A Woman's Guide to a Healthy Stomach

A Woman’s Guide to a Healthy Stomach

A Woman’s Guide to a Healthy Stomach

Taking Control of your Digestive Health

Jacqueline L. Wolf, M.D.

To the Loves of My Life:

My husband, David,

and

My daughters, Laura and Rebecca

CONTENTS

Introduction

Chapter 1

How Uncouth: Stomach Shame

Chapter 2

Endometriosis and Feminine GI Troubles: Symptoms Every Woman Should Understand

Chapter 3

“Do These Pants Come with an Elastic Waist?” The Truth about Gas, Bloating and Irritable Bowel Syndrome

Chapter 4

When You Know Every Bathroom in Town: Diarrhea

Chapter 5

When You Just Can’t Go: Constipation

Chapter 6

Stinky Burps: Heartburn and Halitosis

Chapter 7

When It’s Really Bad: Time to Get Help

Chapter 8

Nine Months of This? Minimizing Stomach Problems During Pregnancy

Chapter 9

Eating Your Way to Health

Chapter 10

Doctors’ Visits and Medications

Appendix 1

Glossary

Appendix 2

GI Tests

Appendix 3

Resources

References

Acknowledgments

Introduction

“Part of the secret of a success in life is to eat what you like and let the food fight it out inside.”

—Mark Twain

This is a different kind of bathroom book. It’s a book about bowel function—blowing the lid (so to speak) off the secrecy and shame surrounding female digestive ailments once and for all. This is a reassuring guide for women by a woman. It explains the causes and cures for our most embarrassing, urgent and common stomach problems. Wondering what those PMS cramps might mean? Always guzzling Pepto-Bismol before a big meeting? Read on.

Stomach ailments might just be the last great taboo in American culture. Women are the ones who suffer (I’m not just saying this—statistics back me up), and yet we’re not whining about it! Seems silly, doesn’t it? Bowel function is a necessary fact of life. We all go. But how many times have you hunched in the office bathroom stall, waiting for the boss to comb her hair and wash her hands, before letting loose with a massive explosion? Or wondered if your bad breath was caused by the onions you had for lunch—or something more sinister, like acid reflux? You’re not going to cry about this over cocktails with your friends or coffee with your mother. No, it’s easy to think everyone else is clean and pure, while you’re the only woman alive with gas, acid, pain and cramping. But I’m here to tell you that your glamorous coworker with the designer clothes and perfect hair has stomach problems just like you, and it isn’t always pretty.

It’s during times like these, when things aren’t pretty, that our stomachs become the center of our universe. The stomach is where we feel stress, nervousness, anxiety, pain. Just ask Freud. Yet, strangely, there aren’t any books or websites that deal with stomach problems in a way that isn’t completely satirical (ratemypoo.com) or incredibly technical (I won’t bore you).

As a physician, I see this as a huge problem. Because when legitimate illnesses become shrouded in shame, they pose life-altering consequences for those who suffer from them. The repercussions range from the severe (undiagnosed ovarian cancer) to the annoying (planning out your driving route based on the nearest rest stop). By the time many patients reach my office, they’ve suffered alone for years, or they’ve been brushed off by doctors or told to take an over-the-counter medication.

Why? Bowel issues are hard to diagnose, thanks to symptoms that could really mean anything, and they’re tough to talk about. They involve bad smells and strange noises. You might have constant gas, but who wants to go to a doctor complaining of humiliating farting? You might get constipated during your period, but would this move you to get a GI referral? No, probably not. That’s where I come in. Consider this book your cheat sheet to bowel problems. This isn’t a substitute for a doctor’s visit—and please, if you have unusual symptoms, don’t hesitate to get checked out—but this is a jumping-off point for women who need answers.

Just as important, I think it’s helpful to recognize that men have it easier in this arena. (Sorry, guys.) As I’ve seen in my practice, stomach complaints are largely a “woman thing.” Like it or not, men are more apt to boast about farting or joke about bathroom escapades. Prostate exams are a rite of passage that men fret about—and joke about, too. You can’t turn on the TV without seeing a bronzed man in a hot tub singing the praises of Viagra. It’s okay for men to talk about and make light of their issues! Why not women?

I’m not sure why. But I do know that when it comes to the stomach, women are more prone to suffer quietly, with physical and emotional consequences. We also suffer from issues, like PMS and endometriosis, that just don’t affect men. And women are more likely than men to get gallbladder disease, autoimmune disease, irritable bowel syndrome (IBS) and constipation.

This shame and reluctance to seek help—or the tendency to seek it too late—have real-life repercussions. According to the National Institutes of Health, more than seventy million Americans suffer from digestive diseases. In 2004 more than 236,000 Americans died from digestive ailments. Over half of the deaths were due to cancer—colorectal cancer accounting for almost 40 percent of all cancer deaths. And in many of these cases, deaths could have been prevented if routine screening had been done and treatment had been sought at the outset of symptoms. In the United States, Canada and Northern Europe, women are more than twice as likely as men to seek the advice of physicians for changes in bowel function. In my gastroenterology practice at Beth Israel Deaconess Medical Center in Boston, 70 percent of my patients are women. And almost universally, these women feel alone and scared. There’s no road map, no resource to reassure them that they’re not imagining their problems or that they’re going to be okay.

Instead, symptoms mean fear: Could my bloating mean cancer? Could my endometriosis mean that I can’t get pregnant? I often find myself in the role of psychologist as much as gastroenterologist. And my message for the afflicted woman is this: you’re not alone!

Each chapter in this book touches on the physical, emotional and social consequences of women’s most common bowel conditions, from endometriosis to irritable bowel syndrome. In many cases, I highlight patients whose diagnoses are illuminating or particularly interesting (though for space’s sake, they are abridged here, and out of concern for privacy, their names, occupations and other possible identifiers have been changed). These women wanted to tell their stories so that other women might know that, yes, we’re all in this together. Indeed, while digestive dysfunction can point to serious problems, often it’s a common ailment with a clear-cut solution. How reassuring for the millions of women scouring the Internet in secrecy, running to the bathroom between appointments and avoiding social situations for fear of an eruption to know that there’s help. Each chapter also includes Q&As, designed to answer the most common questions I hear in my practice. You’ll also find advice on what to ask your doctor and which medications are worthwhile (and which ones aren’t), as well as nutrition tips.

So find a quiet corner—maybe your bathroom, even?—and start reading!

Chapter 1
How Uncouth: Stomach Shame

“For marriage to be a success, every woman and every man should have her and his own bathroom. The end.”

—Catherine Zeta-Jones

Why are stomach ailments shrouded in shame and embarrassment for women? We all have to cope with them at some point in our lives—a volcanic explosion after a Mexican dinner, a knot in the stomach before a big job interview or after fighting with a spouse. This is normal, and speaks to how acutely stress and discomfort resonate in our stomachs.

But, for some of us, our stomachs are the center of our very being. Many of us live with constant constipation, diarrhea, indigestion, cramping…without relief and without answers. Often, we suffer quietly—scouring the Internet to self-diagnose or bouncing from doctor to doctor, trying to figure out what’s going on. Even worse, many women simply figure that this is the way life has to be, and we don’t get the help we need. It doesn’t have to be this way!

Chances are, if you’re reading this book, you have stomach issues or care about someone who does. This chapter offers basic information about the digestive system and the way it affects our lives when it goes haywire. I’ll focus on an overview of common issues that I see in my practice every day and the typical effects these problems have on my patients’ lifestyles. In the discussion below, when I use the word stomach, it’s as a general term to describe any problem with the digestive tract below the chest (the abdomen or belly).

First things first: Bowel function is a fact of life, and it shouldn’t be humiliating. Everyone goes to the bathroom! And when we go normally, we don’t spend too much time thinking about it, right? However, when something goes wrong, it affects us deeply. For most of us, stomach function is a complete mystery, and we take it for granted when our digestive system works as it should. The flip side of this is that when it doesn’t, we tend to panic.

Part of the reason for this panic is that it’s socially unacceptable to talk about bowel problems. We have no problem moaning about a horrible headache or even PMS cramps, but if we’re going to the bathroom constantly—or not at all—there’s really no one to tell. This is ironic since children are often obsessed with excrement, both as a curiosity and as something that’s a little naughty and taboo. However, as we become “socialized,” we lose that obsession, or we just joke about it and brush it under the rug.

This isn’t a new phenomenon. In the eighteenth and nineteenth centuries, the health of the bowels was often equated with the health of the soul. Bad odors indicated that rot lurked inside. Better to cover up the odors with perfume and sprays! This stigma hasn’t evaporated with time. Bad breath, gas, belching—if we can produce such horrible smells and sounds, there must be something awry, possibly deep within our bodies. There’s a reason people load up on mouthwash, chewing gum, perfume and floral-scented bathroom sprays!

Yes, our odors are best kept hidden. Society has deemed it unladylike to smell bad. It has not always been that way, of course. Here, it’s instructive to examine the life cycle: Shortly after birth, a baby has its first bowel movement, beginning a lifetime “practice.” The mother (or father), who usually changes the diapers, is aware of the baby’s poops, gas and colic. She knows whether the baby’s elimination is effortless or distressing, and there’s no taboo in discussing this with the pediatrician. The toddler eventually becomes toilet trained. At this point, Mom and/or Dad have to be actively engaged in the elimination practices of their child, often spending hours in the bathroom, cajoling and pleading and teaching, plus many hours changing and washing sheets or clothes. We sit around with other parents and commiserate about our kids’ bathroom woes. We have no problem sharing gory details about their bathroom habits—but would you really tell your fellow playgroup moms about your own constipation, gas or diarrhea? Not exactly something you gossip about over lunch. I think that kids must sense our discomfort with our own guts and exploit that unease. When children don’t want to do something, they will often develop a gut ailment—abdominal pain, nausea or vomiting. It often takes an astute parent to recognize this action for what it is.

When then does “poop,” gas or abdominal pain become a taboo subject of conversation? Why are they considered dirty, disgusting and embarrassing? As we get older, the bathroom becomes an intensely private place for women. In high school, guys shower and use the bathroom en masse in the locker room. Women, of course, require privacy and closed doors. As we get older and enter romantic relationships, a double standard begins to emerge: It’s okay for your boyfriend or husband to joke or brag about his odors and noises, but it’s just not something women do. Remember on Sex and the City, when Carrie Bradshaw hid from Big after accidentally farting at his apartment? Or when Charlotte York exploded with diarrhea on the girls’ trip to Mexico and was mortified? Not pretty! These are lighthearted examples, but the core issue is troubling: Women do not like to discuss their stomach problems. And, as a result, they often suffer in silence for long periods of time.

In the United States, Canada and Northern Europe, women are more than twice as likely as men to ultimately seek the advice of physicians for changes in bowel function. Yet most women won’t talk about their fears until pushed. They don’t discuss them with their family members, significant others, friends or, in many cases, with their physicians; many women who come to see me skirt the reason for the visit until I pry it out, and once I do, I’m the first person they’ve told. Moreover, some stomach issues are woman-only problems, like endometriosis, ovarian cancer and that good ol’ standby, PMS. Also, women just seem more likely to react sensitively to the issues that stomach ailments cause. The gut can become the center of a woman’s life if she has belly pain, has too few or too many stools, has a hard time having a bowel movement, is worried about finding a toilet in time or has a problem with gas.

How can something so central to our well-being cause such embarrassment? The results of silence can be serious and life-altering: Some women I know won’t leave their homes until they feel it’s “safe” and they’ve done all they can do in the bathroom, lest they risk going to the bathroom in their underwear, or interrupting their commute or a work meeting to flee to the nearest toilet. Many wake up extra early and spend hours laboring in the bathroom, without anything to show for it except strained muscles. This may result in lateness to work, lost jobs, even depression and isolation. Many women are afraid to go out for dinner, to exercise or to travel. They fabricate elaborate excuses to stay home or just say they don’t feel well. More than anything, they feel alone.

So you feel less alone, here are some of the most common complaints and concerns I hear from my patients. Can you relate? Short, easy-to-follow solutions are suggested for each concern. I’ll address all these topics in detail in the book!

DR. WOLF’S TOP TEN MOST COMMON ISSUES:

1. “What if I can’t make it to a toilet in time?”

Are you one of those women who can’t go to the movies or the theater because you’re constantly scrambling for a restroom? Or when you’re on the highway, you’re always searching for a sign pointing to the next exit with a possible bathroom. So many women end up altering their social lives or reducing them to nothing because it’s just too embarrassing. Some of my patients have actually ranked public restrooms (note: hotels are usually safe bets) or highway rest stops because they so fear inopportune bowel explosions.

Try to use the bathroom before you leave the house. If you have frequent diarrhea associated with stress or IBS, you can take a half or a full dose of Imodium (loperamide) before you leave. (Check with your doctor if you have inflammatory bowel disease before taking loperamide.) If your bowel movement can be timed with your meals, eat earlier than usual, eat lighter than usual or delay eating until you get to your destination. If the diarrhea can be urgent and you can’t hold it, you could wear an adult diaper (e.g., Depend). You’re the only one who knows! It can give you security. Pack an extra set of underwear and clothing in your car, just in case.

2. “How can I go completely when my kids are banging at the door?”

I see countless mothers who suffer bowel issues yet can’t fully evacuate, because their kids need attention. Parents rarely have time enough for themselves as it is. It’s even tougher to be a mom when you’re constantly running for the bathroom or spending extended periods crouching on the toilet.

Try to carve out some time for yourself. Often you need to relax before you can completely relieve yourself of feces. While on the toilet, it sometimes helps to put your feet on a stool or phone books or to bend down in order to give the poop a straighter, more direct way out. It is best to go sit on the toilet when you have an urge. It usually doesn’t do any good to just sit down and wait.

3. “What if I fart while having sex?”

Not exactly the biggest aphrodisiac. Many women who suffer from gas, IBS and diarrhea often come to me with this fear.

Try to make this a nonissue. Avoid eating foods that cause gas several hours before you anticipate having sex. Go to the toilet before bed and see if you can eliminate gas or possibly stool. And relax. Don’t occupy your mind with this worry, or you really won’t enjoy the sex.

4. “How can I afford to buy all the supplements, vitamins and medications necessary to make my stomach feel normal again?”

Wander the aisles at any health food store, and you’ll see plenty of pricey supplements promising stomach serenity. Unfortunately, you could spend a small fortune trying to compose your own stomach-soothing cocktail, with dubious results. How do you know what’s worth it and what isn’t?

Become an informed consumer. Television ads and company information are almost certainly biased toward the product, and it’s often hard to assess the product’s potential usefulness and whether the potential benefit for you justifies its expense. And the advice dispensed by a friendly salesperson might be uninformed. Read newspapers, magazines or online media for new studies. Manipulating your diet and lifestyle changes are cheap and could have major positive effects on your health. Lose weight if you are overweight, exercise, stop smoking and eliminate foods that could be causing symptoms, as discussed in the following chapters. Vitamin D and calcium, if not obtained in food, are important supplements for good health. Generic medications in most instances are cheaper and just as good as name-brand medications. Starting with a cheaper medication over a more expensive one is advisable. Probiotics have many health benefits, as will be described. Insurance will not pay for them and they can be expensive. All claims made about probiotics are not always based on studies. If you have IBS and want to take a probiotic, be sure to take a probiotic that includes a bifidobacillus. Other suggestions are given in the chapter on diarrhea.

5. “How can I afford to eat healthfully?”

These days everyone wants to be Mario Batali, trotting through bustling markets for the freshest produce. It’s trendy, the food looks great, and you feel good about yourself after loading up your cart with shiny fruits and veggies, organic farmed fish and big bags of granola. But make a habit of shopping at fancy stores, and before long you’ve spent your entire shoe budget or mortgage payment. These delicacies might look pretty on the shelves—but buying them may not be the most money-wise thing to do. How can you eat well without breaking the bank?

Buy in bulk. Food is cheaper if you buy more than three pounds. Often joining a food co-op or a discount or wholesale market is cheaper. Specialty stores and organic food stores are more expensive. Think creatively. You can get much-needed protein from legumes and can add to them a small amount of meat and vegetables if you would like. Fish heads with the bones may be available from the fish market or store for a minimal cost. These can make a delicious soup. Many people don’t think about eating a turkey unless it’s Thanksgiving. However, turkeys are usually cheap and meaty and can stretch to feed many people. Buy items on sale and expand your palate. You might have to buy greens that you’ve never tried before—and you just might like them! You can freeze meat. Just make sure that you label it with the date and wrap it carefully. Check out the prices of frozen vegetables, as well as fresh vegetables. Make sure that you eat what is good for your condition.

6. “I’m always late for work because I can’t get off the toilet!”

So many women I know end up running for the subway because they’ve spent more time sitting on the toilet than putting on their clothes. There’s always that one last pitstop for the road—which sometimes turns into an hour of straining, grunting and pushing, to no avail. How many times can the “I was stuck in traffic” excuse hold up?

If the problem is that it takes you a certain amount of time after you wake up to finish your morning toiletry, wake up earlier. If the problem is that your cup of coffee sets you off, drink your coffee earlier, drink it on your way to work or wait until you get to work—whatever works. If the problem is that when you think of leaving home, you have to go to the bathroom, you should learn some biofeedback techniques. You may need to take an Imodium to get out. If you are taking fiber or a laxative during the day, try changing your intake schedule.

7. “I can’t go out to eat—everything makes me sick!”

What fun is going to a restaurant when the menu is a land mine? Some acidic foods cause heartburn; other foods cause major gas. And forget about alcohol. How can you enjoy dining out if you have to order a prune salad or a milk of magnesia cocktail?

Try to scope out the menu ahead of time. The Internet is great for that. Know what you can eat. Call ahead and discuss your food preferences or needs with the chef. Often he/she will be very accommodating. If no accommodation will be made, go somewhere else. You should also carry a card noting what you cannot eat; this can be slipped to the waiter. If you have allergies or celiac disease, you absolutely need to make sure the chef understands your forbidden foods. Some restaurants will list gluten-free choices. If you don’t think you can eat much at the restaurant, eat snacks at home before leaving and just order a few things (maybe just beverages) so that you can be social.

8. “My belly bloats up by the end of the day and I look seven months pregnant.”

Do you have to open your zipper to feel comfortable or wear elastic-banded pants or find a loose-fitting dress to hide your figure?

The first thing to do is to try to eliminate any foods that cause increased gas, as this may cause bloating. Reducing stress may help. Learn biofeedback or meditation techniques to control stress and to reduce the physical accompaniments to stress. It is not known if strengthening the abdominal muscles will help prevent increased bloating, but it is worth a try and healthy, too. Probiotics may help. If bloating continues, try wearing loose clothing. Elastic-waisted clothes can expand during the day and be hidden by beautiful oversize sweaters. Body shapers can help control the belly bloat as well as the bulge. Most times no one else will notice. Don’t broadcast your problem to your date or companion. Keep it to yourself.

9. “I can’t control the noises my stomach makes!”

You’re leading a board meeting, proudly giving a PowerPoint presentation, when suddenly your stomach erupts like Mount Vesuvius. Not the quickest route to a promotion. How do you rein it in?

This may require a course in biofeedback or a way that you find for controlling your emotions or stress. Sometimes there is nothing one can do. Everyone has had this problem at some time. Try to make light of it if you see someone staring at you. If your stomach makes loud noises when you’re hungry, have a low-calorie snack before you go into that important meeting. Try to figure out what causes the noises, and then try to reduce the precipitating factor.

10. “I can’t stop farting in public!”

You’re sitting in class or at a meeting when suddenly a noxious odor seeps from your body. You avert your eyes or stare suspiciously at that annoying guy from accounting, trying to pin the blame on him. We’ve all been there at one time or another. But for some women, this kind of deviousness is a way of life.

First try to reduce the foods that cause gas. Do you need to eliminate milk products, gas-forming vegetables or other foods? If, after changing your diet, you continue to have this problem, you may need to be evaluated with breath tests. Could you have a parasite? Does simethicone (Gas-X) or enteric-coated peppermint capsules (do not use if you have heartburn) help? If you still have gas after changing your diet, consider a diet that eliminates fructose, lactose and other carbohydrates that cause gas, or a specific carbohydrate diet, or consider trying probiotics. If flatulence persists, you could try purchasing carbon filter underwear, which is available online. This could help absorb the odor, although not the noise.

The following questions and answers will help you understand your digestive system:

What is normal digestive function?

Remember these four facts:

1 There’s a wide range of normal! Bowel movements can range anywhere from twice per day to three times per week. It’s about understanding what’s normal for you. If something feels off, don’t ignore it. Bowel movements are affected by where you are in your menstrual cycle. Due to hormonal changes, many women have diarrhea or loose stools during their period, and constipation leading up to it. Some women actually look forward to their periods to empty out their bowels, not just to reassure them that they aren’t pregnant.

2 Stool form varies from person to person and from event to event. No, it’s not always a firm, one-inch-wide and six-inch-long form with a curled end. It can depend on your diet and fluid intake. “Paperless” was the ideal state of the bowels described by Heinrich Böll in Group Portrait with Lady, in which the stool comes out in one complete piece and leaves no residue behind. However, not many people have this kind of stool.

3 Gas occurs in everyone! In fact, we all pass between a half quart (500 mL) to a quart and a half (1500 mL) per day if we’re normal. Some people make more gas than others. The amount depends on what you eat. It’s normal to pass gas ten to twenty times per day.

4 Check your meds! Medications, including herbs and over-the-counter medications, can sometimes cause constipation, diarrhea or heartburn. But remember: most people have heartburn at one time or another—40 to 50 percent of Americans monthly and about 10 to 20 percent weekly.

How soon after I eat should food be expelled from the body?

You should eliminate that delicious sushi feast or burrito dinner within three to five days.

As a woman, how does my digestive system differ from a man’s?

Well, we’re all human, and for men and women, the digestive tract is made up of the same parts. It is a hollow tube that travels from the mouth to the anus. When food is ingested, it migrates from the mouth through the esophagus into the stomach and then into the small intestine. The small intestine comprises the duodenum (which is short), followed by the jejunum and finally the ileum. Then, remaining food goes to the large intestine or colon. The small intestine is twenty to thirty feet long, while the colon is three to five feet in length.

But there are differences. A woman’s esophagus is shorter than a man’s regardless of her height. Also, a woman’s colon is often longer and “twistier” than a man’s. This could contribute to more constipation, although no one has looked at the association of the number of bowel movements with the length of the colon. (It definitely makes it harder to perform a colonoscopy on women!) Finally, what’s left of the food after its digestive tract travel is eliminated as waste.

Here’s a handy diagram:

Figure 1-1. The parts of the gastrointestinal (GI) tract with their locations are indicated. The food travels from the mouth through the esophagus, into the stomach and then out of the stomach into the small intestine. The small intestine is made up of (1) the duodenum, which is joined to the stomach in the upper right abdomen and then descends for a short distance before it heads across the belly to the left side, where it connects to the jejunum in the upper abdomen; (2) the jejunum; and (3) the ileum, which connects to the colon (large intestine) at the level of the cecum in the lower right side of the abdomen. There is no clear distinguishing characteristic marking the junction of the jejunum and the ileum. After the small intestine, the food travels into the colon at the level of the cecum. The main parts of the colon from cecum to rectum are indicated on the diagram. Bile is made in the liver, stored in the gallbladder and excreted into ducts. The common bile duct enters the small intestine in the duodenum. The pancreas makes digestive enzymes that are excreted into ducts, with the main duct entering the duodenum, usually with the common bile duct.

What does my digestive system do?

1 The saliva in the mouth moistens the food and starts the digestion process.

2 In the stomach, food gets mixed together, then broken down into smaller pieces, and digestion really starts in earnest with the help of acid and enzymes.

3 The small intestine breaks down the food substances with the help of more enzymes and proteins and absorbs nutrients and water into the body.

4 The large intestine (colon) takes out even more water to give you the stool form that we all know.

5 The intestines, particularly the colon, harbor helpful and harmful bacteria that produce nutrients and digest the food you eat.

6 The gut acts as a barrier to harmful substances and pathogens (organisms), keeping them out of the body.

7 The gut contributes to the immune response, making antibodies and fighting off disease.

8 The digestive system produces hormones and neurotransmitters that affect blood sugar, appetite and bowel function.

9 The digestive system eliminates indigestible substances as stool.

It’s disgusting to think that I have “germs” inside me. What do these bacteria do?