It is important to understand how the GI tract works normally and to identify differences in men and women which may be associated with possible worsening of GI problems. These differences may present with unique symptoms in women for shared diseases or even unique diagnoses for women.
A woman’s unique experience of symptoms starts with the tongue and goes through the entire digestive tract. More women can be classified as “supertasters” – they are able to taste both bitter and sweet foods more strongly than men. They don't need as much of the food to determine if the food is bitter or sweet. This increased sensitivity of the gut to different types of stimulation is seen throughout a woman's GI tract. Normal women have been shown to be more sensitive to pressure from an inflated balloon placed in the esophagus (swallowing tube between the mouth and the stomach), small intestine, colon or large intestine, and rectum than men. Through each area of the digestive tract, we will talk about symptoms unique to women, their causes, risk factors, testing and treatment.
The GI tract muscles in women may function differently compared with men. Between the end of the esophagus and the beginning of the stomach, there is a muscle which acts like a door. When one eats, the door opens allowing the food to slide into the stomach and then quickly closes again, preventing the food from flowing back up into the esophagus. The muscle in women, especially premenopausal women, squeezes shut with more force than that found in men, making certain that the food and stomach juices stay in the stomach. There is a similar muscle protecting the windpipe from esophageal backflow. In women, tests have shown that after drinking fluids, this muscle tightens more than in men. In part due to this finding, women may have more occurrences of “globus” (the feeling of a “lump in the throat”) that is not necessarily associated with swallowing food. However, overall these strong muscles suggest that women may have some extra protection in the esophagus, normally.
Although women may experience heartburn, they generally have less damage in their esophagus than men. Women secrete less stomach acid than men, throughout their lives and they tend to have fewer ulcers related to acid. The stronger muscles at the end of the esophagus and the lesser amount of stomach acid present in women may help to explain the milder damage to the esophagus. However, because women are more sensitive to irritants, they may experience heartburn more strongly than men. Several things can precipitate heartburn symptoms, including spicy or acidic foods, caffeine, large meals, obesity, or eating prior to lying down. The treatment for heartburn includes modification of any precipitating factors followed by a trial of an acid-suppression medication if symptoms persist. There is data suggesting that prolonged duration of higher-dosed acid-suppressive medication may increase the risk of osteoporosis. This risk can be discussed with your doctor before starting the medication. For refractory cases of heartburn, an endoscopy (a procedure that involves looking into the esophagus and stomach with a small camera) is often indicated to exclude other diagnoses.
Women also seem to have slower emptying of food from the stomach than men. This may be important in explaining why women tend to experience nausea and bloating more frequently than men. Certain conditions including diabetes, prior stomach surgeries, infections, medications, and low thyroid levels can cause damage to nerves that are responsible for gastric emptying, leading to a condition called gastroparesis (delayed gastric emptying). Common symptoms include abdominal bloating, nausea, fullness and weight loss. The diagnosis requires testing by your doctor. The treatment involves eating smaller, more frequent meals that are lower in fat. Although medications may be prescribed by your doctor, options are limited due to drug side effects.
Another stomach problem that may affect women includes inflammation of the stomach (known as gastritis). Many women use aspirin and aspirin-like compounds, known as non-steroidal anti-inflammatory drugs (NSAIDs); ibuprofen is included in this class of medications. Some NSAIDs are available in over-the-counter form while others require a prescription. Women, especially older women, use these medications more often than men for a variety of reasons. These drugs, if used persistently, are known to cause irritation to the stomach lining and may lead to bleeding from ulcers. In recent years, new types of prescription NSAIDs have become available, such as COX-2 inhibitors, which reportedly have less adverse effects on the GI tract, but have been linked to an increase in heart attacks. All patients should discuss with their doctors if the COX-2 inhibitors are right for them. Women should tell their doctors if they are using NSAIDs, whether prescribed or purchased in a drugstore, in order to develop a regimen to help protect their stomach.
Women also have slower emptying from the large intestine when compared with men but this difference disappears in old age. This may be important in explaining why women tend to be more constipated than men. Additionally, at the end of the rectum, the anal sphincter is the muscle that allows us to delay moving our bowels until we find an appropriate place, such as a bathroom. When physicians evaluate the function of the anal sphincter, they measure squeeze pressure - how firmly the patient can squeeze the muscle shut. Most investigators agree that women have less squeeze pressure than men. The anal canal (the passage from the opening to the rectum) is shorter in women and the length of both the sphincter and area of highest pressure is also shorter in women. Men tolerate more volume in the rectal area. Overall, men anatomically should be better able to handle an episode of diarrhea than women.
Chronic constipation is common in women and tends to worsen with age. Treatment includes at least 20-35 grams of dietary fiber per day, adequate fluid intake, and regular exercise. Non-prescription medications may include stool softeners and laxatives. If you don’t respond to these therapies, your doctor may order additional testing or medications.
Irritable Bowel Syndrome (IBS) occurs 2 to 6 times more often in women than in men. In patients with IBS, there is super-sensitivity to irritants (such as intestinal gas) that would not be bothersome to other people. The etiology is believed to be due to the way intestinal nerves send messages to the brain, the interpretation that the brain makes, and its response back to the gut. If a person has emotional stress, the IBS response appears to be worse. The good news is that there is no damage to the intestinal lining. This is a “functional” problem - that is, the bowel is not functioning at a normal level, but at a super- or suboptimal level. Symptoms often include diarrhea, constipation or combination of both. Bloating and abdominal pain are part of the syndrome, and often improve after bowel movements. The diagnosis is made based upon specific criteria and lack of other objective findings. Currently, there is no one treatment to cure this disorder, but many effective management strategies exist. Lifestyle changes are recommended, which include the development of coping strategies for life stressors. This is a chronic condition and many patients have reached satisfactory results working with their physicians as a team.
Inflammatory bowel disease (IBD) includes both Crohn’s and Ulcerative Colitis. IBD is more frequent in women with a ratio of about 2:1. Women may have a milder course of Crohn’s, especially if they have given birth to several children. Hormones during pregnancy could improve or worsen the disease; this is not similar for all subsequent pregnancies in the same patient. Symptoms may include diarrhea, blood in the stool, weight loss, and anemia. Diagnosis is generally made after colonoscopy and review of biopsy specimens by pathology. Treatment can vary but often requires long-term medications, many of which are safe in pregnancy.
Colon cancer is the number 3 cancer for women in the United States. Women should be advised to follow current guidelines to be screened at age 50, and talk to their doctors if they have a family history of the disease, in which case they should be screened at an earlier age and at more frequent intervals. Patients should discuss screening options with the doctor to determine the best individual screening option. There are familial colon cancer syndromes that are also associated with uterine, ovarian and breast cancers, so if several of these cancers are found within a family, genetic counseling should be offered.
Women have slower gallbladder emptying than men normally and are twice as likely to develop gallstones as men. This effect is exaggerated during pregnancy due to unique female hormones, and may be one reason why many women develop gallstones after having a baby. Symptoms of gallbladder disease may include right upper abdominal pain after eating, nausea or vomiting. Gallbladder disease can often be diagnosed by your doctor based upon history and ultrasound results.
There are two areas where women have different enzyme systems from men where the effect can be important. There are enzymes in the small intestine as well as in the liver that help break down medications. The enzymes function slightly differently in men and women. Because of this, women may handle various medications differently, resulting in either little effect of the drug or too much effect of the drug. Therefore, it is important that patients ask their doctors if medications that they prescribe may behave differently in women.
Pregnancy is associated with nausea, which occurs early in the pregnancy. This effect may result from a slowing of stomach emptying, beyond what is seen normally in women. One of the pregnancy hormones, progesterone, is associated with delaying muscle contraction, and it is believed that this is a major cause of the nausea seen with pregnancy. Women also experience heartburn during pregnancy. This seems to be caused by the increasing levels of progesterone during pregnancy as well as the increasing size of the baby. It is most prominent during the second half of the pregnancy. Constipation is common for similar reasons.
The muscle coordinating moving one's bowels can be damaged by a tear during childbirth, leading to possible long-term problems. Therefore, it is important for pregnant women to perform the Kegel exercises, which help to strengthen this area, and to discuss any concerns with their obstetrician.
Rebecca Ensley, DO, and Alissa Speziale, MD, FACG, FACP, Naval Medical Center San Diego, San Diego, CA – Updated July 2013.
Robyn G. Karlstadt, MD, MACG, Shire Pharmaceuticals, Wayne, PA – Published October 2002. Updated April 2007.
The views expressed in this presentation are that of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.
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