Endo Belly Series Part 1: Core Dysfunction
When I had shi*ty, active endo and I found out there was a word for the shi*ty, enormous bloating associated with it, I was enamored. “Endo Belly! Yes! There is a reason for my golum-like appearance!” I shouted to no one in general. Not only did I have it, but other endo-folk also did too. There’s oddly something comforting about knowing others out there had ballon-like bellies just like mine…
The problem was I thought it was just another endo symptom I couldn’t do much about. I couldn’t afford a properly done surgery at the time, and since endo belly was “caused by endo” there wasn’t much I could do, right? *Queue me spending $300 on Spanx products, not even kidding.
After doing extensive research for my best-selling book, Heal Endo, I realized there’s a LOT more to this “endo belly” stuff than I realized. Many factors, some related to endo lesions, many not. In fact, some are so within our control we may be able to pop that endo belly in months, rather than learn to hide it under suffocating body wear.
So, what is Endo Belly?
What little novice me didn’t understand is that endo belly is NOT a diagnosis. It’s simply a slang term referring to the significant bloating and digestive distress often experienced by those with endo, and it may or may not be caused or provoked by the endo lesions themselves.
Endo Belly Provoked By Lesions
For one thing, bloating occurs more frequently and tends to last longer for individuals with endometriosis due to several factors. While many women may experience some level of bloating during and around their menstrual periods, those with endometriosis often experience a more significant impact.
One possible reason is the abnormal growth of endometrial tissue outside the uterus, which characterizes endometriosis. This tissue can adhere to various organs and structures within the abdominal cavity, forming abnormal lesions. As a result, the body's inflammatory response is triggered, causing swelling, discomfort, and bloating that can be more pronounced compared to typical menstrual bloating.
Additionally, endometriosis can lead to the production of excessive amounts of prostaglandins, hormone-like substances that regulate inflammation and pain in the body. Elevated levels of prostaglandins can cause increased fluid retention and bloating.
Moreover, the presence of endometrial implants and scar tissues in the abdomen can disrupt the normal functioning of the digestive system. This interference may affect the regular movement of food and waste through the gastrointestinal tract, leading to abdominal bloating and discomfort.
Furthermore, hormonal imbalances associated with endometriosis can contribute to bloating. Fluctuations in estrogen and progesterone levels, which are essential for regulating the menstrual cycle, can disrupt the natural balance in the body and contribute to water retention, gassiness, and bloating.
Endo Belly May Not Be Due To Lesions
Endo belly can also be a symptom of your body that is unrelated to the lesions. It has been found that there is a notable association between endometriosis and irritable bowel syndrome (IBS). Research conducted by Schomacker et al. (2018) suggests that women with endometriosis are at a higher risk of developing IBS. This link between the two conditions implies that if a woman experiences gastrointestinal issues, it would be advisable to have it evaluated, as it could potentially be related to the presence of both endometriosis and IBS. SIBO, for example, is a huge trigger for many women with IBS and endo. Digestive insufficiency, ulcers, dysbiosis, they all play a role for perhaps many of us. And, they’re all factors we can address now.
This is kind of why I wish it wasn’t called “endo belly.” Thinking endo belly is simply caused by endometriosis means there’s not much we can do about it besides have surgery. To be sure, surgery has totally fixed some endo bellies! But not for everyone. Many clients I worked with had extreme endo belly continue after surgery, and could only address it by addressing other factors I’m about to talk about. Using this same approach, others have deflated their endo belly without surgery.
Moreover, it’s important to address endo-belly, no matter what the cause, for the sake of your endo. That’s because the factors I’m about to talk about may play a greater role in endo than you realize. They’re associated with inflammation, immune dysfunction, under-nutrition, and cellular damage that, yes, promotes more inflammation. It is why I’m writing this series, where we will uncover the 5 big (like, endo belly big) factors that may be behind many of our endo bellies. Your endo belly may be provoked by one, two, three, four, or, well, all of them :) They include:
Endo lesions, cysts, or adenomyosis
First up, I’d like to talk about core dysfunction, since I believe many (if not most) of us have it, and it can be making our endo bellies huge.
Core Dysfunction and Endo Belly Bloat
Core dysfunction posts are my most popular because nearly everyone can relate to this issue: Lower tummy pooch that will not budge. This lower belly protrusion is a visual of your lovely internal organs, tipping down, forward and out of your belly, instead of held up, in, and lifted off your uterus and pelvic floor.
For most of us? Nope, not happening. Nothing is lifted, that’s for sure!
So we do planks, leg lifts, crunches, and… omg it’s still there! Now we suck in, flex, put on Spanx, but man, that pooch sure is strong. It pressurizes our nether regions, adds pelvic weight, embarrassment, and contributes to painful pelvic floor, period, or sex issues. It seems the only time the pooch is gone is the few minutes between waking and drinking or eating something for breakfast. Then … it’s back.
Why do I have the lower belly pooch???!
Core dysfunction. More specifically, dysfunction of the deep core musculature, which includes the transverse abdominus, diaphragm, pelvic floor, and multifidus. These 4 elements work in synergy to to keep your organs up and lifted, and abdominal pressure low.
Core dysfunction, which is different from traditional bloating caused by factors like gas or inflammation, is a key aspect to consider when discussing the phenomenon known as endo-belly. While endo-belly is not formally recognized as a textbook symptom of endometriosis, it is a term that is commonly used to describe a severely distended abdomen in individuals with this condition. The root cause of this endo-belly lies in core musculature rather than the typical factors that cause bloating.
However, it's important to note that if there are other underlying issues such as excess gas from indigestion, SIBO, dysbiosis, or food intolerances, or inflammation and swelling from lesions, cysts, gastritis, or ulcers, which can further exacerbate core dysfunction. In such cases, the already present pressure in the core area intensifies, resulting in a more pronounced appearance of endo-belly. This visual manifestation distinguishes it from the discomfort of regular bloating. It can be likened to the sensation of having a beach ball forcefully inserted into your abdomen.
“Pressure inside of me??” You gasp. Don’t worry, not pressure like a soda can (you don’t pop if someone pokes you). Intra-abdominal pressure refers to the slight pressure in your abdomen that increases as space decreases. Think about it, there are no direct holes in or out of your abdomen (like when you’re really bloated, extra “stuff” doesn’t pop out of your belly button to make room). Rather, your abdomen is an airtight container that houses your vital organs, so when something happens to take up more room inside (like inhaling air, or being gassy), the pressure in your abdomen increases a tad, rather than organs falling out. When this pressure is correctly managed (with the proper expansion of your ribs and firing of your deep core muscles), this is not a problem.
Unfortunately, we’re not using the muscles of our core enough, nor in the correct ways. This leads to atrophied muscles, which become stiff, inflexible, and weak—altogether unable to function correctly. In addition we’re often telling our core what to do rather than letting it work as it should. We suck in our flab, flex our abs, hold in farts, hold Kegels, and stand with poor posture. Not to mention chronic pain itself can cause incredible tension in the pelvic floor. Now your core musculature isn’t just weak, it’s confused. Core dysfunction ensues.
When this happens, your deep core musculature is no longer working together properly. A confused and weak deep core forgets how to manage the totally natural increase in pressure that happens with each breathe, sneeze, cough, or yell. When this happens, 11 pounds of internal organs that should be nicely lifted up, is instead pushed DOWN … onto your uterus, ovaries, endo lesions, cysts, and pelvic floor. This is obviously a problem, something that leads to pelvic pain, pelvic floor dysfunction, digestive problems, sexual dysfunction, disk herniation, prolapse (where your uterus can literally be shoved into your vagina or rectum, so high is the pressure), and a bloated looking tummy—a direct visual of your organs being pressurized right out of your abdomen and pelvis.
Here’s a perfect example using me 6 weeks postpartum. In the pic on the left I locked my ribs closed the way they used to be, shrinking room for the diaphragm. As space shrunk, my tummy had to give and - POP- there they are, organs popping right out go my lower belly! This used to be me all the time, and why I always “sucked in”. Instead, to correct on the right, I relaxed my ribs and imagined growing taller in posture. This naturally activates the deep core WITHOUT sucking in, and voila: organs lifted back up. Pretty cool huh? It can take a while to get here where the core naturally activates like that, but it will happen with training, and without you even thinking about it.
How do I know if I have core dysfunction?
Core dysfunction is different than “bloating” in the traditional sense, where the pressure inside of your body increases due to something like gas or swelling from inflammation. Instead, it has everything to do with musculature. However, if you have something like excess gas from indigestion, SIBO, dysbiosis, or food intolerances, or inflammation swelling from lesions, cysts, gastritis, or ulcers, it can exacerbate core dysfunction. Think, now that little bit of internal pressure is now lot of pressure, which can increase the problem. It’s why bloating without core dysfunction feels uncomfortable, but it doesn’t look like bloating with core dysfunction— which looks like someone shoved a beach ball in your belly.
To differentiate between the factors, here are a few tests you can do at home, right now to see if core dysfunction may be playing a major factor in your endo belly:
Cough Test: Put one hand on your lower tummy, below the naval, to see what it does. Now, take a breath in and …. cough! Did you feel your lower stomach slightly suck in or brace (yes!), or did it poof out (uh-oh)? If it poofed, it shows your deep core isn’t correctly activating when IAP increases (i.e. core dysfunction). If this happened with with coughing, sneezing, running, planks, etc. Meet your organs as they “high five” your lower tummy and pelvic floor with just about every activity you do! This may be exactly why you had that endo flair last exercise session or burst a cyst getting off the couch.
Rib Test: Look in the mirror while you inhale deeply. Notice if your ribs relax and open wide side to side (yes!), or do they not budge at all and the only way you can take a “deep” breath is if you allow your lower belly to balloon out (uh-oh)? Meet: core dysfunction! Your ribs should not be locked in a static position… ever. They are the key to reducing mismanaged IAP.
Uterus Test: Do you often queef or feel air bubbles come out of your vagina? Do you sneeze pee or leak urine when you run or jump? Does your tampon fall out? Or maybe you can’t insert it all the way because your uterus is that close to your vaginal opening? These are all signs of pressure pushing your organs south, signs of poorly managed IAP and core muscle dysfunction.
Loaf Test: If you lie on your back and do a crunch or double leg lift, do you see a bulge that resembles a “bread loaf” poof out of your tummy? That bulge simply should not be there, as it’s a direct visual of your organs bulging out and down rather than being supported by correctly functioning core musculature.
OH NO! My core is dysfunctional! What do I do about it?
In my book I detail the 5 steps to begin rehabbing the core. There’s a whole chapter in there, actually, so if you’re interested check out my endometriosis book to read all the nerdy details. For the sake of this blog post I’m going to talk about one key factor needed to retrain the core (and suck the organs back up) that no one talk about. Like, ever. THE RIBS.
Cracking the Ribs Open
Remember a moment ago when I asked you to look in the mirror while you inhaled to see if your ribs budged? You may not have been able to do this because you’ve been “breathing” in the wrong place: the tummy.
“But I thought deep belly breathing was good?” you ask.
Deep belly breathing is great—when lying down. It’s done by totally relaxing your abdominal and pelvic floor muscles, and inhaling deeply. As your diaphragm descends down, it pushes on your organs down as well, which is why you see your lower belly rise. This relaxes your deep core and pelvic floor while reminding your body how to let your diaphragm descend (many of our diaphragms are so weak they need help like this to wake up).
Yet, because the goal of deep belly breathing is deep core relaxation, it should never be done when you’re standing or moving against gravity!
When you’re up and moving and grooving, most of your breath (and the increased pressure that comes with it) should stay in your thoracic cavity, not down on your uterus.
Why are the ribs so stuck? For many of us we’re shallow breathers, breathing in the top part of the chest which never utilizes the deeper parts of the rib cage. Over time this atrophies the deep breathing muscles and they become locked down, almost literally. I was so “locked” I couldn’t move my ribs AT ALL when I started.
Instead, you want to train your ribs to flow easily and smoothly open with every breath, keeping most of that nice pressure in a place meant for it (the rib cage, where there’s bones to handle the pressure, not the lower tummy where there’s only soft tissue!).
Because this should happen without you thinking about it, it will take some ninja training. To do so, you need to strengthen the terribly atrophied rib muscles (called the intercostals) as well as train the diaphragm to expand side to side rather than drop down (didn’t know your diaphragm was supposed to be strong and expand wide? Now you do!). You will also need to retrain the breathing pattern you’ve been nursing for perhaps decades. But, in the process, you can truly rehab!
Without ribs that flow open easily with each breath (and increase of pressure), that lower belly bulge will. never. go. away. So stop sucking in, and instead, use these three tips to start the rehabilitation process. And, remember, if you ever want to suck in, don’t! Expand your rib cage instead ;)
1) To start strengthening the ribs (or even just forcing them to start moving if they don’t move, like, at all), try these tips:
Inhaling through the nose, force the air in through the back (between and below the shoulder blades). Imagine the muscles in between the ribs relaxing and expanding the entire back and sides of the ribcage as if it’s growing twice the size. As you do this, you should also be able to visually see the front of your ribcage spread open from side to side.
You can help do this by visualizing your strong diaphragm pushing your ribs apart from the inside.
If your shoulders are tense while you do this, or you shrug your shoulders as you breathe (often a sign of a shallow breathing pattern), take them out of the equation while you wake up the breathing musculature. Lie on your back with your arms relaxing on the bed above your head; now try.
Still having trouble not breathing shallowly in the upper chest? I so, place one hand on your chest for awareness, and now try to force the inhalation lower in the lungs and into the back while making sure your hand doesn’t move. It doesn’t matter if you’re belly breathing while you do this (as long as you’re lying down), just stick with this exercise until your ribs can move more easily and your diaphragm can widen from within. It honestly could take a few weeks if your breathing musculature is very compromised.
Whereas before your ribs were locked and your breathing pattern confined to your upper chest and lower belly, you’re now on your way to having your ribs and diaphragm to do the breathing work for you as they should!
2) Add some deep core
Once your ribs can move again (thanks goodness), add this next step:
Standing tall (like an invisible rope is lengthening you towards the ceiling), inhale gently through the ribs. As you gently exhale, use the rib strength to keep the ribs wide! This means your tummy will slowly deflate as you keep your ribs as wide as they can go.
Repeat this pattern as long as you can, inhaling and exhaling while trying hard to keep as much room as possible in the thoracic cavity. This will start to remind your deep core to use it’s own strength (rather than tension) to hold your upper body up. If you’re core is very weak you may shake a little bit.
Retaining your ribcage to have strength like this will help to widen it, and relax it, which is key for the lower belly bulge to disappear.
3) Retrain your entire breathing pattern from tummy breathing to thoracic cavity breathing, see Dr. Angie:
If you can swing it, get this program taught by Dr. Angie, the core guru who retrains core’s to function optimally! For example, if you failed the cough test, after this program you will pass the cough test. In the meantime, check these videos below.