EP.373/ Study Spotlight: Peppermint for Endometriosis Pain - Can It Help and Why?

Podcast

30 Nov

Today we’re continuing our Study Spotlight Series on the study: Dietary Modification and Supplement Use For Endometriosis Pain.

And today, we’re looking at the effects of peppermint supplementation. So first, let’s look at what this study found, that out of those who tried peppermint supplementation, roughly 26% experienced a reduction in pain.

So, before we dive into other research, let’s look at this research specifically first. So, remember that this was a pretty large study, of 2388 endometriosis patients, but unfortunately, we don’t know (or at least I can’t tell!) how many of these people tried peppermint specifically, so it could have been a much smaller number. We also don’t know the dose people tried, and remember that this was a survey study, it wasn’t a trial, so it wasn’t a study were people are all given the same amount of peppermint, for the same amount of time, to take at the same times each day. Instead, this was self-administered peppermint, from different brands, different doses, different formulations and on top of that, some people may have tried it for a few days, others a few weeks, others a few months. So these all create huge variables. For example, people who didn’t experience improvement, may have taken a lower dose, may have only tried it for a few days and so on.

We of course also need to acknowledge the placebo effect here, that those who experienced improvements in symptoms may have expected to feel improvements because they read good things online or looked at the studies, and so therefore did feel improvements because they’re brain expected to.

And finally, we need to also consider that this was a survey study, which means we are relying on participants to accurately remember their experience of taking peppermint.

Now, peppermint can benefit those of us with endo in a few ways, and one of them, as you’re learn about more shortly, could have improved the symptoms of endo patients with certain types of issues. Peppermint is evidenced based for improving abdominal pain, bloating and IBS symptoms, so if some of these endo patients also had IBS, SIBO or general gut issues, then the improvement of these could have improved overall pain and inflammation in the abdominal and pelvic area. So that’s another consideration - essentially, it could be better suited to some endo patients than others.

Okay, so now we’ve explored those points, let’s look at what other research says. Now, I couldn’t find any specific studies on peppermint for endometriosis, but please do correct me if I’m wrong, and if you’re a researcher, please find a way to conduct one!

But what we do have are a lot of studies on IBS and period pain.

So let’s start with period pain. There have been a number of studies on the effects peppermint for menstrual pain and PMS, and a recent review, just published this year, looked at the key studies and concluded that peppermint could in fact be an effective treatment for both menstrual pain and PMS.

Now, some of these studies looked at topical application of peppermint, which was also very effective, but that’s not what we’re talking about today and I’ve covered that on the show before, and in my Period Pain Relief Toolkit Masterclass, but let’s look at a few of the studies that used oral supplementation of peppermint.

One double blind clinical trial from 2016 compared peppermint capsules to a placebo in 102 participants with primary dysmenorrhea. The peppermint group were given capsules containing 330mg of peppermint oil, to be taken three times a day, for the first three days of menstruation. The study found that peppermint significantly reduced menstrual pain severity in contrast to the placebo group.

Another randomised crossover study found that peppermint decreased the severity of menstrual pain and how long it lasted, but also improved diarrhoea, nausea and vomiting, which I know so many of you with endo suffer with, especially if your prostaglandin levels are high, as they can trigger these symptoms. What was even more interesting about this study was that they were comparing peppermint to mefenamic acid, which is a medication many of us have been prescribed, and peppermint was shown to be just as effective for pain severity, and showed reductions in the intestinal symptoms I just mentioned, whereas mefenamic acid didn’t. It’s also worth noting that both groups required less additional pain medications, though the mefenamic acid group required less than the peppermint group, and the mefenamic acid group also experienced a reduction in bleeding. This study used capsules containing 187mg of peppermint oil, once a day, for the first three days of menstruation.

A final study looked at peppermint and ginger (individually, not combined) in comparison to a placebo. The participants were given 3 capsules a day, for five consecutive days, beginning two days before their period and the first three days of their period, for three months, and each capsule contained 250mg of peppermint. The study found that peppermint resulted in a reduction in pain severity, but that ginger was significantly more effective than peppermint, and both peppermint and ginger were more effective than placebo - in fact, there were no significant changes in the placebo group.

What’s also incredibly interesting and encouraging, is that other studies they looked at in this review, showed improvements in PMS when peppermint was taken at 187mg per days for 10 days prior to menstruation, with improvements in physical symptoms and mental symptoms like emotions and behaviour. In fact, the review concluded that these randomised controlled trials showed not just improvements in period pain and PMS, but improvements in GI symptoms, mood and cognitive function.

The caveats to consider here are that this review, and the studies included, all looked at primary dysmenorrhea, not secondary. Now, to explain the difference, primary dysmenorrhea is period pain caused by your period - basically, the mechanisms behind your period that can cause elevated pain levels, with the key culprit being elevated inflammatory prostaglandins, which we talk about a lot on this show, but there are other factors too, like low calcium levels, etc. Now, secondary dysmenorrhea is period pain with an underlying cause, such as endometriosis.

So, it is possible that peppermint may not be as effective on people with secondary dysmenorrhea as it is for those with primary dysmenorrhea - we just don’t know, because we don’t have the research. And remember, as I’ve said again and again in this series, just because we don’t have research on something, it doesn’t mean it’s unhelpful or unsafe - it just means it hasn’t been studied yet, so don’t get too caught up on that. I think people are often very quick to throw a tool out because there’s not research on it, but if we waited for research, we might be waiting our entire lifetimes, and who knows - peppermint might be life changing for you.

The other caveat is that whilst most of these studies were not of poor quality, the researchers acknowledge that they do come with limitations and further randomised clinical trials are required to confirm current findings.

Now let’s look at the research we have on IBS and period pain.

First off, it’s worth noting that research has shown that people with endo are three times more likely to also have IBS in contrast to those without endo, and early research is indicating that up to 80% of us may have small intestine bacterial overgrowth, which the latest studies are finding may actually be the root cause of around 60-70% of IBS cases.

Now, IBS can cause abdominal bloating, abdominal pain, abdominal pressure, and of course classic symptoms like diarrhoea and constipation. All of this can create intestinal inflammation that can spread locally to the pelvic area, and additionally, can cause pelvic pain from the pressure, and general IBS symptoms. And just to remind you, the bladder sits at the front of your pelvis, followed by your uterus in the middle and the rectum behind - so all of these organs sit in tight proximity to each other, and we know prostaglandins from the uterus during menstruation, can literally spread to the colon and cause diarrhoea, so the idea that IBS issues can cause inflammation and pain in your pelvic area, is not a reach at all.

So, now you understand the relevance of IBS symptoms in the context of endo pain, let’s look at the impact of peppermint on IBS.

There are a vast number of studies on peppermint oil for IBS symptoms, but in 2019, a systematic review analysed five decades worth of randomised clinical trials looking at 835 IBS patients from all over the world.

The conclusion of this review was that peppermint was a safe and effective treatment for significantly reducing abdominal pain as well as all symptoms of IBS. The even better news is that the validity of these findings were confirmed by the significant difference in improvement between the use of peppermint oil for IBS over placebo, shown in these clinical trails. And in terms of limitations, the quality of the studies were considered as high and moderate, so the data is reliable - unlike most of the systematic reviews and meta-analyses we look at on this show, the researchers did not call for better quality research, which is reassuring.

So, for some of us with endo, there is a high chance, based on the data we have so far, that gut issues are at least in part, contributing to some of our abdominal and pelvic pain and symptoms, so you can see why peppermint oil may be more effective for some than it is for others.

So, why is peppermint effective? How does it work?

The key component is that peppermint is antispasmodic, meaning it relaxes the smooth muscle of the intestines, which eases cramping, and also aids the transition of gas through the intestine, which is often a cause of bloating, pressure, pain and distension in people with IBS and SIBO.

Peppermint is also anti-inflammatory and is an antioxidant, and we know that people with endo have high levels of both inflammatory markers and oxidative stress markers, and when treated with antioxidants like vitamin C and vitamin E, inflammatory and oxidative stress markers actually reduced, so whilst we haven’t got studies on peppermint and endo specifically yet, there is a chance that it is lowering inflammatory markers and oxidative stress levels in endo folk using it.

Finally, aside from the pain relief brought on by reducing muscle contractions, peppermint is consider analgesic (meaning pain relieving) as it influences the nervous system’s pain-signalling pathways, creating a cooling effect and activating natural pain-relief mechanisms in the body.

So, if you want to try peppermint for endometriosis, how should you go about it? So firstly, remember that this general information only, and I cannot prescribe you treatments - so please discuss this with your doctor.

But, there are two methods you could take. You could replicate some of the studies used for menstrual pain, for example, two days prior to your period and the first three days of your period, or just the first three days of your period, as some studies did.

And in terms of doses, we can see some studies just used 187mg a day, whereas others used up to 330mg three times a day.

Now, most of these studies were conducted over at least 8 weeks, with one being three months, so even though you’d only be taking peppermint around your period, the effects came from taking it over repeated cycles.

But what about for IBS?

The best effects for IBS came from taking peppermint daily, for at least a month. In fact, symptom relief almost doubled when peppermint oil was taken daily, three times a day, at 180mg, in contrast to the same amount in a 24 hour period. So if you’re someone who suffers with IBS symptoms, intestinal pain, gas, bloating, etc. then you may find that you have better results with taking peppermint daily, rather than just around your period.

Now finally, let’s look at the type of peppermint capsules. Most of the studies are using peppermint oil, not peppermint powder, leaf, etc. so you need to check the label for that. And additionally, most use and advise enteric coated, which means the peppermint capsules open up in the small intestine because they are in a protective coating, and so are not broken open and released in the stomach, which could actually trigger nausea and acid reflux by relaxing the lower esophageal sphincter, which keeps the contents of the stomach sealed off from the esophagus, and when that relaxes it can open up, allowing for acid to move upwards.

And finally, let’s look at doses and brands. So a number of the IBS studies used a brand called Colpermin, and interestingly, a number of the menstrual pain studies used Colpermin too. Now Colpermin is an over the counter product, you can buy it in the UK at any pharmacy, like Boots, and it’s available in a number of countries around the world, and if you can’t find it, you can ask your pharmacist for something similar. Colpermin contains 180mg of peppermint oil, and allows you to take one to two capsules three times a day, which would be about 360mg, so a little over that higher studied dose we saw in one of the menstrual pain studies. But, you’re taking label dose, you’re not exceeding the label dose, so it’s safe (but of course, again, discuss with your doctor). Now, the label dose state that Colpermin can be used for up to two to three months, so if you wanted to exceed that, I would again, discuss with your doctor.

Now unfortunately, Colpermin does contain a number of E numbers, so if you want to avoid those, you can find a lot of peppermint oil capsules from supplement companies, that are of a similar dosage, but you just need to make sure they’re enteric coated, or you may see them label as ‘triple coated’.

Okay, so that’s it for this week. I really hope you’ve found this episode useful, and if you do try peppermint, I’d love to hear your response to it!

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References

Study Spotlight

https://www.theendobellycoach.com/podcast/new-endo-survey-study-review

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831953

Peppermint and menstrual pain

https://www.researchgate.net/publication/397219004_The_Effects_of_Peppermint_on_Menstrual_Disorders_A_Systematic_Review_of_Randomized_Controlled_Trials

https://www.cabidigitallibrary.org/doi/full/10.5555/20163324108

https://pubmed.ncbi.nlm.nih.gov/27563318/

https://www.scielo.br/j/cta/a/jVbCJJcPpj8DJTS5qp6qwyh/

Peppermint and IBS

https://link.springer.com/article/10.1186/s12906-018-2409-0

https://link.springer.com/article/10.1186/s12906-018-2409-0/tables/3

IBS and SIBO

https://www.youtube.com/watch?v=Sv8LjTgpmP0

https://www.ibssmart.com/sibo-symptoms-and-diagnosis

https://www.nature.com/articles/s41598-022-05933-1

https://www.msjonline.org/index.php/ijrms/article/view/15048

SIBO and endometriosis