Part 6 Of 12 Part Series: Reproductive (Delayed Puberty, Amenorrhea, Infertility, Impotence, Chronic Pelvic Pain, Fetal Complications, Premature Birth, Miscarriages, And Early Menopause) Symptoms In Undiagnosed Celiac Disease

October 1, 2009 · Filed Under 12 Part Series: CD Symptoms 

This is the sixth in a series of posts discussing the variety of symptoms that can be caused by undiagnosed Celiac Disease (CD). In this post, reproductive symptoms associated with undiagnosed CD will be discussed.

There are studies, articles, and books identifying an association between CD and reproductive symptoms (1-39). However, the pathogenesis of reproductive symptoms due to ingestion of gluten and the resulting autoimmune damage is unclear. Hypothetically, these symptoms may result from auto-antibodies directed at hormones, organs necessary for development in puberty, reproductive organs, or fetal tissue. This is plausible since we know that auto-antibodies in CD (resulting from autoimmune reactions to ingested gluten) can cause damage to a variety of bodily tissues such as the intestinal mucosa (villous flattening), muscles, nerves, skin, pancreas, and liver. Additionally, if intestinal damage occurs (well researched), the intestinal villi are less able to absorb nutrients leading to various nutrient deficiencies that may affect sex hormones, health of the reproductive organs, threaten the viability of a fetus, or decrease success with breast feeding. Collectively, these influencing factors are likely responsible for the reproductive symptoms evident in CD. Reproductive symptoms may be the first to develop in undiagnosed CD and can occur without bowel or other extra-intestinal symptoms (1,2,3,4,12,23,36,49,50,63,64).

Symptoms

Reproductive symptoms may include hypogonadism, pubertal delay (failure to develop secondary sex characteristics), delayed or retarded menarche, secondary amenorrhea, chronic pelvic pain, dysmenorrhea (severe uterine menstral pain), dyspareunia (intercourse is painful), vaginal infections, vaginitis, decreased sex drive (decreased libido), impotence, sperm abnormalities, infertility (in men or women), preclampsia, miscarriages, zygote abnormalties, fetal complications (birth defects, intrauterine fetal growth restriction, lower birth weight, premature birth), abnormal bleeding or infections post birth in mother, poor breast milk quality and production, and early menopause (1-39). The sense of loss experienced by individuals with these symptoms can be overwhelming and psychologically scarring. Imagine the loss of reproductive years due to infertility, the loss of a baby, or dealing with birth defects (stress, worry), only to find out later that it was due to the ingestion of gluten. Diagnosis and the implementation of a gluten-free diet is key to the primary prevention of reproductive symptoms in those with CD. Unfortunately, diagnosis of CD can be delayed for years due to the elusive presentation of symptoms (1,49,50).

I was diagnosed at age 38. I didn’t suffer from infertility and had 3 children. I did have delayed menarche and also had some problems with my pregnancies. My first child was born 3 weeks early due to my water breaking and I had anemia and palpitations during the pregnancy. I did not have any intestinal symptoms (classic CD symptoms) until after the birth of my first child. I was told that I had irritable bowel syndrome (see my gastrointestinal post). With my second pregnancy, I was hospitalized and put on bedrest due to premature inter-uterine contractions and pain. I also had anemia with this pregnancy and delivered 2 weeks early. With my third pregnancy, I had inter-uterine fetal growth restriction and had to decrease my activity. I remember adding lots of pasta and bread into my diet to help increase weight (exactly the opposite of what I needed since the pasta and bread had a high gluten content). My third child was born 1 1/2 weeks early at 6 pounds, 6 ounces and did receive some assistance with breathing when she was born. My mother (diagnosed with CD at age 60) almost lost her second child due to pregnancy complications.

I breast fed all 3 babies. However, I had to stop breast feeding the third after six weeks due to poor breast milk quality and production. I was ill with bowel symptoms at that time and likely had multiple nutrient deficiencies.

Note: Delivery of a baby by 2-3 weeks early is still considered full-term. However, I thought that the fact that all 3 children were born before their due date is worth mentioning.

Nutrient Deficiencies

Nutrient deficiencies (common in CD) that may contribute to reproductive symptoms in CD include vitamins A,D,E K, B complex, C, essential amino and fatty acids, carbohydrates, iodine, electrolytes, calcium, magnesium, phosphorus, iron, copper, manganese, zinc and molybdenum (1,41-48). Severity of nutrient loss and related symptoms are dependent on the location, length and severity of intestinal villi damage, which can be patchy in nature, and the presence of other factors such as diarrhea, vomiting, medications that affect nutrient absorption, other associated diseases, intestinal parasites, a poor diet, past stomach and intestinal surgery, smoking, or alcoholism (1-3,36,41,42,49,50).

Do You Have Any Of The Above Symptoms?

CD can be present in preteen/adolescents that are growing normally so normal growth rate (height) should not be a factor that excludes the possibility of CD in those with delayed puberty (55). Many individuals with undiagnosed CD will have no bowel symptoms (3,50,52,56). Weight loss may or may not occur, and is dependent on the amount of the intestine that is damaged (3,56). Therefore, the symptoms in this post could occur in the absence of stunted growth, weight loss, or bowel symptoms.

The presence of reproductive symptoms as discussed in this post, indicates that you should talk to your MD about tests for CD and tests to rule out other possible causes of your symptoms. Testing for CD is important because undiagnosed CD increases the risk of developing other autoimmune diseases, lymphomas (skin, brain, lymph nodes, intestine), cancers (thyroid, esophageal, mouth, tongue, pharynx, tonsil, and small intestine), allergies, complications from malabsorption issues, possible decreased immune response to other illnesses (1,2,5,6,50,81), and many other health complications that will be discussed in the posts about CD symptoms. It is my hope that if you have reproductive symptoms you can print out this post complete with medical references to take with you to the MD when you request a CD test. Highlight or underline the sections that apply to your symptoms. I’ll be posting a simplified summary and checklist in the 12th post.

There are factors that can cause a false negative CD test. The blood tests for CD (IgA endomysial antibodies and IgA tissue transglutaminase) tend to correspond with the severity of intestinal damage. Therefore, if the autoimmune damage is in another area (ex. skin form of CD called dermatitis herpetiformis) and no or very little intestinal damage is present, a negative result could occur. If the above tests are negative, a bloodtest for  antigliadin antibodies may be helpful to identify if increased intestinal permeability has allowed gluten (gliadin) to leak in through the tight junctions between the intestinal epithelial cells. This leakage could potentially lead to a gluten sensitivity and with continued exposure, potentially CD. A positive antigliadin result suggests that a gluten sensitivity may exist and the individual may benefit from a gluten-free diet. Antibodies against deamidated gluten should be also be added to the screening (65). Additional tests are available as well such as fecal tests and genetic tests. Other causes of false negative CD tests could include IgA deficiency (IgG tissue transglutaminase antibody test may be helpful), low gluten consumption, or the intestinal biopsy may have missed the diseased mucosa since it can be patchy in nature (multiple biopsies can be helpful to avoid this) (1,5,6,51-54,54,57,58).

It is also possible that some of your symptoms could be due to a food allergy/sensitivity or other disease process. A consultation with an allergist and/or naturopathic doctor may be helpful. There are a variety of tests that are useful for identifying allergies and sensitivities. Some individuals use the core or elimination diet to do this. A Registered Dietitian can help to ensure all nutrient requirements are fulfilled. Other tests can help rule out other diseases. I encourage everyone to have their symptoms thoroughly investigated by their MD and specialists before implementing a therapeutic diet. Keep your MD informed about any dietary changes you are making and also the results. Of course, I would love to hear your story as well (41,57-61).

I recommend waiting until CD testing is complete before initiating a gluten-free diet because it may create a false negative. Discuss this with your MD or specialist. USE CAUTION WITH SUPPLEMENTS. Toxicities can occur with over supplementation and this can lead to permanent damage. Consult your MD, Registered Dietitian, or other medical specialists involved in your care to determine which nutrients should be supplemented and to identify appropriate dosages for you. Review your symptoms and everything in this post with a Medical Doctor and your specialists before you make any changes. Your MD knows your medical history and the treatments that are appropriate for you.

References

1. Excellent Book: Green PHR, Jones, R. Celiac Disease A Hidden Epidemic. Collins, Harper Collins Publishers, 2006 http://tinyurl.com/ljeqjc

2. Pruessner Harold T, MD. Detecting Celiac Disease In Your Patients. American Family Physician. March 1st, 1998.

3. Feldman Mark, MD, Friedman Lawrence S, MD, Sleisenger, Marvin H, MD, Gastrointestinal and Liver Disease Pathophysiology/Diagnosis/Management 7th Edition, Volume11, 2002,Saunders

4. Barrett KE. Gastrointestinal Physiology. Lange Medical Books/McGraw-Hill 2006.

5. Excellent Book: Lieberman Shari PhD,CNC, FACN, with Linda Segall. The Gluten Connection. How Gluten Sensitivity May Be Sabotaging Your Health. Rodale Inc., 2007. http://tinyurl.com/nwsc79

6. Excellent Book: James Braly, MD., Ron Hoggan, MA. Dangerous Grains. Penguin Group, Inc., 2002. http://tinyurl.com/knswhn

7. ELIAKIM Rami (1) ; SHERER David M. (2) ; Celiac disease : Fertility and pregnancy.  (1) Division of Gastroenterology, Rambam Medical Center, Technion School of Medicine, Haifa, ISRAEL. (2) Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke’s-Roosevelt Hospital Center, University of Columbia College of Physicians and Surgeons, New York, N.Y., ETATS-UNIS. http://cat.inist.fr/?aModele=afficheN&cpsidt=859066

8. Rudolph Colin D., Rudolph Abraham M., Hostetter Margaret K., and Lister George E. Rudolph’s Pediatrics,  McGraw-Hill Professional; 21 edition, 2002.

9. Green-Hernandez Carol, Singleton Joanne K., and Aronzon Daniel Z . Primary Care Pediatrics Lippincott Williams & Wilkins; 1 edition (Jan 1 2001)

10. Hudson Tori. Women’s Encyclopedia of Natural Medicine: Alternative Therapies and Integrative Medicine for Total Health and Wellness McGraw-Hill; 2 edition (Sep 20 2007)

11. Ayhan Abaci, MD; Ihsan Esen, MD; Tolga Unuvar, MD; Nur Arslan, MD; Ece Bober, MD. Two Cases Presenting With Pubertal Delay and Diagnosed as Celiac Disease. Clinical pediatrics. http://cpj.sagepub.com/cgi/content/abstract/47/6/607

12. Gianni Bona, Daniela Marinello, Giuseppina Oderda. Mechanisms of Abnormal Puberty in Coeliac Disease. Horm Res 2002;57:63-65.

13. Coeliac disease and birth defects in offspring. (Letters to the editor) Gut 2001;49:738; doi:10.1136/gut.49.5.738

14. Aubrey J. Katz M.B., B.Ch., F.C.P.1, Z. Myron Falchuk M.D.1, and Harry Shwachman M.D.1The Coexistence of Cystic Fibrosis and Celiac Disease. PEDIATRICS Vol. 57 No. 5 May 1976, pp. 715-721.

15. Malena Cohen-Cymberknoh1, Michael Wilschanski2 Concomitant cystic fibrosis and coeliac disease: reminder of an important clinical lesson. BMJ Case Reports 2009 [doi:10.1136/bcr.07.2008.0578].  Copyright © 2009 by the BMJ Publishing Group Ltd.

16. Venuta A, Bertolani P, Casarini R, Ferrari F, Guaraldi N, Garetti E. Coexistence of cystic fibrosis and celiac disease. Description of a clinical case and review of the literature. Pediatr Med Chir. 1999 Sep-Oct;21(5 Suppl):223-6.

17. Sharma KA, Kumar A, Kumar N, Aggarwal S, Prasad S. Celiac disease in intrauterine growth restriction. Int J Gynaecol Obstet. 2007 Jul;98(1):57-9.

18. A.Gasbarrini, E.Torre, C.Trivellini, S.De Carolis, A.Caruso, G.Gasbarrini. Recurrent spontaneous abortion and intrauterine fetal growth retardation as symptoms of coeliac disease. The Lancet, Volume 356, Issue 9227, Pages 399-400.

19. Rami Eliakima, David M. Shererb Celiac Disease: Fertility and Pregnancy. Gynecol Obstet Invest 2001;51:3-7.

20. Porpora, Maria Grazia MD; Picarelli, Antonio MD; Porta, Romana Prosperi MD; Di Tola, Marco BSc; D’Elia, Claudia MD; Cosmi, Ermelando Vinicio MD, PhD.  Celiac Disease as a Cause of Chronic Pelvic Pain, Dysmenorrhea, and Deep Dyspareunia. Obstetrics & Gynecology: May 2002 – Volume 99 – Issue 5, Part 2 – p 937-939.

21. Rujner J. Age at menarche in girls with celiac disease. Ginekol Pol. 1999 May;70(5):359-62.

22. Pradhan M, Manisha, Singh R, Dhingra S. Celiac disease as a rare cause of primary amenorrhea: a case report. J Reprod Med. 2007 May;52(5):453-5.

23. P Collin, S Vilska, P K Heinonen, O Hällström, P Pikkarainen. Infertility and coeliac disease. Gut 1996;39:382-384; doi:10.1136/gut.39.3.382.

24. K Rostami, EAP Steegers, WY Wong, DD … – Coeliac disease and reproductive disorders: a neglected association. European Journal of Obstetrics and Gynecology, 2001 – Elsevier. Science Ireland Ltd. All rights reserved.

25. Bradley, Ryan J. * and; Rosen, Mitchell P. MD + Subfertility and Gastrointestinal Disease: ‘Unexplained’ Is Often Undiagnosed. Obstetrical & Gynecological Survey. 59(2):108-117, February 2004.

26. Carmen Lívia da Silva MartinsI; Lenora GandolfiII; Pedro Luiz TauilIII; Marilúcia de Almeida Rocha PicançoIII; Maria Ophelia Galvão de AraujoIV; Riccardo PratesiV  Celiac disease and female infertility: a frequently neglected association. Rev. Bras. Ginecol. Obstet. vol.28 no.10 Rio de Janeiro Oct. 2006

27. K. Sharma, A. Kumar, N. Kumar, S. Aggarwal, S. Prasad. Celiac disease in intrauterine growth restriction. International Journal of Gynecology & Obstetrics, Volume 98, Issue 1, Pages 57-59.

28. Gian Mario Tiboni1,3, Maria Grazia de Vita1, Raffaella Faricelli2, Franca Giampietro1 and Marco Liberati1 Serological testing for celiac disease in women undergoing assisted reproduction techniques. Human reproduction Vol 21, No. 2 pp376-379,2206. http://humrep.oxfordjournals.org/cgi/reprint/21/2/376.pdf 

29. Kotze, L M S PHD. Gynecologic and Obstetric Findings Related to Nutritional Status and Adherence to a Gluten-Free Diet in Brazilian Patients with Celiac Disease. Journal of Clinical Gastroenterology: August 2004 – Volume 38 – Issue 7 – pp 567-574.

30. G.F. Meloni1,4, S. Dessole2, N. Vargiu2, P.A. Tomasi3 and S. Musumeci1 The prevalence of coeliac disease in infertility. Human Reproduction, Vol. 14, No. 11, 2759-2761, November 1999.

31. Adams Scott. Miscarriage: Italian Researchers Link celiac Disease To Spontaneous Abortion And Fetal Growth Retardation. www.celiac.com http://tinyurl.com/yaxxj6s

32. Adams Scott. Fertility And Pregnancy In Women With Celiac Disease By Michelle Melin-Rogovin. www.celiac.com  http://tinyurl.com/yac24el

33. Adams Scott. Undiagnosed Celiac disease Increases Risk of Adverse Fetal Outcome. www.celiac.com http://tinyurl.com/y9cxjqt

34. SE Ferguson, GN Smith, MC Walker Maternal plasma homocysteine levels in women with preterm premature rupture of membranes. Medical Hypotheses, Volume 56, Issue 1, Pages 85-90.

35. James L. Mills*,2, John M. Scott{dagger}, Peadar N. Kirke{ddagger}, Joseph M. McPartlins§, Mary R. Conley*, Donald G. Weir§, Anne M. Molloy§ and Young Jack Lee* Homocysteine and Neural Tube Defects. The Journal of Nutrition.* Division of Epidemiology, Statistics and Prevention Research, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892 {dagger} Department of Biochemistry, Trinity College, Dublin, Ireland {ddagger} Health Research Board of Ireland, Dublin, Ireland § Department of Clinical Medicine, Trinity College, Dublin, Ireland

36. Nelson David A. Gluten-Sensitive Enteropathy (Celiac Disease): More Common Than You Think. American Family Physician, December 15th, 2002.

37. Ciacca C, Cirillo M, Auriemma G, Di Dato G, Sabbatini F, Mazzaca G. Celiac Disease And Pregnancy Outcome. Am J Gastroenterol 91(4): 718-722, 1996.

38. Norgard B, Fonager K, Sorensen HT, Olsen J. Birth Outcomes Of Women With Celiac Disease: A Nationwide Historical Cohort Study. Am J Gastroenterol 94:2435-2440, 1999.

39. Ludvigsson JF, Montgomery SM, Ekbom A. Celiac Disease And Risk Of Adverse Fetal Outcome: A Population Based Cohort Study. Gastroenterology 129:454-463, 2005.

40. Adams Scott. Impotency and Celiac Disease. www.celiac.com  http://tinyurl.com/yeawdrv

41. Gibney MJ, Marinos E, Olle L, Dowsett J. Clinical Nutrition. Blackwell Publishing 2005.

42. Gibney MJ, Vorster HH, Kok FJ. Introduction to Human Nutrition. Blackwell Publishing 2002.

43. S. E. Fergusona, G. N. Smithb and M. C. Walkera Maternal plasma homocysteine levels in women with preterm premature rupture of membranes. Medical Hypotheses Volume 56, Issue 1, January 2001, Pages 85-90.

44. Edward J. Massaro and John M. Rogers. Folate And Human Development. Humana Press; 1 edition (Mar 10 2002)

45. Robert A. DiSilvestro. Handbook Of Minerals As Nutritional Supplements. CRC Press LLC, 2005.

46. Shils, Maurice E Shils, Moshe Shike, and A. Catharine Ross. Modern Nutrition In Health And Disease. Lippincott Williams & Wilkins; 10 edition (Aug 1 2005)

47. Namanjeet Ahluwalia* and Hélène Grandje. Nutrition, an Under-Recognized Factor in Bacterial Vaginosis. American Society for Nutrition J. Nutr. 137:1997-1998, September 2007.

48. Corenthian J Booker, MD, Coauthor(s): Serdar H Ural, MD. Prenatal Nutrition. http://emedicine.medscape.com/article/259059-overview

49. Devlin Shane MD, Andrews Christopher MD, beck Paul MD, Celiac Disease. CME Update May 2004.

50. Kagnoff MF. AGA Institute Medical Position Statement on the Diagnosis and Management of CD. Gastroenterology, Official Journal of the American Gastroenterological Association (AGA). December 2006.

51. Ford RP. The Gluten Syndrome: A Neurological Disease. Med Hypothesis. 2009 Sept;73(3):438-40. Epub 2009 Apr 29.

52. Hadjivassiliou M, Gibson A, Davies-Jones GA, Lobo AJ, Stephenson TJ, Milford-Ward A. Does Cryptic Gluten Sensitivity Play A Part In Neurological Illness? Lancet. 1996 Feb. 10;347(8998):369-71.

53. Ron Hoggan. Celiac Disease—Gluten Sensitivity: What’s the Difference? www.celiac.com  http://tinyurl.com/ybt76oz

54. Ron Hoggan. Medical Superstitions of the Twenty-First Century. www.celiac.com  http://tinyurl.com/bwvo9p

55. Lejarraga H, et el. Normal Growth Velocity Before Diagnosis Of Celiac Disease. J Pediatr Gastrenterol Nutr 2000;30:552-556.

56. M Hadjivassiliou,a A K Chattopadhyay,b G A B Davies-Jones,a A Gibson,a R A Grünewald,a A J Loboc Neuromuscular disorder as a presenting feature of coeliac disease. J Neurol Neurosurg Psychiatry 1997;63:770-775 ( December )

57. Gislason Stephen. Core Diet For Kids. Persona Audiovisual Productions, 1989.

58. Alessio Fasano, M.D. Physiological, Pathological, and Therapeutic Implications of Zonulin-Mediated Intestinal Barrier Modulation. American Journal of Pathology, 2008;173:1243-1252.

59. Susan M. Lark. Menstrual Cramps. Celestial Arts; REV edition (Sep 1 2004). http://tinyurl.com/yde8gpj

60. Jonathan Brostoff and Stephen J. Challacombe. Food Allergy And Intolerance. A Saunders Ltd. Title; 2 edition (Aug 5 2002).

61. Perkin. Food Allergies And Adverse Reactions. Aspen Publishers, Inc.; 1 edition (Sep 21 1990)

62. Wong M, et el. Proximal Myopathy And Bone Pain As The Presenting Features Of Coeliac Disease. Ann Rheum Dis, 2002, 61(1):p87-8.

63. Carroccio A, Iacono G, Montalto G, Cavataio F, Marco C Di, Balsamo V, Notarbartolo A. Exocrine Pancreatic Function in Children With Coeliac Disease Before and After a Gluten-free Diet. Gut. Vol 32(7): 796-799, Jul 1991.

64. M Hadjivassiliou,a A K Chattopadhyay,b G A B Davies-Jones,a A Gibson,a R A Grünewald,a A J Loboc Neuromuscular disorder as a presenting feature of coeliac disease. J Neurol Neurosurg Psychiatry 1997;63:770-775 ( December )

65. S. Rashtak, M. Ettore, H. Homburger, J. Murray. Comparative Usefulness of Deamidated Gliadin Antibodies in the Diagnosis of Celiac Disease. Clinical Gastroenterology and Hepatology, Volume 6, Issue 4, Pages 426-432

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