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Well Poop! Menopause and Your Guts

During menopause, many women experience a range of gastrointestinal (GI) issues, including bloating, gas, acid reflux, constipation, and diarrhea. Some of the GI symptoms can be explained by aging, but some are clearly linked to the the menopausal decrease in estrogen and progesterone. The presence of estrogen receptors throughout the gut and progesterone receptors in the colon point to a direct effect of sex hormones on digestion and absorption. In addition, estrogen and progesterone participate in the production of the stomach acid and bile that is necessary to break down food. We know that stress, sleep, and exercise also have profound effects on gut function, and evidence is clear that menopause can negatively impact all of them. A weakened pelvic floor and/or medications used by mid-life and older women for common health conditions can also negatively effect gut health.

Women have estrogen and progesterone receptors throughout their bodies, including in their brains and guts. For menopausal women, reduced levels of estrogen and progesterone cause slowing of food through the gut, which increases the likelihood of constipation, gas, and bloating. When the digestive process takes longer, more water can be reabsorbed back into the bloodstream which makes poop harder, drier, and more difficult to pass. Decreases in estrogen and progesterone also can cause bile in the gallbladder to become more concentrated, which slows emptying of the bile into the gut. Gallstones can develop as a result. Additionally, reduced bile secretion can decrease the breakdown of fat in the gut, which can lead to diarrhea.

Estrogen helps women keep their cortisol levels low. Cortisol is a stress hormone that, among other things, slows the digestive system so that blood and energy can be devoted to other systems more essential in fight-or flight situations. The reduction in estrogen in menopausal women means that cortisol is less controlled, which can lead to constipation. Cortisol also can cause relaxation of the colon, which can lead to diarrhea.

Some postmenopausal women also have weakened pelvic floor muscles. This can make it difficult to eliminate stool, especially when it is hard and dry. And as women age, they may also use medications that can be constipating. Common examples are blood pressure medication, iron supplements, antidepressants, pain medication, and thyroid medication.

Studies show that women with pre-existing GI disorders, like IBS, tend to get worse during menopause. The same findings are not observed in age-matched men, suggesting that the hormone changes during menopause may be responsible for the worsening symptoms. A recent study demonstrated a correlation between some menopause symptoms, like hot flashes, and GI disruption. In the study, women with constipation experienced more severe menopause symptoms. In the same study, researchers also found that women who self-reported experiencing more stress were more likely to have more severe menopause symptoms. More research is necessary to determine the exact physiological mechanisms involved.

What can you do to improve your GI symptoms? Evidence is clear that women who exercise regularly are less likely to experience constipation.We also know that a diet high in fiber decreases constipation since fiber absorbs water which makes stools easier to pass. You should eat more whole grains, fruits, vegetables, beans and peas, and nuts and seeds. You also can use a fiber supplement - Metamucil, Citrucel and FiberCon - but supplements don't have a variety of fiber types or the vitamins and minerals that you can get from eating whole foods. Supplemental magnesium can help with constipation by drawing water into the bowels which softens the stool and improves motility. I recommend staring with a dose of 180 mg/day of magnesium malate. You can increase the dose to 360 mg/day if needed. Getting adequate sleep (at least 7 hours per night) can reduce stress (and cortisol levels) which can help with proper gut performance. Staying properly hydrated also is important to reduce the risk of GI symptoms. Finally, stress relief should be a significant focus of a menopausal woman's life. Without estrogen to help control cortisol levels, menopausal women are more prone to a variety of health issues, including GI disturbances. Find a stress relief outlet that works for you - meditation, breathwork, yoga, hypnosis, behavioral therapy - and stick with it.

If the above suggestions aren't working, you can try a stool softener like Colace, which works by allowing water and fats into the stool. Don't use stool softeners for more than one week without speaking with your doctor. Please note that you should avoid stimulant laxatives (e.g., Ex-Lax) because they can cause a rebound effect (that is, they can worsen, instead of treat, constipation.) Talk with your doctor if lifestyle changes, fiber, magnesium, and stool softeners do not resolve your constipation.

There are other causes of GI symptoms besides those association with menopause. For example, having too much thyroid hormone (hyperthyroidism) can cause nausea, vomiting, and diarrhea. Having too little thyroid hormone (hypothyroidism) can cause constipation. Endometriosis can cause abdominal pain and bloating, constipation, gas, diarrhea, and pain with bowel movements. Similarly, fibroids can produce symptoms of bloating and constipation. Gall bladder disease commonly produces symptoms of gas, nausea, abdominal pain, and diarrhea. Ovarian, uterine, and colon cancer can also cause GI symptoms. And it goes without saying that diseases of the GI tract can replicate the same symptoms. See your doctor if you have blood in your stool, haven't had a bowel movement in more than 3 days, experience unexplained weight loss or gain, or your symptoms aren't resolved within a few weeks with changes to your diet, increased exercise, stress relief, improved hydration, and use of OTC medications.

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Oct 24, 2023
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Dr. Bernstein has given all women a huge gift with these informative articles written so that anyone can understand without being too basic. Take a moment and pick an article to send to a friend. I remember when I was in my 30's an older friend told me about her menopause experiences because "no one told me anything" and she felt so in the dark having to figure it all out by herself. She said that women need to share this kind of information with others BEFORE they get there to normalize menopause. I would add that it is still a great idea to share this blog with your sisters, friends, and health practioners no matter if they are premenopaus…

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Thanks for the compliment. I'm happy to hear that the blogs are helpful. Please let me know if there is a specific topic that you'd like addressed in the future. And I couldn't agree with you more - we have to normalize women's health issues. For far too long, women have been the victims of lack of education, research, and treatment because of antiquated ideas.

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