The Food Medic - S8 E9: What every woman needs to know about her gut

Episode Date: August 25, 2022

In this episode Dr Hazel is joined by Professor Barbara Ryan - co-author of What Every Woman Needs to Know About Her Gut. Professor Barbara Ryan is a consultant gastroenterologist at Tallaght University Hospital and Hermitage Clinic in Dublin, and a professor of gastroenterology at Trinity College, Dublin in Ireland. she is also one half of TheGutExperts alongside dietitian Elaine McGowan RD. This episode covers:*How the female gut differs to a male gut*IBS and other gut related conditions that are more common in women *The role of the mind in gut functioning *The role of sex hormones in the function of the gut*How pregnancy alters the gut *Changes to gut function during the menopause*The role for probiotics for vaginal healthIf you loved this episode make sure to give it a review, rating (hopefully 5 stars) and share it with your friends and family. Thank you to our season sponsor WHOOP. Right now, you can get your first month free when you checkout through join.whoop.com/thefoodmedic@thefoodmedic / www.thefoodmedic.co.uk Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

Did you know that the digestive system of men and women are different? Any woman who suffers with gut issues will know firsthand how the menstrual cycle can have a big impact on symptoms. Those who have been pregnant or are currently pregnant can probably vouch for this also with symptoms of heartburn and constipation. And women who have gone through the menopause may also notice that their bowel habits have changed. In this episode, I'm joined by Professor Barbara Rine, co-author of What Every Woman Needs to Know About Her Gut. Professor Barbara Rine is a consultant gastroenterologist at Talley University Hospital and Hermitage Clinic in Dublin, and a professor of gastroenterology at Trinity College Dublin in Ireland. She's also one half of the gut experts

alongside dietitian Elaine McGowan. Today's podcast is brought to you by our season sponsor Whoop. Whoop 4.0 is a 24-7 digital fitness and health coach that provides actionable insights to help you recover faster, train smarter and sleep better. And unlike most other wearables in the sense that it doesn't just tell you what you've done, but it tells you what you really need to know. Now, as many of you know, I've been using my WHOOP for the last couple of years and I'm constantly impressed by how accurately it can quantify how I'm feeling. So each morning when you wake up, you get a recovery score from WHOOP and this is based on your sleep and other health metrics. Now that score can help guide your day and informs you how much strain you're ready to take on. One of my favorite features is the built-in sleep coach. It lets you know how much

sleep you should be getting based on your expected activity level for the following day. WHOOP can help anyone perform better so whether you're preparing for a 5k, training for an event or just looking to build healthier habits, Whoop can help you make smarter lifestyle decisions with data that is personalized to you. And right now, you can get your first month free when you check out through join.whoop.com slash thefoodmedic. Professor Barbara Ryan, welcome to the podcast. Thank you very much, Dr. Wallace. I've been really looking forward to having this conversation with you, but I'd love to start by asking you a little bit more about yourself and also your clinical

background. Sure. Yeah, so I am an Irish doctor, obviously. I'm a consultant gastroenterologist and I am a clinical professor of gastroenterology at Trinity College Dublin. I grew up not too far from you, a little bit down the road, and I went to Trinity College. I did my basic training in gastroenterology and medicine in Ireland. And then I spent a few years working in the Netherlands, did a fellowship there. I spent a little bit of time in Germany doing a fellowship there. And then I worked as a consultant in Manchester before I returned to Ireland so I've had a bit of

a roundabout route to my current job in a teaching hospital in Dublin and I suppose I have been what drew me to gastroenterology was that I had some pretty inspirational and our professor medicine back in the day was a gastroenterologist, and he was just a really lovely man. And he really made the gut seem like an incredibly interesting organ. And in fact, probably, we I think we subsequently found out that it is incredibly interesting, probably more interesting than we more interesting than we knew back then. So that was really what drew me to gastroenterology. And I kind of like doing things with my hands. So it's a really nice specialty in terms of,

it's kind of a mixture between having to do a bit of thinking. And also you kind of get to do practical procedures that can really give instantaneous relief to people as well. So that's, and that's where I am today. Amazing today amazing I love gastro I've done a lot of it in my training um and you have just published a book with Elaine McGowan who is a dietitian and which is titled what every woman needs to know about her gut and once I heard the title of this book I was instantly interested because I've just published my own book around female health. And I love that this is getting some airtime. And it's a topic that I certainly didn't learn about at medical school.

And I was really interested to get your book. So first of all, what made you write the book? Well, I took a little time. Myself and my brother, we'd been meeting for years to go and do something together. So we took a week out of work, how I felt that a lot of people with functional problems like IBS and things like that, I was, I was going on and on and on. I was saying, you know, you know, people do not listen to and people, women with a lot of these conditions, they're, they're dismissed. And I think my brother just maybe to kind of shut me up said, look, I, why don't you write a book about it? And I came home and I was thinking, you know, that is really true. There are not women's guts and men's guts. They are actually different and conditions affect us differently. And I, it really made me

to, made me think that there does actually deserve to be a book. And I think what you've done as well is really, is really fascinating. And I think we're all kind of exploring this area more that women's digestive systems and men's digestive systems, how things affect us are different. And the more I delved into it and the more, you know, when I started, you know, I had to do some research for my book, as I'm sure you did. And, you know, the explosion of information we have nowadays at how hormones affect our gut, that was not known 20 years ago when I started doing gastroenterology. So there's been a huge, you know, explosion of information over that time. And, and I think working clinically, I mean, I've, I've been a consultant for almost 25 years now. And I've,

I've not, I don't know how many 10s of 1000s of patients I've seen. But, you know, you do realize that women with irritable bowel syndrome, for example, tend to have quite different symptoms to men, men tend to have more diarrheal symptoms, we don't very often see men with constipated type IBS, it's much more common in women, or women tend to alternate between the two. So, you know, working clinically, without somebody ever telling you, you sort of begin to instinctively know, well, men tend to get those symptoms, women tend to get these symptoms. Bloating, which I think is the bane of so many women's lives is more common in women than men and the hormone you know our menstrual cycle plays a huge role on that and menopause transition plays a huge role so yeah the more I started thinking about it the more I realized that every day I see people who

men and women are different so I thought that that that needed a bit more exploration and uh yeah and that's that's how the book came then I approached Elaine we'd been working together for years and she said oh my god I've wanted to do a book about this sort of thing for years so that was it and then Covid struck maybe like yourself and then we suddenly had nowhere to go but sit down and spend evenings writing and and talking so yeah so that's really what what made me write the book amazing made us made us write the book yeah absolutely on a basic level what differences have you found between a female gut and a male gut okay so they look pretty much the same um and I was and again I was just thinking about this today we know that our guts have loads of sex hormone receptors so the female gut is like every cell in our body has got estrogen and progesterone receptors, but the gut is particularly rich. So, and funnily enough, people with IBS tend

to have more dense estrogen receptors on their gut than, than, than people who don't have IBS, which suggests they might be more sensitive to these hormone receptors. So at a really small level, there are differences, but say on an, on a, just on a, on a gross level, or when you, if I'm doing a colonoscopy on a woman, on a thin, on a say slim young woman like yourself, that is a much more difficult procedure than if I do a colonoscopy on a, on a young man, because the women's, woman's bowel tends to be much more twisty and tortuous. And, and, you know, we've got the same length of bowel pretty much packed into a smaller frame. So our bowel is more bendy. And that might explain why or explain in part why women tend to have a slower transit because our bowel is, you know, it's like an S bend all the way along, whereas a man's bowel tends to be a little bit straighter.

Obviously, we've got all those things in our pelvic floor, the uterus, our pelvic floor is different and a little bit more packed than men's pelvic floors as well. And our body fat is different and our body fluid, our ratio of fat to liquid is different. So, for example, one of the things that I talk about in the book as well is that alcohol affects men and women differently because men have more water in their body compared to women so when women drink say same amount of alcohol as a man and it's more concentrated in our bloodstream because it doesn't go into the fat so and our livers are smaller about 30 percent smaller than male uh livers so all our organs are you know they're slightly different size and they you know they function a little bit a little bit differently differently. And particularly the effects of, of alcohol on our body as well is very, very different. We're much more sensitive to alcohol. So, you know, our hormones are different. Our pelvic floor is

different. The bowel is packed in, in a slightly different way. And I think, and clearly obviously our genetics are different and that probably explains why some conditions are more common in women as well. So we're different on every level and yet we've always been treating these things the same yeah doesn't it doesn't make sense no I completely agree with you and I think that point on transit time and gut motility is so important um one of the things I was looking into for the book was the differences in kind of pharmacology research and most of it's based on male bodies and male mice and women are twice as likely to experience adverse drug reactions but it makes sense when you talk about it because we have smaller livers we have a slower gut transit

time so absorption is going to be different and also fat and water ratios in terms of like us holding those drugs in our bodies absolutely yeah couldn't agree more it's it's fascinating I think we do need to do sex specific studies on on all of these things and um you know I think I think we're we're starting a new era and I think there's a much greater awareness of this um And like even doing a study on transit would be dependent on the time of a woman's menstrual cycle. Because if you do one, you know, in the first few days after a period, things will probably be a bit faster. The week before a period when estrogen and progesterone levels are at a high level, things will tend to be much slower. And a lot of women will, they kind of know that anyway, if you look at what happens your, your bowel function over your over the monthly cycle, you know, most women tend to

get a bit more frequent stools or a bit of diarrhea around the time of their period, that might have been the week before their period, things might have slugged, got a bit more sluggish, they're feeling a bit more bloated. And that is, it's not it's that is related to those hormonal changes. And that and it does vary from person to person um but if you're somebody who suffers with you know constipated type IBS that could be an that's going to be an absolute killer the week or two before your period and you might actually get some relief when your period comes and the bowel motions are a bit more free if you're somebody who has diarrhea predominant IBS your periods could could make what is a kind of a tolerable

situation really intolerable. And you might find the week before your period when you're a little bit constipated, that's actually a good thing, because that makes you kind of feel a bit more normal. So we have to, every woman is individual. And, and, you know, we cannot dismiss the effects of the hormone of our hormones on our gut and that that needs to be taken into consideration in studies particularly in things like IBS. Yeah and that's what I'd love to speak to you about next is the we you know that anatomically and physiologically there are some differences but then they manifest in different conditions between men and women and one of the specialties I worked in which is quite niche was neurogastroenterology and so it was largely well mostly functional gut issues and 99% of our patients were female and so I was really

interested reading your book in that like IBS and dyspepsia and gastroparesis those kind of conditions very much are predominantly in females yes is that what you see as well absolutely i mean like the sort of the the figures from international studies would suggest that um ibs and ibs particularly is about three times more common in women than men so seven out of ten patients with ibs um are women um and ibs is incredibly common, it affects like one in 10 people. So it actually affects one, almost one in five or one in six women. So you're absolutely right, most patients with IBS are, are female, funnily enough, functional dyspepsia, although it is also it's kind of like the upper I call it, when I'm explaining it to patients, I call it the upper

digestive version of IBS, because everybody's kind of heard of IBS, and it means something to them. But if you tell somebody you've got functional dyspepsia, it's like, what, what is that? And that's where somebody's all kind of uncomfortable symptoms, but all in their upper tummy, like bloating, and maybe nausea and belching and discomfort. That is also more common in women, but funnily, not quite as common as much, you know, that much more common than IBS. So there are differences between these things as well. But I think the hormonal part has a huge part to play in that. But one of the upshots, I think, of the fact that these things are more common in women and medicine, thankfully, it's changed hugely, but medicine has been a very male dominated area, obviously. Now that's really changed in the last

10, 15 years. But I think these sort of functional conditions like IBS, where there wasn't an obvious structural abnormality or no test that would show you what was going wrong. I think people were dismissed a lot. And I think that led to their sort of sense of isolation. They felt that people weren't listening. People were saying it was all in their head. And I think a lot of people with these conditions traditionally have been really poorly served by Western medicine. And, you know, I think that's been part of the problem. So I think opening the conversation has been incredibly helpful, even if we don't have immediate solutions for everything, at least validating people's experience, I think is incredibly important. Absolutely absolutely why do you think IBS is more common in in females well I think the hormonal the whole

hormonal piece is is huge and the gut is exquisite of all organs in our body apart from our our reproductive organs the gut is exquisitely exquisitively sensitive to um to hormonal changes um so I think that piece is being unraveled, you know, or it's being slowly unraveled. And, you know, we're learning more and more. I think the gut microbiota we know now is different between men and women as well. Obviously, dietary factors play a role in that, but it's also possible that hormonal factors are playing a strong role in that as well. And the gut bacteria, in turn, are involved in, you know, estrogen metabolism as well. So it's kind of, there's a bit of a cycle going on there between the gut bacteria, production of estrogen and what you eat.

And I think things like psychological factors differ as well. Serotonin levels, which are obviously serotonin, but 70% of serotonin, 90% of serotonin is produced in our gut, isn't it? And, you know, there are differences in concentrations of serotonin receptors in between men and women. So we've got a lot of kind of interesting little snippets telling us, yes, hormones probably play a role, the gut bacteria play a role, maybe serotonin and cortisol, which changes at different times of the cycle all these hormones play a role and then probably genetics do too but we just don't we haven't identified the genes and obviously men and women are different genetically as well yeah yeah there's so many factors like you said um and you mentioned uh kind of you know the psychological psychological component and

IBS has in the recent years has kind of been understood as almost like this gut brain axis disorder and I wanted to talk to you a little bit about that like the role between what do you think what role do you think the mind has to play in in the condition of IBS and these are very functional conditions because women are are more likely to be diagnosed with anxiety twice as likely actually I mean I think I think I think of the the sort of the gut brain and you're absolutely right these conditions now and I think I think it's a better name they're now called disorders of gut brain interaction as opposed to being called functional conditions because if you know as a doctor Hazel functional conditions there's a there's a kind of there has

been traditionally anyway a slightly pejorative and you know implication with that the other they're in some way they're imagined so I think saying this is a disorder of gut brain interaction is really helpful um and the gut brain access as you know is like this two-way information super highway go between the the brain and the gut the vagus nerve is obviously involved but all the nerve endings in the gut and that they travel also back via the spinal cord so there's this constant cycling of information between the brain and the gut. And what's going on in our brain affects what's going on in our gut. But I think, and that's obvious what's going on in our brain, you know, in our brain affects every part of our body. But the really fascinating thing in recent times, I guess, is that what's going on in our gut also affects our brain. So the gut bacteria

produce substances, short chain fatty acids, lots of neurotransmitters and dopamine, serotonin, and all these things that in turn affect the brain. So there is this kind of a two way flow of information. So it makes sense that if you're anxious, or if you're, you know, if you're depressed or low mood, that that can have an effect through that gut brain axis on what's going on in your gut. And I suppose at a very simple level, you know, if you're going to, you know, run in a 10k, or you get the butterflies in your stomach, that's your gut brain axis. Or if you're going to do go for an interview, and you suddenly feel nauseated, that's your gut brain axis slowing down your gut motility um so um yeah i mean at the gut we know

that the gut brain axis has a huge role to play in all of these things and again you know we talk about it as if we know exactly how it all works but we don't really we've only got we you know it's a little still it's still a little bit mysterious um and again we're learning more all the time um and i know you've a huge interest in gut microbiota. And I think one of the nicest, we talk about, again, you know, the gut microbiota as if we know exactly what it's all about. But I love some, I read a book a few years ago and they called it the mysterium, which rather than the microbiome, you know, the gut mysterium. Because, you know, it is a bit of a mystery still. There are so many bugs in there that we haven't even identified. There are

all these other things apart from bacteria, like archaea, that are really hard, that are those things that probably produce a lot of methane that people can have problems with. So it's, it's a really fascinating area. And, and I'm not trying to, you know, put things off, but we don't understand how it all works but we do know that what's going on in your head affects your gut um but also what's going on your gut affects your head and I suppose you you know everybody quotes the the smiles study which is a fascinating study from Australia that showed that people who ate ate a Mediterranean diet for a 12-week period people who suffered with depression, and were given a

Mediterranean diet to follow, and no changes in their medication, had a significant improvement in their mood simply by through improving their diet. And, you know, that's, I guess, where they're now looking at probiotics for mood, etc. So, yeah, it's really fascinating. And I feel really, you know, privileged to be practicing medicine at a time when there's so much happening in this area um yeah yeah I completely agree it's exciting and I do think that we're learning more and more about the gut and its relationship with our mind I want to circle back a little bit to sex hormones and the role that they play in the function of our gut now we mentioned a little bit around kind of the menstrual cycle in that pre-menstrual period and lots of women report having diarrhea but also like you mentioned

some people will have constipation it's it's very variable that from my understanding that's related to prostaglandins um and that that's why women experience it is that correct or i mean i think there is obviously prostaglandin levels change around that time but i think also estrogen and progesterone and their effects directly on uh the gut receptor estrogen and progesterone and their effects directly on the gut receptor, the estrogen and progesterone receptors on the gut have a direct effect on motility. And that's through lots and lots of different molecules that affect gut motility. They also affect serotonin receptors and serotonin, we obviously know, everybody knows serotonin is very important for mood, but there are also lots of different types of serotonin receptors in your gut. And, and, and oestrogen affects the the density of the number of those receptors in the cells, and can affect motility in that way as well. And it's kind of complicated,

because it's not even just the level of oestrogen or progesterone. It's also been shown that the rate of change of those hormones can also affect motility. So in general, progesterone slows down motility. Estrogen can slow down motility as well. But if it changes very rapidly and goes from high to low very quickly, it can do the exact opposite. So in any one person,

they will tend to have a fairly, a menstrual, their hormone changes each month will tend to be quite similar a menstrual they will tend their hormone changes each month will tend to be quite similar but some people may get a more rapid fall off in their hormones before their before they menstruate than other people and that will affect how their gut motility um changes as well um so it's it's it's quite complex there are a lot of you know there are so i mean there's so many different receptors involved oestrogen also affects um cortisol and receptors in the gut and cortisol as ever people might know as a sort of a stress hormone and levels of that change before before menstruation so you know lots of people are very aware of you know PMS and getting stressed and at a gut level the changes

we're seeing may be also related to the sort of interaction between oestrogen and and cortisol so I guess I'm not I can't give you a straight answer Hazel and say it's oh it's it's it's just this one thing it's all of them yeah and it's and it is very complicated and I suppose as we're learning about it we're realizing how complicated it is and there isn't an easy you know magic bullet tablet to make all those things go away but the more we understand about it um and the more you know we will be able to help people at least manage their symptoms better yeah but yeah it is complicated it's complicated but I think for women and I is it's reassuring to know that it's common and and it's not imagined yeah that's what I that I but I think that is so important I mean people who have been struggling with symptoms with any

with any condition be it fibromyalgia or or or migraine or brain fog or any of these conditions where there isn't an easy test to say, oh, yes, this is what you have. I think validation and, you know, for people to say, yes, we know that these are the symptoms. They are absolutely, they're really bad. They, you know, they can be completely debilitating and really affect your quality of life. I think that's very important as a starting point. And then you build from there to try and help people find their solutions. Absolutely. And then another like major hormonal fluctuation would be pregnancy. What kind of changes to the gut should a woman experience while she's going through pregnancy? Well, I mean, one of the biggest hormonal changes during pregnancy is that

progesterone levels, you know, become very high during pregnancy, particularly the first few months, and they get a very rapid rise and progesterone really slows down gut motility. So a lot of women will find they get very constipated. And the sort of the funny thing is they can get very constipated before the baby's very big or before their uterus has got very big, it can be very marked, particularly in the first trimester when baby's still very, very small. So that that effect is really purely a hormonal one. Now, obviously, later on in pregnancy, you also have a very large uterus with a baby sitting in your tummy, which can cause pressure effects on the on the gut and on the pelvic floor as well. There's also another very important hormone, relaxin, which causes our ligaments to

relax, to allow our pelvis to expand a little bit, the ligaments in our pelvis, that also can slow down gut motility as well. And when gut motility is slowed down, we have a tendency towards constipation, but it also can affect the upper digestive system as well so a lot of women will will experience reflux symptoms and again people can get reflux symptoms quite early on in pregnancy it's not just when you've got a very big baby sitting in your tummy causing pressure upwards it's also caused by the fact that gastric emptying the stomach emptying can slow down. So things sit in your stomach for longer and then can tend to, you know, to move backwards up into your esophagus or your gullet and cause some reflux symptoms. So they would be the main ones that cause problems.

And then obviously, as pregnancy progresses, you've got a baby sitting in your tummy and pressure on your pelvic floor, um, pressure down on the rectum, which is the lower part of your bowel, which can cause, you know, a little bit of problem and actually expelling the bowel motions. So it's really important during pregnancy to try and keep moving so that, you know, to try this movement and exercise helps gut motility, but to make sure you're drinking plenty of fluid and that you're taking all you know enough fiber because most women will experience constipation um and and many women will obviously suffer with the reflux as well um they would be the main ones um and then obviously after pregnancy if you if you go through a natural labor your pelvic floor is never with even with the bet you, with the most stringent

Kegel exercises and doing everything that it says on the tin, you know, the pelvic floor is never quite the same after a normal labor, or even what's a normal labor, but I mean, a vaginal delivery. So there can offer a lot of people will have a little bit of what we call pelvic floor descent. So the so the organs, the rectum and the womb and the bladder have all moved down a little bit. And that can cause people to have problems with expelling the bowel motions, going to the toilet, as well as all the other sort of more common ones that people will know about with maybe a little bit of leakage for a period of time, which in most people, fortunately, improves. So pregnancy actually is a huge event that occurs in a female body for many women more than once.

And when I was, again, trying to do some research for the book, you know, pregnancy is really one of those things that excludes women from most studies because all studies are really, for obvious reasons, ethically don't include pregnant women, but even a lot of observational studies, just to say, well, when you're pregnant, and you have IBS, for example, what happens, really very poor information about that, only a few small studies, but, and some women, it would seem, who have IBS will get a little bit better with during pregnancy, particularly people who have diarrhea predominant symptoms because things do slow down a little bit whereas people with constipation predominant IBS can get a lot worse and the bloating can feel an awful lot worse and they can go from maybe

passing a bowel motion every three days to every seven days so we really need to recognize that this is a problem for for women and if you are, you know, if you're going into pregnancy already with a history of kind of constipation, we need to try and nip that in the bud. Yeah, absolutely. And I think having these conversations is very important, even for anyone like listening who is a healthcare professional

looking after pregnant women to be aware of these changes. Obviously, we learn about heartburn and nausea and constipation during pregnancy and kind of medical studies but it's it's important again for women to be aware of them and and also to know that there is help available should they run into problems yeah and then I think forewarned is you know is forearmed if you kind of know what to anticipate you can instigate all the changes with your fiber with your exercise with your fluid with you know gentle bulking agents like

you know fiber supplements etc before maybe before you you know you haven't gone to the toilet for two weeks you know it's it's much better to try and prevent these things than than you know to it's easier for somebody if we can help them prevent it. Absolutely and then I guess thinking about the final major hormonal milestone in a woman's life would be then the perimenopause and the menopause do we see changes in gut function during this transition? Yeah we do and again there are you know not that many studies around the world looking at this. There's a large Seattle women's study that's been done. And there was a SWAN study in the States, study of women across the nation that have looked at some of these things.

And we certainly do see an increased incidence of digestive symptoms over the menopause transition. I think it's really good and nice that you call it menopause transition because it is a period going on for a few years. And it also, it appears that different phases of that menopause transition are associated with different gut symptoms. So for example, one study showed that about a quarter of women will get reflux symptoms

during early menopause transition. And those symptoms actually seem to improve a little bit later on. A lot of women will find if they've IBS, that their symptoms get worse in the sort of early menopause transition. But actually, after they go through menopause transition and kind of come out the other side, potentially, that they things can things can actually improve. And there's very little evidence telling us what happens when people do go on on HRT and obviously that's that's something that's that's so much more spoken about and so many so many more women are taking that now um we we really we really need to

do those sort of prospective studies over a few years to say, well, if we do get people on HRT at an early point, does that actually help them in terms of all the digestive symptoms? I mean, you'd imagine that it should. But certainly as a clinician, the biggest change that I would see or the biggest problem that women described to me around that time would be increasing constipation. It seems that the bowels do become a bit more sluggish in most women. Now, a small minority of women might find that they become a bit more frequent or a bit looser, but constipation tendencies are much more common. And a lot of women also will describe more bloating. And that's a combination of things that can be partly due to increased constipation. We also know that the gut microbiota

change around menopause, really interesting, actually, when they did some studies show they show that they've shown that women, post menopausal women have actually a gut microbiota, microbiota that more resembles that of males. So, whereas pre menopausal women and men have very different microbiota or microbiome populations. So there is a change that might be contributing to bloating in some women. And some women, you know, our metabolic rate goes down a little bit when around menopause, when we start to lose our muscle bulk. And I know you're very much an advocate of helping women keep keep their muscle and it is incredibly important but when our metabolic rate goes down tendency to gain a little bit of weight that if that weight goes on around the midriff area that can also contribute to bloating so certainly constipation and bloating would be the the biggest problems that I would see

um and uh and there are lots of things that can be done to help particularly in terms of dietary intervention etc and obviously the whole role of HRT is important too. Yeah I think it's just so interesting that we're even having this conversation because I don't feel like it's like gut issues are ever considered in the main menopausal symptoms you hear about like night sweats and hot flashes and mood changes and brain fog but you don't hear about the changes to the gut so it's really good that we're having the conversation but like you really pointed out there's not very much research around it and I don't think it's common knowledge even within a medical community. No absolutely you know and I think that's why it is really important and I

think it's really important to talk about it and i think it's really important for women to report their symptoms because um to their gp or if they're seeing a you know a menopause specialist um because this is how the the body of information really increases but we do need large-scale prospective studies of people as well and to find out what what works best for this you know is it um what sort of do people need is it fiber supplements is? You know, is it, what sort of, do people need, is it fiber supplements? Is it bulking agents? Is it, you know, is it there are other, there's a, as you well know, there's a whole range of medications to stimulate gut motility. What works best in this, in, for people with these problems? I mean, my own feeling is that as much that can be managed through dietary changes, that that's, that's obviously the best and the most natural way to

do things. But for a lot of people, these problems are more than that. And if you've worked in a neuro gastroenterology unit, you know that, you know, things can be very, very complex and symptoms range from very mild to very severe. And if you're at the severe end of the spectrum with symptoms, well, then it's very likely that you're going to need some form of medication. And there are some really helpful medications around. So I think I always, you know, one of the things I like, I try to say to people is, you know, don't suffer in silence.

Do talk to your doctor or do, you know, maybe seek referral to a specialist if you're really struggling with symptoms, because there are a lot of things that can be done nowadays to help people. Yeah, I agree with you. I think there's still often some stigma with accepting medication or medical support, especially if there's something that does have a known dietary intervention. Like patients can often feel like they're failing themselves or failing their doctor. But sometimes you do need medication or you need more than that. Yeah.

So, yeah, that's a really important point. The other thing I'd love to ask you about, I mean, we talked about probiotics a lot on this podcast in terms of general health and also its role in IBS, but I wonder what your feelings are for probiotics in female health, because there's so many that are targeted towards vaginal health in particular. And whether you as a gastroenterologist feel like this is you know something that women should start considering or whether we need more research I think we need more research on it I think we need more research on the whole area of probiotics in general I think the evidence to support probiotics for say vaginal health is sparse enough. And I think it is an evolving area. So I think that probably most women

don't need to take them. But I think it is evolving area. But my personal feeling about probiotics in general is that probiotics, it's like saying, they're like sweets. There are so many different types of sweets and they're not all the same and they don't do the

same thing. And people will find, you know, they'll go into a shop and say, I'm going to take a probiotic. But I think if you're going to take a probiotic, it's really important to do your own research to say, well, what bacteria are in this particular probiotic formulation? And what's the evidence to support that, to suggest that there's any benefit of this probiotic for the condition of what for the symptoms that I have. I mean, I'm not a I'm not a, you know, a female health expert. I'm a gastroenterologist. And I would know my own feeling and probiotics in digestive health is that, you know, they don't benefit most people they in terms of studies and large scale,

scale studies for IBS would show that one in seven people might benefit from a probiotic and it's very dependent on the type and the strains of bacteria in that so if you want to try one do your research and see what studies have been done to show that this particular combination of bacteria is helpful and if you are going to take when the British Society of Gastroenterology advice for example for IBS would be it's reasonable to take one ideally multi-strain one for for three months and if you don't see any benefit stop taking it because not everybody will benefit and as you say you've spoken a lot about you know gut health and microbiome etc and I personally feel that you can manipulate it hugely through your diet,

and that most of us don't need probiotics. And the other thing is that, you know, the studies would show that for most people, probiotics are passengers kind of through the gut, they don't really take root in your gut, they're there in your, in your gut while you're taking them, and you can detect them in the bowel motions, say, while somebody's taking them. But if you look three months after somebody stopped taking that probiotic, those strains of bacteria would probably not be there anymore. And it'll be back to what their baseline bacteria were like. So to get sustained changes to your gut bacteria, I think diet is key with that. And, you know, all the things we know that we should do in that regards that you've spoken about before. Yeah I think that's the resounding advice from any

gastro doctor that's been on this podcast and that's been amazing I would love to finish off the podcast with three questions that we ask every guest and the first one's easy well I think it's easy but you can tell me what's your number one takeaway that you want people to take from this particular episode? Okay, well, my number one was that if you are a person who suffers with irritable bowel syndrome, that it is absolutely not in your head. Don't let anybody tell you that. It is a very real condition and it deserves to be taken very seriously because it has such a huge effect on people's quality of life. As a gastroenterologist, that will be what I would like people to know. Amazing. The next one's about you. What's your most important lesson that you've learned over

your career? When I started off my training in gastroenterology, I was very fortunate to work with a gastroenterologist who, this was say 25, 28 years ago, who really believed he was absolutely dedicated to the cause of IBS and functional dyspepsia. This was before the Rome Foundation really even was established or just around that time. And he used to always say to all of us, his trainees, he used to say, I don't know is the second best answer. If you know something fantastic, you know it. But if you don't know it, say, I don't know, and go and try and find out. And I think that applies to anybody who works in medicine or in healthcare. We can't know everything. And you should not pretend you know everything. It's impossible to know everything, but don't be afraid to say, I don't know,

but you know what, let's go and try and find that out. And I think the more people do that, the more honest conversations we can have with our patients. Yeah, that's fantastic. And the final one is, what's your motto in life? I knew you were going to ask me this. My motto in life, and I might have to explain it because it sounds really corny,

but this is really true. It is plow your own furrow. Okay. Which means if you're, I'm not a farmer, but you know, if you're plowing a field, you plow your own, your own furrow, your own, your own trail in the, in the field. It means follow your own path. And I know where I live, when you come out, it's sort of a town in the countryside. And when you come out of the town, you go through a little bridge.

And when you turn the corner, there's a lovely field up on the left-hand side. It goes slopes up a hill, and it's always beautifully plowed. And my dad, when I was a kid, used to come around that field, around the corner, and he would say, you should plow your own furrow. And it's really stuck with me because I think we all should follow our own path in life and, you know, don't necessarily follow the crowd. And I know certainly when I was in school, I was a bit of a nerd, but I was also kind of sporty, which kind of made me half acceptable to the sporty people, even though I was a nerd. So I just think plow your own furrow, follow your own path and you'll get there in the end yeah i'm a big fan of that message and finally i mean i'm sure people want to know more about where they can find information

about you and the book and the work that you're doing so where should we direct them um well we're at the gut experts uh that's our social handle on instagram facebook and we're with the gut experts.com we have a website um with what we hope is lots of helpful information for people with digestive conditions, particularly things like we spoke about IBS, pelvic floor problems, functional dyspepsia. That's one of our things we want people to know about functional dyspepsia

because it's so common and yet so few people have heard about it. So we'd be really, really delighted if some of your listeners had a look at some of our handles. That would be fantastic. Absolutely. And the book, What Every Woman Needs to Know About Her Gut is, I imagine, everywhere in all good bookstores and online.

It is. And online, Amazon, et cetera, as well. Yes, it is. Wonderful. Definitely worth a read, even if you feel like you're not struggling with gut issues. I feel like as a woman, I learned a lot. And, you know, for medical practitioners or anyone in the healthcare space it's worth a read thank you thank you very much and very best of luck with your own book thank you thank you for

speaking with us today thank you Hazel thank you so much for tuning in today if you loved the episode you know what to do leave us a review a rating and share it with someone you know will love it too that's all from me. See you again next time.