EP.394/ Could SIBO Antibiotics Also Help Treat Endometriosis?
Antibiotics, understandably, have a bad reputation because of how much they’ve been overused in the past few decades, and the impact that has had on our gut microbiomes and overall health, not to mention, resistance development.
So, when it comes to antibiotics for SIBO, most of my clients are initially hesitant to consider them, and will typically opt for antimicrobial herbs instead.
However, there are some potential benefits of antibiotics for endometriosis, so I thought it was worth sharing these with you, so that if you find yourself having to treat SIBO, you can make an informed decision about which path you’d like to take.
So, first up, let’s just do a quick recap on antibiotics for SIBO:
Antibiotics reduce gases by 30ppm on average per round, so if a client has a level of 60ppm, they'll need at least two rounds.(1)
A round is 10 days-3 weeks. It would be 3 weeks if gas levels were above 70ppm, but most doctors do not prescribe this long.(2)
Antibiotics have an average 70-73% success rate, but have been shown to have up to a 91% success rate.(3)
The main antibiotics used that have been shown to be successful for SIBO treatment:
Rifaximin (4)
Neomycin (5)
Metronidazole (6)
Rifaximin is the leading antibiotic for hydrogen.(7)
Methane is notoriously harder to treat so we need to double up on antibiotics for effectiveness - we use Rifaximin PLUS either metronidazole or neomycin. (8)
For hydrogen sulphide, it’s typically Rifaximin plus bismuth.(9)
Both neomycin and metronidazole have been studied for endometriosis. In a few studies, metronidazole was shown to shrink lesions, prevent growth and reduce inflammatory pathways associated with endo growth, likely due to its systemic effects.(10) What I mean by this, is that rifaximin tends to stay local and treats the small intestine only, neomycin treats the small and large, but metronidazole is systemic, so it affects the whole body and that means, all the microbiome sites.
Whilst this is not ideal when we already have healthy microbiome sites, for endo, it’s potentially not the worst thing given microbiome dysbiosis is seen in both the gut and the reproductive tract in endo patients and animals. This dysbiosis typically leaned towards higher levels of opportunistic and gram negative bacteria, like e.coli and shigella, and lower levels of beneficial bacteria.(11) Whilst of course, we don’t want to wipe out the little good bacteria we have, if metronidazole is needed, the good news is that we can rebuild our microbiomes in a way that favours the growth of healthy bacteria.
So let’s talk a bit about the research for endo.
Metronidazole was shown to reduce endo progression in a mouse model after three weeks. The mice had smaller lesions, reduced proliferative cells (meaning growth was slowed) and actually lower levels of inflammatory immune chemicals involved in endo development, called cytokines. However, diversity in the gut microbiome had decreased, so if the same were to happen in humans, we’d need to support that to recover. (12)
However, despite having anti-inflammatory effects, a more recent study which used 14 days of metronidazole following surgery, showed no improvement in pain levels in women with endometriosis.(13) I’d be interested to see whether another study in those who haven’t had surgery and still have present lesions, would have a different experience.
Now - just as a side note, another study treated women with endometriosis and endometritis with doxycycline, and found CA125 levels reduced following treatment, which is a marker for endo disease severity. However, the size of endometriomas, if present, did not reduce, and those with chronic endometritis experienced no reduction in CA125 levels.(14)
Additionally, many endometriosis patients have reported experiencing symptom improvement after a course of antibiotics.
Now, what about neomycin? Whilst researchers did compare neomycin and metronidazole, the reduction in lesion size in mice only occurred in the metronidazole group, likely due to its ability to reach the reproductive tract, in contrast to neomycin.(12)
So, now let’s look at rifaximin, because whilst it doesn’t reach the reproductive tract, it has some very interesting benefits.
Rifaximin is anti-inflammatory and lowers inflammatory cytokines,(15) which are elevated in endometriosis.(16)
Rifaximin increases glutamine levels, helping with leaky gut, reducing the risk of LPS and bacterial translocation.(17) Now, for those of you who don’t know what LPS are and why leaky gut matters, last week’s podcast episode will fill you in. But in short, they are toxins that come from gram negative bacteria, that trigger the inflammatory immune reaction that furthers endo progression, and researchers believe the bacteria and the LPS are getting to the pelvic cavity of people with endo, via leaky gut, which allows them to translocate (move).(18)
To further add to this win, rifaxmin has actually been shown to reduce levels of LPS.(19)
Last, rifaxmin has actually been shown to normalise the gut microbiome rather than harm it, which may be helpful given that endometriosis patients are more prone to gut dysbiosis.(20)
Whilst we don’t have any direct studies of rifaximin on endometriosis, it has been proposed as a possible treatment for IBS symptoms and pain in people with endometriosis, due to the positive effects it has on IBS severity. (21)
So, whilst antibiotics do come with risks, when approached mindfully and with the right support to reduce this risks and encourage proper microbiome recovery, a SIBO antibiotic protocol may actually end up also helping with your endometriosis.
I’m very excited to see where research takes us in the next couple of years, and hope that we see more studies on endometriosis and the modulation of the gut microbiome.
If you’d like help testing for SIBO, and creating an antibiotic protocol that also supports gut health recovery and endometriosis, you can always book in for a SIBO Session package, for £200, or a single session, for £150.
However - remember, I cannot prescribe and treat, and you will need to discuss your SIBO plan or antibiotic options with your doctor.
I’ll see you next week.
References
1) Dr Siebecker estimates, in course: https://siboprocourse.siboinfo.com/?ref=15748-Allison-Siebecker
2) https://www.siboinfo.com/antibiotics.html
3) https://pmc.ncbi.nlm.nih.gov/articles/PMC5299503/, https://www.cghjournal.org/article/S1542-3565(09)01331-7/fulltext
4) https://pmc.ncbi.nlm.nih.gov/articles/PMC5299503/, https://www.cghjournal.org/article/S1542-3565(09)01331-7/fulltext, https://www.siboinfo.com/antibiotics.html
5) https://pubmed.ncbi.nlm.nih.gov/24788320/, https://pubmed.ncbi.nlm.nih.gov/19996983/, https://www.siboinfo.com/antibiotics.html
6) https://pubmed.ncbi.nlm.nih.gov/29574688/, https://www.siboinfo.com/antibiotics.html
7) https://pubmed.ncbi.nlm.nih.gov/28078798/ , https://pubmed.ncbi.nlm.nih.gov/26780631/, https://www.siboinfo.com/sibo-antibiotics.html, https://pubmed.ncbi.nlm.nih.gov/19243285/
8) https://pubmed.ncbi.nlm.nih.gov/24788320/, https://pubmed.ncbi.nlm.nih.gov/19996983/, https://www.siboinfo.com/antibiotics.html, https://pubmed.ncbi.nlm.nih.gov/29574688/, https://www.siboinfo.com/antibiotics.html
9) https://www.triosmartbreath.com/intestinal-sulfide-overproduction, https://pubmed.ncbi.nlm.nih.gov/9558280/
10) https://www.sciencedirect.com/org/science/article/pii/S2633838624000046
11) https://pmc.ncbi.nlm.nih.gov/articles/PMC12942269/, https://www.mdpi.com/2076-2607/11/8/2089
12) https://pmc.ncbi.nlm.nih.gov/articles/PMC6554192/
13) https://www.sciencedirect.com/science/article/pii/S0002937824007506#bib26
14) https://academic.oup.com/humrep/article/39/Supplement_1/deae108.658/7703802
15) https://pubmed.ncbi.nlm.nih.gov/21806984/, https://pubmed.ncbi.nlm.nih.gov/20816942/, https://pmc.ncbi.nlm.nih.gov/articles/PMC2957776/, https://pubmed.ncbi.nlm.nih.gov/26618923/,
16) https://pmc.ncbi.nlm.nih.gov/articles/PMC10855755/
17) https://pmc.ncbi.nlm.nih.gov/articles/PMC5543406/
18) https://www.theendobellycoach.com/podcast/lipopolysaccharides-endo-pain-growth
19) https://pubmed.ncbi.nlm.nih.gov/21806984/, https://pmc.ncbi.nlm.nih.gov/articles/PMC11617758/, https://pmc.ncbi.nlm.nih.gov/articles/PMC5543406/
20) https://pubmed.ncbi.nlm.nih.gov/20852272/, https://pubmed.ncbi.nlm.nih.gov/12120885/, https://pubmed.ncbi.nlm.nih.gov/25244596/, https://pubmed.ncbi.nlm.nih.gov/30555323/, https://pubmed.ncbi.nlm.nih.gov/32885687/, https://pmc.ncbi.nlm.nih.gov/articles/PMC5504364/, https://pubmed.ncbi.nlm.nih.gov/30391527/
21) https://pmc.ncbi.nlm.nih.gov/articles/PMC10458414/, https://www.sciencedirect.com/org/science/article/pii/S2633838624000046
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