The Relationship Between Bloating, Painful Periods and Anxiety

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In the past decade, a condition called Small Intestinal Bacterial Overgrowth has risen to the forefront of functional and wholistic medical paradigms. 

As the name of the condition implies, SIBO refers to the growth of bacteria in the proximal (upper portion of the) small intestine.  The bacteria that grow in the small intestine in SIBO are not “bad” per se, they just aren’t meant to be there. The proximal small intestine, unlike it’s big brother, the large intestine, is supposed to be relatively sterile, that is, free of micro-organism growth. SIBO is a condition that underlies over 50% of IBS diagnoses and is a treatable condition.

If the bacteria strains themselves are not pathogenic, what is the harm of having an extra couple bugs living in the small bowel? 

The width of the small intestine is about 2 - 3 cm smaller than that of the large intestine, the rightful home of our microbiome. When the microbes in the small intestine break down and ferment foods, primarily fibers and specific carbohydrates, gas is formed. The gas, trapped in this small diameter tube, can created highly uncomfortable bloating, cramping, and as the gas moves to escape, either belching or flatulence. This is why many SIBO patients find that a FODMAPS diet and avoidance of specific carbohydrates alleviates their symptoms, but does not cure them (as the microbes continue to live in the small intestine). Constipation may be a result of  slow bowel function that extends into the large intestine and contribute to poor gut flora health in the large intestine. Oppositely, many SIBO patients may actually experience spastic or increased contraction in the large intestine, leading to diarrhea, or a fluctuation between constipation and diarrhea leading to a diagnosis of mixed type irritable bowel syndrome. 

Why does bacteria begin to grow in the small bowel? 

This is an excellent question, and must be answered for an individual case if SIBO is to be cured and dissuaded from returning. The reason for the development of SIBO is individual, but the failure of a rather specific mechanism is thought to be behind bacterial overgrowth in the small bowel. 

Migrating Motor (Myoelectrical) Complexes, nicknamed the MMC, is a periodic pattern of electromechanical contractions through the gastrointestinal smooth muscle that creates sweeping motions between meals, thought to flush materials through the gastrointestinal tract. An MMC has 4 distinct phases and cycles around every 1.5 to 2 hours. Secretions from the stomach, pancreas and biliary tract are thought to accompany the contractions. Regulated by the central nervous system and enteric hormones, the MMC is an essential part of keeping the 6 meter long small bowel healthy. 

The MMC is thought to be damaged in many cases of SIBO, such that the flushing fails to occur and microbes begin to inhabit the small bowel. Autoimmunity may be implicated in certain cases by interfering with the nervous system’s regulation of the MMC. An infection via food poisoning or other episode of intestinal infection is another common inciting event for IBS that points to an underlying picture of SIBO. Low stomach acid, stress, and a diet that does not support gastrointestinal health, may also be implicated. 

There are two other important causes of SIBO that I find to be of special interest for many women: 

  1. Endometriosis is a condition where uterine lining tissue is found outside of the uterus in the abdomen and during the monthly cycle may cause bleeding with distinct discomfort and pain. The inflammation and subsequent adhesions from endometriosis are thought to be a factor that disrupts proper MMC function and contributes to SIBO.

  2. Pharmaceuticals used in the treatment of depression and anxiety, particularly Selective Serotonin Reuptake Inhibitors, or SSRIs, have been known to come with an increased risk of IBS development, and very likely SIBO, as the drugs can slow movement in the small bowel through anti-cholinergic actions (the release of the neurotransmitter choline is what nerves use to pass on conduction signals and thus cause muscular contractions).

Not only can the treatment of anxiety and depression with pharmaceutical interventions become a cause of poor gastrointestinal health, but we know that the Gut-Brain connection runs so deep that dysbiosis, that is, imbalances in the ratios of gut bacteria as well as gut inflammation, can trigger anxiety and depression in the brain. Up to 90% of the body’s serotonin, the feel good hormone that medications try to increase in anxious and depressed patients, is actually made in the gut

Once again, the triad comes full circle as mental health is directly tied to gastrointestinal and hormonal health. 

SIBO is diagnosed through a naturopathic intake and non-invasive breath testing. In long standing cases of SIBO, investigation into the gut flora of the large intestinal may also be warranted. Many patients are given a clean bill of health (despite feeling the complete opposite of healthy!) when their colonoscopies and other imaging comes back clean, as these diagnostic measures fail to identify SIBO or other causes of IBS symptoms.

Treatment of SIBO is multi-faceted: the treating professional must be able to restore the healthy MMC patterns in the small bowel, encourage balance in the flora of the gut, and treat concomitant symptoms of IBS such as anxiety, stress, necessary dietary changes, poor sleep, etc. Once the integrity of the gut is restored, working towards hormonal balancing and the resolution of endometriosis or other autoimmune presentations is necessary. 

It is my hope that this article will serve to educate about the intricate linkage between female gut health, hormonal health and mental health; and that to treat one is to treat all. This will begin to serve as a template for the wholistic treatment of women's health so that we are healing the body rather than covering up a vicious cycle of symptoms.