IBD and the Menstrual Cycle

Having Crohn's disease or ulcerative colitis may have an effect on menstruation

Inflammatory bowel disease (IBD) affects the whole person. This means that people who live with Crohn’s disease, ulcerative colitis, or indeterminate colitis may also experience a variety of health issues that take place outside the digestive system. For people who menstruate, they may find that their IBD symptoms change during their period

It may also be that one’s period may change as a result of how active the IBD is at that time (how much inflammation is occurring). Anecdotally, patients will discuss having an uptick of symptoms during their period, or right before.

However, there has not been a lot of study into how having a period intersects with IBD. This article will discuss the menstrual cycle and IBD and how they may affect one another.

A calendar for tracking periods with a tampon and birth control pills.
Carol Yepes / Getty Images

Why Periods Are Important In IBD

IBD is a disease of young people. Most people are diagnosed between the ages of 15 and 35. This means that people may be diagnosed before getting their first menstrual period or even soon after.

This brings up questions about what’s considered “normal” for a menstrual cycle because it is not one set of criteria—it is a range of them. Further, there may be confusion as to whether having IBD, or having active IBD, may affect periods. 

The menstrual cycle may change over time and also in response to health conditions. This means that it could be used as one more measure of the overall health of a menstruating person.

In fact, in their committee opinion, the American College of Obstetricians and Gynecologists called the menstrual cycle a “vital sign” for girls and adolescents. They urge physicians to help educate young menstruators and their caregivers about what’s considered “normal” for a period.

Being able to determine when the pattern of one’s period is out of that normal range may help in identifying health problems.

Periods Before an IBD Diagnosis

Changes in the menstrual cycle may happen before IBD is diagnosed. One study showed that women often found that their monthly cycle had changed in some way in the year prior to being diagnosed with ulcerative colitis or Crohn’s disease.

Of the 121 women included in the research, 25% said the timing of their cycle had changed (further apart, closer together, or becoming irregular). There were 21% who said that the flow during their period changed in some way, either becoming heavier, lighter, or irregular.

Among the 40% (48 women) who had pain with their period (also called dysmenorrhea), 33% (16 women) found that their pain had increased in the year before diagnosis. Based on these percentages, the majority of women included in the study reported no change in their cycle.

The researchers don’t know why some people have these changes in their period and some don’t. However, it does seem that a big enough percentage of people do experience differences so that period changes are important to discuss and to keep track of in the context of IBD.

Periods After an IBD Diagnosis

There is some good news for the relationship between IBD and the menstrual cycle. After the first year of diagnosis, for most people, periods tended to become regular. Meaning that for any one particular person, their periods had about the same pattern of cycle and flow length in the years after an IBD diagnosis.

The researchers thought that perhaps around the time of an IBD diagnosis, there is additional stress which could affect a monthly cycle. That might explain why some women have changes in their cycle in the year before a diagnosis and for a time after.

Having a regular period is important especially in the setting of fertility. Women with IBD are shown to have about the same risk of infertility as women who don’t have IBD.  However, there is a persistent misconception that IBD, and especially Crohn’s disease, may lead to a greater risk of infertility.

The study showing that most people with IBD have regular periods may be a reason to think that the factors that influence fertility might not be affected. That would support the studies that have shown that IBD doesn’t usually have a major effect on fertility.

It also means that interventions for infertility (such as in-vitro fertilization, or IVF) may have the same chance for success in women with IBD.

IBD Medications and Menstruation

Researchers in one study found that when women were taking steroid medications, there was an increased risk of having an irregular cycle. However, those who were taking either a thiopurine (such as azathioprine or mercaptopurine) or an anti-TNF medication (such as Cimzia, Humira, Remicade, or Simponi) along with a steroid did not have the same risk.

This led the authors of the study to say that having a regular cycle is another reason that IBD patients should have a long-term therapy that helps them discontinue steroids.

Another study of 139 patients (72% with Crohn’s disease and 28% with ulcerative colitis) from Israel found that women receiving biologic medications experienced more of certain symptoms both before and during their period. Before their period, women reported irritability, nervousness, leg swelling, pelvic pain, and fatigue.

During their period, women reported pelvic pain, lower back pain, abdominal pain, and fatigue. These signs and symptoms were at higher levels in women taking biologics than they were in those who were not receiving this type of drug.

IBD and Irregular Periods

An irregular period is when the timing of the menstrual cycle is out of what is considered the normal range. That could mean having periods that are sometimes closer together or sometimes further apart. One measurement that is used to define “irregular” is if the time between periods varies by more than 20 days from month to month.

Irregular periods are a reason to see a healthcare professional. The three times when an irregular period may be on the spectrum of “normal” are in the first year or two after menstruation starts, when entering perimenopause (the time leading up to the end of menstruation), or after a miscarriage, pregnancy termination, or giving birth.

In one study of 121 women, researchers used a type of survey called the Inflammatory Bowel Disease Questionnaire (IBDQ) to understand how their periods affected them. The IBDQ is often used in clinical studies and helps to understand how IBD is having an effect on quality of life.

What researchers found was a connection between IBDQ scores and more irregular cycles. Those people who said their menstrual cycle was “fairly regular” had lower IBDQ scores than those who said their cycle was “regular.” People who said their cycles were “irregular” also had lower IBDQ scores when compared to those who said their cycle was “fairly regular.”

Is It IBD or Is It My Period?

Some women, both those that are healthy and those that live with IBD, find that they have gastrointestinal symptoms around the time of their period. This can include symptoms like nausea, vomiting, lack of appetite.

Other symptoms that occur with IBD which might also happen at certain times in a woman’s cycle include trouble sleeping, depression, feeling irritable, and aches and pains. For this reason, it might be challenging to figure out when signs and symptoms might be from IBD versus those that might be associated with a menstrual period.

However, it’s important to know if any symptoms in the digestive system are related to menstruation and not IBD. This is in order to avoid a change in medications when it’s not truly needed, because it turns out that symptoms are not being caused by the IBD.

One study of 47 women with IBD and 44 healthy controls found that those with IBD had symptoms more often during their menstrual cycle. Some of the signs and symptoms that were more common included abdominal pain, nausea, and gas. However, the researchers note that IBD symptoms did not change much during this time.

Another study compared symptoms during menstruation. It compared 139 women with IBD and 258 healthy women.

What the researchers found was that a number of symptoms, including irritability, nervousness, restlessness, headache, anxiety, nausea, vomiting, leg swelling, low back pain, constipation, excessive urination, abdominal pain, and fatigue were “significantly” more common in the women with IBD.

Why Charting Periods May Help

People who menstruate who have IBD will note that they are often asked by healthcare professionals about when they had their last period. Making a note of when a period starts, how many pads/tampons are needed each day, and how many days it lasts is helpful.

Keeping track of symptoms is also worthwhile. This can be done in a variety of ways, anything from a paper calendar to using apps that help track periods

A menstrual cycle is charted by keeping track of the length in days. The days that are counted should be from the first day of period bleeding to the next first day of period bleeding. This is the cycle length.

Keeping track in this way helps when healthcare providers ask about menstruation and also in being prepared for the time when the next period will begin.

What’s important is keeping on top of any patterns that develop. Are periods happening on a regular schedule? Is the amount of flow pretty much the same from period to period? Are there symptoms like cramps, nausea, mood alterations, or problems sleeping?

It might also make sense to keep track of these symptoms alongside those that are associated with the IBD. This could help in understanding if, for instance, a symptom like diarrhea happens more frequently during certain days of the menstrual cycle.

Treating Period Symptoms 

Some people who menstruate treat pain related to their cycle with non-steroidal anti-inflammatory drugs (NSAIDs). This includes common over-the-counter drugs such as aspirin and ibuprofen.

However, gastroenterologists often tell their patients with IBD to avoid these medications. This is because some research has shown that the frequent use of NSAIDs could be associated with an increase in IBD inflammation.

At least one study has shown that low doses might not have an effect on IBD. However, using NSAIDs more than five times a month was associated with active disease in Crohn’s disease. It’s important that people who live with IBD discuss the use of NSAIDs to treat pain in order to understand the risk.

When To Talk To a Doctor

For people who live with IBD, it can be difficult to know which physician to talk to about extra-intestinal problems. For questions about the menstrual cycle, an obstetrician-gynecologist (OB-GYN) may be the best person to provide answers.

However, it is important to also keep the IBD team (such as the gastroenterologist or IBD nurse) updated about issues with menstruation and gynecological health. It can help to ask that the IBD team communicate with the OB-GYN.

This is especially true if there are issues with the menstrual cycle that may affect overall health. For instance, if periods are very heavy, and there is also bleeding because of active IBD, there could be an increased risk of anemia. 

For some people who menstruate, the length of the cycle can vary a bit from month to month. The number of flow days might also have some differences from month to month (such as being little lighter or heavier).

What’s important is the pattern of the menstrual cycle and if that pattern starts to change. Sometimes there are clear reasons that something might not be right with the menstrual cycle. 

Some of the reasons to seek out help from an OB-GYN about menstruation include when:

  • Periods haven’t started within three years after breast development starts
  • Periods haven’t started started by age 14 in girls who have excessive body hair growth (hirsutism), have a history of an eating disorder or who may be over-exercising
  • Periods haven’t started by the age of 15
  • Periods are closer together than every 21 days
  • Periods are further apart than every 45 days
  • There are 90 days or more between periods (even one time)
  • A period lasts for more than seven days
  • A period is so heavy that pads or tampons need to be changed every one to two hours
  • Periods are heavy and there’s also a history of a bleeding disorder (either personally or in the family) or excessive bruising or bleeding

A Word From Verywell

There has not been a significant amount of research done on the intersection of IBD and the menstrual cycle. Further, the studies that have been done have some drawbacks.

One problem is that minority populations are not included in significant enough numbers in these studies. This means that White women are over-represented and women of Black, Hispanic, Asian, Native American, and other backgrounds are under-represented in this research.

Another is that some studies may include more women who are older. That brings a concern that some of the research may include too many women who may be experiencing changes in their menstrual cycle because of perimenopause.

People who menstruate may notice that they experience diarrhea or other symptoms before or during their period, but may not connect it to IBD or mention it to a gastroenterologist or an OB-GYN.

It’s worth discussing these changes with the healthcare team in order to keep track of any changes that may happen over time. Knowing the difference between which symptoms may be from menstruation, from IBD, or from medication side effects is important. 

For those who may want to become pregnant, it’s also going to be important to start that conversation early. Understanding the menstrual cycle and how it may or may not affect IBD will be part of planning conception and pregnancy.

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