Motility Specialist: Why The Standard Constipation Protocol Is Failing Roughly 7 In 10 Women On Mounjaro, Ozempic, Wegovy And Zepbound — And What I Tell My Own Patients Instead

After 14 years inside motility medicine and roughly 2,400 GLP-1 patients in my own clinic, I can tell you exactly why the fiber, the Miralax, and the prescription laxatives aren't working. And why so many women end up quitting the medication that was finally doing what nothing else had.

by Dr. Sarah Marsh, MD | Board-Certified Gastroenterologist | Updated March 2026

I wrote this article because my own mother spent 8 months on a GLP-1 medication, did everything her primary care doctor told her to do, and ended up worse than when she started.

By the time she called me she was eating crackers and broth for dinner just to avoid the feeling of food pressing on food. She was on a weight loss medication and starving herself on top of it.

She isn't unusual. I see roughly 15 women a week in exactly her position.

The protocol her primary care doctor was following — drink more water, eat more fiber, take Miralax, stronger prescriptions if those don't work, eventually come off the medication — was developed for a problem she didn't have.

She wrote about the Saturday I drove 3 hours to her kitchen table to explain what was actually happening. If you found this article through hers, what follows is the medical explanation I gave her, with the research behind it.

If you didn't, you should still keep reading.

Because what I'm about to walk you through is the reason most women on a GLP-1 quit within 12 months. And it has almost nothing to do with the medication itself.

WHAT I SEE IN MY OFFICE EVERY WEEK

Roughly 7 in 10 women on a GLP-1 will discontinue within 12 months.

The single most common reason cited is GI side effects. Constipation. Bloating. Sulfur burps. Cleanout cycles that get more brutal until one of them lands the woman in the emergency room.

Of the women who quit, most regain a significant portion of the weight they lost within 12 months of discontinuation. Many lose their insurance approvals and can't restart.

I see them in my office a year later. They come in asking how to get back on something. By then their approvals have lapsed, the medication has been reformulated or repriced, or their doctor has moved them onto a different management strategy.

That conversation is the worst part of my week.

Not because the medication failed them. Because the protocol that was supposed to manage the side effect was working on the wrong organ the entire time.

WHY THE PROTOCOL YOUR DOCTOR IS FOLLOWING WAS WRITTEN FOR A DIFFERENT PROBLEM

Your primary care doctor isn't lying to you.

She is following the standard treatment protocol for chronic constipation. That protocol was developed for women with constipation that originates in the colon — IBS with constipation, opioid-induced constipation, age-related slow transit. In every one of those conditions, the dysfunction is downstream. In the colon. Where the protocol's tools actually work.

GLP-1 constipation is mechanically different.

GLP-1 medications work by slowing gastric emptying. That is the mechanism that produces weight loss. Your stomach used to empty in about 4 hours. On Mounjaro or Wegovy it can take 10 or 12. Food sits in the stomach 2 to 3 times longer than it should.

That delay is not in your colon. It is 6 feet upstream from your colon. In the organ the protocol does not address.

Treatment guidelines update on 5 to 7 year cycles. GLP-1 medications went from a niche diabetes treatment to a mass-prescribed weight loss intervention in roughly 2 years. The guideline framework simply hasn't caught up. Primary care doctors are running the only protocol available to them. It's the wrong one for this patient population.

That is the entire explanation. Institutional lag. Not malpractice.

WHY EVERY PRODUCT IN YOUR MEDICINE CABINET IS WORKING ON THE WRONG ORGAN

The protocol my mother spent 8 months following targets the colon. Every component of it.

Fiber adds bulk to stool that hasn't yet entered the colon. When the stomach has stopped emptying efficiently, adding fiber on top of food that isn't moving mechanically increases retention time in the stomach. The pressure gets worse. The bloating gets worse. Nothing reaches the colon to begin with.

Miralax pulls water into the colon to soften stool. There is barely any stool in the colon to soften — the food is still trapped in the stomach. The water sits in an empty descending colon and produces cramping without evacuation.

Dulcolax and senna trigger colon contractions. The colon contracts around empty space. Magnesium citrate, same organ, same wrong organ. Probiotics seed beneficial bacteria into the section of the gut that isn't broken.

The newer prescription motility agents — Linzess, Trulance, Motegrity — work by stimulating receptors in the colon wall. They are an upgrade over Miralax in many clinical scenarios. For GLP-1 constipation, they have the same architectural problem as the OTC products. They trigger the colon to contract harder. The colon is not what needs to contract. The stomach is.

I am not saying these products are useless. They are useful, in the conditions they were designed for. They weren't designed for delayed gastric emptying caused by a GLP-1 receptor agonist. The protocol that ports them over to GLP-1 patients was written by clinicians who don't work in motility every day.

I do.

WHAT THE SOLUTION ACTUALLY HAS TO DO

The colon doesn't need to be hydrated. It doesn't need to be triggered.

3 things have to happen, in this order. The stomach has to start emptying efficiently again, mechanically, without overriding what the GLP-1 is doing for appetite and weight loss. The fermentation byproducts already built up in the stalled stomach — the sulfur compounds, the methane, the hydrogen — have to be neutralized at the source, not masked. And the lower gut has to be supported in a way that doesn't pile more bulk onto a system that already can't move what it has.

If even one of those 3 jobs goes unaddressed, the cycle restarts within weeks.

This is the part of the conversation almost no woman on a GLP-1 has ever had with her doctor.

WHAT I STARTED RECOMMENDING TO MY OWN PATIENTS

About 4 years ago I started building a short list of formulations I'd recommend to women in my clinic who had hit the wall on the standard protocol.

The first compound I evaluated was apigenin. A flavonoid concentrated in celery juice extract. The motility research on it is genuinely interesting — it acts as a natural prokinetic, promoting the contractions of the smooth muscle in the stomach wall that push food into the small intestine. It does this without forcing the stomach the way a stimulant would, which means it doesn't override what the GLP-1 is doing to appetite.

The concentrated juice extract specifically. Not the powder you see in green-drink mixes. Not the celery seed in pill form. Most apigenin on the supplement shelf is the wrong form at the wrong dose and has degraded in light exposure — apigenin is photosensitive, and the molecule loses activity if it sits in a warehouse for months.

The second was stabilized chlorophyllin. The sulfur compounds, the methane, and the hydrogen that have already built up in a stalled stomach are not going to leave on their own when the stomach starts emptying. Chlorophyllin binds those compounds at the molecular level and renders them inert. It doesn't cover the smell. It neutralizes the compound itself.

The third was a specific kind of soluble prebiotic fiber — distinguishable from the bulk-forming fiber the standard protocol uses. The soluble version doesn't add mechanical mass. It feeds the bacteria in the lower colon and produces butyrate, which keeps the lower gut moving once the stomach is emptying again. Downstream support without piling more onto an already stalled on-ramp.

3 components, 3 different mechanisms, all targeting the actual problem in delayed gastric emptying.

I found one product on the market that combined all 3 at clinically relevant doses, in the form women on GLP-1s could actually absorb.

It's called Motilli.

It is a small company. They make a celery juice gummy that contains the concentrated apigenin extract, the stabilized chlorophyllin, and the soluble prebiotic fiber. Designed specifically for women on GLP-1 medications.

WHY A GUMMY AND NOT A CAPSULE

The choice of delivery format isn't cosmetic.

A capsule has to dissolve in stomach acid before the actives release. Dissolving a capsule reliably requires a stomach that is moving and producing acid at normal rates. A woman on a GLP-1 whose gastric motility is impaired is exactly the patient for whom a capsule will fail to deliver its payload at the right time and the right concentration.

A gummy is essentially pre-dissolved. The matrix breaks down within minutes of being chewed and releases the actives almost immediately, even on a stalled stomach.

I evaluated 3 other celery extract supplements before settling on Motilli. 2 were capsules. 1 was a powder. None of them worked in the GLP-1 patients I tried them with. The mechanical absorption problem was the reason.

WHAT TO EXPECT IN THE FIRST 90 DAYS

I tell every patient who starts on this the same thing.

Week 1 you will probably feel nothing. Apigenin needs to accumulate in the system. Women who quit at day 4 or 5 never get to the part that matters. Don't do that.

By week 2, post-meal pressure starts easing. Most women describe it as the pressure under the ribs lightening.

Weeks 3 and 4, spontaneous bowel movements without Miralax, without the night-before magnesium, without a cleanout. This is the point at which most women realize what they have been missing.

By month 2, the bloating has resolved for most patients. The sulfur fermentation byproducts have dropped substantially, which means the sulfur burps go quiet.

By month 4, women aren't planning their day around restaurant bathrooms. They are staying on the medication that is doing what it was supposed to do for their weight, without the side effect that was about to drive them off it.

WHAT THE WOMEN I'VE RECOMMENDED THIS TO HAVE TOLD ME

I want to be careful with the numbers I quote because I don't run a clinical trial in my office. I run a clinic.

What I can tell you is the pattern across the women I have referred to this formulation over the last 2 and a half years. The majority who give it a full 60 days report measurable changes. Bloating drops first. Bowel movement frequency normalizes by week 3 or 4. Sulfur burps stop almost entirely by week 6.

Most of them stay on their GLP-1.

That is the outcome that matters.

A handful of women I have recommended this to didn't feel a difference. I don't know exactly why some women respond and others don't. Motility is multifactorial. Other medications, comorbidities, and individual gut microbiome differences all play roles I can't fully predict. The 90-day guarantee exists for those women.

MY 90-DAY GUARANTEE

The 90-day money-back guarantee is in place for exactly the women I just described.

If you use Motilli daily for 90 days and your digestion isn't measurably better, you send the bottles back and receive a full refund. No phone calls. No forms. No questions.

I wouldn't recommend this formulation to my own mother if I weren't willing to stand behind it for my patients. My mother has been on it for over a year. She made it to my brother's anniversary dinner last fall and stayed for coffee. That has been the new normal for her since week 6.

TWO VERSIONS OF NEXT YEAR

In the first version, you keep doing what the protocol is telling you to do. Fiber. Miralax. Stronger prescriptions. Cleanouts that work less each time. Eventually you call your doctor and tell her you can't keep going. You come off the medication. Most women in this group regain the weight within a year. By the time they ask to restart, the approval landscape has often shifted under them.

In the second version, you stop treating the wrong organ. The stomach starts emptying again. The bloating drops. The bathroom maps come off your phone. You stay on the medication that was actually working.

The medication isn't the problem. The protocol your doctor is following is.

WHAT TO DO NEXT

Click below to check current availability. Motilli is a small batch product because of the apigenin degradation issue I mentioned earlier. When a batch sells through it takes weeks to replace. If it is in stock when you read this, that is the day to order.

P.S. My aunt Diane is my mother's older sister. She started Wegovy 3 and a half years ago. She quit at month 4 for exactly the reason most women quit. She gained the weight back inside a year. She has spent the years since trying to get back to where she was, and she has not. If you have a sister, a friend, or a daughter on a GLP-1 who is being told the answer is more fiber, send this article to her. The women who quit don't quit because the medication failed. They quit because nobody explained the protocol gap in time. My mother almost became my aunt. I wrote this so other women wouldn't have to.

P.P.S. I am not going to tell you the page is coming down or that we are running out of bottles. What I will tell you is that every week you stay on the standard protocol is a week closer to the conversation where you decide to quit. The protocol that brought you here is not going to fix the problem it created.