EP.154/ How Adhesions from Surgery Can Cause Endo Belly and Five Tips to Prevent Adhesion Formation Post-Surgery
So, you’ve had an endometriosis surgery and you’re really hopeful that’s this is it – you’re going to have some relief, for a while at the least.
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Maybe your periods are better, your chronic pelvis pain is better, things are improving. But after a few months, the endo belly comes back. Or maybe you get it for the first time ever. You’re bloated all the time or maybe you bloat badly after meals, or maybe it gets worse over the day? Perhaps it’s also accompanied by IBS issues like constipation, gas, or loose stools. If any of this sounds familiar, this episode is for you.
Whilst surgery is essential for many people, it doesn’t come without its risks. And I honestly feel like it’s a disservice that these aren’t more talked about. So today, I’m talking about why you may get endo belly for the first time, a return of it or a worsening of it as a result of adhesions, and what you can do to prevent them.
If you haven’t heard me bang on about these guys before, adhesions are a form of scar tissue. They are web-like structures and bands of collagen that grow in response to injury and trauma, to ‘knit’ back together a wounded area and as part of the healing process from infection and inflammation. Collagen strands bond together to protect the damaged area to allow healing to occur in a safe and isolated environment, and if an infection is present, they protect the rest of the body by preventing the spread.
Adhesions occur in nearly all cases of abdominal surgery, the results vary from study to study, but one large and long study found that between 55% to 100% of women who had pelvic surgery developed adhesions, and up to 90% of people who had major abdominal surgery - so something like a caesarean - developed adhesions. So, if you’ve had even one or more surgeries for endo, it’s very likely that you have some adhesions.
Now adhesions are a leading cause of the condition, small intestine bacterial overgrowth. This is another topic I bang on about all the time, but if you’re new here, I am specialised in endometriosis and SIBO, because SIBO is so prevalent in our community, the research at present is indicating that 80% of us have it. And SIBO is a condition where the normal bacteria which should be in our large intestine (this is referred to as our gut microbiome), starts accumulating in our small intestine, where it shouldn’t be. Normally, bacteria are moved through the small intestine into the large intestine with the help of something called the migrating motor complex, and this MMC is a wave like motion that sweeps the small intestine of any left-over food bits and bacteria, and it kicks in about two hours after meals and at night whilst we’re asleep. Now a number of things can damage the MMC or prevent it from doing its job. Food poisoning or gastroenteritis is the main cause of damage to the MMC, and that actually damages nerves and muscles that control it. But adhesions, even if the MMC is working well, they can stop it from doing its job properly. And they do this by pulling on our intestines. So, imagine you have an adhesion that is going from your pelvis to somewhere on your intestines, it’s going to be pulling down on your intestines and distorting the shape or the flow of the intestines. In fact, your intestines need to be able to slip and slide over each other, they need to be able to expand and accommodate food and waste, but if they’re being yanked in different directions and they’re being held in place by adhesions, the flow is going to disrupted. There may even be adhesions wrapped around the intestine, which would create an obstruction, or the adhesions may have caused the intestine to loop over itself, creating a pocket area that the bacteria can’t escape from.
Whatever is happening, the result is the same. The small intestine can’t get clean, and bacteria builds up, causing SIBO. And the small intestine isn’t designed to house bacteria, so this causes all sorts of problems like bloating, which is a main cause of the endo belly and IBS issues. The gases that are released from the bacteria can also cause brain fog, fatigue, joint pain, and body pain to name a few symptoms. I’ve linked to a couple of episodes where I break down SIBO in more detail, so if you’re not familiar with it, have a listen to that.
Now even if SIBO hasn’t developed yet, adhesions may still be a source of your bloating. If they’re not affecting your small intestine, they could still be affecting your large intestine and may be causing a build-up of waste or gas, you may not be able to have regular bowel movements or your intestines might be sluggish and slow, allowing for gases to accumulate, creating that swelling.
So, what’s the solution? Prevent the adhesions from taking root in the first place, or if they have, start to break them down.
So first up, just as a caveat, we want to be lowering inflammation levels before and after surgery with good anti-inflammatory nutrition. Now inflammation occurs during healing, it’s actually part of the healing process, but too much of it for too long will encourage adhesion formation. We want a healthy level of inflammation that aids in healing, not a chronic level that accelerates the growth of adhesions. So, before your surgery and during your healing phase, make sure you’re filling your diet with those anti-inflammatory foods I always harp on about: colourful vegetables and fruits; healthy fats like avocado, olive oil, nuts, seeds, and fatty fish; antioxidant packed herbs and spices; and organic lean protein sources beans and lentils, free range organic omega 3 rich eggs, wild caught fish and free range, organic, grass-fed meat. If you want to learn more, I’ve linked to a few of my podcast episodes on anti-inflammatory nutrition and a free copy of my cookbook in the show notes. I should also be bringing out a nutrition for endo workshop in the next few weeks too, so keep your eyes peeled for that.
Okay, so now that’s cleared up, let’s dive into the extra strategies. I’m going to start with what you can do before and initially after the surgery, and then what you can do once the scars have healed.
1. Number one is supplementing with omega 3 fatty acids.
Fish oil was shown to reduce adhesion formation following surgery on mice with induced endometriosis, and reduced the inflammatory healing process post-surgery, which could reduce the chances of further endo development as inflammatory chemicals like prostaglandins fuel endometriosis. This led to the mice who were fed with fish oil to have fewer lesions than those who were fed a standard diet without fish oil supplementation, so even though we don’t have research specifically on adhesion formation and omega 3 on humans with endo, this could be a potential helpful supplement before and after surgery (though I would argue it’s an essential daily supplement).
The therapeutic dose is between 1000mg to 3000mg a day. I personally find I get more pain relief from the higher doses, but it can be tricky to get hold of those levels without exceeding the dose recommendations on the bottle. I have linked to a few higher dose supplements in the show notes, but if you chose to exceed the dose recommendations on the label, obviously that’s your choice but you’ll need to consult with a practitioner to be on the safe side. However, omega 3 fatty acids are generally very safe at these doses.
If you’re vegan, look for an algae-based supplement that contains both DHA and EPA, because we need both. I’ve linked to a few in the handout.
The only risk is that they can sometimes thin blood, so speak to your surgeon ahead of surgery to see whether you need to stop taking them a few days beforehand, for keyhole surgery it’s unlikely, but just check.
2. Number 2 is proteolytic enzymes. Proteolytic enzymes are natural substances that break down protein, and of course, the building blocks of muscle and tissue are amino acids, which form protein. As a result, proteolytic enzymes help to reduce adhesion formation and they also reduce inflammation post-surgery and aid in clearing waste products from the wound site. The research is limited, with most of the research being in oral surgery or sports related injuries but there is one study on endometriosis.
So, the only study we have on enzymes for endo is the use of a brand we use commonly at IWHI and that’s Wobenzyme. In the study, Wobenzyme was shown to reduce pain and inflammation post-surgery, reducing the chances of adhesions growth and it also inhibited the formation of new blood vessels, reducing the chances of further endo development.
The dose used in the study was the label dose for 40-60 days pre-op and then 60 days post op.
One thing to note is that because proteolytic enzymes reduce adhesion formation, there is the risk that if there is an infection at the site of the wound, that it could spread, as adhesions play a role in isolating infection sites from the rest of the body. This is rare but has been known to happen.
3. Number three is home Arvigo Massage. Now, everyone is different, but my recommendation is as soon as your scars have healed and the therapist gives you the go ahead, learn Arvigo massage from a licensed therapists and start practising on yourself every day or a couple times a week. This really increases blood flow and helps to clear away scar tissue. It only takes 10 minutes and can be part of your evening routine, because if you do it at night, it actually helps to stimulate your MMC, so that will also help to reduce your chances of clearing SIBO.
So that’s a great tool you can be trying at home and that’s like your daily maintenance. But we do want to go in with the bigger guns and that’s so that’s number four.
4. Number four is having some form of professional abdominal massage known as manual therapy, which is designed to break up adhesions. Manual therapy is a form of organ massage and manipulation to break down and prevent adhesions from forming, unstick organs and release a frozen pelvis. Your main options are visceral manipulation or Clear Passage.
Visceral manipulation is a form of manual therapy which was designed by Jean-Pierre Barral. It’s generally the more affordable and accessible option and is very effective for treating adhesions. Not much research has been specifically done on its effects on endometriosis, but there is plenty of research on its effects for pain conditions and lots of clinical research with endo patients experiencing success from treatment.
The holy grail of manual therapy is Clear Passage. This is a unique form of manual therapy which is designed for adhesions and is incredibly effective for SIBO and endometriosis. In fact, there is even amazing research behind it for these conditions, showing its effectiveness. If you’re contemplating a surgery but you’re not sure it’s necessary or the right path for you, for whatever reason, and you have the money to afford Clear Passage, you may want to look into it first because it can even prevent the need for surgery with endometriosis. Of course, if you have cysts that need removing or deep infiltrating endo that’s damaging your organs, I am not saying to ignore the advice of a surgeon and not have surgery, but in some cases, surgery isn’t the best option – especially if you’ve already had a few. Research has shown that the pain relief from Clear Passage is the same as surgery and is long lasting, and they all have remarkable results for endometriosis related infertility, pain during sex, and menstrual or ovulatory pain.
They also have wonderful results for SIBO and are endorsed by many of the world’s leading SIBO doctors. Honestly, I wish all of my clients with SIBO, and endo could have Clear Passage because the results from the studies are so positive. However, it’s very expensive so if you can’t afford it, honestly, don’t worry and try the Arvigo massage and visceral manipulation approach.
5. Lastly, you could also try regular castor oil packs.
I know countless leading women’s health practitioners who use castor oil to soften and break down adhesions and who experience great success with it with their clients. However, it’s generally considered that more research needs to be done, though there is research on castor oil’s abilities to lower inflammation, reduce symptoms of constipation, improve circulation, and stimulate muscle relaxation.
I actually asked Arvigo Therapist Tara Ghosh about using castor oil packs for breaking down adhesions and she explained how it works. So, castor oil actually triggers the immune system, due to some of its chemical components, but once it responds to the call and finds no poison to clear, the immune system goes about utilising its tools on repairing and healing the pelvic area seeing as it’s already there, which in turn helps to break down and clear adhesions. She also emphasises that it lowers of inflammation and improves of blood flow to the area, and that this also helps to clear adhesions or prevent their formation.
If you want to learn how to make your own castor oil pack and how and when to safely use them, I advise listening to my interview with Tara who has a really quick and easy method as opposed to the often messy and sticky traditional approach! You can try a castor oil pack alongside your Arvigo massage a couple of times a week once your scars have healed.
And if you’re years past surgery, don’t worry – other than the proteolytic enzymes, you can use all of these strategies to break down any old adhesions that have formed! With the proteolytic enzymes, we only have research that focuses on pre- and post-surgery, so I really couldn’t say whether they would work years after surgery, you could try, but I just can’t make any guarantees!
So that’s it! I hope that this episode provides you with a bit of a protocol for healing post-surgery and preventing adhesion formation. I think it’s actually appalling that we’re not told about them and how to manage them, given that they cause people with endometriosis so many problems, but hopefully this gives you some tools to get to work with.
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