Unpacking the Links Between Endometriosis Bloating and Gut Health

• Endo-Belly|
• Gut Health|
• Diet|
• Supplements|
• Exercise|
• Pelvic Floor Therapy|
• Conventional Treatments|
• Summary|

Endometriosis is when tissue that is like the interior uterine lining (endometrium) grows outside the uterus and causes extreme pelvic pain [1]. 

It can also cause “endo-belly,” severe bloating that can add discomfort and affect body image and self-esteem.

Understanding the connection between the gut and reproductive system can help address endometriosis bloating. Let’s explore what endo-belly is and what research says about how endometriosis patients might relieve it.

What Is Endo-Belly and What Causes It?

Endometriosis bloating, or endo-belly, is a common but often unrecognized symptom of endometriosis. Over 80% of people with endometriosis experience it, so it deserves more attention [2].

Symptoms of endo-belly include painful abdominal bloating with significant swelling. The severe bloating may cause striking abdominal pain and tenderness that worsen throughout the day. Some of our clients with endo-belly report that by the evening, they look pregnant and can’t button their pants.

We don’t know exactly what causes people with endometriosis to have bloating and other common symptoms, like diarrhea, painful bowel movements, constipation, and nausea. In some cases, these issues may arise when endometrial-like tissue invades the intestines, as it does in bowel endometriosis. Estimates suggest that bowel endometriosis affects around 4–37% of people with endometriosis [3].

However, the more common type of endometriosis, which affects mainly the ovaries, fallopian tubes, and ligaments supporting the uterus, also correlates with bloating and digestive symptoms, even though it does not directly involve the gut.

For example, one observational study involving 355 women found that about 240 (83%) of the 290 confirmed cases of endometriosis had bloating. However, only around 8% of them had bowel endometriosis [2]. 

The bottom line: Endo-belly is pretty standard in those with endometriosis.

The Link Between Endo-Belly and Gut Health

There’s no conclusive answer as to what causes endo-belly in people whose endometriosis hasn’t invaded their bowels.

However, statistics show that endometriosis and related bloating overlap with irritable bowel syndrome (IBS). In fact, women with endometriosis have a two-to-threefold greater risk of having IBS [4]. The overlap between the two conditions can increase the risk of misdiagnosis, so a gynecologist or gastroenterologist needs a full history and list of symptoms to confirm.

Endo-belly and IBS may also have these possible root causes in common [5, 6]: 

• Chronic inflammation
• Abnormally sensitive pain receptors
• Increased mast cell activity
• Dysbiosis (more bad than good intestinal bacteria)
• Increased gut permeability, or leaky gut

More research has yet to help us understand the links between gut health, endometriosis, and endo-belly. However, given the established link between hormones and gut health, and the fact that endometriosis requires estrogen to occur, it follows that gut health and endometriosis may be tied together. 

From our experience in the clinic, improving gut health can reduce endo-belly bloating, which can help calm endometriosis pain. Therefore, tackling underlying gut health can make a big difference for people with endometriosis and endo-belly.

Dietary Changes to Help Endo-Belly

We don’t know which diet is best for endometriosis or endo-belly, but the following dietary patterns are associated with (but don’t necessarily cause) endometriosis: 

• Eating too much red meat and processed meat [7]
• Diets high in trans fats (processed fats in some takeout and other deep-fried or highly processed foods) [8]

If they do contribute to endometriosis—and therefore to endo-belly—it’s likely via inflammation. Inflammation can trigger and worsen endometriosis [9], which suggests that foods that create inflammation may contribute to endo-belly.  

On the other hand, a personalized anti-inflammatory diet that excludes your unique food sensitivities might dampen endometriosis and endo-belly symptoms. 

If you don’t yet know what foods inflame your system, a Mediterranean diet is an easy-to-follow anti-inflammatory diet to try. It reduces red meat and boosts anti-inflammatory foods, such as omega-3-rich oily fish, fruits, and vegetables [10].

If the Mediterranean diet doesn’t sufficiently improve endo-belly symptoms, eliminating gluten is a reasonable next step to try [11]. Feeling better without gluten could suggest a gluten sensitivity, which may trigger inflammation that worsens endometriosis symptoms.

The Paleo diet is a healthy version of a low-gluten or gluten-free diet that many of my clients have found helpful.

Those who don’t find sufficient relief with a Mediterranean or Paleo diet may have a wider set of food intolerances, which a low-FODMAP diet can help to identify. 

FODMAPs are fermentable oligosaccharides, monosaccharides, and polyols, or types of carbs that commonly impact people with gut issues, like IBS. They are found in a wide variety of healthy foods, including legumes, some fruits and veggies, and gluten-containing foods. In fact, FODMAPs so often accompany gluten that sometimes what appears to be gluten intolerance (NOT celiac disease) is actually FODMAP sensitivity [12, 13].

A low-FODMAP diet is restrictive and therefore not the one I’d recommend right off the bat, but it can be helpful for endo-belly. For example, one clinical trial found the diet might have improved both gastrointestinal and endometrial symptoms [14]. 

After following a 4-week low-FODMAP diet, 43 of 59 volunteers with confirmed endometriosis had half or less of the symptoms—including endo-belly—they’d had before. In fact, a low-FODMAP diet worked better for women with  endometriosis than those with IBS alone, so it may be worth a try for endo-belly.

Helpful Supplements 

Diets lacking certain nutrients can contribute to hormonal changes, gut dysbiosis, and inflammation, which are hallmarks of endometriosis and endo-belly. Selected supplements could therefore be useful for people with endometriosis who follow a restricted diet, like low FODMAP.

A randomized controlled trial looked at the effects of taking a multivitamin/mineral, fish oil, and a Lactobacillus/Bifidobacterium probiotic on endometriosis. After 6 months, this regimen was more effective than a placebo for relieving endometriosis-associated pain and improving quality of life [15]. 

The multivitamin/mineral supplement may have helped round out nutrients missing from the volunteers’ diets. The omega-3 supplement likely helped because of its anti-inflammatory effects [8]. Other supplements with anti-inflammatory properties that may reduce endometriosis symptoms include curcumin (the active ingredient of turmeric), quercetin, resveratrol, and methylfolate (vitamin B9) [16, 17].

But, of the supplements in that randomized trial, I would bet probiotics are the most helpful for reducing endometriosis pain and bloating. 

Probiotic Benefits

At the clinic, we rank probiotics so highly because they correct gut dysbiosis, which is more common in people with endometriosis. 

Studies where probiotics have reduced endometriosis pain used Lactobacillus species alone or combined with Bifidobacterium species [18, 19]. However, we get better results in the clinic by combining a Lacto/Bifido blend, a beneficial yeast (Saccharomyces boulardii or S. cerevisiae), and soil-based probiotics, according to the following protocol:

A triple-therapy probiotic regimen like this is available in these convenient powder sticks that don’t require refrigeration.

Exercise

The research on the effectiveness of physical activity for managing endometriosis bloating is limited and inconclusive. According to a systematic review of endometriosis and exercise, physical activity (such as aerobic exercise or hatha yoga) seemed to improve pain, stress, well-being, or self-image [20]. However, the quality of the studies wasn’t good enough to make any firm conclusions. 

Still, exercise has such widespread and anti-inflammatory benefits that it’s worth adopting into daily life and noticing whether endometriosis symptoms improve after a few weeks. 

Physical Therapy for the Pelvic Floor 

Some research shows that pelvic floor dysfunction may be common in people with endometriosis. 

For example, a small study of 30 women with endometriosis found that every participant had pelvic floor dysfunction, which manifested as pelvic floor muscle spasms. They also had myofascial dysfunction (pain and tightness in the connective tissue surrounding muscles) all over the body [21]. 

That observational research helped pave the way for researchers to test manual pelvic floor therapy for people with endometriosis pain and bloating, but the results have been inconclusive. 

Manual pelvic floor therapy, which requires a specialized physical therapist, addresses muscle and soft tissue issues that contribute to pelvic pain. If done properly, it relaxes the muscles, releases the fascia, and reduces discomfort. 

Manual pelvic floor therapy can also break down painful adhesions (scar tissue that binds internal organs together), which may occur in up to 82% of women with endometriosis [22].

One small clinical study showed that when women with endometriosis received manual (massage-based) pelvic floor therapy, they reported significantly better sexual function, less pain during sex, and less pelvic pain during menstruation [23]. 

However, a recent randomized controlled trial (which is a stronger study) found that a different type of pelvic floor massage had no impact on sexual, urinary, or bowel functions in women with severe endometriosis [9]. 

The important takeaway is to expect that pelvic floor therapies may vary and help with some but not all aspects of endometriosis. 

But if you get relief from manual pelvic floor therapy, it could help reduce endo-belly. 

Conventional Treatment Options

Conventional options for pain management typically include standard nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen, with or without hormonal contraceptives or synthetic progesterone [24]. Unfortunately, these address only symptoms—not the root cause—and they may not prevent symptoms from getting worse over time. Also, NSAIDs don’t address endometrial bloat directly and may lead to further gut dysbiosis as a side effect [25]. 

There is nothing wrong with taking NSAIDs to get you through the most painful bouts of endo-belly or other symptoms of endometriosis. But incorporating an anti-inflammatory diet, probiotics, and exercise may help reduce your need for painkillers.

Conventional approaches for those who don’t respond well to pain meds and hormones might include a trial of a medication that suppresses the hormones that fuel endometriosis, or surgical removal of endometrial tissue (laparoscopy). And in the most severe cases, a doctor may recommend removing the ovaries (oophorectomy) with or without removing the whole uterus (hysterectomy). 

When searching for relief, the important thing is not to suffer in silence. If self-help isn’t enough, talk to a gynecologist and see what options are open to you.

Ending Endo-Belly Starts With Healthy Habits 

At its heart, endometriosis is an inflammatory condition. Dietary and lifestyle changes designed to reduce inflammation can help reduce painful endometriosis and endo-belly.

With our endometriosis clients, we start by identifying a gut-healthy, anti-inflammatory diet and tailoring it to their needs. We then support gut health with probiotics, and further reduce inflammation with regular exercise. Often, this approach has lessened the pain within a few menstrual cycles.

If you are struggling with endometriosis, you can always reach out to consult with one of our clinicians at the Ruscio Institute. It’s always a joy when we get to empower people with the knowledge they need to navigate their endometriosis or any other women’s health challenges. It also pays to have regular visits with your gynecologist to maintain an integrated approach.

The Ruscio Institute has developed a range of high-quality formulations to help our clients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you. The information on DrRuscio.com is for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment.

Dr. Michael Ruscio is a DC, Naturopathic Practitioner, researcher, and clinician. He serves as an Adjunct Professor at the University of Bridgeport and has published numerous papers in scientific journals as well as the book Healthy Gut, Healthy You. He also founded the Ruscio Institute of Functional Health, where he helps patients with a wide range of GI conditions and serves as the Head of Research.