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Research has shown that there is an association between endometriosis and the risk of irritable bowel syndrome (IBS) in adults. However, adolescents and young women have been underrepresented in these studies and the extent to which there is an association between endometriosis and IBS in this population is unclear.
In Clinical Gastroenterology and Hepatology, Stacey Missmer, ScD, scientific director at the Boston Center for Endometriosis, and Amy DiVasta, MD, MMSc, of the division of adolescent/young adult medicine at Boston Children's Hospital, and colleagues, investigated the association between endometriosis and IBS in adolescents, and whether other factors, such as pain disorders or mood disturbances, influence that association.
What was the motivation behind this study?
Missmer: In 2020 the only definitive diagnosis of endometriosis is through surgical visualization. That means that we have a lot of anecdotal information about what women and patients are reporting and what clinicians are observing in their practices.
We also have this layer of complexity where the characteristics that get you to a surgical visualization appear to be associated with endometriosis. We know from our adult endometriosis patients -- but also particularly from our adolescent endometriosis patients -- that many of them when they present to pediatricians, adolescent medicine doctors, and family practitioners with pelvic pain, end up being referred to gastroenterology before being referred to gynecology. So, we have this very common, well-documented pattern of having had work-ups and dietary change recommendations, and several other recommendations specific to IBS, which is common in the history of those who ultimately come to gynecologists and have a surgical documentation of endometriosis.
Our study has one of the first longitudinal cohorts that specifically focuses on adolescents with endometriosis and we wanted to have a more precise quantification of the overlap in the history of endometriosis and IBS.
What were the results of the study?
Missmer: This study included 323 adolescents who had complete data and were under the age of 21. There was about a five-fold higher risk of IBS among those diagnosed with endometriosis compared with those who weren't.
The other thing that we thought was also important to explore was the overlap in this population of IBS and endometriosis diagnoses and the life-impacting markers in adolescence -- mood and sleep for instance -- and also the overlap with urinary symptoms. The figures show this is a really diverse group, that girls and young women with endometriosis present with a myriad of symptoms, and a myriad of life-impacting, multi-systemic sequelae that really have to be considered by the clinical practitioner to ensure that all aspects around quality of life, and health and wellness, are being taken into account.
Do we know what is behind this overlap between endometriosis and IBS?
Missmer: There are biologic hypotheses of why the two may arise concurrently. There are inflammatory milieu that present in both conditions. There are issues of smooth muscle contractility -- how the bowel and uterus function in terms of cramping and pelvic pain. There is also overlap around visceral hypersensitivity -- the experience of pain. There is a subgroup of patients who have pain expressions in multiple ways.
There is also a diagnostic overlap. If you are having abdominal pain, then you are looking at diagnosis differentials across gastroenterology and gynecology. That they are both being picked up independently is a function of how our medical system works.
What does the study suggest about the way gastroenterologists and gynecologists should be managing these patients?
Missmer: We think this is the most important takeaway from the study. Both gynecologists and gastroenterologists -- particularly those treating adolescents and young women -- need to be aware that these two conditions can co-present, and that given the presence of one, there is this five-fold increased risk that the other is present.
So, we want to make sure that both subspecialties are asking comprehensively about pain across the menstrual cycle, and for gastroenterologists to ask about cyclic pain, about menstrual-related symptoms, in addition to traditional IBS and gastroenterologic symptoms. And on the other side, gynecologists need to be asking about GI symptoms and bowel and urinary upset. Both specialties need to be doing this concurrently.
We have a sizeable portion of our adolescents who have finally been successfully diagnosed with endometriosis, but who spent years being treated by gastroenterology and never had endometriosis mentioned. And we also had the reverse, with those who have a successful endometriosis diagnosis not having their IBS symptoms addressed. The evidence from this study should solidify the belief that there is a significant overlap between IBS and endometriosis and that a holistic approach is needed.
What are the implications of your study regarding treatment?
Missmer: There are distinct but complementary treatment approaches around diet, about broader pain management, and around specifically cyclic versus acyclic pain. So knowing that both conditions are present brings together the full symptom spectrum, and the opportunity for improvement on all fronts, instead of just focusing on that one aspect of the adolescent's health.
Any future areas of research?
Missmer: As we keep following these young women we would like to evaluate if those who present with IBS symptoms, and then have a successful endometriosis treatment, have all of their symptoms improve over time. And the reverse, as well. If we can demonstrate that clinical attention on both fronts is having a superior outcome in both quality of life and symptom remediation for both conditions, that would be ideal.
Read the full article
Stacey Missmer, ScD, on the Association Between Endometriosis and IBS in Adolescents