The association between new generation oral contraceptive pill and the development of inflammatory bowel diseases

Use of contraceptives and risk of inflammatory bowel disease: a nested case-control study

BACKGROUND

How contraceptive formulation, dose, duration of therapy and mode of delivery affects the risk of inflammatory bowel disease (IBD) is poorly described.

AIM

To examine associations between types of hormonal contraception and development of IBD.

METHODS

This was a nested case-control study using IQVIA Medical Research Data. Women aged 15-49 years with a new diagnosis of IBD were matched with up to six controls by age, practice and year. Odds ratios (OR) and 95% confidence intervals (95% CI) for incident IBD and use of contraception were calculated.

RESULTS

4932 incident cases of IBD were matched to 29 340 controls. Use of combined oral contraceptive pills (COCPs) was associated with the development of Crohn's disease and ulcerative colitis (OR 1.60 [1.41-1.82] and 1.30 [1.15-1.45], respectively). Each additional month of COCP exposure per year of follow-up increased risk of Crohn's disease by 6.4% (5.1%-7.7%) and ulcerative colitis by 3.3% (2.1%-4.4%). Progestogen-only pills had no effect on Crohn's disease risk (OR 1.09 [0.84-1.40]) but there was a modest association with ulcerative colitis (OR 1.35 [1.12-1.64]). Parenteral contraception was not associated with the development of Crohn's disease or ulcerative colitis (OR 1.15 [0.99-1.47] and 1.17 [0.98-1.39], respectively).

CONCLUSIONS

We observed an increase in the risk of IBD with increasing duration of exposure to COCPs. Progestogen-only pills were not associated with Crohn's disease but there was a modest association with ulcerative colitis. There was no association between parenteral progestogen-only contraception and IBD. These findings are broadly consistent with a hypothesis that the oestrogen component of contraception may drive IBD pathogenesis.

Estrogen receptor actions in colitis

In recent years, researchers have demonstrated that estrogen and its receptors, aside from their role in regulating several biological functions, contribute to the development and progression/severity of inflammatory bowel diseases (IBDs). IBDs include both ulcerative colitis (UC) and Crohn's disease (CD). Epidemiological data indicate a clear difference in the incidence, severity, and complications of IBDs between sexes. Men present a higher risk of developing colitis than women and a higher risk of developing colorectal cancer, a common complication of this condition. However, fluctuations of estrogen levels have yielded inconsistent data, where oral contraceptives and hormone replacement therapy have been associated with an increased risk of IBDs in premenopausal women but significantly reduce disease activity after menopause. Likewise, improvement of symptoms related to CD has been reported during pregnancy, but not in UC, who often experience worsening symptoms. In the colonic epithelium, estrogen receptor β (ERβ) is the predominant form of the protein expressed, and it helps maintain normal epithelial function and organization. Preclinical data suggest that ER expression and activation via estrogen confers different responses on disease severity depending on the model used to induce colitis, which may reflect what is observed in patients with IBDs. Hence, this review aims to provide an overview of estrogen and its receptors, particularly ERβ, in the pathophysiology of IBDs.

Sex-based differences in inflammatory bowel diseases: a review

Sex-based differences in inflammatory bowel disease (IBD) pathogenesis, disease course, and response to therapy have been increasingly recognized, however, not fully understood. Experimental and translational models have been leveraged to investigate hypothesized mechanisms for these observed differences, including the potential modifying role of sex hormones and sex-dependent (epi)genetic and gut microbiome changes. The primary objective of this review is to comprehensively describe sex-based differences in IBD including epidemiology, pathogenesis, phenotypic differences, therapeutic response, and outcomes.

Environmental Factors in Romanian and Belgian Patients with Inflammatory Bowel Disease - a Retrospective Comparative Study

Background:Several environmental factors have been associated with onset of inflammatory bowel diseases (IBD): smoking, hygiene, microorganisms, oral contraceptive pills (OCPs), non-steroid anti-inflammatory drugs, antibiotics, appendectomy, diet, breastfeeding, vitamin D, stress and ambient air pollution. The aim of this study was to investigate the prevalence of these factors in a Romanian and Belgian population with IBD. Material and methods:A total of 129 patients with an IBD diagnosis (76 from Romania and 53 from Belgium) participated in an interview and were asked to fill in a questionnaire regarding environmental factors before and after the onset of IBD; 35 Romanian and 21 Belgian healthy individuals constituted the control group. Results:A total of 40 patients with ulcerative colitis (UC) and 89 with Crohn's disease (CD) were included. Gender distribution was 43% males and 57% females. They had a median age of 42 years (range between 19-74 years), a median disease duration of eight years and 79% were in clinical remission. Both Romanian and Belgian IBD patients reported an increased antibiotic consumption before IBD onset compared to controls: 58% vs 10% (p<0.001) and 51% vs 5% (p<0.001), respectively. Belgian IBD patients declared significantly more frequent OCP use (53% vs 9%, p <0.001), they were breastfed in a lower proportion (49% vs 76%, p <0.001) and had experienced a higher level of psychosocial stress (p<0.001). Conclusion:Antibiotic consumption before IBD onset may play a pivotal role in IBD development in both Romanian and Belgian populations. In Belgian patients, OCP consumption, a higher level of psychosocial stress and lack of breastfeeding may also be involved.