Irritable Bowel Syndrome (IBS) is a condition that causes millions of Americans to suffer with intestinal cramping, bloating, gas, constipation and/or diarrhea. And it affects women twice as often as men. Some women with IBS have constipation that can persist for days, weeks, or even months. Others have frequent loose stools. Alternating bouts of constipation and diarrhea are super common, and sometimes people with IBS have a crampy urge to have a bowel movement, but nothing happens. Many women patients have sent me photos of themselves looking 5-7 months pregnant – when they are not pregnant at all; it's due to bloating after a meal and has caused them substantial social embarrassment. Some of my patients have had such significant problems with gas or loose stools that they are anxious about social events, and what should be normal activities like going grocery shopping or having to travel any more than short distances for fear of needing a bathroom quickly.
If you've been there, I don't need to tell you how uncomfortable it can be. While I want us to let go of the stigma of bloating, and the eternal quest for a flat belly, I also know that you feel very real discomfort – so let's get to the bottom of that so you can be free of all that! And that is possible.
The Why and When of IBS Symptoms
About half of all women experience regular digestive discomfort, and IBS is so common that fully 30% of all referrals to a gastroenterologist are for IBS symptoms. In the past, before IBS was a recognized condition, women have been told that the problem was basically psychological (are we ever going to stop telling people it’s all in their heads just because stress can be a trigger?). It's now known that people with IBS actually have greater sensitivity in the nerves and muscle fibers in their intestines than those who don’t have it. This means they are more reactive to a variety of stimuli including certain foods, chemicals we produce under stress, and hormones. In some women, this may be hardwired genetically, but in many, if not most, it may be acquired due to a variety of factors we're gonna' talk about here.
IBS symptoms may occur just situationally, for example, before a major exam, job interview, date, or public speaking engagement, or they can occur regularly, making you uncomfortable, or even downright miserable, many times each day, though most people with IBS struggle with it regularly even without major obvious emotional triggers.
Most, though not all, IBS sufferers report that their symptoms occur or are worse after a meal. Many women report that symptoms are worse just before the start of their periods. And IBS is definitely associated with endometriosis – so much so that endometriosis is often overlooked and instead solely the IBS diagnosis gets made.
Conventional treatments include a variety of medications from antispasmodics to reduce cramping, to laxatives to control constipation, to antidepressants and anti-anxiety medications to control mood. These all provide symptomatic relief but do not get to the root causes, meaning the underlying factors that lead to the gut hypersensitivity or irritability.
The good news is that IBS does not cause permanent damage to the intestines or lead to any dangerous or life-threatening disease. But for many, it can be socially disabling and downright uncomfortable.
My experience as a practicing integrative and functional medicine doctor has shown me that there are clear causes for IBS, and that it can be cured. I’ve seen it happen so many times that I’m sometimes shocked that conventional medicine just hasn’t caught on yet.
I’m going to share with you exactly what I share with my patients about how to get to the roots of IBS, and how to move beyond it – because it doesn't have to be a permanent condition, and even if you are hardwired to have it, you can learn to identify your triggers so you can completely manage it and become symptom-free. I've seen this happen many times in my own medical practice and want more women to understand the tricks of the trade when it comes to preventing and resolving IBS – so here we go!
The Four Root Causes of Irritable Bowel Syndrome (IBS)
IBS has four main root causes: diet, food intolerances, stress, and dysbiosis (a disrupted gut microbiome) — and in knowing these, we can already see the arrow pointing us to the solutions. In most cases, there’s a combination of all or several of these going on at once. Often, one cause leads to another. For example, you might be more intolerant to dairy than you realize, and this might be the core trigger of your gas and bloating, and even your constipation or loose stools, but overtime, this intolerance also causes inflammation in your gut which in turn causes you to develop “dysbiosis” (messed up gut flora) that leads to gas, bloating, and other symptoms of IBS.
We're going to talk about each of these root causes in just a minute, so you can figure out which are affecting you. And we're going to talk about how you can restore balance so you can move beyond a life that revolves around your digestive discomforts!
Identifying Your IBS Triggers
When identifying your IBS triggers, the first thing you have to do is learn to connect the dots – that is, you have to start to pay attention to when symptoms occur. Doing this can start to clue you into some of the causes of your IBS – and each person’s are slightly unique to them, though this article reviews the common themes. One of the most effective tools for identifying your triggers is to keep a 5-day food journal. Write down what you eat at each meal and snack and then notice how you feel between 15 minutes and an hour later. You can find a downloadable Food-Mood-Symptom Chart here (free).
The amazing thing is that once you start to connect the dots between your triggers and your symptoms, you’ll realize that staying IBS-free isn’t as hard as you might think. Initially it’s a matter of paying attention to your body and knowing how to anticipate and prevent triggers, and over time, healing your gut so you have fewer triggers that you need to avoid.
IBS with constipation:
A diet high in protein and low in fiber from fruits, vegetables, and whole grains can be very constipating, so if you are predominantly constipated, increasing your intake of fruits and veggies, especially high fiber veggies -like cooked leafy greens including kale, collard greens, and broccoli – and high fiber fruits like apples, can really get your bowels going.
For IBS with constipation:
- Increase your fiber intake (30-50 grams/day) by eating a variety of veggies, ideally 2 servings per meal.
- 1-2 TBSP ground flax seed daily
- 300-600 mg of magnesium citrate before bed to get your bowels going regularly
- A probiotic
- Ginger which can which can help with intestinal motility, gas, and bloating, and amla (an Ayurvedic herb)
Additionally, certain foods trigger many people, and tend to be more problematic if you have IBS. These include: caffeine, fatty foods, and alcoholic, so pay attention to whether they trigger you and avoid them for now if they do.
IBS with loose stools:
On the other hand, if you are more prone to loose stools, fruit and veggies, especially those high in fructose, can be a major trigger for you. If a high fiber diet gets you on the run, then:
- If you are prone to loose stools, fruit and veggies can be a trigger for you. If a high fiber diet gets you on the run back down on the raw veggies and lean into steamed, etc.
- Go Fructose and Lactose free for 4 weeks, after 4 weeks reintroduce only one or the other for a week, see how you feel and if symptoms return, that's your answer, give another week and repeat with the alternate group that you hadn't yet reintroduced.
- Treat gut dysbiosis (see below)
- Ginger, which can which can help with gas and bloating
Lots of other surprising foods contain fructose and can be causing your symptoms, so follow the fructose elimination diet completely, and keep a food journal as you go to be able to track improvements or symptoms.
It's very common to have a flare of symptoms premenstrually, and as I mentioned, BS is highly associated with endometriosis, so a few specific notes on these:
- If gas, bloating, or loose stool are a problem premenstrually, you can try the “low FODMAPs gentle” plan (below) plan in this article for 3 to 5 days before your period.
- If you struggle with ‘endo-belly' – gas, bloating, loose stools, constipation, at any time in your cycle, or premenstrually, due to endometriosis, you can also try the “low FODMAPs gentle” plan (below) – low FODMAPS gentle has been shown to be helpful for endometriosis-related digestive symptoms but is too strict as a daily diet; low FODMAPS gentle is much easier to do.
One of the facts known about IBS is that “visceral hypersensitivity,” an extra-sensitive state of the intestinal lining in people with IBS, can be caused or aggravated by inflammation in the intestinal lining. Food sensitivities are one of the most common reasons for intestinal inflammation. Therefore, identifying your food triggers is key.
The most common foods that lead to intestinal irritation are gluten-containing foods (anything with wheat, barley, or rye) and gluten cross-reacting grains, especially corn and dairy products including milk, yogurt, cheese, and other milk-based products (with the exception of butter which is usually easy to tolerate).
Of note, many people who are diagnosed with IBS might actually have celiac disease that has not been diagnosed. If taking gluten out of your diet significantly improves symptoms, and adding it back in aggravates them again, then also consider whether you could have celiac disease.
An Elimination Diet, done for at least 4 weeks, along with a 4R program to heal your intestinal lining, can help relieve sensitivity to many foods, however, some folks are permanently sensitive to gluten or dairy, and might need to keep those out of the diet indefinitely. The reintroduction phase of the elimination diet can help you sort this out. If you're looking for a deeper gut healing program I highly recommend the plan in my book Hormone Intelligence and my 28-Day Gut Reset.
A “Low FODMAP Gentle” Approach for Irritable Bowel Syndrome (IBS)
If you've been searching for answers for IBS, you’ve likely heard of the Low FODMAP Diet since it's a commonly suggested diet approach in both conventional and integrative and functional medicine. If you’re unfamiliar, the Low FODMAP Diet is a diet in which you avoid foods high in specific short-chain carbohydrates which are found in many gut healthy fruits, vegetables, and legumes. Studies have shown that it may provide symptom relief for IBS, including when it’s associated with endometriosis.
But here’s the problem: While this diet may be helpful for symptoms in the short – or long-run, the overall goal is not to completely or permanently remove these foods from your diet, but to become able to tolerate them through healing your gut. Eliminating these foods indefinitely is not only extremely difficult, it’s also not optimal as it removes many healthy foods, including some of the most important foods for gut healing and long-term health like high greens, legumes and beans.
But you don't have to be that restrictive to get results. Here are two compatible options:
- A standard IBS-friendly diet has been shown to be effective at relieving IBS symptoms as effectively as stricter elimination plans, so it’s not always necessary to go to this level. This includes eating regular meals, avoiding coffee, spicy foods, and unhealthy fats, and getting ample fiber, fresh fruits and veggies, and good quality fats. This is the exact plan I give you 5 weeks of meals for in Hormone Intelligence!
- When a more advanced approach is needed, what is called a “low FODMAP Gentle” approach is excellent – it's been found to be as effective and more sustainable than a complete low FODMAP plan, since it’s far less restrictive. It removes a few foods that are the worst offenders when it comes to high FODMAP foods, including:
- Gluten containing grains (wheat, barley, rye)
- Dried fruit
- Stone fruit
Remember, this is not meant to be a long-term diet so it’s important to expand your diet using a reintroduction protocol to re-challenge these foods after about 6-8 weeks. Working with an integrative or functional nutritionist can be helpful in offering guidance.
If you’ve ever had “butterflies” in your stomach, felt like “you just couldn’t stomach something,” or if you just “knew something in your gut,” you’re probably not surprised that science has established, beyond any doubt, that there is a direct relationship between the brain and the gut. In fact, the nerves in the intestine come from the same origins as the nerves in the brain and spinal cord in the fetus, and are closely connected in adults. As a result, chemicals that affect our nervous system, mood, and emotions affect our gut, and in someone with IBS, this connection is even more sensitive. It also works the other way around – symptoms in your gut can affect your emotions! Therefore, if you have IBS, you’ll want to have a set of tools you can use to keep your inner peace as much as possible.
Mindfulness and meditation have been shown to keep moods more even and helps to relieve IBS symptoms. These don't require sitting in one place and breathing deeply for an hour – think of it more as learning to get into a tranquil mindset by using specific thoughts, images, or deep breathing to calm yourself and bring your emotions to center, while calming your gut. Here’s one of my favorite meditations, called The Quickie. You can do it anywhere, at anytime! Use mindfulness before and during your meals to eat slowly and in a relaxed, enjoyable way, rather than anxiously eating because you're anticipating symptoms after. Keep calm and don't panic is a great way to think of it!
Of course, getting to the bottom of any ongoing stresses in your life is important, too.
Western medicine has, until recently, pretty much overlooked the important role of the microbiome – the vast collection of bacteria and other organisms that live in our intestines (and outnumber us by factors of 100s!) in health. This is part of why an effective cure for IBS hasn't been “discovered” by conventional medicine. However, as our awareness of the impact of diet, lifestyle, and emotional stress on the microbiome has grown, so too have our insights into how dysbiosis, or imbalance in the microbiome, can contribute to IBS.
If you experience gas, bloating, and particularly if it’s worse after meals, you likely have dysbiosis. What is dysbiosis? It's too many of the harmful gut bugs, and not enough of the good ones. This can arise because of lack of variety in the diet, especially of high fiber vegetables, overuse of antibiotics and other medications like ibuprofen and PPIs (i.e., Prilosec) that impact the gut and gut flora health, as can prolonged stress. Most commonly, in functional medicine practice, we see conditions like SIBO, overgrowth of candida species in the intestines, and too little of the good guys like Lactobacillus and Bifidobacterium species.
Key ways to improve gut flora include
- Eliminating medications that interfere with gut flora and gut health,
- Adding fermented foods into your diet on a regular basis (saukerkraut, kimchi, miso, and if you tolerate it, yogurt or kefir), and
- Taking a daily probiotic that contains the helpful species I mentioned above.
Sometimes it is also necessary to reduce the number of the not-so-great gut bugs using herbal medicines such as Oregon grape root, oregano or thyme essential oil, or others. A couple of the products I use in my practice that contain herbs like these are Candibactin AR, which I use for gas and bloating, and Candibactin BR, which I use for SIBO. In some functional medicine practices, severe dysbiosis is also treated with anti fungal medications or a non-absorbing antibiotic. Dysbiosis is discussed more extensively in the 4R program.
Is Medical Testing Necessary?
If you have blood in your stool, then it is important to speak with a doctor because this can indicate that you have more than just IBS going on. Crohn's disease and ulcerative colitis can cause blood in your stool, as can colon cancer, whereas IBS should not (though endometriosis can, so be sure to mention the IBS -Endo connection to your doctor if you have endometriosis symptoms). However, straining to have a BM can cause hemorrhoids which lead to blood in your stool.
Many integrative and functional medicine doctors use quite a bit of extensive testing to diagnose what’s going on in your gut. This includes looking for food sensitivities with IgG and other tests, gut microbiome analysis, tests for parasites, digestive enzymes, and intestinal antibodies. I recommend giving an elimination diet 6-12 weeks, following the 4R program for this same amount of time, and only after this, if you haven’t gotten substantial relief, would I suggest pursuing testing, as it can be expensive and doesn't always provide valuable information.
The Key to Lasting Relief: Healing Your Gut
All of the above steps alone or in the combination can bring you significant or even complete relief, but if you try those for 6-12 weeks and they don’t, or you get relief but not completely, you can always grab a copy of Hormone Intelligence for an IBS friendly gut healing plan, and consider signing up for my 28-Day Gut Reset, a complete gut healing plan for women, which you can learn all about here.