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1

the guts behind the woman


It's no secret that women are different from men. We think differently, we feel differently, we communicate differently. And women live longer than men-an average of 5.4 years, to be exact. To some extent, women and men even have different digestive systems.

In fact, the two sexes seem to be separate subspecies when it comes to gastrointestinal health problems. Menstruation, pregnancy, and menopause all put a distinct feminine stamp on your digestive tract. So although you may have the same digestive symptoms as a man, you may not be suffering from the same digestive health problem.

After all, men don't experience the nine months of digestive disturbances that can come with pregnancy. Nor do they cope with the bloating, diarrhea, or constipation that waxes and wanes with menstrual cycles. And men certainly don't get painful hemorrhoids after delivering a baby.

These are just a few of the reasons why you, as a woman, need a digestive health book that you can call your own. Although you might reach for the Pepto-Bismol that your husband or boyfriend uses, the cause of your symptoms may be completely different. You may require a different diagnostic workup and a different course of treatment.

It's for this very reason that I, as a gastroenterologist, decided to focus my practice on women's health. I wanted to address the special concerns of women like you.

I really came to understand the importance of gender differences in gastrointestinal (GI) disorders after medical school, during my gastroenterology fellowship training in the early 1990s. I began to see so many women with diverse digestive problems that stemmed from a wide range of sources such as eating disorders, pregnancy, hormone replacement therapy, and childbirth. At that time sex-based differences in disease weren't included in my medical school or specialty training. I knew, of course, that when it came to digestive problems, women had unique issues that set them apart from men. But I really gleaned my knowledge from experience and by digging up GI research studies that highlighted women's health issues.

A decade ago women weren't included in clinical trials. It was assumed that diseases in men and women were the same and that women would react to medications the same way men did. This was a very wrong assumption to make, as researchers found out when they began including women in studies.

The National Institutes of Health now have an Office of Research on Women's Health that funds studies performed exclusively on women. As a result of these pioneering efforts, researchers have gathered a significant amount of evidence delineating differences in GI function in men and women. Women are unique. And there is a definite connection between a woman's reproductive tract and her digestive tract.

One study published in the Gastroenterology, the official journal of the AGA, found that women with gastrointestinal disorders like irritable bowel syndrome (IBS) and inflammatory bowel disease are far more likely to experience premenstrual syndrome (PMS) than healthy women. The study also found that women who had digestive disorders and PMS often reported that their symptoms-like diarrhea, constipation, and abdominal pain-got better and worse during the course of their menstrual cycle.

The latest research shows that female hormones, such as estrogen and progesterone, affect the function of your GI tract. Here's just one example: A 2002 finding from the landmark Heart and Estrogen/Progestin Replacement Study (HERS) found that postmenopausal women who used hormone replacement therapy for six years had a 45 percent increased risk of developing gallbladder disease compared to their counterparts who did not take hormones.

Some exciting research findings have dramatically altered the way digestive problems are diagnosed and treated in women. In recent years several myths have been shattered. For example, little more than a decade ago women with IBS were told that their symptoms were all in their head or were caused by too much mucus in their gut. Today gastroenterologists know that both of these assumptions were wrong: IBS has been shown to be caused by a breakdown in the way food moves through the intestines or by a heightened sensitivity of the intestines to the normal movement of food. Our diet and even our emotional state can be aggravating factors in this syndrome. Another myth that's gone by the wayside is that ulcers are caused by too much stress or spicy foods. We now know they're caused by the bacteria Helicobacter pylori or by the chronic use of nonsteroidal anti-inflammatory drugs like aspirin or ibuprofen (Advil, Nuprin)-taken by millions of women who suffer from chronic back pain, headaches, or arthritis.

Physicians have also become more aware of GI diseases that are more common in women than men. These include constipation, pelvic floor dysfunction, and certain liver diseases such as primary biliary cirrhosis, which can cause liver failure. One research study found that women who need liver transplants due to severe liver disease have much higher rates of bone fractures. This led to additional research, which found that women who had liver problems were at much higher risk of developing osteoporosis than men with liver problems. Further research found that women with other GI problems like inflammatory bowel disease also have a higher risk of osteoporosis. As a result of this work, women with these conditions now have bone density tests routinely and are given appropriate medications to prevent bone loss.

New findings also suggest that medications don't always work the same in women as in men. Researchers have discovered that men and women metabolize drugs differently because some of the liver enzymes that break down drugs are more active in women than in men. At least four of ten drugs removed from the market in recent years, due to unacceptable side effects, posed greater health risks to women than to men.

The field of women's digestive health is no passing fad. Female medical school students are entering gastroenterology in greater and greater numbers, often becoming subspecialists in women's health. During the last few years the number of women entering gastroenterology fellowship training increased dramatically. In 2002 one in four GI "fellows" was a woman! And many GI practices are specifically seeking out women to join their practice.

What's more, this past year the American Gastroenterological Association (AGA) along with the American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the American Association for the Study of Liver Disease, updated the GI training curriculum used for all gastroenterology fellows to include women's health issues. This training will focus on digestive disease issues specific to women, such as how menstruation, pregnancy, and menopause affect our digestive tract. It also touches on the use of stress management, herbal therapies, and other alternative therapies to relieve GI symptoms.

All of these issues are vital to getting the solutions you need to cure your digestive problems. They are all addressed in this book and really form the basis for why you, as a woman, need a digestive health book that's tailored for your unique health needs. Through this book I want to pass on the knowledge that I've learned by serving for more than ten years as an attending physician in the gastroenterology department at the University of Virginia (UVA) Hospital in Charlottesville. As founder of the Women's GI Clinic at UVA, I have focused my own clinical and research interests in women's digestive health.

why i started a women-only gi clinic

By and large, research studies on women's digestive health were just coming to light when I first made my decision to open a women's GI clinic four years ago. The basis for my decision was-pardon the pun-a gut instinct. My interest in women's health began several years ago when a colleague of mine, a midlife-health gynecologist, started referring all her patients over fifty to me for colon cancer screening. At that time flexible sigmoidoscopy was the most common scoping procedure to screen for colon cancer. During this procedure patients don't need to be sedated because the scope only goes part of the way up the colon. (Colonoscopy, which usually requires sedation, has begun to replace sigmoidoscopy because the colonoscope can reach through the entire span of the colon instead of just the lower one-third portion reached by the sigmoidoscope.)

As I performed sigmoidoscopies on these women, I found that many took the opportunity to ask me-in a confidential tone-about their GI woes. "I have diarrhea at certain times of the month. Is this normal?" asked one patient. "Why do I sometimes leak stool?" asked another. Another woman wanted to know, "Is it normal to have my bowel movements feel like they're getting stuck at the end of my rectum?"

I was peppered with questions about bloating, gas, hemorrhoids, and chronic indigestion and soon discovered that these women hardly ever discussed these problems with their primary care physicians. Most were too embarrassed to bring up their bowel habits during an annual exam. Many women told me they felt more comfortable talking to me because I was a woman. None had considered seeking out a gastroenterologist for help.

After talking with patient after patient during their routine colon screenings, I really felt that I had something to offer to the women of our community. I wanted to create an environment where women would feel comfortable opening up about their GI problems. I also knew from my experience that far too many women had digestive problems that ran much deeper than their symptoms. I've seen women whose constipation was caused by lingering memories of childhood incest or by years of sexual abuse by their husbands. Mothers have brought their daughters to me with unexplained diarrhea and vomiting and were shocked to hear that their daughters had an eating disorder and were inducing the diarrhea (by taking laxatives) and vomiting.

I knew there was a void in the area of women's digestive health that needed to be filled. My boss, Fabio Cominelli, the head of the gastroenterology department, agreed with me 100 percent. He backed my idea to start a women-only GI clinic staffed with women health professionals.

Mary, a fortyish mother of two, was one of my first patients. She suffered from such severe attacks of abdominal pain and diarrhea that she had trouble holding down a job and caring for her family. In fact, she told me, she knew the location of every public bathroom between her home and her workplace and found herself making frequent stops along the way. Mary saw several doctors in town but was never able to get relief from her symptoms. She began to think her doctors didn't believe she was actually in severe pain. Finally, her family physician called me and asked me to see her.

Mary and I spent the entire appointment talking about her symptoms and their triggers. I believed that she had IBS, and a few tests to rule out other conditions confirmed my diagnosis. On our next visit Mary paced around my office and told me that the last year had been incredibly stressful because of a troubled relationship with her daughter and her increased responsibility caring for her aging mother. I told her that I understood what she was going through and that I believed that her symptoms were very real. I also reassured her that her condition wasn't life threatening. Suddenly, I saw her shoulders relax. She stopped pacing and sat in a chair. She turned to me and for the first time really began to listen as I gave her details about a medical condition that had been plaguing her for many years.

We mapped out a plan of action. Mary agreed to keep a symptom diary, and I discussed several treatment options for her diarrhea and abdominal pain. I referred Mary to our pain psychologist to help her cope with her anxiety. I also encouraged her to take better care of herself. "IBS is most likely to strike when you're at your weakest, so if you exercise, cut the fat in your diet, and take time to do the things you enjoy, you'll be safeguarding yourself against another attack." At first I saw Mary every week, then once a month as her symptoms improved.

Now years later Mary still checks in with me every once in a while. She still has occasional bouts of IBS, but she now has control over her symptoms and has regained a full quality of life. Best of all, she has the awareness of why her attacks are occurring. She can usually pinpoint the stress trigger or knows when she's strayed from her healthy habits like walking every day or eating ample servings of fruits and vegetables.

If I had to sum up the goal of the Women's GI Clinic, I would use four words: Put women at ease. I want patients to feel as comfortable as possible so that they can freely discuss all those strange bodily functions that make us all squeamish. I have definitely found that communication is the absolute key to getting treatment. Even the best doctors can't diagnose and treat you if they don't know the full extent of your symptoms.

I hold the philosophy-as do many doctors-that you have to treat the whole person in order to effectively manage the medical problems. Too often we're tempted to just write a prescription and send patients on their way. But this is doing an extreme disservice. The Women's GI Clinic is based on a team approach. I am fortunate to work with some incredible women. From my secretary, Susan, to my invaluable nurse, Beth, we try hard to listen, care, and nurture. We know that medical conditions are usually triggered by a combination of factors-not one single thing.

In addition to nurses and medical residents, I wanted psychologists and nutritionists on hand to deal with the deeper issues that cause GI problems. I envisioned a holistic health center that would deal with a woman's digestive health problems on all levels-from psychological issues to nutrition planning.

Let's say you came to me because you were severely bloated, and part of the reason for your problem was that you were embarrassed to pass gas in a public place. I might refer you to a female psychologist that I work with who would suggest behavioral strategies for overcoming your problem. (I outline these strategies in Chapter 5.)

But I'm not here to tell you that you need to find a women's GI clinic in order to achieve relief from your symptoms. That would be hard to do if you don't live near one, and there are only a handful of clinics like mine scattered throughout the United States. You can still get the optimal care you deserve by finding the right doctor who will take all your symptoms seriously and treat you as a whole patient and by using this book as a supplement.