Inflammatory Bowel Disease--A Complicating Factor in Gynecologic Disorders?

, , Cleveland Clinic Foundation

Disclosures
In This Article

Abstract and Introduction

Abstract

Gynecologic disorders occur commonly in women with Crohn's disease and ulcerative colitis. Frequently, these women also suffer menstrual disorders with gastrointestinal symptoms that overlap with those related to inflammatory bowel disease (IBD). Knowledge of the range of gynecologic problems--for example, dysfunctional uterine bleeding, fistula or abscess of the perineum or vagina, dyspareunia, subfertility possibly due to tubal blockage, and ovarian dysfunction related to bowel disease--that have been associated with IBD will assist practitioners in treating these women. Prostaglandins, released by the endometrium at menstruation, cause contraction of uterine smooth muscle, resulting in the cramping pain of dysmenorrhea. Prostaglandins also are an important component of the inflammatory process in active IBD; by increasing contractility of GI smooth muscle, they are associated with diarrhea and abdominal pain. Menstrual pain and menses-related GI symptoms may be difficult to distinguish from symptoms related to IBD. Endometriosis may present with symptoms similar to an acute episode of IBD. Mucosal changes in the bowel can occur in association with endometriosis, and can be confused with the histologic features of IBD. The distinction is important. For example, while nonsteroidal anti-inflammatory drugs may relieve symptoms of dysmenorrhea, they often are contraindicated in IBD. To provide optimal evaluation and treatment, all health care professionals who treat women with IBD should be aware of the spectrum of gynecologic conditions that may be encountered.

Introduction

Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, are a set of chronic recurring diseases with equal gender ratio.[1]Most patients are diagnosed in young adulthood, although the disorder may develop at any time of life. The incidence of IBD is relatively low, with 9-10 cases of Crohn's disease and 15-19 cases of ulcerative colitis per 100,000 women occurring each year.[2,3] However, because of recurring episodes of active disease, the prevalence of IBD is much higher than the incidence. The prevalence of ulcerative colitis is between 70 and 99 cases per 10,000 people. That is about twice the prevalence of Crohn's disease, which is between 35 and 56 cases per 10,000 people.[4] By not identifying asymptomatic cases, current studies probably underestimate the true prevalence of IBD by 27% to 38%.[4]

The causes of IBD are unknown. It is likely that genetic factors are important, since there is an increased risk in first-degree relatives.[1] Environmental factors are also important. The incidence of ulcerative colitis is inversely related to smoking, while Crohn's disease is directly associated with smoking.[5] Pathophysiologic features of the diseases show some overlap. Crohn's disease is characterized by transmural bowel inflammation, most commonly affecting the terminal ileum and colon, although the alimentary tract may be affected at any site. Symptoms include abdominal pain, diarrhea, fever, weight loss, fistula formation, and extra-intestinal manifestations, including arthritis, uveitis, and erythema nodosum. The pathologic features of ulcerative colitis include superficial ulceration extending in a continuous fashion proximally from the rectum. The cardinal symptom is bloody diarrhea; systemic symptoms and signs are less common than with Crohn's disease. Indeterminate colitis refers to those cases where a definite distinction between Crohn's disease and ulcerative colitis cannot be made (Fig. 1).

Figure 1. Crohn's disease involving the small intestine. Mucosal surface shows hyperemia and focal areas of ulceration. Reprinted with permission from The University of Utah Health Sciences Center WebPath Copyright © 1994-1996, 1997 by Edward C. Klatt, MD, The University of Utah Health Sciences Center, and by designated contributors.
Figure 2. Eroded mucosal surface in ulcerative colitis extending proximally from rectum. Only islands of mucosa remain, creating "pseudopolyps." Reprinted with permission from The University of Utah Health Sciences Center WebPath Copyright © 1994-1996, 1997 by Edward C. Klatt, MD, The University of Utah Health Sciences Center, and by designated contributors.
Figure 3. Endoscopic view of (A) bowel with mild Crohn's; (B) normal bowel; © bowel with mild ulcerative colitis. Reprinted with permission from Atlas of Gastrointestinal Endoscopy, Copyright ©1997, Atlanta South Gastroenterology, P.C. All rights reserved.

Gynecologic disorders occur commonly in women with IBD, although they have received relatively little study.[6,7] There may be considerable overlap in symptoms attributable to gynecologic disorders, IBD, or both. Knowledge of the range of gynecologic problems that women with IBD may experience will assist practitioners in caring for these women. This article reviews the relevant literature and presents strategies for identifying and managing common gynecologic disorders in women with IBD. The challenge is often to identify and correctly associate the condition with IBD, so that further evaluation and management can be carried out as indicated.

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