Gastrointestinal symptoms in occurrence with menstrual cycle in young women with inflammatory bowel disease: a complex relationship

Women with inflammatory bowel disease (IBD) often experience changes in gastrointestinal symptoms during the menstrual cycle. Little is known about the mutual influences between the menstrual function and gastrointestinal symptoms. We present the case of a girl affected by IBD who experienced a close relationship between gastrointestinal symptoms and disabling dysmenorrhea. The girl was diagnosed with pancolic UC at 12 years of age. Since onset, menses became painful and irregular and seemed to trigger relapses of abdominal pain, urgency and diarrhea. Due to severe dysmenorrhea, a gynecological evaluation was performed and therapy with norelgestromine (6 mg/day) and ethinyl estradiol (600 mcg/day) was prescribed as transdermal patch. After 3 months of this therapy no benefit was observed, the girl underwent a pelvic ultrasound, that showed a functional cyst of 14 x 15 mm in the right ovary. A new therapy with vaginal progesterone was prescribed but dysmenorrhea associated with diarrhea and urgency persisted. The frequent relapses leaded to endoscopic re-assessment which showed active proctitis and mild hyperemia from sigmoid to transverse colon without any ulcerative lesions. She had several courses of steroids, optimization of rectal steroids and mesalazine, and escalation with mesalazine, azathioprine and infliximab with poor symptom control; a close relationship between UC activity and menses persisted causing frequent relapses in concurrence with menses. Finally transdermal gestodene (2,10 mg) and ethinyl estradiol (0,55 mg) were prescribed continuously (suppressing occurrence of menses) achieving symptom resolution and stable remission for 7 months but the latter treatment was withdrawn from the market and had to be suspended; the patient started to feel unwell again with menses. Transition to the Adult Gastroenterology Service is ongoing and together with the adult gastroenterologist we are evaluating whether endoscopic reassessment and further treatment escalation for IBD is appropriate or whether the cyclical mestrual-related IBD symptoms should be controlled by hormonal contraception or if the symptoms are a result of an overlap with irritable bowel syndrome (IBS).The relationship between IBD, IBS and menstrual cycle is complex; often one aspect may mimic, mask, worsen or activate another and it is often difficult to differentiate which component is truly responsible of the clinical picture. A better understanding of the relationship between hormonal fluctuations due to the menstrual cycle and gastrointestinal symptoms in young women with IBD is crucial for an appropriate management of IBD.