Bloating is a common and often uncomfortable symptom, and it’s nearly synonymous with PMS. But, is bloating normal, or does it signify a deeper underlying problem such as a hormone imbalance?
In clinical practice, I find that many of my patients use the word “bloating” to refer to different things. Sometimes, “bloating” refers to water retention, sort of like swelling of hands, fingers, feet, face and toes. That’s not what we’re talking about in this post. Rather, in this post, we will use the term “bloating” to refer to the sensation of distension and fullness in the abdomen, typically the lower abdomen, but it can also include the abdomen as a whole.
The sensation of fullness, discomfort, and even distension in the abdomen can be caused by several factors related to hormonal imbalances, inflammation, and other structural or functional issues in the reproductive system. Understanding how conditions like endometriosis, polycystic ovary syndrome (PCOS), ovarian cysts, fibroids, and pelvic floor dysfunction contribute to bloating can help identify the underlying causes of their symptoms and explore effective treatment options.
The Connection Between Reproductive Hormones and Bloating
When it comes to the pelvis and the organs that reside there, structure determines function. And, as I like to say in functional medicine, chemistry likewise determines structure. Swelling and inflammation of the uterus, cystic changes of the ovaries, as well as changes in bowel habits can all be driven by disruptions and imbalances in hormonal systems of the body.
Let’as take a look at how hormonal imbalances play a role in strutural changes that create the symptom of bloating.
1. Endometriosis and Inflammation-Induced Bloating
Endometriosis is a chronic condition in which tissue similar to the lining of the uterus (endometrium) grows outside the uterus, typically on the ovaries, fallopian tubes, and other organs within the pelvic cavity. This growth of endometrial-like tissue leads to inflammation, pain, and a variety of gastrointestinal and reproductive symptoms, including bloating.
How inflammation contributes to bloating: Endometriosis causes the release of pro-inflammatory cytokines and other immune system factors that promote inflammation in the pelvic area (Wang et al., 2018). This inflammation can disrupt the normal functioning of the gastrointestinal tract, leading to symptoms like bloating, constipation, and diarrhea. Additionally, the endometrial tissue outside the uterus can create adhesions, which can lead to intestinal obstruction and further contribute to bloating (Viganò et al., 2004) through inflammatory immune chemicals. Whenever inflammatory immune chemicals are released, water retention follows.
In endometriosis, bloating can sometimes be severe, so much so that it has its own nickname: endo-belly.
Treatment for bloating caused by endometriosis is complex, involving many factors including food sensitivities, gut health and the immune system. However, being an autoimmune, inflammatory condition, addressing endo-belly in my practice often involves proteolytic enzymes as well as anti-inflammatory, estrogen-clearing herbs and medications, like DHA and DIM.
2. Polycystic Ovary Syndrome (PCOS) and Blood Sugar Dysregulation-Related Bloating
Polycystic ovary syndrome (PCOS) is a hormonal disorder that affects women of reproductive age. It is characterized by irregular menstrual cycles, elevated levels of androgens (male hormones like testosterone), and cysts on the ovaries. One of the less-discussed but significant features of PCOS is blood sugar dysregulation, which can contribute to bloating because of the profound inflammation that accompanies it.
How blood sugar dysregulation contributes to bloating: in nearly 70% of cases, insulin resistance accompanies PCOS, which is a condition where the body’s cells become less responsive to insulin, leading to higher levels of circulating insulin (Teede et al., 2018). Insulin resistance disrupts normal carbohydrate metabolism, causing blood sugar levels to fluctuate. This can lead to gastrointestinal discomfort, bloating, and indigestion, especially after meals that are high in refined carbohydrates or sugars.
Additionally, insulin resistance affects gut motility, leading to slower digestion and bloating. The imbalance of estrogen and progesterone in PCOS also exacerbates gut symptoms, as these hormones influence how the gut functions (McAllister et al., 2020). Women with PCOS often report feeling bloated around the time of their period or after consuming certain foods. Elevated estrogen levels seen in PCOS negatiely impact the ability of the gut to clear inflammation and toxins, which leads to build-up of these chemicals in the body.
Concerned you have a hormone imbalance but not sure how to find out? Download my FREE hormone guide to figure out your symptoms once and for all!
In my practice, treating PCOS means first identifying which type of PCOS is present. Did you know there are 4 types of PCOS? Learn more in this blog post.
3. Ovarian Cysts and Fibroids: Structural Issues Leading to Bloating
Ovarian cysts and uterine fibroids are both structural issues that contribute to bloating, particularly in individuals with hormonal imbalances. In these cases the bloating doesn’t come from gas, inflammation or fluid, but of structural changes and growth that take up physical space. Both cysts and fibroids are diagnosed with ultraosund imaging.
Ovarian cysts: Ovarian cysts are fluid-filled sacs that form on or within the ovaries. These cysts can be functional (normal and temporary) or pathological (abnormal and persistent). Functional cysts typically resolve on their own, but large or persistent cysts can cause bloating, pelvic pain, and pressure on nearby organs. As cysts grow, they can push against the abdominal wall and intestines, leading to discomfort and a feeling of fullness or bloating (Sahu et al., 2017). Sometimes, surgery is required to remove large or complicated ovarian cysts. Iodine deficiency, use of hormonal IUDs, hypothyroidism and perimenopause all increase risk of developing functional ovarian cysts.
Uterine fibroids: Fibroids are benign growths in or on the uterus that can vary in size and location. Large fibroids or multiple fibroids can cause significant abdominal bloating, pressure, and pain. Fibroids can disrupt the normal movement of the gastrointestinal tract and cause a sensation of fullness, bloating, and even constipation (Lethaby et al., 2015). Hormonal fluctuations, particularly high estrogen levels, contribute to the growth of fibroids, making the condition more likely to cause bloating in individuals with hormonal imbalances.
The presence of these structural issues can also cause other symptoms like heavy menstrual bleeding, pelvic pain, and lower back discomfort, which can be exacerbated by bloating.
4. Pelvic Floor Dysfunction and Bloating
Pelvic floor dysfunction refers to a range of conditions where the muscles of the pelvic floor (the muscles that support the bladder, uterus, and rectum) become weak or overactive. This dysfunction can lead to symptoms like urinary incontinence, pelvic pain, and bloating. It also can affect passage of stool, which can trap gas or cause constipation, both of which also contribute to abdominal bloating.
How pelvic floor dysfunction contributes to bloating: When the pelvic floor muscles are not functioning properly, it can affect the body’s ability to manage intra-abdominal pressure, especially during digestion.
Individuals with pelvic floor dysfunction may also experience bloating related to the inability to properly relax the pelvic floor muscles during defecation, leading to a buildup of gas in the intestines and the sensation of bloating. The pelvic floor muscles play an essential role in normal bowel and bladder function, so dysfunction can lead to a cascade of digestive symptoms.
The best treatment for pelvic floor dysfunction is to see a pelvic floor therapist. You can find a physical therapist, chiropractor or occupational therapist of this credentialing through the Herman and Wallace Website. (This is the best, most renowned training program for pelvic floor therapists.)
How Functional Medicine Approaches Hormonal Disorders and Bloating
Functional medicine emphasizes addressing the root causes of health problems, including hormonal imbalances, inflammation, blood sugar dysregulation, and structural issues. When it comes to bloating related to reproductive hormone disorders, a functional medicine approach may include:
- Addressing hormonal imbalances: Through personalized treatments like bioidentical hormone therapy, herbal supplements, and lifestyle changes, functional medicinebalances hormones such as estrogen, progesterone, and testosterone. For example, in PCOS, regulating insulin resistance and restoring hormone balance can reduce bloating and other symptoms (Moran et al., 2015).
- Reducing inflammation: Anti-inflammatory approaches are crucial in managing conditions like endometriosis. Functional medicine often recommends dietary changes, such as increasing omega-3 fatty acids and reducing inflammatory foods (e.g., refined sugars and ultra-processed foods), as well as using herbal supplements like enzymes and curcumin to help reduce inflammation and manage symptoms.
- Improving gut health: Gut dysbiosis (an imbalance of gut bacteria) can contribute to bloating. Functional medicine also involves the use of probiotics, prebiotics, and digestive enzymes to support gut health. Additionally, an elimination diet or food sensitivity testing may help identify specific triggers that exacerbate bloating (Bartz et al., 2020).
- Supporting pelvic floor health: Pelvic floor exercises, like Kegels, stretching and physical therapy, and mindful movement techniques, can help address pelvic floor dysfunction.
Bloating can be a frustrating and uncomfortable symptom, especially when it is linked to hormonal disorders such as endometriosis, PCOS, ovarian cysts, fibroids, and pelvic floor dysfunction. The underlying causes of bloating are multifactorial, which is why understanding the root cause is essential for making progress. A functional medicine approach to treating bloating focuses on restoring hormonal balance, reducing inflammation, improving gut health, and addressing any structural or functional problems that may contribute to digestive distress.
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I’m Dr. Alexandra MacKillop, a functional medicine physician, food scientist and nutrition expert.
I specialize in women’s health & hormones, addressing concerns like fertility, PCOS, endometriosis, dysmenorrhea (painful periods), PMS symptoms like bloating and mood changes and more.
If you’re looking for a new way to approach your health, I’m here to help you through it. Click to learn more.
References
Bartz, D., et al. (2020). Gut health and its link to the reproductive system. Journal of Women’s Health, 29(7), 900-912. https://doi.org/10.1089/jwh.2020.8184
Berg, E., et al. (2015). The role of pelvic floor dysfunction in gastrointestinal disorders. The Journal of Gastrointestinal Surgery, 19(8), 1461-1469. https://doi.org/10.1007/s11605-015-2855-9
Lethaby, A., et al. (2015). Uterine fibroids and bloating: A systematic review of symptoms and treatments. Cochrane Database of Systematic Reviews, 3, CD010747. https://doi.org/10.1002/14651858.CD010747.pub2
McAllister, K., et al. (2020). PCOS and its relationship to gastrointestinal symptoms. European Journal of Endocrinology, 183(3), 277-283. https://doi.org/10.1530/EJE-20-0296
Moran, L., et al. (2015). Insulin resistance and obesity in PCOS. Endocrinology and Metabolism Clinics of North America, 44(3), 373-385. https://doi.org/10.1016/j.ecl.2015.04.003
Sahu, A., et al. (2017). Ovarian cysts and their impact on abdominal bloating. The Journal of Reproductive Medicine, 62(7), 543-551.
Teede, H. J., et al. (2018). PCOS and insulin resistance. International Journal of Obesity, 42(8), 1367-1377. https://doi.org/10.1038/s41366-018-0094-4
Viganò, P., et al. (2004). Endometriosis and gastrointestinal symptoms. The Journal of Reproductive Medicine, 49(6), 437-442.
Wang, X., et al. (2018). Inflammatory mediators in endometriosis. International Journal of Inflammation, 2018, 8478049. https://doi.org/10.1155/2018/8478049
Zhang, H., et al. (2019). The role of turmeric in reducing inflammation in endometriosis. Journal of Pain Research, 12, 513-524. https://doi.org/10.2147/JPR.S215752