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IBD and Your Period: All You Want to Know and Then Some

Worse IBD Symptoms During Menstruation?

If you feel like your IBD symptoms become worse during your period you’re definitely not alone. Menstruating individuals who have been diagnosed with Crohn’s disease or ulcerative colitis often report worsening of symptoms during menstruation. Here you’ll find the most comprehensive guide on Inflammatory Bowel Disease and menses on the internet. Guaranteed or your money back! 

Feel free to use the table of contents below to quickly access the information you are looking for.

Table of Contents

What Causes Symptoms to Become Worse During That Time of the Month?

Is it Hormones?

The exact cause of worsening GI symptoms for folks with IBD during menstruation remains unclear and has hardly been studied. One idea is that hormones are to blame. The gonadal hormone prostaglandin could be one contributing factor. Prostaglandins are an important element of the inflammatory process in active IBD because prostaglandins are made at sites of tissue damage or infection where they cause inflammation as part of the healing process. Prostaglandins are also responsible for the contraction of smooth muscle in the intestines which may cause more frequent trips to the bathroom during your period if there is an excessive release of this hormone from the uterine cavity. Painful periods, known as dysmenorrhea, are linked to having too much or an imbalance of prostaglandins and arachidonic acid metabolites.

Illustration of female reproductive system

What the what?

Prostaglandins are hormones that help control several different processes in the body like smooth muscle contraction, the menstrual cycle, and causing inflammation as part of the bodies healing process. Since this hormone is responsible for smooth muscle contraction you may experience more frequent trips to the bathroom during your period. Muscle contractions = spasms and cramps. If a lot of this hormone is released it could create more contractions in your gut which would result in more bowel movements. 

Prostaglandins regulate the female reproductive system and are involved in the control of ovulation and the menstrual cycle. These hormones are released by the endometrium (inner mucous membrane of the uterus) during menstruation, causing contraction of smooth muscle in the uterus that results in the cramping pain you are familiar with during your period. Because of this, symptoms attributed to menstruation and IBD may overlap. 

What in the?

Simply put: Those darn hormones prostaglandins are at it again with their ability to cause smooth muscle contractions. Not only is it responsible for the contraction and relaxation of the muscles in the gut, it’s also released from the uterus during your period and causes cramps. It could become confusing to determine whether or not the pain and other symptoms you are experiencing are because of IBD or because of your period, and sometimes it could be both. It has not been specifically studied but it is possible that women may experience an exacerbation of symptoms of IBD during their periods.

Is it Iron Deficiency Anemia?

Another thing that could be making you feel worse during your period is iron deficiency anemia. Iron deficiency anemia is a common problem for patients who have Inflammatory Bowel Disease. Symptoms of IDA include fatigue, pale skin, dizziness, rapid heart rate, reduced performance, and headache. If you experience heavy periods, known as menorrhagia, it could contribute to worsening symptoms of iron deficiency anemia.

Do Patients with IBD Experience More or Worse Symptoms During Menstruation Compared to Those Without IBD?

In a study comparing 47 menstruating people with IBD who were either in remission or had mild disease activity to 44 healthy females without IBD, premenstrual symptoms were significantly higher in the group who had IBD. Abdominal pain, nausea, flatulence, and the urge to evacuate the bowels were much higher in the patient group compared to the group who did not have IBD. Diarrhea, straining, and constipation didn’t seem to vary too much between the two groups. Of the systemic symptoms studied, depression, acne, headache, anxiety, edema, and breast pain also showed little difference between the two groups. 

The study evaluated premenstrual, menstrual, and post-menstrual phases of the menstrual cycle. A significantly higher number of stools, loose stools, and more severe abdominal pain occurred in the group who had IBD. Though the study had limitations, “it highlights the fact that IBD patients are more likely to report PMS and GI symptoms than healthy women, without exacerbation of disease specific symptoms.” 

In another study aimed to investigate the correlation between worsening GI symptoms and the menstrual cycle they compared 49 patients with ulcerative colitis, 49 patients with Crohn’s disease, 46 patients with IBS, and 90 healthy controls. Though 93% of all females in the study reported premenstrual symptoms they were reported statistically more often by patients with Crohn’s disease. Those with Crohn’s disease were also more likely to report increased GI symptoms during menstruation with diarrhea being the symptom reported the most. Compared to the healthy controls the patients in the disease group had a significantly higher cyclical pattern to their bowel habits. These cyclical symptoms included abdominal pain, diarrhea, and constipation. 

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Source: Sunanda V. Kane, MD, MSPH

Females in the disease groups reported more cyclical symptoms, diarrhea, and abdominal pain compared with the healthy controls. 

So what does it all mean?

Both studies show that almost all menstruating persons report changes in bowel habits during their menstrual cycle whether they have IBD or not. Gastrointestinal symptoms seem to become more prominent in IBD patients during menstrual periods, as indicated by previous studies, probably due to changing levels of prostaglandins. Menstrual pain and menstrual-related gastrointestinal symptoms may be difficult to distinguish from the symptoms related to inflammatory bowel disease. GI’s should be aware that worsening symptoms may not be due to disease exacerbation but could be due to menstruation. This implies that menstrual cycles should be considered by GI’s in the clinical setting. 

Irregular Periods and IBD

Aside from an increase in symptoms during your period IBD may also contribute to irregular or absent periods. A normal menstrual cycle lasts 28 days, plus or minus seven days. Menstrual bleeding is considered irregular if it occurs more often than every 21 days or lasts longer than 8 days. Missed, early, or late periods are also considered signs of an irregular cycle.

In one study menstrual abnormalities such as irregular periods, loss of period (secondary amenorrhea), never having a period (primary amenorrhea), painful periods, and heavy bleeding were reported in 58% of 360 women with Crohn’s disease.

Causes of irregular periods:

  • Hormones: Many menstruating people diagnosed with Crohn’s disease or ulcerative colitis seem to have irregular periods. No one knows for sure why this happens but hormones could play a role because inflammation affects the hormones that cause menstruation. If disease is well controlled regular periods usually return. 
  • Nutrition: Undernutrition results from inadequate ingestion of nutrients, malabsorption (may be due to extensive bowel surgery or active disease), loss of nutrients from diarrhea, or when nutritional requirements increase (active disease or infection). Undernutrition and nutritional deficiencies may lead to an irregular period. In females who have been diagnosed with IBD before the onset of puberty undernutrition may cause delayed growth and puberty resulting in irregular or absent periods. 
  • Stress: It’s not uncommon to experience stress and anxiety when you’re living with a chronic illness. Emotional stress, even if for a brief time, can contribute to irregular periods by messing up hormonal balance. 
  • Excessive weight loss or weight gain: Being underweight can cause your period to become irregular. This may happen when disease is active and appetite is significantly reduced. Some are unable to eat enough due to abdominal pain, strictures, or fear of food due to IBD. Overnutrition is another form of malnutrition. Excessive weight gain can also cause irregular periods. One cause of weight gain for patients with IBD is the use of steroids to induce remission. If you have gained a significant amount of weight you may experience irregular periods. 
  • Zinc deficiency: Crohn’s disease can cause zinc deficiency in patients with severe symptoms. Zinc deficiency correlates with lower levels of estradiol (estrogen-like hormone), testosterone, and lutenising hormone (LH). LH levels remain at baseline level until right before ovulation when it dramatically increases and triggers ovulation. Low levels of LH, as seen in zinc deficiency, can cause menstrual abnormalities.

Causes of Absent Periods (Amenorrhea) in IBD

  • Low body weight and/or weight loss: Some females may experience secondary amenorrhea due to active disease and/or weight loss. Secondary amenorrhea occurs when a female has already had a period but then stops having them. Having a low body weight could cause secondary amenorrhea because when calorie restriction is severe the production of adequate hormones to allow menstruation to occur is not at the top of the body’s priority list. Your body will do whatever it needs to conserve energy so that vital functions are maintained. In this case menstruation is not a vital function. This type of secondary amenorrhea is called hypothalamic amenorrhea and usually occurs when a female weighs less than 10% below their ideal body weight.
  • The endocrine system:  A condition known as hypogonadism is not uncommon in people who have IBD. This occurs when your sex glands produce little to no sex hormones. The production of these hormones play a role in sexual development during puberty and also play a role in menstrual cycles. Having hypogonadism can cause amenorrhea. Aditionally the endocrine system may cause amenorrhea because adipokines such as leptin, adiponectin, and resistin are involved in a number of processes that characterize IBD including anorexia, malnutrition, and altered body composition.
  • Stress: Everyone experiences stress and living with a chronic illness certainly contributes. Stress can temporarily alter the function of your hypothalamus, an area of your brain that controls the hormones that regulate your menstrual cycle. As a result ovulation and menstruation may stop. Regular periods usually resume after stress decreases.
  • Delayed growth:  For young females primary amenorrhea (not starting your period by the age of 15) may occur because of undernutrition which can cause delayed growth. Having a body fat of 17% may be necessary for menstruation to begin. For adolescent girls with IBD the age at which menstruation begins seems to be connected with body weight and fat percentage rather than chronological age. This suggests that for young female patients with IBD to begin menstruating they must reach optimal weight rather than a specific age. Most doctors think that nutritional deficiencies are the main reason for delay in growth and puberty in pediatric patients with Inflammatory Bowel Disease. Delayed growth in pediatric girls caused by a low weight, undernourishment, or chronic use of steroids could cause amenorrhea.

Surgery and Your Period

  • Of menstruating individuals who have had surgery related to their IBD, heavy periods and irregular bleeding occurs in 60% of those with Crohn’s disease and 53% of those who have ulcerative colitis.
  • Among females who have had restorative proctocolectomies with ileo-pouch anal anastomosis (J-pouch) surgery: one study reports that 31% of women who have had J-pouch surgery experienced menstrual problems after surgery vs 23% who did before surgery. 
  • Menstrual patterns were similar before and after surgery in females who have had proctocolectomies.
  • There seems to be a high rate of menstrual abnormalities with IBD but it has not yet been explained. One idea is that those whose IBD was severe enough to require surgery would probably experience more menstrual abnormalities. 
  • Impaired ovarian function due to multiple surgeries, the stress of chronic disease, or poor nutrition could cause abnormal periods. 

What You Can Do to Improve QoL During Menstruation

  • Get IBD under control: The most important thing for your health is finding a treatment that can put your IBD into remission and keep it there if possible. If your disease is well managed you are less likely to experience dramatic weight loss, stress related to chronic illness, and nutritional deficiencies; all of which could lead to abnormal menstruation. For pediatric patients controlling disease is important to help prevent delayed growth and puberty and thus amenorrhea. 
  • Keep track of your symptoms: Keep track of your symptoms throughout the month taking note of number of bowel movements, abdominal pain, loose stool, etc. This could help you see if your symptoms get worse during your period and can be a guide to talking about it with your doctor. It can also help prevent your doctor from overtreating your IBD if your symptoms are related to menstruation and not to Inflammatory Bowel Disease.
  • Manage stress: If stress is contributing to irregular or absent periods counseling could help. Some hospitals with IBD centers even have counselors specifically trained to help patients with Crohn’s disease or ulcerative colitis. You may also benefit from stress reducing activities like yoga, meditation, journaling, taking walks, or biofeedback.
  • Correct nutritional status and weight in adult females with IBD:  For those who experience secondary amenorrhea a resumption of mensus usually occurs when weight gain is 10% higher than when the loss of periods began. Often correction of nutritional status requires managing the disease better and working with your GI and a registered dietitian to figure out what may help you. If your disease state is severe you may require supplemental drinks, tube feeding, or TPN to give the bowel a rest and/or restore weight. 
  • Correct nutritional status and weight in pediatric IBD females: Restoring nutritional status and weight in the pediatric female is extremely important for those with IBD who have delayed growth and/or puberty. Correcting nutritional deficiencies or low body weight could aid in proper growth and onset of puberty, thus aiding the young person to experience normal menstruation. Nutritional intervention may also be used to control disease activity in pediatric patients with IBD. This is usually done with enteral nutrition via an NG tube. When disease activity is controlled regular periods are more likely.
  • Contraception: Contraception can be used in many ways to help regulate periods and control symptoms. If you experience painful periods, heavy bleeding, absent or irregular periods then using birth control may help. The patch, pill, and ring can be continuously cycled which can benefit those who experience worsening of their IBD symptoms during their periods.
  • Eat foods that contain iron: If you experience heavy bleeding during menstruation you can reduce your risk of anemia by eating foods that are rich in iron. These include red meat, beans, seafood, pork, poultry, dark green leafy vegetables, raisins, and iron-fortified cereals, breads and pastas. It’s important to note that females who already have iron deficiency anemia and do not tolerate supplements well may require iron infusions.
  • Have your bone density checked: Individuals who have a history of menstrual abnormalities or those who have received steroid treatment for IBD may be at especially high risk for osteoporosis. Having a bone density test will help determine if bone mass is low and therapy is needed. Some hormonal contraceptives may prevent osteoporosis later in life for people who have hypothalamic amenorrhea (loss of period due to low weight). 
  • Calcium and Vitamin D: It is recommended that every female who experiences amenorrhea consume 1200 to 1500 mg of calcium daily (or take a calcium supplement) and a vitamin D supplement of 400 IUs daily.

Easing the Pain

Illustration of girl clutching her abdomen with a pained expression on her face

Here are some things you can use to reduce pain during mensus:

  • Typically NSAIDs are used to treat dysmenorrhea (painful periods) but they are not recommended in people who have IBD because they can cause ulceration, irritation, and bleeding in the gastrointestinal tract. Talk with your doctor about other options.
  • Heat: Use a heating pad or take a warm bath. Heat opens vessels and improves blood flow so that pain lessens.
  • Contraceptives: Some contraceptives can prevent monthly periods which can help people who have severe pain during mensus.
  • Excercise.
  • Rest when needed.
  • Avoid caffeine and alcohol.
  • Lower back and/or abdominal massage.
  • Drink water.

And that concludes today’s post!

Sara

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Sources:  

1. Kane, S. V., Sable, K., & Hanauer, S. B. (1998). The menstrual cycle and its effect on inflammatory bowel disease and irritable bowel syndrome: A prevalence study. The American Journal of Gastroenterology Am J Gastroenterology, 93(10), 1867-1872. doi:10.1111/j.1572-0241.1998.540_i.x

2.  Bharadwaj, S., Barber, M. D., Graff, L. A., & Shen, B. (2015). Symptomatology of irritable bowel syndrome and inflammatory bowel disease during the menstrual cycle. Gastroenterol. Rep. Gastroenterology Report, 3(3), 185-193. doi:10.1093/gastro/gov010

3.  Lim, S. M., Nam, C. M., Kim, Y. N., Lee, S. A., Kim, E. H., Hong, S. P., … Cheon, J. H. (2013). The Effect of the Menstrual Cycle on Inflammatory Bowel Disease: A Prospective Study. Gut and Liver Gut Liver, 7(1), 51-57. doi:10.5009/gnl.2013.7.1.51

4.  Stein, J., & Dignass, A. U. (2013). Management of iron deficiency anemia in inflammatory bowel disease – a practical approach. Retrieved July 26, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959949/

5.  Ballinger, A. B., Savage, A. M., & Sanderson, I. R. (2003). Delayed Puberty Associated with Inflammatory Bowel Disease. Pediatric Research, 53(2), 205-210. doi:10.1203/00006450-200302000-00002

6.  Feller, E. R., MD, Ribaudo, S., MD, & Jackson, N. D., MD. (2001, November 15). Gynecologic Aspects of Crohn’s Disease. Retrieved July 26, 2015, from http://www.aafp.org/afp/2001/1115/p1725.html#afp20011115p1725-b12

7. You & Your Hormones. (2013, October 24). Retrieved from http://www.yourhormones.info/hormones/prostaglandins.aspx

8. Tigas, S., & Tsatsoulis, A. (2012). Endocrine and metabolic manifestations in inflammatory bowel disease. Retrieved July 26, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959350/

9.  Mamula, P., Markowitz, J. E., & Baldassano, R. N. (2008). Pediatric inflammatory bowel disease. New York: Springer.Pages 141-143

10.  Weber AM, Ziegler C, Belinson JL, et al: Gynecologic history in women with inflammatory bowel disease. Obstet Gynecol 86:843-847, 1995.

11. Metcalf AM, Dozois RR, Kelly KA: Sexual function in women after proctocolectomy. Ann Surg 204:624-627, 1986.

12. Wikland M, Jansson I, Asztely M, et al: Gynaecological problems related to anatomical changes after conventional proctocolectomy and ileostomy. Int J Colorect Dis 5:49-52, 1990.

13. Menstruation abnormalities linked to IBD in pathogenesis.

14. Inflammatory Bowel Disease – A Complicating Factor in Gynecologic Disorders?

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