Endometriosis: Link to Constipation and Bloating

By Iris Kerin Orbuch, MD

Did you know that Gastrointestinal (GI) symptoms are as common as gynecological symptoms in women with endometriosis? Do you suffer from bloating and/or constipation? Endometriosis may be the cause of your bloating and/or constipation. Over 90% of women diagnosed with endometriosis actually present with GI symptoms as their initial symptoms. Before we delve into why women with endometriosis present with GI symptoms years before they are diagnosed with Endometriosis, let’s review some basic facts about Endometriosis. There is so much misinformation about endometriosis in media, so let’s set the record straight with facts about endometriosis.

What is Endometriosis?

Endometriosis is an inflammatory condition which occurs when cells similar to those found in the lining of the uterus (endometrium) are found external to the uterus. More specifically, it occurs when cells similar to endometrial glands and stroma are found in locations other than the lining of the uterus.

How many women are affected by Endometriosis?

Endometriosis is common affecting 176 million women worldwide. It occurs in 7-15% of women.

What are symptoms of Endometriosis?
The symptoms of endometriosis vary and can include all of the listed symptoms below, some of the symptoms, only one symptom in some cases, or no symptoms other than infertility.

Pelvic pain during menses, before menses, after menses and/or anytime during the month
Constipation
Bloating
Painful intercourse with deep insertion or certain positions
Right and/or Left sided pelvic and abdominal pain
Diarrhea
Painful bowel movements
Lower back pain
Heavy or irregular periods
Urinary frequency, and/or urgency, and/or painful urination
Fatigue
Malaise
Infertility

Symptoms of Endometriosis

The symptoms of endometriosis can be related to the areas where endometriosis invades. Endometriosis of the uterosacral ligaments/cul-de-sac often leads to painful intercourse, constipation, diarrhea and painful defecation. Endometriosis on the ovary can lead to left sided or right sided pain. Bladder endometriosis may lead to urinary frequency or urgency. You may have only one of the above symptoms or many. Even one symptom can be suggestive of Endometriosis. Many of women do not have any symptoms listed above, and only discover they have endometriosis when they are having trouble conceiving. If your doctor told you that you have ‘unexplained infertility’, endometriosis is the culprit in 40-50% of cases of unexplained infertility. Dr. Orbuchs’ surgical Excision of endometriosis decreases inflammation and can improve fertility.

Where is Endometriosis found?
Endometriosis has been reported in every organ except the Spleen! More commonly, endometriosis is found on the ovaries, bowels, bladder, uterus, cul de sac (the area in front of the rectum and behind the cervix/vagina and uterus), appendix, and abdominal wall. It also can occur on the diaphragm, lungs, surgical scars and less commonly throughout the rest of the body.

Treatment of Endometriosis

Laparoscopic surgery is the definitive method to diagnose and treat endometriosis. Excision of Endometriosis is the gold standard treatment for endometriosis. Ideally all endometrial lesions should be excised. Unfortunately most gynecologists are not trained in these advanced surgical techniques for treatment of endometriosis. Others approach endometriosis with laser, electrocautery, coagulation or burning. All of these modalities have been shown to be far inferior to excision using scissors, the method performed by Dr. Orbuch. With scissors, the endometrial implants are removed, but with cautery or a laser (the unskilled surgeons only superficially treat lesions), the lesion remains and continue to cause pain necessitating more surgery. A surgeon utilizing laser may vaporize the surface of the lesion, but still leaves active endometrial tissue below. Deep fibrotic endometriosis usually does not respond well to hormonal suppressive therapy. Drug therapy may suppress symptoms of endometriosis, but not eradicate the endometriosis. Adequate surgical excision of endometriosis implants provides the best symptomatic relief and long term results. In addition, surgical excision has been shown to improve fertility rates in women. The definitive treatment of endometriosis is NOT hysterectomy or removal of both ovaries; rather it is the complete excision of endometriosis lesions.

da Vinci Excision of Endometriosis

Advantages of Robotic Surgery

Robotic Surgery is an advanced form of Minimally Invasive Surgery. Minimally Invasive Surgery, which includes laparoscopic surgery, uses small incisions instead of large incisions to perform surgery thus reducing the damage to human tissue. The da Vinci System is a sophisticated robotic platform designed to expand a surgeons capabilities. With da Vinci, small incisions are used to introduce miniaturized wristed instruments and a high-definition 3D camera. This allows Dr. Orbuch to view a magnified, high-resolution 3D image of the surgical site allowing for superior visual clarity of anatomy with up to 10x magnification. At the same time, state of the art robotic and computer technology converts Dr. Orbuchs’ hand movements into precise small movements resulting in extreme dexterity. The robotic ‘wrists’ rotate a full 360 degrees that enable Dr. Orbuch to control the miniature surgical instruments with unprecedented accuracy with a wide range of motion. These technological advancements allow Dr. Orbuch to perform complex surgery with precision, dexterity and control. The da Vinci System enables Dr. Orbuch to perform more precise, advanced techniques and enhances her capability to perform complex minimally invasive surgery.

Risk Factors for Endometriosis
It is important to note that while the following risk factors increase one’s likelihood for endometriosis, there are many women who develop endometriosis without any of the following risk factors:

Family history, especially mother or sister. If your mom has endometriosis, you have a 7 times higher risk of developing endometriosis
Early menses
Early onset painful periods
Short frequent menstrual cycles
Mullerian abnormalities
No children
Autoimmune disorders (thyroid, rheumatoid, eczema, food allergies/sensitivities)

Endometriosis and GI Symptoms

Bloating is the most common presenting symptom, and is typically reported by 83% of women with endometriosis¹. 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 it². 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 woman 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.
Endometriosis must always be considered in the differential diagnosis of women with GI symptoms. Make sure that your endometriosis is treated properly–see my websites for more information: www.LAGynDr.com or www.nygyn.com or www.nycrobotic.com.

About The Author

Dr. Iris Orbuch is the Director of the Advanced Gynecologic Laparoscopy Center in Los Angeles and New York City. Dr. Iris Orbuchs’ practice is limited to Laparoscopic and Robotic Gynecologic Surgery, and is primarily a referral practice.

Her training, under the guidance of Dr. C.Y. Liu and Dr. Harry Reich — both pioneers in the field of advanced laparoscopic surgery — allows Dr. Orbuch to be one of a handful of physicians across the country trained to perform advanced minimally invasive procedures.

Dr. Orbuch provides both compassionate and individualized care while performing advanced laparoscopic techniques at St. Johns Hospital in Santa Monica, California. Dr Orbuch also operates at Lenox Hill Hospital, Mount Sinai and Beth Israel Hospital in New York City. Dr. Orbuch is board certified in OB/GYN.

Dr. Orbuch offers Gentle, Compassionate Care and a Personal Touch.

When you visit her office, you won’t find a rushed, impersonal environment. Instead, Dr. Orbuch and her staff are committed to providing personal, compassionate services to each and every client. Dr. Orbuch is devoted to helping women live a productive and pain-free life.

Dr. Orbuch specializes in pelvic pain and endometriosis. She understands that endometriosis is a major reason women experience pain, though she strives to assess for all additional co-existing generators of pain in order to help women live pain free productive lives.

Dr. Orbuch is a fellowship trained Endometriosis Excision Surgeon. She sees the value in addressing Endometriosis, an inflammatory and autoimmune disease, via eastern and western approaches. The cornerstone of endometriosis treatment is surgical excision of endometriosis, though she understands the importance of incorporating integrative medicine and combining eastern & western medicine approaches in helping her patients heal and getting them on the road to recovery.

References:

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

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical and occupational therapy?

Pelvic floor physical and occupational therapy is a specialized area of physical and occupational therapy. Currently, physical and occupational therapistss need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical and occupational therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical and occupational therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical and occupational therapists will take a detailed history. Following the history the physical and occupational therapists will leave the room to allow the patient to change and drape themselves. The physical and occupational therapists will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical and occupational therapists will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical and occupational therapists will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical and occupational therapists will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical and occupational therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical and occupational therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical and occupational therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical and occupational therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical and occupational therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical and occupational therapistss who work at PHRC have undergone more training than the majority of pelvic floor physical and occupational therapistss and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical and occupational therapistss focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical and occupational therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.