, by recirculating waste oestrogen if needed, rather than allowing it to be excreted through a bowel movement. Researchers looking into the alterations of the gut microbiome and its connection to oestrogen dependent diseases hypothesise that people with endometriosis may have higher levels of beta-glucuronidase, and this is certainly the case with many of my clients when we test them. In fact, another study, sadly on monkeys with endometriosis, found significant dysbiosis including low levels of lactobacillus, which is a bacteria that helps to keep beta-glucuronidase in check and at the right levels.
This of course means that the gut dysbiosis could be the cause of or worsening any excess oestrogen or oestrogen dominance you may have, and that can in turn be worsening your water retention and swelling.
Another point to add here is that the same study on monkeys also found high levels of gram-negative bacteria in the microbiome. Gram-negative bacteria can be disease or illness causing, such as for example, certain strains of e.coli, but there are also normal gram-negative bacteria found in our guts that don’t cause disease, again, like certain strains of e.coli, but they have the potential to evolve and cause illness.
What’s really important here is that gram-negative bacteria break down, they release parts of their cell walls called lipopolysaccharides or LPS for short. Lipopolysaccharides trigger a huge inflammatory response from the immune system, and these monkeys were shown to have higher levels of intestinal inflammation, which would make sense!
More recently, research has found LPS in the pelvic cavity of people with endo and it’s believed that this LPS has been transferred from the gut, through leaky gut, and it has also been found that LPS contributes to the inflammation and disease growth of endo.
But what’s even more interesting is that recent research (though on a small study of 40 and this study does have its limitations) has found that gram-negative bacteria and LPS may actually increase in the blood in the lead up to our periods. They studied the immune responses to LPS throughout the cycle at four stages (Day 7, Day 14, Day 21, and Day 28), and found peak levels being on Day 28, indicating that there were higher levels of LPS in the blood stream around this period of time because there were higher levels of LPS antibodies.
They suspect that LPS and gram-negative bacteria actually increases in the blood due to translocation, so just to remind you that’s the movement (usually of bacteria) from the gut to outside of the gut. This, they believe, could be due to changes in the gut wall caused by progesterone rising in the second half of the cycle, so essentially, progesterone is causing temporary leaky gut. This in turn is creating an exaggerated inflammatory immune response, and one of the trademark symptoms of inflammation is a swelling of the inflamed area.
Now prior to this study, much research has shown that the immune system is actually suppressed in the second half of the cycle, and the theory is that this is to support healthy implantation and fertilisation of the egg, without the risk of the immune system attacking it. This occurs when progesterone rises following ovulation, so early to mid-luteal phase your inflammatory immune reaction should be somewhat dampened. However, as progesterone begins its decline ahead of your period about 9 to 11 days after ovulation, inflammation returns as the immune system begins to return to its normal strength.
This correlates with the findings of this study on LPS immune reactions. The strongest reaction from the immune system comes at the end of the cycle, around Day 28, and this would make sense given that the immune system is pretty much back to full strength by then. They also show that Day 14 has the lowest reaction to LPS, which would make sense of course as this is roughly around the time that ovulation occurs, although it varies from person to person and from month to month, the idea that we all ovulation on Day 14 or 15 is actually a myth!
So, as the immune system is only suppressed between say day 14 and day 25-ish, if the LPS and bacteria were present all month round, we should have seen a higher level of immune reaction on Day 7 when the immune system is still fully functioning, but we’re not, the immune response is in fact at its lowest point here, along with Day 14.
So, in this study it was the antibodies to the LPS which were measured, not the LPS levels or the gram-negative bacteria, but they have concluded from the rising antibodies that this indicates rising LPS and gram-negative bacteria levels in the second phase of the cycle, with a strong immune reaction towards the end of the cycle when the immune system returns to fully functioning. Now the limitation here is that we don’t actually know for sure the levels of LPS or bacteria as the microbiome was not studied itself and there were no stools tests taken at all, we’re simply going off the LPS antibodies in the blood, so I hope that more research is done to look into this further and see whether these findings are consistent.
But if this research is correct and we’re able to replicate it in future studies, then it would make sense that people with endo, who have a higher load of gram-negative bacteria in their guts, and maybe even more so in the case of SIBO or some other pathogen, would have more LPS in their blood stream in the second half of their cycle. Especially because there’s the possibility of leaky gut already being present, which is often the case when we have dysbiosis, or SIBO or another gut health condition. So if progesterone is expanding those tight junctions in the second half of the cycle, there’s the chance that it’s making big gaps in the gut lining even bigger, allowing more bacteria and toxins to travel through. And if LPS and gram-negative bacteria are escaping in the luteal phase, and are finding their way into the pelvic cavity, this could be contributing to swelling in the area thanks to an inflammatory immune reaction towards the end of the cycle. As I mentioned earlier, there’s already LPS in the pelvic cavity of people with endo, so if these findings turn out to be accurate and can be replicated in future research, perhaps this could explain why there’s even more an inflammatory reaction in the abdomen and pelvis of people with endo, in the lead up to their period, in contrast to the rest of the month and to those who don’t have it.
So to wrap up, of course, endometriosis can cause some degree of swelling due to the inflammatory nature of the disease, so this could definitely be contributing, but the bulk of inflammation occurs at menstruation, as the uterine lining sheds and prostaglandins and histamines are released, not beforehand (though prostaglandins are being released in the uterus in the lead up to menstruation), so this extensive swelling the week or even two weeks before, doesn’t really correlate. In my opinion, it’s the impact of this increased LPS, the returned immune response, the presence of endo, gut dysbiosis and hormonal imbalances that are creating the perfect recipe for swelling and bloating ahead of your period.
So now you’ve got some information on why it’s happening, next week I’m going to take you through some simple strategies for supporting the gut and balancing your hormones and some easy methods for quick bloating relief in the lead up to your period.
Show Notes
Fluid retention
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2849969/?fbclid=IwAR3kn0CVHyH4aZsIJ0hPq8__O7k4WfM_rk7EWKSLWj4RmQlVZsnCbnEu4Yg#R7
https://joe.bioscientifica.com/view/journals/joe/89/2/joe_89_2_011.xml
Progesterone and constipation
https://nicolejardim.com/howyourperiodaffectsdigestivetract/
Gut Mircobiome
https://academic.oup.com/humrep/article/17/7/1704/576914
https://www.maturitas.org/article/S0378-5122(17)30650-3/pdf
https://www.nature.com/articles/s41598-017-04081-1
LPS
https://www.cambridge.org/core/journals/acta-neuropsychiatrica/article/menstrual-cycle-may-not-be-limited-to-the-endometrium-but-also-may-impact-gut-permeability/4312A69492836C1A9D93A510D144B08D
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5902457/
Immune system and endo
https://pubmed.ncbi.nlm.nih.gov/29778270/
https://www.sciencedirect.com/science/article/abs/pii/S1568997211002977
Prostaglandins
https://pubmed.ncbi.nlm.nih.gov/16992446/
https://pubmed.ncbi.nlm.nih.gov/1115176/
https://pubmed.ncbi.nlm.nih.gov/7411005/
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