Admit it, you’re dying to know. WHY DO I BLOAT LIKE THIS?????? Your doc may have told you it’s just your endo, the internet may have told you it’s your hormones, your vegan friend says its meat, your keto friend says it’s carbs, and you’re still stuck in embarrassing agony looking for a solution.

While it’s true endometriosis lesions can cause inflammation of the abdomen and pelvis, this is rarely the only factor at play! The truth is, there are most often real issues we can point to far beyond endometriosis.

While I talk about this all in depth in my best-selling book, Heal Endo (have you read it?), here are six reasons you may be as bloated as a balloon.

1) POOR DIGESTION AND ENDO BELLY

After you eat do you feel like a lump of coal has hit your insides and won’t move? Do you often feel uncomfortably full? Do you have heartburn, gastritis, or acid reflux? Does your stool have partially digested food in it? Do you have a hard time salivating? And, yes, do you bloat big after meals? Meet some classic symptoms of poor digestion, and boy can this make you bloat like a balloon.

Digestion is the very first thing that happens after you eat. It’s an essential step, since digestion is what breaks down those proteins, fats, and carbohydrates into teeny tiny particles that can be absorbed in your intestinal tract. So digestion happens first, then absorption next — two totally different processes in totally different places.

These particles also need to be teeny tiny so they don’t putrefy or ferment in your small intestine … or feed the wrong types of bacteria (which produce gases that bloat you). So, if your digestion is NOT working, and large (undigested) pieces of fats, carbs, and proteins are making it to your small intestine, get ready for some bloat-a-licious issues. Not to mention some right quadrant pain as your IVC becomes super inflamed (read all about that specific endo belly issue here)

Digesting well is absolutely key for reducing bloat, not to mention absorbing nutrients and reducing dysbiosis! I have a very educational post about this important topic here.

2) DYSBIOSIS, LEAKY GUT, AND ENDOMETRIOSIS BLOAT

Unfortunately, if you have endometriosis, research shows it’s highly likely that you will also have dysbiosis of the gut and reproductive tract, leaky gut, and the endotoxemia associated with it. Yup, even if you don’t have digestive issues.

In one study, researchers compared the gut microbiome of women with endo versus healthy controls, finding significantly less alpha diversity in the endo group (which is plain speak for we all pretty much have dysbiosis). And the level of dysbiosis may correlate with disease level, as other research found women with stage 3 or 4 endo had so many gram-negative populations that they dominated their gut microbial communities (which is Bad with a capital B)! Another small study uncovered that 80% of women with endo and digestive issues were positive for SIBO.

With all this dysbiosis in the gut eroding the mucous and damaging the epithelial lining, it shouldn’t come as a surprise that a preliminary study found 100% of endo-folk to have leaky gut. [5] In a healthy small intestine, thick, luscious mucous membrane protects the delicate intestinal lining. This way, food, bacteria, toxins, and the rest can flow right through and out to the toilet. It keeps the “inside of your intestines” outside of your body. If you have a sick (and leaky) small intestine, infections or other gut issues will thin the mucous membrane while inflaming and degrading the intestinal barrier.

Now rancid and partially digested food particles, toxins, and pathogens can escape directly into the bloodstream. This is akin to a direct IV drip of issues your immune system needs to respond do, as the “inside of your intestines” are now inside your bloodstream. Yikes. If this happens every day (which it will unless you fix your gut) chronic inflammation and immune system issues will ensue.

Put together, this may be one reason why those with endometriosis were found to have significantly higher levels of LPS in their blood (endotoxemia) than healthy women.

I have an AWESOME post on all this here, with a lot of references for the endo nerd in all of us.

3) FOOD INTOLERANCES AND ENDOMETRIOSIS

If you have gut hyper-permeability (i.e. leaky gut) you will automatically be reacting to certain foods more than the average person. For some of you, that may mean extreme bloating or gastro distress with certain foods.Foods that I commonly see women reacting to like this include gluten, dairy, eggs, and/or alcohol. You may be reacting to one, or all!

The other food intolerance many of us suffer from is a reaction to high FODMAP foods. FODMAPs are highly fermentable carbohydrates, and if you react to them, you may be blowing up like a balloon from perfectly healthy (and even low-carb) foods. The main reason you react to FODMAP foods is because of - you guessed it - dysbiosis!! And especially SIBO. SIBO stands for Small Intestinal Bacterial Overgrowth, and means there’s a big ocean of bacteria living where it shouldn’t be: your small intestines. When you feed this misplaced bacteria, it reacts as usual (ie ferments the food) but when that’s happening in your small intestine it’s a horror story.

This is why you should always get tested for SIBO and other patterns of serious dysbiosis if you’re reacting to high FODMAP foods. Also, for those of you with IBS, SIBO has been shown to be the root cause for up to 84% of all IBS cases (and why a lowFODMAP diet is often recommended for IBS sufferers).

Cutting out high FODMAP foods will not fix the dysbiosis, but it will help mitigate symptoms until you can get tested and fixed up. In the meantime, cutting them out can be beneficial for some folk to investigate further to see if these foods are problematic. It’s not easy, per se, because high FODMAP foods are random! For example, cauliflower is high, while broccoli is not. Onions are high, mustard is low. Fermented dairy is high, but fresh milk is not. But remember, you should only consider a lowFODMAP diet if your symptoms are severe and you’ve tried some other easier steps first. Then, if you find you react, please go. get. tested. to find out more about your particular type of dysbiosis and how to address it so you can eat high FODMAPs again (they’re really healthy foods is why)

If you’re curious about which foods are causing you bloat, check out this cool device called the Food Marble! I’m obsessed!!

4) YOUR MMC IS BROKEN

Your migrating motor complex (MMC) is an incredible piece of the endo-belly puzzle most of you have never heard of - so gather round the fire while I tell you the story of your long lost friend, the MMC.

Your small intestine is about 20 feet long, crinkled with many pockets and folds (mucosal folds), and lined with microscopic nutrient-absorbing “seaweed” called villi. In order for your body to distribute the now pre-digested food passed on from your stomach all the way down that 20 feet of tubing requires a process called the MMC. This is also known as peristalsis. This wave of contraction and distention moves the inner contents along, churning it along the way in order to continuously present nutrients to the villi and simultaneously shake off any pockets of bacteria, yeasts, or viruses that might otherwise set up shop where they shouldn’t.

It’s like a toilet flushing every 90 minutes so grossies don’t take over, and your villi always have nutrients to feast on.

The thing is, your small intestinal MMC only functions in a fasting state, then at 90-minute intervals after that. That means about 90 min after you finish eating, you have your first MMC flush, then at 180 min your second, etc (you do the math). Problem: you eat all the time. No no, I’m not calling you a pig, just that most people can’t stop munching on food or drinks all day long, even a bite of almond or a sip of green juice will shoot your MMC timer back to zero. For some, that means your MMC doesn’t flush your belly-toilet alllll day long (think, when was the last time you ate 3 square meals/day without snacking AT ALL), and if this is consistent, then your whole MMC can break - more professionally known as MMC down regulation.

That’s why rehabbing your MMC is utterly important to your bloat, your dysbiosis, your leaky gut, and your endo. I write about HOW TO DO THIS in my fun blog here.

**Note, women with intestinal or bowel endo should be particularly aware of this issue, as endometriosis growths in the intestinal tract can also contribute to MMC downregulation.

5) STARCHES AND ENDOMETRIOSIS BLOATING

As you can see, grains have about as much fiber as veggies, but with up to 5x the starch! Too much of this type of food acts more like dysbiosis snacks than anything else, especially if you’re not properly digesting.

I write a lot about blood sugar regulation and how us endo-gals are often stuffed to the brim with excess glucose. EVEN WITH THE WOMEN THAT SAY THEY DON’T EAT SUGAR, I often see them eating tons upon tons of starches in the form of grains, beans, gluten free items and fruit. The goal isn’t to swing the pendulum to the opposite end of the spectrum (per the ever popular keto diet), it’s to shoot for a moderate amount of carbohydrates, well digested. Think of this as getting your carbs from veggies of all kinds! And then making sure those carbs are processed beautifully through your Four-Fecta! And do note, if you can’t seem to tolerate carbohydrates well at all, this is often a big ‘ol sign of more serious dysbiosis.

If you want to check out a cool way to find out your own carb threshold, learn all about the Endometriosis Honey Blood Test here.

6) CORE DYSFUNCTION

In 2013 the NYTimes asked readers’ opinions about a 15-year-old gymnast who suddenly developed an absurdly distended belly and chronic constipation. 500 specialists submitted possibilities and only 6 were in the ballpark of correct: pelvic floor dysfunction and abdominal phrenic dyssynergia. Basically, her core musculature was not functioning correctly. at all. But because there wasn’t any “organic disease” present, doctors were scratching their heads. She almost got the “IBS” diagnosis…

The core is often “trained” to be dysfunction through improper use. See, when you inhale, your diaphragm is supposed to naturally lower, your ribs relax and open, and your pelvic floor relax when you squat, fart, or poop yet be strong when you’re sitting, walking, or standing up. All this should happen synergistically without you ever having to think about it.

But then one day, you probably did think about it. You thought your tummy was fat, so you sucked it in; you thought the kegal was king and starting tensing your pelvic floor in every position thinking this was “strengthening” it; you thought a six-pack was sexy, so did a lot of crunches and ab flexing that led you to have overly strong upper abs and nada below.

The other BIG issues that contributes to core dysfunction is sitting in a chair-like fashion the majority of your life. Your core, glutes, and pelvic floor are all amigas, you see, and by using a chair to keep you upright instead of your core musculature, you train these muscles to behave incorrectly.

Because now when you stand up, these muscles have forgotten how to hold you up (their main job). Instead you rely on your ligaments, your back, your quads, all the things that shouldn’t be holding you up all the time. Welcome to bad knees, hips, ankles, and everything else, and a poochy lower belly

If this is you, your belly might look like these images on the right.

Just to bring it home, it’s estimated a whopping 1 in 3 Americans have some sort of pelvic floor or core dysfunction. For the endo community, I would argue it’s 100%… I have a neat blog on that here.

LAST) EVERYTHING ELSE

There are definitely other reasons you may have endo-belly.

Of course, there’s the endo itself. If you have severe endometriosis, it may have made it into your bowel, obliterated (even the word “obliterated “sounds painful!) your cul-de-sac, or frozen your pelvis. My own cul-de-sac area was destroyed, and going #2 could be intensely painful. Endo can wrap around and through tissues, it can appear on your intestines, and it can sear tissues together that are supposed to be mobile and free to move food through your system. When this happens, endometriosis is definitely a piece of your endo-belly puzzle. You need mobility in your abdominal organs to function properly, and bleeding in your intestinal tract is never a good thing. Plus, if it’s messing up normal function, you’re much more likely to develop other issues such a SIBO, dysbiosis, etc. So this all goes hand in hand.

As far as adenomyosis, a healthy woman is near menstruation, her uterus may grow 10-15% of its normal size as the uterine lining thickens in preparation for a potential pregnancy. This can be what causes a slightly heavy feeling in your pelvis around flow-time. For women with adeno, it’s another story. As the adeno responds to monthly hormone fluctuations, blood can swell in the myometrium, enlarging the uterus even more. The bloating feeling that comes from this is quite literally your abdomen swelling from this abnormally large uterus pushing your other organs out of place. This wouldn’t be considered bloating, but instead distention or abdominal swelling.

Then there’s stress or anxiety (yup, they can cause serious bloating if you’re chronically stressed) or even serious disease presentations such as Coeliac, Crone’s or Colitis, or - not to scare you - cancer. [Did you notice how I didn’t say IBS? That’s because I think an IBS diagnosis is usually B.S. since most doctors haven’t ruled out all other possibilities, but I’ll rant about that later]. For now know this “everything else” is worth considering if your endo-belly bloat comes with truly terrible symptoms of digestive pain, ceaseless diarrhea or constipation, fever, blood in your stool, weight-loss or anything else freaky.

TELL ME MORE! HOW DO I FIX FOUR-FECTAS? OR KNOW IF I HAVE DYSBIOSIS?

It’s important to understand there are often many issues contributing to your endo belly, and although some of you may have issues beyond your control (like stage 4 endo or adeno), many women haven’t even begun to address their Four-Fecta, dysbiosis, or leaky gut. In fact, you may be surprised that even if you do have stage 4 endo, just how much better you feel via pain, fatigue, etc when you start to address this INCREDIBLY important part of the puzzle.

If you’re curious about how to even BEGIN to address issues 1-5 from above, check out my 100 page ebook where I deep dive into everything Endo-Belly.