Introduction: Women and IBS

For all women out there who think urinary frequency is a big annoyance, can you imagine having to use the toilet three to five times per day with runny diarrhea? Or possibly worse, not being able to have a bowel movement except every two or three days with sharp cramping, bloating, and flatulence.

Women with bowel troubles are commonplace and their symptoms are debilitating. I know: I’ve seen it over and over in my private obstetrics and gynecology practice. OB/GYN’s are often the only physicians a young woman sees if she is otherwise healthy.

In the United States, women with symptoms of irritable bowel syndrome (IBS) are more likely to visit a doctor with their concerns compared to men. In other countries, like India, men are just as likely to seek treatment for IBS.1 Based on my experience as a physician in the United States, males wait until symptoms are severe either due to fear of doctors or their culturally ‘stoic’ upbringing.

IBS affects 10-20% of the population and is considered a functional gastrointestinal disorder (GI) with symptoms of abdominal pain and excessive or infrequent bowel habits. 2 IBS is differentiated from IBD or inflammatory bowel disease (like Crohn’s and ulcerative colitis) in that there is no underlying inflammation or physical defects such as ulcers or scarring.

IBS in females can be more severe

IBS and its symptoms may be more severe in females, especially during pregnancy. One of my patients came to me when she was pregnant, explaining that her bowel movements had become even less frequent and that they hurt terribly because the stool was hard. Marissa3 was only into her tenth week of pregnancy and said that she had used laxatives and an enema to relieve herself.

Upon questioning, I learned that she was diagnosed with IBS by her family physician. IBS in pregnancy can present with unique challenges since constipation often worsens in pregnancy for a variety of reasons, including iron intake, poor hydration due to increased physical demands, and elevated progesterone levels.

Signs and symptoms of IBS in women ‐ and men

  1. Altered bowel habits such as constipation with hard stools of narrow caliber, pain with bowel movements, infrequent bowel movements and poor response to laxatives. Diarrhea with frequent and small amount of loose stools with urgency and urgency after meals are additional findings.
  2. Abdominal pain which can be diffuse and left lower abdomen in location, pain can be sharp or dull. Meals initiate the pain and defecation relieves the pain.
  3. Abdominal bloating and distension.4

Additional symptoms consistent with irritable bowel syndrome in females

  • Clear or white mucus with bowel movements.
  • Vaginal secretions may mimic mucus from stool.
  • Indigestion or heartburn worse in pregnancy.
  • Nausea and/or vomiting worse in the first trimester of pregnancy.
  • Sexual dysfunction (including pain with sex or poor libido).
  • Urinary frequency and urgency is more common in women.
  • Worsening of symptoms in the peri-menstrual period.
  • Fibromyalgia or diffuse muscle pain.
  • Stress-related symptoms and premenstrual syndrome aggravates.

IBS and how to diagnose and treat it

IBS in women can be aggravated or triggered by hormones, which explains its onset in adolescence in many cases. The occurrence of menarche5 is a result of the pituitary gland and the hypothalamus in the brain triggering the ovaries to produce the hormones estrogen and progesterone.

Both hormones are necessary for egg release and menstruation (in the case of lack of fertilization). It has been well established that both hormones impact gut motility,6 primarily in that progesterone causes slower gut transit time.7

Progesterone levels peak at the time of egg release (ovulation), which is when constipation is more likely. Conversely, when both progesterone and estrogen levels drop prior to the onset of menses, crampy diarrhea may result, which is aggravated by the prostaglandin release during menstruation. Often, the cramps of menstruation (from prostaglandin release) can mimic the cramps before bowel movements or trigger the loose bowel movements themselves.

However, in a study conducted on rats, it was found that low levels of Progesterone (P) increased GI motility, while high doses of P decreased it. After injection with oxytocin (OT), the rats demonstrated gastrointestinal inhibition. This mimics the later stages of pregnancy. Progesterone levels continue to increase in pregnancy until the third trimester and that can explain the common constipation findings in pregnant women independent of hydration and iron intake. Oxytocin is the hormone that initiates the labor process.8

One study found an increased rate of miscarriage and ectopic pregnancy9 in women with IBS but no increased risk of stillbirth or pre-eclampsia.10 The exact mechanism is unknown.11

More evidence that hormones affect IBS symptoms in women

According to Everson,12 the gallbladder and GI tract are organs quite responsive to hormones and this is the reason women are more prone to IBS in pregnancy and throughout their reproductive years. The gallbladder enlarges and empties more slowly in response to meals during pregnancy. The small bowel moves slower and the esophagus’ muscle tone is reduced, leading to heartburn.

All these effects are reversed after the baby is born. The return of normal motility in the postpartum period proves that IBS in women is hormonally triggered. One possible mechanism for the effects of pregnancy on motility may be the progesterone-induced change in calcium levels on the smooth muscle cells. Smooth muscle cells need calcium for GI motility.13

Diagnosis of IBS is Based on Symptoms

The diagnosis of IBS is made on the basis of clinical grounds14 such as the woman’s description of her bowel movements, their frequency, consistency, and appearance. The Rome IV Criteria15 are most commonly used. Abdominal pain that occurs at least once per week for approximately three months that is also associated with two or more of the following: changes in stool appearance, frequency, or increased pain.

The Bristol Stool Scale16 is often used to characterize stool types:

Type 1
Consists of separate hard lumps that are hard to pass
Type 2
Consists of lumpy sausage -shaped stool
Type 3
Consists of sausage-like with cracks on the surface
Type 4
Consists of sausage-shape but smooth and soft
Type 5
Consists of soft, rounded masses with distinct edges
Type 6
Consists of mushy or fluffy with shredded edges
Type 7
Consists of watery with no distinct masses

Categories of IBS

Ultimately, there are four classification categories for IBS based on the Rome IV Criteria:

IBS-C
Where constipation is the primary symptom.
IBS-D
With diarrhea predominance.
IBS-M
With both symptoms of diarrhea and constipation.
IBS-U
For those that are not in any of the above categories.

Mucus production and abdominal bloating are additional features of IBS, but not diagnostic of any particular sub-type. Women in one category can change their subtype.

A comprehensive history and physical examination are the most useful tools to make the diagnosis as long as other concerning findings are absent and there is no family history of inflammatory bowel disease.

The following high-risk features should alert a healthcare practitioner to perform additional testing: weight loss, anemia, family history of colon cancer or inflammatory bowel disease.17

Screening studies to rule out other disorders include: blood work to look for anemia, infection, and inflammation. Stool samples for evidence or bacteria that cause diarrhea and dehydration status are additional tests. Elevated white blood cell count for infection, low hemoglobin for anemia, erythrocyte sedimentation rate (ESR)18 and C-reactive protein (CRP)19 are markers of inflammation. More advanced tests such as biopsies and breath testing to look for gluten sensitivity and bacterial overgrowth can be performed in high-risk individuals.

Conclusion on women and IBS symptoms

Women have unique challenges to manage their IBS successfully. Symptoms of IBS in women vary wildly and underlying hormonal disturbances play a key role. There are multiple triggers that increase a woman’s susceptibility to flares of IBS. Managing hormone fluctuations with oral contraceptive pills and avoiding stress are two possible tools to diminish the symptoms of IBS.

According to Gastroenterologist Dr. David Kahana, food choice, stress, and antibiotics are to blame for the gut microbiome disturbances that plague IBS sufferers. The GI microbiome, which can be considered an organ, has a relationship with other organs such as the brain.20

Fascinating developments in how we treat disorders caused by brain dysfunction with microbiome manipulation are underway.21 Research into changing the gut microbiome with probiotics and prebiotics have preliminarily yielded favorable results with improved mood, normal bowel movements, and less pain.

  1. Ghoshal UC, Abraham P, Bhatt C, et al. Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force. Indian J Gastroenterol. 2008;27:22–28. [PubMed]
  2. Bercik P, Verdu EF, Collins SM. Is irritable bowel syndrome a low-grade inflammatory bowel disease?. Gastroenterol Clin North Am. 2005 Jun. 34 (2):235-45, vi-vii. [Medline]
  3. Not her real name
  4. Also commonly spelled as distention. This is the kind of bloating that occurs due to a buildup of gas or fluid.
  5. The first menstrual period
  6. The movements – stretching, contracting – of the muscles in the GI tract.
  7. Everson GT, “Gastrointestinal Motility in Pregnancy”, Gastroenterol Clin North Am. 1992 Dec;21(4):751-76.
  8. Liu, Chuan-Yong, Chen, Lian-Bi, Liu, Pei-Yi, Xie, Dong-Ping, and Wang, Paulus S., “Effects of Progesterone on gastric emptying and intestinal transit in male rats”, World J Gastroenterol. 2002 Apr 15; 8(2): 338-341.
  9. Where the fertilized egg gets stuck somewhere along the way to the uterus, often in one of the fallopian tubes.
  10. A pregnancy complication marked by high blood pressure.
  11. Khashan AS; Quigley EM; McNamee R; McCarthy FP; Shanahan F; Kenny LC, “Increased risk of miscarriage and ectopic pregnancy among women with irritable bowel syndrome”, Clin Gastroenterol Hepatol 2012; 10(8):902-9.
  12. Everson GT, “Gastrointestinal Motility in Pregnancy”, Gastroenterol Clin North Am. 1992 Dec;21(4):751-76.
  13. Everson GT, “Gastrointestinal Motility in Pregnancy”, Gastroenterol Clin North Am. 1992 Dec;21(4):751-76.
  14. That is, where no lab tests are needed unless there is a suspicion of more serious conditions, acute onset like an infectious cause, family history of cancer of the colon or IBD.
  15. Schmulson MJ, Drossman DA. What is new in Rome IV. J Neurogastroenterol Motil. 2017 Apr 30. 23 (2):151-63. [Medline]. More at the Rome Foundation.
  16. Heaton, K W & Lewis, S J 1997, ‘Stool form scale as a useful guide to intestinal transit time’. Scandinavian Journal of Gastroenterology, vol.32, no.9, pp.920 – 924.
  17. Brandt LJ, Chey WD, Foxx-Orenstein AE, et al, for the American College of Gastroenterology Task Force on Irritable Bowel Syndrome. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. 2009 Jan. 104 suppl 1:S1-35. [Medline].
  18. “The rate at which red blood cells sediment in a period of one hour.” – From Wikipedia, Erythrocyte sedimentation rate
  19. A protein found in blood plasma
  20. Major G, Spiller R,”Irritable bowel syndrome, inflammatory bowel disease and the microbiome” Clin Opin Endocrinol Diabetes Obes. 2014 Feb;21(1):15-21.
  21. See our discussion on the gut microbiome.