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This might be of interest to you if you or a loved one has been diagnosed with IBD and wants to learn more about how their illness and treatment may affect puberty and their period.
Although people of any sex can have inflammatory bowel disease (IBD), the effects of IBD are not totally equal between sexes and genders: if you’re a woman and/or assigned female at birth (AFAB), there’s a unique set of concerns. Biological sex can affect physiology and dictate whether you will menstruate, or experience certain symptoms, whereas gender also affects your emotional state and how you interact with the world around you. These factors can impact your physical and mental health as well. Therefore, people with female reproductive organs (mainly AFAB) or whose gender is female have to consider how IBD can affect their reproductive health, medication effectiveness, mental health, bone health, sexuality, body image, and health monitoring. There’s a lot to unpack on this subject, so we’re making a series of blog posts on the specific needs of women and AFAB people living with IBD.
In scientific literature, distinctions between sex and gender are rarely made when studying populations. Therefore, much of the research we will be addressing to explore the relationships between IBD and the health of AFAB people and women is combined, such that we can’t distinguish between biological connotations and gender-based concerns. To this end, a lot of research tends to utilize the terms female and women as equal statements. There is a lot more behind these terms than what is expressed when they’re used in research, but we will often refer to these terms to stay aligned with the research.
There’s plenty of experiences and health considerations that one might go through as they navigate their IBD and maturation. Let’s start with menstrual health and contraception.
As people who menstruate will know, hormonal fluctuations during the menstrual cycle can trigger unpleasant digestive symptoms like nausea, changes to bowel habits, and cramping. These consequences overlap with gastrointestinal symptoms experienced by menstruators with IBD [1,2]. There is limited research on how the menstrual cycle specifically affects IBD, but premenstrual diarrhea has been proven to be more prevalent among people with IBS and IBD than the average person . Researchers have shown that people with Crohn’s disease experienced more symptoms during any part of their menstrual cycle compared to people with ulcerative colitis or who are healthy, who tend to experience less symptoms at the end of their period . Another study actually found that menstruators with Crohn’s had a higher likelihood of experiencing more diarrhea before and during their period, while menstruators with ulcerative colitis were more likely to have more diarrhea only during their period .
IBD can also delay puberty such that menstruation starts later, especially when the disease is active. While the cause for this is uncertain, it’s been suggested that nutrient deficiencies, being underweight, and taking corticosteroid medications can affect growth and therefore change the body’s development. It’s also possible to experience changes to your flow: it’s been recorded that 21% of people with IBD experienced abnormal duration of their period within the year before their diagnosis. 
Why is this all important to know? Mentally preparing and being aware of potential changes in menstrual health can help menstruators with IBD assess whether their symptoms are a result of their period or IBD disease activity. It’s not surprising that many patients would assume that symptoms are a sign of a flare up, so giving people the education and tools to monitor their health is a key aspect of ensuring that menstruators with IBD have a good quality of life . This ties into our purpose at Phyla: to empower people with the tools they need to optimize their health by starting in the gut.
There are countless reasons why people may consider using a contraceptive like an IUD or the birth control pill. Maybe you’re in your “childbearing years” and want to avoid an unplanned pregnancy . Maybe you use it to manage your period and period symptoms better. Whatever the reason, if you have IBD and want to use a contraceptive, there are some things you should consider. Most importantly, the decision about which contraceptive to use and how to use it safely should be tailored to each patient with the support of their medical team. Luckily, there has been some research on the use of contraception for people with IBD, so we’d like to share what we found.
Let’s start with one of the most famous options, the birth control pill, an oral contraceptive (OC) that is widely prescribed; in Canada, about 75% of women will use OCs at some point in their life . These pills change hormone levels in the body to make it less habitable for fertilization. However, there are concerns about reduced efficacy of OCs or negative effects on those with IBD.
OCs are largely absorbed by the small intestine to do their work in the body, so for those whose Crohn’s disease affects the small intestine by causing inflammation and/or ulceration, or for those who have difficulty digesting things because of surgery, their OC might not work as well as intended [1,3]. When IBD mainly affects the colon, it doesn’t seem to affect absorption of OCs. While studies have not proven that OCs will trigger an IBD flare up , there are other risks to consider, such as thrombosis, or blood clots. This is already a known risk of taking the pill, but the risk of “thrombotic events” has gotten more attention recently due to the rare complication of some COVID-19 vaccines . But what no one really seems to talk about is how if you have IBD, you’re more likely to get blood clots, especially with severe or active disease . Another risk to consider based on some reports is antibiotic use. It’s been suggested that the antibiotic rifampin affects OC efficacy, but more research should be done to verify this .
There’s also some talk of OCs actually leading to IBD and triggering more flare ups; a report has found that OC use causes particularly higher risks of developing Crohn’s disease [1,8,9]. However, according to other research studies, OCs don’t significantly increase relapse rates for people with IBD [10–12]. In terms of flare ups, one study confirmed that three different types of OCs, progesterone only, low dose estrogen, or high dose estrogen, had no effect on initiating flare ups  and in fact, a 2014 report showed that 20% of menstruators with IBD actually benefited from OCs in the sense that they relieved the gastrointestinal symptoms they’d get around their period . So, there’s still nothing too concrete to prove that OCs may cause and/or trigger symptoms; more research is needed.
Plus, there are other options besides OCs, and the CDC actually recommends alternatives above it for those with IBD. Their top recommendations are intrauterine devices (IUDs) and contraceptive implants. Secondary options for treatments are injectable contraceptives and progesterone OCs. Beyond this, doctors will recommend estrogen-based OCs, skin patches, and vaginal rings . There’s a lot of different choices, with varying degrees of research on their effects on IBD, so let’s focus on IUDs.
The IUD can prevent pregnancy by preventing egg fertilization through a hormonal or copper version of the device. There is some controversy about their use for IBD patients on immunosuppressants, as in some cases there’s been evidence of worsening IBD symptoms after getting an IUD . If complications from one’s IUD occur, the individual and/or their medical team may take this for an IBD relapse when instead inflammation of the pelvis should be investigated further . So while some studies do report IBD flare ups after insertion of an IUD [14,15], larger studies are needed. If you have concerns about use of an IUD, make sure to ask your medical team.
While menstruation and contraception are two big topics for women and AFAB people living with IBD, there are plenty more. Stay tuned for our next blog on fertility, body image, pregnancy, and birth.
And while you wait, why not start tracking your menstrual flow, contraceptive medication use, and related symptoms in the Phyla app? This can help you monitor how your gastrointestinal symptoms change during your period and/or with contraceptive use. This information is useful for you to take better control of your health by understanding the factors that affect your gut wellness.
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