Gender & the Gut: Managing Women’s Digestive Health

Dr. Buch:
Over the last few years, we've only started to gain an understanding of how gender affects our approach to GI illnesses.  And since a greater awareness of these differences will help us become better clinicians, today we're taking a look at some common GI problems in women and how we can manage them. 

Welcome to GI Insights on ReachMD.  I'm your host Dr. Peter Buch, and here with me is Dr. Asma Khapra, a Clinical Assistant Professor at the University of Virginia Medical School who specializes in women's digestive health. 

Dr. Khapra, welcome to the program.

Dr. Khapra:
Thank you for having me, Dr. Buch. 

Dr. Buch:
It's a pleasure.  So let's just dive right in.  What special approaches are necessary when evaluating and treating female patients with irritable bowel syndrome? 

Dr. Khapra:
So as you may know, irritable bowel syndrome, or IBS, is a very common syndrome in women, and so a lot of my patients come in with very similar complaints, though it's a pretty broad spectrum of complaints that you see with IBS.  So I think the first thing I always do when I diagnose a patient with IBS or think a patient has IBS is sort of define it and tell them that this is defined by the clinical Rome criteria, and it's not one test that you can get to give you the diagnosis.  And I think it's important for people to be kind of reaffirmed that it is something that we see a lot of, that it's a true diagnosis, and that there is a way to diagnose it.  And once I do that, it's very helpful to treat patients and to make them understand that there is a whole process in which we use to treat patients with IBS. 

The first thing I typically do is I always get a detailed symptom history.  And it's actually very interesting, but talking to women you really want to get down to the details of, like, How many bowel movements are you having, like the type of movements?  Is it urgent?  Is it crampy?  Do you get relief of your pain with your bowel movements? All these types of things that we know occur in irritable bowel syndrome.  And then, once we really get down to the nitty-gritty and we say that you understand what kind of symptoms people are having, you can kind of define them in two categories.  Either it's very constipation predominant or diarrhea predominant.  And often people are in between, and that's what we call mixed IBS, and they have a little more difficulty with treatment. 

But then understanding if there's a particular trigger that really is big onset, for instance, do people notice it worse with stress.  And one of the questions I ask is, "When you go on vacation, do your symptoms get better?" because that's a very unique way to tell if stress is involved.  "Do you find that there are specific dietary things that will cause the symptoms?"  I focus on that with patients.  And then, one of the things that we know is that infections can be a cause of IBS, and so I find if there's a predrome of an infection or use of antibiotics or something that may have preceded some of the symptoms that they've have had for a while.  And I spend a lot of time on talking to my patients, and I think a history, a really good understanding of what their problems are makes it much simpler to treat them. 

Dr. Buch:
Can you tell us about your stepwise approach to evaluating your female patients with fecal incontinence? 

Dr. Khapra:
So I think the first thing you really have to do is take a really good history.  And this sounds so basic, but with fecal incontinence, you want to see if it's a secondary cause because there are many other conditions that will eventually result in fecal incontinence, or this is actually a primary fecal incontinence.  So when we talk about a history, we're talking about defining it—is it passive? Is it urge? Is it just a little seepage? Finding out if they have other comorbid conditions, you know, ruling out Crohn's disease or making sure that you understand what their obstetric history is, like how many deliveries have they had?  I always ask, "Did you have traumatic births? How long was your labor? Did you use vacuum, forceps?"  These details are extremely important, and then finding out if they have other central nervous problems or spinal cord problems or neurologic problems because that can also affect it, so you really have to delve deep into their general history. 

And then once you know the history, the physical exam—and Dr. Buch, you may have been taught this in medical school too—but the digital rectal exam is underutilized in the physical exam.  And one of the things that we see is that there are sort of three big components.  One is inspection, so you want to look at that area and make sure everything is good and that there's no trauma or obvious things that you would miss, surgical scars—right?—like things that obviously you should know about.  And then you can actually sort of test for perianal sensation, and that can tell you if there is neuropathy, for instance.  And then you really do a good exam.  If you do a digital rectal exam, you want to see are there masses, are there lesions, like they could have a rectal cancer, for instance, or an anal cancer.  Anal cancers are often very missed on—even by gastroenterologists because they can be very subtle.  And then you assess the rectum for their pelvic floor muscles.  You ask them to squeeze.  You ask them to hold.  You ask them to do all kinds of maneuvers to see what the status of their pelvic floor is. 

And once you kind of understand where that problem lies, you can actually go into more in-depth testing; like you can do things like an endoanal ultrasound if you know they have had an obstetric injury or an MRI to look at the sphincter muscle.  You can do anorectal manometry to look at rectal compliance.  You can do an MRI defecography to look at pelvic floor muscles.  So there's a ton you can do after that if that's just like a sphincter-related issue.  If it's obviously a secondary issue, you deal with it. If it's Crohn's disease, you treat the Crohn's disease.  If it's a neurologic disorder, you can work with your neurologist.  But these are the types of things you can do, and it really breaks down the evaluation of fecal incontinence to a very simple kind of 3-step process. 

Dr. Buch:
For those just tuning in, you're listening to GI Insights on ReachMD.  I'm Dr. Peter Buch, and I'm speaking with Dr. Asma Khapra about managing GI illnesses in our female patients. 

So, Dr. Khapra, let's move on to inflammatory bowel disease.  Based on your experience, do women have a different perspective of their disease than men? 

Dr. Khapra:
You know, this is an interesting question.  So I actually have sort of a unique interest in inflammatory bowel disease, and I have a lot of female patients who have inflammatory bowel disease. Typically, as you know, inflammatory bowel disease peaks in the 20s, and then there's a second smaller peak of diagnosis in the 60s, so you see a lot of young women in particular who have this disease.  So, of course, the first thing that comes into mind is childbearing, and their question is, "Can I get pregnant because I have Crohn's or ulcerative colitis?"  And then they say every time they think about medicines, their concern is that a problem for pregnancy, and so pregnancy is a huge issue. 

The other thing is that if you actually delve down into what they're concerned about, when they learn about the disease, their first concern is of having an ostomy or something very extreme.  And I think it's all about kind of the quality of life and sort of embarrassment and those sort of psychosocial issues that I think actually are really prominent in women, and so I think education is very key about the disease process and let them know that there are very good treatments, and understanding how to manage medicines and the disease make it much more kind of comfortable for women in particular to grasp having this diagnosis. 

Dr. Buch:
Is there a particular algorithm that you follow when you're talking to your patients about the diseases? 

Dr. Khapra:
Yeah, I actually have—this sounds terrible—but a canned speech almost when I have a patient that comes in.  When I diagnose them—or even I get a lot of second opinions, and so sometimes they'll come in having the diagnosis—I start with the same thing.  I explain the disease.  I tell them that inflammatory bowel disease is a disease of Crohn's and ulcerative colitis, and then I draw them a pyramid of all the medications—or now it's actually more of a spiky kind of round circle where I put all the different types of medications that are available and tell them where they fall into this algorithm based on the severity of the disease, and then I go through the pros and cons of all these medicines in general and tell them that they are mild or they're moderate, they're severe, where they are, and how we're going to treat the disease.  And then I actually refer them to the CCFA website because what they need is more information, and they need to have a community, and the CCFA is one of the best GI organizations out there.  And so there are patient communities.  And so patients really get good information, and then they come back and they ask questions, and then you can have a real discussion.  And again, it's all about really being comfortable with the information. 

Dr. Buch:
So now before we close, Dr. Khapra, are there any other insights you would like to share with our audience today? 

Dr. Khapra:
I think that over the last sort of 15 years of my career, I've noticed that there is definitely this trend of specific women's GI complaints, and you see them over and over and over again as like 90-plus percent of my population is female, and so I really hope that in the future there's more targeted research, information, education given to physicians about how to treat women in GI because I think that's a little bit of a gap.  The last real material that was of good content was about 2016.  The ACG just did another issue specifically for women last year, and in the last year and a half or so we've seen a big impetus in terms of more education about women's issues in GI.  So I think this is an exciting time, and I look forward to what we see in the future. 

Dr. Buch:
Well, that brings us to the end of today's program.  I want to thank my guest, Dr. Asma Khapra, for helping us better understand common GI illnesses in our female patients.  Dr. Khapra, it was a pleasure having you on the program. 

Dr. Khapra:
Well, thank you very much for having me. I do appreciate it. 

Dr. Buch:
For ReachMD, I'm Dr. Peter Buch.  To access this and other episodes in this series, visit ReachMD.com/GIInsights, where you can Be Part of the Knowledge.  Thanks for listening and see you next time.