Irritable bowel syndrome (IBS) is a common bowel condition that can affect up to a quarter of the population — and is twice as prevalent in women than men. In addition to the many women who already have IBS prior to surgery, 3% of women develop it after their hysterectomy, according to a 2008 study. Common symptoms are abdominal pain, diarrhoea and/or constipation, and bloating, which is often reported as the most troublesome aspect of the disorder.
If you already have IBS, a hysterectomy can occasionally have the effect of improving symptoms, due to the settling of hormone levels in cases where ovaries are removed. That said, as your healthcare provider will explain, this should not be taken into account when making the decision about the type of surgery to undergo or whether to go ahead with it, as there are no guarantees. Surgery should never be considered a treatment for IBS.
If you don’t have an IBS diagnosis, it is especially important to rule it out in cases of chronic pelvic pain — a 2004 study found that around a third of women diagnosed with this may in fact have IBS, and be experiencing symptoms solely because of it. A hysterectomy may not be beneficial in these circumstances.
Remember too that there are some shared features of menopausal symptoms and IBS symptoms — these include bloating, constipation and straining on the toilet. Abdominal pain, though, is solely a feature of IBS, and this should be thoroughly investigated by your doctor.
How is IBS diagnosed?
A few tests are needed, even when symptoms develop post-surgery, as IBS should never just be ‘assumed’. In this case, any symptoms may settle after a few weeks, but if they continue do see your GP.
The tests are generally performed to ‘exclude’ other possibilities before IBS can be confirmed, and include:
- test for coeliac disease, a genetic disease caused by gluten in the diet, whose symptoms overlap with IBS, eating a diet containing gluten is essential for a diagnosis.
- a blood or stool test for inflammatory bowel diseases;
- investigations for bowel or ovarian cancer.
- investigations for possible adhesions — pelvic organs and the bowel ‘adhering’ together post-surgery.
How can IBS be managed before and after a hysterectomy?
Here are some tips:
- If you are preparing for surgery and your usual IBS symptoms are constipation or alternating constipation and diarrhoea, talk to your doctor about a suitable laxative well before surgery. Lactulose should not be used.
- Keep well hydrated. Eight to ten glasses of fluid a day are important to prevent constipation, and guards against dehydration in those with diarrhoea. Water, dilutable squash, decaffeinated or weak tea or coffee are all suitable. Some women find peppermint tea useful for abdominal cramps, although if you have reflux and IBS, it can sometimes aggravate it.
- Keep up your calcium intake, especially if you are going through menopause. Adequate calcium in the diet helps prevent osteoporosis, as can HRT, which is worth considering with your doctor, particularly if you are having an early hysterectomy. Calcium supplements can cause either diarrhoea or constipation for some women with IBS, so it is better to up your intake through dietary means, if you can. If milk-based foods cause symptoms, consider lactose-free options; if you choose dairy-free vegan alternatives, ensure they have added calcium and vitamin D.
- If you are constipated, fibre helps. When you can, choose fibre-rich varieties of the starchy foods that you tolerate — for instance, brown rice over white — but don’t increase wheat or wheat bran, as this can make things worse. Aim for five portions of fruit and vegetables a day, although for some, limiting fruit to no more than three portions and spreading those throughout the day can help. If you do not have much fibre in your diet and plan to increase it, do so slowly so your bowel adjusts.
- Linseeds can be a better tolerated source of soluble fibre, which can help with bloating and wind. Start with one tablespoon added to soups or breakfast cereals. They can take time to work, so persevere. Ensure you have a glass of fluid with each dose as the liquid helps the fibre move through your bowel.
- If you are struggling with constipation despite modest changes to your diet, go back to your healthcare provider, as there may be issues with your pelvic floor. Sitting on the toilet for some time with a strong urge to go, but being unable to actually pass a stool, is a common symptom. If you find this a difficult and embarrassing subject to discuss with your doctor, write down your symptoms instead.
- Avoid sugar free chewing gum and sugar free mints containing sorbitol, xylitol and mannitol. These can trigger symptoms.
- A low-FODMAP diet could be considered if moderate changes have not improved symptoms. This reduces the intake of various kinds of sugars which are known to ferment in the gut, and trigger symptoms. Although known to be effective for 70% of people with IBS, it is a complex diet and should never be attempted without the help of a dietitian. This diet might not be a suitable diet for all women, including those who suffer from adhesions, and other diet options might be better for you. Either way, ask your doctor for a referral to a dietitian.
Going through a hysterectomy is a major challenge for any woman, and additionally difficult if you are also dealing with IBS. The good news is that there is support and information available out there, including from charities such as the IBS Network. Learning about what to expect can give you the confidence you need to best manage your wellbeing.
Julie Thompson is a specialist Gastroenterology Dietitian, director of the Calm Gut Clinic, and dietary advisor to The IBS Network. She is the co-author of IBS: Dietary Advice to Calm Your Gut (£8.99, Sheldon Press), now out.
- The IBS Network: www.theibsnetwork.org.
- The British Dietetic Association’s calcium diet sheet: https://www.bda.uk.com/foodfacts/Calcium.pdf
- The British Dietetic Association’s dietary advice for menopause: https://www.bda.uk.com/foodfacts/Menopause.pdf
- The British Dietetic Association first line diet advice for IBS: https://www.bda.uk.com/foodfacts/IBSfoodfacts.pdf