Celiac Disease in women

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Celiac Disease in women

• Mohamed Kandeel, M.D.
• Professor of Obstetrics and Gynecology
• Menofyia University
• Egypt

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Learning Objectives

• At the end of this presentation you should
• 1-Enumerate the problems a woman affected with
  celiac disease may encounter during her life
• 2-Be aware of the methods of diagnosis of celiac
  disease
• 3-Describe effective control for the disease to
  minimize symptoms and long term sequelae of the
  disease

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Magnitude of the Problem of Celiac Disease

• Celiac disease is an autoimmune disease
  affecting the small intestine. Various studies
  have shown its association with other autoimmune
  endocrinologic disorders affecting different
  organs -systems- of the body such as diabetes,
  thyroid disorders and infertility. In fact 50 of
  patients affected with celiac disease have
  atypical presentations not involving the GIT and
  consequently, many celiacs are expected to seeks
  medical advice from specialists other than
  gastroenterologists. We, as Ob/Gyns, should be
  aware of the different presentations of the
  disease that we may encounter at the office.

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Definition

• Celiac disease is a life long autoimmune
  enteropathy affecting small intestine
  characterized by a permanent intolerance to
  dietary gluten. Gluten is a protein found in the
  cereal grains of wheat, rye, barley oats.
• In affected individuals, ingested gluten causes
  inflammation and damage to the small bowel. This
  damage impairs the normal absorption of food
  leading to nutritional deficiencies and
  therefore, can affect the body in many different
  ways.

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Incidence

• The incidence of Celiac disease varies between
  1-100 to 1-300 in the general population
  according to geographical distribution. Generally
  speaking, celiac disease is more common in women
  than men. This high incidence can be explained by
  the fact that women are more keen about their
  health compared to males and therefore, they seek
  early medical advise. The high incidence of the
  disease in women can be just a simple reflection
  of this behavior.

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Incidence (Cont.)

• The incidence of celiac disease varies among
  specific groups. It ranges between 4-8 among
  women diagnosed with unexplained infertility.
  About 6 of anemic women have undiagnosed celiac
  disease. A recent study suggested that 3-4 of
  women who have osteoporosis have celiac disease.

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Effect on Menstruation

• 1- Amenorrhea is a possibility
• 2-Short fertile period affected women have late
  menarche and early menopause

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Effect on pregnancy and lactation

• 1-Iron deficiency anemia due to
• a-Malabsorption of dietary iron
• b-Occult blood loss from gastro-intestinal tract
• 2-Poor absorption of folic acid leading to
  recurrent miscarriages and increased theoretical
  risk of of neural tube defects in babies of
  affected mother

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Effect on pregnancy and lactation

• 3-Increased incidence of IUGR and low birth
  weight babies
• 4-Higher incidence of preterm birth and Cesarean
  sections among affected mothers
• 5-Shorter duration of breast feeding

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Effect on Fertility

• 1- Unexplained infertility
• 2-Recurrent miscarriages
• 3-Poor quality seminal fluid was detected in
  males affected with celiac disease

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Effect on bone mineral density

• Celiac disease decreases bone mineral density in
  affected women. The underlying mechanism is
  related to calcium malabsorption and subsequent
  increase in parathormone secretion by the
  parathyroid which, in turn, increases bone
  turnover.
• Treatment with vitamin D may be required in the
  presence of osteomalacia. 

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Complications

• 1-Malignancies lymphoma of the small intestine,
  non Hodgkins lymphoma, Cancer of the pharynx,
  oesophagus and small intestine are all well
  recognized in association with celiac disease.
• 2-Osteoporosis
• 3- Bleeding tendency
• 4-Refractory celiac disease in longstanding
  cases not on or not responding to, free gluten
  diet

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Diagnosis

• I- Symptoms include
• 50 of patients show the classic form of the
  disease of chronic diarrhoea, nausea, vomiting,
  flatulence, bloating, abdominal pain and weight
  loss. Fatigue, weakness and lethargy are also
  common associated symptoms.
• Many affected adults lack GI symptoms present
  with a wide spectrum of manifestations such as
  insulin-dependent diabetes, joint pains,
  osteoporosis, iron, folate, B12 deficiency,
  depression, dermatitis herpetiformis
  infertility

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Diagnosis (Cont.)

• II-Serology tests are used to measure antibodies
  formed against the breakdown products of ingested
  glutens and the enzymes that mediate the tissue
  damage in the disease. Because of their high
  sensitivity, they are used for screening. They
  also can be used to monitor response of patients
  on strict gluen diet.
• 1-Antigliadin antibodies (AGA)
• 2-Anti-tissue antibodies (tTGA)
• 3-Antiendomysial antibodies (EMA)

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Diagnosis (Cont.)

• III-The gold standard diagnostic test is
  endoscopic biopsy of the upper small bowel.
  Because of the invasive nature of this, it should
  be reserved only for those with positive
  screening serology tests. However, A negative
  test may still prompt a biopsy if the clinical
  suspicion is high. 4-8 biopsies should be
  obtained for diagnosis from either the distal
  duodenum or the proximal jejunum.

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Diagnosis (Cont.)

• IV-Prothrombin time and partial thromboplastin
  time useful to identify deficiency of vitamin K,
  which predisposes patients to hemorrhage
• V-Radiology has no role in the diagnosis of
  celiac disease. However, it can help rule out
  other pathologies of gastro-intestinal disease.

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Treatment

• 1-The standard treatment is gluten free diet for
  life. It is essential to relieve symptoms and
  avoid long term complications of the disease.
  Avoid all foods made from wheat, rye, and barley.
• Examples are
• -Breads, cereals, pasta, cakes and cookies
• -Sausages, processed and canned meats
• -Yogurt, ketchup and mustard
• -Candy bars and ice cream

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Treatment (Cont.)

• 2-Avoid medications and vitamin preparations
  which contain gluten.
• 3-Steroids or immunosuppressants in refractory
  cases
• 4- Supplemental iron, folate, B12, calcium and
  magnesium.

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Thank You