EP.156/ How Endo Surgery Could Cause Endo Belly, Affect Your Digestion and Cause Gut Problems – and What to Do About It
So last week I did an episode on adhesion formation post-surgery and how that can affect or literally cause endo belly – and you guys loved it!
LISTEN NOW
And I’m glad that you did, because I had another linked episode to follow up with, a part two in a way…
So today, aside from adhesions, I am talking about the ways in which endo surgery could have worsened or even caused your endo belly.
Now of course, adhesions are included in that, but they’re a big topic hence the separate episode, so I encourage you to listen to that if you haven’t done so already!
So, let’s dive in…
1) Number one is constipation. The medications, like pain relief and some of the other medications they may use in surgery, can be a cause of constipation following your laparoscopy.
Even just having to water fast and not eat anything before surgery, can cause constipation.
There’s also the possibility that if you don’t feel like eating much post-surgery, or you’re stressed from surgery, your gut feels sore after surgery or you suddenly eat a lot more stodgy comfort foods post-surgery, that you may get constipation.
Now a lot of people think constipation is just a matter of discomfort and that it’s not a big deal, but actually, we eliminate oestrogen through daily bowel movements.
You’ve heard me talk a lot about excess oestrogen and oestrogen dominance in the past, and how it can be a potential driver of endometriosis and endometriosis symptoms in some of us. However, for many, the symptoms of endo look very similar to the symptoms of oestrogen dominance or oestrogen excess. When we have too much oestrogen in our bodies or we have oestrogen levels that are too high in relation to progesterone, we get symptoms such as heavy periods, period pain, clotty periods, mood swings, breast tenderness and bloating in the lead up to our periods, post-ovulation. So, we may think that our endometriosis is out of hand and causing all of these problems, but if we spent even just a month balancing our hormones, we may see a dramatic reduction or even complete elimination of these symptoms. Now of course, you can have these symptoms of oestrogen dominance or excess AND the excess oestrogen may also be fuelling your endo or worsening your symptoms, that’s certainly a possibility, but for some of us, the cause of the symptoms is the hormone imbalance itself.
Regardless, we want to ensure we’re supporting your hormones, especially after surgery, because we want to build on the good work of the surgery, and we don’t want to have excess oestrogen circulating in our system and possibly feeding any future endo growth. It’s not that oestrogen is bad, it’s a wonderful and essential hormone, but we want to ensure it is in the correct levels and in its healthiest form, as high levels and unhealthier forms of oestrogen are behind issues like breast cancer, fibroids, and endo.
So already, you can see that constipation can have a knock-on effect on our health with endo. But aside from this, constipation or sluggish bowels can cause bloating and discomfort in the abdomen, as waste and gases continue to build up, and this will of course mimic what we call the endo belly. Now as I’ve said before, I don’t believe the endo belly is just the endo belly and it’s one sole root cause is endometriosis. In fact, I usually see multiple causes behind the bloating and swelling my clients experience, and sluggish bowels is one of them.
So, if post-surgery you’re getting a lot of bloating and swelling (which you will of course, for the first few days, from the gases they use to inflate our bellies), just consider whether you’re having healthy bowel movements.
You should be having at least one bowel movement a day, and it should be long, snake-like with a banana like consistency. If it’s hard, cracked, like pellets or stones of difficult to pass, that’s constipation. And if you’re not going daily, that’s constipation too. Often, we’re led to believe that we only have constipation if we’re not going as regularly as we normally would, but that’s not healthy! If you go once a week and then you start going every 10 days, that doesn’t mean your once a week was healthy. A healthy bowel habit for optimal health, hormones and waste elimination is at least once a day.
So, if you are constipated, what can you do about it?
Firstly, don’t panic. You might be a little constipated for a few days post-surgery as your organs essentially get over the shock of going through surgery, it is after all, a trauma to the body. Even with the methods I’m going to suggest, it might take a few days to get things moving, so don’t worry, just get started with them and give yourself some time. Hopefully within two or three days we can get things moving again.
So, the first tip would be to move, gently. This is a basic first line therapy that we genuinely use with gut healing – simply to exercise. It’s low risk and is free. I’m not saying to jump on a trampoline, but your body requires movement to get things moving and constipation can often be aided by exercise. Now if we weren’t post-surgery, you could maybe do some yoga, go for a run, or do some Pilates, but clearly, we’re not going to do that post-surgery.
So, just like is suggested in the post-surgery recovery guidance, just ensure you’re getting up regularly and moving around gently for a couple of minutes. I don’t mean a fast walk, I don’t mean standing up until you hurt, I literally mean every 30 minutes or an hour, or further apart if that’s all you can handle, just gently get up and walk slowly around your room or house, for a few minutes. It could even just be one minute to start with. But if you’re lying down for eight hours then things are not going to be moving well in your body.
Doing this is also going to speed up your recovery, because it ensures that blood is flowing to the area of your surgery and getting to work with healing the wounds.
Now, you’ve likely heard your doctors encourage you to move gently after surgery, but I do want you to check in with them on this, because of course, I don’t know the type of surgery you’re having or have had. If you had a six-hour surgery then they may give you different advice, so please do check in with them on this.
Next up is a very simple strategy and that’s warm or hot water, drunk slowly in the mornings. Yes, really! This actually triggers something called the gastrocolic reflex, which stimulates movement in the large intestine, creating the urge to have a bowel movement.
You can also try increasing your intake of healthy fats, like egg yolks, fish oil (so maybe you take an omega 3 rich oil), or full-fat yoghurt (dairy free if that’s better for you, and organic to avoid added hormones if you’re having animal-based yoghurt), ideally in the mornings, as this will increase motility (which basically means movement) in the large intestine, and generally, we’re more likely to have bowel movements in the morning because digestion has been working overnight and it should take between 12-24 hours to for the food we eat to form a bowel movement.
If none of these simple at home methods work for you, you can try magnesium citrate or oxide. This works by drawing water into the intestines, creating looser stools and encouraging a bowel movement. You can safely take between 500mg to 2000mg, at night, before bed, but normally 1000mg tends to work well for people. You’ll need to build up until you find the right dose for you, as going straight in at 1000mg or 2000mg may cause diarrhoea. So, start at 500mg and increase slightly every other night until you get a bowel movement, but keep in mind may take 2-3 days as it can take a little while to get going. If you get bloating or abdominal pain from the magnesium, you’ve probably taken too much, and you’ll need to reduce back down.
Of course, consult your doctor before starting any new supplement!
2) Number 2 is that the stress from surgery, whether emotional or the physical stress of your body undergoing surgery, can turn off your digestion. Your digestion is controlled by a part of your nervous system called the ‘rest and digest response’, whereas your stress response, which helps us to power through stressful or genuinely life-threatening situations, is controlled by a part of the nervous system called the ‘flight or fight response’. The two cannot be operating at the same time and unfortunately or fortunately, depending on the situation, the stress response will always win, because it ensures our survival. This has allowed us to survive and evolve as humanity, but in modern times, even just a stressful email might trigger the flight or fight response, turning the rest and digest response off.
And the thing is, post-surgery we really want the rest and digest response to be operating well, because not only does it control digestion, but it also controls healing. So, when our body and mind is feeling stressed from having a surgery, our healing and recovery time is impaired.
But back to digestion. When digestion shuts off, a few things happen. Firstly, our digestion and motility tend to slow down. Now for some people, you may get exaggerated and increased motility in the large intestine, resulting in diarrhoea, but that doesn’t mean things are moving well in the small intestines. So, if things have slowed down in the stomach and small intestine, this creates stagnation and a chance for bacteria to populate in the small intestines where they shouldn’t be.
Now that of course, sounds like small intestine bacterial overgrowth, which is a condition many people with endometriosis have, where bacteria which should be in the large intestine, happily existing in the gut microbiome, are living in the small intestine. This creates a whole host of problems and symptoms like bloating (which we may think is the endo belly), gas, constipation, diarrhoea, and abdominal pain to name a few. Now this likely wouldn’t be enough to cause you to develop SIBO alone, because once the rest and digest mode is switched back on, hopefully your motility is working well enough that the bacteria are swept out of the small intestine and into the large intestine where it belongs. However, if you also have adhesions or low stomach acid, or other risk factors for SIBO, it might be enough if you keep returning to this state of fight or flight and you’re really chronically stressed.
So, if SIBO does happen to develop, that most certainly is going to cause what we see as the endo belly, which in my experience with my clients, is most of the time at least in part caused by SIBO, so that’s one possibility. However, even if you don’t have SIBO, that slowed down motility and digestion is going to leave food hanging out in your intestines, whether that’s the small or large, leaving lots of time for bacteria to have a good munch on that food, and in turn, they make gas as a result. That’s the process of fermentation.
Additionally, when digestion turns off, we also don’t get a release of gastric juices like stomach acid and digestive enzymes. These guys are absolutely vital for breaking down food and extracting nutrients, so without them, we’re going to have chunks of food in our intestines that can’t be broken down and that can result in pain, bloating, gas, constipation, or diarrhoea.
A side note here is that we really want to be absorbing our nutrients. Our body requires vitamins, minerals, amino acids, glucose, and fats to heal, not just for the energy but for the actual process of healing and repairing the tissue. If our digestion is shutting down and we’re not absorbing our nutrients properly, we’re going to have a harder time healing and are most likely going to experience more inflammation and more pain.
Lastly, stomach acid and digestive enzymes actually play a role in protecting us from SIBO and bad bacteria. They kill off bacteria as it enters the gut, and so if those levels are lowered, it’s like our first line of defence is lower and bad bacteria can more easily move in. Having low stomach acid is also a risk factor for developing SIBO, it’s not usually enough on its own, but coupled with another risk factor it could take us to the point where we do develop it
So, what can we do about this?
So, the first thing, of course, is creating feelings of safety in the body and lowering our stress response. There are numerous ways to do this, but some proven effective strategies for turning off the flight or fight response include tapping (where you tap on different points of your body and repeat certain statements), meditation, deep breathing, and spending time in nature. There are other strategies like yoga and exercise, but I’m trying to only highlight the ones that you’ll be able to do post-surgery. So even though you may not be able to go for a run or something in nature, maybe you might be able to sit in your garden, or by a window, or when you get stronger, maybe you can manage a 10-minute walk in the park.
Now of course, we can’t always live in a stress-free bubble, and you may have recurring feelings of stress about your surgery, so it’s not that we’re trying to totally remove you from the feeling of stress, because that could get pretty stressful in itself! But what we want to do, is a few times a day, take some time to lower our stress response, so the body gets these reminders that it’s safe, that you are safe. So perhaps you do some gentle breathing in the morning, maybe you do some tapping at lunch and some meditation before bed, for example.
In the show notes, I have linked to a few apps where you can learn these techniques.
Next up is digestion support. Firstly, we want to ensure that when you’re eating, your rest and digest response is actually switched on. So, to do that, we want to be eating in a calm environment and taking time with our meal rather than rushing, if we’re rushing or eating when we’re tense, the flight or fight response will be switched on and digestion will be switched off! You can further encourage the rest and digest response to be on by taking a deep breath or a few deep breaths before eating – in through the nose, and out through the mouth, with your exhale longer than your inhale. This helps to turn the flight or fight response off and the rest and digest response on.
Finally, we can further support your digestion by adding in stomach acid support and digestive enzyme support.
You can stimulate the production of stomach acid by drinking one tablespoon of apple cider vinegar in 8 tablespoons of water 15 minutes before a meal. Drink through a straw to protect your enamel and don’t do this if you have a history of stomach ulcers or inflammatory bowel disease. If you have interstitial cystitis or histamine intolerance, the vinegar may not be the best option for you, so I recommend adding bitter foods with your meals, like rocket in your salad, as that can also help stimulate stomach acid – not dramatically, but somewhat. Of course, always consult a doctor before adding in supplements or digestive support.
You can also buy tinctures known as bitters, which are a blend of bitter herbs, and you can take a few drops of that before a meal instead of the vinegar. Again, these tinctures do tend to contain alcohol so people with IC may need to be careful.
You can actually take a supplement called betaine HCL, that literally provides you with more stomach acid, but at first, it’s best to see how you respond to these options as it can be very strong and is not always suitable for some people. So, start here and if you don’t feel like it’s helping, I have a protocol for taking betaine HCL in my upcoming course The Endo Belly Course and I think it might be in my endo belly podcast series as well
For digestive enzymes, certain herbs and spices have actually been shown to stimulate the production of digestive enzymes! These are:
· Garlic
· Mint
· Onion
· Turmeric
· Ginger
· Fenugreek
· Caraway
· Fennel
· Coriander
· Cumin
So, adding a mix of these to dishes can help to increase your digestive enzyme levels. A mix is always best because they tend to increase different digestive enzymes and you need an array of them, so for example, don’t just rely on garlic in a meal, try to add one or two other herbs to get the best support.
You can also use digestive enzyme supplements, which you take with meals, as directed on the label. Unless you have a gut health condition, it’s best not to use these for more than a month so that your body doesn’t get too reliant on them, but I do use them longer term for people with SIBO and anyone with more extensive gut health issues.
3) The last way endo surgery can cause endo belly and gut problems is by causing leaky gut. As you may know, the pain relief drugs known as NSAIDs can cause leaky gut, but so can stress as the chemicals released in the stress response actually directly damage the gut lining.
If you’re not familiar with leaky gut, I have a whole episode on it which I’ve linked to in the show notes, but leaky gut or intestinal permeability occurs when tiny holes appear in the gut lining. Think of the gut lining as a sausage skin, it’s a tube from the mouth to the colon that separates what’s coming in and going out from the rest of the body. The lining is incredibly thin, just one cell thick and these cells are tightly packed together with only the tiniest gap between them, to allow for the absorption of nutrients. When the gut gets inflamed or damaged from chronic IBS reactions, chronic stress, NSAIDs, infections, SIBO, allergies, intolerances, an inflammatory microbiome, etc. the gaps begin to widen.
When this happens, food particles can pass through the gut lining alongside bacteria and toxins from bacteria, known as LPS. While some of the immune defences are inside the gut, there is also a large amount on the outside of the gut lining, waiting to attack anything that passes through which shouldn’t be there. It doesn’t matter if this is food or bacteria, inflammatory immune cells will be released and because the blood stream is also on the other side of the gut lining, the inflammatory cells can get swept along the blood stream, causing full body inflammation.
If you have leaky gut, this is going to be happening every time you eat, putting you in a state of chronic inflammation.
Additionally, leaky gut can cause gut irritation, creating reactions like bloating (or what we may see as the endo belly) and IBS issues. Over time, leaky gut can cause food intolerances as the immune system begins to create antibodies to the foods passes through.
Of course, we don’t want this to be happening whilst we’re trying to recover from surgery. We want a healthy level of inflammation to help us heal, not chronic inflammation, and we certainly don’t want swelling or abdominal distress putting pressure on our stitches or the internal sites which have been excised.
So, what can we do about it?
Well of course, firstly we want to try and lower stress as I mentioned before, so go back to those practices.
Secondly, if we can, we want to lower our reliance on NSAIDS during this period. Now if you can’t, don’t worry – don’t feel guilty or pressured, just focus on the stress piece and maybe the next tip too. But if you can, there are supplements that have been shown to be just as effective as NSAIDs for reducing pain, in particular, ginger powder.
Ginger has been shown to be just as effective as ibuprofen and mefenamic acid for dysmenorrhea, it’s also been shown to be a wonderful pain reliever in numerous studies for migraines, arthritis pain, back pain and so on. Dose wise, ginger is safe to take at up to 2000mg a day, but it needs to be divided into doses rather than taken all in one go, as that can cause diarrhoea. You could start at 1000mg a day and take it four times a day, so 250mg per dose or some supplement brands are 500mg a dose, so you could start there and do two a day or four a day, depending on the level of pain you’re in. You could take it like this daily, to just keep pain down, or you can literally take it at the onset of pain, like a pain killer.
Now ginger is a blood thinner, so if you decide to start taking it before surgery, to lower inflammation ahead of time, just consult with your surgeon as they may want you to stop taking it for a few days or a week before your surgery date.
Curcumin has also been shown to be just as effective as ibuprofen for pain relief when taken daily for 4 weeks at 1,500mg. It was also shown to have less GI side effects than ibuprofen, which is great for the endo belly! And guess what else? Curcumin helps to heal leaky gut and reduce intestinal inflammation, so double bonus.
Now curcumin is also natural blood thinner, so what you could do is take it for four weeks prior to your surgery to gain the beneficial effects and build up that level of pain relief, and then stop before your surgery if instructed to by your surgeon, so check in with them ahead of the surgery in case they want you to stop, and then start again after your surgery to continue reaping the pain relieving effects. You’ll probably only be pausing your dose for a few days, two weeks at the maximum, but it’s likely they’ll only ask you to stop taking it for a week or even less before the surgery, especially if it’s only keyhole.
Of course, you may need some more pain relief than these alone, but for some of us, they’re enough, and if you’re also using some of the supplements, I mentioned in my last episode on the endo belly and surgery, then you really may not need any additional pain relief. However, if you do, hopefully the addition of ginger and maybe curcumin, might lower your need for as many
Finally, I don’t want to throw too many supplements at you for this episode and so if you do want some specific supplements and strategies for leaky gut, head to my episode on leaky gut and endo belly healing, which are linked in the show notes. But for now, I want to give you a very simple at home method for calming the gut and healing leaky gut, and that’s bone broth. Bone broth contains amino acids and collagen, which help to heal leaky gut.
Now a few caveats to this, if you’re vegan or vegetarian, this is of course not the one for you, and so what I recommend is you just really focus on a diet rich in anti-inflammatory foods to lower intestinal inflammation, support your gut with curcumin and perhaps listen to my episode on leaky gut and try some of the other tips from there.
The other caveat is if you have SIBO, you might react to bone broth because the collagen in there actually can feed SIBO. Some people with SIBO do fine on bone broth, but others get bloated or get abdominal discomfort, so test how you feel on it.
Finally, if you have histamine intolerance, bone broth is high in histamine, so this also may not be for you. You can make a low histamine bone broth by cooking it for much less time, but it won’t be as healing for leaky gut because it’s going to contain less of those amino acids, collagen, minerals, etc. from the bones.
So if for whatever reason, bone broth is not for you (and actually, even if it is) the foundational thing you can do to support your gut lining to heal, is to eat a nutrient dense diet full of anti-inflammatory foods, because if we just spend our time recovering eating sugar, alcohol and fast foods, the gut lining is going to become even more inflamed and any damage from NSAIDs or stress is just going to be exaggerated. But if you can add bone broth, it’ll be a wonderful healing addition to this protocol.
So that’s it! You have lots of options to choose from, and you certainly don’t have to try them all. Pick and choose what suits you, your values, and your lifestyle, and they will go a long way to helping your gut to recover and heal post-surgery and preventing recurrence or worsening of the endo belly.
Show notes
Stress relief tools
Ginger research
https://pubmed.ncbi.nlm.nih.gov/23865123/
https://pubmed.ncbi.nlm.nih.gov/26177393/
https://pubmed.ncbi.nlm.nih.gov/25912592/
https://onlinelibrary.wiley.com/doi/10.1002/ptr.6730
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171779/
https://pubmed.ncbi.nlm.nih.gov/23657930/
Curcumin
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4533742/
https://www.karger.com/Article/FullText/491886
https://www.sciencedirect.com/science/article/abs/pii/S0753332217346838?via%3Dihub
https://www.sciencedirect.com/science/article/pii/S1756464615000092
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407015/
https://pubmed.ncbi.nlm.nih.gov/24672232/
https://pubmed.ncbi.nlm.nih.gov/25277322/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476912/
Leaky gut epsiodes
https://www.thisendolife.com/this-endolife-podcast-episodes/endometriosis-leaky-gut
https://www.thisendolife.com/this-endolife-podcast-episodes/-the-endometriosis-belly
https://www.thisendolife.com/this-endolife-podcast-episodes/understanding-the-endometriosis-belly-part-2
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