Letter to Editor Concerning: Menstrual-Associated Gastrointestinal Symptoms and Their Impact on IBS Diagnosis in Adolescents

To the Editor, We read the article: “Menstrual‐Associated Gastrointestinal Symptoms and Their Impact on IBS Diagnosis in Adolescents” with great interest [1]. One of the most significant limitations of the Rome IV criteria is that the algorithm considers a cluster of cyclic gastrointestinal (GI) symptoms as “active menstrual bleeding” that lasts for only 4 days/month for 2 months, thereby inadvertently misclassifying these symptoms. This is an important consideration, because changes in gonadal hormones have a profound effect on enteric smooth muscle function, visceral nociception, and the severity of GI symptoms throughout the menses [2]. There are, however, some methodological and clinical factors that need to be taken into consideration. First, a symptom‐based questionnaire does not clarify the cyclical GI discomfort attributable to hidden or undiagnosed gynecological pathologies. The exclusion of patients with known organic disease is a wise decision, but there remains a diagnostic gap in adolescent gynaecologic cases, which have long periods of pre‐diagnosis. Symptoms of early‐stage endometriosis, adenomyosis, and congenital obstructive reproductive tract anomalies include cyclic pelvic pain and secondary dysmenorrhea with diarrhea or constipation, especially during menstruation [3]. The 4–11 year time interval between formal clinical diagnosis and the onset of these structural and inflammatory pathologies would pass the history‐based exclusion. This raises the possibility that adolescents who reported symptoms of the menstrual cycle only might have had an underlying undiagnosed gynecological condition and not a primary disorder of gut–brain interaction. Second, data on the use of hormones in contraceptive products are lacking. Hormonal contraceptives or progestin implants are often used in adolescents as treatments for non‐contraceptive indications such as menorrhagia, hypothalamic–pituitary‐ovarian axis immaturity, and severe primary dysmenorrhea, which suppresses dysmenorrhea and may also alter GI symptoms [4]. Thus, the use of hormonal contraceptives may have confounded the results. Third, the menstrual symptom definition was based on a single retrospective self‐report and was not validated across consecutive cycles [1]. Retrospective reporting is susceptible to recall bias for reporting functional GI symptoms and may result in higher scores than will be seen in prospective monitoring [5]. If the adolescent has an unusually heavy period, they may be misdiagnosed because they might remember meeting the shorter 4‐day criteria for pediatrics in one period. Multi‐cycle, daily symptom diaries for pelvic symptoms, and formal gynecological screening and pelvic imaging should be incorporated in future prospective studies to enhance the reliability of the findings. Author Contributions Maheen Hamid: Conceptualization, manuscript writing, formatting, editing and revision. Funding The author has nothing to report. Disclosure Declaration of Use of AI: No generative AI was used to generate scientific content. Conflicts of Interest The author declares no conflicts of interest. Linked Articles This article is linked to Arrizabalo et al. papers. To view this article, visit https://doi.org/10.1111/nmo.70382. Data Availability Statement Data sharing not applicable to this article as no datasets were generated or analysed during the current study. References - 1. Arrizabalo S., Banegas K., Velasco‐Benitez C. A., Velasco‐Suarez D. 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