Coeliac disease, the lesser-known culprit affecting reproductive health

Coeliac disease in susceptible individuals is triggered by the ingestion of gluten, found in products that contain wheat, barley, rye and avenin in oats. If left undiagnosed this autoimmune condition can have a significant implication on women’s health (including fertility) particularly if adherence to the gluten-free diet is poorly managed.

Left untreated coeliac disease damages the small intestine, leading to poor adsorption of essential nutrients like iron, folate, zinc and vitamins A, D, E and K. These deficiencies can affect reproductive health causing irregular menstrual cycles, anovulation (lack of ovulation) and infertility in women, as well as reduced sperm quality and motility in men. 

How coeliac disease affects reproductive health

Coeliac disease is not only a digestive-related disorder, its effects touch just about every system of the human body. One of the lesser-known effects of coeliac disease is its impact in women’s reproductive health.

Coeliac disease is associated with various female fertility complications, including:

• Menstrual cycle disturbances: Delayed menarche (first menstrual period) in adolescents and early menopause in adulthood.
• Amenorrhea (absence of menstruation) or infrequent menstruation as a result of the body’s stress response to malnutrition and inflammation.
• Infertility: Unexplained inability to conceive after at least 1 year of unprotected regular sexual intercourse.
• Adverse pregnancy outcomes: Miscarriage, growth restriction, low birth weight, and infants born small-for-gestational age.

Who is affected by coeliac disease?

Coeliac disease is hereditary and both genetic and environmental factors impact when and how it affects an individual’s health. It is currently estimated that 60,000 to 70,000 New Zealanders have coeliac disease (1 in 70), however up to 80% of those are unaware they have the condition. 

While it can develop at any age, the symptoms of coeliac disease vary considerably and can include fatigue, weakness, and lethargy diarrhoea or chronic constipation. Typically, coeliac disease is presented in childhood with diarrhoea, loss of appetite, weight loss or failure to thrive, but this classical presentation is now less commonly identified. Approximately 20% of individuals are asymptomatic, and about half present with a variety of non-classical symptoms including chronic fatigue, iron deficiency, abdominal pain, bloating, constipation, nausea and vomiting, headaches, anxiety, and depression. Related symptoms include skin rashes, tooth enamel defects, mouth ulcers and difficulty concentrating (‘brain fog’) and infertility.

For more information about coeliac disease diagnosis and follow up see the Coeliac NZ YouTube channel or watch their free 16 minute webinar: What are the symptoms and causes of coeliac disease?

Why does coeliac disease affect fertility?

Some of the reasons as to why women with coeliac disease have a greater risk of fertility and pregnancy complications could be due to the damage to the intestine. This damage can cause major disruptions to nutrient levels. These deficiencies can affect hormone metabolism, egg development, and uterine health in many ways. Since coeliac disease is an autoimmune condition, the chronic inflammation triggered by gluten exposure in those undiagnosed, also has a systemic effect. This kind of chronic inflammation can alter the function of all organ systems throughout the body.

People with coeliac disease also have a greater likelihood of developing a second autoimmune disease which can further affect reproductive health. In particular, endometriosis is a chronic inflammatory disease that is believed to have an autoimmune origin. It is known to affect around 1 in 10 women of reproductive age and impact fertility through triggering excess inflammation and scaring in the reproductive tract.

Malnutrition from coeliac disease can also disrupt the balance of reproductive hormones, such as oestrogen and progesterone, which are essential for ovulation and maintaining a healthy pregnancy. It is also associated with an increased risk of thyroid disorders, such as hyperthyroidism, which can interfere with fertility. Thyroid hormones are crucial for reproductive health, and an imbalance can lead to menstrual irregularities and difficulties with ovulation.

What can be done

A strict, lifelong gluten-free diet is the mainstay of treatment of coeliac disease currently.  Diagnosing those with undetected coeliac disease and commencing a gluten-free diet appears to reverse the effects of coeliac disease on fertility problems - i.e. women with coeliac disease who follow a strict gluten-free diet experience similar rates of fertility and pregnancy complications as women without.

In studies looking at women with unexplained infertility, up to 2.5-10.3% are found to be undiagnosed/untreated coeliac. Once diagnosed a coeliac women with previous unexplained infertility can conceive and successfully deliver to term within 2 to 15 months on a gluten-free diet. 

After conception, women with undiagnosed coeliac disease also have a nine-times increased risk of miscarriage, compared to those with the condition who followed a gluten-free diet. Coeliac disease is also associated with an increased risk of pregnancy complications including intrauterine growth restriction, low-birth weight babies, small-for-gestational-age babies, preterm births, stillbirths, and post-partum haemorrhages.

Next steps

While coeliac disease can significantly impact fertility, early diagnosis and a strict adherence to a gluten-free diet can mitigate many of these effects, improving the chances of conception and a healthy pregnancy. For individuals facing unexplained infertility, screening for coeliac disease can be a critical step, as a delay in diagnosis can prolong the period of fertility impairment. 

Once we understand the root of the problem, we can then go in and optimise the diet with plenty of nutrient-dense fertility-supporting foods. In particular coeliac disease can deplete a person’s zinc, iron, and B vitamin levels. The best foods for replenishing these are eggs, organ meats such as liver, red meat, shellfish, and for vegetarians, lentils, and fermented soy.

Conclusion

Research shows that the gluten-free diet reverses the effects of coeliac disease on fertility. The rates of pregnancy complications are no greater among women living with coeliac disease once they follow a strict gluten-free diet. 

It is vital to continue eating gluten (not excluding gluten-containing foods) until the diagnosis of coeliac disease is confirmed. Reducing or excluding gluten prior to doing antibody blood tests, or especially prior to endoscopy and small bowel biopsy, will likely affect the results and delay or obscure the correct diagnosis.

If you react to dietary gluten and/or are concerned about your reproductive health take the online self-assessment on the Coeliac New Zealand website coeliac.org.nz and talk to a health professional to get a full diagnosis.

About Sylvia Goedeke, PhD, NZRD

Sylvia is an NZ Registered Dietitian, lecturer at AUT, and has a PhD specialising in insulin resistance, gestational diabetes, and pregnancy nutrition. Having been primarily clinically based in private practice over the previous five years she works closely with patients with complicated digestive issues. Seeing first-hand the changes that whole-food nutrition and lifestyle-based strategies can have on many aspects of health, she is a keen advocate for helping patients get to the bottom of longstanding digestive and inflammatory issues. Learn more about Sylvia here.

References

• Schiepatti, A., Sprio, E., Sanders, D. S., Lovati, E., & Biagi, F. (2019). Coeliac disease and obstetric and gynaecological disorders: where are we now? European Journal Of Gastroenterology & Hepatology, 31(4), 425–433.
• Khizroeva, J., Nalli, C., Bitsadze, V., Lojacono, A., Zatti, S., Andreoli, L, Makatsariya, A. (2019). Infertility in women with systemic autoimmune diseases. Best Practice & Research. Clinical Endocrinology & Metabolism, 101369.
• Lurie Y, Landau DA, Pfeffer J, Oren R. Celiac disease diagnosed in the elderly. J Clin Gastroenterol. 2008;42:59-61.