A Woman's Guide to a Healthy Stomach

What is IBS?

Irritable bowel syndrome (IBS) occurs in about 14 to 25 percent of women, although most people with symptoms do not consult a physician and suffer in silence, due to shame or being told that they’re overreacting. IBS also mimics many other issues, like endometriosis, so it’s difficult to pinpoint right away. Elizabeth had a particularly bad and chronic case of IBS. Women are twice as likely to get IBS as men, and many of these women have suffered abuse, just like Elizabeth had. Symptoms vary and are sometimes confused with those of inflammatory bowel disease (ulcerative colitis or Crohn’s disease), which is a physical disruption or abnormality in the intestines that causes inflammation or damage to the bowel. With IBD, an X-ray, colonoscopy, endoscopy and so forth will show an abnormality; but with IBS they won’t. IBS is a syndrome, not a disease.

The diagnosis of this syndrome is based on symptoms. There’s no study that determines IBS; rather, the absence of abnormal X-rays and colonoscopy tests points to an IBS diagnosis. The diagnostic criteria have changed over the years but have always consisted of recurring abdominal pain and a change of bowel function—constipation, diarrhea or alternating constipation with diarrhea. Ask yourself this: Have you had recurrent abdominal pain or discomfort for three or more days per month? Has this been going on for at least the past three months? Does going to the bathroom help? Have the stools changed in frequency or form? And what about gas? Have you got it? If you have pain with the stool changes, you might have IBS.

Who gets IBS?

Those with a low quality of life are more likely to be afflicted because IBS may have a negative impact on one’s overall well-being. Several psychological factors and childhood rearing practices have been reported to increase the risk of IBS. One study suggests that IBS in children is more common if the mother paid a lot of attention to complaints of illness and if children had many absences from school. A child with a parent or a twin with IBS is also more at risk for developing IBS due to genetic factors. Identical twins have a greater risk for developing IBS than nonidentical twins when one twin is diagnosed with the condition. The development of new onset IBS is associated with frequent visits to doctors, anxiety, sleep problems and somatic complaints (physical complaints, like aches, where the cause can’t be found). Sometimes IBS crops up in the wake of a viral or bacterial infection; in this case, diarrhea is more likely to occur than constipation.

Some gut infections are more likely to cause IBS than others. After an infection with Campylobacter jejuni, a bacterial infection that comes from food poisoning from eggs and poultry, the risk of developing IBS is as much as 13 percent. It occurs less after Salmonella infections. But if you get antibiotics for your Salmonella infection, your risk almost doubles to over 17 percent, according to one study, which is why Salmonella usually isn’t treated, except in the very young or elderly. Factors that increase the risk of developing IBS after an infection are being female, being younger than sixty, increased duration and (probably) intensity of the infection, psychological factors such as anxiety and depression, and smoking. Sometimes IBS is brought on by stress. Remember, your gut is hypersensitive and feels stress acutely. This is one way that it reacts.

What are the symptoms of IBS?

Without abdominal pain or discomfort, you don’t have IBS! The pain or discomfort has to recur at least three days per month for three months in a row and also has to persist for six months. Secondly, the pain or discomfort has to be relieved by a bowel movement or be associated with a change in stool frequency (for you), or a change in stool appearance or form. This can be an increased or decreased frequency of stool or such changes in the stool as watery or mushy, hard, incompletely evacuated or requiring straining to evacuate. Bloating, gas and frequent urination, as well as the urgent need to urinate, are associated with IBS. Fibromyalgia and depression are also common in those with IBS. IBS is divided into subtypes, which are usually treated differently. These are constipation, diarrhea, mixed pattern (alternating between diarrhea and constipation) and undetermined. The constipation subtype is much more common in women, while the diarrhea subtype occurs equally in men and women.

Many women will tell you, though, that gas is their worst and most humiliating symptom. It’s present in women with IBS 72 percent of the time.

My doctor asks me to describe my stool. I barely want to even look at it, let alone describe it!

Knowledge of the form your stool takes helps your doctor make an assessment about what might be happening in your intestines. A scale, dubbed the Bristol Stool Form Scale, has been developed just for this purpose. This scale helpfully describes seven major consistencies and shapes of stool, from little pieces (pebbles, rabbit droppings) to mush or liquid, so we doctors don’t have to grope for vivid descriptions! Type 1 and 2 are hard to pass and occur with constipation. Type 3 and 4 are normal in the sense that they are more easily passed. Type 5 and 6 are soft and may come out with more force, and type 7 is diarrhea. Be sure to tell your doctor if your stool is bloody, that is, if blood is present either on the toilet paper or in the toilet, or is mixed in with the stool.

Figure 3-1. This chart shows the different types of stool form. Types 1 and 2 are hard to pass and are seen with constipation. Types 3 and 4 are considered normal (and ideal, by some people). Types 5 and 6 tend toward diarrhea. Type 7 is definite diarrhea with liquid and no form.

Can I get tested for IBS?

First things first: All women over age fifty and African-Americans women over age forty-five should have a colonoscopy to make sure there are no polyps or cancer. No matter what her age, any woman with unexplained rectal bleeding should have a colonoscopy to make sure there are no polyps, cancer or inflammation. Sorry, though, there are no accurate blood tests to make the diagnosis of irritable bowel syndrome. However, new blood tests have been developed to identify markers of substances (biomarkers) in the blood that are associated with irritable bowel syndrome. If there is a high suspicion of IBS and the test panel is positive—the tests have good predictability. Conversely, if there is a low suspicion of IBS and the test panel is negative, again, the test has good reliability. But if IBS is suspected and the test panel is negative, well, you still might have it.

Unfortunately, there are large numbers of people having these tests who could be overlooked and who do have IBS, or who are incorrectly told they have IBS. The blood tests sometimes used for diagnosing IBS include ones that are useful in making the diagnosis of celiac disease and inflammatory bowel disease; people with IBS could be told they have one of these other conditions. Other tests—such as stool cultures; routine blood tests looking for anemia or high white blood cell counts, which could indicate an infection or an inflammatory process; X-rays; or endoscopic tests—are useful in ruling out other conditions. However, for most people under fifty, they’re not usually necessary. Celiac sprue (gluten allergy) (see Chapter 4) can be discounted by doing a blood test called tissue transglutaminase antibody.

If I’m diagnosed with irritable bowel syndrome how do I know that I got the right diagnosis?

You can’t be 100 percent sure. Warning signs that would require other diagnoses to be eliminated with testing are:

 Onset of symptoms over age fifty

 Rectal bleeding

 New anemia

 Unexplained weight loss

 Worsening of IBS symptoms

 Poor appetite

 A family history of other diseases that affect the gastrointestinal tract

 Vitamin deficiencies

Reassuringly, studies have shown that the diagnosis of IBS does not usually change. After six months to six years after the diagnosis was made, only 2–5 percent of irritable bowel syndrome patients were diagnosed with another GI disease. With long-term follow-up of IBS, on average two years, about 2–18 percent of people developed worse IBS, 30–50 percent of patients had no change in IBS symptoms and 12–38 percent of people had a complete disappearance of their symptoms, for reasons unknown. If your symptoms change, tell your doctor.

Why do women bloat?

A great question that is still only partially understood! Most women do not have excess or an increased amount of gas, even though it might feel that way when you’re squeezing into your favorite pair of jeans. The problem seems to be more that the gas doesn’t move out of the small intestine like it should. And when it’s there, watch out! Women with irritable bowel syndrome or other functional GI disorders feel it more. There is an increased sensitivity toward and awareness of what is happening inside the body.

However, not everyone who feels bloated actually has a larger belly. (In a study from Olmsted County, Minnesota, a quarter of the women studied reported they were bloated, but in actuality, only half of the bloated women had an increased circumference when measured!) Younger women are more likely to bloat than older women. Bloating is more common in the lower abdomen than the upper, unless someone has upper intestinal symptoms (like heartburn), whereby bloating can be anywhere in the abdomen or throughout the abdomen. With recurrent nausea, vomiting and pain (called dyspepsia), bloating is also more common in the upper abdomen. Men, meanwhile, are lucky. They bloat and distend only half as much as women. No wonder their pants fit better!

What about distension? Doesn’t that mean you have more gas?

Again, not necessarily. Sometimes your ab muscles just aren’t working right. The diaphragm comes down, the air and intestinal contents pool and the only way for the belly to go is out. Women can bloat if they get stressed. This may be due to a release of hormones or other substances that cause a change in the movement of the bowel or abdominal wall muscles, or just hypersensitivity. Another overlooked but likely cause of bloating is the bacteria in the bowel. The bacteria that are the normal inhabitants of the bowel are different in women with irritable bowel syndrome than those without it—one study shows decreased or absent species of lactobacilli in the intestines of patients with IBS. The fruits that are least likely to cause gas are white grapes, strawberries, blackberries, raspberries, pineapples and oranges. Fruits that are more likely to cause gas are prunes, pears, sweet cherries, peaches and apples. The bacteria in our guts break down the food products that get to the colon and can release rotten gas or compounds, like fatty acids, that could cause bloating.

What causes gas?

There’s no getting around it: Gas is often a by-product of what we eat. We share our body with bacteria; in fact, there are ten to one hundred times more bacteria than cells in our body. These bacteria also inhabit our bowels. When the carbohydrates and fat within our food aren’t broken down by the substances (enzymes) our bodies make and are not absorbed by the intestines into our bodies, the bacteria metabolize them and form gas as a by-product. For instance, if someone is missing the enzyme in the small intestine to break down lactose (the sugar in milk), she becomes lactose intolerant. The lactose travels down to the colon, and the bacteria break down the lactose and release hydrogen gas as a by-product. Fructose is poorly absorbed into the body unless it is accompanied by the sugar glucose. Therefore some fruits are more likely to cause gas than others. These fruits have less glucose than fructose. There are other poorly absorbed short-chain carbohydrates that will cause gas when broken down by bacteria. These are termed FODMAPs (Fermentable Oligo-, Di and Mono-saccharides and Polyols).

The oligosaccharides consist of fructans (wheat, onions, artichokes) that have long chains of fructose and galactans (legumes, cabbage, brussels sprouts). The disaccharides are lactose- (milk) containing foods. The mono-saccharides are fructose-rich foods (fruits). The polyols include sorbitol (added to low calorie foods). A more extensive list of the foods that may cause gas is found on pages 52–53.

Why do I feel stress—and, consequently, gas—so acutely in my stomach?

Strange as it seems, your gut has a brain. More than 95 percent of serotonin resides in the gut, and serotonin, coincidentally, helps modify mood. It is important for the movement of the gut and is a strong determinant of constipation, diarrhea and pain. But cortisol, the “fight or flight” hormone made in the adrenal gland, also causes increased movement in the gut and may be responsible for some of the increased gas when you’re stressed. People with IBS also have a lower threshold for pain in the gut.

One of the tests done to look at how sensitive one’s bowel is to noxious stimuli is to place a balloon in the rectum and distend it. If a balloon is distended in the rectum of an IBS patient, the tolerated volume of air in the balloon is less than that of a person without IBS. In IBS patients, when the balloon is distended in the rectum (ouch!) or if pain is anticipated, areas of the brain are activated. These can be seen on PET (positron-emission tomography) scans that examine blood flow. However, women’s and men’s brains light up in different places. In women, the limbic and paralimbic areas light up. These are areas that amplify pain. In men, areas that are more concerned with inhibiting pain (prefrontal cortex, insula, dorsal pons) light up. Men, too, experience intense pain; it just registers differently.

Why, oh why, does gas smell so disgusting?

Gas is actually a mixture of different gases. Only a minority cause odor (it’s true!). The culprit for the rotten egg smell exuded by some gaseous odors is hydrogen sulfide. Other compounds like methyl mercaptan and short-chain fatty acids, like skatoles, can also impart a noxious odor to our released gas. Ironically, skatoles in small amounts have a flowery smell and are found in several flowers and essential oils, such as orange blossoms and jasmine (though I don’t know of anyone who describes her gas as perfume-worthy). It’s the sulfur-containing compounds that impart most of the bad odor to the gas. Depending on the type of bacteria residing in your gut and what food you eat, different gases and therefore different odors will be released.

What foods are notorious bloat causers?

Bananas, prunes, legumes, pretzels, cabbage, beans and raisins are big culprits. And, of course, dairy products produce bloating in lactose-intolerant people. Sorbitol, the sugar often found in chewing gum, causes gas, too.

How can I relieve gas and bloating symptoms while driving, or in a meeting, if I can’t rush to a bathroom right away?

Whenever you’re in for a long haul, visit the bathroom beforehand. And avoid those aforementioned foods that are likely to cause gas and/or bloating. If the trip or meeting is long, take bathroom and walking breaks. I’m also a big fan of relaxation techniques, such as meditation. Is that dragon-lady boss or tailgating driver really worth getting upset about, at the expense of your health?

Why are some women gassier than others?

Some women simply swallow air when they get nervous or eat. Some women aren’t able to break down lactose. Still others have issues breaking down the sugar in fruits, called fructose. Some women also eat lots of beans and legumes, which have a nonabsorbable sugar known as raffinose, which is broken down by the resident gut bacteria that cause gas. Women like Elizabeth with irritable bowel syndrome often have gas and bloating—which is worse during the hormonal shifts around their periods.

What are some of the less common—and more severe—causes of distension?

Fluid in the belly, known as ascites, is one cause. This fluid can appear for a variety of reasons, from cancer to pancreatitis (inflammation of the pancreas) to cirrhosis (scarring of the liver). Abdominal masses and abdominal hernias are less common causes of bloating and distension. But bear in mind, all these issues are relatively uncommon and can often be detected on physical examination or with radiological tests.

Okay, so what foods should I avoid to reduce IBS and gas symptoms?

For IBS symptoms (abdominal pain, diarrhea), you should first try to eliminate “CAF” (caffeine, alcohol, fatty foods). If this doesn’t work and you still have IBS symptoms or gas, try eliminating lactose for one week (milk, ice cream, cheese products). Decrease your meal size and eat smaller amounts more frequently. If this doesn’t work, try decreasing fruits, followed by insoluble fiber. Red meats also seem to be poorly tolerated by some people with IBS symptoms. If all these things fail, sometimes a dietitian can help with an elimination diet.

Here are some commonly troublesome foods for causing gas:

 Beans and lentils (humans don’t have the proper enzymes to break these tasty treats down. Sorry!)

 Brussels sprouts

 Carrots

 Celery

 Onions

 Apricots

 Bananas

 Prunes

 Raisins

 Pretzels

 Wheat germ

Beano, an over-the-counter preparation of the enzyme galactosidase, may help prevent the gas formed from the digestion of beans and peas. Women with bloating should avoid lactose and see if it makes a difference in bloating and gas. If it doesn’t, you could go back to lactose. Sometimes it is not just the lactose but the milk proteins that cause belly discomfort.

Warning! Foods with lactose:

 Milk

 Cream

 Cheese

 Butter

 Yogurt

 Ice cream

What if I change my diet? I’ll do anything! Give up ice cream! Throw away the wine! Will that help?

Many people report that diets for IBS and gas help. Unfortunately, not all diets help all people. One diet that helps one person may make another person worse. If allergy testing reveals food allergies, then elimination of food triggers may help symptoms. It is important for everyone to try to associate symptoms with a possible food that may have been eaten within the previous six hours (usually during the most recent meal). Keep a food diary! If there isn’t a pattern, and allergies aren’t found, there are certain things you can do to try to see if they help. Irritants to the gut, causing an increase in stimulation of gut movement and perhaps pain, are coffee, caffeine, alcohol, fatty and fried foods, and large meals in general.

As I mentioned before, some people get gas and pain from lactose, fructose or sorbitol. Insoluble fiber, mainly found in whole grains, raw vegetables and fruits, are often rough on the stomach. This may be due to the bacteria in the bowel eating up some of the fiber that gets to them or the stimulation of the bowel to have more contractions. However, it’s hard to predict which foods will be tolerated and which won’t.

I need help and I need it now. Can’t I just run down to the local drugstore?

For gas, a simple treatment, such as simethicone (Gas Relief, Gas-X), works wonders. To reduce spasms, try enteric-coated peppermint capsules, sold under the name Pepogest at nutrition stores and specialized health-food grocery stores. Charcoal also binds the gas, and you can buy it as CharcoCaps. Keep in mind that charcoal turns the stool black, so don’t be alarmed when that happens to you. Also, be sure not to take CharcoCaps with other medications, as it can bind up the medications so that they may not be absorbed effectively into your body. Pepto-Bismol may also be helpful to remove or decrease some of the foul odors.

Can’t I just wear a “filter” in my underwear, kind of like the filter in my air conditioner?

Panty liners and underwear designed to absorb odors are available on the Internet, and I think they work pretty well. One study tested how well different products worked. Carbon fiber briefs extract almost all the foul-smelling gases, while pads made of fabric-covered charcoal absorb 55 to 77 percent of sulfide gasses. Cushions with carbonized cloth might also help. Sexy they’re not, but then again, neither is a foul aroma.

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