Karen Szabo, a Milwaukee-based nurse, has had two colonoscopies. The first time around, she received sedation in the form of the drug fentanyl. When it came time to get scoped again, Szabo opted out of sedation so she’d be able to leave the procedure on her own. “I live an hour away from the hospital,” she said, “and I didn’t want anybody to have to drive me home.”

Plus, other nurses had described unsedated colonoscopies as uncomfortable but not unbearably so. What Szabo didn’t know was that as a woman who’d had prior abdominal and gynecological surgeries, including an appendectomy and a hysterectomy, she faced an increased risk of pain during her colonoscopy.  

Being awake from start to finish proved to be more than just uncomfortable. When her gastroenterologist struggled to push the scope through twists in her colon, the pain intensity rivaled that of childbirth. “There were certain parts,” Szabo said, “where I thought, ‘Stop! I’m going to die!’”

Had Szabo known skipping sedation was a recipe for torture, she would have gladly spent the procedure knocked out. But she wasn’t warned.

Colonoscopies let gastroenterologists remove precancerous polyps (small clumps of cells that form on the lining of the colon), detect early-stage colorectal cancer and save lives. Colorectal cancer, meaning of the lower colon or rectum, is among the deadliest types, but it’s also one of the most preventable, provided people do as they’re told and get scoped. The American Cancer Society recommends that adults with an average colorectal cancer risk begin screening at age 45. Colonoscopies, considered the “gold standard” screening test, are supposed to be repeated anywhere from every 10 years to every three to five years, depending on family history and colorectal health.

Unlike prostate cancer screenings or mammograms, colonoscopies are a universal patient experience. But that doesn’t mean the procedure is the same for men and women. Not only do cisgender women report higher levels of pre-colonoscopy anxiety than their XY counterparts, it’s also well-documented that colonoscopies are more complicated and, as Szabo learned first hand, potentially painful procedures for female patients. Still, experts say women shouldn’t be deterred from getting scoped. Instead, they should arrive at their colonoscopy consultations armed with information and questions.

The long and winding female colon

A colonoscopy works like this: A patient lies on their side while a gastroenterologist inserts a colonoscope — essentially a camera on the end of a long, flexible tube — into their anus. From there, the doctor can use the scope to navigate through the entire large intestine. In addition to being an important preventive care measure, colonoscopies are performed on an as-needed basis for patients with abdominal pain and chronic diarrhea, among other intestinal problems. While no two colonoscopies will be identical, doctors consistently say performing colonoscopies on female patients is more difficult.

The reasons for this are thought to be largely anatomical. As Dr. David Greenwald, a gastroenterologist at Mount Sinai Hospital in New York City, explained, women’s colons tend to be longer than men’s. On average, research suggests, the female colon is 8 cm to 10 cm longer. It’s also often squished into a smaller abdominal cavity, meaning a gastroenterologist has to maneuver the scope through more twists and angles. 

Sharp, angular intestines are a pronounced issue in young, thin women, one of the most difficult patient populations to perform the procedure on. Older intestines are easier to excavate because the tissue connecting the intestines to the abdominal wall slackens with age. And parts of the colon are more angular in women with low BMIs (body mass index).

The female colon is more likely to dip into the pelvis, says Dr. Laura Raffals, who directs the Gastroenterology and Hepatology Fellowship at the Mayo Clinic in Rochester, Minnesota. As a result, “looping,” the process of knots (loops) forming in the scope while it traverses sharp angles in the intestine, occurs more frequently in women.

To undo loops, a gastroenterologist needs to pull back and adjust the scope. Until they’re corrected, loops can stretch out the walls of the colon, causing even sedated patients to exhibit signs of pain (although fortunately, many won’t remember it). In a 2007 paper, discomfort from looping is described as “possibly the most common patient-related source of difficulty” encountered in performing a colonoscopy.

The heightened difficulty of scoping female patients is associated with undesirable outcomes: Women overall are more likely than men to suffer colon perforations, have incomplete procedures and experience pain, especially when an inexperienced gastroenterologist is at work. Incomplete procedures are particularly likely for women with below-average BMIs. Risk for pain during unsedated colonoscopies is elevated for women with previous gynecological conditions or surgeries.

Because the ovaries, uterus and fallopian tubes are in same location as the colon, Greenwald explained, any surgery performed in that area, even a C-section, can leave behind bands of scar tissue called adhesions. These abdominal adhesions are sticky, so the colon can become affixed to them. “It actually can make colonoscopy more difficult and potentially more painful.”

Experience matters

Experience appears to help gastroenterologists overcome the challenges associated with female colonoscopies. 

A colonoscopy is considered incomplete when a gastroenterologist doesn’t reach the beginning point in the large intestine, called the cecum. Since cancerous cells can originate in the cecum, examining this area is a crucial part of colorectal cancer screening. Multiple studies have found that doctors who’ve performed higher numbers of colonoscopies have fewer problems reaching the cecum successfully and in a timely manner. Among gastroenterologists with less experience, one study found, delays in reaching the cecum are longer and more common with female patients.

These findings jibe with the trajectory Dr. Aboud Affi, a gastroenterologist at Aurora Sinai Hospital in Milwaukee, has noticed in his own career. Early on, women’s colonoscopies were harder for him and took longer to perform. Over time, though, the differences in duration and difficulty have faded almost entirely.

In addition to gaining experience wielding a colonoscope, gastroenterologists need to become educated about sex-based differences. Unfortunately, the American Society for Gastrointestinal Endoscopy recommends the same screening tools and guidelines for male and female patients.

Some experts acknowledge that physicians’ comprehension of this subject isn’t where it needs to be. “I suspect that many colonoscopists are unaware of the association between colonoscopy discomfort and hysterectomy, and even the association between colonoscopy discomfort and gender,” as Dr. Matthew D. Rutter, a gastroenterologist at University Hospital of North Tees in England, wrote in a 2015 op-ed for the Journal of Gastroenterology and Hepatology.

Though few and far between, efforts are underway to train doctors with expertise in the female colon. Brown University has gradually introduced women’s health training into its gastroenterology fellowship. In 2003, the school implemented a mandatory two-month rotation in a women’s-only endoscopy unit. The school later introduced a three-year program called the Women’s Gastroenterological Health Pathway. While a handful of gastroenterologists across the country lecture and conduct trainings about women’s health, the Brown program is the only one of its kind, according to director Amanda Pressman.

The program was originally created to address GI issues in pregnant women, but Pressman now also teaches future gastroenterologists about the psychological and emotional barriers preventing women from undergoing colorectal cancer screening. Women are getting screened at lower rates than men, despite having an equal cancer risk and visiting gastroenterologists more frequently for other issues.

Citing the statistic that approximately 1 in 5 women has been sexually assaulted, Pressman emphasized the anxiety many women feel over losing bodily control during sedation, not to mention undergoing such an invasive procedure. Research suggests women have more pre-procedure anxiety than men. “We try to remove barriers for women who need to have colonoscopies but are afraid,” Pressman said.

What to ask before getting scoped

While more gastroenterologists are gaining familiarity with women’s health issues, experts still urge female patients to ask their doctors a few questions before scheduling a procedure.  

Before going under the colonoscope, women should tell their doctors about any past surgeries and discuss plans for sedation. Sedation, which research suggests wears off faster in women, should be tailored to the needs of the patient. Some patients do brave colonoscopies without it. But that number is shrinking in the U.S., where over half are now performed with anesthesia care, meaning propofol administered and monitored by an anesthesiologist. Almost all the rest are completed with nurse-administered “twilight” anesthesia, also known as IV sedation, a combination of fentanyl and the sedative midazolam.

Women should also ask their doctors which type of scope they plan to use. Even though it’s not a one-scope-fits-all procedure, formal screeding guidelines don’t advise doctors to use different tools to excavate women’s long, angular colons. But many still do. “I use a pediatric colonoscope on all my female patients, except morbidly obese patients,” Affi said. “The benefit is that it feels easier to get around any adhesions and scars in the abdomen.” Greenwald and Raffals also said they use a pediatric colonoscope on women because the smaller diameter facilitates easy maneuvering. This has increasingly become the norm. But if a gastroenterologist only uses an adult-sized colonoscope, it might be worth asking if it’s a slimmer, newer model.

Women who are pregnant or trying to get pregnant should talk to their gastroenterologists about the safety of the procedure. While one 2010 study published in the Journal of Reproductive Medicine concluded that colonoscopies are safe during the second trimester, pregnant women are often advised to hold off until after they’ve given birth.

Once women address these questions with their doctors, they shouldn’t hesitate to schedule a colonoscopy. The biggest risk women can take with this procedure is skipping it.

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