Gastroenterology / Women's Health

Reproductive health considerations for women with inflammatory bowel disease

June 20, 2016
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Inflammatory bowel diseases like ulcerative colitis and Crohn’s disease afflict nearly 1.4 million people in the United States alone. According to recent studies from the Association of Reproductive Health Professionals, women with inflammatory bowel diseases must be especially aware of its potential effects on fertility and pregnancy.

Inflammatory bowel diseases are typified by chronic or relapsing over-activate immune responses in the gastrointestinal tract. They are chronic and have no known definite causes. They are also increasingly prevalent in the West over the past 50 years, according to Rochester, MN, Mayo Clinic gastroenterologist Sunanda Kane, MD. Identifying this increase, a systemic review of population-based studies determined that the annual incidences of Crohn’s disease and ulcerative colitis in the United States were 20.2 per 100,000 person-years and 19.2 per 100,000 person years, respectively. Though Crohn’s disease and ulcerative colitis are both characterized by inflammation, they affect different areas of the gastrointestinal tract and often have different presentation.

Crohn’s disease is denoted by the presence of skip lesions — discrete and intermittent sections of diseased bowel interspersed with normal bowel tissue — that can emerge along any and all portions of the gastrointestinal tract. Ulcerative colitis, on the other hand, entails continued mucous tissue inflammation that begins rectally before extending proximally. Crohn’s diseases symptoms include abdominal pain, hematochezia, and tenesmus.

Inflammatory bowel diseases as a whole are risk factors for colorectal cancer. In spite of the increased prevalence of IBD, rates of colorectal cancer deaths among women have dropped over the past 50 years due to improved awareness of and increased screening for the disease. Likewise, increased disease management and improved screening may decrease cancer risks among patients with inflammatory bowel diseases.

Inflammatory bowel diseases may play a role in the delayed onset of menses in affected patients. One study reported a dozen menstrual abnormalities afflicted nearly 6 in 10 of the women tested. The abnormalities included amenorrhea, irregular menses, dysmenorrhea, and menorrhagia among others. Another study analyzing the connection between gastrointestinal abnormality and the menstrual cycle found that IBD patients reported more severe abdominal pain throughout the entire menstrual cycle than the control group. Evaluating this relationship is important to both clinicians’ and patients’ understandings of inflammatory bowel disease and the menstrual cycle.

This evolving knowledge has previously led to oral contraceptives — the most popular form of contraception in the US — being considered too risky for women with IBD to take, as use of the pill can increase the risk of gastrointestinal inflammation. The U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) describes alternative methods like the Copper-T and levonorgestrel intrauterine devices or contraceptive implants that can be utilized without specific restriction in women with IBD. Each of these is listed as a Category 1 method; combined contraceptive pills are listed as Category 2/3, meaning that the benefit/risk dynamic is unclear.

Consultation with IBD patients regarding contraception should emphasize the particularity of their condition. Oral contraceptive methods should contain the lowest possible amount of estrogen as estrogen theoretically harms gastrointestinal tissue — estrogen has even been implicated in ischemia through its tendency to increase blood clotting. As with non-IBD patients, it is advised that IBD patients on contraceptives stop smoking. Patients that also have a history of liver disease or blood clots, oral contraception is cautioned against for its coagulative tendencies.

For women with IBD that are planning on starting a family, assistant professor at the University of Utah in Salt Lake City, Lori Gawron, MD, emphasizes that the most important element of their preparation is active and frequent consultation with both their gastroenterologist and their obstetrician-gynecologist. She further advises that women seeking to start a family should be cleared by their gastroenterologist and their OB/GYN for 3-6 months while being adequately medicated.