EP.162/ What's a Healthy/'Normal' Gut vs. What's Endo Belly?
This week’s episode is a snippet from my upcoming course, The Endo Belly Course.
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I realised when creating this lesson, that this information is info everyone should know, not just my students! So today’s episode is all about what’s a ‘normal’ and healthy gut vs. what is the endo belly?
So first up, I wanted to actually talk about what the endo belly is.
The ‘endo belly’ is not actually a medical term, but instead is a name the community has coined in reference to the severe bloating we often experience. So, there isn’t technically a set definition, but it is generally thought to be severe bloating/swelling that tends to be attributed to endometriosis and is sometimes accompanied by pain. Some experts, articles and endo patients also include gut problems within this term too, but not always.
My definition, from my training and from seeing so many clients with these symptoms is that the endo belly is exaggerated/severe bloating, often accompanied by gut symptoms, pain or discomfort - but it is not always caused by endometriosis directly.
So here are some of the common symptoms I see in my clients and that I tend to think of as fitting under the term ‘the endo belly’:
Flares up with stress/food/pain/cycle - but not always, this might just be a daily thing for you.
Normally comes with IBS issues like diarrhea, constipation, abdominal pain, gas. These might not be flares, but more so just your daily bowel habits and gut issues. So, for example, you may tend to always lean towards constipation or loose stools, or you may have a lot of gas on a daily basis.
It’s often debilitating - so it may disturb social life, diet, work, or confidence. You might worry about eating out because you’re scared of a flare up, you might have to eat a restricted diet to control symptoms, you might have to sometimes take sick days, or you just struggle at work with your symptoms. It’s not as simple as just feeling a bit bloated after lunch.
Normally a dramatic increase in abdominal size - endo patients often report looking pregnant, requiring different sized clothing, having swelling that’s so bad they’re in pain.
And finally, I just want to note - some sources discuss the endo belly swelling being lower down in the abdomen and that IBS issues are higher up, but I think the problem with this is that it’s not true for everyone and it might mean you dismiss any other possible causes because you think “Oh it’s low down, it’s just my endo”. I’ve seen lots of people with SIBO and endo, whose bloating is from their diaphragm all the way down or starts from their belly button and goes down to their pubic bone, so I really wouldn’t pay a huge amount of attention to where the bloating is, unless of course you’re just getting a tiny bit of bloat or a bump on say one side near your ovaries, which might indicate a cyst, for example.
So, something I really think is important to discuss is what is normal vs. what is endo belly, because I don’t want us to be trying to reach for an unattainable vision of a healthy gut.
So here are some signs of the endo belly/something more is going on with your gut…
Bloating and gut problems get worse and worse as day goes on. You get more uncomfortable, maybe your pain increases and by your last meal your stomach has swollen to triple its normal size.
Symptoms can only be controlled through restriction - a ‘normal’ diet can’t be achieved, and you find yourself skipping meals or having to restrict to avoid flare ups.
Often can no longer fit into clothes or need to change to be comfortable when your belly swells up because it’s become so distended. In short, the bloating is severe and significant.
May be accompanied by other health problems and nutrient deficiencies like achy joints, fatigue, low B12 or low iron. These are signs of inflammation and malabsorption of nutrients.
You might get constipated before period. From a functional medicine point of view, which is what my training is based on, you should have at least one daily bowel movement, and this is actually really important for hormonal health, because old oestrogen is excreted through waste and that needs to occur daily. However, in contrast, dieticians and conventional doctors tend to take a different stance and say whatever is normal for you, is normal or at least three times a week. In terms of my training with Dr Allison Siebecker, Dr Jessica Drummond, etc. we would consider that as constipation, basically anything that is not once a day, is leaning towards a form of constipation. It might be considered normal, but we wouldn’t class it as optimal for health.
Diarrhea on period which causes abdominal discomfort, eating problems (maybe you have to avoid food or eat a restricted diet), affects daily life (you might not be able to have a normal workday because you’re stuck in the toilet), sicks days, etc.
Often affects daily life/confidence because you’ve been asked so many times whether you’re pregnant, you get comments or you just feel fed up with not being able to wear the clothes you’d like. Additionally, your gut symptoms are affecting your daily life, so for example, I had a client who would get several bouts of loose stools every morning, to the point where she would sometimes be late for dropping her child off to nursery. Another client wouldn’t be able to finish meals without needing to dash to the toilet.
Wake up bloated already or with gut problems/sleep is disturbed due to discomfort. So, I had one client who had a distended belly all the time, and it was so bad she actually got to the point where it was too painful to sit or stand up, she had to lay down all the time. Another client wouldn’t be able to sleep because by the evening, her belly was so bloated she couldn’t get comfortable, and she’d be in agony from all the gas inside her.
So, in contrast, I wanted to talk about what is normal for a healthy gut, and some of this might surprise you -
Feel satisfied after eating, not overly full or like food isn’t going down. Of course, if it’s Christmas or Ramadan you might be feasting on more food than you normally would, so of course sometimes you’re going to feel full to bursting, but generally, you should feel like you’re able to digest your food and like it’s going down. It’s not just sitting there for hours afterwards.
May be a bit bloated or gassy after meals (esp. high fibre. or large meals), but the bloating should subside a few hours later and it’s not accompanied by GI distress. This is because our good gut bugs actually eat our food and ferment it, as part of the digestion process. We actually need this to happen to get all of our nutrients. But a result of this process is the creation of gas from the bacteria, and so naturally we will get a bit of expansion after a meal and of course, we’re putting food into our stomach, you wouldn’t expect to fill an empty bag with food shopping and for it not to expand or look bigger. So, there will be some extension of your abdomen after meals, but it shouldn’t be painful, be accompanied by GI distress, be severe or worsen as the day goes on. It should naturally go down and not affect your life or comfort. Additionally, so you know, according to the NHS, a normal amount of passing gas is about 5 to 15 times a day.
You should wake up with a relatively flatter stomach in contrast to after meals. This is because your digestion has been working overnight. Now note I don’t say your stomach should be flat in the morning, it will be flatter in contrast to after meals, because you haven’t eaten in something like 10 or 12 hours.
And to follow on from that, a normal healthy gut doesn’t mean your stomach is flat all the time. Your stomach shouldn’t be flat all the time, it should naturally expand a bit with food!
Bloating tends to increase towards period and in luteal phase, but it shouldn’t be severe/painful/debilitating. This is because progesterone and oestrogen affect water retention, and so bloating and swelling can increase towards your period when progesterone is at its highest. Now if your hormones are imbalanced, this will be worse, so supporting your hormones (which this course will help with) should minimise the effects, but they won’t eradicate them entirely. Additionally, those inflammatory chemicals, prostaglandins, naturally begin building in the uterus from ovulation to your period, and as we know, inflammation creates swelling, so there may be some level of normal swelling during this time, but again, it shouldn’t be severe. If it is, this may be an indicator that your inflammation levels are too high, which is likely to be the case anyway, given that the endometriosis lesions release prostaglandins. Lastly, progesterone relaxes muscles, including the muscles of the intestines, so as a result, digestion slows down, meaning things become a bit sluggish and we get a bit more of a build-up of gas and waste, leading to a bit of bloating - again, it shouldn’t be severe.
Bowels might feel a bit sluggish towards period but shouldn’t have full-blown constipation or if you do have any, it should at least short lived, so a day or so, for example. Or maybe your stools are a little harder or more cracked than normal.
In contrast, it’s normal to have bowel movements that are looser during your period. This is because those prostaglandin E2 causes the muscles to contract, and as your uterus is right next to your colon, this can create contractions in the colon, resulting in a bowel movement and looser stools. If your inflammation levels are high, you may get full blown diarrhea, and that’s when we’ll want to reduce those levels. Ideally, a normal scenario is maybe more bowel movements which are a bit looser on your period, but they shouldn’t be causing you pain or affecting your day-to-day life during this time.
Bloating after meals doesn’t require a new dress size!
Image from Integrative Women’s Health Institute
To show you what a healthy stool looks like, here is the Bristol Stool Chart. This is a diagnostic tool used to determine the health of stools, especially in IBS populations. In terms of functional medicine training, at IWHI we aim for a 4, so your stools should be snake like, smooth, easy to pass with a banana-like consistency. You should be having one to three bowel movements a day, one is the minimum because for optimal health and hormonal health, we want to removing waste on a daily basis, including old oestrogen, to prevent hormonal imbalances.
Now, dieticians and conventional medicine will likely say to aim for somewhere between a 3-5. In terms of my training, we see 3 as beginning to lean towards constipation and 5 beginning to lean towards diarrhea. This is something that we focus on heavily with SIBO, a lot of people think that they don’t have constipation, or they don’t have diarrhea - but these bowel movements actually exist on a spectrum. Stools that are like pellets, hard and round, or difficult to pass, is a form of constipation. In my training, anything before 4 is a form of constipation and above 4 is a form of diarrhea or loose stools. They don’t show pudding like stools here, but I would consider that as form of diarrhea. However, opinions will vary as I have mentioned, so be guided by what feels best for you.
The caveat here is that if you are vegan and eat a lot of plants (not processed vegan food), you may have softer stools, nearer to a 5, so I wouldn’t worry too much about that. The other thing I would say is don’t chase perfection, which I’ve been guilty of. When my IBS was the most managed it’s ever been (at the time of recording it’s not, because I’ve had a SIBO relapse), my stools were about a 5 but I was very caught up on getting them to a 4! So, if your endo belly dramatically improves, if you get an all clear for gut conditions, etc. but sometimes your stools are a little either side of type 4, this is probably not something to worry about. It might just be that you ate a little more or a little less fibre that week, or maybe that’s just your normal. If you’re concerned about it, certainly see a gut health practitioner, but I just wouldn’t obsess about it that’s the only issue left and there are no other signs that something is up with your gut.
Just to finish off this section, I want to hammer this home. A super flat stomach does not equal a happy gut - in fact, it sort of suggests that the gut microbiome is under fed or non-existent, because for them to thrive, they need to eat food and as a result, that creates gas.
So, we’re not aiming for washboard abs all the time, we’re aiming for gut health that doesn’t affect your daily life, cause you pain or physical/mental/emotional distress.
Show Notes
https://www.siboinfo.com/symptoms.html
https://www.endofound.org/endo-belly
https://drseckin.com/endo-belly/
https://www.nhs.uk/conditions/irritable-bowel-syndrome-ibs/symptoms/
https://www.nhs.uk/live-well/eat-well/remedies-for-bloating-and-wind/
https://nutritionstripped.com/is-bloating-normal/
https://www.nhs.uk/conditions/flatulence/
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.xm
https://nicolejardim.com/howyourperiodaffectsdigestivetract/
https://pubmed.ncbi.nlm.nih.gov/16992446/
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