1. IBD: Issues With Menstruation and Contraception

2. Menstrual Cycle and Bowel-Pattern Fluctuations Bowel-pattern fluctuation is common during the menstrual cycle Bowel-pattern fluctuation is common during the menstrual cycle IBD symptoms may increase during the menstrual cycle IBD symptoms may increase during the menstrual cycle Suppression of menses via hormonal contraceptive methods may be considered in presence of debilitating symptoms Suppression of menses via hormonal contraceptive methods may be considered in presence of debilitating symptoms

3. Potential IBD-Related Menstrual Symptoms Most frequently reported symptoms Most frequently reported symptoms –Pelvic pain 52% –Lower back pain 36% –Diarrhea 26% –Irritability 23% –Headache 20% Incidence of any menstrual symptoms significantly higher for IBD patients than for healthy controls (P .01) Incidence of any menstrual symptoms significantly higher for IBD patients than for healthy controls (P .01) Kane SV, et al. Am J Gastroenterol. 1998;93:1867-1872.

4. IBD: Issues With Menstruation There is a trend for patients with CD to be affected by IBD symptoms during menstruation to a greater extent than are patients with UC There is a trend for patients with CD to be affected by IBD symptoms during menstruation to a greater extent than are patients with UC CD patients experienced diarrhea significantly more often than did controls (P=.004) CD patients experienced diarrhea significantly more often than did controls (P=.004) Kane SV, et al. Am J Gastroenterol. 1998;93:1867-1872.

5. OCs and IBD Risk Controversial data Controversial data Increased incidence of CD with use of OCs? Increased incidence of CD with use of OCs? OCs related to flare of CD activity? OCs related to flare of CD activity? Newer OCs with lower estrogen content associated with decreasing incidence of CD in women? Newer OCs with lower estrogen content associated with decreasing incidence of CD in women?

6. CD Flare and OCs Adapted from Cosnes J, et al. Gut. 1999;45:218-222 with permission from BMJ Publishing Group. Days After Inclusion 500 0 60 50 40 30 20 10 Patients With Flare (%) OC use No OC use 0400300200100

7. OCs and IBD Risk 2.5 0.0 0.5 1.0 1.5 2.0 1960 Baltimore F:M incidence for 20-29-year age group Olmstead F:M incidence for 20-29-year age group US OC use (  5 million) Adapted from Alic M. Gut. 2000;46:140 with permission from BMJ Publishing Group. F:M Incidence Ratio 196519701975198019851990

8. Contraindications for OCs History of thromboembolic disease History of thromboembolic disease Active obstructive liver disease with elevated liver enzymes Active obstructive liver disease with elevated liver enzymes Breast cancer Breast cancer Smokers over the age of 35 Smokers over the age of 35 Pregnancy Pregnancy

9. IBD and Contraception: Conclusions OCs should have lower estrogen content (eg,  35 µg) OCs should have lower estrogen content (eg,  35 µg) Avoid for women with known hypercoagulability Avoid for women with known hypercoagulability Avoid for women with IBD-associated liver disease Avoid for women with IBD-associated liver disease Avoid for women with IBD who smoke Avoid for women with IBD who smoke