Endometriosis and Gastrointestinal Symptoms | Dr Iris Orbuch

Did you know that Gastrointestinal (GI) symptoms are as common as gynecological symptoms in women with endometriosis?  Over 90% of women diagnosed with endometriosis actually present with GI symptoms as their initial symptoms. Bloating is the most common presenting symptom, and is typically reported by 83% of women with endometriosis[1].  In addition to bloating, other gastrointestinal symptoms including diarrhea, constipation, painful bowel movements, nausea and/or vomiting are also common symptoms in women with endometriosis.  It is also interesting to note that GI symptoms are independent of location of endometriosis lesions in relation to the bowel.  This means that you can have GI symptoms without endometriosis actually infiltrating into the bowel.  Your endometriosis lesion may be nearby to your bowel without actually being on it[2].  It is nonetheless important to remember that for some women, endometriosis can often infiltrate the bowel, distort intestinal anatomy, alter normal bowel physiology, which then can also lead to constipation, bloating, painful bowel movements, diarrhea, nausea and vomiting.

Complicating matters, endometriosis can also present primarily with cyclical bloating and altered bowel habits indistinguishable from Irritable Bowel Syndrome (IBS)[3].  Many women seek help from a gastroenterologist and are subsequently diagnosed with Irritable Bowel Syndrome long before they seek help from a gynecologist.  Here’s a typical and unfortunate scenario…a young women suffers from constipation and bloating. What does she do? She schedules an appointment with a gastroenterologist.  What happens?  She undergoes an upper endoscopy and colonoscopy, both of which find no identifiable gastrointestinal abnormalities and is subsequently labeled as suffering from Irritable Bowel Syndrome (IBS).  Has this happened to you?  Despite treatments from their GI for IBS, women rarely get better—that’s because endometriosis is the cause of their IBS symptoms. It is therefore critical to establish the diagnosis of endometriosis in order to effectively relieve the gastrointestinal symptoms. Make sure that your endometriosis is treated properly through medical management or excisional surgery.  Endometriosis must always be considered in the differential diagnosis of women with GI symptoms.

Many women with endometriosis also suffer from Small Intestinal Bacterial Overgrowth (SIBO).  The association of SIBO and endometriosis probably occurs from systemic inflammation.  SIBO is a common condition, albeit under-recognized cause of gas, bloating, diarrhea and abdominal cramping.  Studies suggest that as many as 50-75% of patients with IBS have SIBO.  Since so many women diagnosed with IBS have SIBO, it makes sense to look for it in women with endometriosis. It’s easy to diagnose.  Just ask your GI to order a Lactulose-Hydrogen breath test.  It is not an invasive test and often can be done in your GI’s office.  This test measures hydrogen and methane gas levels once lactulose, a harmless alcohol-sugar, is given orally; elevation of these gases in the breath suggests bacterial overgrowth. The overgrowth can accompany inflammatory conditions such as Endometriosis, Interstitial Cystitis, chronic stress and many more conditions beyond the scope of this article.  The initial treatment of choice is Xifaxan, a non-absorbed antibiotic with rare (if any) side-effects taken 3 times a day for 14 days as well as dietary changes to decrease processed foods, complex carbohydrates and foods high in simple sugar.  Treatment is not a cure and many patients do require subsequent or adjunctive courses of antibiotics.  To determine if SIBO is eradicated, some GI’s may repeat the breath test about a month later or simply administer another combination of antibiotics. It is important to remember that while treatment for SIBO involves antibiotics and dietary changes, endometriosis is dealt with through both medical management and/or surgical excision of endometriosis.  After reading this article, it is my hope that you can find improvement in your GI symptoms.


[1] Maroun P, Cooper MJW, Reid GD, Keirse MJNC. Relevance of Gastrointestinal Symptoms in Endometriosis.  Australian and New Zealand Journal of Obstetrics and Gynecology 2009; 49: 411-414

[2] Malin E, Roth B, Ekstrom P. Gastrointestinal symptoms among endometriosis – A case cohort study.  BMC Women’s Health (2015)

[3] Luscombe GM, Markham R, Judio M, Grigoriu A, Fraser IS. Abdominal Bloating: An Under-Recognized Endometriosis Symptom. J Obstet Gynecology Can 2009:31(12): 1159-1171.