Mind-Body Digestive Center
underhead

Home
All About IBS
About our Center
Services We Offer
Make an Appointment
 
 IBS RESEARCH & RESOURCES
MBDC Original Research
Relationships & Health
Stress & IBS
IBS: Global Outlook
For Women: Special Issues
Journal Reviews
Links of Interest
  Join the Mailing List
Contact Us
 


For Women:
Special IBS Issues


General Information

It has long been known that women, especially those age 15 to 45, make up the bulk of IBS patients — approximately two-thirds of IBS patients are female. Among women who visit physicians because of their IBS symptoms, the ratio is even higher, from 3:1 and up.
     This section was developed in response to an e-mail inquiry to us by an IBS patient. She described her elation in being freed from IBS symptoms during her pregnancy. However, one month after delivery, her symptoms returned. This prompted a search of the IBS literature for the effects of female hormones on IBS.
     There are a number of gynecological aspects of IBS. Many women consult gynecologists rather than gastroenterologists because of their IBS symptoms with less than satisfactory results. We hope the following information will be helpful to women who visit our site.

Women with IBS

In women with IBS, GI symptoms are even more common around the time of menstruation. Symptoms may include abdominal pain, diarrhea, constipation, flatulence and nausea. It is not yet clear how menstrual cycle hormonal changes result in this increase in IBS symptoms.

Women without IBS

It is quite common for women to experience GI symptoms before menstruation. Constipation or diarrhea are included as part of the pre-menstrual syndrome. A majority of women describe some change in bowel habits during menstruation such as nausea which may be associated with painful uterine cramping (dysmenorrhea).

Gynecological Problems

A common condition suffered by women is known as Chronic Pelvic Pain (CPP). Like the colon in IBS, there is no discernible pathology of gynecological organs and the pain of chronic pelvic pain is considered to be "functional". While CPP is distinct from IBS, there is an increased frequency of IBS in CPP patients and psychological testing shows many of the same psychological patterns in both conditions.
     Women with IBS may have pain during intercourse (dyspareunia).

Gynecological Surgery

Many women who have gynecological surgical procedures for pelvic complaints also have IBS. In one study, 47.7% of women having diagnostic laparoscopy for chronic pelvic pain and 39.5% of women having elective hysterectomy had IBS. More importantly, in the hysterectomy group, IBS patients were more likely to have chronic pelvic pain and abnormal menses as a reason for surgery than the non-IBS patients.
     One year after laparoscopy, IBS patients had lower overall health status and lower pain improvement ratings than non-IBS patients. For women who had hysterectomy because of pelvic pain, those with IBS had less pain improvement.
     What was the conclusion of this study? Women with IBS may have chronic pelvic pain, a functional disorder that does not require surgery. So the presence of IBS in a patient with gynecologic symptoms may adversely affect the symptomatic outcome of laparoscopy and hysterectomy. Therefore, women with IBS and CPP should be carefully evaluated before a decision for surgery is made.
     In the Whitehead article described below, 21% of women with IBS had hysterectomy compared to a national average of 5.5%. The authors recommend that the need for hysterectomy in women with pelvic Pain and IBS should be carefully assessed.
     While caution is advised, there may be situations where reduction of hormonal levels results in improvement in IBS. One study showed that some women with IBS improved after hysterectomy performed for gynecological reasons. Another describes several IBS patients who improved after medication-induced cessation of menses. So surgery for gynecological reasons may help some IBS patients.
     This is clearly a somewhat controversial area. What is our recommendation? There should be increased collaboration between gastroenterologists and gynecologists in the care of women with IBS and chronic pelvic pain.

[ TOP OF PAGE ]


Research Articles

The following summaries of research articles deal with the problem of IBS and the menstrual cycle.


Evidence for exacerbation of irritable bowel syndrome during menses

Whitehead W, Cheskin L, Heller B, et al. Gastroenterology 1990; 98:1485-1489.

METHODS:
Two groups of women with IBS were studied, one seen at a Planned Parenthood center and the other at a university Gastroenterology Clinic. Excluded from the study were women who had a hysterectomy. (It is noteworthy that 21% of the IBS patients had hysterectomy, far greater than the national average of 5.5%.) The remainder of the IBS patients were compared to a control non-IBS group attending Planned Parenthood.
     At Planned Parenthood, there were 30 IBS patients and 234 controls. At the Gastroenterology Clinic, there were 42 IBS patients and no controls.
     All patients received questionnaires regarding their gastro-intestinal symptoms during menses and their psychological state. Psychological tests measured neuroticism, extraversion, openness, agreeableness and conscientiousness. The neuroticism scale included anxiety, hostility, depression, self-consciousness, impulsiveness and vulnerability.

RESULTS:
Symptoms during menses in IBS patients in Planned Parenthood were similar to those in the Gastroenterology Clinic so these IBS groups were combined and compared to the controls who did not have IBS.
All the symptoms studied were significantly greater in IBS patients than in the controls. Menses-related increases were seen in the following symptoms in IBS:

Gas 48%
Diarrhea 29%
Constipation 24%

Increased bowel symptoms were unrelated to psychological test scores described above. Also a Menstrual Distress Questionnaire was used to measure negative affect and behavior (such as irritability) during menses. Again, there was no significant correlation between these traits and bowel symptoms.

CONCLUSION:
Women with IBS have greater exacerbation of gastro-intestinal symptoms during menses than a control population.

[ TOP OF PAGE ] [ RESEARCH ARTICLES ]



The menstrual cycle and its effect on inflammatory bowel disease and irritable bowel syndrome: a prevalence study

Kane SV, Sable K, Hanauer S. Amer J Gastroenterology 93: 1867-1872, 1998.

METHODS:
Thirty-one IBS patients seen at a university GI clinic were compared to healthy controls and to patients with inflammatory bowel disease (IBD, which includes ulcerative colitis and Crohn's disease). They were asked about typical premenstrual syndrome symptoms, as well as nausea, vomiting, diarrhea, and constipation during pre-menstrual or menstrual cycles. They were also asked whether they noticed bowel habit changes during pregnancy.

RESULTS:
  1. Pre-menstrual: There was a significant increase in diarrhea and nausea pre-menstrually in both IBS and IBD, compared to controls. There were no significant difference in non-specific symptoms such as irritability, depression or weight gain in IBS patients.
  2. Menstrual: Diarrhea was increased in IBS and IBD while constipation was significantly increased only in IBS, again compared to controls.
  3. Pregnancy: 291 pregnancies were reported in 139 women. While bowel habits changed during pregnancy, there was no significant difference in those changes among IBS, IBD and control patients. 45% of IBS patients who had been pregnant reported a change in symptoms, the most common being constipation, found in 20%.
  4. Cyclical patterns: Patients' IBS symptoms occurred in a cyclical pattern. They noted increase in diarrhea, constipation or abdominal pain, in the pre-menstrual or menstrual phase of their monthly hormonal cycle.

CONCLUSIONS:
While most women have gastrointestinal symptoms around the time of menstruation, symptoms are more likely to occur in women with IBS.
     What is the significance of this? Patients with IBS symptoms such as abdominal pain, diarrhea and constipation may notice and even expect an increase in their symptoms during the menstrual phase of the monthly cycle. Knowing this may help in coping with and managing the treatment of IBS.

[ TOP OF PAGE ] [ RESEARCH ARTICLES ]



Sleep Disturbance Influences Gastrointestinal Symptoms in Women with Irritable Bowel Syndrome

Jarrett M, Heitkemper M, Cain KC, Burr RL, Hertig V. Digestive Diseases and Sciences, 45: 952-959, 2000

STUDY DESIGN:
This study compares two populations, 82 women with irritable bowel syndrome and 35 controls. The main variables studied are sleep disturbance, gastro-intestinal symptoms and psychological distress, including stress. Women were asked to fill out questionnaires including a 7 day retrospective assessment of sleep disorder and a daily diary from the first day of menses through the fifth day after cessation of menses for 2 consecutive months. Questionnaires included the SCL-90 (a measure of psychological distress), the Womenís Health Research diary, and a Daily GI Distress Score measure. This included pain, bloating, constipation, diarrhea and gas. Questions regarding sleep were culled from the SCL-90 and the daily diary.

RESULTS:
IBS patients had significantly more sleep disturbance, occurring in 25%. They also had more psychological distress and GI symptoms, both on retrospective and daily diary scores. When results were looked at for the total group of IBS patients and controls, there was a correlation between sleep disturbance and GI symptoms. In other words, for women with higher average sleep disorder, there also was higher average GI symptoms. When results were analyzed for the individual woman to see whether altered sleep on any given night was associated with GI disturbance the next day, the results were only significant for the IBS women. Interestingly, sleep was not effected by GI symptoms occurring the same day. So the sequence was poor sleep followed by worsening IBS, not preceded. While IBS patients had more psychological findings than controls, this was not the reason for the association between sleep and GI symptoms. The authors used a statistical method where they controlled for the psychological difference between the two groups; altered sleep and IBS symptoms were still significantly correlated with each other. So stress and emotional factors were not the reason for the main findings of this study.

COMMENTS:
This study supports previous data showing increased sleep disturbance in IBS patients. A new observation is the finding that this is true even when controlling for psychological factors. However, others have reported an association between altered sleep and depression in IBS, so emotions might still play a role. In other reports, it has been shown that REM sleep is increased in IBS. REM sleep is associated with increased activity of the autonomic or involuntary nervous system, especially increased sympathetic output. This can result in increased colon sensitivity, one of the features of IBS. Increased activity of the sympathetic nervous system has been found in other studies of IBS patients.
     While the association between IBS and sleep disturbance is not fully understood, it occurs and may not be fully recognized by patients and physicians. We encourage IBS patients to be aware of this problem and, if it exists, to discuss it with your physician.

[ TOP OF PAGE ] [ RESEARCH ARTICLES ]



Gender-Related Differences in IBS Symptoms

Lee OY, Mayer EA, Schmulson M, Chang L, Naliboff B. American Journal of Gastroenterology, 96: 2184,2193, 2001.

In most surveys of patients with IBS, women outnumber men by ratios from 2:1 to 4:1. While various hypotheses have been offered to explain this female predominance, there is not much research data addressing this observation.
     The purpose of this study was to see if men and women with IBS differed in regard to self-reporting of gastro-intestinal, musculo-skeletal and other extra-intestinal symptoms. It also examined whether differences might be affected by the menstrual cycle.

SUBJECTS AND METHODS:
714 consecutive subjects with IBS seen at the UCLA Center for Functional GI Disorders participated. Mean age was 47 years and 63% were female. They were asked to fill out questionnaires related to bowel symptoms, psychological status and quality of life. The bowel symptom scale included questions about musculo-skeletal pain, altered taste or smell, food sensitivity, response to medication and health care utilization.

RESULTS:
There were no gender differences in psychological status or health care utilization. While there was no difference in frequency of abdominal pain, there was a significant increase in nausea and abdominal distension among women. Women also reported more alteration of taste and smell, as well as more muscle stiffness in the morning.
     In terms of bowel pattern, women were twice as likely to have fewer than three bowel movements per week, and to have hard stools. Men reported more diarrhea than women.
     Women reported greater food sensitivity in relation to GI symptoms and a greater amount of perceived side effects from medication.
     In regard to the menstrual cycle, women did report worsening of symptoms pre-menstrually (shown in other studies as well) but there was no difference in symptoms among pre or post-menopausal women.

CONCLUSIONS:
The authors raise several hypotheses to explain the gender differences they were able to document. There may be true physiological differences manifested by altered motility- as in constipation, and increased nerve sensitivity or perception- as in bloating and distension. Alternatively, women may be more vigilant or attentive to symptoms, possibly related to a difference in the way the brain processes information.
     It had been thought that women who feel bloated and distended are, in reality, not bloated or distended, but just feel that way. However, a recent study has documented measurable distension in IBS patients after gas infusion into the small intestine, so this subject requires some re-thinking.
     Finally, the authors refer to a new theory that suggests women's response to stress or threat is different than men. Rather than react with fight or flight, women may react with relax and restore, resulting in a different gut reaction to stress.

OUR COMMENTS:
We have reviewed this article because there is so little data in the medical literature regarding gender differences in IBS. The findings, while not dramatic, seem well substantiated. One possible source of bias is the use of self-reporting measures since women and men may report their symptoms differently. Of course, this is the only kind of information available to the treating physician.
     The discussion about why these differences occur, is quite hypothetical. Hopefully, more research will be forthcoming that examines the underlying reasons. Areas that seem worth exploring include the interesting question of hypervigilance in women. Women seem to have a greater sensitivity to visceral and somatic pain than men. Why? Are women more concerned about body image and thus physical sensation? Do men dismiss symptoms because pain and discomfort might lead to dependence or a diminished "macho" identity?
     It is noteworthy that recent trials in IBS with serotonin related drugs such as alosetron have found a significant difference in gender response--with benefit found only in women. Serotonin is a neuro-transmitter chemical released in the wall of the colon that effects sensation and motility. So there may be biochemical differences between female and male colons.
     We endorse this kind of large-scale investigative study, because IBS patients can benefit from any information which helps them locate their own distress, which is generally fluctuating, and highly individual. We think that demographic studies of this sort, coupled with our own intensive, small sample clinical research will lead to better coping in the future.
[ TOP OF PAGE ] [ RESEARCH ARTICLES ]



Emotional Abuse, Self-Blame and Self-Silencing in Women with Irritable Bowel Syndrome

Ali A, Toner BB, Stuckless N, Gallop R, Diamant NE, Gould MI, Vidins EI. Psychosomatic Medicine 62:76-82, 2000.

In previous studies, it has been suggested that women with IBS have a higher incidence of physical and sexual abuse in their childhood than the normal population. In this article, current degree of emotional abuse, as well as self-blame and self-silencing was evaluated in women with IBS as compared to women with inflammatory bowel diseases (IBD), ulcerative colitis and Crohn's disease. In addition to emotional abuse, physical abuse and sexual abuse were also measured.
     What is self-blame? It is a tendency to blame oneself for an event or interaction, i.e. a car accident on an icy road.
     What is self-silencing? It is a tendency not to speak one's mind, putting others' feelings first.
     Women (25) diagnosed with IBS were compared to women (25) diagnosed with IBD. The average age of the women was 35 and most of them had their illness for an average of 15 years.
     Women in the IBS sample were more depressed and had significantly higher scores on emotional abuse, self-blame and self-silencing (though self-silencing was the least important of these psychological states).
     IBS patients reported being physically and sexually abused, as well, but emotional abuse had an effect beyond the physical and sexual.

What does this study tell us?
  • IBS, more significantly than IBD (inflammatory bowel disease) is associated with adult emotional abuse and self-blame.
  • In this study, depression was not connected to emotional abuse and self-blame, though levels of depression were higher in the IBS patients.
  • Self-silencing wasn't as important a characteristic of IBS patients.
What issues/questions would we raise at the MBDC?
  1. The questionnaire used to investigate emotional abuse doesn't talk about specific relationships. We think it is important to separate out general and casual relationships, from significant ones. We believe that key emotional (romantic and friendship), family and work relationships are most crucial in terms of stress transmission. In fact, one of us, (Gerson MJ, Schonholtz J, Grega CG, Barr DR. The importance of the family context in inflammatory bowel disease. The Mount Sinai J Med. 65:398-403, 1998) in a study of IBD patients, found that self-blame, was correlated with other forms of blame in the family, that is blaming another family member, or the patient being blamed by others.
  2. The authors do say that the results can't claim that emotional abuse and self-blame cause IBS symptoms. This is a crucial point.
  3. From a circular mind-body perspective, IBS itself, because it is so hard to treat and so frustrating, could actually lead sufferers to develop an unfortunate pattern of self-blame.
  4. It is interesting that depression was not connected to self-blame, abuse or self-silencing. It might be, as the authors suggest, this is a finding of this particular study, since the women were seeking help from a specialist, and those who visit specialists have been frequently diagnosed as depressed.
  5. But what is important here is attention to specific emotional factors in IBS sufferers. Too often patients have been labeled "psychosomatic," without specific psychological description.
[ TOP OF PAGE ] [ RESEARCH ARTICLES ]



The Role of Abuse in IBS


The role of abuse history in IBS was first introduced by Drossman et al in 1990. A number of other research reports have confirmed the observation that a history of sexual or physical abuse may be associated with IBS in later life. The following is a summary of relevant research.

ABUSE HISTORY AND IBS:
A history of sexual and physical abuse is more common in IBS than in a normal population.
  • Talley et al. (1994) found that 50% of their 130 cases of IBS reported a history of abuse compared with 23.3% of those without IBS.
  • Blanchard et al. (2001) found similar values: 47.1% of IBS patients reported childhood sexual abuse compared with 29.6% of nonpatients.
  • Drossman (1995) reported that the more severe the IBS, the greater the history of abuse.
Is there Abuse History in Organic GI Illness?
There also may be a higher percentage of abuse history in IBS than in organic GI diseases such as Inflammatory Bowel Disease.
  • Drossman et al. (1990) documented a higher level of early (pre-adolescent) sexual and physical abuse among female patients with functional GI disorders (IBS) than among female patients with organic GI diseases (IBD).
  • Of the IBS patients, 50% (19 out of 38) reported early physical or sexual abuse.
  • Walker et al. (1993) also found a significantly greater history of sexual abuse among IBS patients (54%) than among a group with IBD (5%).
There is contradictory evidence showing no significant correlation between abuse and IBS compared to abuse and other GI disorders:
  • Talley et al. (1995) found no differences on total abuse among 997 GI patients: 22.1% of patients with functional GI disorders had early abuse compared with 16.2% of those with organic disorders.
  • Leserman et al. (1996) also failed to find significant differences on abuse between patients with functional vs. organic GI disorders.
The Definition of Abuse:
  • The criteria for "Sexual Abuse" has not been defined in the literature. One study defined sexual abuse "if there was force or a threat of harm involved" (and did not distinguish between different levels of severity of sexual abuse)
  • The criteria for physical abuse has not been defined in the literature, and has ranged from one experience of being "mugged" to repeated and severe domestic violence.
  • Emotional abuse has not been considered in IBS (but may be just as important as other forms of abuse)
Are there Cultural Differences?
  • Italy: Porcelli reported a 7% rate of abuse in a tertiary center for treatment of functional bowel disease
  • France: 32% of French subjects with IBS were found to have a history of physical and sexual abuse.
  • These figures are somewhat lower than reported in the U.S. and suggest that there may be cultural differences in abuse rates. On the other hand, cultural difference may affect the degree with which IBS patients are willing to report a history of abuse.
Why Is There A Possible Relationship Between Abuse and IBS?
  • A history of abuse may result in a higher level of physical sensitivity. Secondly, abuse history may naturally lead to a greater sense of physical vulnerability and thus more preoccupation with physical symptoms. It may, unfortunately, leave a psychological trauma residue of depression and/or anxiety, which only intensifies the experience of having a difficult to manage, unpredictable illness.
  • Whether there is a greater disposition for patients with abuse history to develop gastrointestinal symptoms more than other organically based symptoms, awaits the findings of future research.
[ TOP OF PAGE ] [ RESEARCH ARTICLES ]
  © 2008 Mind-Body Digestive Center design strudelmedia.com