H, a 28 year-old lady walked into my consultation room with an anxious and depressed look. She worked as an account assistant in an accounting firm and studied a part-time degree course at night.
“Doc, my work-life has been quite stressful recently. I have been suffering from tummy cramps with constipation and bloating for the past six months. The symptoms have become worse during menses. I have googled and thought that abdominal pain during menses could be the symptoms of endometriosis. I am worried.” she said.
On further questioning, H had more symptoms of the digestive tract than those related to her reproductive system. Though she had constipation most of the time , she would have occasional diarrhea if she ate certain “sensitive“ foods. Her tummy was always bloated. “Sometimes, I have no choice but to rush to the public toilet to ease myself. I feel embarrassed because of the noise of the gas and the smell from the bowel movements,” she sheepishly confessed.
Her menstrual cycle was regular and the pain was described as “mild” and occurred occasionally on the first day for the last two months. Vaginal examination did not reveal any tenderness around the womb and pelvic ultrasound examination was normal. I reassured her that she did not have clinical evidence of endometriosis and referred her to a Gastroenterologist who diagnosed her to suffer from irritable bowel syndrome (IBS) after investigations. IBS can mimic endometriosis in that the abdominal cramps can be pronounced during menses. The menstrual cramps can occur during bowel movements. There may be nausea and/or vomiting during menses if the pain is severe. However, there are some differences. IBS patients are more likely to have bowel habit changes, i.e. constipation, and/or diarrhea. The colicky pain does not always coincide with the menses. Gaseous distension and pain in the upper abdomen are more common. The cramps are triggered by food and/or stress.
Patients with endometriosis, on the other hand, tend to have more menstrual symptoms such as bleeding between menses and heavier menses. The menstrual pain may start in the premenstrual phase and may last throughout the menses. Pain during sexual intercourse and infertility are more common. Research studies have found that IBS symptoms which are aggravated during menstruation are due to the effects of sex hormones produced by the ovaries. Sex hormones affect IBS in the following ways.
First, they affect the smooth muscles of the intestines which control how fast the food passes through the digestive tract. In an animal study, the intestines took a longer time to empty when they had a low dose of the hormones than when they received a higher one. This may explain why constipation is worse during menses. Second, low levels of sex hormones during menstruation reduce the pain threshold of the patient resulting in more severe cramps. Lastly, sex hormones can raise the levels of inflammation throughout the body including the gut, thus making IBS symptoms worse.
Few months had passed. H came to update me on her condition. “Doc, thanks for your prompt referral. My condition has improved a lot. Besides medications, I have been counselled on stress reduction, lifestyle and dietary changes. I am more careful with what I can or cannot eat. I practice yoga 3 times a week and I don’t have to rush to toilet so often now”
I am happy that H is on her way to recovery.