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Endo-Belly: How Endometriosis Bloating and IBS Are Connected

Unpack the Links Between Endometriosis and Gut Health 

Endometriosis bloating, sometimes referred to as “endo-belly,” is an underappreciated and underrecognized symptom of endometriosis, and its cause is poorly understood. While bloating isn’t always talked about, it is a common symptom [1, 2, 3]. Between 81% and 96% of women with endometriosis experience bloating [4, 5].

The link between hormonal health and gut health is well-established, and we know that endometriosis is an estrogen-dependent condition. So it makes sense that gut health and endometriosis would be tied together. Understanding the risk factors and causes that overlap between the gut and the endometrium may help you devise a plan of action to address endometriosis bloating. 

Let’s take a look at what the research says about how endometriosis patients who experience “endo-belly” or other digestive symptoms might be able to get some relief.

Understanding Endometriosis

Endometriosis is a chronic inflammatory disease where tissue similar to the lining of the uterus implants outside of the uterus [1, 6]. This tissue (called endometrium) is the substance that sheds from inside your uterus and flows out of the vagina during menstruation [7].

Most commonly, “rogue” endometrial-like tissue will implant in the ovaries and cause blood-filled cysts, which can be extremely painful. But this tissue may also implant in the fallopian tubes, uterosacral ligaments, the gastrointestinal tract, the urinary system (ureter, bladder, urethra), and less often in pleura (tissue that covers the lungs and lines the chest cavity), pericardium (the sac that surrounds the heart), or the central nervous system [1, 6].

Endometriosis affects 10-15% of women of reproductive age, and the most common symptoms are pelvic pain and infertility. Other common symptoms of endometriosis may include [1, 2, 3]:

  • Painful intercourse (dyspareunia)
  • Painful menstruation (dysmenorrhea)
  • Bleeding between periods
  • Painful urination
  • Painful bowel movements
  • High pain sensitivity
  • Chronic lower abdominal pain
  • Chronic low back pain
  • Uterine masses

Abdominal bloating and irritable bowel syndrome (IBS) are also highly prevalent in endometriosis patients, but these symptoms are underrepresented in the literature [4, 5].

What Causes Endometriosis?

Endometriosis is thought to be caused by the backward movement of menstrual flow (staying inside and moving around, rather than exiting through the vagina), but a number of other complex theories may explain certain types as well [1]. Prior surgery, such as cesarean section or laparoscopy, may cause endometriosis that’s lodged in the abdominal wall [8]. Oxidative stress and the resulting free-radical damage, inflammation, having high estrogen and/or low progesterone, genetics, epigenetics, and environment factors all appear to play a role in the development of endometriosis [1].

Other factors that may increase your risk include beginning menses younger than the age of 12, menstrual cycles shorter than 26 days, heavy menstrual bleeding, chemical exposure, and high red-meat intake [1, 6].


Like so many chronic conditions, diagnosis of endometriosis can take some time. The average delay from onset of symptoms to diagnosis is between four and 11 years [1]. This delay is at least partially due to the fact that symptoms of endometriosis overlap with so many other conditions. 

Furthermore, there’s no biomarker test to determine a diagnosis. The best way to definitively diagnose endometriosis is through a laparoscopic procedure in which a surgeon can physically see the endometrial tissue present outside the uterus. That being said, a physical exam as well as sharing a thorough patient and family history with your gynecologist are important to help determine whether or not a laparoscopic procedure is appropriate. During a physical exam, your doctor will look at [1]:

  • Family history of endometriosis
  • Pelvic pain
  • Benign ovarian cysts
  • Previous pelvic surgery
  • Infertility
  • Tenderness on vaginal examination
  • Presence of palpable nodules, growths, fibroids, or masses
  • Immobility of the uterus

Importantly, because symptoms overlap with other health conditions, women of fertile age experiencing severe bloating, constipation, pain in the lower abdomen, or IBS symptoms should always seek medical advice to rule out endometriosis, especially if they’d like to conceive [9].

Bowel Endometriosis 

Bowel endometriosis occurs when uterine tissue escapes the uterus and infiltrates the bowel. Endometriosis usually occurs in the ovaries, however, during bowel endometriosis, endometrial-like tissue can implant in the bowel wall [10]. Roughly 3.8-37% of women with endometriosis have bowel endometriosis, making it the most common type of endometriosis outside of the pelvis [11].

The uterosacral ligaments are frequently affected in this type of endometriosis. These ligaments attach part of the uterus (the cervix) to the tailbone (sacrum) and help provide structural support/stability. Pelvic floor dysfunction (PFD) and pelvic pain are both potential problems with all forms of endometriosis, including bowel, and treating PFD through physiotherapy may help with pain relief and increase stability [12]. We’ll dive more deeply into PFD later in this article.

Symptoms of bowel endometriosis include [11]:

  • Pain during menstruation
  • Deep pain during intercourse (dyspareunia)
  • Chronic pain
  • Painful bowel movements
  • Diarrhea during menstruation
  • Blood in the stool
  • Abdominal bloating
  • Pain while sitting
  • Radiation of pain to the perineum (area between the anus and vagina)

In rare cases, a bowel obstruction may be present and require surgery. Lesions that infiltrate deeper into the bowel wall are more difficult to resolve and can result in more severe symptoms [10].

Nodules (small tumors of less than 3 cm in diameter) may be present in superficial bowel endometriosis, and while smaller nodules may not cause symptoms, larger ones can lead to pain, bloating, constipation, and diarrhea. Importantly, the authors of the study looking at nodules noted that a bowel movement led to pain relief in those with IBS but not in those with bowel endometriosis [13].

Endometriosis Bloating and IBS

While bowel endometriosis seems like the most obvious explanation for IBS-like symptoms, all types of endometriosis correlate with bloating and gut health challenges. An observational study involving 355 women found that 81% of the women with confirmed endometriosis had bloating, but only 7.5% of those had bowel endometriosis [4].

Endometriosis has a significant overlap with IBS symptoms across all types. One literature review found that endometriosis and IBS have similar disease mechanisms, including chronic inflammation, stimulation of pain receptors, mast cell activation, dysbiosis, and leaky gut [14]. Another review stated that bowel endometriosis lesions can affect the nervous system in the gut (called the enteric nervous system) and result in nausea and vomiting [11].

Women with endometriosis have a two-to-threefold increased risk of having IBS [9]. The similarities between the two conditions can increase the risk of misdiagnosis, so it’s important to give your gynecologist and gastroenterologist the full picture of your symptoms.

What Causes Endo-Belly?

Endo-belly is a non-medical shorthand for endometriosis bloating. Although there are a number of scientific guesses as to what causes it, there’s not a conclusive answer. The nodules sometimes associated with bowel endometriosis are definitely responsible for a number of gastrointestinal symptoms, but, as we mentioned before, most women with endometriosis don’t have the bowel type but still experience bloating. 

Inflammation of the enteric nervous system, stimulation of pain receptors, mast cell activation, and gut dysbiosis as a result of leaky gut may also be at least partially responsible for endo-belly [5]. It certainly makes sense that a health condition that results in gut dysbiosis would lead to bloating, but more work in this area needs to be done to better understand the links between pain and bloating. What we do know is that addressing endometriosis pain may also address the bloating, and vice versa.

How to Address Endometriosis Bloating

Much like other hormonal and gut conditions, lifestyle and dietary changes should be the first courses of action to address the discomfort of endo-belly. When eliminating food from your diet to address a health concern, start slowly so that you’re only eliminating what’s necessary rather than going super-restrictive right away. Supplements like vitamins, fish oil (omega-3 fatty acids), probiotics, and medicinal herbs may also be helpful in reducing symptoms. 

Gentle physical activity like yoga and working with a physical therapist on stabilizing the pelvic floor may also help reduce the bloating and pain associated with endometriosis. 

Dietary Changes

We noted earlier that overconsumption of red meat can lead to endometriosis, so curbing red meat consumption and replacing those calories with anti-inflammatory fruits and vegetables is a great place to start. Following a Mediterranean or Paleo-style diet is an easy-to-follow choice for reducing red meat and adding in more anti-inflammatory foods [15].

Going gluten-free is another, slightly more restrictive way to reduce inflammation in the diet and in the gut. A low-nickel diet and low FODMAP diets are even more restrictive, but both were shown in randomized clinical trials to improve both GI and endometrial symptoms. In fact, the low FODMAP diet worked better for women with symptoms of endo-belly than those with IBS alone [15].


Diets lacking in certain nutrients can lead to hormonal changes, gut dysbiosis, and inflammation. Supplementing may help fill in the nutritional gaps, reduce oxidative stress and the presence of free radicals in the body, as well as lower overall inflammation. A randomized controlled trial looked at the effects of supplementing with a multivitamin/mineral supplement, a lacto/bifido probiotic, and fish oil over a six-month time period and found that the regimen was more effective than the placebo for endometriosis-associated pain relief and improvement of quality of life [15].

Another study looking at a novel group of dietary supplements (fish oil, quercetin, niacin, methyl-folate, turmeric, and parthenium) showed that those taking it versus a linseed oil and methyl-folate combination had significant improvement in symptoms over the course of three months [15].

Probiotics alone may also help reduce menstrual pain and bloating after an eight- to 12-week course [16, 17]. Women with endometriosis have been shown to have decreased diversity of their gut bacteria compared to healthy women. Additionally, probiotics have been shown to improve dysbiosis, leaky gut, and chronic inflammation, all of which may underlie endometriosis. 

Physical Activity

The research on the efficacy of physical activity for managing endometriosis is mixed. The most effective form of exercise appears to be hatha yoga, accompanied by meditation. Based on the study, it’s unclear whether the yoga, the meditation, or the combination were responsible for reports of pain reduction in participants. However, participants in the yoga/meditation group reported a significant improvement in well-being and body image over the control group [18]. We might not have a specific protocol to recommend, but it seems that — much like everything else in our modern society — slowing down and doing some self-care is beneficial.

Physical Therapy for the Pelvic Floor

Another characteristic of endometriosis is pelvic floor dysfunction (PFD), which involves abnormal functioning of the muscles of the pelvic floor. A small study of 30 women with endometriosis found that every single participant had pelvic floor muscle spasms in addition to myofascial dysfunction, pain, and trigger points (sensitive areas of tight muscle fibers) [19]. Women with pelvic floor dysfunction have overactive muscles and difficulty relaxing their pelvic floor muscles. PFD can lead to experiencing pain during sex or general pelvic pain. 

Manual pelvic-floor therapy is designed to address adhesions and restrictions in the soft tissue mobility in the abdomen and pelvic floor — to relax the muscles, release the fascia, and reduce pain. A small study examining the effects of manual physical therapy showed significantly improved sexual function, reduced pain during sex, and reduced pain during menstruation [20].

Conventional Treatment Options

Conventional options for pain management include standard NSAID drugs like ibuprofen and naproxen, but they don’t address the root cause and may make gut symptoms worse over time. NSAIDs don’t address endometrial bloat directly and may lead to further dysbiosis. 

Surgery to remove cysts or even partial hysterectomies are also lines of conventional treatment to consider if other treatments don’t help. 

The Bottom Line

Endometriosis is typically treated in gynecology, but it overlaps significantly with the GI system, specifically in the form of IBS symptoms and endometriosis bloating. Although most endometriosis occurs in the ovaries, it may also occur in other areas of the abdomen, including the bowel. Endo-belly, the bloat associated with endometriosis, can occur in all forms of the condition, but it’s an underrecognized symptom that calls for deeper examination and greater attention.

It’s important for women of reproductive age with GI issues to talk with their doctors about an endometriosis screening in order to rule it out, as it’s a condition that’s often diagnosed years after the onset of symptoms. 

Dietary changes and the addition of supplemental support, including probiotics, vitamins, minerals, and fish oil, are some of the first changes you should make if you’re suffering from endo-belly. 

Reach out to talk with one of our clinicians at the Ruscio Institute for Functional Medicine about the best way to address your endometriosis.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.

➕ References

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