EP.305/ How to use flax and chia for constipation with endo
Many people with endometriosis, including about 60% of my clients, suffer with constipation.
Is this because of endometriosis directly? Not exactly. There are several reasons someone with endo can have constipation, whilst this episode isn’t about that, here’s a quick low down on some of the key causes:
Endo – Of course, whilst this isn’t the case for everyone, endo can be located on the bowel, which can cause structural changes to the bowel, making bowel movements harder.
Adhesions – Adhesions from either endo itself or from surgery can attach to the intestines and cause kinks and loops which make it harder for stools to pass through the bowels. P.S. Adhesions from abdominal surgery occur in between 50-100% of patients, and if the abdominal surgery is more significant, the risk is much higher.
SIBO – Small intestine bacterial overgrowth, where bacteria overgrow in the small intestine, is a key culprit of constipation, especially in people who have methanogen overgrowth. There are three types of SIBO; hydrogen, methane and hydrogen sulphide. Methane is no longer technically a type of SIBO, it has a new name, methanogen overgrowth, because it occurs not just in the small intestine and in the large too. But the testing and treatment remains the same, so honestly, it’s really just a new name and a new way of thinking of it, but we would still informally call it methane type SIBO. Research indicates that people with endo have a higher prevalence of SIBO.
Gut dysbiosis – gut dysbiosis is where we have an imbalance of gut bugs in our large intestine, and this can lead to IBS-like symptoms such as constipation. Research is showing an increasing link between endometriosis and microbiome changes.
Luteal phase – in the second half of your cycle, after ovulation, known as the luteal phase, our progesterone levels rise (in theory, some people need to boost their progesterone, but that’s a conversation for another time). Progesterone is a muscle relaxant, and as a result, it relaxes the muscles of the intestines and slows down motility. This might mean, for the average person, bowel movements are a bit slower, but that they don’t have full on constipation. However, if you suffer with any of the above, this hormonal change can trigger or worsen constipation.
So, whilst there are many other reasons someone with endo may have constipation, these are some of the most common I see in my practice.
So, what can we do about it? Getting to the root cause and resolving it, is of course, the most important factor here, however, that can take time.
There are multiple methods for alleviating constipation, and I discuss various ones in articles, podcasts and in my courses, and I’ve linked to a few in the show notes, but today I want to discuss two foods which can help with constipation, that are evidenced based, but may cause some hesitation or fear in the community, so I wanted to address it.
The first food, and the primary subject of today’s podcast, is flax seed. Research has shown that flaxseed is just as effective as some common prescription laxatives, like lactulose! The method is so effective, that it is a recognised and advised treatment by the NHS for constipation.
Flaxseeds contain a type of fibre called soluble fibre, this helps to draw water into the stools and makes them softer.
The studies used low to relatively high doses, one being 10g per day and another being 50g per day. Additionally, both studies used ground flax seeds.
However, I would caution you not to go in straightaway at high doses like 50g. When consuming more fibre, it’s always best to go slow, because it takes a while for gut the to adjust and so at first, we may find we have more bloating, gas, etc. and so we want to give our body time to get used to the new fibre and to reduce the chances of symptoms or at least reduce the severity of them. If you do have symptoms at the start, this doesn’t necessarily mean flax isn’t for you, but that your body just needs some time to settle in. I’ll talk about how to address this shortly.
The other reason to be cautious with serving sizes is because if you have too much flax, especially if you’re not drinking much water with it, this can actually cause constipation because the flax just dries everything up (because it absorbs water) and may cause a build-up.
Another thing our community may be wary of is that people with intestinal adhesions may find stool bulking agents like flax to cause pain or further difficulties with passing stools, because if the stool is becoming bigger, even if it is softer, and it encounters a kink or loop in your intestines, it might be difficult to get past. This is absolutely not always the case and flax is generally very safe and a reliable constipation treatment, but it’s worth mentioning and discussing with your doctor if you do suspect adhesions on your intestines.
Finally, and this is probably the biggest fear factor for our community, is that flax is a phytoestrogen. This means it mimics oestrogen in the body, but it is much weaker. Research has actually shown benefits of flax for people with oestrogen dominance, because it prevents real oestrogen from locking into our cell receptors, and locks into them instead, creating weaker oestrogenic reactions. Additionally, in people with low oestrogen, this can be helpful too, by boosting levels. This is why flax seeds are used in the hormone balancing practice of seed cycling, which requires you to eat a tablespoon of flax and pumpkins seeds in the first half of your cycle, and a tablespoon of sesame and sunflower in the second half.
Despite the positive research, in my experience, people with endometriosis have varying reactions to flax. I really couldn’t give you an accurate estimate here, but I would say that maybe 70-80% of my clients respond well to flax, with about 30-20% of them finding it worsens symptoms of oestrogen dominance and/or endo.
Personally, I always thought flax didn’t agree with me and caused me oestrogenic symptoms, mainly because I thought that when I took it, I was getting ovulation pain on my right side. I’ve more recently discovered that is much more likely due to an adhesions on my lower right quadrant, just at the end of my small intestine, which is making it difficult for bulky flax to pass by.
The other times I’ve had problems with flax is when I’ve used the oil or pre-ground flax. Flax oil, and flax in general, but oil is more concentrated, is high in omega 6. This is a great, essential fatty acid, but it needs to be counter balanced with sufficient omega 3. Omega 3 is the precursor, meaning it makes, anti-inflammatory prostaglandins (immune chemicals), whereas omega 6 makes inflammatory ones. We need both for a healthy immune system, but we don’t need excessive levels of omega 6 to omega 3, because that can cause high inflammation levels, and therefore, more pain. We know from the research that people with endo have higher levels of inflammatory prostaglandins, so the last thing we want to do, is to consume high amounts of these in the absence of omega 3.
Now, omega 6 is in lots of incredibly healthy foods, like nuts and seeds. Does this mean you should avoid nuts and seeds? No, because they come with lots of nutritional benefits for the gut, hormones, endo and much more. But fried foods, fast foods, processed foods, etc. all contain high omega 6 levels, and the problem with many modern day diets is that they’re higher in processed foods, and lower in omega 3. So really, the key is to eat healthier sources of omega 6, and much more omega 3 from foods like walnuts, chia seeds and fatty fish.
When I was taking flax oil, I wasn’t trained in nutrition as I am now, I was newly vegan and I wasn’t eating any fatty fish or much in the way of omega 3, plus I wasn’t taking any omega 3 supplements, which is important when you’re vegan. So, reflecting back on that, it’s no wonder I had trouble.
Another time when I’ve had problems with endo and flax is when I was using preground packets that just sat in my cupboard for months. This had likely gone rancid pretty quickly, making the flax more inflammatory, and again, was when I was newly vegan and low on omega 3.
So, if you similarly have assumed flax didn’t work well for you in the past – consider how you ate it, how much and how it was stored.
So, getting us back on track to using flax for constipation, as you can see, all of these caveats bring us back to starting low and slow, to see what agrees with you. The NHS actually recommend 10-15g of flax seeds per day for constipation, with an extra 150 ml water/liquid per 15g. 15g is about a tablespoon. Gut expert, Dr Megan Rossi, recommends building up to 2 tablespoons a day of flaxseed, so it’s up to you which route you’d like to take.
The important thing is you start with a smaller dose, perhaps ¼ or ½ tablespoon, increasing each week until you reach the full 10-15g or whatever dose you’re aiming for. If you notice negative symptoms, scale back to where you were comfortable at, and keep there and see if the constipation improves with just that dose. If you don’t experience increased bowel movements at the dose, you could try increasing again but this time, slower. If you’re still not getting on well with it, flax might not be a good option for you.
Also, remember, it can take a couple of days at the full dose for flax to get things moving, so be patient.
The best way to use flax for constipation is to grind it, but grinding fresh is healthier as flax is very vulnerable to oxidation from air, light, etc. which means it chemically changes. This lowers the nutrient status of flax and can cause it to go rancid, which will make it more inflammatory, when in fact, fresh flax is very anti-inflammatory due to its rich levels of antioxidants. Because flax goes rancid quicker, it is better stored in the fridge in an airtight container, and then you just grind it fresh in a coffee grinder each morning. You can get a coffee grinder on Amazon for about £15-£20.
If you know flax isn’t suitable for you, or you’re worried about trying it, you could try chia seeds. Chia seeds pretty much work in the same way as flax for constipation by bulking the stool and drawing in water to make a soft and slippery gel consistency. I tolerate chia seeds very well at low doses of 10g-15g every day – so chia could be a better option for some of you too.
Chia seeds, like many plant foods, are phytoestrogens, but they are much, much weaker than flax. It’s really flax and soy that are the strongest, and even then, they are weaker than real oestrogen.
The research on chia seeds for constipation is less than flax, but there is some out there and I’ve linked to it in the show notes.
Whilst we don’t have a definitive studied dose, of chia, 15g/a tablespoon would be a good, conservative place to start. Typically, 15g-30g chia seeds is considered a normal serving of chia anyway, so we wouldn’t really want or need to go higher than this, unless a specific recipe required us to.
Another reason I like to keep to conservative doses for both of these, is because if you have SIBO, lower FODMAP serving sizes can be helpful, especially with higher fibre foods, such as flax and chia. A low FODMAP serving of chia seeds is 24g, whilst 15g flax is low FODMAP, with 30g being considered high.
Whilst lowering FODMAP won’t be the cure for SIBO, it can help. However, some people with SIBO find flax and chia aggravates their SIBO, so you’ll really need to see what works for you, but typically, both of these are good options for the SIBO community.
Okay, that’s it for this week!
There are some other foods that are evidence based for constipation, so let me know if you’d like to hear about those too.
Show Notes
Flax research
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944250/
https://apjcn.nhri.org.tw/server/APJCN/29/1/61.pdf
https://www.nhstaysidecdn.scot.nhs.uk/NHSTaysideWeb/idcplg?IdcService=GET_SECURE_FILE&dDocName=PROD_338907&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1
Chia
https://onlinelibrary.wiley.com/doi/full/10.1002/fsn3.3035
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9739531/#B17-jcm-11-07073
Seed cycling
https://www.researchgate.net/publication/369913915_Advantages_of_seed_cycling_diet_in_menstrual_dysfunctions_A_review_based_explanation
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10261760/
Free resources:
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Ways to work with me:
This EndoLife, It Starts with Breakfast digital cookbook
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Live and Thrive with Endo: The Foundations DIY course
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Produced by Chris Robson