SIBO Made Simple | EP 13 | Digesting For Two: Infertility, SIBO & What Pregnant Mothers Need to Know About Gut Health with Dr. Aviva Romm

Welcome BACK to season 2 of SIBO Made Simple! I’m so excited for all that’s to come, but perhaps the most pumped about today’s episode, which is all about digesting for TWO. Believe it or not, one of the most frequent questions I got during season 1 was about either a) fertility and SIBO or b) treating SIBO while pregnant.

Luckily, I was able to bring on the perfect person to guide you through the subject of fertility and child bearing, and give us a more in depth view of how our vaginal ecosystem relates to our gut microbiome. Dr. Aviva Romm is a midwife, herbalist, and Yale-trained MD, Board Certified in Family Medicine with Obstetrics, who has been bridging the best of traditional medicine with good science for over three decades. She is also the author of the fabulous book The Adrenal Thyroid Revolution.

Even if you’re child-free like myself, and not yet on the baby making band wagon, I think you’ll find this episode fascinating because of the wide range of things we cover in regards to women’s health. If you’re in the infertility camp, make sure to check out my tips on egg retrieval recovery and how to prevent a fertility issue from becoming a gut issue.

A quick taste of what we’ll cover:

• What gut issues could cause infertility and why
• How the gut microbiome effects the vaginal microbiome
• Estrogen dominance and the downstream effects on fertility
• Leaky gut, vaginal PH and yeast—the role of all three in your procreation plan
• The importance of greening your feminine care products
• What happens to your digestive health during pregnancy, especially to those with Hashimoto’s, Celiac, or another inflammatory condition
• What treatments and herbs to avoid if you are pregnant and have SIBO
• The importance of healthy fats for women and what to do if you’re not digesting them properly
• Strategies for recovering from a C-section for mom and baby to ensure good gut health thereafter

Resources, mentions and notes:

• Dr. Romm’s website
• Dr. Romm’s book, The Adrenal-Thyroid Revolution
• Dr. Romm’s podcast episode on Hashimoto’s and Pregnancy
• Dr. Romm’s podcast episode on Vaginal Seeding
• Dr. Romm’s podcast episode on C-Section prevention
• Phoebe’s post on how to request a full thyroid panel
• Dr. Romm’s favorite pre-natal probiotics: Klaire Labs Therbiotic and Integrative Therapeutics Pro Flora for Women
• Myo-inositol plus selenium for thyroid health

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WHY DOES GUT HEALTH IMPACT A WOMAN’S FERTILITY?

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PHOEBE: Dr. Aviva Romm, thank you so much for joining us today on the show.

DR. ROMM: It’s a pleasure to be here, Phoebe. Thank you for having me.

PHOEBE: Okay, so I’ve gotten a lot of questions as the first season went on about fertility, about pregnancy in SIBO, and just how these things tie into gut issues. I want to start by talking about the fertility piece. I know you go through a lot of the ways in your book that our modern environment has caused women’s hormones to go off the rails. I’d love to focus on what role the gut plays in that, the good, the bad, the ugly, and how it contributes to our fertility picture. Can you start by giving us just a basic overview of why we should even look towards the gut as a piece of the puzzle?

DR. ROMM: Absolutely, so it’s one of these areas – to me, the gut is so exciting in so many ways. First of all, it’s the first time I’ve watched conventional medicine perk up about something that’s, one, kind of alternative and, two, very earthy, and I’m loving it. I’m a super science geek, and so for me, it’s a little bit like – it’s like the Star Trek: Enterprise of health right now at going where no one’s gone before and all these new discoveries and species and planetary inhabitants. It’s really exciting. When it gets down to the gut and women’s health, it starts to get for me even more geeked out, exciting, especially being a midwife and a women’s doctor. I keep unpeeling these layers of new research that’s coming out, so I’m actually deep in it right now with my hormone stuff that I’m doing research for my next book.
Let’s start with the gut in and of itself and the gut microbiome. There are a couple of aspects of the gut. One is the microbiome, and that’s really important for women’s health, women’s hormones, women’s fertility. Then there’s inflammation vis-á-vis things like leaky gut, and then it starts to get into the gut microbiome and how that affects the vaginal microbiome, which has a whole new spin for fertility. Let’s start with the gut, just basics. You’ve got your microbiome, and the microbiome is involved in a number of really important things around women’s hormones and women’s health. One of those is there’s a whole special gut that’s – gut microbiome called the estrobolome, and the entire reason for being of this estrobolome is to metabolize estrogen.

Estrogen is that hormone that makes women juicy and curvy, and it’s important for that mid-cycle surge that allows us to ovulate. That ovulation is critical for then having something called a corpus luteum, which is the spot where the egg pops out on the ovary that then creates progesterone, and without that estrogen and progesterone, you can’t have a fertile cycle. You don’t get proper uterine growth for implantation, and so that very core microbiome is critical. It also determines how much estrogen we eliminate. We have to eliminate estrogen, so the liver breaks down what our body produces and also all of the kinds that we pick up from the environment, from our cosmetics, plastics, herbicides, all the things that no matter how green and organic we are we still get some exposure to. The liver breaks all that down, but then we have to poop out what we’ve broken down, and so you have to have a healthy microbiome and good gut elimination. Otherwise, you reabsorb a more toxic form of estrogen, and that causes other risks, including things like breast cancer so microbiome, super, super important.

Another aspect of the microbiome is that it’s critical for maintaining healthy weight. Now, I don’t think that there is any perfect, beautiful woman’s body size. Women’s bodies and shapes are gorgeous however we are, and within that also, we know that women who are too underweight or too overweight often have problems with conception much more than women who are in a healthier weight range for their fertility, let’s say. The microbiome is also critical in how we absorb nutrition from our food. If we absorb too much nutrition in the form of calories from the foods we’re eating which can happen when we have the wrong kinds of gut flora growing in there, we can actually lean toward overweight. On the other hand, if you don’t have a healthy gut and you have too much inflammation or not healthy microbiome, you might not absorb a lot of the critical nutrients that you need like Vitamin D and Vitamin E for healthy hormone function.

Then the third piece of that that I was talking about is gut inflammation and leaky gut. That’s another area that can cause, one, general systemic inflammation, and systemic inflammation can cause all kinds of problems from endometriosis, PCOS, uterine fibroids, and cycle imbalances, menstrual cycle imbalances that can affect fertility as well. Then leaky gut is another reason that you might not absorb your nutrition. Then the other thing is that the whole vaginal, anorectal, urinary tract, it’s all – all the openings are hanging out within about a couple of inches of each other down there. What’s going on in the gut has some pretty direct impact both because of migration of microorganisms, but the overall microflora in general influences vaginal microbiome. There is some crazy studies out there that show how important that vaginal microbiome is for women’s pelvic health. We know that changes in the vaginal microbiome as a result of changes in the gut microbiome can decrease IVF success, embryo transfer success, but also can increase inflammation in the uterus itself, which makes the uterus less of ideal place for implantation and can change cervical mucous. It’s all connected, and there’s a lot going on. Getting that gut healthy is really important.

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YEAST AND THE HEALTH OF OUR VAGINAL MICROBIOME

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PHOEBE: That’s an amazing answer, and I could ask 100 follow-up questions right now. I’ll actually start in an area that I didn’t think we are even going to go in this conversation, which is the vaginal microbiome, and I’m so glad you brought that up. I think, for a layman, people I think maybe know that there’s, obviously, a bacterial ecosystem, but when they feel something off, I think people think more yeast than bacteria. Since I also get a lot of questions about candida issues and the connection with SIBO, can you talk a little bit about how yeast factors into all this and has a relationship with the main microbiome as well as the vaginal microbiome?

DR. ROMM: Yeah, so we all have yeasts in us and on us, right? We’re all part of one giant ecosystem that is our planet and everything that grows on it. I think, more than anything, the microbiome is really that – where the blur starts to happen between am I myself? Am I a collection of other organisms? Am I just another creature inhabited on the planet just like all the other creatures out there? I think the answer is largely yes, and yeasts are amongst those creatures that live in us and on us. The thing is is that we have been apparently inoculated, if you will, by yeast for millions of years. I mean, essentially since we introduced dairy into the human diet, we have also been colonized by lactobacillus and other organisms, and these have become mutually beneficial for us and us mutually beneficial for them. We feed them, but they also keep our vaginal pH and our gut health in check as part of just some of the organisms that take up space. In the vaginal microbiome or in the vaginal ecology, as I call it, the lactobacillus are critical for maintaining a healthy vaginal pH, and it’s that vaginal pH that prevents us from getting other infections or developing infections like bacterial vaginosis.

Essentially, yeast isn’t a problem unless it starts to grow out of control, and that is a secondary problem to either nutritional issues, or immune system issues, or gut microbiome, or other vaginal microbiome issues, or as a result of exposures. Just to give you an example would be if you are using scented tampons, or scented sanitary products, or douches, or even a lot of the vaginal lubes on the market change vagina pH, and they can change it in a direction that affects the lactobacillus. If you take antibiotics, it can kill off the lactobacillus, and that changes your vaginal pH. That changed vaginal pH can make your vaginal mucous and cervical mucous less hospitable for conception, but also can, again, add to that inflammation in the uterus that makes implantation more difficult too. Then in the gut, we do have some yeast also, and they’re just, again, a normal part of all the inhabitants that are living in there. The problem is, again, antibiotics, things that change our digestive systems, acid, like taking acid blockers, which affects your stomach acid, but then that affects what’s growing in your stomach and your upper intestine. Our diet has a dramatic impact on our gut pH. All of these things just throw off the natural environment.

It’s like a garden. If you intensively plant a garden and you have healthy soil, you’re going to grow healthy vegetables, and you don’t have to do that much work weeding. If you plant things closely enough and abundantly enough and the garden is healthy, it just crowds out the bad stuff. Weeds aren’t necessarily bad either, but you don’t want them taking over your garden if you’re trying to grow squash and broccoli and lettuce. It’s the same in your gut. Yeasts are like dandelions. They’re not necessarily a bad thing. In fact, they can be just fine, but you don’t want them crowding out your vegetables and your other things that you’re trying to grow. That’s where the problem gets in, and that’s where we also have a tremendous amount of influence over the health of our gut and then, by proxy, the health of our vaginal microbiome and what’s going on in our urinary tract as well.

PHOEBE: Yeah, I love that you brought up our personal care products down there. I think it’s the final frontier for a lot of women who clean up their diet, even cleaning up their personal care products in terms of skin care and makeup and beauty but then are still using conventional tampons. How does that actually impact our gut microbiome? Does using a scented tampon and changing the pH of the vaginal microbiome actually have upwind effects for the gut?

DR. ROMM: It’s usually the other way around. There’s more of a connection between what’s going on in the vaginal ecology and the bladder and the urethra. You can get more irritation. If you get a yeast infection or bacterial vaginosis, you can also get some urinary symptoms with that, but it’s more that the gut is going to be more likely to contribute to what’s going on in the other two places than the other two places contributing to what’s going on in the gut. That said, if you get recurrent vaginal infections or recurrent urinary tract infections and you’re taking antifungals and antibiotics, then that could definitely cause a problem, and certainly, inflammation anywhere in your body can affect other areas of your body.

PHOEBE: Yeah, so I think you really outlined it so well what all the various gut related issues could be that could lead to infertility. I’m curious if SIBO is one of them or if it’s just one of those things that’s related more indirectly to some of the root causes like Hashimoto’s, slowing motility, or again, the actual leaky gut that SIBO could create, or just maybe one of the autoimmune issues that was a precursor to SIBO. I feel like on this podcast we talk about chicken or the egg with all these things a lot, and it’s so hard to pinpoint since there’s so much that’s still left to know. I’m curious from your experience working with women if there are any trends in terms of their gut health and the connection to infertility?

DR. ROMM: There’s definitely trends in gut health and infertility. For example, we know that, hands down, celiac disease can be a very unsuspected cause of recurrent miscarriages and difficulty getting pregnant, so that is unquestionable. That’s partly the autoimmune component of it and partly the gut inflammatory part of it and then partly the malabsorption part of it. You’re just not absorbing your fatty acids. You’re not absorbing your fat soluble vitamins, for example, and that can affect fertility.
SIBO is a really complicated conversation in some ways in that there are a lot of diagnoses that are floating around right now, and probably thyroid problems, adrenal fatigue, and SIBO are three of the big ones that a lot of things are getting chalked up to. When you actually look at the literature, the medical literature and the prevalence, the epidemiology, we do know that Hashimoto’s and thyroid problems in general are drastically underdiagnosed. We know that, while there’s no such thing truly as adrenal fatigue, what we’re really talking about, this picture of women being – people being exhausted and burnt out and all the physical symptoms that can come with that is a very real thing, and it does have to do with cortisol and adrenaline. It’s not true that the adrenals get tired out. Hashimoto’s is definitely a real medical diagnosis that’s being missed a lot. Adrenal fatigue not a recognized medical diagnosis but definitely a phenomenon that we can put our finger on.

SIBO is a real medical diagnosis, but from all the studies that have been done, it appears that the amount of diagnosis that’s happening in the functional medicine world is far greater than when scientists are actually looking at populations and studying them based on the same kinds of test the functional medicine world is doing. They’re just not finding it as much. There may be some over inflation of what we’re calling SIBO that may be definitely some gut stuff going on, or the people who are seeking help maybe are more likely the ones that do have SIBO. The problem is is that every single study that has looked at the effectiveness of the tests that we have basically show that they’re really not that reliable. Even some of the world’s most leading experts on SIBO who are quoted by people like Chris Kresser and others, people who I know are trying to do their homework on this stuff are saying, yeah, but the tests aren’t actually as reliable as we in the functional medicine world are saying they are. Knowing what exactly is and isn’t SIBO and who does and doesn’t have SIBO is a little bit tough.

What I would say is that gut health is really important. Whether or not we know that it’s SIBO, if someone is having a lot of gut issues, then it’s definitely worth looking at those, ideally, before a woman gets pregnant, one, because the nutritional absorption issues are so great. Two, pregnancy tends to exacerbate digestive issues for a lot of women, both things like reflux, slowing motility. Hormones actually slow down motility, increase pressure from the baby, increasing constipation, so it’s better to go into pregnancy gut healthy. Then, also, we know unquestionably that the mom’s microbiome has a huge influence on the baby’s microbiome and the baby’s health of their immune system, their stress response system, their resilience in general. All those reasons make it really important to step back and take a look and say, okay, what’s going on?

We also know that women with Hashimoto’s as you mentioned, great call on that, hypothyroidism in general, do have delayed gut motility. Sometimes having the digestive symptoms can get us to look for, as you say, those root causes that in and of themselves can be problematic. Hashimoto’s or hypothyroidism even if it’s not autoimmune increases a woman’s risk of having trouble getting pregnant, having a miscarriage, having prenatal and postpartum depression. Really important to suss out is that a cause of it – it’s also, again, celiac has a lot of health implications. Celiac is one of the very underdiagnosed reasons for gut problems and delayed motility in SIBO. Then women with IBS, irritable bowel syndrome, are also much more likely to have SIBO. If you have IBS and the normal things you’re doing aren’t working, then it is a good time to say, hmm, is this something more?

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FERTILITY TIPS FOR IBS, HASHIMOTO’S AND CELIAC DISEASE

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PHOEBE: Yeah, so I would love to hear what your game plan is for someone with IBS and/or someone with Hashimoto’s who wants to get pregnant, but just since we brought it up with the breath testing, I’m curious. Do you even use them, or do you just look at all of the other factors in someone’s chart and also how they feel when they eat fermented foods and whatnot to make a call on whether or not SIBO could be affecting them?

DR. ROMM: Yeah, so any patient that I have who has abdominal pain or discomfort, bloating, abdominal distention, especially up underneath the diaphragm. Not so much lower bloating like women get right before their period a lot of times or if you just get gassy. That feeling of having almost like a bicycle inner tire underneath the diaphragm is how it feels actually as a doctor when I palpate it, but it’s also how people describe it, if they have diarrhea, a lot of gas, if they’re weak and tired a lot. Then anyone who I have come in who I’ve tested for nutritional deficiencies, particularly if they have digestive symptoms already, or if they have nutritional deficiencies – like I had a patient two years ago that I think of. She had really low Vitamin D and really low B12, and all the normal things that we did to build up her D and her B12 just – it didn’t go anywhere. I was like you know what? Let’s check you for SIBO.

Sometimes the symptoms are really obvious, and I’m going to use just a very natural approach. I don’t feel like I need to necessarily do breath testing because, one, it’s not necessarily reliable. You could have a negative breath test and still have SIBO. You could have a positive breath test, and it doesn’t mean you actually have SIBO. It could just be normal gas production from your microbiome in your gut, so I don’t necessarily automatically test this. I always say if it walks like a duck and quacks like a duck, it’s probably a duck.

If we’re going to use botanicals and supplements and dietary therapies, then I don’t, but if I’m going to use any of the pharmaceuticals like Xifaxan which is also called rifaximin, then I always test. The reason is, one, I don’t want to use any pharmaceuticals that a patient doesn’t need because that’s not necessary for the patient. Two, I worked really hard to get my medical license, and I don’t want to lose it by giving a medication when I haven’t done a test to prove that what I’m using it for is there. Three, rifaximin can be really expensive. I mean, it can be 6 or $800 for a 2-week course of it. I try to steer toward the natural therapies first because, actually, studies show – the limited numbers of studies that are out there do show that they are equally effective, and so if I’m basing it on that, then I don’t. If I’m not sure if it’s SIBO or something else, then I might do the breath test, and if the breath test is frankly positive, like when I say off the chain – not just a little, maybe, maybe not. If it really is off the chain, then we could pretty much say it’s a positive test.

PHOEBE: Right, I mean, if it’s really high, what else could be causing that?

DR. ROMM: The thing is and this is really interesting, there is no proven upper number that says you definitely have SIBO because that number can be different for different people. There’s no proven number at which your bacteria produce hydrogen or methane versus what my bacteria produce hydrogen or methane or how far down your small intestine those are and how much of a reading you get. Really, the science behind the SIBO testing is not definitive enough to say this little elevation is possibly SIBO but maybe not. This elevation definitely is. There’s controversy over whether you should use the hydrogen, or the methane, or both, so it’s still a little bit of a Wild West. The thing is that conventional medicine has a lot to offer, but it’s also very limited. Functional medicine has a lot to offer, but it often over claims on things.

Then somewhere in the middle there’s a sweet spot where somebody’s not feeling well. Their conventional doctor is saying but you’re fine, and it’s probably just stress. You’re saying, yeah, I don’t think so because nothing’s really changed in my life, and I feel really terrible, or I actually was fine until I got this gastrointestinal virus on vacation. Now, a month later, something’s wrong. There’s something that happens, and then you’re not what you felt before. On the other hand, just because functional medicine says this tests works doesn’t mean that all the claims to it are exactly what is being said. Sometimes you’re in that middle ground, and you’re like, well, I don’t want to do nothing. I want to treat this patient, and I want to figure out what’s going on, or you’re wanting to treat yourself, but you’re wanting to be cautious to not jump on a bandwagon that may be a little bit undetermined yet.

I do use the testing because sometimes there’s just – there’s no other way to figure out what’s going on. Conventional medicine doesn’t really have the answer, and even when it comes to one of the gold standards for testing for SIBO, that’s an endoscopy with a biopsy. Even that, they don’t know exactly how much, basically, ten to the X number or exponent bacteria is considered okay and not okay for any individual, so it’s really not determined yet.

PHOEBE: It really is the Wild West, and that’s what I think people are so confused about and why I wanted to start this podcast in the first place. I also really appreciate you talking about that gap between functional medicine and conventional medicine. I have definitely felt the stress of that gap having gone from one side to the other. It just felt like two extremes for me a lot of the time as a patient, and yeah, I think it’s important for more people to talk about where there can be more wiggle room in the middle.

DR. ROMM: Yeah, and there’s some interesting stuff. For example, when people start to get a little bit more granular like the researchers who are really looking at SIBO, they have discovered things like it’s not just having bacterial overgrowth, but the different types of overgrowth can tell you different things about what might be growing in there. For example, one group of researchers have found that you might have overgrowth of bacteria specifically that helped to break down bile salts. If you have an overgrowth of those bacteria and they’re not doing their job well, you can get fat malabsorption, or you can see more – well, sorry to be gross, but you can see more fat floating in the bowl if you have a bowel movement and you’re getting fat malabsorption whereas you can have other microorganisms that would rather chomp on carbohydrates, and they want to change those to different kind of carbohydrate chains. Those might produce more gas with bloating, but not cause the diarrhea with the fatty poops. Then there are other kinds like Klebsiella that can produce toxins that can cause a little bit more bowel inflammation and almost celiac kind of symptoms.

Getting more into the art of differentiating what’s going on can also be really helpful in figuring it out. Then there’s also trial by treatment, right? If you take a lot of carbs out of the diet, take a lot of the sugars out of the diet, or if you treat IBS and it goes away, then maybe it was just IBS, but maybe it was SIBO. I’m not sure if you get better if it matters which label that you put on it.

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HEALTHY FATS IN A WOMAN’S DIET & FAT MALABSORPTION WITH SIBO

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PHOEBE: Actually, before we get to the pregnancy game plan, I want to actually talk for a second more about fat malabsorption. I think it’s interesting in the context of our conversation today since there’s so much talk about how important healthy fats are, especially for women and regulating hormones. If you’re a woman who has some digestive distress, how can you tell if you need more healthy fats or if you’re malabsorbing fats and there is potentially another fix that needs to be made before you just throw all the coconut oil in your spoon in the other morning?

DR. ROMM: Yeah, so needing more fats and needing more essential fatty acids versus a stool issue, they can be related. If you’re not absorbing your fats because of a stool issue, then, of course, your fatty acids are going to be low systemically. The bottom line is that studies have looked at Americans and particularly American women and women who are planning to get pregnant, so all these different levels of studies have been done. Across the board, most of us, 80% of us are actually fat insufficient or deficient. We’re not getting the essential fatty acids we need, so we’re not getting the omega-3s. We’re not getting a healthy ratio of omega-6s. We’re often not getting enough of the really good polyunsaturated and monounsaturated fats.

A lot of your listeners are probably more health conscious. More likely, they are getting some good coconut oil in their diet and some good olive oil, hopefully, in their diet, but a lot of people who are more health conscious are also going more toward vegetarian or vegan if they’re going plant-based and also are avoiding fish because of mercury, all very reasonable choices. That leads us to often not get the omega-3s that we desperately need, and then if you add fat malabsorption onto that, then you can just be really like a car running with low oil. Not to compare us to cars. We’re much better than cars but Lamborghinis.

PHOEBE: That’s so much better.

DR. ROMM: We’re the Lamborghinis running on some really low octane. If you’re not absorbing fat, you are probably – not necessarily but probably having some other digestive system symptoms like some loose stools. You might see a little bit of oil or fat in the toilet, often like a shiny sheen on it, and you may have some of that gas or bloating that I talked about. Then, certainly, you can have things like dry skin, irritability, PMS, menstrual cramps, anxiety, depression, autoimmune-like symptoms. I mean, there’s just a whole host of symptoms that you can have, mental health symptoms in addition to anxiety and depression. That can be a result of low essential fatty acids.

I strongly encourage folks to either get really good quality salmon in their diet twice a week. Sardines are fine too. They tend to be lower on the mercury, and nothing is mercury free anymore when it comes out of the ocean. It’s just not. It’s really sad, so that’s the lowest, the lower level of mercury. That seems to be a reasonable amount both pregnant or not pregnant and then taking a central fatty acid. Taking a central fatty acid supplement, a fish oil supplement to round that out. When I’m working with women who are trying to conceive, I always put them on a pretty – like a 2,000 mg a day essential fatty acid dose.

PHOEBE: Do you add anything to that? If they have fat malabsorption, how can you make sure that they are reaping the rewards of their expensive fish oil pills?

DR. ROMM: Yeah, so fat malabsorption, you want to make sure that there’s nothing more serious going on and insidious like a pancreatic issue or celiac. In that case, if you think you have fat malabsorption, that’s a great time to see an integrative functional – or even a standard family doc, or internal medicine doc, or gastroenterologist can run a fecal fat test just to make sure. It doesn’t have to be a fancy functional medicine test. It can be a standard stool fecal fat and just some pancreatic enzymes to make sure that those important things are normal, and that you don’t have a disease process as opposed to more of a functional disruption or a root cause problem. If you have an actual disease, celiac is really serious. It’s a leading cause of colon cancer. It can have all kinds of manifestations outside of the intestine without you ever even realizing you have it. Similarly, pancreatic problems can be an issue.

That said, sometimes digestive enzymes can help, especially pancreatic enzymes that help to break down those digestive enzymes, the fecal fats, getting good fiber in the diet, so at least 30 grams of fiber every day in the diet can help with creating the kind of organisms in the gut that break down the fats. You want to feed good gut flora because it’s good gut flora that are taking those long-chain fats and breaking them down into short-chain fat, so anytime you can feed the gut, you’re going to be helping. If there’s gut inflammation like leaky gut or if you have ulcerative colitis or Crohn’s disease, by definition, if the gut is disrupted, if there’s inflammation, then you’re probably going to have disruption in your microbiome too. They nourish each other, and they are adjacent to each other. If there’s inflammation in the gut, that changes the chemical environment in the gut itself. That changes what microbiome grow so good quality fiber, really important.

Trans fats feed bad gut flora. Healthy fats feed good gut flora, so it causes the ones that you want to grow to be nourished. Think about eating good fat to have good fat absorption because you’re feeding the good gut flora. Think of good fiber. Get rid of trans fats, artificial sweeteners. Be really thoughtful if you have to be on an antibiotic. Of course, I don’t want you to go off of it, but a lot of the medications that we use disrupt the gut. Ibuprofen, Tylenol affects the liver, but ibuprofen affects the gut lining itself. A big cause of SIBO is acid blockers, and so you can cause disruption in the small intestinal overgrowth that way. Of course, antibiotics are just so prevalent. People take them so often for so many things, so anytime you can take a natural approach and forego the antibiotic if it’s not truly, truly necessary, it’s a great choice.

PHOEBE: Yeah, that’s all fantastic advice. Is there anything else besides the points you just mentioned and the fish oil that you would add to your HashiPosse, gut challenged women who are trying to get pregnant?

DR. ROMM: Yeah, the one thing I would say is variety. It’s funny. I was at a functional medicine conference, and one of my friends was giving a talk, Robert Rountree. Robert’s amazing. I’ve known him for 25 years. Bob is incredible. He’s a great speaker. He gets up to speak about gut health, and the first thing he said is, “If all you remember from my talk is this one thing, remember that diversity is the most important thing that you can do for your gut.” I remember thinking why did he say that? Now, I don’t remember anything else he said after the first thing he said.

Basically, what happens a lot of times is, particularly for women with chronic health problems, gut problems, when you suspect that there are food intolerances, so many women get their diet down to just a few foods that they feel like they can tolerate, and they’re not eating very much variety. When you lose that variety, you start to actually also lose the diversity in your gut. Again, to go back to an agricultural or gardening analogy – I’m an organic gardener. When you have monoculture, which means you just grow one crop, which happens in big Agra, so you just grow corn, or you just grow cotton, or you just grow soy, or you just grow anything, one thing. You deplete the soil, and you have to have variety to keep the soil healthy because different things that you plant feed the soil different nutrients through the bacteria that are growing on the bottom of those plants. They bring nitrogen. All kinds of things are happening.

Similarly, if all you’re eating are three or four foods and you’ve eliminated this, you’ve eliminated that, you’re not – I don’t eat this. I can’t eat that. I can’t tolerate that. What starts to happen is monoculture in your gut. As hard as it may seem to expand the repertoire of what you’re eating particularly around fruits and vegetables, it’s so important to do that.

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DIET, GUT HEALTH & FERTILITY

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The other thing I would say and this is going to be I’m sure controversial with listeners is dairy. I had dinner about a year and a half ago with a gentleman who is one of the leading microbiome researchers in the country, and he’s got a leading microbiome test kit now too. I won’t name names and products, but he was saying that before he created this gut kit, he was looking at the gut flora of people who ate dairy and people who didn’t eat dairy. His area of research is not gut bacteria, but it’s actually the gut fungi so the yeast and viruses. What he found is that people who did not eat dairy had less healthy, less robust gut diversity, and gut diversity is the key. Diversity is key to everything, but gut diversity is just key to gut health.

It’s really interesting harkening back to what I was saying earlier about our bodies being colonized with lactobacillus when we essentially introduce fermented dairy into the diet. Looking at the cultures like the Blue Zone cultures, with the exception of the Okinawans and I think the Seventh-day Adventists but I’m not – I can’t remember if they do fermented dairy products. Most cultures do actually include some fermented dairy. Now, I am not a believer that human beings need dairy past breastfeeding. I think we don’t actually need it necessarily. From a gut perspective, I have worked with many people who had taken it out of their diet because they were so afraid it was inflammatory and damaging, but then when they put in full fat, unpasteurized, or un-homogenized good quality organic dairy, they actually started to do better. It’s just something to think about.

I’m not suggesting that everyone needs to eat dairy but as part of restoring healthy flora, and it can be other fermented foods. It was just interesting that this researcher particularly found that the dairy was a linchpin, so I’m a huge proponent of fermented foods. Then if you do get pregnant, you can’t eat raw milk, dairy. The Listeria can be a risk, so then you have to get pasteurized dairy but just something to think about that we often turn our backs on but may actually be beneficial.

PHOEBE: Yeah, that’s so interesting. I would love to know if it is just the fermented element, or if it’s the dairy itself. A lot of people are turning to coconut yogurt these days, and I’ve made it at home. It’s quite easy.

DR. ROMM: It is. I know. I think it’s great, and I think that if you’re doing well and you’re able to add that in. It’s interesting. I was reading an article about the guy, Dannon, who created Dannon yogurt before Dannon yogurt was the crappy sugar filled stuff you can get. He actually lived to 104 and was fully functioning and working and self-reliant until he died. Basically, it was like, hmm, that says something interesting. Then when I was in Italy a couple years back, they had – at every breakfast, they had – they called it biodynamic. It was biological yogurt is what they called it. It was from a local farm. Sometimes it was cow, but sometimes it was sheep yogurt.

I just think it’s an interesting possible missing element, but very culture has some fermented foods, whether it’s Jewish people or Eastern European people eating sauerkraut, or miso, or other forms that people have included in their diet. I think whatever you do, if you can tolerate fermented foods, great. I think that the issue of SIBO and fermented foods is probably a little bit overblown. I mean, if you can’t tolerate it – you eat it, and you just can’t tolerate it. That’s one thing. I wouldn’t not eat it because you have SIBO or you’ve been diagnosed with SIBO. There’s no evidence that says that that is a problem or that introducing it worsens it at all.

PHOEBE: Yeah, no, that’s great advice so moving into once you’re actually pregnant. This may be a weird question, but I have a lot of friends who have reassured me as a member of the HashiPosse, autoimmune gal, what have you that, when you’re pregnant, your body figures itself out in some ways. I was just wondering if pregnancy can ever help gut issues. I know that we – you mentioned before a lot of ways that more gut issues could result from being pregnant. What happens to our guts while we’re pregnant and especially if we have a preexisting issue like SIBO or another type of dysbiosis? Does the body adjust or adapt, or does it make your “condition” worse?

DR. ROMM: There’s certain things like slower motility, which happens as a result of increased estrogen and progesterone, especially the estrogen. It just slows the gut from moving as fast. That probably is an evolutionary way to allow us a little bit slower transit time, so we absorb more nutrition from our foods. If it sits in their longer, you absorb more nutrition. There are also just some practical things. You’re nine months pregnant with an eight pound bowling ball in there, a lot of fluid and a placenta. It’s sitting right on your intestines, and it’s a little bit – some people just find that it’s a little harder to fully evacuate at that time. Not everyone. My gut was great during pregnancy, all four of my pregnancies. I didn’t have gut issues otherwise.

In general, pregnancy’s a cool thing in so – it’s so cool, obviously. That’s such an understatement of the century. Some really cool things happen in your immune system in that – in part of your body adapting to the fact that there’s a foreign object growing in it, meaning the baby and the placenta, basically. It has to shift in a way that your immune system doesn’t reject that baby. Your immune system has to allow almost this stealth protection to go down, and it makes you overall a little bit more tolerant. A lot of women find that some of the inflammatory problems that they had before actually get better, so their autoimmune symptoms are a little bit better in pregnancy if they have inflammatory gut issues.

Especially until maybe very, very late pregnancy, they’re often better. The whole immune system tends to quiet down. Women who have had inflammatory acne say that it’s calmer. You system is just a little bit more cooled down when you’re pregnant, so that’s a really wonderful thing. I have never had a woman who was pregnant who persisted in having serious SIBO or serious IBS symptoms per se. It seems like that usually does take care of itself, but if you have IBS, you are more likely to have some reflux if you tend toward reflux. If you have slow motility, you’re more likely to get that heartburn when you’re pregnant so being mindful of that.

The other thing and this I see all the time is, when you are pregnant, your body craves more calories. You tend to crave more carbs, and so a lot of women want to eat more pasta and bread when they’re pregnant. I mean, even like the most healthy plant-based, online celebrities with their 100,000 followers – hundreds of thousands followers who I get the privilege of sometimes working with when they got me on speed dial are like, oh, my gosh, I’m craving a bagel right now. I’m like what are you going to do? If you tend to have those cravings because of gut dysbiosis, which can happen at – I jokingly say that I want to create a T-shirt that says my microbiome made me eat it. When you have disrupted microbiome, it does tend to make you want more sugar. I always say it’s like, if you’ve ever baked bread, you know that you have to add sugar to the yeast in the water to make the yeast grow, right? That’s how alcohol works. Sugar feeds the yeast, and that’s what makes things ferment. When you have a lot of yeast, particularly, it often makes you want more sugar too.

You do have to be careful when you’re pregnant that your cravings are met in healthy ways like healthy, slow carbs. Not too much. Trying to get your needs met by good quality protein and fat rather than just going crazy on, okay, now I’m pregnant. I can eat everything. It may actually aggravate the symptoms, and then that’s what you don’t want. Then you don’t want to pay for it after when your immune system goes back to normal with your Hashimoto’s now flaring or your other symptoms now flaring.

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SIBO DIET AND PREGNANCY

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PHOEBE: That’s a really good lead-in to one of our reader questions which was do pregnant women really need to eat every couple of hours? Spacing out my meals has been a huge part of my SIBO recovery, but what is the best way to approach it during pregnancy?

DR. ROMM: That’s a wonderful question.

PHOEBE: I know. I thought so too.

DR. ROMM: It’s really good. Yeah, I don’t know that anyone’s asked me like that before. A couple of thoughts on that, when you’re pregnant – I want to dispel a myth right away. When you’re pregnant, you don’t actually need – physiologically, you don’t actually need more calories until the third trimester. Technically, you need 100 more calories a day in second trimester. That’s nothing. A hundred calories, it’s a handful of almonds or something, right? Then by third trimester, it’s 300 calories a day. By standard definition, the way an OB/GYN would explain that, that’s the equivalent of a glass of milk and a half a sandwich. We all know what that looks like in terms of nutrients and amount, right?

It’s not that much. Twins, you need more, but if it’s a single pregnancy, you don’t actually have to eat that much more. You don’t have to eat every two hours in terms of, oh, gosh, now I need all this extra nutrition to feed the baby. You don’t have to do that. The only reason to eat more frequently during pregnancy and it’s especially the first and into maybe a couple of weeks of the second trimester is because it tends to help quell nausea. It’s that empty stomach that tends to make you get that prenatal nausea. Often it’s carbs that do help you keep that feeling at bay, but there are other things that you can do for prenatal nausea. If spacing out your food to not – eating your typical every whatever, three meals a day, if that’s enough for you and you’re doing well with that, there’s no need to change that.

PHOEBE: It’s not as much about the frequency as it is about just making sure you’re satiated, period.

DR. ROMM: Yeah, getting the good quality nutrition that you need so really making a nutrient dense – I call it eating on purpose. Making sure that everything you eat has nutritional value for you and the baby. I hate to get into nutritionism where we start to talk about food as macronutrients, but making sure that you are getting those fats that you need, the proteins that you need. You do actually need some carbs when you’re pregnant. Biologically, you need some. Those can come from sweet potatoes or winter squash, which are often more tolerable if you’ve been struggling with SIBO, but I always say that your pregnancy nutritional needs, your baby’s needs trump worrying so much about what you’re eating as long as you’re feeling okay.

PHOEBE: Right, would you say that – with that diversity in mind and the need for carbs in mind that something like a low-FODMAP diet, which many people feel very married to even after even getting a negative SIBO breath test in terms of prevention, do you think that’s just not a good idea in general while you’re pregnant? You should just let go of all your food rules and just see what happens?

DR. ROMM: I don’t think that you should let go of your food rules if you’re feeling great. It’s so funny. I’ve been doing this work for, really, decades now. Obviously, FODMAP hasn’t been around for decades, but ever since it’s been around, no matter how many times I’ve prescribed it to a patient, I still have to look up all the foods. I was on it. It’s like wait, is that – it’s not necessarily so logical.

PHOEBE: It’s not logical at all.

DR. ROMM: It’s not. I know. It drives me nuts. If following a low-FODMAP diet gives you mental peace and also keeps you physically comfortable, as long as you’re nutritionally supported for your pregnancy, there’s no reason. There’s quite a lot of foods that you can eat on a low-FODMAP diet. I mean, it’s really not – it’s not that restrictive. It’s just you have to remember which ones are which. Keep your chart with you, basically.

I think that if it’s making you feel good and also psychologically it’s making you feel safe, then do it because it’s fine. If it’s driving you nuts or your body is really asking for things that are not in your diet, I would trust your body and eat it and see how you do. Now, if your body is saying I want a Dunkin’ Donut, glazed, whatever, whatever, no, uh-uh. That’s your mouth or your brain, your history or something. If your body is saying I want to eat that bok choy something, something, something with rice noodles and some salmon, yeah, I would eat that.

PHOEBE: My mother was a vegetarian for I think over a decade until she was pregnant with me. She claims it wasn’t her body. It was me telling her to eat the hamburger.

DR. ROMM: I’m telling you, I was a vegetarian from the time I was 15 ‘til I was pregnant with my fourth baby when I was 29. I was vegan most of the time. I went through three pregnancies, three breastfeedings, including two tandem breastfeedings. When I was pregnant with that fourth baby – years ago I saw this movie. It was Billy Crystal and Catherine Zeta-Jones and Julia Roberts. I want to say it’s called America’s Sweetheart or something?

PHOEBE: Yeah, that sounds right.

DR. ROMM: Yeah, Julia Roberts has broken up with her boyfriend or whatever, and she’s at a hotel. They’re on some movie junket, and she has ordered the entire continental breakfast. She’s eating it at her table. There’s food everywhere, and she’s just shoveling it in. Billy Crystal comes over, and he says, “So are you going to stop when you hit linoleum?” I remember sitting at the table eating my beautiful vegan meal, and I’m a pretty good cook. I just could not get enough. I just remember that movie flashing in my head. I’m like I am not going to stop until I hit linoleum.

That was it for me. I was like this baby needs chicken. I had to call my mother-in-law and ask her how to cook a chicken. For me, it was a spiritual issue. It was an ecological issue. I just needed to do what my body needed to do. My diet is still primarily plant based, and now I’m 52. I still continue to eat some meat, but man, was my body – it was screaming for chicken and beef. It was crazy, and fish.

PHOEBE: That’s amazing. Okay, so one irony that I feel is interesting is that, if you have an autoimmune issue or inflammation in your gut, it’s harder to get pregnant, but then once you’re pregnant, your life gets a little bit easier. Then what happens afterwards? I hear it gets harder again, and I hear that it’s not uncommon for a woman to come down with a new thyroid or autoimmune condition after birth. Why does this happen? What does it have to do with the gut, and how can we avoid developing a new condition?

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POST-NATAL HYPOTHYROIDISM AND AUTOIMMUNITY

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DR. ROMM: Okay, so lots of layers to that. Again, pregnancy does that switch from one type of T helper immunity to a different type of T helper immunity, and that probably is what’s providing some of – it’s not probably. It is. It’s scientifically what’s providing some of the protective benefits that you get when you’re pregnant. The other thing is that, when you’re pregnant, your body switches the predominant kind of estrogen. When you’re not pregnant and when you’re not in menopause so most of our adult lives, we’re producing something called estradiol. That’s the very strong kind of estrogen.

When we’re pregnant, we produce more estriol than estradiol, and it’s a milder form of estrogen, if you will. It’s a little bit gentler on the system. Some of the forms of estrogen like the estradiol may be implicated in some of the autoimmune conditions. Also, when your body switches hormonal levels really intensely, that can also be a precipitator for some autoimmune conditions. Also, a lot of women have some burgeoning Hashimoto’s that’s never been detected, and pregnancy and birth just push them over the edge because of the increased demand. You have a lot more demand on your thyroid when you’re pregnant, and then you have that immune system switch. Then you’re freaking tired all the time because you’re taking care of this little person who wants to wake up at night. It’s emotional too. It’s the biggest learning curve of your life.

It’s just a lot of challenges that happen at once, and we live in a culture where there’s not necessarily a ton of support for new moms either. You add all those factors together, and you can get tipped over. It’s like a bunch of straws that add up and break that camel’s back, so that is a common time that – it’s mostly Hashimoto’s that – or an autoimmune thyroid condition that pops up at that time. It can be other autoimmune conditions. You know what? Then there are other conditions that pregnancy really can help with also. A lot of women with chronic pelvic pain or endometriosis, they report that they feel a lot better after a pregnancy, so it can go both ways.

PHOEBE: Yeah, it’s so interesting. Is there any way to avoid coming down with Hashimoto’s post-pregnancy? Obviously, I’m sure there’s just a lot of unavoidable lifestyle factors, as you mentioned, taking care of an infant. I’m curious, yeah, if there’s any specific diet or supplement advice that you have.

DR. ROMM: Yeah, there actually is. For listeners too, I have a whole blog and a podcast episode just on how to prevent and address hypothyroidism in pregnancy, and then another one for postpartum. What we know is that probably about 60% of women who have some of form of burgeoning or just percolating thyroid problem in pregnancy are actually missed. They just don’t get tested properly. I always say, if you have the opportunity to be either consciously trying to conceive so you know you’re going to have a baby in the next six months, or a year, or two years, or whatever, or if you even have the opportunity, if you will, to be struggling a little bit with a fertility problem, the opportunity is in that you get to look for a lot of things and maximize them that women who got pregnant and never thought to check never addressed. One of those is thyroid function.

In my practice, any of the women I’m working with who are planning to conceive in the next couple of years, or who are actively trying now, or who are struggling with a fertility problem, I check them for a full thyroid panel. The reason for that is that is the most predictive way to determine who’s going to develop a thyroid problem in pregnancy. If I have a woman who’s come to me and she’s already pregnant, I check her then because that’s the most predictive of who’s going to develop a postpartum one and developing a thyroid problem in pregnancy or postpartum means that you’re more likely to end up with a lifetime thyroid problem. I check for the TSH, which is the standard test that most doctors check for. I also always check free T4, and I check for thyroid antibodies. I always just put a T3 in – free T3 in while I’m doing it. Free T4 being abnormal, or antibodies being elevated, or a TSH being abnormal, it doesn’t have to be all three of those. It doesn’t even have to be two of three of those. Any one of those three can indicate that a woman is at risk for or, depending on how out of range the numbers are, has a thyroid problem.

For all women who are even just percolating a thyroid problem a little bit, I get them on to selenium and inositol. I usually use a blend of myo-inositol and inositol. Those together, even though the studies are small, have been shown to help women normalize their thyroid antibodies and prevent them from becoming hypothyroid, or Hashimoto’s, or postpartum thyroiditis, which can also be almost like a short-time Graves’ condition sort of thyroid picture so hyperthyroid. Then if they come back positive for any of those thyroid tests during pregnancy, then I will also make sure that I’m testing them throughout the pregnancy and postpartum, and if they need thyroid medication, then when you’re planning to get pregnant or are pregnant, it’s really important to be on it if your numbers show that you need it. That can make such a difference in your pregnancy health, going full term with your baby, not having a miscarriage but also baby’s health, and then your long-term health. You don’t want to have postpartum depression, or one of the things that can happen with hypothyroid postpartum is difficulty producing enough breast milk. Who needs to be more tired when you have a new baby?

PHOEBE: Yeah, so do those two work for your normal Hashimoto’s patients as well?

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WHAT SIBO SUPPLEMENTS AND HERBS NOT TO USE WHILE PREGNANT

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DR. ROMM: Yeah, absolutely, I just wanted to say a word about SIBO and pregnancy. I know that there’s at least one blog out there that says that you can use Iberogast and you can use some of the antimicrobials during pregnancy. That is not true. Iberogast has herbs in it that are completely contraindicated during pregnancy, and those botanicals, like any of the essential oils, any of the berberine containing products, completely not appropriate for use during pregnancy. The only things that are appropriate for SIBO treatment during pregnancy are dietary support. You can use ginger up to 1 gram a day. Ginger is a great gut motility agent. You can use chamomile tea. You might see that on contraindicated herb lists. That’s inaccurate. You can use chamomile during pregnancy.

I really want to emphasize you cannot use Iberogast. You cannot use Candibactin-AR or BR. You can’t use any of the oregano oil, thyme oil, sage oil, absolute all totally no for a pregnancy.

PHOEBE: Why is that? What happens?

DR. ROMM: The Iberogast has herbs in it that can stimulate uterine contractions, and the essential oils like sage oil is something that can cause a miscarriage. You don’t even have to use that much of it. In fact, even eating too much turkey stuffing with sage isn’t even really appropriate during pregnancy, interestingly. Then, all of those essential oils, not only can they cause miscarriage and uterine irritation, but they all cross the placenta and can get to the baby and affect the baby’s growing nervous system.

PHOEBE: Wow! Just more proof that herbs are not benign.

DR. ROMM: They’re not. They’re super-powerful medicines, which is why I love them, and they’re my first go-to always in my practice, diet, mind, body, and herbs always, always, always before even supplements or pharmaceuticals. I’ve been doing herbal medicine for 35 years now, and it’s never failed to provide the support that I need in the context I’m using it, but also, I have a huge respect for herbs that you can use during pregnancy, but then herbs that you should definitely not use during pregnancy.

PHOEBE: Yeah, I’m so glad you brought that up. That’s fantastic advice. Okay, well, two last quick pregnancy-related topics. We know that C-sections aren’t ideal for the child since they’re getting inoculated through the birth canal, but we’ve also talked about how abdominal surgeries of any kind put you at risk for SIBO. I’m just curious if there’s anything else that can happen in the aftermath for the mother and if there are any strategies that you recommend for women who have no choice but to get a C-section and then are maybe worried about some gut-related health issues down the line.

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C-SECTIONS AND MICROBIOME HEALTH FOR MOTHER AND BABY

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DR. ROMM: Yeah, so the C-section rate in the United States is an astonishing 34% average. Average meaning that there’s really very few places that are under 20%, but there are a few places that are as high as even 60%. The average is 34% when you look at all across the board. One in three women has a pretty good chance of having a caesarean so anything that you can do to lower your caesarean section risk, which we could have a whole other ten hour conversation on. Basically, having a midwife or a doula with you are two huge ways that you can prevent having a C-section, being physically active, walking a lot during pregnancy, eating really well during pregnancy, making sure that you’re getting the nutrients you need but being prepared, whether it’s hypnobirthing or working with a really wonderful prenatal childbirth educator who gives you a lot of resources and skills. Then, again, I’m going to emphasize doula or midwife. Just having another woman who is skilled at birth in and of itself reduces your C-section risk.

Those are some big things you can do, but because one in three women is going to have a C-section and we know that the babies born by C-section do have some increased risk of some long-term potential issues – I don’t want to scare women. It doesn’t mean just because you have a C-section your baby’s going to have these problems later in life, but there is some increased risk of eczema, some childhood asthma and allergies but then also long-term risks of even obesity and diabetes because of the importance of that early inoculation. We know that some of that risk can be mitigated by mom taking a probiotic during the third trimester, so that’s something that I just routinely do now. I put all my pregnant mommas on a prenatal probiotic. You can use any of them that have a good blend of lactobacillus and bifidobacterium strains. I also recommend when you’re pregnant taking one that has lactobacillus reuteri in it and rhamnosus in it. The reason is those are specifically vaginally important microorganisms. Then, also, we know that baby born by C-section getting a probiotic during that first six to eight months after birth directly – so giving it to the baby. You can do a little bit of a liquid dilution in some breast milk and give it with a dropper, also really protective.

Those are the two things that I do and then anything that you can do to avoid antibiotics during labor. I mean, if you have Group B strep and you’re having a baby, it’s – I do have a blog on that too. It’s a complicated conversation, and I definitely error on the side of protecting yourself and your baby over worrying about – you can always fix things later if you need to with a probiotic and etc. over the risk of the baby getting really sick. It’s a very big conversation so, that aside, anything you can do to avoid excessive vaginal exams, fetal scalp monitor. Honestly, just staying out of the hospital as long as you can and letting people do as little to you as possible once you get there truly is the best way to prevent any kind of infection during labor. The other thing is that getting an epidural can alter your body temperature in a way that it makes it look like you have a fever. Getting dehydrated can do the same thing, so there are some things that give a false impression that you have an infection that can also buy you a ticket to an antibiotic.

Having someone there, again, a well-educated doula, who can help troubleshoot and say you know what? How about we try some fluids before we give an antibiotic, or how about this, that, or the other, really, really important. It’s so complicated. I mean, it’s hard to know if you’re a woman in labor and somebody’s coming in every two or three hours to do another vaginal exam that you actually don’t need that. Not only that, you shouldn’t be having that, and it’s actually bad for you and your baby. It’s hard to know how to be empowered and say that, and it’s hard to do that when you’re in between contractions so, again, having that person who can help you.

If you’ve had antibiotics during labor, it’s a little tricky. The new study just came out this past year saying that taking probiotics after antibiotics may actually slow the gut’s return to its normal inhabitants. I would say while taking one preventatively is really beneficial, if you’ve had a C-section, maybe wait a couple of weeks ‘til you start taking one again, but it’s okay to go ahead and give it to the baby. I mean, the studies are still good on giving it to the baby.

PHOEBE: That’s such good advice. Just to clarify because I’m child-free at the moment, is it just the fear of the mother having some sort of, I don’t know, virus or bacterial infection, fever, what have you that you would get given an antibiotic during labor, or does it happen when you get a C-section?

DR. ROMM: Yeah, so in the US, an antibiotic is given routinely at the time of a C-section, so every woman who has a C-section gets IV antibiotics. Then up to 40% of women are colonized at any given time with this thing called Group B strep, which, again, is a normal inhabitant in our flora, but when it grows out of control, if it gets passed on to the baby, the baby can get a really serious infection. I guess it was 80s, 90s. It became routine if a woman tested positive and was in labor for X, Y, Z hours or had broken waters to get an antibiotic, so a lot of women are getting antibiotics for that but also even just a long labor. If you get exhausted, your temperature goes up, stress, so there are a lot of things that can make it falsely look like you have an infection too.

PHOEBE: What can you do if you’re getting a C-section to avoid an antibiotic, or is there no avoiding it?

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IMPROVING GUT HEALTH AFTER A C-SECTION

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DR. ROMM: Nothing, I mean, have your baby in Europe. Yeah, you can have your baby in Sweden, or France, or somewhere else where they don’t do that routinely, but in the US, there’s nothing you can do. I’m a big advocate for changing birth practices in the US. There are a lot of things that need to change, and that is maybe the lowest risk of them. I did a podcast over at my podcast, Natural MD Radio, with the woman who is the foremost international researcher, Maria – Gloria Marie Dominguez-Bello, and she’s the one who’s done all the research on this thing called vaginal seeding where women use a vaginal swab to seed the baby if they’ve had a C-section. This is not ready for prime time yet at all but definitely worth a listen to the podcast with her.

Then also, I did a podcast with Marleen Temmerman, who is one of the world’s leading proponents of reducing cesarean section rate. She was actually the senator on the Senate for Belgium for eight years. She’s amazing. She’s a total radical activist. Then another one with a guy named Neel Shah, who’s an OB at one of the leading centers in Boston who also is a huge – you see him in the New York Times a lot. He’s a huge voice for reducing unnecessary cesarean sections, and most of them are. I mean, we know that at least half of them are unnecessary, so for listeners who want to – if you’re pregnant, thinking about having a baby, and want to know more about that, those are some important resources.

PHOEBE: Yes, I will absolutely link to all of these episodes and the resources you mentioned in the show notes. This has been so incredibly informative. I learned a lot. Is there anything else you want to add before we sign off today that we missed in terms of infertility, gut health, SIBO, pregnancy?

DR. ROMM: I think it’s really just going back to food diversity and trying to nourish your body into health more than restricting. How can we get soft? How can we get soft instead of rigid and resistant? I know that’s really hard when you’re struggling with food, but sometimes I think that stress of the battle with food can make it worse. It’s almost like how can we get soft and embrace our food and start to relax into the process a little bit more? I know it’s a little bit vague, but I hope that’s conveying the feeling rather than being in that battle with your body. I think, a lot of the language around SIBO, we talk about battle.

We use a lot of military metaphors as opposed to nourishing your body, getting soft with it, getting curious about it, letting down the battle a little bit, and trusting that your body will take care of itself with the right food, the right nourishment, the right rest. We didn’t really talk about that, but the incredible role of the stress response system on the gut, it’s so dramatic. How can we embrace that self-care part of it to love ourselves back to health?

PHOEBE: I love that, and I imagine that it is even more important when you’re caring another life to just relax and lean into your diet and healing. I highly encourage everyone to go pick up a copy of The Adrenal Thyroid Revolution where you do talk a lot about rest and just all the aspects of restoring your system, so thank you so much, Dr. Romm, for joining us today.

DR. ROMM: Oh, thank you, Phoebe, for having me. This is wonderful.

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Disclaimer: The information in this podcast does not provide medical advice, professional diagnosis, opinion, or treatment. The information discussed is for educational purposes only and is not a substitute for medical or professional care.