What are the treatment options for Irritable Bowel Syndrome (IBS) in women?

Treatment of Irritable Bowel Syndrome in Women

Women with IBS should begin with lifestyle modifications including regular exercise and soluble fiber supplementation (ispaghula 3-4 g/day, gradually increased), followed by symptom-specific pharmacotherapy: antispasmodics for pain, loperamide for diarrhea, or osmotic laxatives for constipation, with tricyclic antidepressants (amitriptyline 10-30 mg daily) reserved for refractory cases. 1, 2, 3

Initial Management: Establish Diagnosis and Patient Education

• Make a positive diagnosis in women under 45 meeting Rome criteria without alarm features (unintentional weight loss ≥5%, blood in stool, fever, anemia, family history of colon cancer or inflammatory bowel disease) to avoid unnecessary testing. 2, 3

• Provide clear explanation that IBS is a disorder of gut-brain interaction with a benign but relapsing/remitting course, addressing patient fears directly—particularly concerns about cancer, which are common. 4, 2

• Listen to the patient's concerns and identify their beliefs about the condition, as this therapeutic relationship forms the foundation of successful management. 4, 3

First-Line Treatment: Lifestyle and Dietary Modifications

Exercise and Lifestyle

• Recommend regular physical exercise to all women with IBS, as this provides significant benefits for global symptom management. 1, 2, 3

• Advise adequate time for regular defecation, particularly for constipation-predominant patients. 4

Dietary Interventions

• Start with soluble fiber supplementation (ispaghula/psyllium) at low doses of 3-4 g/day, building up gradually to avoid bloating and gas, which is effective for both global symptoms and abdominal pain. 1, 2, 3

• Avoid insoluble fiber (wheat bran) as it consistently worsens symptoms, particularly bloating. 1, 3

• Identify and reduce excessive intake of lactose (>280 ml milk/day), fructose, sorbitol, or caffeine in women with diarrhea-predominant symptoms. 4, 3

• Consider a supervised trial of low FODMAP diet delivered in three phases (restriction, reintroduction, personalization) by a trained dietitian for moderate to severe symptoms not responding to first-line measures. 1, 3

Probiotics

• Trial probiotics for 12 weeks for global symptoms and bloating; discontinue if no improvement occurs, as no specific strain can be recommended. 1, 3

Pharmacological Treatment by Predominant Symptom Pattern

For Abdominal Pain and Cramping

• Use antispasmodics with anticholinergic properties (dicyclomine) as first-line therapy for abdominal pain, particularly when symptoms are meal-related, though dry mouth, visual disturbance, and dizziness are common side effects. 1, 2, 3

• Consider peppermint oil as an alternative antispasmodic, though evidence is more limited. 1, 3

For Diarrhea-Predominant IBS (IBS-D)

• Prescribe loperamide 2-4 mg up to four times daily (either regularly or prophylactically before going out) as first-line therapy to reduce stool frequency, urgency, and fecal soiling. 1, 3

• Rifaximin (550 mg three times daily for 14 days) is FDA-approved for IBS-D in women and is effective as a second-line agent, though its effect on abdominal pain is limited. 1, 5

• Consider 5-HT3 receptor antagonists as second-line options for refractory diarrhea. 1

For Constipation-Predominant IBS (IBS-C)

• Increase dietary fiber or use soluble fiber supplements (ispaghula/psyllium) as first-line therapy. 1, 3

• Start polyethylene glycol (osmotic laxative) for persistent constipation, titrating the dose according to symptoms, with abdominal pain being the most common side effect. 1

• Linaclotide is the most effective secretagogue for IBS-C and should be the preferred second-line agent when first-line therapies fail, though diarrhea is a common side effect. 1

• Lubiprostone is an alternative secretagogue if linaclotide is not tolerated. 1

For Mixed IBS (IBS-M)

• Tricyclic antidepressants are the most effective first-line pharmacological treatment for mixed symptoms, starting with amitriptyline 10 mg once daily at bedtime and titrating slowly to 30-50 mg daily. 1, 3

Second-Line Neuromodulators for Refractory Pain

• Prescribe tricyclic antidepressants (amitriptyline 10 mg once daily, increased slowly to maximum 30-50 mg) for women with refractory abdominal pain and global symptoms despite first-line therapies. 1, 2, 3

• Start at low doses and explain the rationale clearly, as these are used for pain modulation via gut-brain interaction, not for depression. 3

• Continue TCAs for at least 6 months if the patient reports symptomatic improvement. 1, 3

• TCAs may worsen constipation, so use cautiously in IBS-C and ensure adequate laxative therapy is in place. 1

• Consider selective serotonin reuptake inhibitors (SSRIs) as an alternative when TCAs are not tolerated or worsen constipation, or when there is concurrent mood disorder. 1, 3

Psychological Therapies for Persistent Symptoms

• Refer for IBS-specific cognitive behavioral therapy or gut-directed hypnotherapy when symptoms persist despite pharmacological treatment for 12 months. 1, 2, 3

• These brain-gut behavior therapies are specifically designed for IBS and differ from psychological therapies that target depression and anxiety alone. 3

• Dynamic (interpersonal) psychotherapy is particularly beneficial for women who relate symptom exacerbations to stressors, have associated anxiety or depression, or have symptoms of relatively short duration. 1

Treatment Monitoring and Adjustment

• Review treatment efficacy after 3 months and discontinue ineffective medications. 1, 3

• Use a symptom diary to track triggers and guide treatment choices, recognizing that symptoms may relapse and remit over time, requiring periodic adjustment. 2, 3

• Manage expectations realistically, as complete symptom resolution is often not achievable; the goal is symptom relief and improved quality of life. 1

Critical Pitfalls to Avoid

• Do not pursue extensive testing once IBS diagnosis is established in women under 45 without alarm features. 2, 3

• Do not recommend IgG antibody-based food elimination diets, as they lack evidence and may lead to unnecessary dietary restrictions. 1, 2

• Do not recommend gluten-free diets unless celiac disease has been confirmed. 1

• Avoid opioids for chronic abdominal pain management due to risks of dependence and complications. 1

• Recognize the high placebo response (averaging 47% in trials), which may reflect the value of the therapeutic relationship and adequate time for explanation. 4

Multidisciplinary Coordination

• Build collaborative links with gastroenterology dietitians for supervised low FODMAP diet trials and nutritional assessment. 3

• Refer to gastropsychologists when IBS symptoms are moderate to severe, the patient accepts that symptoms relate to gut-brain dysregulation, and has time to devote to learning new coping strategies. 3