Oral contraceptive use and ischemic colitis in young women

Source: Deana DG, Dean PJ: Reversible ischemic colitis in young women: association with oral contraceptive use. Am J Surg Pathol 1995; 19: 454-462

Summary: Canadian Medical Association Journal 1996; 154: 527-528

Although ischemic colitis is unusual among adults under the age of 40, it can occur in association with conditions such as hypovolemic shock, vasculitis and drug use. In addition, infection with Escherichia coli 0157:H7 can mimic spontaneous ischemic colitis. Although many reports have linked the use of oral contraceptives to ischemic colitis in young women, evidence has been limited to case studies and small series. Researchers in Tennessee reviewed cases of ischemic colitis in patients under the age of 40 seen over 5 years in a Memphis hospital.

Thirty-five patients were found to have had ischemic colitis, as confirmed by colonic mucosal biopsy. Of these, 17 were excluded because of positive culture results for E. coli 0157:H7, severe hypotension or incomplete colonoscopic examination. Of the remaining 18 patients 17 were women. The mean age was 29 years. All had clinical and laboratory findings consistent with transient ischemia of the left colonic mucosa but were otherwise healthy, normotensive and afebrile, with no evidence of enteric pathogens. Symptoms resolved within 4 days in all patients.

Ischemic colitis in these patients could not be linked to cardiovascular disease, the use of nonsteroidal anti-inflammatory drugs, antibiotics or illicit drugs, food ingestion or endometriosis. However, 10 (59%) of the 17 women were using low-dose estrogen-progestin oral contraceptives. This percentage was higher than the 1988 national average of 18.5% of women aged 15 to 44 years. Calculations revealed a relative risk of 6.31 for ischemic colitis among women using hormonal contraception. Four other women had previously used oral contraceptives for 2 to 8 years, and the remaining three were receiving oral estrogen replacement therapy. One woman who continued to use an oral contraceptive had a recurrence of ischemic colitis 20 months later; after she stopped the hormonal contraception she was free of recurrence for at least 34 months.

The authors argue that it is plausible that the use of exogenous estrogens, which has been associated with arterial and venous hyperplasia and with an increased incidence of thromboembolism, could trigger episodes of ischemic colitis in otherwise healthy women. Despite this association, their data do not support the cessation of oral contraceptive use in women experiencing reversible colonic ischemia. Young women, especially those using oral contraceptives, are at high risk for reversible ischemic colitis, which should be considered in the differential diagnosis of acute segmental colitis in young adults.

| CMAJ February 15, 1996 (vol 154, no 4) |