What is the workup and treatment for bloating prior to menses (menstruation)?

Management of Premenstrual Bloating: Workup and Treatment

For bloating prior to menses, the most effective approach is a combination of dietary modifications, central neuromodulators, and behavioral therapies tailored to symptom severity, with exclusion diets showing long-term remission in approximately 50% of patients. 1

Diagnostic Workup

Initial Assessment

• Document symptom pattern in relation to menstrual cycle
• Two-week symptom and dietary diary to identify triggers 1
• Rule out organic causes:
  • Food intolerances (lactose, fructose, sorbitol)
  • Small intestinal bacterial overgrowth (SIBO)
  • Constipation
  • Visceral hypersensitivity
  • Abdominophrenic dyssynergia (APD) 1, 2

Diagnostic Testing (if symptoms persist)

• Breath testing for carbohydrate malabsorption or SIBO 2
• Upper GI endoscopy if symptoms persist >8 weeks despite therapy 2
• High-resolution manometry with impedance monitoring if belching is a prominent symptom 2

Treatment Algorithm

First-Line Approaches

1. Dietary Modifications

   • Supervised exclusion diet with a dietitian 1, 2
   • Low-FODMAP diet for 2-4 weeks with planned reintroduction phase 2
   • Reduce intake of:
     • Gas-producing foods
     • Artificial sweeteners
     • Lactose (if intake >280ml milk/day) 1
   • Monitor with food and symptom diary 1

2. Over-the-Counter Options

   • Simethicone for gas-related bloating 2
   • Alginate antacids for breakthrough symptoms if acidity is present 2

Second-Line Approaches

1. Pharmacological Interventions

   • For visceral hypersensitivity:

     • Tricyclic antidepressants (e.g., amitriptyline) 1
     • Serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine, venlafaxine) 1
     • Pregabalin for IBS-related bloating 1

   • For constipation-related bloating:

     • Secretagogues (lubiprostone, linaclotide, plecanatide)
     • Prucalopride (selective 5-HT4 receptor agonist) 1

2. Brain-Gut Behavioral Therapies

   • Relaxation training (10 sessions over 8 weeks) 1
   • Cognitive behavioral therapy 1, 2
   • Gut-directed hypnotherapy 1, 2
   • Diaphragmatic breathing exercises 1, 2
   • Biofeedback therapy (particularly if bloating is associated with dyssynergic defecation) 1, 2

Special Considerations

• Hormonal influence: Premenstrual bloating may be related to hormonal fluctuations during the luteal phase 3, 4
• IBS overlap: Women with IBS report more significant bloating during menstruation 4
• Abdominophrenic dyssynergia: Consider this diagnosis when there is paradoxical diaphragmatic contraction and abdominal wall muscle relaxation leading to visible distention 1

Treatment Pitfalls to Avoid

1. Inappropriate dietary restrictions: Overly restrictive diets may worsen nutritional status and quality of life 1
2. Empiric probiotic use: The American Gastroenterological Association does not recommend probiotics specifically for bloating 2
3. Focusing only on gas: MRI studies show that actual intraluminal gas volume may not correlate with bloating symptoms during menses 5
4. Overlooking psychological factors: Anxiety and depression can amplify bloating sensations 1
5. Neglecting patient education: Explanation and reassurance are crucial components of treatment given the high placebo response (47%) in functional GI disorders 1, 2

Monitoring and Follow-up

• Review symptom diary across multiple menstrual cycles
• Assess response to dietary interventions after 2-4 weeks
• Evaluate efficacy of pharmacological therapies after 4-8 weeks
• Consider combination approaches for refractory symptoms

By addressing both the physical and psychological aspects of premenstrual bloating, most patients can achieve significant symptom improvement and better quality of life.