Inflammatory Bowel Disease and Menopause

Inflammatory bowel disease (IBD), which includes Crohn’s disease, ulcerative colitis, and indeterminate colitis is often diagnosed in people between the ages of 15 and 35. These diseases are not curable, which means that they affect people throughout their entire lifetime. For women, there are concerns with how IBD may affect their monthly menstrual cycle both during the childbearing years and after. As women enter menopause, the hormonal changes result in various effects which in turn leads to questions about how this may affect the course of IBD. While there is not a lot of research on how IBD affects menopause, this article will look at what information is available in order to help women better prepare for this stage of life.

Menopause and Perimenopause

Menopause is a normal part of the aging process. Menopause is defined as the time after a woman’s monthly period (menstruation) has stopped for a period of 12 months (one year). The time leading up to menopause is another normal stage in the aging process that’s called perimenopause. For most women, menopause begins when they are in their 40s or 50s. There is no one age where women enter perimenopause or menopause. There are variations in the average age of the start of menopause which can be affected by ethnicity, geographic location, and socioeconomic status.

Perimenopause can last anywhere from seven to 14 years, according to the National Institute on Aging. The ovaries are glands that are located on either side of the uterus. The ovaries contain eggs but they also produce the hormones estrogen and progesterone. During perimenopause, the ovaries stop producing eggs and begin to slow down their estrogen production. 

Estrogens are a group of hormones that are made in the ovaries as well as in the adrenal glands and in fat cells. Estrogens are important in regulating the menstrual cycle but also affect many other parts of the body, including the urinary tract, blood vessels, pelvic muscles, and the brain. An increase in estrogen levels in girls during puberty leads to the development of what are called secondary sex characteristics, such as hair growth under the arms and between the legs. 

The variation in hormone levels during perimenopause can lead to several different effects on the body. One of these is that bones lose some density, which means that post-menopausal women may experience a greater risk of bone fractures. Another is that the body changes the way it uses energy, which, for some women, may mean it’s easier to gain weight. Women in perimenopause may also find they experience other changes, including sleep disturbances, mood changes, vaginal dryness, and urinary incontinence.

During perimenopause and menopause, some women start to experience changes in their menstrual cycle, including periods that are closer together or further apart. The lower estrogen level can lead to symptoms that include hot flashes and difficulty sleeping. Hot flashes (the medical term is vasomotor flush) happen when the brain thinks the body is overheating and starts sweating and increasing the heart rate to cool itself down. After a time (usually a few minutes), the symptoms stop, the brain thinks the body is cooled down, and the hot flash is over. 

For women who have had surgery to remove their ovaries (called an oophorectomy), menopause may start at that time. The ovaries may or may not be removed at the same time as the uterus, which is called a hysterectomy. Without the ovaries, hormones won’t be produced. Because the hormone drop may be abrupt for women who have not gone through menopause, hormone replacements may be prescribed in order to make the transition. Women who have had a hysterectomy but have not had their ovaries removed may begin the menopause transition earlier than women who have not.

After menstruation has stopped for a year, a woman is now in the post-menopausal stage. Women post menopause have different healthcare needs because the risk of heart disease and osteoporosis may increase.

How Menopause May Affect IBD

In one study of 456 post-menopausal women, about 65% reported that their IBD symptoms didn’t change. Another 16% said that they noticed their IBD symptoms had improved. For about 18% of women in this study, their symptoms were “somewhat” or “much” worse. The researchers noted that women who were diagnosed with IBD at an older age (with the older vs younger being 44 years old vs 32 years old) were more likely to report that their symptoms were worse during menopause.

An older study done in Wales compared 196 women with Crohn’s disease to women who did not have IBD. The women filled out surveys about their menstrual cycle and when menopause started, along with information about the use of oral contraceptives (the pill) and smoking. The authors found that women with Crohn’s disease reported entering into menopause slightly earlier than the healthy women: 46 to 47 years old versus 49.6 years old.

A retrospective study of 65 women with IBD (20 with ulcerative colitis and 45 with Crohn's disease) at the University of Chicago looked at how IBD was affected after menopause. The authors found, in this group, that the age of onset for menopause was similar to that seen in healthy groups of women. Active symptoms during premenopause were reported by 35% of women, and 38% experienced a flare-up sometime in the two years after menopause. This study also compared women receiving hormone replacement therapy with those who were not. Researchers noted was that hormone replacement therapy had a “significant protective effect" on the IBD. What this means is that women who received hormone replacement therapy were 80% less likely to have an IBD flare-up than the women who did not. The authors conclude that while menopause doesn’t change the likelihood of a flare-up, it may be the estrogen in hormone replacement therapy that protects against IBD disease activity.

Hormone Replacement Therapy and IBD

Part of menopause is the reduction in the hormones estrogen and progesterone. Replacing these hormones to mitigate the effects that the decrease has the body, including some uncomfortable symptoms, is called hormone replacement therapy. Over the years, hormone replacement therapy has been the subject of a lot of study and there were some concerns about the long-term effects that it had. There were some studies that showed that hormone replacement therapy might increase the risk for breast cancer and heart disease, among other conditions. 

However, as more study was done and the effects of hormone therapy were better understood, it became clear that the risks of other health problems were not as great as they appeared to be initially. For women who begin hormone replacement therapy before they reach the age of 60 or within 10 years of the start of menopause, the benefits North American Menopause Society concludes that the benefits may outweigh the risks. However, therapy should be individualized and take into account a woman’s current health concerns as well as personal preferences.

There has not been a lot of study on IBD and hormone replacement therapy. However, one large prospective cohort study of 108,844 postmenopausal women found a connection between ulcerative colitis and hormone replacement therapy. The women included in the study had no prior history of IBD or cancer. There was an increase in the diagnosis of ulcerative colitis among women who received hormone replacement therapy. The likelihood of a diagnosis increased with the longer and current use of hormones. The risk decreased after the hormone therapy was stopped and continued to decrease the more time passed after stopping it. There was no association found with a diagnosis of Crohn’s disease in women who were receiving hormone replacement therapy.

Another study that looked at the role of hormones in IBD among a variety of women of different ages also provides some information about hormone replacement therapy. There were 111 women with IBD who were in menopause and also receiving hormone replacement therapy. Most women, (88% with Crohn’s disease and 91% with ulcerative colitis) thought that their IBD was unchanged by hormone therapy. The remainder of the women reported that their symptoms were either “somewhat” or “much” better. There were no women who reported that their symptoms of IBD were made worse with hormone replacement therapy.

Bone Fractures and IBD

People with IBD are already at an increased risk of losing bone density and developing osteopenia or osteoporosis. Osteopenia could affect as many as 32% to 36% of people with IBD and osteoporosis could be diagnosed in 7% to 15% of people with IBD. Osteoporosis is when bones start to lose their mass, making them weaker and more prone to breaking. Osteopenia is when bones have started to weaken but are not yet at the point where they may break more easily.

People with IBD who have received steroids (such as prednisone) to treat their disease or who have vitamin D and calcium deficiencies may be at increased risk for developing osteopenia and/or osteoporosis. For that reason, it may be recommended that some people with IBD have a bone density scan (called a DEXA scan) in order to determine if their bone density has begun to decrease. An initial DEXA scan may be done to obtain a baseline level and then repeated every so often in order to determine if bone loss is continuing.

Post-menopausal women are also at an increased risk of osteoporosis. The risk of fractures has not been well-studied in people with IBD or in post-menopausal women with IBD. However, one review paper that included seven studies found that the risk of osteoporotic fractures in people with IBD was increased by as much as 32%. For that reason, it may be necessary to make changes to one’s care plan to manage bone loss. The European Crohn and Colitis Organization recommends exercise, calcium and vitamin D supplements, and the prescription of a bisphosphonate medication for those who have already experienced a bone fracture. Some of the common bisphosphonate medications include Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate), and Reclast (zoledronic acid).

One study looked at the use of Actonel (risedronate) to treat osteoporosis in women who have IBD. This study was done for 3 years and followed 81 women, 40 of whom received the Actonel and 41 who received a placebo. The researchers found that the long-term use of this drug increased bone mineral density in the women who received the drug. When compared to placebo, the drug was also associated with a decreased risk of certain types of bone fractures.

A Word From Verywell

Because IBD is a lifelong, incurable condition, it will have an effect on all stages of a person’s life. There have been many studies that have looked at the role of female hormones in the development and the disease course of IBD, but as of now, no firm conclusions have been made. Many women with IBD report that their menstrual cycle does have an effect on their IBD, in most cases being an increase of symptoms such as diarrhea during their period. While there has not been a great deal of research involving menopausal and post-menopausal women with IBD, it does seem to track that menopause may result in the IBD being more stable.

Women with IBD will need to approach the perimenopause, menopause, and post-menopausal stages of life with an eye on how to prepare for the future. Decisions will need to be made, in conjunction with healthcare professionals, on how to manage any discomfort that occurs during perimenopause and if there’s a need for hormone replacement therapy. Post-menopausal women with IBD will also want to understand their risk of bone fractures and if there could be a need for any treatment to prevent further bone loss.