If you get a painful side stitch when running or doing other exercise or experienced a side stitch when you were a kid, you may be as intrigued as I was to learn there is new research that points to an anxiety/stress connection. This cross-sectional observational study was done involving an anonymous survey of one hundred sixty-eight male and female adults who were running at least 10 miles/16 km per week.
The conclusion of this study, Thorn in Your Side or Thorn in Your Head? Anxiety and Stress as Correlates of Exercise-Related Transient Abdominal Pain, is as follows: “anxiety and stress are associated with the presence of ETAP.” A runner’s side stitch is referred to as ETAP i.e. exercise-related transient abdominal pain. The authors mention the fact that this is the first study to reveal this anxiety/stress connection. This is relevant given the numerous recent studies looking for a cause and no definitive solutions.
This research is also really intriguing to me given what Dr. Carl Pfeiffer MD, PhD, identified 50+ years ago in the 1970s i.e. side stitches are common in those with pyroluria/social anxiety. What’s important is the fact that the pyroluria nutrient protocol eases social anxiety and prevents side stitches in my clients. You’ll read feedback from individuals in the community who resonate with this research and the pyroluria connections. I share more about pyroluria below in case it’s new to you and a possible cause of the side stitch pain.
My feedback and feedback from others in the community
I have pyroluria and always got a left side stitch as a kid, in my teens when running and playing squash and in my 20s/30s when running. And then they stopped (and the social anxiety and related symptoms resolved) when I addressed my pyroluria with zinc, B6 and EPO, and a copper-free multi that contains manganese. I see these kinds of results with my clients all the time so a light-bulb went off when I read this new research .
I shared this research and the anxiety/stress/pyroluria connection on Facebook and asked: did you/do you get side stitches when running/exercising? Here is some of the feedback I received, where the pyroluria protocol did help.
Kameka shared this: “I had side stitches as a kid and as an adult. Running was the main exercise that caused it and it was usually the left side. Now that you mention it, I haven’t had them since I started supplementing for pyroluria. Also, my social anxiety is sooo much better as well!”
She did the symptoms questionnaire and the pyroluria urine test (which can give false negative results) and confirmed she takes vitamin B6, zinc, magnesium, and primrose oil.
Bec shared this: “I hated PE at high school for that reason. While everyone was running, I was suffering from side stitches (I think it was my right side) and having breaks. I have pyroluria with lots of symptoms. I do well with zinc and P5P.”
Not everyone reported an improvement with the protocol but many folks resonated with the side stitch/pyroluria connections:
Megan said: “Couldn’t run as a kid. A stitch every time. I can’t recall which side, never really paid too much attention. Looking at the pyroluria symptoms, I think I may have always had it.”
Janie exclaimed: “Oh, boy, did I!” (while distance running). She finds it hard to remember but thinks it may have been on her right side. She also shared that “tests for zinc come back normal, but I have many of the [pyroluria] symptoms, especially the less common ones. I scored high. I always want breakfast but all the other questions fit me like a glove, like pieces of a puzzle with my photo on the box.
My lack of dream recall is another sign. I take 25 mg of methylated B6, but still no dreams. The question regarding being seated in the middle of a restaurant…THAT IS ME!! My throat will feel like it’s closing up, so much tension.”
I explained that most zinc testing is not accurate and that we increase until we get symptom resolution. I also referred her to the pyroluria chapter in my book.
Susie shared this: “Yes I always got side stitches so I gave up running. I suspected pyroluria but not sure if I have it.”
Leah said “I’d say my daughter and I both [had side stitches] more when we were younger. Both socially anxious and pyroluria. Less exercising now too.”
Information if you’re new to pyroluria
Pyroluria is frequently associated with a type of anxiety characterized by social anxiety, avoidance of crowds, a feeling of inner tension, and bouts of depression. People with this problem experience varying degrees of anxiety or fear, often starting in childhood, but they usually manage to cover it up and push through. They tend to build their life around one person, become more of a loner over time, have difficulty handling stress or change, and have heightened anxiety symptoms when under more stress.
Also on the list of symptoms is this one: “Upper abdominal pain on your left side under the ribs or, as a child, having a stitch in your side as you ran.”
Addressing low levels of the mineral zinc and vitamin B6, together with some other nutrients and stress management, are key to addressing these symptoms.
Here is the complete symptoms questionnaire on the blog. This questionnaire can also be found in the pyroluria chapter in my book, The Antianxiety Food Solution. You’ll find the detailed supplement protocol and additional information on how to assess for low zinc and low vitamin B6 in this chapter too.
You can read more about the prevalence and associated conditions here. It’s most often considered a genetic condition but is possibly environmentally triggered too.
There are many pyroluria blog posts where I cover various aspects such as the importance of addressing pyroluria for recovery from MCAS and Lyme, pyroluria and Ehlers Danlos Syndrome, pyroluria and intrusive thoughts and many more. I encourage you to use the search feature on the blog.
A possible cause of the side stitch in pyroluria
Here is an excerpt from a paper published in 1974 by Dr. Pfeiffer and colleagues, Treatment of Pyroluric Schizophrenia Malvaria With Large Doses of Pyridoxine and zinc, describing why the side pain probably occurs:
This 15-year-old upper middle-class patient (now 19 after studying for four years) represents a case of nutrient deficiency in which vitamins (specifically B6) and the trace minerals manganese and zinc were inadequate for the development of normal knee joints and normal brain function.
The deficiency was sufficiently severe at its peak to cause prolonged psychosis, atypical seizures, arthritis, amenorrhea, constipation, and splenic pain. The pain is probably due to hemolytic crisis in which red cell fragments engorge the Kupfer cells of the spleen and liver, extend the capsule, and cause pain. The double deficiency is produced by the formation of KP [kryptopyrroles] which combines with pyridoxal and zinc.
Based on the above and other publications by Dr. Pfeiffer, when the stitch happens on the left side, my understanding is that the pain is in the spleen. And when it happens on the right side, the pain is in the liver area. Most individuals with pyroluria say they felt/feel their side stitch on the left side. Either way it appears to be caused by low zinc, low vitamin B6 and the other nutrients needed by those with pyroluria. And resolved when on the pyroluria protocol.
I would love to see these ETAP researchers take their anxiety/stress research one step further and identify how common pyroluria is in runners who get side stitches and if the pyroluria protocol prevents the side stitches.
My book as a resource and pyroluria supplements
As mentioned above, there is an entire chapter on pyroluria in my book, The Antianxiety Food Solution – How the Foods You Eat Can Help You Calm Your Anxious Mind, Improve Your Mood, and End Cravings, I highly recommend getting it and reading it before jumping in and addressing these deficiencies. And be sure to share it with the practitioner/health team you or your loved one is working with.
Keep in mind that these nutrients are cofactors for making neurotransmitters and are a key part of my protocol when working with individual amino acids.
The book doesn’t include product names (per the publisher’s request) so this blog, The Antianxiety Food Solution Amino Acid and Pyroluria Supplements, lists the pyroluria supplements and amino acids that I use with my individual clients and those in my group programs. You can find them all in my online store.
If you are a practitioner, join us in The Balancing Neurotransmitters: the Fundamentals program. This is also a paid online/virtual program with an opportunity to interact with me and other practitioners who are also using the amino acids and pyroluria protocol.
Thanks to everyone who contributed to the discussion on Facebook. Now I would love to hear from you so I can approach the authors with their feedback and yours too.
Did you get a side stitch as a kid and did it affect your ability to take part in school sports?
Do you still get a side stitch when running or doing other exercises? If yes, does it hold you back and with which exercise?
Did/does the side stitch occur on the left or right side?
And do you have pyroluria? (based on the symptoms questionnaire and/or pyroluria urine test)?
Does the pyroluria protocol prevent your painful side stitches? And had you made the connection to pyroluria/anxiety/stress?
Are you seeing a similar pattern with your kid/s? (pyroluria, side stitch and the protocol helps them too)
If you have questions and feedback please share them here too.
I also got side stitches when running longer distances. Running in PE in school was always difficult and I was often last, or unable to finish the run bc I had to take breaks. Thanks to your questionnaire I realized I likely have pyroluria a few years ago. I took a B complex and zinc and magnesium for years (even before learning about pyroluria). I have noticed that if I stop taking B vitamins I start to get the popping sound in my joints – which I found out from your questionnaire is a sign. Recently, I decided to try to stop taking B vitamins and get them through food as recommended in the Cure your Fatigue protocol. My plan was to take liver supplements instead but I have trouble swallowing enough of the huge pills. But despite not taking B vitamins and not taking much liver, the popping didn’t come back for the first time ever. It suddenly clicked that I have been having 2 egg yolks for breakfast almost every morning for a few months. I suspect the egg yolks are providing me with enough B vitamins and I’m so happy to be getting them from a food source (natural and balanced). I don’t know if my stitch would still appear bc I’m too tired to run. Nor do I remember what side it was on, but I’m definitely another person with that connection. It’s very helpful to know or random symptoms like that for ppl to help identify pyroluria. Thank you for getting the word out.
Liz
Thanks for sharing and glad you’ve made the connection between pyroluria, side stitches and joint popping. Glad to hear egg yolks are beneficial for the joint popping but keep in mind that with pyroluria much higher doses of vitamin B6 are typically needed and there are liquid B6 options.
I’d also be monitoring other symptoms on the pyroluria questionnaire – like social anxiety and dream recall.
There is also a pyroluria/chronic fatigue connection. More here https://www.everywomanover29.com/blog/pyroluria-chronic-fatigue-syndrome-link/
Thanks for your reply Trudy. The CFS/pyroluria connection is very interesting and news to me! I have pretty poor dream recall and have had social anxiety my whole life, while at the same time loving talking to people and being very sociable (I have anxiety but also love the connection). Supplementing with a B complex and taking zinc piccolinate for years didn’t change much. The only symptom I can see a difference in is joint popping so I use it as a guage to tell if I have enough B6. Not sure if it’s a good guage though.
Liz
Thanks for sharing this additional information
Hi Trudy,
If the Pyroluria urine test often gives a false negative, is there another test or do you just rely on the questionnaire?
Thank You
Mary
I primarily rely on the questionnaire and response to the supplement protocol. As laid out in the pyroluria chapter in my book (and too much to obviously cover in a blog post) we also do zinc challenge, monitor dream recall and fatty acid testing. There are also markers on OAT/organic acid test but I seldom do this. I may also have folks test plasma zinc/serum copper – we want a ratio of 1:1 (more on this here https://www.everywomanover29.com/blog/zinccopper-balance-in-autismpyroluria-dr-usman/).
Do you suspect pyroluria and did/do you get side stitches when exercising?
Crazy!! I’ve had side stitches my whole life when exercising, until the last 6-12 months…which just happens to coincide with finding the right doses of B6 and zinc for my body. I was joking with a friend that I must have finally outgrown them (at 35! Ha!), but this would explain it. Semi-related, they were almost always right side pain & my doctor has been concerned about/supporting my liver for several years as well now.
Michelle
Thanks for sharing. Glad to hear vitamin B6 and zinc is helping. Good to know about the right side/liver support aspect too.
Can you describe your side stitches and what exercise caused them?
May I ask how much zinc and vitamin B6 you use and how you know it’s the right dose for your body? Did you have anxiety/social anxiety (and how do you score on the pyroluria questionnaire). And does this help reduce social anxiety and other symptoms on the questionnaire?
I went back and looked – my initial score on the questionnaire was 36 (37 if “has look alike sisters” can be counted as “has all daughters who look identical”); crippling social anxiety that didn’t improve when neurotransmitter support (tryptophan and GABA) significantly reduced my other anxiety symptoms was another aha moment . If I look just at what I’m currently experiencing, my score is 7, and several of those are explainable by other heath conditions. Not an exaggeration to say that learning of & treating for Pyroluria completely changed my life!
My side stitches were intense cramps that would fold me over and force me to stop what I was doing. They seemed to be caused by activities causing heavy breathing for more than short bursts. Softball was a great sport for me; running, basketball, soccer, etc were torture.
I’ve worked with a functional med doctor who could explain how we arrived at the right dose/type far better than I, but it was mostly just trial and error along with symptom monitoring using your questionnaire, and occasional labs. I tend to have strong or unusual responses to things (there’s that liver thing again…)I have MTHFR but have found even the standard doses of methylated B’s in an adult multi will start to cause signs of B12 & B6 toxicity, including elevated levels on blood work. For the last 6-12 months, I’ve done well on 1.5mg B6(as Pyridoxine HCl, this is from all supplement sources) and 100mg zinc picolinate (in liquid form) daily. “Done well” is judged by having few/minimal symptoms that, as mentioned above, tend to be the more vague ones (fatigue, cold hands, anemia, etc) and are easily attributable to other less well-managed conditions (endometriosis, thyroid, etc).
Michelle
Thanks for sharing this additional information – love that learning of and treating pyroluria completely changed your life! It’s great that you do so well on such a low dose of pyridoxine.
Glad to hear tryptophan and GABA significantly reduced your other anxiety symptoms.
What brands and dosage is it a methylated B6 and what type of zinc are you taking?
Interesting!! Ummm does that mean I had pyroluria? I haven’t ran in a while so not sure if I still get side stitches, but I’ve been supplementing with B vitamins and zinc for a while now.
Amanda
Thanks for sharing – I’m guessing you used to get side stitches? Which side and let us know when you next do a run. It’s possible side stitches are just a sign of zinc/vitamin B6 deficiency.
I have clients use the pyroluria questionnaire to figure out if pyroluria is suspected and not just the fact they have had side stitches. Do you have anxiety/social anxiety (and how do you score)? Do the B vitamins and zinc help reduce social anxiety and other symptoms?
Thank you, Trudy.
The pyroluria case study in this article also mentioned that he had side stitches as he ran, when he was a teenager. The individual had low RBC zinc, elevated HPL, and symptoms of pyroluria that also included another family member. Some of his symptoms dramatically improved upon replenishment of zinc.
https://www.hormonesmatter.com/zinc-deficiency-and-pyroluria-a-case-study/
Kind regards,
Mahmood Bilal
Dr. Mahmood
Thanks for sharing this pyroluria case – I love to read about results like this and am curious to learn about your interest in this condition
Hi Trudy,
I am a clinical scientist and co-lead a diagnostic clinical laboratory. My interests involve defining methods to better evaluate nutritional status. Some of my interest include iodine and thyroid hormones, zinc/copper as it relates to immunity and mental disorders, and fertility. I’ve linked some of my work below regarding iodine.
I appreciate all of your work and insights in pyroluria. I look forward for the medical field to expand their understanding of this condition (through diagnostics and research).
https://www.frontiersin.org/articles/10.3389/fimmu.2017.01573/full
https://karger.com/mpp/article/29/5/412/204574/Iodide-Transporters-in-the-Endometrium-A-Potential
Kind regards,
Mahmood Bilal
Hi Dr. Bilal
Thanks for your kind words and for sharing some of your papers on iodine – very interesting! Thank you for doing this work.
I do appreciate you publishing the pyroluria case on the Hormones Matter site and would love to see this and other pyroluria cases published in the mainstream research to further spread more awareness about HPU and the importance of zinc, vitamin B6 and other nutrients that are invaluable in cases like this.
I appreciate that this case “confirms that some individuals with elevated urinary HPL are highly susceptible to specific nutrient depletion; in this case, zinc.” I see a large number of pyroluria cases in my clinical work and can confirm this from my clinical experience too.
I’ll also add that I do see many false negatives on urinary HPL tests and yet many individuals score high on the pyroluria symptoms questionnaire and see symptom resolution with zinc, vitamin B6, evening primrose oil (which enhances zinc absorption) and other supporting nutrients.
I have pyroluria myself, score high on the symptoms questionnaire, do exceptionally well on the nutrient protocol and have had 2 urinary HPL tests show different results – one positive and one negative. These were a few years apart and I was not supplementing before either test.
(I tried to add some of this as a comment on the Hormones Matter site but no comment showed up – maybe it needs approval?)
Oh and I don’t see a mention of a side-stitch in the case you linked to?
Dear Trudy,
Thank you, I appreciate your input. Your work on pyroluria is very valuable to physicians, scientists, and patients.
That comment on Hormones Matter was just approved 🙂
I completely agree with “many false negatives on urinary HPL tests and yet many individuals score high on the pyroluria symptoms”. Like with other metabolites, the concentration of HPU can vacillate in an individual due to biological variations. Therefore, a person may get evaluated (urine in this case) when it is at a lower concentration than the average for that individual. This means that testing at least a couple of times (if it is not elevated, but symptoms indicate) can be helpful.
Hi Dr. Bilal
My understanding is that urinary HPL is fragile and unstable in light and this affects testing results. Before I wrote my book we used Vitamin Diagnostics lab in New Jersey and the results always correlated with the symptoms questionnaire for all our clients. This lab became HDRI / Health Diagnostics Research Institute and for a number of years we did not see the same correlation between symptoms and lab results. Dr. Tapan Audhya, one of the authors of “Discerning the Mauve Factor, Part 1” and 2 which you reference in your article, was a lab director and acknowledged this issue.
To this day I continue to see unreliable results with urinary HPL testing with other labs and rely more on the symptoms questionnaire and response to the supplements. It’s far from ideal but it changes lives and that’s what matters.
Thanks for approving the Hormones Matter comment
Hi! I was wondering if you know if Evening Primrose oil can make a hormonal IUD (Mirena) less effective? I understand that hormonal IUDs birth control pills cause issues, but for now I would like to keep my IUD and add B6, zinc and Evening Primrose if that is safe with an IUD. It’s medically important I don’t get pregnant since I am still dependent on my SSRI that is not compatible with pregnancy and I am not able to function well as a mother when off of it. Do you typically recommend that women on birth control take even more B6 and Zinc? Also- is Evening primrose oil also recommended for children aged 5 years who have suspected pyroluria?
Dana
I am not aware of any issue with Evening Primrose oil making a hormonal IUD (Mirena) less effective but would suggest checking with the pharmacist or doctor.
I do recommend women on birth control take sufficient zinc and vitamin B6 and also learn about non-hormonal birth control approaches such as FAM. More on that here https://www.everywomanover29.com/blog/contraception-depression-anxiety-fam/
Yes I have had young children with suspected pyroluria use EPO. Doing a fatty acid test is often helpful to confirm the need (for adults and children).