Preparing for Endometriosis Excision Surgery and Bowel Prep

Once you decide to have endometriosis excision, there are many preparations you must make, and bowel prep is often the hardest. This post focuses on preparing you for endometriosis excision surgery and the required bowel prep in a holistic, hormone and gut friendly way.

Endometriosis Excision Surgery Prep

Preparing for endometriosis excision can feel daunting, especially after you (likely) spent years seeking answers to the cause of your pain. Endometriosis is a systemic disease and not limited to the pelvic and reproductive organs, so if you are like most women (yes men can have it too but it’s very rare) – your pain can be widespread through the body.

Some of the areas you can experience pain include:

• Headaches and migraines
• Fatigue (not a painful experience, but it is debilitating)
• Orofacial pain
• Chest pain and painful breathing
• Gastrointestinal and painful digestion
• Abdominal pain
• Painful urination
• Painful bowel movements
• Painful intercourse
• Pelvic pain
• Painful periods
• Pain that perists into and beyond menopause, even after your cycles stop
• Nerve pain (burning, hot, cold, stinging, dull aching, &/or sharp pain) that can radiate through the buttocks, down the legs, and into the groin and crotch area
• Hip pain that can be mistaken for hip labral tears or impingement

This is certainly not an exhaustive list, but these are the most common areas of pain I see patients experience. As an endo survivor, I have certainly experienced many of them up close and personal, and it is exhausting and all consuming.

I have the utmost compassion for any woman suffering from endometriosis, so as you prepare for your surgery, I offer up this post as a way to help you prepare, calm fears, know what questions to ask, and generally get ready for the big day – the first day of what hopefully is the end of a lifetime of suffering. And if you are receiving top notch excision surgery – see Nancy’s Nook to help you find a qualified excision surgeon – it is certainly the end of your medical gaslighting journey.

The first scary thing to tackle is deciding to have the surgery. It’s often difficult to get insurance to cover appropriate endometriosis surgery care, so that is very stressful and scary. But once you have taken the leap of faith to get the care you deserve, next is preparing for the big day – and that includes another step – bowel prep.

When I first read the bowel prep instructions for my own surgery, I immediately noted two things – the standard issue instructions for all GI surgery are pretty much the same – and unfortunately ALSO pretty harmful to the gut microbiome, blood sugar, and hormone health.

So I set out to see if I could change the bowel prep instructions to allow them to avoid depleting the good bacteria in your gut microbiome, maintain hormone balance and metabolism (especially of estrogen), and steady glucose levels.

Step One in Preparing for Endometriosis Surgery

Pain Medication(s)

You need to be prepared to manage pain in the immediate post-operative time frame, which I define as the first 3-5 days. I always tell patients to stay ahead of the pain, which means taking pain medications as prescribed, and of course as the pain subsides, looking to taper the opioid medication prescribed at the earliest possible time. This is because one of the many side effects of opioids (in addition to addiction) is horrendous constipation and higher risk of falls. Your physicians will typically recommend weaning from opioids as soon as possible and replacing them will alternating Tylenol and NSAIDS (nonsteroidal anti-inflammatories).

Managing Gas Pain

Depending how long you are “under” anesthesia – you will have a certain amount of “gas pain” from having the abdomen distended with carbon dioxide gas, which is necessary during surgery. The carbon dioxide gas used to inflate the abdomen during the laparoscopy can irritate the phrenic nerve. The phrenic nerve innervates the respiratory diaphragm. Carbon dioxide gas can be trapped against the diaphragm (breathing muscle), and it can be quite painful. Pain can be felt as chest pain and neck and shoulder pain. The pain can occur while trying to take deep breaths, which are effective for pain management – but because of the gas – can make breathing painful. Some remedies to assist with gas pain include:

• Avoid drinking ice water
• Suck on a mint or ginger chews, which serve a dual purpose of quelling post-op nausea and improving gastric motility
• Take frequent short walks to encourage peristalsis (digestion)
• Drink warm teas with lemon, peppermint, or ginger
• Have a partner give you a shoulder and neck massage when the pain is at its worst
• Do the “I Love You Massage” – a type of abdominal/visceral massage which can help with digestion, gas movement, and pain

One of the extra fun things that happens to me when I have laparoscopy is subcutaneous emphysema, which is trapped gas bubbles under the surface of the skin. It typically presents in the torso around the areas of the surgery, including the back, and when you run your hand over the surface of the skin, the bubbles feel like the sound of rice krispies crackling. This typically spontaneously resolves, but it could take a few weeks. If it persists or is associated with pain or breathing difficulty, it’s always a good idea to consult your physician.

Pain, Incision, and Edema (Swelling) Management

Swelling is to be expected in the abdominal area for several weeks to even months after surgery. I know it took me months before I could comfortably wear pants again. Partially from swelling and in part because my incisions were incredibly sensitive for a long time. This is why pelvic physical therapy is essential after excision surgery. Scar work is an integral part of the manual therapy that should happen to normalize scar mobility and sensitivity after surgery, and to avoid fibrosis of the scar and/or the scar adhering to other muscles or organs. For example, midline abdominal scars around the umbilicus/belly button can create urinary urgency, and sometimes the portal scars on the side of the abdomen can mimic hip or back pain.

To manage pain, consider these techniques:

– Breathing – Avoid the 4 horsemen of pain – open mouth breathing, chest breathing, mask breathing, and paradoxical breathing by learning to identify and avoid all these 4 abnormal breath patterns  

– Use Belly breathing for pain management – but remember that gas pain will often limit belly breathing and excursion of the diaphragm. So if this happens, you can try Umbrella Breathing, which is breathing into the side and back ribs, rather than only into the belly. Practice Belly Breathing below:

– Do gentle yoga postures in bed. You may not feel like getting on the floor in a yoga pose for the first few weeks, so yoga in bed is a great option. Some postures could include:

• Windshield wipers,
• Child’s pose (see below),
• Windshield wipers,
• Knees to chest, are all good therapeutic yoga postures to keep the pelvic floor relaxed

– Log roll to get in and out of bed – do NOT try to sit straight up

– Brace or splint the abdominals with a pillow – Use a weighted pillow or hold a pillow into the belly in order to splint the abdominal cavity with bed transfers, coughing, laughing, and/or sneezing

– Traveling – wear your binder, hydrate, put a pillow between you and the lap belt – Watch this short Reel on how to survive a 4+ hour car ride after surgery

– If you need it for pain management – rely on ice over heat for the first 1-2 weeks. Heat can increase swelling issues. 

– Do Orofacial Release – as much as you need it (include scalp fascial release).

Urinary Care

After surgery you may have bladder numbness and a lack of urgency/frequency post-op if they do have a bladder distension to check for endometriosis lesions (which is usual and customary care). As a result, you may need to be reminded to try to go empty the bladder because you may not feel the urge to go. Additionally, make sure to stay hydrated with room temperature or warm beverages. After the first 3-5 days, you can go back to drinking cold or iced beverages again. There is no hard, fast scientific rule for hydration amount. But aiming for straw colored urine and pain bladder emptying is the goal. Typically, drinking half your body weight in ounces (i.e. 120 female would need at least 60 ounces of water daily) is a good starting target.

Bowel Care

You will be constipated after surgery due to the medications and surgery itself. Many times you will be encouraged to continue to take your stool softener that you take for the bowel prep ahead of surgery. However, if you are one of many women who cannot tolerate stool softener – magnesium citrate in small doses may be a best alternative. Discuss this option with your physician ahead of time so you have a solid plan, and the nursing staff doesn’t offer you the typical stool softener (Colace) post op.

Nutrition & Nausea

Surgeons will typically have a list of medications and supplements that you must stop taking prior to surgery. Make sure to ask your physician when you can return to your supplement schedule, especially if you were taking supplements for hormone, bowel, bladder, and sexual health prior to surgery. These supplements will influence your recovery.

For healing – focus on eating whole foods (no canned, boxed, or fast food soups or foods please) with a plan-based emphasis. Target easy to digest soups that are homemade (you can make these ahead of time and freeze them if you don’t have anyone to cook for you) and high in protein, vitamin C, and omega 3’s, for starters.

Some people opt for electrolyte tablets and vitamin C in their water, which is an excellent way to boost nutrition and hydration. Nuun tablets are an option (no I do not get paid to mention them nor is it an endorsement).

For nausea management – electrolyte tablets, ginger chews, peppermint tea, bland foods like simple soups with legumes, shredded chicken and vegetables, can all help in managing nausea. Eat regularly, and if nausea becomes intense you can consider the P6 acupressure point and even anti-nausea meds (like patches behind the ear) which your physician can prescribe. Some even do the patch as you go into surgery so you wake up with immediate nausea relief.

See how to do the P6 point, here: I have found the point to be MOST effective when someone presses BOTH wrist points at the same time, not just one at a time.

Other Questions you may want to ask the surgical nurse prior to surgery include:

• What areas are they checking for endometriosis lesions? Endometriosis lesions are not confined to the reproductive organs and pelvis. They can be found in the thoracic cavity, bowel, sciatic nerve and other pelvic nerves, as well as the pericardium of the heart and in lymph nodes.
• Are they going to do PRP? Read about PRP in endo here
• Will you have an abdominal binder after surgery (recommended) and how long should you wear it?
• Will you have a nausea patch? When will it be applied? How long will the prescription last for and will it be easy to renew if the nausea persists?
• When will the surgeon’s office send the surgical plan for you to review and approve?

Step 2: Bowel Prep for Endometriosis Excision

Standard bowel preparation for surgery consists of a similar preparation to a colonoscopy. Fasting, laxatives, and hydration are necessary to clean the bowel in case a bowel resection or deep infiltrating lesions are found. While bowel prep is necessary, it’s not fun.

Once I began to read the instructions, I realized just how risky it was for anyone who has a history of the following:

• diabetes in their family,
• glucose sensitivity,
• hypo- or hyperglycemia (regardless of diabetes status),
• sensitivity to laxatives,
• tendency toward nausea when taking medications,
• low body weight or BMI (body mass index),
• and/or they do not consume sugar on a regular basis.

Additionally, the typical bowel prep includes chemicals known to contribute to dysfunctional estrogen levels and subsequent dysestrogenism (propylene glycol for example). It’s important to note that women with endometriosis should aready be eliminating xenoestrogens from their diet. Read a post on how to do that here

Because endometriosis is mediated by estrogen, it is counterintuitive to introduce xenoestrogens (fake estrogens) into the body. At worst, xenoestrogens can contribute to endometriosis flares (pain) and worsen the spread of endometriosis lesions. At a minimum, they are well known to create menopause-like symptoms including weight gain via altered metabolism and excess fatty tissue accumulation in the body, increased appetite, and obesity. For example, exposure to organochlorine pesticides, phthalates, and parabens are linked with insulin resistance and an increased risk of developing Type 2 diabetes, as well as fertility issues in men and women, and an increase risk of cancer. Read more on endometriosis and toxic chemical exposure

Additionally endometriosis management is linked to the health of the gut microbiome, not least of all because the metabolism of estrogen requires healthy digestion and elimination. For example, constipation is one of the first stops in holistically managing endometriosis in pelvic physical therapy.

A Holistic Bowel Prep for Endometriosis Excision Surgery

I would encourage you to send questions about shifting your bowel prep toward a more “flare friendly” one, like the one below, to your endometriosis surgeon if you have any of the following issues:

• Estrogen dominance
• Gut micriobiome issues
• IBS
• Constipation
• Diarrhea
• Tendency toward nausea with taking medications
• Tendency toward low blood sugar
• Diabetes
• Sensitivity to artificial flavoring, preservatives, sugar/glucose, and/or coloring
• You do not want to introduce chemicals into your body that are known to increase risk of fertility issues, cancer, menopause-like symptoms, and estrogen dominance.
• You have gut dysbiosis or a sensitive stomach.
• You appreciate healthy good bacteria in your gut, which supports immune function, fertility, mood stability, pain management, and healthy digestion.

Sample Bowel Prep Script

Feel free to adapt this script to make it personal. The Center for Endometriosis in Atlanta has already adapted their their bowel prep instructions based on my humble request as a patient and a pelvic PT.

I would like to ask for a different bowel prep routine as below:

Bowel Prep Recommendations that avoid exacerbating or contributing to dysestrogenism and hyperglycemia in sensitive populations:

• I have a history of sugar/glucose sensitivity.
• I have a history of hypo/hyperglycemia with sugar consumption.
• I have a history diabetes or prediabetes in my family.
• I have a history of sensitivity to consuming artificial chemicals.
• I have a history of sugar consumption flaring my endo symptoms.
• I have a history of artificial chemicals and sugar either causing diarrhea and/or constipation.
• I have a history of nausea and vomiting when taking laxatives.

The “traditional” bowel prep recommends fluids with sugar not just water. However they spike blood sugar and the resulting symptoms/signs are intense nausea and/or hyperglycemia. Therefore, I need to avoid the list of beverages typically recommended, like gatorade, coconut water, pops, or jello. I do not eat these things on a regular basis.

I fully understand the bowel must be empty. I need a holistic alternative for fluid consumption that does not include sugar-based beverages or sugar substitutes.

If you have low BMI: A complicating matter could also be low existing BMI or body weight, which exacerbate hypoglycemia.

Alternative Solution:

Bone broth is a safe alternative as it is also a clear liquid but has no sugar, and actually has micronutrients which support healing and nutrition. Clear herbal teas and water are also options, but bone broth does actually provide healthy nutrients and calories.

Next, Miralax contains endocrine disruptors like propylene glycol, artificial coloring and flavors. Additionally, Mirilax can cause severe nausea and intense vomiting, which has personally happened in this case with previous surgery.

Alternative Solution:

Magnesium citrate is a safe alternative to clean the bowel without causing the issues above. It can be taken in the proportions that Miralax is recommended to get the same effect.

The holistic protocol follows the same schedule as the biomedical protocol.

Thank you very much for considering this alternative bowel prep. I hope it meets your approval.

Sincerely,

Dr. Ginger Garner