Gastro-gynecology – The Gut-Gyn Connection

By Dr. Sandberg-Lewis

The longer I practice naturopathic gastroenterology, the more I realize I need to keep adding to my knowledge of gynecology. The reproductive and digestive tracts are intimately related on at least two levels – 1) physical proximity, 2) hormonal and detoxification pathways.

The peritoneum is a thin lubricated membrane that encases most of the abdominal organs and covers the uterus, ovaries, and tubes. It protects and allows them to move, expand and change shape. When a woman ovulates, the egg and surrounding fluid is released into the peritoneal cavity which contains peritoneal fluid. From there, fingerlike processes on the fallopian tube waft the egg into the tube so that it may be fertilized by sperm. The ovarian fluid and the peritoneal fluid are mixing during this process. 

The surfaces of the ovary, uterus, and tubes are bathed in peritoneal fluid. The peritoneal fluid is rich in a variety of hormones and other factors that control inflammation and other normal functions. It has also been proposed that peritoneal fluid is the medium through which the two ovaries communicate.

A good example of this fluid exchange is seen in endometriosis. In this disease, cells from the lining of the uterus travel into the abdominal cavity through the fallopian tubes. In fact, this transfer of uterine tissue may be occurring in all women, not just in endometriosis cases! These tissue fragments enlarge and bleed with the hormonal changes of a woman’s cycle, just as they would if they were still in the uterus. The monthly bleeding into the peritoneum can lead to adhesions which is, perhaps, the best explanation of how endometriosis commonly causes digestive problems.

Disease associations between Gut and Gyn

Pregnant women with irritable bowel syndrome (IBS) have an increased rate of miscarriage. Women with either endometriosis or polycystic ovarian syndrome (PCOS) have an increased risk for developing IBS (independent of being overweight.) Those with endometriosis have up to a 3.5-fold increased risk for being diagnosed with irritable bowel syndrome.  

Adhesions

Abdominal and pelvic adhesions (scar-like formations between internal organs) are a major cause of infertility, chronic pelvic pain, and small intestinal obstruction. When surgery is performed on the abdominal or pelvic regions, adhesions are created in 55% to 95% of cases.  This phenomenon is equally common in either laparoscopic or open surgeries. Adhesions can even form in areas that were not directly involved in the surgery. Any abdominal or pelvic surgery may cause these, but common gynecological examples that I see in my practice are hysterectomy, inguinal hernia surgery, exploratory laparoscopy, and other endometriosis procedures. Endometriosis itself (discussed above) is another common cause of these internal adhesions. 

One explanation as to why adhesions can cause pelvic or abdominal pain is the fact that most adhesions contain nerves which may allow for increased pain perception when they are stretched. Probably just as important is that adhesions may narrow the passages on the inside of the intestines (like a napkin ring around the outside) or create hairpin turns or kinks in the intestine. These narrowed or kinked areas can lead to partial obstruction, slowing down the flow of food, waste, and bacteria. I encounter this commonly in my practice as a cause of small intestinal bacterial overgrowth (SIBO). When adhesions are present, SIBO tends to recur after treatment. Adhesions can also cause kinks or narrowing in the fallopian tubes which is a cause of infertility. 

The good news is that adhesions can be treated non-surgically by a skilled physical therapist or other bodyworker with training and experience in manual visceral adhesion therapy.

Sometimes surgeons will perform a surgery called adhesiolysis (surgically cutting or destroying adhesions.) This seems like a good idea, except that the procedure itself often creates new adhesions.

In eight larger research studies of adhesiolysis pain relief, only two included a placebo group. In these two, no difference was found in pain relief between the placebo and adhesiolysis groups. If these surgical procedures are done, I recommend following them with the manual therapy to deal with any new adhesions while they are still smaller and less complex.

How the Gut Influences Estrogen and Estrogen Metabolism

Many common gynecological diseases are associated with something called estrogen dominance. Ideally estrogen levels are in balance with the sister hormone progesterone and other intermediary forms of these hormones. Estrogen dominance can stimulate more tissue growth in the reproductive organs. Examples of such conditions include fibrocystic breast and other breast masses, uterine fibroids, endometrial hyperplasia, and dysfunctional uterine bleeding. When estrogen is produced in the ovaries or in fat cells it can continue to have hormonal effects until it is inactivated and removed. 

The primary pathways for estrogen processing involve something called conjugation which occurs in the liver. Conjugated estrogen enters the bile and flows to the gallbladder. When a woman eats a meal containing fat, the gallbladder is triggered to contract and expel bile into the small intestine. The conjugated estrogen travels through the small and large intestine and is removed from the body.

There are many species of bacteria in the large intestine. Some of these reverse the conjugation (a process called deconjugation) of the estrogen before it leaves the body. The bacteria produce an enzyme called beta glucuronidase. This allows reactivation of the estrogen and its absorption into the blood. The imbalance of higher blood estrogen compared to progesterone creates estrogen dominance.

The bacteria and their genes that control estrogen levels in this way are called the estrobolome. This is a complex process and cannot be fully explained in this short article.

In summary, the female reproductive organs and GI tract share secretions and hormones in the peritoneal fluid and affect each other by their proximity. Adhesions between folds of intestine or between intestine and gynecological structures can cause disease in either or both body systems. Bacteria in the gut are an important part of the hormonal balance of estrogen and other female steroid hormones.

Hive Mind Medicine blog posts are for educational purposes only and are not intended as medical advice. Please consult with your health care practitioner for personalized guidance.