Need for Awareness and Training in Women's Gastrointestinal Health: A Call to Action

Patient care

Quality of medical healthcare is often assessed based on the patient's relationship with their provider and satisfaction with meeting expectations. A female patient may be less likely to discuss her bowel habits or seek medical care for delicate problems such as fecal incontinence unless she is in a comfortable setting. This underscores the importance of having gastroenterologists and fellows recognize the gender differences that underlie seeking medical care. Multiple studies have suggested that female patients prefer female endoscopists, and are willing to wait for their procedures until one becomes available. ^{3 –5}

Women face added challenges during endoscopies, particularly colonoscopy. They tend to have longer and more tortuous anatomy, and those who previously underwent hysterectomy or other pelvic surgeries may be predisposed to adhesions, complicating the procedure. This results in lower completion rates, longer procedure times, and greater sedation requirements. Women are also less compliant with colorectal cancer screening and less likely to be referred by their primary care physicians compared with breast or cervical cancer screenings. ⁶ Studies have shown that women tend to underestimate the risk of colorectal cancer, despite the fact that it is the second most common malignancy in women. ^6,7 In a survey conducted by Bocci et al., women reported greater embarrassment to undergo a colonoscopy compared with a PAP smear. ⁶ However, >40% of women felt they would feel less awkward if the colonoscopy was performed by a member of the same sex. ⁶

Training

In 2003, the Gastroenterology Leadership Council mandated training in women's health issues in digestive diseases as part of the Gastroenterology Core Curriculum (GCC). ⁸ They insisted that gastroenterology fellows gain an understanding of both general women's health issues and specific digestive diseases more prevalent in women, especially during pregnancy and childbearing. In addition, 25% of all patients seen in each of the clinical settings, including continuity clinics and procedures, must be women. ⁸ However, inadequate guidance and implementation, lack of exposure to appropriate patient populations (e.g., pregnant patients), deficits in knowledge in this field at the faculty level, and poor multidisciplinary collaboration, prevent some programs from meeting these specific training goals. ⁹

At present, there is only one fellowship program specific to women's GI health. This program was founded in 1996 at the Warren Alpert Medical School of Medicine/Brown University, with a well-developed curriculum that was adopted from the GCC to address the spectrum of women's health issues (Table 1). The goal of this program is to develop academic gastroenterologists with a specific interest and expertise in women's GI health, who can subsequently become leaders of this emerging field.

The Women and Infants Hospital is associated with this fellowship program and has a women's-only endoscopy unit designed for women to feel comfortable during their procedures. In 2009, they reported 699 outpatient encounters for either a new consultation or a follow-up visit for a GI disorder in pregnancy. ¹⁰ They noted a threefold rise in the number of visits >3 years, suggesting an increasing need and demand specifically for gastroenterologists overseeing women during pregnancy. ¹⁰ A few other academic programs have started adopting similar initiatives to train their gastroenterology fellows in this field; however, most are lagging behind.

The women's GI health fellowship incorporates an equal exposure to inpatients, outpatients, endoscopy, didactic conferences, and research in this field. Fellows perform inpatient consultations covering pregnant and nonpregnant women with GI problems, daily at the Women and Infants Hospital and Rhode Island Hospital. Fellows also care for dedicated pregnant women weekly in the GI pregnancy clinic for women with new or pre-existing GI disorders in pregnancy. In an attempt to further expand their exposure, fellows are given an option to rotate with the urogynecology and colorectal surgery services to learn a multidisciplinary approach to managing pelvic floor disorders. They can also choose to collaborate with the clinical nutrition or obstetrics medicine team to better care for their pregnant patients.

Female gastroenterologists bring unique attributes to a practice, and many show interest in a multidisciplinary approach—especially for women's health. Studies show that they are more likely than men to enact policies favorable to women and children's health. ¹¹ The Association of American Medical Colleges in 2018 reported that only 17.6% of women were actively practicing as gastroenterologists, whereas 33.9% of female fellows pursued the gastroenterology training. ¹² In 2019, only 13% of women matched into the advanced endoscopy fellowship. ¹³ It is not uncommon to see fewer women than men in academic gastroenterology, particularly in senior positions.

Gender discrimination has negative effects beyond the damage to individual women's careers, including psychological stress, worsening physical health, lower job satisfaction, organizational commitment, and detachment to work. ¹⁴ Organizations miss out on gender-balanced leadership, whereas some patients may prefer the unique communication skills of a female physician. Similar to other professions, women in gastroenterology face gender-specific challenges, namely flexible work hours, access to childcare, and loss of confidence after pregnancy. ¹⁵ Historically, training programs have rarely attempted any form of formal evaluation of the experience provided by their training. ¹⁵

Owing to the relatively small numbers of women in gastroenterology, female trainees have limited female role models and opportunities to be mentored and sponsored by senior women in their fields. We need more women in leadership positions speaking at national meetings and sharing their experiences, working closely with the industry, and publishing articles to pave the way for the next generation. Women should also be actively recruited for research and leadership opportunities to allow their perspectives to be heard. A recent study showed that first time female principal investigators received an average of $40,000 less in NIH funding per grant than male principal investigators despite controlling for researcher qualifications and subject content. ¹⁶ Department leaders should ensure female physicians have similar opportunities and are equally compensated as their male counterparts.

Women's GI health

A better understanding of GI and liver disease effects on fertility, pregnancy, and vice versa will help deliver better subspecialty care for women. Common pregnancy-related problems such as heartburn (present in 80% of pregnant women) require vast and deep knowledge of drug safety and the pathophysiology of gastroesophageal reflux disease. For more potentially serious problems such as abdominal pain, one needs a deeper understanding of the causatives and time of occurrence during pregnancy.

Most pregnancy-related mild GI symptoms such as vomiting and constipation are managed by the obstetrician ¹⁷ ; however, gastroenterologists should be aware of certain serious complications. Gastroesophageal reflux disease and inflammatory bowel disease (IBD) may be exacerbated during pregnancy and conversely, IBD may be associated with worse pregnancy outcomes, even during quiescent disease. ^18,19 Abortion and preterm birth may happen during active disease, whereas there is an increased risk of preterm birth, stillbirth, and low birth weight during exacerbations. ¹⁹ Therefore, it is advised that IBD women have a 3- to 6-month period of sustained remission before conception. ¹⁸ Active disease during pregnancy should be treated, as inflammation poses a higher risk to the fetus compared with the side effects of medications. During pregnancy, most treatments can be used except methotrexate and thalidomide, as they are teratogenic. ²⁰ The latest European Crohn's and Colitis Organisation consensus recommends stopping anti-tumor necrosis factor therapy in the last trimester, but other studies have demonstrated a benefit in maintaining treatment through all trimesters. ²¹

Hepatobiliary disorders unique to pregnancy include intrahepatic cholestasis of pregnancy, hemolysis, elevated liver enzymes, low platelet count syndrome, and acute fatty liver of pregnancy. A recent study highlighted that women with maternal Hepatitis B surface antigen-positive status may have a higher risk of gestational diabetes, intrahepatic cholestasis of pregnancy, preterm birth, and neonatal asphyxia. ²² Meanwhile, acute hepatitis E infection compared with other hepatotropic viral infections is found to be more virulent during pregnancy, causing frequent progression to fulminant hepatic failure with a mortality rate of up to 10%–20%. Unfortunately, treatment remains supportive, and the best approach is through prevention. ²³

Endoscopy is considered low risk during pregnancy for appropriate indications, and all elective procedures are deferred until after delivery. Upper endoscopy with epinephrine injection, thermocoagulation, sclerotherapy, and endoscopic band ligation are safe and successful procedures during pregnancy. ²⁴ Sigmoidoscopy is generally performed to evaluate major lower GI bleeding, suspicion of colonic mass, and severe persistent diarrhea with unknown etiology. ²⁴ Colonoscopy, in contrast, is only performed if necessary for diagnostic or therapeutic decisions. Endoscopic retrograde cholangiopancreatography is usually avoided due to radiation exposure to the fetus; however, endoscopic ultrasonography can be done to reduce unnecessary interventions in patients who have a lower or moderate probability of choledocholithiasis. ²⁴

Estrogen and progesterone levels change during menstruation, pregnancy, and menopause, which affect the GI tract and liver function, may worsen pre-existing functional disorders such as gastroesophageal reflux disease and irritable bowel syndrome. The involvement of estrogen in visceral pain processes is complex, as estrogens drive both pro- and antinociceptive pathways that affect abdominal pain perception in women and quality of life in disease states. ²⁵ Many GI disorders and chronic diseases may also psychosocially impact a woman's daily life. This should be addressed in the outpatient setting, and an effective treatment plan may include a multidisciplinary approach, depending on the GI disorder.

Pelvic floor dysfunction, which includes pelvic organ prolapse, urinary incontinence, and fecal incontinence, is seen in about 25% of women and becomes more prevalent as they age. ²⁶ The Mature Women's Health Study reported two-thirds of women with fecal incontinence do not seek care for their symptoms even though 40% of them experience symptoms severe enough to affect their quality of life. ²⁷ Fecal soiling is also the second leading cause for placement in a skilled nursing facility, resulting in emotional distress and skin irritation, which may cause further decline of the elderly. ^26,27 Treatment typically starts with noninvasive strategies, including dietary changes, Kegel exercises, and pharmacological agents. Later, minimally invasive procedures such as nerve stimulation, sphincter augmentation with injectable bulking agents, or radiofrequency energy are commonly attempted before resorting to invasive surgeries such as sphincteroplasty, sphincter repair, or fecal diversion surgery.