Updates on Women’s Health Issues in Patients with Inflammatory Bowel Disease

  • Nirupama Bonthala
  • Sunanda KaneEmail author
Inflammatory Bowel Disease (G Lichtenstein, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Inflammatory Bowel Disease


Purpose of review

Inflammatory bowel disease affects approximately 800,000 women in the USA with the peak incidence between ages 15 to 40. Thus for many females, IBD can impact nearly every stage of their life from menarche to pregnancy, menopause, and beyond. This paper will review the most recent updates on the topics of sexual health, cervical cancer screening, menstruation, fertility, contraception, and menopause.

Recent findings

Menarche can be delayed in females especially those who are underweight, malnourished, or with active inflammatory bowel disease. Cyclical GI symptoms during a menstrual cycle are very common in women with IBD and should not be confused with flares. Overall fertility is similar to the general population unless females with IBD have had significant abdominal surgery but reassuringly this infertility appears to be restored with the use of in vitro fertilization. Discussion regarding family planning is imperative in women with IBD with a strong recommendation to consider long-acting highly effective contraceptives such as intrauterine devices or implants. Cervical cancer screening should be tailored in women on immunosuppressive medications and all women under 26 years of age should be advised to receive the human papilloma virus vaccination.


As gastroenterologists will have longitudinal relationships with their female IBD patients, they must be knowledgeable about sex-specific issues during each stage of life from puberty to after menopause to optimize their patient’s care.


Ulcerative colitis Crohn’s disease Inflammatory bowel disease Fertility Contraception Puberty 


Compliance with ethical standards

Conflict of interest

Nirupama Bonthala declares no conflict of interest.

Sunanda Kane has received consulting fees (paid to her institution) from AbbVie, Janssen, and Spherix Health.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    • Shivashankar R, Tremaine WJ, Harmsen WS, Loftus EV Jr. Incidence and prevalence of Crohn’s disease and ulcerative colitis in Olmsted County, Minnesota from 1970 through 2010. Clin Gastroenterol Hepatol. 2017;15(6):857. This article provides the most up to date incidence and prevalence of UC and IBD.–63. Scholar
  2. 2.
    Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46–54. Scholar
  3. 3.
    Johnston RD, Logan RF. What is the peak age for onset of IBD? Inflamm Bowel Dis. 2008;14:S4–5. Scholar
  4. 4.
    Ballinger B, Savage MO, Sanderson IR. Delayed puberty associated with inflammatory bowel disease. Pediatr Res. 2003;53(2):205–10. Scholar
  5. 5.
    Ferguson A, Sedgwick DM. Juvenile onset in inflammatory bowel disease: height and body mass index in adult life. Br Med J. 1994;308(6939):1259–63. Scholar
  6. 6.
    Brain CE, Savage MO. Growth and puberty in chronic in inflammatory bowel disease. Baillie’re’s clinical Gastroenterology. 1994;8(1):83–100.CrossRefPubMedGoogle Scholar
  7. 7.
    Heuschkel R, Salvestrini C, Beattie RM, et al. Guidelines for the management of growth failure in childhood in inflammatory bowel disease. Inflamm Bowel Dis. 2008;14(6):839–49. Scholar
  8. 8.
    Moore J, Barlow D, Jewell D, Kennedy S. Do gastrointestinal symptoms vary with the menstrual cycle? Br J Obstet Gynaecol. 1998;105(12):1322–5. Scholar
  9. 9.
    • Bharadwaj S, Kulkarni G, Shen B. Menstrual cycle, sex hormones in female inflammatory bowel disease patients with and without surgery. J Dig Dis. 2015;16(5):245–55. This article discussed cyclical GI symptoms with menstrual cycle. Scholar
  10. 10.
    Kane SV, Sable K, Hanauer SB. The menstrual cycle and its effect on inflammatory bowel disease and irritable bowel syndrome: a prevalence study. Am J Gastroenterol. 1998;93(10):1867–72. Scholar
  11. 11.
    Parlak E, Dağli U, Alkim C, Dişibeyaz S, Tunç B, Ulker A, et al. Pattern of gastrointestinal and psychosomatic symptoms across the menstrual cycle in women with inflammatory bowel disease. Turk J Gastroenterol. 2003;14(4):250–6.Google Scholar
  12. 12.
    • Gawron LM, Goldberger A, Gawron AJ, Hammond C, Keefer L. The impact of hormonal contraception on disease-related cyclical symptoms in women with inflammatory bowel diseases. Inflamm Bowel Dis. 2014;20(10):1729–33. Improvement in cyclical IBD symptoms was reported in 19% of women using estrogen-based therapy and 47% of women using a levonorgestrel intrauterine device. Scholar
  13. 13.
    • Saha S, Zhao YQ, Shah SA, Esposti SD, Lidofsky S, Salih S, et al. Menstrual cycle changes in women with in inflammatory bowel disease: a study from the ocean state Crohn’s and colitis area registry. Inflamm Bowel Dis. 2014;20(3):534–40. Up to 25% of females experienced changes in their menstrual cycle the year prior to their diagnosis of IBD.
  14. 14.
    Lim SM, Nam CM, Kimetal YN. The effect of the menstrual cycle on inflammatory bowel disease: a prospective study. Gut and Liver. 2013;7(1):51–7. Scholar
  15. 15.
    Kappelman MD, Rifas-Shiman SL, Kleinman K, et al. The prevalence and geographic distribution of Crohn’s disease and ulcerative colitis in the United States. Clin Gastroenterol Hepatol. 2007;5(12):1424–9. Scholar
  16. 16.
    Mountifield R, Bampton P, Prosser R, Muller K, Andrews JM. Fear and fertility in inflammatory bowel disease: a mismatch of perception and reality affects family planning decisions. Inflamm Bowel Dis. 2009;15(5):720–5. Scholar
  17. 17.
    Sellinger CP, Eaden J, Selby W, et al. Inflammatory bowel disease and pregnancy: lack of knowledge is associated with negative views. J Crohns Colitis. 2013;7(6):206–13.CrossRefGoogle Scholar
  18. 18.
    Marri SR, Ahn C, Buchman AL. Voluntary childlessness is increased in women with inflammatory bowel disease. Inflamm Bowel Dis. 2007;13(5):591–9. Scholar
  19. 19.
    Mahadevan U. Fertility and pregnancy in the patient with inflammatory bowel disease. Gut. 2006;55(8):1198–206. Scholar
  20. 20.
    Tavernier N, Fumery M, Peyrin-Biroulet L, Colombel JF, Gower-Rousseau C. Systematic review: fertility in non-surgically treated inflammatory bowel disease. Aliment Pharmacol Ther. 2013;38(8):847–53. Scholar
  21. 21.
    Willoughby CP, Truelove SC. Ulcerative colitis and pregnancy. Gut. 1980;21(6):469–74. Scholar
  22. 22.
    Hudson M, Flett G, Sinclair TS, Brunt PW, Templeton A, Mowat NAG. Fertility and pregnancy in inflammatory bowel disease. Int J Gynaecol Obstet. 1997;58(2):229–37. Scholar
  23. 23.
    Fréour T, Miossec C, Bach-Ngohou K, Dejoie T, Flamant M, Maillard O, et al. Ovarian reserve in young women of reproductive age with Crohn's disease. Inflamm Bowel Dis. 2012;18(8):1515–22.
  24. 24.
    Cornish JA, Tan E, Teare J, Teoh TG, Rai R, Darzi AW, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. Dis Colon rectum. 2007;50(8):1128–38.
  25. 25.
    Bharadwaj S, Philpott JR, Barber MD, Graff l, Shen B. Women’s health issues after ileal pouch surgery. Inflamm Bowel Dis. 2014;20(12):2470–82. Scholar
  26. 26.
    • Pabby V, Oza SS, Dodge LE, Hacker MR, Moragianni VA, Correia K, et al. In vitro fertilization is successful in women with ulcerative colitis and ileal pouch anal anastamosis. Am J Gastroenterol. 2015;110(6):792–7. This study demonstrated that live birth rates after IVF in women with IPAAs were comparable to women with UC without IPAA and women without UC.
  27. 27.
    Heetun ZS, Byrnes C, Neary P, et al. Review article: reproduction in the patient with inflammatory bowel disease. Aliment Pharmacol Ther. 2007;26(4):513–33. Scholar
  28. 28.
    Zelissen PM, van Hattum J, Poen H, et al. Influence of salazosulphapyridine and 5-aminosalicylic acid on seminal qualities and male sex hormones. Scand J Gastroenterol. 1988;23(9):1100–4. Scholar
  29. 29.
    O'Moráin C, Smethurst P, Doré CJ, et al. Reversible male infertility due to sulphasalazine: studies in man and rat. Gut. 1984;25(10):1078–84. Scholar
  30. 30.
    Levi AJ, Fisher AM, Hughes L, Hendry WF. Male infertility due to sulphasalazine. Lancet. 1979;2(8137):276–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Grosen A, Kelsen J, Hvas CL, Bellaguarda E, Hanauer SB. The influence of methotrexate treatment on male fertility and pregnancy outcome after paternal exposure. Inflamm Bowel Dis. 2017;23(4):561–9. Scholar
  32. 32.
    Mahadevan U. Gastrointestinal medications in pregnancy. Best Pract Res Clin Gastroenterol. 2007;21(5):849–77. Scholar
  33. 33.
    Francella A, Dyan A, Bodian C, Rubin P, Chapman M, Present DH. The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study. Gastroenterology. 2003;124(1):9–17. Scholar
  34. 34.
    • Gawron LM, Gawron AJ, Kasper A, Hammond C, Keefer L. Contraceptive method selection by women with inflammatory bowel diseases: a cross-sectional survey. Contraception. 2014;89(5):419–25. This survey study revealed that 23% of women with IBD who were at risk for pregnancy did not use any form of contraception and that only 17% used highly effective methods such as an intrauterine device. Scholar
  35. 35.
    •• Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016;65:1. Long term reversible contraception and progestin only contraceptives are the preferred method of contraception in women with IBDGoogle Scholar
  36. 36.
    Zapata LB, Paulen ME, Cansino C, Marchbanks PA, Curtis KM. Contraceptive use among women with inflammatory bowel disease: a systematic review. Contraception. 2010;82(1):72–85. Scholar
  37. 37.
    • Gawron LM, Goldberger A, Gawron AJ, Hammond C, Keefer L. The impact of hormonal contraception on disease-related cyclical symptoms in women with inflammatory bowel diseases. Inflamm Bowel Dis. 2014;20(10):1729–33. Nearly 20% of women with IBD reported improved GI symptoms related to menses while on OCPs. Scholar
  38. 38.
    Peragallo Urrutia R, Coeytaux RR, McBroom AJ, Gierisch JM, Havrilesky LJ, Moorman PG, et al. Risk of acute thromboembolic events with oral contraceptive use: a systematic review and meta-analysis. Obstet Gynecol. 2013;122(2 Pt 1):380–9.
  39. 39.
    Yuhara H, Steinmaus C, Corley D, Koike J, Igarashi M, Suzuki T, et al. Meta-analysis: the risk of venous thromboembolism in patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2013;37(10):953–62.
  40. 40.
    Nguyen GC, Sam J. Rising prevalence of venous thromboembolism and its impact on mortality among hospitalized inflammatory bowel disease patients. Am J Gastroenterol. 2008;103(9):2272–80. Scholar
  41. 41.
    • Cotton CC, Baird D, Sandler RS, Long MD. Hormonal contraception use is common among patients with inflammatory bowel diseases and elevated risk for deep vein thrombosis. Inflamm Bowel Dis. 2016;22(7):1631–8. Nearly one third of women surveyed were on hormonal contraception even despite elevated risk of deep vein thrombosis. Scholar
  42. 42.
    Timmer A, Sutherland LR, Martin F. The Canadian Mesalamine for remission of Crohn’s disease study group. Oral contraceptive use and smoking are risk factors for relapse in Crohn’s disease. Gastroenterology. 1998;114(6):1143–50. Scholar
  43. 43.
    Cosnes J, Carbonnel F, Carrat F, Beaugerie L, Gendre JP. Oral contraceptive use and the clinical course of Crohn’s disease: a prospective cohort study. Gut. 1999;45(2):218–22. Scholar
  44. 44.
    Sutherland LR, Ramcharan S, Bryant H, Fick G. Effect of oral contraceptive use on reoperation following surgery for Crohn’s disease. Dig Dis Sci. 1992;37(9):1377–82. Scholar
  45. 45.
    Bitton A, Peppercorn MA, Antonioli DA, Niles JL, Shah S, Bousvaros A, et al. Clinical, biological, and histologic parameters as predictors of relapse in ulcerative colitis. Gastroenterology. 2001;120(1):13–20.
  46. 46.
    Cornish JA, Tan E, Simillis C, Clark SK, Teare J, Tekkis PP. The risk of oral contraceptives in the etiology of inflammatory bowel disease: a meta-analysis. Am J Gastroenterol. 2008;103(9):2394–400. Scholar
  47. 47.
    • Ortizo R, Lee SY, Nguyen, et al. Exposure to oral contraceptives increases the risk for development of inflammatory bowel disease: a meta-analysis of case-controlled and cohort studies. Eur J Gastroenterol Hepatol. 2017;29(9):1064–70. This meta-analysis of 20 studies showed an increased risk of 30% for the development of UC and an increased risk of 24% for the development of CD in those who were exposed to OCPs. Scholar
  48. 48.
    Curtis KM, Martins SL. Progestogen-only contraception and bone mineral density: a systematic review. Contraception. 2006;73(5):470–87. Scholar
  49. 49.
    Ali T, Lam D, Bronze MS, Humphrey MB. Osteoporosis in inflammatory bowel disease. Am J Med. 2009;122(7):599–604. Scholar
  50. 50.
    Wakeman J. Exacerbation of Crohn’s disease after insertion of a levonorgestrel intrauterine system: a case report. J Fam Plann Reprod Health Care. 2003;29(3):154. Scholar
  51. 51.
    Cox M, Tripp J, Blacksell S. Clinical performance of the levonorgestrel intrauterine system in routine use by the UK family planning and reproductive health research network: 5-year report. J Fam Plann Reprod Health Care. 2002;28(2):73–7. Scholar
  52. 52.
    • Takahashi TA, Johnson KM. Menopause. Med Clin North Am. 2015;99(3):521534. This study reviewed demographics of menopause in women with IBD.CrossRefGoogle Scholar
  53. 53.
    Lichtarowicz A, Norman C, Calcraft B, Morris JS, Rhodes J, Mayberry J. A study of the menopause, smoking, and contraception in women with Crohn's disease. Q J Med. 1989;72(267):623–31.PubMedGoogle Scholar
  54. 54.
    Kane SV, Reddy D. Hormonal replacement therapy after menopause is protective of disease activity in women with inflammatory bowel disease. Am J Gastroenterol. 2008;103(5):1193–6. Scholar
  55. 55.
    Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the women’s health initiative randomized controlled trial. J Am Med Assoc. 2002;288(3):321–33.Google Scholar
  56. 56.
    Khalili H, Higuchi LM, Ananthakrishnan AN, et al. Hormone therapy increases risk of ulcerative colitis but not Crohn’s disease. Gastroenterology. 2012;43(5):1199–206.CrossRefGoogle Scholar
  57. 57.
    Timmer A, Bauer A, Dignass A, Rogler G. Sexual function in persons with inflammatory bowel disease: a survey with matched controls. Clin Gastroenterol Hepatol. 2007;5(1):87–94. Scholar
  58. 58.
    Metcalf A, Dozois R, Kelly A. Sexual function in women after proctocolectomy. Ann Surg. 1986;204(6):624–7. Scholar
  59. 59.
    Weerakoon P. Sexuality and the patient with a stoma. Sex Disabil. 2001;19(2):121–9. Scholar
  60. 60.
    Muller KR, Prosser R, Bampton P, Mountifield R, Andrews JM. Female gender and surgery impair relationships, body image, and sexuality in inflammatory bowel disease: patient perceptions. Inflamm Bowel Dis. 2010;16(4):657–63. Scholar
  61. 61.
    Borum ML, Igiehon E, Shafa S. Physicians may inadequately address sexuality in women with inflammatory bowel disease. Inflamm Bowel Dis. 2010;16(2):181. Scholar
  62. 62.
    Massad LS, Riester KA, Anastos KM, Fruchter RG, Palefsky JM, Burk RD, et al. Prevalence and predictors of squamous cell abnormalities in Papanicolaou smears from women infected with HIV-1. Women’s interagency HIV study group. J Acquir Immune Defic Syndr. 1999;21(1):33–41.
  63. 63.
    •• American College of Obstetricians and Gynecologists. ACOG guidelines for womens health care. Washington, DC: The College; 2014. Updated from 2010, this document provides guidance on a wide variety of womens health issues.Google Scholar
  64. 64.
    Nguyen ML, Flowers L. Cervical cancer screening in immunocompromised women. Obstet Gynecol Clin N Am. 2013 Jun;40(2):339–57. Scholar
  65. 65.
    Bhatia J, Bratcher J, Korelitz B, Vakher K, Mannor S, Shevchuk M, et al. Abnormalities of uterine cervix in women with inflammatory bowel disease. World J Gastroenterol. 2006;12(38):6167–71.
  66. 66.
    Kane S, Khatibi B, Reddy D. Higher incidence of abnormal pap smears in women with inflammatory bowel disease. Am J Gastroenterol. 2008;103(3):631–6. Scholar
  67. 67.
    De Sanjose S, Quint G, Alemany L, et al. Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol. 2010;11(11):1048–56. Scholar
  68. 68.
    Lees CW, Critchley J, Chee N, Beez T, Gailer RE, Williams AR, et al. Lack of association between cervical dysplasia and IBD: a large case-control study. Inflamm Bowel Dis. 2009;15(11):1621–9.
  69. 69.
    Singh H, Demers AA, Nugent Z, Mahmud SM, Kliewer EV, Bernstein CN. Risk of cervical abnormalities in women with inflammatory bowel disease: a population-based nested case-control study. Gastroenterology. 2009;136(2):451–8. Scholar
  70. 70.
    • Rungoe C, Simonsen J, Riis L, Frisch M, Langholz E, Jess T. Inflammatory bowel disease and cervical neoplasia: a population-based nationwide cohort study. Clin Gastroenterol Hepatol. 2015;13(4):693–700.e691. This is a population-based cohort of nearly 30,000 women with IBD which reported increased risk for cervical dysplasia in women with IBD and increased risk of cervical cancer in those with CD. Scholar
  71. 71.
    • Pandey N, Herrera HH, Johnson CM, MacCarthy AA, Copeland l. Preventative Care for Patients with inflammatory bowel disease in the veterans health administration. Medicine. 2016;95(27):e4012. Retrospective study performed at the Veteran’s Health Administration showed that among women under 65 years of age with IBD, 15% had abnormal Pap smears compared to 5% among normal patient population. Scholar
  72. 72.
    • Bulletins—Gynecology CoP. ACOG practice bulletin number 157: cervical cancer screening and prevention. Obstet Gynecol. 2016;128(4):111–30. This practice bulletin provides the most recent guidance on cervical cancer screening.CrossRefGoogle Scholar
  73. 73.
    Moscandrew M, Mahadevan U, Kane S. General health maintenance in IBD. Inflamm Bowel Dis. 2009;15(9):1399–409. Scholar
  74. 74.
    •• Farraye F, Melmed G, Lichtenstein R, et al. ACG clinical guideline: preventitive care in inflammatory bowel disease. Am J Gastroenterol. 2017;112(2):241–58. This ACG clinical guidelines for preventitive care recommends yearly Pap smears in women who are on immunosupressive treatments. Scholar
  75. 75.
    • Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the advisory committee on immunization practices (ACIP). Morb Mortal Wkly Rep. 2014;63:1–30. This guideline recommends HPV vaccination for females aged 9 to 26.Google Scholar
  76. 76.
    Wasan SK, Coukos JA, Farraye FA. Vaccinating the inflammatory bowel disease patient: deficiencies in gastroenterologists knowledge. Inflamm Bowel Dis. 2011;17(12):2536–40. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Inflammatory Bowel Disease CenterCedars Sinai Medical CenterLos AngelesUSA
  2. 2.Department of Gastroenterology and HepatologyMayo Clinic College of MedicineRochesterUSA

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