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Unwelcome digestive symptoms including bloating, diarrhoea, constipation, and abdominal pain and discomfort are often reported by women during periods of hormonal fluctuation and decline. This is true for women both with and without IBS.
Pre-menopause, each menstrual cycle brings with it a rollercoaster of sex hormones, and during peri-menopause these hormones decrease haphazardly until menopause when hormone production stops or drops to very low levels.
These hormonal changes are not the cause of IBS, which is typically diagnosed before the age of 35. However, some women report an increase in IBS-like symptoms during menopause and after their reproductive years have come to an end. By contrast, other women report an improvement in their IBS during these life stages.
So, what’s going on?
Oestrogen and progesterone are involved in several digestive processes:
Intestinal contractions that regulate gut transit time
They help the smooth muscle of the intestines contract to move food through your digestive system. When hormone levels change, this can affect the time it takes for food to move through the digestive tract (this is known as ‘gut transit time’).
Progesterone relaxes the muscles in the colon, slowing everything down, whereas oestrogen speeds things up. When gut transit time is slow, this can contribute to constipation, and when gut transit time is quick, the result can be diarrhoea. Abdominal pain, bloating and gas often come hand-in-hand with these changes in bowel habit.
Hydrochloric acid production
They contribute to the production of stomach acid. When stomach acid is insufficient, this can lead to discomfort, bloating, excess gas, diarrhoea, upper-GI symptoms like indigestion and nausea (as well as an increased risk of gastrointestinal infection and nutrient deficiencies).
Ageing also leads to a decline in stomach acid production, independently of hormones.
Bile production in the liver
They are involved in bile production. Bile helps to digest fat and eliminate waste, and if your body isn’t producing enough bile, you can experience diarrhoea, urgency, cramping pain and excess gas which can be foul-smelling.
Dietary fat is reported as a trigger for women with IBS-D (diarrhoea predominant IBS), and insufficient bile can also affect absorption of fat-soluble vitamins.
Pain in the enteric nervous system
Oestrogen boosts the production of serotonin, a mood-boosting neurotransmitter, reducing pain from IBS. This hormone also protects nerves from damage. A lack of oestrogen may therefore mean more digestive discomfort.
Other factors that may be involved in IBS-like symptoms during peri-menopause and menopause:
Menopause can be a stressful experience for many women, and fluctuating hormone levels can affect your emotional state.
While there’s still a lot to learn, the connection between the central nervous system (your brain) and the enteric nervous system (your gut) – AKA the gut-brain axis – plays an important role in the functioning of the digestive system and maintaining good mental health.
The feeling of having butterflies in your tummy when you feel nervous or excited is a great example of the gut-brain axis in action.
This flow of information between the gut and the brain is bi-directional; it moves both ways. Stress can exacerbate IBS symptoms, and distressing symptoms can increase feelings of anxiety. IBS sufferers are also three times more likely to have anxiety and/or depression, and mental health issues are both a trigger and consequence of IBS.
Stress affects the digestive system in a number of ways:
- Digestion gets ‘put on hold’ which can cause a build-up of gas and bloating
- Gut transit time can be impacted
- ‘Visceral sensitivity’ increases, lowering the pain threshold of the gut
- Reduced mucus production which protects the inner lining of the intestines
- Reduced beneficial bacteria in the gut
Changes in sleep quality and duration are frequently reported by peri- and post-menopausal women.
A lack of sleep can exacerbate IBS symptoms and IBS can interfere with sleep; it’s a two-way feedback loop.
If you’ve a bad night’s sleep, you may experience worsened IBS symptoms the following day, as we tend to feel more pain when we’re tired.
A lack of sleep can also make us crave high-energy foods (like takeaways, fried foods etc.) which may trigger IBS symptoms in some people.
50% of IBS sufferers report frequent sleep disruption – trouble falling to sleep or waking a lot during the night – often due to their symptoms, or anxiety about their condition.
The gut microbiota is also associated with sleep, again in a cyclical manner. Sleep and circadian rhythm disturbances can negatively impact gut microbial composition, and total microbiome diversity is positively associated with increased sleep efficiency and total sleep time.
HRT – maybe?
You may have read elsewhere online that HRT increases the risk of IBS, so I wanted to address this and perhaps provide some balance.
This is based on a study of UK women who were taking, or had previously taken HRT, compared with women who had never used HRT. Both groups’ subsequent IBS diagnosis was assessed, and it was found that there was an almost two-fold higher incidence of IBS in the HRT taking group. The increased prevalence is similar to that seen in premenopausal women taking the contraceptive pill (birth control). So, while it is significant, it’s not especially surprising.
At present we do not have any studies that investigate the impact of HRT on women with pre-existing IBS. Balancing hormones through HRT use may have a positive effect on IBS and based on what we know about how female sex hormones interact with the digestive system, this is entirely plausible, in my opinion.
It’s also important to remember that association does not necessarily imply causation. Think of it this way: there is an increase in drownings when ice cream sales are high. This does not mean people are drowning because they are eating ice cream. The more logical explanation for this is that it’s summer and therefore more people are taking risks swimming in unsafe bodies of water to cool off.
For many women the health benefits of taking HRT will outweigh the risks as IBS can be successfully managed through various diet and lifestyle modifications.
Other lifestyle factors
Changes to work and family roles during menopause and menopause can alter food intake, eating habits and physical activity.
These factors can contribute to poor digestion and IBS-like symptoms, particularly constipation, bloating and excess gas.
Where to get help with managing IBS during menopause
If you’re suffering with IBS-like symptoms such as pain, bloating, a change in bowel habit (constipation, diarrhoea or both) and excess gas, please see your doctor in the first instance.
IBS should always be diagnosed by a doctor who will use a symptom-based assessment called the Rome IV criteria to confirm a diagnosis. They should also carry out some blood tests to screen you for Coeliac disease and check for inflammation as well as your blood levels of certain nutrients, including iron.
As an aside, it’s important not to remove any foods from your diet until you have seen your doctor and had these tests.
If you have been diagnosed with IBS, or a functional gut disorder, a gut health or IBS specialist nutritionist or dietitian will be able to provide you with personalised management strategies to help keep your symptoms under control.
What to watch out for
If you are over 50 years old when your symptoms begin, or if you have a family history of bowel disorders other than IBS, you’ll need to make sure there’s nothing more sinister behind your symptoms.
The symptoms of IBS overlap with organic diseases such as inflammatory bowel disease (IBD), intestinal cancers, and coeliac disease.
If you have any of the following red flag symptoms, which are not typical of IBS, please see your doctor ASAP:
- Unexplained weight loss
- Bleeding when you go to the toilet
- Recurrent vomiting
- Severe and persistent watery diarrhoea
- Waking at night to empty your bowels
- Symptoms that progressively get worse
Peri- and post-menopause support
Jane and I share a similar philosophy to healthcare and her pragmatic approach complements mine. Putting our heads together means we can help more people find relief from their digestive and hormonal symptoms. Something we both feel very passionate about!
Jane is a Menopause and HRT Educator who helps women with a practical evidence-based approach to all things HRT related.
Jane founded Menopausal Not Mad® after over 30 years of working within the personal growth and nutrition industry, and her own experiences of being peri and now post-menopausal.
She is an Allied Health Professional with the British Menopause Society (BMS), a Senior Member of the International Menopause Society (IMS) and an Associate of the Newson Health Menopause Society (NHMS).
She has accredited certifications and qualifications in menopause, nutrition, and female pelvic physiotherapy.
Jane’s very active Facebook group offers fact-based support and guidance to peri- and post-menopausal women, and I highly recommend you check it out. It’s an incredible resource!