UNDERSTANDING ENDOMETRIOSIS,

IRRITABLE BOWEL

SYNDROME AND CHRONIC PELVIC PAIN

Probiotics and Digestive Health:

A Guide from The Gut Foundation

A Guide from The Gut Foundation

At a glanceEndometriosis, irritable bowel syndrome (IBS) and chronic pelvic pain are common conditions ­affecting­women­during­their­­reproductive­years.

It­can­be­difficult­to­diagnose­each­of the conditions, and some of their symptoms­overlap.­

IRRITABLE BOWEL SYNDROME

ENDOMETRIOSIS CHRONICPELVIC PAIN

There­are­often­long­delays­to­­accurate­diagnosis.

Effective­treatments­are­­available.­

A response to treatment can confirm­the­diagnosis.­

Information,­help­and­support­is­­available­for­women­­experiencing­endometriosis, IBS or chronic pelvic pain.

Back to basicsThe lower abdomen and pelvic cavity­contain­organs­of­the­­gastrointestinal­tract­(the­colon­and­rectum),­the­entire­female­reproductive­system­(including­the­uterus,­ovaries­and­Fallopian­tubes)­and­the­urinary­system­(the­­bladder).­They­are­­protected­­within­the­muscular­­abdominal­wall­and­the­bony­pelvis.­The­­pelvis­is­ attached to the lower part of the spinal­column­(backbone).

Problems­in­any­of­the­organs,­muscles,­bones­and­nerves­in­this­region­can­lead­to­pain­and­­disability.­It­can­sometimes­be­­difficult­to­identify­the­exact­­problem,­so­it­can­take­time­to­make­an­exact­diagnosis­and­work­out­the­most­effective­­treatment.

FEMALE REPRODUCTIVE SYSTEM

www.gutfoundation.com2Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 3

During the normal menstrual cycle the lining of the uterus (the endometrium) is lost through menstrual bleeding. In many women small amounts of endometrial tissue sometimes move in the wrong direction and escape into the abdominal cavity through the fallopian tubes.

EndometriosisWhat is endometriosis?

In a minority of women, the endometrial tissue­attaches­to­pelvic­organs­­including­the­ovaries,­­Fallopian­tubes,­uterus,­­bladder,­bowel­and­peritoneum­(the­lining­of­the­abdominal­­cavity).­­

The­­tissue­­develops­and­then­­continues­to­respond­to­the­­hormonal­changes­of­the­menstrual­­cycle.­

ENDOMETRIUM

What are the symptoms of endometriosis?Endometriosis can lead to a wide range­of­symptoms.

They­include:• Pelvic­pain,­especially­just­before­and­during­a­menstrual­period.­Unlike­usual­period­pain,­it­often­does not respond well to standard treatment­such­as­analgesics­and­oral contraceptives

• ­Irregular­and/or­heavy­menstrual­cycles

• ­Dyspareunia­-­pain­during­or­after­sex

• Infertility• ­Voiding­dysfunction­–­problems­with­fully­emptying­the­bladder,­leaking­associated­with­urgency,­pain­when­passing­urine,­difficulty­holding­on­when­you­have­a­full­bladder­and­having­to­go­frequently

• Pain­during­a­bowel­motion• ­Other­gastrointestinal­­symptoms,­especially­bloating,­but­also­­nausea,­constipation,­­vomiting­and­rectal­bleeding

• Bleeding­after­intercourse• Straining­at­the­beginning,­during­

and at the end of defecation and voiding

• History­of­haemorrhoids­and/or­fissures

• Rectal­pain­during­or­after­defecation

• Difficulties­in­starting­a­bowel­motion,­and­in­fully­emptying­the­rectum­and­bladder.

How common is endometriosis?About­one­in­ten­women­of­­reproductive­age­(that­is­between­the onset of periods as a ­teenager­and­menopause)­have­­endometriosis.­Not­everyone­with­endometriosis­will­have­­symptoms.

How is endometriosis diagnosed?The history of symptoms, the ­findings­on­physical­­examination­and­information­from­an­­ultrasound­of­pelvic­organs­can­suggest­the­presence­of­­endometriosis.­

Currently,­the­only­way­to­make­a­definite­diagnose­is­to­­identify­­abnormal­tissue­­during­a­­laparoscopy.­This­involves­­passing­a­thin­tubular­instrument­through­the­wall of the abdomen to physically inspect­the­pelvic­­cavity.­­

The bleeding and breakdown of endometrial tissue each month can lead to scar tissue and adhesions between pelvic organs.”

www.gutfoundation.com4Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 5

How is endometriosis managed?Treatment for endometriosis is carefully­adapted­to­the­needs­of­each­individual.­It­aims­to­reduce­pain and other symptoms, and to improve fertility for women who want­to­become­pregnant.­

Due­to­the­impact­of­endometriosis­in the abdominal and pelvic cavity,­pelvic­floor­physiotherapy­and physical activity can prove an­effective­pain­management­strategy,­particularly­in­Dysmenorrhea (period pain)

Standard­medications­like­ paracetamol and nonsteroidal ­anti-inflammatory­drugs­such­as­ibuprofen­(‘Nurofen’)­can­help­control­pain.­If­pain­relief­is­not­­effective­for­what­sems­to­be­­period­pain,­then­it­suggests­that­other­problems­might­be­the­cause.­

Hormonal treatments include standard oral contraceptive pills, progesterone-like medications, and gonadotrophin-releasing hormone agonists which regulate the menstrual cycle. The choice of the best medication will depend on person’s exact needs.”

www.gutfoundation.com6Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 7

If­the­disease­causes­severe­ problems and has not responded to other treatments, then some ­women­will­consider­­hysterectomy.­This­decision­should­not­be­taken­lightly,­and­it­is­important­to­note­that this may or may not solve the problem,­with­some­women’s­pain­persisting­after­hysterectomy.­

A­number­of­­hormonal­­treatments­can­help­to­­reduce­symptoms.­Medication­which­reduces­the­number­of­menstrual­periods,­or­stops­them­­completely,­can­reduce­the­­cyclical­changes­in­­endometrial­tissue­and­the­­resulting­­symptoms.

They­will­not­get­rid­of­the­­endometrial­tissue­that­is­already­in­place.

Surgery­such­as­excision­surgery­with an excision specialist to remove­endometrial­tissue­will­sometimes be recommended, both to­relieve­pain­and­improve­fertility.­­

Endometrial­tissue­can­re-grow­­after­­surgery,­so­symptoms­can­­occur­again­­after­a­few­years.

There­is­unlikely­to­be­a­single­cause.­Factors­that­might­­contribute­to­IBS­include:

•­­different­levels­of­­muscle­­activity­in­the­wall­of­the­­intestine­-­they­may­contract­more­strongly­or­less­strongly­than­usual

•­­differences­in­how­a­­person­­perceives­normal­muscle­­contractions­and­stretching­of­the­bowel

•­­an­attack­of­­gastroenteritis­or other infection in the past (­accounting­for­about­25%­of­cases)

• stress and anxiety• food intolerance•­­changes­in­the­bacteria­which­are­normally­present­in­the­­intestine.

Due­to­the­pelvic­floor­involvement­in the mechanisms of continence, in­IBS­the­pelvic­floor­increases­its­contraction­to­prevent­us­from­leaking­stools­and,­in­IBS,­a­dyssynergic­pelvic­floor­that­cannot­relax­will­perpetuate­the­cycle­of­IBS­by­inhibiting­the­defecatory­urge­and­contribute­to­an­incomplete­emptying­of­the­rectal­ampoule.­These­symptoms­are­also­linked­with­endometriosis.

How common is IBS?About­5-10%­of­adults­are­living­with­symptoms­of­IBS.­Up­to­30%­may have symptoms at some time in­their­lives.­More­women­than­men­experience­IBS.­

IBS is a disorder affecting the large and small intestine. It can cause cramping, abdominal pain, bloating, gas, and diarrhoea, constipation or both.

Irritable bowel syndrome (IBS)What is IBS?

IBS is called a ‘functional disorder’ as it affects the function of the intestine even though there are no obvious physical changes in the body to explain why it occurs.

What are the symptoms of IBS?Key­symptoms­of­IBS­are:

• ­abdominal­pain,­cramping­or­bloating.­It­is­usually­relieved,­­fully­or­partly,­by­passing­a­bowel­ movement

• ­an­urgent­need­to­pass­a­bowel­movement

• excess­intestinal­gas• diarrhoea or constipation, or sometimes­alternating­bouts­of­diarrhoea and constipation

• mucus­in­bowel­movements• never­bleeding• straining­at­the­beginning,­during­

and at the end of defecation• difficulties­in­starting­a­bowel­motion­and/or­fully­emptying­the­rectum

• dyspareunia­(pain­during­or­after­intercourse)­as­a­result­of­pelvic­floor­tension

• voiding­dysfunction­as­a­result­of­pelvic­floor­tension­

• history of haemorrhoids or fissures.

Symptoms­of­IBS­can­come­and­go.­They­might­­sometimes­­improve­or­even disappear completely, only to return­for­no­apparent­reason.­

Symptoms­can­be­triggered­by­some­foods­(although­true­food­­allergy­is­rarely­a­cause),­stress,­and hormones (symptoms are worse­at­particular­times­in­the­menstrual­cycle,­similar­to­­endometriosis).­

www.gutfoundation.com8Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 9

www.gutfoundation.com10Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 11

How is IBS diagnosed?Diagnosis­of­IBS­is­based­­mainly­on the distinctive pattern of ­symptoms.­

It­is­important­to­rule­out­other­possible­causes­of­­IBS-like­­symptoms,­such­as­coeliac­­disease,­bowel cancer (especially in older patients)­or­colitis.­­However,­the­tests­or­­investigations­needed­to­exclude­other­conditions­need­to­be­adapted­to­the­individual.­In­most cases, people with a typical pattern of IBS symptoms will need only­a­limited­number­of­tests.­

As symptoms of endometriosis can overlap with IBS, the possibility of endometriosis needs to be considered in women of ­reproductive­age.­

IBS­should­also­be­­considered­in­women whose main problem is chronic­pelvic­pain.

Possible­investigations­include­an­antibody­screening­test­for­coeliac­disease,­checking­for­­parasites­and­infections, and, less commonly, colonoscopy­or­­endoscopy.­

­Colonoscopy­is­­essential­if­you­have had bowel cancer or polyps, if you­have­a­strong­family­­history­of­bowel­cancer­or­polyps,­you­have­any­bleeding­from­the­bowel,­or­if­you­have­unexplained­­anaemia.

How is IBS treated?•­­Understanding­the­condition­and developing­strategies­to­cope­with­it.­If­you­have­concerns­that­some­disease may have been missed, you­should­discuss­this­openly­with­your­doctor.­­Improvement­in­symptoms­may­not­occur­­until­you­are­confident­that­serious­­diseases­have­been­excluded

•­­Identifying­factors­in­your­life­which­might­aggravate­it,­such­as­high­levels­of­stress­or­­anxiety,­drinking­too­much­­alcohol,­­medications­which­can­cause­constipation or diarrhoea, or a low level of physical activity

•­­Changes­to­your­diet,­which­should­be­based­on­healthy­­eating­and­guided­by­the­most­­troublesome­symptoms­(for­ example, constipation, diarrhoea, or­bloating­and­excessive­gas).­An accredited dietitian will be able to provide clear advice, and the­­figure­gives­some­­general­­guidance.­The­‘FODMAPS’­diet,­under­the­­guidance­of­a­dietitian,­may­help­to­identify­triggers­of­IBS­symptoms.

A­number­of­medications­and­other­preparations­are­used­in­IBS:

•­­‘Bulking­agents’­like­psyllium­(for­example­in­Metamucil),­­ispaghula­husk­derivatives­(for­example­­Fybogel)­and­sterculia-based­­products­(for­example­Alvercol)­can­be­helpful,­especially­for­ constipation

•­­Antispasmodics­such­as­ mebeverine (for example Colofac) can­reduce­pain­and­the­need­for­urgent­bowel­motions.­For­best­effect,­antispasmodics­should­be­taken­three­times­a­day,­­long-term,­rather­than­just­when­there­are­symptoms.­Other­antispasmodics­include­Buscopan­and Donnatabs

•­­Tricyclic­compounds­including­amitriptyline (Tryptanol) were ­developed­as­antidepressants,­but­when­they­are­used­in­low­doses­they­have­a­separate­effect­on­nerves­and­muscles­in­the­bowel­and­bladder,­and­are­often­helpful­in­relieving­pain

• If the main problem is watery diarrhoea­then­medications­such­as­loperamide­(Imodium)­and­­Lomotil­are­often­useful

•­­Iberogast­is­a­mixture­of­nine­ medicinal herbal extracts that help­to­restore­gut­functioning­and relieve the discomfort of IBS, ­especially­bloating

• Some people with IBS have found­that­probiotics­can­reduce­­symptoms.­More­information­is­still­needed­on­which­specific­organisms,­and­what­doses,­are­­effective.

Diarrhoea

Bloating/Flatulence

GeneralIBS AdviceStop­unnecessary­restrictions

Don’t­over­eat­at­meals

Regular­meal­pattern

Healthy­eating

Consume­plenty­of­fluids

Take­time­at­meals­chewing­foods­properly

Reduce­dietary­soluble­fibre­to­ tolerance level

Reducing­some­of­the­FODMAP­foods­may­be­useful

Minimise­irritants­(caffeine,­spicy­food,­fatty­foods,­alcohol,­&­sweeteners­e.g.­sorbitol/fructose)

ConstipationIncrease­soluble­fibre­(fruits,­veg,­ legumes,­oats­&­barley)

Increase­fluid­intake

If­experiencing­symptoms­of­­constipation­alone­increase­intake­of­all­sources­of­fibre­(bran,­fruit­and­veg­with­skins),­along­with­fluid

Reduce­‘windy’­vegetables­

(brassicas,­onion­&­pulses)

Reduce­alcohol

Reducing­some­of­the­FODMAP­foods­may­be­useful

Reduce­resistant­starch­(cooked­and­cooled potato, pasta, ready meals, & processed foods)

IBS and endometriosisHealth­professionals­might­not­think­of­endometriosis­when­a­woman­first­seeks­help­for­­gastrointestinal­symptoms.­Symptoms­such­as­bloating­and­pelvic­pain­can­occur­in­both­conditions.

•­­In­an­Australian­study­of­­women­with­suspected­­endometriosis,­90%­had­gastrointestinal­­symptoms­and­about­20%­had­­previously­been­diagnosed­with­IBS.­Bloating­was­the­most­­common­­gastrointestinal­­symptom,­followed­by­nausea,­constipation,­diarrhoea,­vomiting­and­rectal­bleeding.

•­­A­summary­of­13­different­­studies­concluded­that­women­with­ endometriosis are two or three times­more­likely­to­also­have­IBS­compared­to­women­­without­­endometriosis.

www.gutfoundation.com12Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 13

How common is chronic pelvic pain?Estimates of the proportion of women who experience chronic pelvic­pain­range­from­15%­to­25%.­

What are the symptoms of chronic pelvic pain? The­features­of­chronic­pelvic­pain can­vary­widely­between­women.­It­may be felt across the entire pelvic region,­but­is­sometimes­focussed­in­a­single­spot.­It­can­be­mild­or­severe,­persistent­throughout­the­day­or­intermittent,­either­dull­or­sharp,­and­sometimes­cause­a­sensation­of­cramping.­It­can­be­associated­with­pain­during­sex,­pain­while­having­a­bowel­­movement­or­­urinating,­or­pain­when­sitting­for­long­periods­of­time.­

How is chronic pelvic pain diagnosed?The­pathway­to­effective­­treatment­of chronic pelvic pain depends on an­accurate­­diagnosis.­

Possible­causes­which­may­need­to­be­­investigated­include­the­­following:

• Period pain is very common, ­affecting­more­than­90%­of­­women.­Muscles­of­the­uterus­tighten,­causing­cramping­or­heaviness in the pelvic area, lower abdomen­or­lower­back.­It­needs­to be assessed in more detail if it­lasts­longer­than­a­few­days­and does not improve despite taking­pain­relief­or­taking­oral­­contraceptives.­

•­­Endometriosis­often­causes­­pelvic­pain,­especially­around­the­time­of­a­menstrual­period.

Chronic pelvic painWhat is chronic pelvic pain?

Chronic pelvic pain is pain in the lower abdomen and pelvic region that is present on most days for six months or more. It can be a symptom of a specific disease that can be diagnosed or treated. In some cases no specific cause can be found, so the goal of treatment is to reduce pain and other symptoms and improve quality of life.

• Adenomyosis is similar to endometriosis, except that cells from­the­endometrium­grow­into­the­inner­muscle­layer­of­the­uterus.­Symptoms­include­­abnormal­or­heavy­menstrual­­bleeding,­painful­periods­and­­painful­sex.

• Irritable bowel syndrome can cause­bloating,­constipation­and­diarrhoea, which can lead to ­pelvic­pain.­

•­­Muscle,­joint­and­bone­pain­can­occur­in­the­pelvic­­region.­­Conditions­that­can­cause­­problems­include­pelvic­floor­­muscle­tension,­inflammation­of­the­pubic­joint,­and­pain­affecting­the­lower­spine.­

• Urinary tract infections (UTIs) are very common in women and typically­cause­a­burning­pain­when­passing­urine,­often­with­more widespread pelvic or lower ­abdominal­pain.

•­­Interstitial­cystitis­­(painful­­bladder­syndrome)­causes­­recurrent­pain­and­a­frequent­need­to­urinate.­Pain often increases as the bladder­fills­up,­and­then­­­­reduces­as­the­bladder­is­emptied.

•­­Psychological­factors­such­as­depression, stress or a history of abuse­can­increase­the­risk­of­all­types­of­pain.­Emotional­distress­can­worsen­pain,­which­in­turn­worsens­the­distress,­leading­to­a­vicious­cycle.

•­­Some­pelvic­pain­is­due­to­low­back­problems­and­can­be­­reproduced­by­bending­to­the­right­or­left­or­hyperextending.­There may also be tenderness over­the­sacroiliac­joints.­Physiotherapy­is­the­answer.

www.gutfoundation.com14Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 15

Flexion Extension Lateral Bending

The tests and investigations used to diagnose a specific cause of chronic pelvic pain will depend on each woman’s pattern of symptoms, history of problems and other individual considerations.

They might include a physical examination, laboratory tests, ultrasound and other imaging such as CT or MRI, and perhaps laparoscopy to check for conditions such as endometriosis.

Remember, though, that a clear explanation might never be found.

How is chronic pelvic pain treated?

If­it­is­possible­to­pinpoint­a­specific­cause,­such­as­endometriosis­or­IBS,­then­treatment­will­focus­on­that­cause.­If­a­cause­cannot­be­identified,­then­treatment­is­likely­to­include­a­number­of­strategies­to­reduce­pain­and­improve­quality­of­life.­For­many­women,­the­best­outcomes­will­require­a­multidisciplinary­team­providing­a­combination­of­treatments.

Medications may be recommended, depending­on­the­cause:

•­­Pain­relievers­are­­often­the­first­step,­starting­with­­over-the-counter­products­and­then­trialling­­prescription­­products­if­needed.­However, pain relievers alone a ­rarely­a­complete­­solution

•­­Hormonal­treatments­including­oral contraceptives can help relieve pain that is associated with the­menstrual­cycle

•­­If­an­infection­is­identified­as­a­cause,­then­it­might­need­ antibiotic treatment

• Some antidepressants can be helpful­for­chronic­pain,­even­for­people who are not depressed

• Medications for endometriosis and IBS­have­been­discussed­­earlier.­

Other approaches to treatment ­include­physiotherapy­(once­again,­focussing­on­the­cause),­­trigger-point­injections­of­­long-acting­anaesthetic­(if­a­­specific­trigger­point­can­be­found),­and­psychological­­­therapies­to­­reduce­anxiety­and­develop­­strategies­to­cope­with­persistent­pain.­­

www.gutfoundation.com16Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 17

Olivia Briggs, aged 26, is well acquainted with the issue of chronic pelvic pain.

Starting at 11 at the commencement of menstruation, her pain was so severe that she regularly experienced cramping, fainting and vomiting.

It was not until she was 18 that she was finally diagnosed with endometriosis.

“Not­knowing­what­was­wrong­with­me­and­being­told­I­just­had­‘bad­periods’­was­really­tough,”­she­says.­“It­was­a­relief­to­be­able­to­put­a­name­to­my­pain­and­to­find­a­way­forward.­It­turned­out­I­was­riddled­with­endometriosis­from­my­uterus­to­my­diaphragm.­No­wonder­I­was­in­so­much­pain!”

Olivia’s­experience­of­seven­years­from the onset of symptoms, to a diagnosis­of­endometriosis­is­right­on­average­according­to­a­study­by­Oxford Academic*.

Olivia­is­unfortunate­to­have­a­range­of other health conditions, two of which are irritable bowel syndrome and­chronic­pelvic­pain.­She­says­she­can’t­remember­when­she­last­had­a­day­without­pain.

“It’s­hard­to­hold­down­a­job­when­you­have­to­take­so­much­time­off­for­flare­ups­or­surgeries,”­she­says.­“My­present­employer­is­very­understanding,­but­in­the­past,­I­have had to leave jobs where they either­didn’t­believe­me,­or­they­couldn’t­afford­to­give­me­more­time­off.

People­don’t­really­understand­Endometriosis and Irritable Bowel Syndrome­and­I­have­had­to­educate­a­lot­of­people­about­the­conditions.­It’s­also­expensive­and­socially­difficult,­but­through­pain­therapy,­I­have­learnt­to­master­my­thinking­and­reshape­how­I­live­with­my­pain.­It’s­a­part­of­me,­but­it­does­not­define­me.

“For­so­long­I­doubted­myself­and­what­my­body­was­telling­me,­but­getting­official­diagnoses­really­helped­to­understand­my­conditions­and­find­ways­to­live­with­them.­I­have­developed­true­grit­and­resilience­and­I’m­proud­to­say­I­hiked­over­800kms­on­the­Camino­de­Santiago­trail­in­Spain­in­2016­-­that­was­a­real­achievement.

I­hope­this­new­report­from­The­Gut­Foundation­will­help­women­like­me­get­a­quicker,­more­accurate­diagnosis­paired­with­the­correct­treatment,­so­they­don’t­have­to experience so many years of unnecessary­chronic­pelvic­pain.­My­hope­is­that­with­education,­women­will­be­equipped­with­more­knowledge­about­their­symptoms­so­they­can­ask­the­right­questions­to­help­reduce­their­pain­and­suffering.”

www.gutfoundation.com18Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 19

Elle Watmough is on a mission to educate women about getting to the bottom of chronic pelvic pain.

For years she suffered from excruciating periods which caused pain in her pelvic area, back and legs. She was told she just had ‘bad periods’ and there wasn’t much that could be done about it.

She­had­also­been­trying­unsuccessfully­to­get­pregnant­for­four­years­and­went­through­10­IVF­procedures.

Finally,­after­doing­her­own­extensive­research,­she­asked­her­doctor­if­endometriosis­might­be­the­problem.­Investigative­surgery­revealed­that­was­indeed­the­case­and­she­had­such­bad­endometriosis that some of her organs­had­fused­together.

Following­a­seven-hour­surgery­to­remove the endometriosis, Elle fell pregnant­on­her­11th­IVF­cycle­and­her­daughter­Jagger,­(now­aged­four)­was­born.

“I­want­girls­and­women­to­know­that­menstruation­pain­shouldn’t­be­agonising,­and­if­it­is,­then­ask­your­doctor­if­it­might­be­endometriosis­or­some­other­issue­such­as­irritable­bowel­syndrome­causing­of­your­pain,”­says­Elle.

“Once­I­knew­what­the­problem­was,­at­least­I­could­do­something­about­it,”­says­Elle.­“It­would­have­saved­me­and­my­husband,­Anthony,­years­of­angst,­heartache­and­many­thousands­of­dollars­had­I­been­accurately­diagnosed­in­the­first­place.

We­absolutely­adore­and­love­Jagger,­but­I­can’t­bear­to­go­through­the­whole­IVF­process­again,­so­we­won’t­have­any­more­children.­I­hope­with­more­education,­that­women­will­be­empowered­with­knowledge­to­ask­the­pertinent­questions­about­their­health,­so­they­can­start­to­get­on the road to recovery, or at least to­access­the­right­treatments­to­lessen­their­suffering.”

www.gutfoundation.com20Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 21

www.gutfoundation.com22Understanding­endometriosis,­irritable bowel syndrome and chronic pelvic pain 23

The Gut Foundation Board.Our Board is made up of Gastroenterologists and a number of professionals from various fields, that are dedicated to improving the digestive health of all Australians through the treatment and prevention of gastrointestinal diseases and conditions.

The Gut Foundation’s mission is to improve the digestive health of all Australians.Through this mission we aim to prevent gastrointestinal conditions and disease through research and increased awareness about prevention, detection and treatment.

Founded­by­Professor­Terry­Bolin­&­the­Gastroenterological­Society­of­Australia­in­1983,­The­Gut­Foundation­was­created­to­help­in­the­prevention­of­disease­through­research­and­education.­

The­Foundation­is­a­not­for­profit­organisation­specialising­in­research­and­education­into­all­aspects­of­gastrointestinal­and­digestive­health,­for­both­the­public­and­fellow­medical­practitioners.

The­Gut­Foundation­works­with­researchers and health professionals all­over­Australia,­to­build­awareness,­improve­community­understanding,­educate,­improve­screening­for­digestive­diseases,­improve standards in practice and research­and­to­engage­in,­and­encourage,­scientific­research­in­relation­to­digestive­disease.

The Importance of digestive health:

The­complexity­of­the­gut­and­its­importance­to­our­overall­health­and­well­being­is­a­topic­of­increasing­research­in­the­medical­community.­

Largely­responsible­for­the­critical­functions­of­the­body’s­digestive­and­immune­systems,­beneficial­bacteria­in­your­digestive­system­have­the­capability­of­affecting­your­body’s­vitamin­and­mineral­absorbency,­hormone­regulation,­digestion,­vitamin­production,­immune­response­as­well­as­your­body’s­ability­to­eliminate­toxins.

Our­educational­and­medical­efforts­focus­on­primary­prevention­through­recommended dietary and lifestyle changes­for­all.

Martin CooperBA LLM

Secretary of The Gut Foundation

Professor Emad M El-Omar

BSc (Hons) MB ChB

Dr Ross WalkerMB.­BS­(hons),­FRACP,­FCSANZ

Professor Terry BolinMD(NSW)­BS(Syd)­FRACP­

FRCP(Lond)­FRCP(Edin)­DCH(Lond)President & Founder of The

Gut Foundation

David CambridgeB.Bus­(Acct.­/­Fin),­CPA,­CTA

Treasurer of The Gut Foundation

Dr Fiona NicholsonMBBS­FRACP­PhD

Paul NicolaouBA,­MCom­(UNSW)­FAMI­CPM

Professor Melvyn G Korman

MB­BS(hons)­PhD­FRACP

Eliza CurbyCEO of The Gut Foundation

Dr Jeffery L EngelmanMB­BS(Hons)­FRACP­MD

Fady DaherB.­Ec

Contributors & AcknowledgmentsProfessor Terry Bolin OAMAssociate­Professor­of­Medicine­at­UNSWConsultant­Emeritus,­The­Prince­of­Wales­Hospital­Sydney,­Australia.MD(NSW),­BS(SYD),­FRACP,­FRCP(Lond),­AGAF,­FACG­FRCP(Edin),­DCH(Lond)

Professor George CondousAssociate­Professor­of­Gynaecology­&­Head­of­Discipline­of­Obstetrics­and­Gynaecology,­Sydney­Medical­School­Nepean,­University­of­Sydney.MBBS­(Adel),­FRANZCOG,­FRCOG,­MD­(Lon)­

Professor Emad El-OmarProfessor­of­Medicine­at­UNSWConsultant­Physician,­St­George­Hospital,­Kogarah,­Australia.BSc­(Hons),­MBChB,­MD­(Hons),­FRCP­(Edin),­FRSE,­FRACP

Chloe McLeodAccredited­Practicing­Dietitian,­Advanced­Sports­Dietitian.Bachelor­Nutrition­&­Dietetics,­Master­Public­Health

Martyn BakerGeneral­Practitioner,­Obstetrics­&­Gynaecology,­Hypnotherapy,­Musculo-skeletal­medicine.MA, MB BChir, D Obst RCOG, DCH

Aline FilipePractising­Pelvic­Floor­PhysiotherapistCommittee­member­of­the­APAWMPH­group­BSc.­Physiotherapy­(Portugal)­,­PGDip.­Women’s­Health­Physiotherapy­(Portugal),­MClinPhysio­(Curtin-­majoring­in­Continence­and­Women’s­Health,­TBC­2020)

SourcesAmerican College of Obstetricians and Gynecologists. Endometriosis.https://www.acog.org/patient-resources/faqs/gynecologic-problems Enck P et al. Irritable bowel syndrome. Nat­Rev­Dis­Primers­2016;­2:­16014.­

Evans S. Management of persistent pelvic pain in girls and women. Australian­Family­Physician­2015;­44:­454-459.

Gut Foundation. Irritable bowel syndrome. Diagnosis­and­management.­

Jean Hailes Foundation. Pelvic pain. https://www.jeanhailes.org.au/news/pelvic-pain-know-the-differences-and-when-to-seek-help

Maroun P et al. Relevance of gastrointestinal symptoms in endometriosis. Aust­N­Z­J­Obstet­Gynaecol­2009;­49:­411–414.­

Mayo Clinic. Chronic pelvic pain in women. https://www.mayoclinic.org/diseases-­conditions/chronic-pelvic-pain/symptoms-causes/syc-20354368­Saidi­K­et­al.­A­systematic­review­and­meta-analysis­of­the­associations between endometriosis and irritable bowel syndrome.­Eur­J­Obstet­Gynecol­Reprod­Biol­2020;­246:­99–105.

Zondervan KT et al. Endometriosis. Nat­Rev­Dis­Primers.­2018;­4:­9.

The Gut Foundation

Level­2,­194­-­204­Pitt­St,­SYDNEY­NSW­200002­9287­6455gutfoundation.com.au

Probiotics and Digestive Health:

A Guide from The Gut Foundation

This contribution is facilitated by the support of Susan Maple-Brown AM & editorial commentary by Tony James

Disclaimer: This­document­has­been­prepared­by­The­Gut­Foundation­and­every­care­has­been­taken­in­its­compilation.­The­booklet­is­intended­to­be­used­as­a­guide­only­and­is­not­an­authoritative­statement­of­every­conceivable­step­or­circumstance­which­may­or­could­relate­to­the­management­of­Endometriosis,­Irritable­Bowel­Syndrome­and­Chronic­Pelvic­Pain.­The­Gut­Foundation­and­the­compilers­of­this­document­shall­not­be­liable­to­users­of­the­document­nor­to­any­other­person,­firm,­company­or­other­body­for­any­loss,­direct,­indirect­or­consequential,­on­whatsoever­account­for­any­omission­or­negligent­mis-statement­contained­therein­or­by­reason­of,­arising­from­or­in­relation­to­any­such­user,­by­any­other­person,­company­or­body­relying­or­acting­upon­or­purporting­to­rely­or­act­upon­any­matter­contained­therein­or­arising­thereout.­This­publication­is­copyright­and­all­rights­reserved.­No­part­of­this­publication­may­be­reproduced,­stored­in­a­retrieval­system,­transmitted,­reported­or­copies­in­any­form­or­by­any­means,­electronic,­mechanical­or­otherwise,­without­prior­written­permission­of­The­Gut­Foundation.­The­information­contained­within­this­document­should­not­be­considered­to­be­a­substitute­for­the­advice­of­a­health­care­professional.­©Copyright­2020­The­Gut­Foundation­ABN­14­084­315­380