Between 1 and 1.4 million people in the United States have inflammatory bowel disease (IBD), a group of conditions that includes Crohn’s disease and ulcerative colitis.1 For women of childbearing age with IBD, there are considerations related to fertility and pregnancy, according to recent information presented by the Association of Reproductive Health Professionals. (Review the information to earn continuing medication education credit. Visit http://bit.ly/1SFbilk, and click on the titles pertinent to IBD.)
In the West, the incidence and prevalence of inflammatory bowel diseases has increased in the past 50 years, says Sunanda Kane, MD, a gastroenterologist at the Rochester, MN-based Mayo Clinic. A systematic literature review that identified population-based studies calculated that in North America, the annual incidence of Crohn’s disease was 20.2 per 100,000 person-years and the annual incidence of ulcerative colitis was 19.2 per 100,000 person-years.2
Inflammatory bowel disease is a chronic idiopathic disease characterized by the tendency of chronic or relapsing activation of the immune system within the gastrointestinal (GI) tract, notes Kane. While Crohn’s disease and ulcerative colitis are inflammatory conditions, they present very differently and involve different parts of the gastrointestinal tract.
Crohn’s disease, which may involve any portion of the gastro-intestinal tract from the mouth to the anus, is characterized by skip lesions, which are discrete areas of diseased bowel separated by normal bowel. Ulcerative colitis involves continuous mucosal inflammation that starts in the rectum and extends proximally, Kane points out. Typical symptoms of this condition are bloody diarrhea, abdominal pain, urgency, and tenesmus (the feeling of incomplete defecation).
Inflammatory bowel disease is a risk factor for colorectal cancer, notes Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. However, rates of colorectal cancer deaths have dropped in women since 1947, primarily due to increased screening for the disease. There is some evidence that cancer risk in patients with IBD may be lower in recent years due to improved disease management and the use of screening to detect premalignant lesions.
The onset of menses may be delayed in women with IBD, especially when the disease is poorly controlled. In one study, 12 menstrual abnormalities were reported in 58% of 360 women with Crohn’s disease, including amenorrhea, irregular menses, dysmenorrhea, and menorrhagia.3 In a study that evaluated the relationships between the menstrual cycle and GI symptoms, researchers found that women with IBD experienced a significantly higher number of loose stools and more severe mean abdominal pain than the controls in all three phases of the menstrual cycle.4
“It is important for clinicians to understand the effect of the menstrual cycle on signs and symptoms of IBD and that cyclic alteration in bowel function may be helpful in determining the true exacerbation of IBD,” notes Kane.
The U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) lists the copper-T and levonorgestrel intrauterine devices, as well as the contraceptive implant, as Category 1 methods that can be used with no restrictions in women with IBD.5 The contraceptive injection and progestin-only pills are listed as Category 2 methods, with which the advantages generally outweigh the theoretical or proven risks.
While combined oral contraceptives remain the most widely used form of contraception in the United States, in years past, women with IBD were counseled against taking combined pills because of the concern that pill use can increase the risk of IBD, notes Kane. However, there is conflicting evidence on a connection between combined pill use and the development of IBD.6 The US MEC lists combined pills, the contraceptive patch, and the contraceptive vaginal ring as a “Category 2/3,” which is a balance between when the advantages generally outweigh the theoretical or proven risks and the theoretical or proven risks usually outweigh the advantages.
When it comes to contraceptive counseling for IBD patients, there are a few special considerations, says Kane. Oral formulations should have the lowest estrogen dose possible, as estrogen does in theory have properties that are harmful to the GI tract, she says. Estrogen is implicated in causing ischemia by propagating blood clots, says Kane.
Smoking cessation must be advised, just as in non-IBD patients, she notes. For those with a history of blood clots or liver disease, an IUD or barrier methods are preferred due to the risk of clots with oral contraceptives, states Kane.
What should women with IBD know when they are planning to start a family? The most important thing is that women should be preventing contraception with an effective method until they get the all-clear from their gastroenterologist, as well as their obstetrician-gynecologist, says Lori Gawron, MD, assistant professor at the University of Utah in Salt Lake City. They must be clear for three to six months, and they must be on appropriate medication, she notes.
REFERENCES
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Cosnes J, Gower-Rousseau C, Seksik P, et al. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011; 140(6):1785-1794.
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Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012; 142(1):46-54.
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Weber AM, Ziegler C, Belinson JL, et al. Gynecologic history of women with inflammatory bowel disease. Obstet Gynecol 1995; 86(5):843-847.
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Lim SM, Nam CM, Kim YN, et al. The effect of the menstrual cycle on inflammatory bowel disease: A prospective study. Gut Liver 2013; 7(1):51-57.
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Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use. Morb Mortal Wkly Rep 2010; 59(RR04):1-86.
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Zapata LB, Paulen ME, Cansino C, et al. Contraceptive use among women with inflammatory bowel disease: A systematic review. Contraception 2010; 82(1):72-85.
