Gut Health & Hormones: What Everyone Needs to Know

Bloated? Backed up? Blame your hormones! We recently welcomed Dr. Kumkum Sarkar Patel to our webinar series to talk about all things hormones and gut health. Dr. Patel is a double board-certified gastroenterologist and expert in digestive health, women's health, and mind-body integrative approaches to gut wellness. She talked with our community manager, Rachel Hughes, about the issues that can arise with your gut during perimenopause and menopause, and how to solve them.

Dr. Patel graduated Magna Cum Laude in Biomedical Engineering from Virginia Commonwealth University, holds a Masters degree in Public Health from Dartmouth Medical School, and received her medical degree from St. George’s University. She is the founder of a concierge gastroenterology and wellness practice, and has been featured in media outlets including KTLA5 News, GoodHousekeeping, and Popsugar Wellness.

We recommend you watch the full webinar on our YouTube, but are sharing some highlights below. The interview has been edited for brevity and clarity, and is for educational purposes only.

Rachel Hughes: Welcome, Dr. Patel. Thank you so much for joining us. I was thinking about how to get this conversation started, and it occurred to me that I don’t know a woman over 40 who hasn’t complained about a shift in how her gut is feeling, whether it’s bloating, gassiness, constipation, or IBS. Help us frame the conversation, and help us understand what happens to our gut during perimenopause. 

Dr. Kumkum Patel: Thank you so much for having me. This is a topic that is up and coming, and I feel that it’s not well understood. First, most physicians haven’t learned about it, much less the general public, and second, we’re starting to learn more and more about the effects of different hormones on our gut health and how it impacts everything. 

When you go through perimenopause and menopause, you experience a decline in your estrogen and progesterone. This changes how the gut moves, it causes a change in the sensitivity of gut issues, and it causes gut-brain issues.

Let’s start with hormones. Estrogen loss slows down the motility, or the movement, of the gut itself. So, when your gut slows down, it leads to bloating. The foods that you’re eating sit there for a longer period of time, and they’re not moving as fast, so they’re producing gas, and you end up feeling a lot more bloated, and you may also have constipation. When you’re in perimenopause, you’re still getting a period, so even though your overall progesterone levels are coming down, you’re still having rises and falls. When you get your period, your progesterone drops, you experience a release in prostaglandins, which causes cramping in your uterus and in your colon, and causes “period poops.” And it can be confusing, because you were bloated, you were constipated, and now you have diarrhea. It’s caused by those fluctuations.

The next big thing that happens is you get something called visceral hypersensitivity, which means you have more nerve hypersensitivity in your gut. This happens as you get older and lose hormones, and it changes the ratio of good to bad bacteria. Your brain sees the change and says, “Oh, okay, we don’t have as much good bacteria. We can’t handle stress as much,” and it puts the body into a low-dose fight or flight mode. And that causes IBS.

There are also changes in the gut-brain axis. This is one of the biggest things that I focus on as a gastroenterologist. Your gut and brain are very intimately tied together. Serotonin, gaba, and dopamine are predominantly produced in the gut, and they can influence your brain in terms of anxiety, depression, and stress. So when you are losing estrogen and progesterone in perimenopause and menopause, you are also reducing the production of serotonin, your happy hormone, because estrogen actually sits on the nerves that influence the production of serotonin, and it modulates tryptophan production. It stimulates tryptophan, which is the precursor to serotonin, the happy hormone. So if you don't have enough estrogen, you're not going to make enough tryptophan, which means you're not going to make serotonin. And guess what? If you don't have enough serotonin, you're going to be depressed. You're going to have anxiety. And this is the reason why you see so many women have major mood changes at this time.

Rachel Hughes: Thank you. I want to learn about leaky gut–it’s a term we hear a lot. Can you break down what it means? Is it a wellness term? A real term?

Dr. Kumkum Patel: Leaky gut is the street term for intestinal permeability. Intestinal permeability means that the junctions, or the little barriers in between each of the cells in the intestine are no longer as tight as they once were. You can think about it like a brick wall. Each of the bricks is tight, but over time, they get looser. WIth the reduction of hormones like estrogen and progesterone, and changes in the diversity of our bacteria, the junctions between our cells are no longer as tight. And when things are looser, other toxins can permeate through, or leak through, and that's why it's called leaky gut. Toxins like alcohol, toxins like medications, antibiotics, can get into your bloodstream and then trigger things such as increased insulin resistance, obesity, or a weakening of the epithelial barrier in terms of your immune system.

This means that you can get sick more easily, you can get viral infections more easily. And this happens because estrogen helps to maintain that intestinal barrier. It helps to maintain the tightness of those cells together. So when you lose estrogen and progesterone, it's not as tight. The other thing that's happening is, you’re losing diversity in your bacteria. In our gut, as we're younger people, we have a lot of diverse bacteria in our gut, and specifically, we have certain strains that are super helpful. They keep us from being obese, keep our metabolism up. When we lose this, our gut microbiome starts to look like a man’s, and we have more obesity in our bellies. We carry more truncal fat, and we have more insulin resistance, and it’s because you’re changing the bacteria and diversity of bacteria. 

Rachel Hughes: Fascinating. Can we talk about brain fog, and how that might enter into the equation?

Dr. Kumkum Patel: Let's talk about brain fog, which is another colloquial term. It means you don’t feel as sharp as you used to. This is because the gut-brain axis has been disrupted. The gut-brain axis is making neurotransmitters, or the happy hormones I talked about earlier, and they’re also making something called short chain fatty acids. Short chain fatty acids are the product of what is getting broken down when you eat fiber. The short chain fatty acid is what is telling the cells to produce serotonin, which makes us happy, and GLP-1 which makes us feel full. It modulates your immune system, and tells your body to reduce insulin when it needs to. 

One of the things that happens as we age and lose estrogen, is a loss of tryptophan, which is the precursor to serotonin, as I said before. I was reading recently a scientific study with rats that showed that acute tryptophan depletion led to IBS, and also to reduced cognitive performance. And they have done tests on women as well that show the same thing. If you don’t eat foods that allow your body to make serotonin, you don’t perform well. And that’s brain fog.

Rachel Hughes: Thank you. Someone asks, “Are probiotics in supplement form effective, or even necessary? Specifically, after taking antibiotics?”

Dr. Kumkum Patel: You do need to replenish and improve the diversity of your microbiome after you’ve taken antibiotics, because when you take antibiotics, you’re wiping out the bad bacteria, but also the good bacteria. So, you need to go back to a healthy diet of having fiber-rich foods and foods with probiotics. But it may not be enough. So, a probiotic supplement may help. 

Rachel Hughes: Just to stay on probiotics for a moment: Since they are, as you laid out, helpful for a number of reasons, are there any specific strains that you would recommend for women in perimenopause and menopause?

Dr. Kumkum Patel: So in perimenopause and menopause, we end up losing a lot of lactobacillus and bifidobacterium, and so replenishing those strains with fermented dairy, fruits, vegetables, and probiotic supplements if you’re not getting them through your diet, is very helpful. Also, we lose akkermansia eosinophilia as we get older and with changes in our hormones, and akkermansia is really crucial in terms of maintaining that gut tightness, and so you're losing those, so to help them replenish is very helpful.

Rachel Hughes: Okay, thank you. Switching gears, I remember when we first spoke, you spoke about hanging out on the toilet and how that can contribute to all kinds of issues. You’re very open about poop and the importance of it. So, I want to get into it: What’s proper poop?

Dr. Kumkum Patel: So obviously with loss of estrogen and progesterone, you're also going to get weaker pelvic floor muscles, because our pelvic floor muscles depend on estrogen and progesterone. So you’re getting slowed bowels, and you’re also getting weaker muscles that are having a harder time pushing things out. So, what can you do about it?

Number one, get a toilet stool. The Squatty Potty brand is a popular one, but you can get any version. What it does is it lifts your legs closer to your chest, and the primary muscle that’s in your pelvic floor actually gets straightened out and makes it easier for poop to slide out at the right angle, and you don’t have to push as hard. I have people who come into my office who are like, “I’m having to do a whole dance routine.” And that’s not a good thing. It’s a sign of pelvic floor dysfunction because those muscles have gotten weaker. So the Squatty Potty is one. And two, is, if you’ve had children, if you’ve given birth, your pelvic floor muscles may have gotten weaker afterwards. So, consider getting pelvic floor physical therapy. One thing that you should know is that when poop is in the rectal vault itself, it should take no longer than one minute to evacuate your bowels. You also shouldn’t sit on the toilet too long. If it’s your safe haven, your 15 minutes away from your kids, great! Just, once you’re done, sit on the toilet with the lid closed instead. Don’t hang around.

Rachel Hughes: Thank you so much. We have some questions that came in. Can we talk about some specifics when it comes to fiber?

Dr. Kumkum Patel: So, the recommended amount of fiber that you need is anywhere between 25 and 38 grams per day, according to the dietary association. A good easy number to remember in your head is 30 grams of fiber a day, 10 at each meal. Fiber is such a big topic, and it’s hard to understand. 

First, there’s soluble fiber and insoluble fiber. Soluble fiber is the type of fiber that’s easier to digest. Think of berries, chia seeds, oats. These are things that you can get, and they are drawing water in from your intestine and forming a gel-like substance that helps to reduce the amount of overall absorption of carbohydrates and sugars. Insoluble fibers are rough veggies. Think about kale and Brussels sprouts, asparagus. You need both of them in order to maintain a healthy gut. 

Rachel Hughes: Thank you. Another question someone asks is, “Does circadian rhythm play a role in a healthy gut microbiome?”

Dr. Kumkum Patel: Absolutely. A circadian rhythm is telling your body when to wake up and when to go to sleep. When you wake up, your brain gets the notion that light is there, and when you open your eyes and see light entering your eyes, you have something called high amplitude colonic propagations. This means that the contractions of your intestines begin as soon as your brain and your eyes open, and your gut starts to move.

It’s also important to get sunlight. Sun in itself helps to maintain and really help produce more of the better bacterial species. So getting a walk outside is very helpful in terms of bacterial diversity as well.

Rachel Hughes: Terrific. Thank you. This is important because we talked a lot about estrogen and progesterone. I did want to ask you about other hormones like cortisol and insulin impacting gut health, and it sort of piggybacks off of this person's question, which is, “If you’re taking HRT and still having bloating and constipation, what might that mean?”

Dr. Kumkum Patel: So, it’s great to replenish your hormones with HRT, because you’re losing a lot of estrogen and progesterone. But that’s only one part of it. You have to also replenish your good bacteria with a healthy diet, including probiotics.

Rachel Hughes: Thank you. What are some practical dietary changes or habits women can adopt today to support gut health during perimenopause and menopause? Can you share your top three?

Dr. Kumkum Patel: 30 grams of fiber per day. 60-80 ounces of water per day. Cut out processed sugar. 

Rachel Hughes: Alcohol has been in the news a lot these last several weeks. The Surgeon General wants to put a sticker warning on it. Do you have tips for women who want to enjoy alcohol but also protect their gut?

Dr. Kumkum Patel: Alcohol can disrupt the microbial diversity. But, if you want to enjoy it, limit it to maybe one or two drinks a week, and try for lower sugar options, like dryer wines. And eat fiber first!

Rachel Hughes: Thank you, Dr. Patel, for sharing your expertise today. Your insights are just invaluable, and I love talking to you, learning from you. Thank you for answering questions. For our listeners, if you're feeling inspired to take steps towards better gut health, start small, stay consistent, reach out to Dr. Patel, remember that change is possible, and until then, take care of yourself!

Dr. Kumkum Patel: Thank you.

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