Age, Gender, and Women’s Health and the Patient
2016; Elsevier BV; Volume: 150; Issue: 6 Linguagem: Inglês
10.1053/j.gastro.2016.02.017
ISSN1528-0012
AutoresLesley A. Houghton, Margaret Heitkemper, Michael D. Crowell, Anton Emmanuel, Albena Halpert, James A. McRoberts, Brenda B. Toner,
Tópico(s)Pathogenesis and Treatment of Hiccups
ResumoPatients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, irritable bowel syndrome, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extraintestinal manifestations, are more prevalent in women than in men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies have suggested sex differences in somatic, but not visceral, pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics, and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been studied adequately. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men. Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, irritable bowel syndrome, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extraintestinal manifestations, are more prevalent in women than in men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies have suggested sex differences in somatic, but not visceral, pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics, and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been studied adequately. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men. This review discusses the patient's perspective and biological basis for sex and gender differences in functional gastrointestinal disorders (FGIDs). Attention is given to the lived experience of irritable bowel syndrome (IBS) as well as the importance of patient interaction with the health care provider. In addition, the review highlights the current literature related to gender- and sex-based differences in visceral and somatic sensitivity, pain, motility, and the overlap of FGIDs, in particular IBS, with other chronic conditions. "IBS is very frustrating: it dominates life style and daily activities mostly through its unpredictability. You must always plan for the 'what if' 'what if I eat more' 'what if toilet facilities are not available' 'what if I cannot break away.' It leaves you feeling 'dirty or unclean' and inhibits social mixing and sexual activity. IBS is frustrating. And that's the bottom line…" IBS study participant. For patients with chronic symptoms, the psychological and social ramifications of their illness are often more important than the physical impairment. Three over-riding themes seem to dominate the experience of living with moderate to severe FGID: (1) a sense of frustration, (2) a sense of isolation, and (3) search for a niche in the health/sick role continuum/dissatisfaction with the medical system.1Bertram S. Kurland M. Lydick E. et al.The patient's perspective of irritable bowel syndrome.J Fam Pract. 2001; 50: 521-525PubMed Google Scholar, 2Drossman D.A. Chang L. Schneck S. et al.A focus group assessment of patient perspectives on irritable bowel syndrome and illness severity.Dig Dis Sci. 2009; 54: 1532-1541Crossref PubMed Scopus (35) Google Scholar, 3Halpert A. Dalton C.B. Palsson O. et al.Irritable bowel syndrome patients' ideal expectations and recent experiences with healthcare providers: a national survey.Dig Dis Sci. 2010; 55: 375-383Crossref PubMed Scopus (23) Google Scholar, 4Halpert A. Godena E. Irritable bowel syndrome patients' perspectives on their relationships with healthcare providers.Scand J Gastroenterol. 2011; 46: 823-830Crossref PubMed Scopus (10) Google Scholar The effects of IBS on quality of life (QoL) often are underestimated. Patients with mild to moderate disease severity report that IBS restricts daily activities on average 73 days per year (20%); resulting in loss of work (13% of patients).5Drossman D.A. Morris C.B. Schneck S. et al.International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit.J Clin Gastroenterol. 2009; 43: 541-550Crossref PubMed Scopus (92) Google Scholar There is often a disconnect between patients' and physicians' views of the IBS experience, regarding perceptions of etiology, severity, treatment approaches, and efficacy.6Heitkemper M. Carter E. Ameen V. et al.Women with irritable bowel syndrome: differences in patients' and physicians' perceptions.Gastroenterol Nurs. 2002; 25: 192-200Crossref PubMed Google Scholar, 7Halpert A. Dalton C.B. Palsson O. et al.What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ).Am J Gastroenterol. 2007; 102: 1972-1982Crossref PubMed Scopus (85) Google Scholar, 8Lacy B.E. Weiser K. Noddin L. et al.Irritable bowel syndrome: patients' attitudes, concerns and level of knowledge.Aliment Pharmacol Ther. 2007; 25: 1329-1341Crossref PubMed Scopus (44) Google Scholar When 1014 patients and 508 physicians used identical scales to rate IBS-related pain and discomfort, responses showed that physicians rated discomfort as significantly less severe than patients.9Lacy B.E. Rosemore J. Robertson D. et al.Physicians' attitudes and practices in the evaluation and treatment of irritable bowel syndrome.Scand J Gastroenterol. 2006; 41: 892-902Crossref PubMed Scopus (32) Google Scholar Conversely, 35% of more than a 1000 IBS patients in an international survey, reported their symptoms as severe. In the same survey, to receive a treatment that would make them symptom free, patients would give up 25% of their remaining life (average, 15 y) and 14% would risk a 1 in 1000 chance of death.5Drossman D.A. Morris C.B. Schneck S. et al.International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit.J Clin Gastroenterol. 2009; 43: 541-550Crossref PubMed Scopus (92) Google Scholar Many patients are reluctant to accept the functional diagnosis and many misconceptions, for example, that anxiety, depression, and diet cause IBS, and fear that IBS leads to cancer.7Halpert A. Dalton C.B. Palsson O. et al.What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ).Am J Gastroenterol. 2007; 102: 1972-1982Crossref PubMed Scopus (85) Google Scholar, 8Lacy B.E. Weiser K. Noddin L. et al.Irritable bowel syndrome: patients' attitudes, concerns and level of knowledge.Aliment Pharmacol Ther. 2007; 25: 1329-1341Crossref PubMed Scopus (44) Google Scholar Such misconceptions likely affect clinical outcomes and health care utilization. "The biggest problem is that no one (in the medical field) treats the whole person. I feel more like I'm going to a drug dealer than someone that looks at the problem in its totality. As a result I have turned my attention to helping myself, and have had some degree of success. I wish doctors would listen to patients more when we talk about the symptoms and how they affect our daily lives," IBS study participant. Only a small proportion (≈25%) of IBS sufferers consult physicians.10Hungin A.P. Chang L. Locke G.R. et al.Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact.Aliment Pharmacol Ther. 2005; 21: 1365-1375Crossref PubMed Scopus (230) Google Scholar However, those who do, have high health care utilization.11Longstreth G.F. Wilson A. Knight K. et al.Irritable bowel syndrome, health care use, and costs: a U.S. managed care perspective.Am J Gastroenterol. 2003; 98: 600-607Crossref PubMed Scopus (168) Google Scholar The nature of the patient–physician relationship is complex. Factors within and outside the health care system are constantly molding patient and physician behavior. Patients feel frustrated with unsatisfactory explanations of FGIDs, which may be experienced as a denial of the legitimacy of their symptoms and perceive lack of empathy.2Drossman D.A. Chang L. Schneck S. et al.A focus group assessment of patient perspectives on irritable bowel syndrome and illness severity.Dig Dis Sci. 2009; 54: 1532-1541Crossref PubMed Scopus (35) Google Scholar Conversely, physician frustration and dissatisfaction related to treating patients with FGIDs stem from a lack of understanding of the disease, limited treatment options, limited training in communication skills, increased workload, and the perception of personality characteristics of patients with IBS with psychiatric comorbidities.12Dixon-Woods M. Critchley S. Medical and lay views of irritable bowel syndrome.Fam Pract. 2000; 17: 108-113Crossref PubMed Google Scholar Gastroenterologists perceive that patients with IBS require longer visits despite not being as sick as patients with other disorders that they manage9Lacy B.E. Rosemore J. Robertson D. et al.Physicians' attitudes and practices in the evaluation and treatment of irritable bowel syndrome.Scand J Gastroenterol. 2006; 41: 892-902Crossref PubMed Scopus (32) Google Scholar and can show gender bias.13Hamberg K. Risberg G. Johansson E.E. Male and female physicians show different patterns of gender bias: a paper-case study of management of irritable bowel syndrome.Scand J Public Health. 2004; 32: 144-152Crossref PubMed Scopus (24) Google Scholar Negative attitudes toward patients with IBS may form a barrier to objective patient assessment and effective physician–patient relationship building, and ultimately negatively impact clinical outcome.14Raine R. Carter S. Sensky T. et al.General practitioners' perceptions of chronic fatigue syndrome and beliefs about its management, compared with irritable bowel syndrome: qualitative study.BMJ. 2004; 328: 1354-1357Crossref PubMed Google Scholar Effective communication skills can be learned and practiced and, importantly, do not increase the encounter time. Rather, effective communication skills make the process of assessment and diagnosis more efficient, improve clinical outcomes, and increase physician job satisfaction.15Kaptchuk T.J. Kelley J.M. Conboy L.A. et al.Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome.BMJ. 2008; 336: 999-1003Crossref PubMed Scopus (419) Google Scholar, 16Conboy L.A. Macklin E. Kelley J. et al.Which patients improve: characteristics increasing sensitivity to a supportive patient-practitioner relationship.Soc Sci Med. 2010; 70: 479-484Crossref PubMed Scopus (21) Google Scholar, 17Dhaliwal S.K. Hunt R.H. Doctor-patient interaction for irritable bowel syndrome in primary care: a systematic perspective.Eur J Gastroenterol Hepatol. 2004; 16: 1161-1166Crossref Scopus (31) Google Scholar IBS can be challenging for both the physician and the patient. Patients must learn to self-manage a condition that can have a profound impact on everyday life. Health care providers can help by eliciting and addressing patient concerns; by offering a positive diagnosis and clear, understandable, and legitimizing explanations of the disorder; show empathy; and enter into a meaningful partnership that helps individuals replace feelings of helplessness with means of empowerment. Sex refers to the biological make-up of the individual's reproductive anatomy whereas gender refers to an individual's lifestyle or personal identity. Often, these terms are used interchangeably. In this article we use sex to describe what is known about biological differences between males and females and gender to refer to what is known about behavior between men and women. The literature on gender and health has discussed the detrimental impact of adherence to some traditional feminine gender roles on women's health and well-being.18Worell J. Remer P. Feminist perspectives in therapy: empowering diverse women. John Wiley & Sons, Hoboken, NJ2003Google Scholar These include gender-related expectations, such as societal standards for attractiveness; social norms regarding women's caretaking role in relationships; and sanctions against anger expression by women. The messages women receive about gender-related expectations and the societal consequences of not measuring up to these expectations can have health consequences.19Toner B.B. Akman D. Gender role and irritable bowel syndrome: literature review and hypothesis.Am J Gastroenterol. 2000; 95: 11-16Crossref PubMed Google Scholar There are several common gender role concerns among women with IBS including shame and bodily functions, bloating and physical appearance, and pleasing others, assertion, and anger.19Toner B.B. Akman D. Gender role and irritable bowel syndrome: literature review and hypothesis.Am J Gastroenterol. 2000; 95: 11-16Crossref PubMed Google Scholar One central theme that women with IBS commonly report is feelings of shame associated with losing control of bodily functions. Women are taught that bodily functions are something to be kept private and secret. One important implication of such teachings is that bowel functioning becomes a source of shame and embarrassment more so than it does for men. The finding that women often score higher on indices of bloating and constipation also can be discussed as a gender-related theme. Society's focus on how women look (eg, thinness as a necessary standard of attractiveness)20Cheney A.M. Most girls want to be skinny: body (dis)satisfaction among ethnically diverse women.Qual Health Res. 2011; 21: 1347-1359Crossref PubMed Scopus (8) Google Scholar can lead women to experience bloating not only as a source of physical discomfort, but of psychological distress as well. The physical and psychological distress that women may experience with abdominal discomfort, coupled with the perception that their pain is being minimized or trivialized by health care professionals, may lead women to respond by becoming more hypervigilant to any sign of pain or discomfort. Women as compared with men are socialized to please others, often at the expense of their own needs. Women who express anger, make demands, or question authority are often given the label of being hysterical, have their complaints dismissed, or have their femininity called into question. Potential repercussions for women who express their own wants and needs often are sufficient to keep women silent. These social expectations of women can lead to the silencing of certain thoughts, feelings, and behaviors rather than jeopardize relationships that are in place.21Ali A. Toner B.B. Stuckless N. et al.Emotional abuse, self-blame, and self-silencing in women with irritable bowel syndrome.Psychosom Med. 2000; 62: 76-82Crossref PubMed Google Scholar A study that compared women with IBS with women with inflammatory bowel disease found that women with IBS score higher on measures of self-silencing than inflammatory bowel disease patients.21Ali A. Toner B.B. Stuckless N. et al.Emotional abuse, self-blame, and self-silencing in women with irritable bowel syndrome.Psychosom Med. 2000; 62: 76-82Crossref PubMed Google Scholar In another study, women reported shame in not living up to gender norm expectations for women in domains of relationships (taking care of others at the expense of their own needs), attractiveness (caused by bloating), and lack of desire to engage in sex (caused by IBS symptoms).22Bjorkman I. Dellenborg L. Ringstrom G. et al.The gendered impact of irritable bowel syndrome: a qualitative study of patients' experiences.J Adv Nurs. 2014; 70: 1334-1343Crossref Scopus (1) Google Scholar Men in this study focused more on IBS symptoms impacting their paid employment and sense of control. They also found that in interactions with health care providers, women risked being trivialized and men risked being overlooked because IBS may be labeled as a women's health concern. It is important to acknowledge that health and illness occur within a larger social context. The meaning and expression of illness occur against a complex backdrop of a multitude of social determinants of health. The social determinants that have been investigated in FGIDs include life stressors; history of sexual, physical, and emotional abuse; and early life experiences including gender role socialization, social support, and social factors as assessed by QoL scales. There have been limited studies to date that have assessed gender differences in life stress related to FGIDs.23Maguen S. Madden E. Cohen B. et al.Association of mental health problems with gastrointestinal disorders in Iraq and Afghanistan veterans.Depress Anxiety. 2014; 31: 160-165Crossref PubMed Scopus (6) Google Scholar Although the data support a significant role for life stress in IBS, future studies will need to determine whether there are differences in the relationship between stress and FGIDs in women and men. Although stress affects the gut in most people, patients with IBS appear to experience greater reactivity to a variety of stressors. One form of social stress that has received attention in the study of FGIDs is sexual, physical, or emotional abuse.24Bradford K. Shih W. Videlock E.J. et al.Association between early adverse life events and irritable bowel syndrome.Clin Gastroenterol Hepatol. 2012; 10 (e1-3): 385-390Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Table 1 shows the summary of studies focused on gender differences in history of sexual, physical and emotional abuse.24Bradford K. Shih W. Videlock E.J. et al.Association between early adverse life events and irritable bowel syndrome.Clin Gastroenterol Hepatol. 2012; 10 (e1-3): 385-390Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 25Longstreth G.F. Wolde-Tsadik G. Irritable bowel-type symptoms in HMO examinees. Prevalence, demographics, and clinical correlates.Dig Dis Sci. 1993; 38: 1581-1589Crossref PubMed Google Scholar, 26Walker E.A. Katon W.J. Roy-Byrne P.P. et al.Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease.Am J Psychiatry. 1993; 150: 1502-1506Crossref PubMed Google Scholar, 27Goodwin L. White P.D. Hotopf M. et al.Life course study of the etiology of self-reported irritable bowel syndrome in the 1958 British birth cohort.Psychosom Med. 2013; 75: 202-210Crossref PubMed Scopus (6) Google Scholar, 28Jones M.P. Oudenhove L.V. Koloski N. et al.Early life factors initiate a 'vicious circle' of affective and gastrointestinal symptoms: a longitudinal study.United European Gastroenterol J. 2013; 1: 394-402Crossref Google Scholar However, most work in this area has included only women or a female-predominate sample. Because of conflicts in the literature, more research is needed to determine whether there are gender differences in history of abuse in FGIDs.Table 1Gender Differences of History of Sexual, Physical, and Emotional Abuse in Persons With and Without IBSReferenceEarly life eventsFindingsGender differences within group comparisons25Longstreth G.F. Wolde-Tsadik G. Irritable bowel-type symptoms in HMO examinees. Prevalence, demographics, and clinical correlates.Dig Dis Sci. 1993; 38: 1581-1589Crossref PubMed Google ScholarChildhood abuse, sexual abuseA history of sexual abuse was more common in women than in men, but the investigators did not differentiate between patients with or without IBSNot addressed26Walker E.A. Katon W.J. Roy-Byrne P.P. et al.Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease.Am J Psychiatry. 1993; 150: 1502-1506Crossref PubMed Google ScholarSevere lifetime sexual trauma, severe childhood sexual abuse, lifetime sexual victimizationAll of the IBS patients studied who reported a history of sexual abuse were femaleWomen > men24Bradford K. Shih W. Videlock E.J. et al.Association between early adverse life events and irritable bowel syndrome.Clin Gastroenterol Hepatol. 2012; 10 (e1-3): 385-390Abstract Full Text Full Text PDF PubMed Scopus (64) Google ScholarGeneral trauma, physical punishment, emotional abuse, and sexual eventsSignificant differences were observed mainly in women with IBS; various types of early adverse life events were associated with the development of IBS, particularly among womenWomen > men27Goodwin L. White P.D. Hotopf M. et al.Life course study of the etiology of self-reported irritable bowel syndrome in the 1958 British birth cohort.Psychosom Med. 2013; 75: 202-210Crossref PubMed Scopus (6) Google ScholarChildhood abuseNo significant association of childhood adversity with the likelihood of developing IBS in either men or womenNo differences28Jones M.P. Oudenhove L.V. Koloski N. et al.Early life factors initiate a 'vicious circle' of affective and gastrointestinal symptoms: a longitudinal study.United European Gastroenterol J. 2013; 1: 394-402Crossref Google ScholarChildhood abuseA history of child abuse was similar in case and control groups, but the investigators did not differentiate between patients with or without IBSNot addressed Open table in a new tab Studies also have investigated whether women and men with FGIDs differ on health-related QoL measures.29Tang Y.R. Yang W.W. Wang Y.L. et al.Sex differences in the symptoms and psychological factors that influence quality of life in patients with irritable bowel syndrome.Eur J Gastroenterol Hepatol. 2012; 24: 702-707Crossref PubMed Scopus (27) Google Scholar For example, in a study of referral center and primary care patients, Simren et al30Simren M. Abrahamsson H. Svedlund J. et al.Quality of life in patients with irritable bowel syndrome seen in referral centers versus primary care: the impact of gender and predominant bowel pattern.Scand J Gastroenterol. 2001; 36: 545-552Crossref PubMed Google Scholar found that women with IBS reported a lower QoL compared with men with IBS. Similar results were found in a Chinese outpatient population.29Tang Y.R. Yang W.W. Wang Y.L. et al.Sex differences in the symptoms and psychological factors that influence quality of life in patients with irritable bowel syndrome.Eur J Gastroenterol Hepatol. 2012; 24: 702-707Crossref PubMed Scopus (27) Google Scholar Dancey et al31Dancey C. Hutton-Young S. Moye S. et al.Perceived stigma, illness intrusiveness and quality of life in men and women with irritable bowel syndrome.Psychol Health Med. 2002; 7: 381-395Crossref Scopus (29) Google Scholar found that men and women with IBS reported similar QoL scores, as well as similar levels of symptom severity, perceived stigma, and illness intrusiveness. However, these investigators also found gender differences in the relationship among these variables. For example, among women, IBS symptom severity exerted a significant impact on QoL, whereas for men, the psychosocial impact of illness intrusiveness was greater in every domain except sexual relations. The authors suggest that these results have implications for how socialization shapes IBS-related gender differences. Most individuals with FGIDs do not seek health care and the decision to seek care introduces bias in research. This section focuses on population-based research, which is used to fully evaluate the epidemiology and clinical symptoms in these individuals. The proposal that FGIDs may be more prevalent in women stems from a variety of sources reviewed elsewhere: studies documenting a greater prevalence of FGIDs with other chronic pain conditions that are more common in women (fibromyalgia, chronic pelvic pain), studies proposing an effect of the menstrual cycle on symptom severity, and studies suggesting that particular agents are more effective in women. Functional esophageal disorders are common.32Drossman D.A. Li Z. Andruzzi E. et al.U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.Dig Dis Sci. 1993; 38: 1569-1580Crossref PubMed Scopus (1486) Google Scholar Globus sensation and rumination syndrome are reported by approximately 1 in 10 of the population,32Drossman D.A. Li Z. Andruzzi E. et al.U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.Dig Dis Sci. 1993; 38: 1569-1580Crossref PubMed Scopus (1486) Google Scholar, 33Gale C.R. Wilson J.A. Deary I.J. Globus sensation and psychopathology in men: the Vietnam experience study.Psychosom Med. 2009; 71: 1026-1031Crossref PubMed Scopus (13) Google Scholar, 34Chial H.J. Camilleri M. Williams D.E. et al.Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis.Pediatrics. 2003; 111: 158-162Crossref PubMed Scopus (73) Google Scholar, 35Tack J. Talley N.J. Camilleri M. et al.Functional gastroduodenal disorders.Gastroenterology. 2006; 130: 1466-1479Abstract Full Text Full Text PDF PubMed Scopus (913) Google Scholar and are more common in women. Men with globus tend to have greater levels of somatization and depression.33Gale C.R. Wilson J.A. Deary I.J. Globus sensation and psychopathology in men: the Vietnam experience study.Psychosom Med. 2009; 71: 1026-1031Crossref PubMed Scopus (13) Google Scholar The prevalence estimates of functional chest pain, based on self-report, vary between 12.5% and 25%,32Drossman D.A. Li Z. Andruzzi E. et al.U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.Dig Dis Sci. 1993; 38: 1569-1580Crossref PubMed Scopus (1486) Google Scholar, 36Fass R. Achem S.R. Noncardiac chest pain: epidemiology, natural course and pathogenesis.J Neurogastroenterol Motil. 2011; 17: 110-123Crossref PubMed Scopus (41) Google Scholar with an equal gender prevalence in the general population.32Drossman D.A. Li Z. Andruzzi E. et al.U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.Dig Dis Sci. 1993; 38: 1569-1580Crossref PubMed Scopus (1486) Google Scholar There is a higher female-to-male ratio in tertiary care referral centers,37Cormier L.E. Katon W. Russo J. et al.Chest pain with negative cardiac diagnostic studies. Relationship to psychiatric illness.J Nerv Ment Dis. 1988; 176: 351-358Crossref PubMed Google Scholar and women tend to use terms such as "burning" and "frightening" more than men.38Mousavi S. Tosi J. Eskandarian R. et al.Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain.J Gastroenterol Hepatol. 2007; 22: 218-221Crossref PubMed Scopus (18) Google Scholar The challenge in research studies of functional esophageal disorders is identifying those individuals who predominantly have a functional esophageal disorder rather than gastroesophageal reflux disease, which is not associated with gender difference in rates or reflux symptoms. Functional dyspepsia affects 15%–20% of the general population39Aro P. Talley N.J. Ronkainen J. et al.Anxiety is associated with uninvestigated and functional dyspepsia (Rome III criteria) in a Swedish population-based study.Gastroenterology. 2009; 137: 94-100Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar and does not vary with gender.39Aro P. Talley N.J. Ronkainen J. et al.Anxiety is associated with uninvestigated and functional dyspepsia (Rome III criteria) in a Swedish population-based study.Gastroenterology. 2009; 137: 94-100Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 40Zagari R.M. Law G.R. Fuccio L. et al.Epidemiology of functional dyspepsia and subgroups in the Italian general population: an endoscopic study.Gastroenterology. 2010; 138: 1302-1311Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 41Talley N.J. Zinsmeister A.R. Schleck C.D. et al.Dyspepsia and dyspepsia subgroups: a population-based study.Gastroenterology. 1992; 102: 1259-1268PubMed Google Scholar Being a women was a significant predictor of functional dyspepsia when compared with organic causes of dyspepsia.42Stanghellini V. Tosetti C. Paternico A. et al.Risk indicators of delayed gastric emptying of solids in patients with functional dyspepsia.Gastroenterology. 1996; 110: 1036-1042Abstract Full Text Full Text PDF PubMed Scopus (445) Google Scholar Although females have physiological evidence of delayed gastric emptying, there is little relationship between these measures and sy
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