Q&A: Endometriosis impact on GI function remains ‘vastly understudied, underrecognized’
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Key takeaways:
- Women with endometriosis had more hospitalizations, phone encounters and abdominal surgeries.
- They also were more likely to have abdominal pain and distension, nausea, change in bowel habits and gastroparesis.
Women with endometriosis had higher rates of health care utilization and were significantly more likely to experience upper gastrointestinal and dyspeptic symptoms, according to preliminary data in Clinical Gastroenterology and Hepatology.
“Females with endometriosis are at three to five times greater risk of developing irritable bowel syndrome than healthy women, with rates of IBS as high as 52%,” Madison Simons, PsyD, a gastrointestinal psychologist at the Cleveland Clinic Digestive Disease Institute, and colleagues wrote. “Patients with IBS and endometriosis experience lower pain thresholds and more painful menstrual cycles than those with either condition alone. This amplification of pain experiences can increase health care utilization and decrease quality of life.”
In a retrospective chart review, researchers compared symptoms and health care utilization among 6,736 women (mean age, 53.8 years; 78.2% white), with endometriosis (n = 3,236) and without (n = 3,500), who presented for GI evaluation between 2010 and 2022.
Although women with endometriosis had fewer outpatient visits compared with those who did not have endometriosis, they had significantly more hospitalizations, phone encounters and abdominal surgeries. They also were significantly more likely to experience abdominal pain, abdominal distension, nausea, change in bowel habits, iron-deficiency anemia and gastroparesis.
Conversely, those without endometriosis were significantly more likely to be evaluated for Crohn’s disease and abnormal weight loss.
In a Healio interview exclusive, Simons discussed the study findings and how they might inform patient care and health care utilization going forward.
Healio: Please expand on the relationship between endometriosis and GI symptoms.
Simons: Although the majority of women with endometriosis experience GI symptoms, we are still in the infancy stages of understanding exactly how endometriosis affects the GI tract.
We understand endometriosis to likely affect visceral sensitivity of the abdominopelvic organs, including the bladder, bowel and reproductive tract, meaning sensations that used to be normal or neutral, such as the passage of food, liquid, stool or gas through the GI tract, can feel uncomfortable or even excruciatingly painful.
There is also evidence that endometriosis may damage the interstitial cells of Cajal, which regulate peristaltic contraction through the GI tract via electrical conductance. This would be associated with higher likelihood of symptoms associated with GI dysmotility.
Healio: Why did your team undertake this investigation?
Simons: I have been very aware of the significant burden many women with GI symptoms face related to their menstrual cycle, so I have been asking these questions clinically for many years. However, the relationship between GI and gynecology is vastly understudied and underrecognized, so to be able to fully advance our knowledge in these areas, we have to systematically begin to bring awareness to the problem.
This study was a preliminary way to understand the types of symptoms women with endometriosis might present with. Although endometriosis may be a differential when a woman presents with more typical symptoms, like lower abdominal pain and altered bowel habits, our study shows we need to be asking these types of questions for women with upper GI symptoms as well.
Healio: What were the key takeaways?
Simons: The two main takeaways from this study are that women with endometriosis may have higher rates of health care utilization than women without and that women with endometriosis are also likely to present with upper GI or dyspeptic symptoms.
Healio: How might these findings inform patient care going forward?
Simons: Clinically, these findings should mean including endometriosis as a differential early on, regardless of area of the GI tract involved, though there are certain symptoms that may be more likely to be associated with endometriosis including nausea or vomiting, abdominal distension and alterations in bowel habits.
It is also worth noting that age should not be a determining factor in whether we consider gynecologic involvement, as it seems that once endometriosis is present in the body, its effects on GI functioning may persist throughout the lifespan.
Healio: How can providers help reduce health care utilization?
Simons: Getting an accurate diagnosis plays an important role in reducing health care utilization in this type of situation.
If there is an underlying concern like endometriosis, it will be critical to involve gynecology to appropriately manage this condition alongside the work we are doing in gastroenterology to manage the symptoms. If we suspect a problem like endometriosis, we might anticipate a worsening of the GI symptoms at various points in the menstrual cycle and can perhaps help women prepare for and respond to their symptom flares if we can accurately predict their recurrence.
Healio: What advice would you give to providers treating these patients?
Simons: The main piece of advice I have in this area is to remain curious. Start by asking patients some basic questions in clinic: Have you had trouble in the past with painful, heavy periods, pain with sexual intercourse, pain with urination, difficulty voiding urine or a history of frequent UTIs?
The work to come is in developing an effective algorithm for who needs to be referred to gynecology, but you will likely start to develop a mental framework for when symptoms need additional investigation from another specialty. Develop a relationship with your colleagues in gynecology so you can offer referrals to specialists in endometriosis evaluation and treatment, as this will improve your ability to provide comprehensive multidisciplinary care.
Healio: What additional research is needed?
Simons: This is a vast spectrum of unmet need. We need to be doing more prospective studies to identify these women and understand how they may present differently than those without endometriosis.
There is a great need to understand mechanistically how endometriosis alters gastrointestinal functioning so that we can mitigate its effects. We also need to understand how various gynecologic interventions may impact GI symptoms, as this will ultimately shape how collaborative we become as two fields.
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