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IBS and endometriosis, is there a link ?

IBS and endometriosis are two diseases that affect a significant portion of women and both have important impacts on quality of life (Viganò et al., 2018).

Is there a connection between endometriosis and IBS?

In short: yes.

If you’d like to learn more, I invite you to read this article 🙂

Endometriosis in a nutshell

Endometriosis is a condition that affects 10% of women. It is estimated that 40% of women with chronic pelvic pain, exacerbated during menstruation, are affected by it (Inserm).

Endometriosis is characterized by the presence of tissue similar (but not identical) to the endometrium (the uterine lining; Figure 1) in other organs such as ovaries, vagina, bladder, peritoneum, etc., and is associated with chronic inflammation within an estrogen-dependent environment (Surrey et al., 2018).

Source: Wikipedia

Women with endometriosis commonly experience disruptions in the menstrual cycle, infertility, abdominal and pelvic pain, as well as digestives issues (Lee et al., 2018).

Endometriosis is characterized by the presence of tissue similar (but not identical) to the endometrium in locations where it shouldn’t be.

How does endomestriosis develop?

Endometriosis is a chronic and multifactorial disease involving genetics, environmental factors, hormonal and immune systems, and various risk factors are associated with this condition, such as long menstrual cycles, <5 pregnancies (resulting in greater estrogen exposure over a woman’s lifetime), and sedentary lifestyle (Borghini et al., 2020; Kvaskoff et al., 2015; Parazzini et al., 2017).

Determining the origin of the disease is complex. One hypothesis is the dissemination of menstrual blood into the pelvic cavity (the blood “flows back” during menstruation), which could trigger typical IBS symptoms (Burney & Giudice, 2012).

However, this theory is not validated and has been challenged by the scientific community (D’Hooghe, 2003).

While the precise mechanisms explaining endometriosis remain to be fully understood, it is recognized that endometriotic cells (cells similar to endometrial tissue that have migrated) require a pro-inflammatory environment to develop and proliferate (Zhang et al., 1993).

Despite the prevalence and impact on the quality of life for women with endometriosis, the origin of this disease remains unclear.

This low-grade inflammation is created and maintained by factors like dysbiosis and increased intestinal permeability (Laschke & Menger, 2016).

Once established, endometriotic cells promote the inflammatory state by secreting cytokines (Iwabe et al., 2002). The immune system responds by activating nociceptors. In response, sensory nerves generate painful impulses and release pro-inflammatory neuropeptides, contributing to the progression of the disease (Laux-Biehlmann et al., 2015).

Irritable Bowel Syndrome

IBS is a functional disorder, meaning there is nothing visible in exams (which are prescribed by doctors).

IBS is also multifactorial, and various factors (dysbiosis, increased intestinal permeability, disturbance of the immune system including increased mast cell presence, alterations in intestinal motility, and dysfunction in the gut-brain axis) interact, promoting chronic inflammation (Viganò et al., 2018).

Links between IBS & endometriosis

According to a recent meta-analysis* (17 studies, total of 96,974 participants), women with endometriosis are about 3 times more likely to develop IBS (Nabi et al., 2022).

*Using Rome II, III, and IV criteria for IBS diagnosis.

This meta-analysis also found that one in five women with endometriosis also has IBS (Viganò et al., 2018).

Possible reasons for this endometriosis/IBS correlation could be chronic low-grade inflammation resulting from mast cell activation (immune cells) (Barbara et al., 2004), neural inflammation, increased intestinal permeability, and dysbiosis (Figure 2) (Viganò et al., 2018).

Figure 2: Diagram illustrating the potential links between endometriosis and IBS. Source: Viganò et al., 2018

Furthermore, women with both endometriosis and IBS experience visceral hypersensitivity, which likely contributes to the severity of intestinal symptoms (Issa et al., 2012).

IBS and endometriosis share similar clinical symptoms(Nabi et al., 2022). The common denominator between these two conditions is the presence of chronic low-grade inflammation (Polak et al., 2015; Sinagra et al., 2016), which partly contributes to the pain (DiVasta et al., 2021).

Conclusion

There appears to be a clear link between endometriosis and IBS. Although these two conditions have various, not fully elucidated causes, they share a common factor: chronic low-grade inflammation.

Some factors inducing and sustaining this chronic inflammation have been found in both IBS and endometriosis contexts (Viganò et al., 2018), such as dysbiosis (Jeffery et al., 2012; Laschke & Menger, 2016) and increased intestinal permeability (Camilleri et al., 2012; Piche, 2014), often associated (Brandl & Schnabl, 2015).

Thus, a possible (and simplified) sequence could be:

[inappropriate environment/lifestyle →] dysbiosis + increased intestinal permeability → passage of toxins released by bacteria → immune system disruption → chronic inflammation → IBS and/or endometriosis.

Working on this inflammation in a personalized manner based on its diverse origins in different women can help alleviate symptoms of both endometriosis and IBS.

Managing endometriosis and IBS requires a multidisciplinary approach (= support from various healthcare professionals like dietitians, psychotherapists, doctors) to tailor treatment and address the underlying causes of the diseases (Viganò et al., 2018).

Key Figures:

  • 10% of women are affected by endometriosis (Inserm)
  • 40% of women with chronic pelvic pain, exacerbated during menstruation, have endometriosis (Inserm)
  • 1 in 5 women with endometriosis also has IBS (Viganò et al., 2018).

References

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