Women Experience IBD Differently Than Men: Why It Matters

Inflammatory bowel disease (IBD) affects roughly an equal number of men and women, but IBD symptoms can be quite different in women due to the hormonal changes they experience throughout their lives. Doctors who understand the unique ways IBD can manifest in women can help their patients achieve better quality of life.

“Pregnancy can trigger flares and menopause can lead to changes in IBD activity, but many providers are unsure how to manage care for women in these scenarios,” said gastroenterologist Puja Khanna, MD

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Diagnosis May Be Delayed for Many Women With IBD

IBD is an umbrella term for chronic autoimmune conditions that cause inflammation and damage to the digestive tract, significant changes to bowel habits, abdominal pain, and other symptoms. The two most common types of IBD are Crohn’s disease and ulcerative colitis.

Doctors don’t always recognize IBD in women as readily as they do in men, which can delay care for women with the condition.

Pregnancy can trigger flares and menopause can lead to changes in IBD activity, but this isn’t well known among general gastroenterologists or even some IBD specialists.

“There are studies showing that it takes much longer for women with IBD to be diagnosed than their male counterparts,” Khanna said. “Women who complain of symptoms might be told, ‘You’re just stressed out,’ or ‘Oh, that’s anxiety.’ A delay in diagnosis can set a woman up for complications that can occur at different parts of her life.”

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Treatment Considerations for Women With IBD

The goal of IBD treatment is remission, which is when symptoms disappear and the digestive tract can heal.

Based on the patient’s symptoms, doctors may prescribe:

• Oral steroids when symptoms flare up
• Medications that can modulate the body’s immune response to reduce inflammation
• Changes to your diet, to help the medication reduce inflammation
• Advanced therapies that target the cause of inflammation

Some women with IBD may need surgery to remove damaged portions of the digestive tract or repair fistulas or other complications.

How Puberty Affects IBD in Women

Girls are rarely diagnosed with IBD during childhood. Around age 14, however, the number of cases increases.

“We’re not really sure why,” Khanna said. “There’s some thought that changes in hormones during puberty may be a trigger.”

In teenage girls, common IBD symptoms to watch out for include:

• Frequent diarrhea
• Blood in bowel movements
• Abdominal pain
• Unintended weight loss
• Anemia

How Menstruation Affects IBD in Women

About half of women with IBD report symptoms become worse around their menstrual periods. The reason for this isn’t fully understood.

“It’s unclear if symptoms such as changes in frequency of bowel movements or pain sensitivity are related to changes in hormones as they act on the gut,” Khanna said.

“Women with IBD should be evaluated by their IBD physician to help them understand if their IBD is truly in remission or if there’s underlying inflammation that gets worse during times of hormone fluctuation,” she said.

Can Women With IBD Get Pregnant? How IBD Affects Fertility

Women with IBD can become pregnant. For better pregnancy outcomes, doctors recommend women wait until their IBD goes into remission for three to six months before conceiving.

“We’re learning that active inflammation in IBD reduces fertility,” Khanna said. “Women with IBD are thought to have the same fertility as women their age who do not have IBD, as long as their IBD is in remission and they haven’t had any pelvic surgeries. Women who have surgery in the pelvic area can develop scar tissue that can affect their fertility.”

Khanna recommends younger women with IBD see a fertility specialist, even if they aren’t thinking about motherhood anytime soon.

“Information is power,” Khanna said. “You could be in your 20s and not have a partner. You could be in your early 30s and thinking about freezing your eggs. A fertility specialist can help you make the best decisions for your future.”

Managing IBD During Pregnancy

Women with IBD who are in remission should remain on pregnancy-safe medication to manage their IBD for the entire pregnancy. Some IBD specialists don’t realize this.

“Some specialists think these medications are dangerous, but they’re lifesaving,” Khanna said. “They keep women with IBD in remission, and there’s very little exposure to the baby.”

Women with IBD who get pregnant before going into remission are more likely to have complications, including miscarriage, preeclampsia (high blood pressure during pregnancy), premature delivery or a low-birthweight baby.

Some pregnant women with IBD experience symptom flares. An experienced provider can help their patient manage them.

“A flare can happen, even if you follow all the rules,” Khanna said. “We are equipped to treat those flares so you can have a healthy pregnancy.”

 How Menopause Affects IBD

During menopause, a woman’s estrogen and progesterone levels drop, which can cause changes to IBD activity in women with the condition.

“Some women with IBD get more symptoms when they enter menopause, while others get fewer symptoms—and it’s really unclear why,” Khanna said.

Menopausal women with IBD should meet with a specialist who can evaluate their symptoms and discuss complications and treatments.

“We’re not all the same, so learning how the disease presents in each individual helps us decide if hormone therapy would help a patient’s symptoms or not,” Khanna said.

How IBD Affects Bone Health and Osteoporosis Risk

Women’s risk of osteoporosis increases after menopause due to decreased hormone levels. IBD can also heighten osteoporosis risk for certain women.

“Treating IBD with medications such as steroids can accelerate bone resorption and turnover and lead to osteoporosis in women with IBD,” Khanna said.

To address this, doctors may send menopausal women with IBD for a DEXA scan (a low-dose X-ray of the hip and lower spine) to monitor bone density. They may prescribe medication to decrease the risk of osteoporosis. They also may recommend patients take calcium and vitamin D supplements.

Specialized Care and Support for Women With IBD

Women with IBD should see a provider who is knowledgeable about its effects on menstruation, pregnancy, menopause and bone health.

To complement the Integrated IBD Pregnancy and Fertility Program at Cedars-Sinai, Khanna is building a menopause clinic at the multidisciplinary Cedars-Sinai IBD Women’s Health Program.

“My vision is to offer a comprehensive women’s health program for IBD patients,” Khanna said. “I want women in our community to know we’re investing in them.”