Crohn's in Women

Because Crohn's disease has a tendency to form fistulas, it may involve other organs near the site of the inflammation. Gynecologic involvement is frequent, diverse and often difficult to diagnose. Inflammation involving adjacent structures has been reported in as many as one third of patients. Fistulas to the vagina, uterus, ovaries, perineum and vulva also have been reported. Diagnosis may not be obvious if pelvic involvement precedes active bowel disease, or if drainage is clear or mucoid. Abscesses, edema and ulceration of the perineum or vulva are common, and are caused by direct extension from the involved bowel or by granulomas separated from the bowel by normal tissue. Lesions presenting with vulvar hypertrophy, a fluctuant mass or ulceration are easily misdiagnosed. Menstrual abnormalities are reported in more than one half of patients. Pelvic manifestations of Crohn's disease can be psychologically crippling. Patients or physicians may be hesitant to address serious psychosocial morbidity. To optimize management, physicians must be aware of the diverse manifestations, confusing presentations and psychologic morbidity of Crohn's disease. (Am Fam Physician 2001;64:1725-8.)

Enteric Fistulas

Transmural inflammation penetrating directly into adjacent organs is common in Crohn's disease, and internal fistulas have been reported in as many as one third of patients. In pelvic structures, enterovesical fistulas are less common in women than in men because of the anatomic position of the uterus and adnexa between the bowel and the bladder in women. These fistulas are associated with dysuria, pneumaturia, suprapubic pain and increased urinary frequency. In women, transmural extension of inflammation from the rectosigmoid colon to the vagina is more common. If the diagnosis is unclear, polymicrobial infections or symptoms refractory to treatment may be clues to a fistula. A perirectal fistula may rupture directly into the vagina.

In a patient with longstanding active bowel inflammation and severe perianal disease who develops a fecal vaginal discharge or passage of gas vaginally, the diagnosis is apparent. However, an enterovaginal fistula may be the presenting feature of Crohn's disease and can be misdiagnosed as being the result of diverticulitis or bowel cancer. Ileal-vaginal fistulas or small fistulas with a clear discharge may not be assessed correctly or may be treated inappropriately as a primary vaginal infection. Diagnosis may be difficult. Usually, a careful examination while the patient is under anesthesia, including vaginoscopy and rectal insufflation while the vagina is filled with saline, will allow the physician to identify the fistula tract. In some cases, a water-soluble rectal Gastrografin enema will demonstrate the underlying pathology. When suspected, communication may sometimes be confirmed by instilling methylene blue stain rectally and documenting dye impregnation on a previously placed vaginal tampon. A fistulogram using contrast dye or methylene blue instilled via a perineal sinus or vaginal opening may be diagnostically helpful.

Transmural intestinal inflammation from the ileum, the proximal colon or the rectum may involve any part of the female reproductive tract. Fistulas have been reported to the uterus, adnexa, vulva and perineum, as well as to the skin, umbilicus and submammary region. Patients with known inflammatory bowel disease should be questioned routinely about skin lesions, especially in the pelvis. Careful physical examination may reveal unsuspected or unmentioned cutaneous erythema, induration, ulceration or drainage.

In August 1998, an antitumor necrosis factor alpha chimeric monoclonal antibody (infliximab; Remicade), the first cytokine-targeted therapy, was approved by the U.S. Food and Drug Administration for use in patients with severe Crohn's disease. Results in patients with previously refractory enterocutaneous fistulas have reportedly been promising. This agent may prove to be useful in the treatment of gynecologic fistulas in Crohn's disease.

Vulvar and Perineal Disease

Abscesses, draining sinuses, edema and vulvar or perineal ulceration are common in patients with Crohn's disease. Physicians must be aware that such involvement may precede bowel symptoms, and these conditions can be misdiagnosed. In patients with known Crohn's disease, any perineal disorder should be considered to be associated with the underlying inflammatory bowel disease. Evidence suggests that in patients with Crohn's disease, vaginal delivery with episiotomy may be associated with a high rate of subsequent perineal disease. Crohn's disease should be suspected in patients whenever severe perineal disease or a rectovaginal fistula develops after vaginal delivery. In patients presenting with ulcerative vaginal lesions, a diagnosis of Crohn's disease must be considered. Excellent results treating perianal and perineal Crohn's disease have been achieved with metronidazole (Flagyl) therapy and increased use of an immunomodulating therapy, including the use of mercaptopurine (Purinethol), azathioprine (Imuran) and antitumor necrosis factor (Anti-TNF)

Vulvar involvement may be caused by direct extension from the involved bowel. Rarely, vulvar granulomatous lesions caused by Crohn's disease that have no connection to the gastrointestinal tract, and ulcerations occurring secondary to pyoderma gangrenosum (a cutaneous complication of Crohn's disease) have been reported. Vulvar squamous cell carcinoma has also been known to arise in such lesions. These lesions may present as unilateral vulvar hypertrophy, a fluctuant vulvar mass, erythema, or draining fistulas, nodules or pustules with necrotic tissue centrally. Biopsy may be crucial to a correct diagnosis. These disorders may be confused with abscess of a Bartholin's cyst, tuberculosis, actinomycosis, lymphogranuloma venereum or metastases, or may mimic genital herpes infection. Physicians must be alert to the complications of vulvar involvement; attempts to incise and drain these fistulas or skin lesions have been associated with a high risk of tissue breakdown, recurrence, delay in appropriate treatment and advancement of further disease.

Menstrual Abnormalities

In one study, menstrual abnormalities (including amenorrhea, irregular menses, dysmenorrhea and menorrhagia) were reported in 58 percent of 360 women with Crohn's disease. Multiple contributing factors are likely, including the influence of chronic disease, poor nutrition and medications. Physicians should be aware that nonsteroidal anti-inflammatory drugs have, in some cases, exacerbated underlying inflammatory bowel disease. These medications are commonly used to treat dysmenorrhea but should be used with caution in patients with Crohn's disease or ulcerative colitis. In some patients, differentiation of pain caused by Crohn's disease and dysmenorrhea may be impossible.

Granulomatous Salpingitis and Oophoritis

In rare instances, Crohn's disease is a cause of granulomatous lesions involving the fallopian tubes or the ovaries, usually by direct extension of the inflammatory process from the bowel. These lesions commonly present with unilateral pelvic pain or a pelvic mass, and may masquerade as pelvic inflammatory disease, endometriosis, active intestinal inflammation, appendicitis, diverticulitis or primary ovarian pathology. The diagnosis of Crohn's disease should be considered when a patient presents with an adnexal mass. Computed tomographic scanning with oral contrast medium will demonstrate a thickened abnormal ileum, and barium contrast studies will document primary bowel pathology. Extensive adnexal disease may also impair fertility.

Psychosocial Manifestations

Pelvic manifestations of Crohn's disease may have a negative psychologic impact, such as damaged self-image, impaired sexuality and increased social dysfunction. It is important to discuss sexuality issues with these patients. Perineal pain with intercourse is common in women with a perineal fistula or abscess. Some patients complain of severe rectal pressure during intercourse or are sexually inhibited because they fear rectal incontinence.

Psychosocial functioning may be impaired by poor body image, embarrassment associated with ileostomy and the debilitating effects of chronic disease. Malnutrition, side effects from medication and frequent problems with pain and diarrhea contribute to psychosocial dysfunction. Post-proctocolectomy, the anatomic position of the vagina is commonly reoriented posteriorly, which can create a predisposition to increased pooling of vaginal secretions and heavy vaginal discharge. Fecal incontinence may be caused by the following: voluminous diarrhea, the destructive effect of inflammatory bowel disease on rectal sphincter competency, active rectal or perineal Crohn's disease, and side effects of previous surgery. However, some women report enhanced social functioning after surgery, most likely because of improved health and sense of well-being.

Health care professionals who treat women with Crohn's disease should be aware of the diverse spectrum of gynecologic disease in these patients and the inherent difficulties of accurate evaluation. It is vital that physicians remember the comforting power and practical importance of the physician/patient relationship. Even patients who are accustomed to discussing their bowel habits may never address the serious psychosocial disabilities of this chronic illness. Understanding the complex relationship between this disease and the effects it has on the patient's psyche, sexuality and socialization helps to validate the patient's complaints. Contemporary advances in medical and surgical therapy have decreased morbidity and improved prognosis in patients with Crohn's disease.

Some commonly asked questions:

Crohn’s disease and ulcerative colitis are primarily diseases of young people, and women are as likely to be affected as men. If you are a woman with IBD, it is important to understand how the events in a woman’s life—menses, pregnancy, and menopause— can affect the course of your disease, and how your disease, in turn, can affect these milestones.The questions in this brochure are those asked most frequently by patients and their physicians. The answers are based upon available data from studies in women with IBD.

WHY ARE MY PERIODS IRREGULAR WITH THIS DISEASE?

Many factors contribute to regular menstrual periods, including hormone levels, adequate nutrition, and amount of stress.When a woman has active disease, the inflammation itself can cause the body to shut down normal hormone function. Restoring health is the mechanism to restore regular periods.

MY DISEASE ALWAYS SEEMS TO BE WORSE THE WEEK BEFORE OR THE WEEK OF MY PERIOD. IS THIS COMMON?

Yes, this pattern is common for many diseases, actually. It is important to appreciate the fluctuation in symptoms that may be associated with menses, so that you are not over-treating your disease when symptoms may wax and wane based on your cycle.

IS THE PILL SAFE TO USE IF I HAVE IBD?

There is no evidence to suggest that the pill causes either ulcerative colitis or Crohn’s disease. It is regarded as safe in ulcerative colitis.There are some studies that suggest that being on the pill can make Crohn’s worse, but most of the women in these studies were also smokers, a habit we know makes Crohn’s disease worse.

IS IT SAFE TO HAVE A COLONOSCOPY DURING MY PERIOD?

Yes.There are no increased risks to the procedure associated with menstrual flow.

IS IT COMMON TO HAVE PAIN DURING INTERCOURSE IF I HAVE CROHN’S DISEASE OR ULCERATIVE COLITIS?

There is no reason that ulcerative colitis should cause dysparuneia (the medical term for painful sexual intercourse). For women with Crohn’s disease, dysparuneia may signal active disease in the perianal region or a fistula in the vagina. Although this may be embarrassing to talk about, you should discuss this symptom with your gastroenterologist and/or gynecologist.

ARE MY CHANCES OF HAVING IRON DEFICIENCY HIGHER WITH IBD?

Yes, the chances are higher for you than for women of the same age who do not have IBD. Not only is there the normal loss of iron from menstrual flow, but also the increased chance of bleeding, and the decreased absorption of iron from inflamed small intestine make the chances higher.

CAN WOMEN WITH CROHN’S DISEASE OR ULCERATIVE COLITIS CONCEIVE AS EASILY AS OTHER WOMEN?

Generally, yes. Studies have shown that women with ulcerative colitis have the same rate of fertility as women without IBD. Studies of the fertility rates of women with Crohn’s disease are conflicting. One large study showed no difference in fertility rates, but older studies and a more recent one show a slightly decreased rate of conception in women. This is true for active Crohn’s disease, not quiescent disease, where the rate looks to be the same as in the normal population. If the male partner is taking sulfasalazine (Azulfidine®), temporary male infertility may occur because this drug decreases sperm production, a reversible side effect. Before attempting conception, the male partner should stop the sulfasalazine and/or change to a 5- ASA compound, such as Asacol,® Canasa,® Colazal,® Dipentum,® Pentasa,® or Rowasa,® which has not been shown to interfere with sperm production.

WILL PREGNANCY HARM A WOMAN WITH CROHN’S DISEASE OR ULCERATIVE COLITIS?

Any woman contemplating pregnancy should consider the state of her health before conceiving. It is a good idea for a woman to have her disease in remission before pregnancy.According to recent studies, women with either illness should do well during the pregnancy if disease was inactive at the time of conception. If a pregnancy occurs during a period of active disease, however, either disease is likely to remain active or to worsen.This worsening generally occurs during the first trimester (three months) in ulcerative colitis, and during the first trimester or the few months immediately after delivery in Crohn’s disease.There is also a subset of women whose disease will actually get better. One study has suggested a relationship between the amount of shared genetic information between mother and child; the more alike they are, the worse the disease will be.

CAN CROHN’S DISEASE OR ULCERATIVE COLITIS AFFECT THE PREGNANCY AND DELIVERY, OR CAUSE HARM TO THE NEWBORN?

Most pregnant women with these illnesses have normal deliveries and healthy babies in roughly the same proportions as healthy women in the general population. If there is a problem affecting the pregnancy, it generally occurs in women with active Crohn’s disease.These women run a greater risk of premature delivery, stillbirth, or spontaneous abortion. If the symptoms become severe enough to require surgery, the risk to the fetus becomes even greater.There are a few studies that show that the rate of C-section is higher in women with IBD, but this is due to physician preference, and not any scientific fact.

DO THESE DISEASES EVER BEGIN DURING PREGNANCY?

There are many reports of ulcerative colitis starting during pregnancy, but recent studies suggest that this time of onset makes the condition no worse than at any other times of symptom onset. Crohn’s disease may also begin during pregnancy. Both diseases may begin during the postpartum period (the weeks immediately following delivery), but this is very rare.

IS IT SAFE TO TAKE 5-ASA COMPOUNDS SUCH AS SULFASALAZINE, OR MESALAMINE, OR PREDNISONE (CORTICOSTEROIDS) DURING PREGNANCY?

It is only natural for the pregnant woman and her obstetrician to want to restrict all medications during pregnancy to avoid possible harm to the fetus. Sulfasalazine, prednisone and the 5-ASA compounds (Asacol,® Canasa,® Colazal,® Dipentum,® Pentasa,® Rowasa®) are the drugs used most commonly to control the symptoms of Crohn’s disease and ulcera- tive colitis. A national study has found no evidence that the fetus is harmed by sulfasalazine or prednisone taken by the mother during pregnancy.Another study done in a prospective manner showed the safety of 5- ASA during pregnancy, with no increase in adverse events. (In this type of study, researchers follow a patient population over a period of time, in order to compare specific data from the beginning of the study to the end.) Because the major threat to the pregnancy appears to come from the active disease itself and not from the medication, these drugs should not be discontinued just because a woman becomes pregnant. If either disease worsens severely during the pregnancy, prednisone, sulfasalazine, or a 5-ASA compound may be introduced or increased. Sulfasalazine or a 5-ASA compound may also be used to maintain a remission for the remainder of the pregnancy and after.

ARE THE SIDE EFFECTS OF THESE DRUGS GREATER WHEN THEY ARE TAKEN DURING PREGNANCY?

No. But sulfasalazine may cause nausea, which adds to the nausea commonly experienced in early pregnancy. The drug also may cause heartburn very much like the heartburn sometimes experienced in pregnancy.

SHOULD A WOMAN TAKING SULFASALAZINE OR PREDNISONE NURSE HER BABY?

Yes, if she wants to. Although some sulfasalazine does pass into the breast milk, its concentration is much reduced, and it has not been shown to harm the newborn. Five-ASA compounds and immunomodulators, such as 6-MP and azathioprine (Imuran®), have not been shown to harm the newborn during nursing. However, there is one report of a nursing baby developing diarrhea following the mother’s administration of a 5-ASA rectal suppository.The baby’s diarrhea stopped when the mother’s therapy stopped.When clinically feasible, the dosage of prednisone should be reduced and the drug discontinued as quickly as possible in any patient, whether pregnant or not. If a mother wishes to nurse her baby while still taking a moderate or high dose of prednisone, the baby should be monitored by the pediatrician.

ARE IMMUNOSUPPRESSIVE DRUGS SUCH AS AZATHIOPRINE, CYCLOSPORINE, AND 6-MERCAPTOPURINE SAFE TO TAKE DURING PREGNANCY?

While some animal studies have shown genetic damage to occur in offspring, these animals were given very high doses of these medicines,much higher than that used in humans. Our evidence comes from the long experience of women on these medications for transplants who have done well. Talking with investigators who have treated many women with these drugs has failed to show any increase in the number of adverse outcomes. Again, the importance of keeping disease inactive overrides the risk of these medications on the fetus.

IS IT SAFE TO HAVE A REMICADETM INFUSION DURING PREGNANCY?

The effects of Remicade (infliximab) have not been studied on pregnant women. It may turn out that it is safe, but currently the recommendation is to not give it if a woman is known to be pregnant.

IS THERAPEUTIC ABORTION EVER RECOMMENDED FOR ANY REASON IN IBD PATIENTS?

Therapeutic abortion is rarely, if ever, performed for active IBD. Instead, the patient is treated vigorously with drug therapy in an effort to control symptoms. Simply having a diagnosis of IBD is not a reason in and of itself for an abortion.

WHICH DIAGNOSTIC PROCEDURES ARE SAFE TO PERFORM DURING PREGNANCY?

Abdominal ultrasound, sigmoidoscopy, rectal biopsy, upper endoscopy and colonoscopy are safe in pregnancy if necessary for diagnosing or managing the disease.An MRI scan is probably safe, but more information is needed. Diagnostic x-rays should be postponed until after delivery. If a medical emergency necessitates an x-ray, however, it should be a limited study, and the baby should be shielded.

IS SURGERY FOR IBD EVER PERFORMED DURING PREGNANCY?

Whenever possible, surgery should be postponed until after delivery. If the disease is severe and not responding to drug therapy, however, it may be more dangerous to the patient not to operate. It is a matter of weighing the risks. Although there are reports of intestinal resections and even of ileostomies performed successfully in pregnant women, when any abdominal surgery is performed, the likelihood that the fetus will survive is reduced.

DOES PREVIOUS BOWEL SURGERY AFFECT THE COURSE OF PREGNANCY?

In Crohn’s disease, previous bowel resection does not appear to affect the pregnancy in any way. In fact, since resection usually results in remission of symptoms, the patient is likely to do better during the pregnancy than she would have with smoldering disease.There is one study in the literature that suggests that pregnancy protects against further disease and that there may be fewer operations in women who have been pregnant versus those women who have not been pregnant.The results of this study have yet to be duplicated by other investigators. After ileoanal anastomosis for ulcerative colitis, women have had successful outcomes in pregnancy.Women with ileostomies for ulcerative colitis or Crohn’s disease occasionally suffer prolapse or obstruction of the ileostomy during pregnancy. If possible, it is best to postpone pregnancy for one year after the ileostomy is constructed (whether conventional or a newer procedure) to allow the body time to adapt to it. In Crohn’s disease complicated by abscesses or fistulas around the rectum and vagina, episiotomy (standard surgery to widen the birth canal during labor) may have to be avoided if involving the diseased perianal area. In these cases, delivery is by Caesarian section.

IF ONE PREGNANCY IS COMPLICATED BY ACTIVE IBD, ARE FUTURE PREGNANCIES LIKELY TO BE AFFECTED IN THE SAME WAY?

There is no evidence that the course of either disease during any pregnancy will be the same during subsequent pregnancies.

WHAT ARE THE CHANCES THAT THE CHILD OF A MOTHER WITH IBD WILL DEVELOP ONE OF THESE DISEASES?

It is possible, but certainly not inevitable, that the child of a mother with one of these illnesses might develop either illness. Recent studies suggest that the risk to the offspring of developing IBD if one parent has the disease is about nine percent, and if two parents have the disease, as high as 36 percent. When IBD clusters in families, there does not seem to be any clear-cut mode of inheritance. Because of this, the diseases are called “familial” and not “genetic.”At present, no one can predict whether a child will “inherit” the disease from his or her parent. If a child is to develop IBD, one cannot predict at what age it will happen.

DO PREGNANT WOMEN WITH IBD NEED TO FOLLOW A SPECIAL DIET?

In general, the pregnant woman with Crohn’s disease or ulcerative colitis should follow the same well-balanced diet recommended for all pregnant women.The obstetrician and/or gastroenterologist may recommend the addition of specific foods, vitamins and minerals. It is particularly important that any woman who is on sulfasalazine therapy while pregnant supplement her diet with plenty of folic acid.This is recommended to prevent birth defects seen in any woman with a diet deficient in this nutrient.

DO EMOTIONAL FACTORS CAUSE FLARE-UPS OF THE DISEASE DURING PREGNANCY OR IN THE WEEKS FOLLOWING DELIVERY?

Emotional stress may cause symptoms to worsen during pregnancy, just as it can at any other time. But this does not mean that stress plays any role in causing the disease. Similarly, the postpartum period is a time normally characterized by rapid change, both physical and emotional, in the new mother.These changes also may cause a temporary worsening of symptoms.

ARE MY CHANCES OF HAVING OSTEOPOROSIS HIGHER IF I HAVE IBD?

Yes, they are. Crohn’s patients are particularly at risk for osteoporosis secondary to decreased calcium intake or absorption, steroid use, and smoking. After menopause, this risk becomes even higher, as a majority of IBD patients in the United States are Caucasian. (Caucasians are at a higher risk for osteoporosis.)

DOES HAVING IBD HAVE AN EFFECT ON MENOPAUSE?

No. If the disease is inactive and periods are regular, menopause occurs naturally. Surgical menopause has been noted to have a positive effect on symptoms that otherwise occur with menses.

On behalf of learning, and use as teaching tools for those of us who need to know about our disease, I have tried to supply you with as much information as I could find on all of the drugs, treatments and disorders associated with Inflammatory Bowel Diseases. I have tried to blend all facts supported by research and also from personal experiences of other IBD sufferers into one readable webpage, and any and all information presented here is not entirely from one source. Most information contained within these pages is found in the public domain. At times you may find information used from another site, and as with all copyrighted materials you may find on these pages, I claim fair use under sections 107 through 118 of the Copyright Act (title 17, U.S. Code). Click here for more info

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