A Woman's Guide to a Healthy Stomach

Changes in bowel habits during menstruation are reported by many women (34 percent in one study), and the symptoms are cyclical in almost 30 percent of women. At the time of menses, gastrointestinal complaints that women report are increased gas (14 percent), increased diarrhea (19 percent), and increased (11 percent) and decreased (16 percent) constipation.

One big tip—get enough calcium! A calcium supplement with vitamin D helps ease some symptoms of PMS. If you’re between the ages of eighteen and fifty, you need at least 1000 mg of calcium per day. If you’re older than fifty, you need 1200 mg. Eat plenty of fruits and vegetables, and get enough whole grains. Avoid alcohol and caffeine. They’ll exacerbate your troubles.

For the bloating, try enteric-coated peppermint capsules before meals, although if they cause heartburn, you should stop. Loperamide (Imodium, one half to two tablets) could help treat or prevent the diarrhea, though too much can cause constipation. Pepto-Bismol is also worth a try—two tablespoons or tablets up to four times per day. Remember your stool and tongue may turn dark or even black after using it, but this is a harmless side effect.

I’m going to have a hysterectomy, and I’m worried that it might affect my bowels. I am already somewhat constipated. Will I get worse?

Probably not. Chronic constipation after a hysterectomy, unless it is an extensive operation for cancer, is not common. One study reported less frequent bowel movements, more laxative use, harder stools and constipation after hysterectomy, but this was not statistically more significant than in women who have not had hysterectomies. In more recent studies, no increase in constipation occurred in women without GI symptoms who underwent a hysterectomy. Furthermore no increase of IBS occurred after a hysterectomy in women without GI symptoms before surgery. Overall, movement of the stool through the colon does not change as a woman gets older, but the signal to let you know the stool is waiting to come out does decrease with age, unfortunately.

Can endometriosis come back?

Unfortunately, the likelihood that endometriosis will return is high. Five years after a patient has stopped medications to treat endometriosis, the recurrence rate is over 20 percent. Endometriosis and the pain associated with it can even recur after a successful ablation (cautery) or hysterectomy. The recurrence rate after surgery is higher when the ovaries (even one) are left or the endometriosis was severe, in which case it recurs in 30 to 47 percent of women. Of over eleven hundred women who had endometriosis diagnosed by surgery and who responded to a 1998 Endometriosis Association survey, 42 percent underwent surgical procedures for endometriosis at least three times.

You always have to be aware that recurrence is a potential problem. A cure of the endometriosis can only be assured if all estrogen, which can stimulate the endometriosis, has been removed. This occurs if a woman has both of her ovaries removed or goes through menopause. However, if one ovary is left behind after endometriosis surgery to prevent a woman from getting hot flashes or other symptoms related to menopause, the endometriosis can continue to be stimulated.

This problem often goes unrecognized. Women are told that they had a hysterectomy and that should “cure” the endometriosis. Not always! They don’t know that a hysterectomy can involve removing only the uterus or removing the uterus with one or both ovaries. If you switch to a new physician, it’s important for him or her to know right away what kind of hysterectomy was performed.

One such blunder happened with Susan, a forty-one-year-old woman who came to me with abdominal pain and diarrhea. Susan was a tough lady: a survivor of child abuse, she acted largely as a single mother to her handicapped son and her daughter while her husband traveled on business. She also worked full-time in a doctor’s office. An avid athlete, she’d begun to curtail her activities because of her bowel problems, and her weight was fluctuating wildly. “I’m no use to anyone,” she cried on our first meeting. “I feel like I’m in the twilight zone.”

She was referred to me for a second opinion regarding her diagnosis of Crohn’s disease. (Crohn’s disease is a chronic inflammatory bowel disease. Crohn’s can affect any part of the GI tract, and symptoms vary by patient depending on where the inflammation occurs. Symptoms can include constipation, diarrhea, abdominal pain, vomiting, weight loss or weight gain, and gastrointestinal bleeding.)

When I met Susan, she was clearly at a low: She’d have just a sip of water, then suffer diarrhea. She was having six to ten yellow, watery bowel movements every day, in spite of taking Imodium daily. Plus, she often woke up with fevers, which caused headaches and confusion. She was still able to work as an office manager at the doctor’s office, but her weekends were consumed with sleep. Her eyes were inflamed, and her back was afflicted with arthritis. She also had hip, neck and leg pain, as well as sores in her mouth and a sore on her neck.

Susan had developed abdominal pain, rectal pressure and cysts in one of her ovaries after a hysterectomy for endometriosis a few years prior. She was treated with a large amount of Anaprox (a nonsteroidal anti-inflammatory drug like aspirin) for pain. She tried to tell doctors that the rectal pain reminded her of how she felt before her hysterectomy, but they brushed it off.

Shortly thereafter, Susan began to experience bloody diarrhea. She was admitted to her local hospital. A colonoscopy showed inflammation in her rectum at the end of her colon, and she was told that she had ulcerative colitis. She was treated with a steroid, prednisone, which has many possible side effects, such as diabetes, acne, and weight gain with short-term usage and bone loss and cataracts with long-term usage. Susan’s symptom complex of abdominal pain, rectal pressure or pain and frequent stools occurred almost monthly. She was taking up to nine medications per day and still having a minimum of six bowel movements every day, too. She was also seeing an array of doctors, including a rheumatologist and an ophthalmologist, for side effects brought on by the steroids. Her weight was also fluctuating between 110 pounds (without steroids) and 150 pounds (with steroids). The steroid was eventually tapered down and stopped, and Susan was changed to a nonsteroid compound. She did well for a while, until she developed diarrhea, a whopping twenty-five times per day. She was treated with steroids yet again, despite the fact that she didn’t even have colitis and had experienced side effects previously.

“I now have eye inflammation, arthritis and decreased calcium in my bones,” she told me at our meeting. “Both specialists, a rheumatologist and an ophthalmologist, say it’s from all the steroids and various other drugs. I am seeing a total of six doctors! Why can’t I get better? The steroids are killing me. Still, I take them, then taper. My weight is going up and down. My old GI doctor is insisting that I have to comply and take the drugs. I tried to ask if it was endometriosis, but he’s insisting it isn’t.”

Susan was somewhat lucky; thanks to her medical background, she knew what kinds of questions to ask. Still, she was seeing so many doctors and taking so many different medications that it was tough to get a clear picture of what was going on. And her doctor had overlooked the strong possibility of endometriosis, which I began to suspect.

I carefully considered her family history: a mother with breast cancer; two aunts with endometriosis, breast cancer, colon cancer and ovarian cancer; another with uterine cancer. Susan also had six older brothers, one of whom had Crohn’s disease and another who had adult-onset diabetes mellitus and obesity. Susan herself had suffered from irritable bowel syndrome as a teenager.

Her examination was normal, save for a dark, raised round area on her neck and slight tenderness on the lower left side of her belly. Her blood tests showed borderline anemia. A repeat colonoscopy and upper endoscopy with samples of the bowel lining were completely normal. She was also tested for gluten allergy and did not have it. A review of the original rectal biopsy, when she was first hospitalized with bloody diarrhea, was consistent with an episode of infection.

These findings suggested that Crohn’s disease was unlikely to be the cause of Susan’s symptoms. Further history revealed that Susan always developed diarrhea whenever she was given the antibiotic clindamycin; not surprisingly, she had received clindamycin before dental work in the past, possibly just before the bloody diarrhea. Prior to her hysterectomy, she experienced rectal pressure, and around her menstrual period she would have diarrhea lasting up to eight days. The rectal pressure and diarrhea both resolved after surgery.

Because I really didn’t think that she had Crohn’s disease, I stopped all her medications. Off all meds, Susan reported that her diarrhea occurred up to six times per day after eating, three to four days out of the month, and was usually controlled by Imodium—a definite reduction from her previous bouts.

An abdominal CT scan was done one month after her second appointment, after all the records had been reviewed and the endoscopic procedures completed. This showed only a 2-by-2.5-centimeter round mass in the pelvis, close to the abdominal wall, the exact location where Susan felt her lower abdominal pain and where an ovarian cyst was found in the past.

Endometriosis as the cause for all her inflammatory symptoms was very unusual. Yet because Susan didn’t appear to have Crohn’s disease and was doing well off all medications, and because the CT scan showed an abnormality where Susan complained of pain, I referred her to a gynecologist who specialized in endometriosis. He performed laparoscopic surgery, which revealed a hemorrhagic ovarian cyst and scar tissue. The doctor didn’t see endometriosis, though. He thought the pain was due to the ovarian cyst and the scar tissue. He drained the ovarian cyst and cut the adhesions. Her abdominal pain improved after surgery.

However, seven months post-surgery she began to develop severe left lower abdominal pain monthly with what she thought was ovulation. The pain was accompanied by sores in her mouth and fever. She continued to develop ovarian cysts, which would rupture. She had cramping abdominal pain at other times (different from the monthly ovulation pain), which she controlled with dicyclomine hydrochloride, an antispasmodic drug.

Her gynecologist started her on Loestrin, an oral contraceptive pill, to try to suppress ovulation. However, she could “feel” ovulation and did not think it had been suppressed, even though her diarrhea decreased. To treat the irritable bowel syndrome with which she had been diagnosed as a teen, she was started on the tricyclic antidepressant desipramine, which is helpful for decreasing abdominal pain and diarrhea.

But two years later she again developed severe lower left abdominal stabbing pain and fevers. Her blood pressure spiked to 146/96, and the Loestrin was stopped. (Hormones will increase your blood pressure at times.) A pelvic and abdominal exam showed tenderness on the left side, in the area of the ovary.

Susan’s gynecologist performed yet another laparoscopy. Endometriosis was buried in the adhesions that were found. At that time, because of all her symptoms, the gynecologist removed both ovaries and tubes. Now, more than two and a half years after surgery, she has had no further abdominal pain or diarrhea. “I’m cured,” Susan told me recently. “I have begun traveling again and exercising. I eat what I want when I want. I feel like a normal human being, and I’m a mom to my children.” She thanked me for listening to her when no one else would.

If your ovaries are left at the time of surgery, endometriosis can come back. Women should discuss having their ovaries removed with their gynecologist, because doctors will often leave an ovary to prevent the menopausal symptoms that can occur after the ovaries are removed. If you have already had the children that you would like to have, removal of both ovaries may be a good option.

Why did Susan have to suffer for so long? Why was she misdiagnosed? The doctors didn’t listen. Or, if they did, their preconceived notions did not allow them to ask the right questions and think outside the box. Perhaps they weren’t knowledgeable about some of the side effects of medications, or perhaps they weren’t knowledgeable about endometriosis. Either way, Susan was treated with the wrong medications—medications that caused a substantial number of side effects. Prednisone could have caused her osteopenia (bone loss), joint pain, weight gain, high blood pressure and possibly the skin infections. Her doctor almost put her on Remicade—a potent drug that suppresses an inflammatory substance called tumor necrosis factor.

Importantly, medications given to Susan by physicians played a major role in Susan’s gastrointestinal illnesses. The Clindamycin, an antibiotic, likely caused the bloody diarrhea by inducing a Clostridia difficile infection, which was responsible for the bloody diarrhea. Nonsteroidal anti-inflammatory medications (NSAIDs), like aspirin, ibuprofen and naproxen, can also cause colitis. It would appear that one physician did not know what another physician had done. Susan tried to ask the right questions. She was more knowledgeable than most women, since she worked in the medical field. However, she wasn’t calling the shots—her doctors were. And her questions were rebuffed.

For doctors, it’s an easy trap to fall into. Once a diagnosis is given, it is often difficult to get that diagnosis changed. It’s often easier to fit symptoms into that diagnosis if they seem to “mostly” fit rather than embark on an evaluation for a possible new diagnosis. When all the results don’t fit—like in Susan’s case—a new way of looking at the old and new problems has to happen. Susan tried to foster that way of thinking. However, the sicker she became and the more she was told she had to live with her problems, the more despondent and hopeless she grew. Some of her symptoms were not typical for endometriosis, and this led her doctors astray. Susan was misdiagnosed and on drugs she shouldn’t have been on, and that caused side effects. I was at least able to correct the Crohn’s misdiagnosis, take her off unnecessary drugs that could have caused substantial side effects and refer her to a doctor who could take care of her problem.

The moral of this story is be vigilant—you know your body best. If something feels wrong, say so. If you’re left with more questions than answers after a doctor’s visit, speak up. Get a second opinion.

WHAT YOU NEED TO KNOW ABOUT ENDOMETRIOSIS:

 1. Endometriosis is a condition in which the lining of the uterus takes up residence outside of its proper location.

 2. It is common in women.

 3. It often mimics common gastrointestinal conditions, such as irritable bowel syndrome.

 4. Many health-care providers are not adequately informed about endometriosis. Be your own advocate—ask whether you could have it.

 5. It is difficult to diagnose with standard radiology tests and often requires an examination with a scope inside the pelvis or abdomen (laparoscopy).

 6. There are both medical and surgical treatments for the condition, but recurrence is high if a woman still has her ovaries.

 7. It is associated with an increased difficulty to conceive, but endometriosis seems to improve during pregnancy.

Chapter 3

“Do These Pants Come with an Elastic Waist?” The Truth about Gas, Bloating and Irritable Bowel Syndrome

“My philosophy on dating is just to fart right away.”

—Jenny McCarthy

This chapter chronicles what happens when we can’t fit into our pants, when gas escapes at inopportune times, when we have to beeline for the bathroom during an important meeting. We’ve all been there. But why does it happen? And, you’re asking, why does it happen to me? After all, body odor is repellent, bizarre and unpleasant—especially for women. She might be gorgeous, smart and hilarious, but if she smells strange, well…all bets are off. Men, on the other hand, are sometimes allowed to smell rugged and musky. Guys work out and smell “ripe,” and that’s okay, maybe even alluring. Not so for women. So pity the poor woman who does suffer from regular flatulence. This is a mortifying situation, leading to low self-esteem and isolation, or at least complete humiliation.

In this chapter we’ll meet Elizabeth, a thirty-seven-year-old art student who went to dozens of doctors in her quest to figure out why she was, in her words, a “gas factory.” Her story is representative of those of many women I see—IBS can destroy a woman’s life. By the time I met her, Elizabeth’s sex life was lousy, her self-esteem was shot, and she’d been spending money running from specialist to specialist, who prescribed everything from antidepressants to antispasmodic drugs, when indeed she had irritable bowel syndrome. She was beginning to think she was crazy.

Elizabeth hardly seemed like a crazy, smelly woman: fragile and birdlike, weighing just one hundred pounds, she was pursuing a graduate degree in sculpture, which had been consistently derailed thanks to her ongoing stomach issues. By the time I met her, she had quit school and couldn’t work. She told me that she had been “gassy” for as long as she could remember. She grew up in a traditional Asian home, where she suffered from frequent abdominal pain and the inability to control her gas. Her parents were mystified and ashamed—gassiness, in their opinion, was not an especially feminine trait. Her dad took to addressing her as “You, smelly girl!” and went so far as to tell her she mustn’t be a girl, since she passed so much gas. “No man will ever want you like this,” he told her.

Of course, this instilled a deep sense of unworthiness and translated into difficulty in intimate relationships. She spent her high school years isolating herself for fear of rejection. “I feel like my childhood and formative years were spent in the bathroom or in search of a bathroom,” she told me when we first met. She also experienced a great deal of pain on a daily basis, which prevented her from connecting emotionally and participating in activities with her peers. Elizabeth’s life, it seemed, had been defined by an ongoing waltz of pain and shame.

Elizabeth was seen by a physician, who brusquely told her to take a tranquilizer and see a psychiatrist. The psychiatrist helped her cope with some of her emotional baggage, but the sessions did nothing to relieve her symptoms. And what awful symptoms they were. She had severe, often debilitating pain and cramps in the abdomen and severe rectal spasms. These gave her the feeling that she needed to run to the bathroom to pass stool or gas, even if there was nothing to pass. She would end up in the bathroom all day, almost every day. This rendered her more or less housebound.

“Every day my main concern is, ‘Uh-oh, do I have to run to the bathroom? Can I leave the house for ten minutes?’ Wherever I go, I need to make sure I have easy access to a bathroom. At lectures I can hardly focus on what’s going on. I’m plotting my escape route. Or else I show up late because I’ve been in the bathroom,” she told me. At night she’d bolt awake with severe pain and rectal spasms, often spending hours on the toilet.

“I have trouble holding onto relationships because of this,” she said wryly. “But I have great relationships with every bathroom in town.” She did have a long-term boyfriend, but he was beginning to get fed up, too. It was hard for him to enjoy going anywhere with her when she was so clearly filled with dread about leaving the house. “I’m constantly preoccupied, and he’s angry,” she said. “My quality of life is in the gutter. My boyfriend is getting annoyed, and I’m not getting any sympathy from physicians. They think I’m exaggerating. It makes me not want to be around other people at all.” She had begun to feel completely desexualized and had stopped having sex entirely. I felt immense empathy for this young woman whose life had clearly ground to a halt.

When I first met her, she was being treated with the antispasmodic medications belladonna and phenobarbital. She said the belladonna and phenobarbital helped a little, but only if she was not under stress. Stress made all her symptoms worse. Without the belladonna, she felt like she was a gas factory. She had to belch or “fart,” or she would get a pressure in her stomach and lower belly. “I know how bad I must smell,” she admitted to me.

Elizabeth was also coping with heartburn, despite the fact that she wisely avoided coffee, onions, mint and other irritants. Even a few bites of a totally bland food, like pudding, would make her feel full and give her heartburn. I suspected IBS and supplemented her medications with Pepto-Bismol, and for her heartburn she was given a prescription for pantoprazole, a proton pump inhibitor that stops acid. With some relief, she left my office.

Over the next month her upper abdominal pain and heartburn improved. However, in spite of the belladonna and phenobarbital, she had rectal pain that occurred throughout the day, lasting up to two hours at a time, which was debilitating. This was affecting her ability to take classes. A few minutes into a lecture she’d feel like she had to run to the bathroom. On the toilet, she might or might not have a bowel movement, but in either case the lower abdominal pain would not go away. I increased her phenobarbital with belladonna to four times per day. Because she still had severe rectal spasms, I tried adding an additional antispasmodic, hyoscyamine sulfate, which she could take as needed.

Over the next six months, her medications were modified. The belladonna and phenobarbital were changed to a long-acting hyoscyamine (Levsin), which would not make her sleepy or tired. Elizabeth continued to improve, with fewer episodes of pain. But when she was in pain, it was severe—she would remain in bed, unable to walk. Tricyclic antidepressants have been shown to help IBS pain, so I suggested she use a tricyclic antidepressant, Elavil (amitriptyline), in a low dose at night. (Studies have also shown that when anxiety or depression is treated, IBS will improve.) With the addition of Ativan (lorazapam) and Lamictal (lamotrigine) by her psychiatrist, her abdominal pain improved even more, although she did have some constipation as a side effect of these medications.

Despite some constipation, her quality of life continued to get better. The intensity of her cramping was much less, and she was able to do more. She still suffered from abdominal tenderness, but it didn’t get any worse. I upped her Elavil even more, and her pain became more and more bearable. In the past she’d spend two hours on the toilet in the morning; this dwindled to just a half hour. Still, gas would return whenever she felt stressed, and she remained embarrassed about her odor, which she described to me as “silently fatal,” particularly when she drank milk. Suspecting bacterial overgrowth (too many bacteria in her small intestines, which can result in abdominal pain and gas), I put her on a short course of tetracycline in addition to her other meds. (Tetracycline has been the traditional first choice of antibiotics for bacterial overgrowth, although rifaximin has fewer side effects and has been shown to help reduce gas and bloating. Unfortunately rifaximin is expensive and is not usually covered by most insurance plans until tetracycline fails.) To try to change the resident bacteria with new ones, I started her on a probiotic once the antibiotics ran their course. She also started drinking soy milk instead of cow milk. Elizabeth remained on the combination of medication that was helpful for her IBS, heartburn and anxiety/depression.

Today she says she feels a million times better. “After seeing Dr. Wolf, my symptoms didn’t get better overnight, but at least emotionally, I felt that finally somebody was taking me seriously and not just writing me off as a hypochondriac. She started me on a set of medications to help me reduce my symptoms so that my daily life is not torture. My cramps used to be so bad, I’d break into a cold sweat. I couldn’t talk. I’d be balled up in the corner of the cardio area in the gym for hours. Now that’s not quality of life. But now it [the pain] is not that extreme. I feel a lot less embarrassed about being outside and being around people. I can function.” In fact, she’s now trying to finish her degree, and she hopes to get pregnant. “Instead of IBS managing me, I’m managing it,” she told me at our latest meeting.