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By Robyn G. Karlstadt, M.D., FACG
Originally published in October 2002. Updated by Robyn G. Karlstadt, M.D., MACG in April 2007.
Normal Physiology
It is important to understand how the GI tract works normally
and to identify differences in men and women which may be
associated with possible worsening of GI problems.
These differences start with the tongue. More women can
be classified as “supertasters”- they are able
to taste both bitter and sweet foods more strongly than men.
They don't need as much of the food to determine if the food
is bitter or sweet. This increased sensitivity of the gut
to different types of stimulation is seen throughout the
women's GI tract. Normal women have been shown to be more
sensitive to pressure from an inflated balloon placed in
the esophagus (swallowing tube between the mouth and the
stomach), small intestine, colon or large intestine, and
rectum than men.
Esophagus
The GI tract muscles in women may function differently compared
with men. Between the end of the esophagus and the beginning
of the stomach, there is muscle which acts like a door. When
one eats, the door opens allowing the food to slide into
the stomach and then quickly closes again, preventing the
food from flowing back up into the esophagus. The muscle
in women, especially premenopausal women, squeezes shut with
more force than that found in men, making certain that the
food and stomach juices stay in the stomach. There is a similar
muscle protecting the windpipe from esophageal backflow.
In women, tests have shown that after drinking fluids, this
muscle tightens more than in men. In part due to this finding,
women may have more occurrences of “globus”(the
feeling of a “lump in the throat”) that is not
necessarily associated with swallowing food. However, overall
these strong muscles suggest that women may have some extra
protection in the esophagus, normally.
Although women may experience heartburn, they generally
have less damage in their esophagus than men. Women secrete
less stomach acid than men, throughout their lives and they
tend to have less ulcers related to acid. The stronger muscles
at the end of the esophagus and the lesser amount of stomach
acid present in women may help to explain the milder damage
to the esophagus. However, because women are more sensitive
to irritants, they may experience heartburn more strongly
than men.
Stomach
Women also seem to have slower emptying of food from the
stomach than men. This may be important in explaining why
women tend to experience nausea and bloating more frequently
than men.
Colon
Women also have slower emptying from the large intestine
when compared with men but this difference disappears in
old age. This may be important in explaining why women tend
to be more constipated than men. Additionally, at the end
of the rectum, the anal sphincter is the muscle that allows
us to delay moving our bowels until we find an appropriate
place, such as a bathroom. When physicians evaluate the function
of the anal sphincter, they measure squeeze pressure - how
firmly the patient can squeeze the muscle shut. Most investigators
agree that women have less squeeze pressure than men. The
anal canal (the passage from the opening to the rectum) is
shorter in women and the length of both the sphincter and
area of highest pressure is also shorter in women. Men tolerate
more volume in the rectal area. Overall, men anatomically
should be better able to handle an episode of diarrhea than
women.
Gallbladder
Women have slower gallbladder emptying than men normally.
This effect is exaggerated during pregnancy and may be one
reason why many women develop gallstones after having a baby.
Liver and Small Intestine
There are two areas where women have different enzyme systems
from men where the effect can be important. There are enzymes
in the small intestine as well as in the liver that help
break down medications. The enzymes function slightly differently
in men and women. Because of this, women may handle various
medications differently, resulting in either little effect
of the drug or too much effect of the drug. Therefore, it
is important that patients ask their doctors if medications
that they prescribe may behave differently in women.
Common Problems which may affect Women
Nausea:
Nausea may occur more often in women. Other symptoms, such as a feeling of fullness
or bloating, pain in the belly, feeling full soon after eating, belching or
burping that is annoying have also been reported more often in women. If these
symptoms persist, women should see their physician to make sure that there
is no serious underlying problem.
Inflammation of the Stomach (Gastritis):
Many women use aspirin and aspirin-like compounds, known as NSAIDs (non-steroidal
anti-inflammatory drugs.) Medications such as ibuprofen make up this class
of medication. Some NSAIDs are available in over-the-counter form while others
require a prescription. Women, especially older women, use these medications
more than men for a variety of reasons. These drugs, used for a long time,
are known to cause irritation to the stomach lining and may lead to bleeding
from the stomach. Women who use NSAIDs chronically are at higher risk for
developing stomach ulcers as well as gastritis. NSAIDs can decrease the level
of mucus that the stomach normally makes to protect itself, and this may
also increase the possibility that a patient will be likely to develop damage
from the medication. In recent years new types of prescription NSAIDs have
become available, such as COX-II inhibitors, which reportedly have a less
adverse impact on the GI tract, but which have been linked to an increase
in heart attacks. All patients should discuss with their doctors if the COX-II
inhibitors are right for them. Women should tell their doctors if they are
using NSAIDs, whether it is prescribed or purchased in a drugstore. This
way they can work with their physician to develop a regimen to help protect
their stomach, should continued NSAID use be needed.
Gallstones:
Women are twice as likely to develop gallstones as men because of the effects
of estrogen and progesterone. Gallbladder emptying may be slowed by progesterone,
a normal hormone secreted during the second half of the menstrual cycle and
during pregnancy. Estrogen and progesterone affect the handling of cholesterol
in the body. Because of the slowed emptying of the gallbladder as well as
an increase of cholesterol in the gallbladder, there is a greater chance
for the development of gallstones.
Irritable Bowel Syndrome (IBS):
Irritable Bowel Syndrome occurs 2 to 6 times more often in women than in men.
One reason for this observation may be that women normally are more sensitive
to irritants of the GI tract. In IBS, the patient is supersensitive to irritants
that would not be bothersome to other people, such as increased gas in the
gut. The basis is believed to be a problem with how the nerves send the message
to the brain, the interpretation that the brain makes, and it’s response
back to the gut. In fact, if a person with IBS puts her hand in ice water,
she can keep it in the bucket longer than someone who does not have this
syndrome - she doesn't feel the pain/discomfort of the ice water as rapidly
as a non-IBS sufferer. The problem lies within the sending of the message
by the nerves.
If a person has some emotional stress, the IBS response
appears to be amplified. Additionally, the gut becomes somewhat
hyperactive and the patient may experience either diarrhea,
constipation, or forms of both. The good news is that there
is no damage to the intestinal lining. This is a “functional”problem
- that is, the bowel is not functioning at a normal level,
but at a super- or suboptimal level.
Currently, there is no one treatment for this disorder.
However, research is ongoing and new therapies will be forthcoming.
In the meantime, lifestyle changes are recommended including
development of coping strategies for life stresses. This
is a chronic condition and many patients have reached a satisfactory
result working with their physicians as a team.
Colonic Disorders:
Inflammatory Bowel Disease (IBD) is a serious problem and is made up of predominantly
two disorders: Crohn’s Disease (inflammation through the intestinal
wall) and Ulcerative Colitis(inflammation of the colon lining). IBD is more
frequent in women with a ratio of about 2:1. Women may have a milder course
of Crohn’s Disease, especially if they have given birth to several
children. Although older literature suggested that more women developed ulcerative
colitis, the more recent work does not support this. The main problem for
women in IBD is when they become pregnant. Women may either get better, get
worse, or remain unchanged when they become pregnant. The response seems
to be triggered by the hormones associated with pregnancy and is expected
to be similar for all subsequent pregnancies in the same individual.
Colon cancer in women can be associated with breast cancer,
lack of giving birth to children, and the appearance of cancer
on the right side of the colon. Some investigators have also
suggested a correlation with surgical removal of the gallbladder,
although this occurs many years after the surgery. Women
aged 55 or younger seem to have a higher frequency of colon
cancer than men. Colon cancer is the number 3 cancer for
women in the United States. Women should be advised to follow
current guidelines to be screened at age 50, and talk to
their doctors if they have a family history of the disease,
which means they should be screened at an earlier age.
Some Common Problems During Pregnancy
Pregnancy is associated with nausea, which occurs early
in the pregnancy. This effect may result from a slowing of
stomach emptying, beyond what is seen normally in women.
One of the pregnancy hormones, progesterone, is associated
with delaying muscle contraction, and it is believed that
this is a major cause of the nausea seen with pregnancy.
Women also experience heartburn during pregnancy. This seems
to be caused by the increasing levels of progesterone during
pregnancy as well as the increasing size of the baby. It
is most prominent during the second half of the pregnancy.
Women are at an increased risk for developing gallstones
due to the sluggishness of the gallbladder during pregnancy.
Between the slowing effects of progesterone on the gallbladder
and the pressure of the increasing baby, the gallbladder
does not function normally and stones can form. If there
is a family history of gallstone disease, the pregnant woman
may want to discuss this with her doctor.
The muscle coordinating moving one's bowels is the same
length in men and women. However, perhaps because women are
smaller, it makes up more of the anal canal in women. This
is important because it can be more easily damaged by a tear
during childbirth, leading to possible long-term problems.
Therefore, it is important for pregnant women to perform
the Kegel exercises, which help to strengthen this area,
and to discuss any concerns with their obstetrician.
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