Recent research suggests that women with celiac disease may face a higher frequency of women’s health disorders, such as polycystic ovarian syndrome, irregular menstruation, infertility and primary ovarian failure.
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This abstract, “Women’s Health Disorders in a Celiac Disease Population — A Nationwide Cohort Analysis,” was recently presented by Rama Nanah, MD, a clinical hospitalist at Cleveland Clinic, during the American College of Gastroenterology (ACG) 2023 Annual Meeting.
“This is part of a series of research on women’s health and celiac disease,” notes Claire Jansson-Knodell, MD who has studied this area extensively and is a supervising author on the study. “Prior work has shown there is a female predominance of diagnosed celiac disease with suggested gender-related differences in clinical presentation. However, many questions remain and there is a need for further study.”
Dr. Jansson-Knodell, Dr. Nanah and colleagues set out to examine the nationwide rates of women’s health disorders affecting female patients with celiac disease in the U.S. and raise awareness of these associations.
Study details and findings
In this large scale, nationwide study, the researchers conducted a retrospective analysis using TriNetX—a database that gathers real-time patient records from 80 healthcare organizations.
“We pulled out all the women with celiac disease and compared them to a population without the condition,” explains Dr. Ramah, while noting that the research used strict inclusion criteria to ensure the women identified had a definitive celiac disease diagnosis.
“Celiac disease was identified using ICD-10 code (K 90.0) as well as a positive celiac serology, dietary counseling or abnormal histology findings,” she says. “We were very careful about our design to make sure that we were capturing the right population. Similarly, we excluded any patients who had a diagnosis of non-celiac gluten sensitivity.”
The researchers performed propensity score matching based on age, race, and BMI. Next, women with celiac disease who were between the ages of 10 and 60 years were compared to ambulatory women without prior positive celiac serology, according to Dr. Jansson-Knodell.
The study included 9,368 women with celiac disease and 25 million outpatient women without celiac disease. When compared to patients without the condition, celiac disease patients were predominantly white (83% vs. 47%) and had a lower mean BMI (24.6 vs. 26.1).
Data showed that women with celiac disease had statistically significant higher odds of primary ovarian failure (0.96% vs. 0.16%) including ovarian dysfunction (4.4% vs. 1.25%) and polycystic ovarian syndrome (3.3% vs. 1%), irregular menstruation (15.5% vs. 6.9%), and dysmenorrhea (10.9% vs. 4.24%).
Additionally, Dr. Jansson-Knodell and colleagues reported that the following women’s health issues occurred at higher rates among those with celiac disease: menopausal and peri-menopausal disorder (4.3% vs. 1.56%), endometriosis (2.3% vs. 0.93%), infertility (1.44% vs. 0.85%), absent/rare menstruation (4.6% vs. 2%) and recurrent pregnancy loss (1.78% vs. 0.37%).
The authors also separated the study population into groups to better understand the effects on different phases of life, explains Jansson-Knodell. “We looked at a pediatric population (ages 10 to 18), a reproductive age group (ages 19 to 35), later reproductive years/pre-menopausal (ages 36 to 45), and then peri-menopausal, menopausal and post-menopausal (ages 46 to 60).
“We found that when we did this our findings remained statistically significant,” she says. “And while we found that concerns change throughout the course of a woman’s life and reproductive years, we still saw higher rates in patients with celiac disease across many of these areas.”
Dr. Nanah adds, “Because findings remained significant in the groups that underwent propensity score matching for BMI, we know that these higher rates are not, at least completely, related to lower weight and malnutrition that patients with celiac disease usually suffer from, as some prior theories suggested.”
Takeaways and next steps
The most significant finding from this study, notes Dr. Jansson-Knodell, is that women with celiac disease have higher odds of a number of gynecologic conditions, in particular, endometriosis, infertility, recurrent pregnancy loss and absent/rare menstruation, compared to their non-celiac disease counterparts.
“We found that the fertile period was shorter for women with celiac disease than those without celiac disease, which could have implications for these patients in terms of family planning,” she says, while also noting that the connection between celiac disease and fertility issues is supported by prior research and anecdotal evidence. “However, we were surprised to see the association between celiac disease and higher odds of a number of different women’s health conditions beyond those related to fertility.”
Dr. Jansson-Knodell cautioned that this study does not include any data on how compliant a person was with a gluten-free diet. “And so, we cannot comment on how protective that may or may not be against some of these conditions,” she notes. “Investigating the impact of a gluten-free diet is an important next step and will require more individual, patient-level data.”
Overall, this study underscores the importance of being aware that these women’s health conditions can coexist with celiac disease, Dr. Jansson-Knodell emphasizes. “Clinicians need to be cognizant of these associations to not only screen for celiac disease in women with these conditions but also detect the presence of these women’s health issues among celiac disease patients,” she says. “We are hopeful that through our research, we are raising awareness of higher rates of women’s health disorders in Celiac women among gastroenterologists.”
“Multidisciplinary care is critical,” Dr. Jansson-Knodell concludes, “Organizations as a whole most work together to take care of our patients, which will include collaborating with our partners in OB/GYN and other departments. Early involvement of multidisciplinary care can decrease suffering and offer more treatment options.”