Women and Constipation: Why Is It More Common? (Part 1)

Many of my female patients suffer from constipation, but it is rarely the reason a woman visits her doctor. Yet research indicates constipation is approximately twice more common in women than in men. Constipation is like that one friend who takes forever to text back—frustrating, unpredictable, and way more common in women than men. In fact, women struggle more with slow-moving digestion, thanks to a fun mix of hormones, a longer colon (yes, really, by about 10 centimeters), and the joys of pregnancy, stress, and pelvic floor drama. Unfortunately, most medical doctors don’t give constipation the attention it deserves unless an individual’s situation is serious (think fecal impaction, when you haven’t pooped in days and it gets stopped up, requiring hands-on assistance).

I spoke about this issue when I was on Andrew Huberman’s podcast, and we discussed root causes, including our longer gut, the more tortuous anatomy, the effects of hormones, and… well, patriarchy.

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Functional constipation is defined as a common gastrointestinal disorder characterized by infrequent bowel movements, difficulty passing stool, or a sense of incomplete evacuation, without any underlying structural or biochemical abnormalities. It is often classified based on the frequency of bowel movements (typically less than three times per week) and may be associated with symptoms such as straining during defecation, hard or lumpy stools, and a feeling of blockage or obstruction. The diagnosis is made by clinicians based on criteria established by the Rome criteria (below), which consider the presence of these symptoms over a specific duration (usually at least 3 months) while excluding other possible causes.

FUNCTIONAL DEFECATION DISORDERS

Diagnostic criteria*     Must include all of the following:

1. The patient must satisfy diagnostic criteria for functional constipation and/or irritable bowel syndrome with constipation
2. During repeated attempts to defecate, there must be features of impaired evacuation, as demonstrated by 2 of the following 3 tests:
3. Abnormal balloon expulsion test
4. Abnormal anorectal evacuation pattern with manometry or anal surface EMG
5. Impaired rectal evacuation by imaging

  *Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis   

I believe we should flag constipation in women as a symptom that warrants intervention and investigation into the root cause. It could be an indicator of deeper health issues. 

Many people are uncomfortable discussing bowel movements often because of embarrassment, unpleasant associations, or shame. However, functional and precision medicine, as well as ancient medicines like Ayurveda and Traditional Chinese Medicine regard regular bowel movements as an essential part of good health. Constipation is a sign of an imbalance that needs to be addressed. 

So let go of the bathroom anxiety. Your digestion reflects your overall health; it’s not a secret to keep. The more we normalize gut talk, the more we reclaim our right to feel light, energized, and unstoppable—from the inside out!

How Do You Define Constipation and What Causes It?

My definition of constipation is when you do not have a bowel movement every single day — ideally in the morning — with a feeling of complete evacuation. Anything less than this particular goal is constipation. My definition is more stringent than conventional medicine, which calls the cutoff for constipation at not one or two days, but three days for a bowel movement. About 50 percent of people have one bowel movement per day or more, which means the other half are likely suffering from constipation, even though their doctor may not see it as a medical problem.

Many factors impact constipation and all too often we offer quick fixes, such as laxatives, rather than address the deeper physiological and psychosocial issues. 

Before I delve into solutions for constipation, here is a summary of the most common causes. 

1. Lack of hydration. If we think of our gastrointestinal (GI) tract as one big water slide, you can see why not getting enough fluids is problematic. After all, you can’t ride the slide without water. Low fluid intake can cause constipation.² Fluids keep food matter moving through your intestines and nourish your intestines with H2O to make them smooth and flexible. 
2. Thyroid dysfunction. Constipation is a common symptom of hypothyroidism, or low thyroid. For women in North America, Hashimoto’s is the most common reason for low thyroid. Hashimoto’s disease, also known as autoimmune thyroiditis or “Hashi’s” for short, is an autoimmune condition that triggers an immune response in which antibodies are made that damage thyroid cells, resulting in low thyroid function over time.
3. Poor gut health. When your gut microbiome is out of balance with bad bacteria overwhelming the good bacteria, cue constipation. If the bad bacteria dominate, issues such as slow transit time, intestinal permeability (leaky gut), and inflammation in the intestinal wall lining increase. All that impacts how your GI tract quickly processes food. 
4. Autonomic nervous system imbalance. Your body needs to be able to switch easily between the parasympathetic nervous system — known as rest, digest and poop mode — versus the sympathetic nervous system, which is the part of the nervous system that activates your fight-flight, freeze-fawn mode. People who spend less time in rest and digest more, struggle more with constipation. The vagus nerve is the most important nerve in your parasympathetic nervous system. An amped-up perception of stress also causes lower vagal tone (or responsiveness), which means the vagus nerve is having performance issues and operating at a lower capacity. Lower vagal tone is linked to a variety of problems that impact the gut, such as slow transit time or irritable bowel syndrome that causes constipation

Sex and Gender Factors 

With women, several other mechanisms contribute to constipation, namely sex and gender differences: hormones, anatomy, physiology, and disorders like irritable bowel syndrome or pelvic organ prolapse. Women experience more stress and dysregulated cortisol, which triggers the fight-or-flight response and shuts down digestion. We’re more likely to overuse laxatives, leading to weaker bowel muscles. We’re also more likely to have painful hemorrhoids, which occur in 40 percent of pregnancies,¹ and to restrain from pooping in public places. 

• Hormones

First, hormonal influences play a significant role. Women experience fluctuations in sex hormones such as estrogen and progesterone, which can affect gastrointestinal motility. Estrogen and progesterone can slow gut motility, making everything down there move at the pace of a lazy river instead of a fast-flowing stream. The main estrogen of the reproductive years and bioidentical hormone therapy, estradiol, inhibits smooth muscle contractions in the colon, which can lead to constipation. This inhibition reduces the overall motility of the colon, contributing to slower transit times. Additionally, estradiol has been shown to decrease colonic permeability, which can influence intestinal barrier function and potentially affect how well contents move through the GI tract. Progesterone has been shown to decrease colonic motility, leading to slower transit times and constipation.

• Anatomy and Physiology

Second, anatomical and physiological differences contribute to the higher prevalence of constipation in women. The female colon is longer and has more twists and turns, like a rollercoaster. Women have a wider pelvis and a more pronounced angle between the rectum and the anal canal, which can affect defecation dynamics and how often you poop. Additionally, pelvic floor dysfunction, which is more common in women, can lead to obstructive defecation and incomplete evacuation. Pregnancy itself slows digestion, but postpartum women often struggle with constipation due anatomical changes and hormonal shifts. Post partum, many women experience fear of pain after a vaginal delivery or cesarean section. Many new moms lack of sleep, and neglect hydration and self-care, further exacerbating sluggish bowels.

• Conditions like Irritable Bowel Syndrome and Pelvic Organ Prolapse

Third, women are more likely to experience conditions such as irritable bowel syndrome (IBS) and pelvic organ prolapse, both of which can exacerbate symptoms and contribute to the chronic nature of constipation. Emotional stress can lead to pelvic floor dysfunction, making it harder to relax the muscles needed for healthy elimination. 

• Pyschosocial Reasons 

Women experience constipation more often than men, not just due to biological factors but also because of sociocultural influences that affect diet, behavior, and stress levels. Here are some key reasons:

• We live in a culture that discourages open conversations about women and digestion, leading many to hold it in rather than use a public or work restroom. This hesitation can disrupt the body’s natural reflex to go, making constipation worse over time. Many avoid discussing digestive issues, leading to less proactive healthcare and untreated chronic constipation.
• Some women in my medical practice, when they first come to see me, delay bowel movements because of embarrassment, lack of privacy, or social norms around bathroom use. They think it’s not ladylike to poop, again leading to conscious withholding of stools, and contributing further to constipation. The longer stool sits in the colon, the drier and harder it becomes—leading to slow transit and discomfort.
• Women more often try restrictive diets that cut carbs, fats, or entire food groups, leading to insufficient fiber and gut motility issues. Lower-calorie, lower-carb, and the “carnivore diet” as eating patterns, or skipping meals and intermittently fasting can slow digestion too much.
• Women’s restrooms often have longer lines and fewer stalls, making it harder to go when needed. 

When I was on Andrew Huberman’s podcast and he asked me why I thought so many women struggled with constipation, my immediate response was “patriarchy.” As expected, in the male-dominated comment section, there was a backlash and ridicule regarding my answer. Yet, it is undeniable that women experience stressors in a way that men do not in our culture, from the organizational and institutional levels to community and family. Women have higher rates of toxic stress and trauma. Women are more often people-pleasers and more likely to prioritize others’ needs over their own, delaying bathroom breaks because of work, childcare, or social obligations. It’s not a stretch to see why patriarchy is a cause of constipation. 

All of these factors can influence bowel habits and contribute to constipation. That doesn’t mean you are stuck with bloating and occasional constipation; there are specific solutions that work well in women. Read the next article: Women and Constipation: How to Find Relief (Part 2).  Pooping is human and an important part of your biology.