Endometriosis Linked to Upper GI Symptoms and Higher Healthcare Usage

New findings from Cleveland Clinic researchers illustrate the importance of evaluating for gynecologic overlap in women presenting with upper gastrointestinal (GI) symptoms such as nausea or gastroparesis. The retrospective chart review, which appeared in Clinical Gastroenterology and Hepatology, compared the GI symptoms and healthcare utilization in women with and without endometriosis.

Although endometriosis is typically associated with abdominopelvic pain and painful, heavy periods, the vast majority of women with the condition experience GI symptoms as well, including constipation, bloating, diarrhea and nausea. Women with endometriosis also have a much higher risk of developing irritable bowel syndrome (IBS) than women without, and some studies indicate rates as high as 52%.¹ Patients with both endometriosis and IBS also report lower pain thresholds and more painful menstrual cycles than patients with just one of the conditions alone.

“As long as I’ve worked in GI, I’ve noticed a high prevalence of gynecologic conditions in our patients,” says Madison Simons, PsyD, a gastrointestinal psychologist in Cleveland Clinic’s Digestive Disease Institute and lead author on the paper. “It’s something that I’ve been screening for since early in my career, and this research was really a preliminary investigation into women with and without endometriosis with GI conditions and how they present. One of the biggest challenges for this patient population is how long a diagnosis can take. So, we felt that any insights that could allow us to identify and diagnose these patients faster would be incredibly valuable.”

Study design and findings

The research group reviewed the medical charts of adult women with endometriosis and compared them with women without who presented for evaluation of GI symptoms to an outpatient gastroenterology clinic at a tertiary care hospital. The final sample of patients included 6,736 women who were seen between the years of 2010 and 2022. Of these, 3,236 were women with endometriosis (GYN) and 3,500 women without endometriosis were included as control subjects (GI). The group evaluated patient demographics, health care utilization (defined as the number of outpatient visits, emergency department visits, hospitalizations, telephone encounters and abdominal surgeries) and how patients were diagnosed at their visits by the ICD-10 codes in their chart.

The study population was 78.2% white and had a mean age of 53.8 years at the time of consultation. The GYN group was younger (M = 49.5 years compared with 57.8 years; P < .001) and more likely to be non-white (P < .001 for both race variables). The GYN group was significantly more likely to have abdominal pain (right upper quadrant, epigastric, generalized), abdominal distention, nausea, change in bowel habits, iron deficiency anemia and gastroparesis. However, the GI group was significantly more likely to be seen for Crohn’s disease and abnormal weight loss.

The researchers also found that the GYN group had higher rates of healthcare utilization than the GI group in most aspects of care provision. While the GYN group had fewer outpatient visits, they had more hospitalizations, telephone encounters, and abdominal surgeries (all P < .001) compared with the control group. The range of emergency department visits for the GYN group spanned from 0-327 visits compared to 0-88 visits for the GI group. The range of hospitalizations for the GYN group (0-147) was also higher than the GI group (0-66).

“We expected that women with multiple conditions would likely have higher rates of healthcare utilization,” says Dr. Simons. “But we found that women with endometriosis had higher healthcare utilization almost across the board. What stood out most from our findings, though, were the types of diagnoses that we saw in women with endometriosis compared to without.”

She continues, “Historically, we’ve focused on the overlap between endometriosis and lower GI symptoms, but that's not what we saw in this data set. Our findings show that these women were often driven by upper GI symptoms — things like dyspepsia and gastroparesis. I think the biggest takeaway here is the importance of thorough screening and recognizing that potential gynecologic overlap in women presenting with GI symptoms can’t be ruled out simply by symptom location.”

Care at Cleveland Clinic

Dr. Simons explains that it has been important for her and her GI colleagues to continue developing relationships with the gynecologists at Cleveland Clinic. She says that the strong connection between the specialty groups has allowed for smooth transitions and collaboration between these disciplines.

“Over the last two years, I’ve seen more gastroenterologists who are exploring gynecologic conditions in patients with GI conditions spanning the GI tract,” says Dr. Simons. “We also have gynecologists who are getting input from their gastroenterology colleagues earlier on in the process. This has helped us identify these women faster so we can give them treatments earlier and help improve their quality of life. If we're asking questions about gynecologic symptoms right at the front end, we're going to shorten the diagnosis time for this patient population and reduce their healthcare utilization.”

References

Issa B, Onon TS, Agrawal A, et al. Visceral hypersensitivity in endometriosis: a new target for treatment? Gut. 2012;61:367–372.