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Endometriosis Associated With Later Development of IBD

  • Authors: News Author: Ricki Lewis, PhD
    CME Author: Laurie Barclay, MD
  • CME Released: 12/29/2011
  • Valid for credit through: 12/29/2012
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Target Audience and Goal Statement

This article is intended for primary care clinicians, gynecologists, and other specialists caring for patients with endometriosis who may be at risk for inflammatory bowel disease.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the risk for inflammatory bowel disease in women with endometriosis vs women in the general population, based on a nationwide Danish cohort study.
  2. Describe the risk for inflammatory bowel disease in women with endometriosis at 20 years after diagnosis, and other factors affecting the association of endometriosis with the risk for the disease.


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  • Ricki Lewis, PhD

    Freelance writer for Medscape


    Disclosure: Ricki Lewis, PhD,  has disclosed no relevant financial relationships.


  • Brande Nicole Martin, MA

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin, MA, has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Endometriosis Associated With Later Development of IBD

Authors: News Author: Ricki Lewis, PhD CME Author: Laurie Barclay, MDFaculty and Disclosures

CME Released: 12/29/2011

Valid for credit through: 12/29/2012


Clinical Context

There is thought to be an association between endometriosis and certain autoimmune diseases, such as multiple sclerosis, Sjögren's syndrome, and systemic lupus erythematosus. Both endometriosis and inflammatory bowel disease (IBD) are chronic inflammatory disorders with immunologic alterations and typical onset in young adulthood, and both diseases may also affect the bowel and may cause abdominal pain.

To date, however, it is unclear whether the presence of endometriosis affects the risk for IBD. The objective of this study by Jess and colleagues was to determine the risks for Crohn's disease and ulcerative colitis in an unselected nationwide Danish cohort of women with endometriosis.

Study Synopsis and Perspective

Endometriosis is associated with an increased risk of developing IBD, according to a large-scale, long-term study by Danish researchers published online December 19 in Gut.

Both endometriosis and IBD present with abdominal pain, typically begin in early adulthood, and are chronic inflammatory disorders. In the past, diagnosis of one has precluded diagnosis of the other. However, Tine Jess, MD, and colleagues from the Statens Serum Institute in Copenhagen, Denmark, examined national registers to investigate the possibility that instead of being mutually exclusive, perhaps endometriosis predisposes a woman to developing IBD.

The researchers examined the medical histories of 37,661 women hospitalized for endometriosis at any time between 1977 and 2007. Of these women, 320 developed IBD (228 women developed ulcerative colitis, 92 developed Crohn's disease). The women with endometriosis had an increased risk for IBD overall (standardized incidence ratio [SIR], 1.5; 95% confidence interval [CI], 1.4 - 1.7), as well as for ulcerative colitis (SIR, 1.5; 95% CI, 1.3 - 2.0), compared with women in the general population. Stratifying the patient groups by those who underwent surgery that verified the endometriosis led to an increase in IBD risk of 80% (ulcerative colitis: SIR, 1.8 [95% CI, 1.4 - 2.3]; Crohn's disease: SIR, 1.7 [95% CI, 1.2 - 2.5]).

The increased risk persisted for 2 decades after diagnosis of IBD, and the average lag between endometriosis diagnosis and development of IBD was approximately 10 years. The fact that the association persists argues for its strength.

The researchers hypothesize 2 explanations for the association between the 2 disorders: that they share a common underlying inflammatory problem, or that treatment for endometriosis (oral contraceptive use) increases the risk for IBD.

Strengths of the study, the authors write, include that the population has free, universal health care and excellent diagnosis registries that collect data prospectively, minimizing recall bias. The study covered many years and adjusted for age and period-specific IBD incidence in the general population.

Limitations of the study include omission of mild endometriosis cases and risk of ascertainment bias, as both types of diagnoses came from the same register. Another confounding factor might arise from the fact that the mean age at endometriosis was elevated (38.6 years), suggesting that some women may have been diagnosed when seeking infertility treatment.

The researchers conclude, "there is still a need for large-scale unselected cohort studies to confirm the influence of oral contraceptive use on the short- and long-term risk of IBD, not least in the context of concurrent endometriosis."

The lead author was supported by a grant from the Danish Council of Independent Research. The researchers have disclosed no relevant financial relationships.

Gut. Published online December 19, 2011. Abstract

Study Highlights

  • In this nationwide Danish cohort study, 37,661 women hospitalized with endometriosis during 1977-2007 were identified via national registers.
  • Mean age was 38 years.
  • The relative risk for the development of IBD after a diagnosis of endometriosis was calculated as the ratio of observed vs expected incidence, yielding SIRs and 95% CIs.
  • The overall risk for IBD was increased in women with endometriosis (SIR, 1.5; 95% CI, 1.4 - 1.7), as were separately calculated risks for ulcerative colitis (SIR, 1.5; 95% CI, 1.3 - 1.7) and Crohn's disease (SIR, 1.6; 95% CI, 1.3 - 2.0).
  • The increased risk for IBD persisted even 20 years after a diagnosis of endometriosis, with the SIR for ulcerative colitis being 1.5 (95% CI, 1.1 - 2.1) and the SIR for Crohn's disease being 1.8 (95% CI, 1.1 - 3.2).
  • When the analyses included only women with surgically verified endometriosis, the associations were even stronger (ulcerative colitis: SIR, 1.8; 95% CI, 1.4 - 2.3; Crohn's disease: SIR, 1.7; 95% CI, 1.2 - 2.5).
  • On the basis of these findings, the investigators concluded that the risk for IBD in women with endometriosis was increased even in the long term, suggesting a genuine association between the diseases.
  • This association could either reflect common immunologic features or an effect of endometriosis treatment with oral contraceptives on the risk for IBD.
  • The investigators also note that a diagnosis of either endometriosis or IBD should not lead to the other diagnosis being excluded and should not disqualify further clinical examination of patients with persisting abdominal or gynecologic symptoms.
  • The role of treatment of endometriosis in the risk for IBD needs to be studied further.
  • Limitations of this study include lack of generalizability to ambulatory settings outside of Danish hospitals, risk for ascertainment bias, rather high mean age of the women diagnosed with endometriosis, and overlap of diagnosis of Crohn's disease and ulcerative colitis in 9.4% of patients.

Clinical Implications

  • In a nationwide Danish cohort study, women with endometriosis had a 50% increase in the risk for IBD vs women in the general population.
  • This nationwide Danish cohort study also showed that women with endometriosis are at increased risk for the development of Crohn's disease and ulcerative colitis, even after more than 20 years of follow-up.

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