A new study has challenged the long-held belief that peptic ulcers are more common in men. The analysis found that the gap in patient numbers between men and women narrows with age, and that postmenopausal women may face a higher risk of severe complications such as bleeding and perforation, suggesting that treatment strategies should differ.
Seoul National University Bundang Hospital announced on the 24th that these findings emerged from a comprehensive analysis of 68 research papers dealing with sex differences in peptic ulcers, conducted by a joint research team of Professor Kim Na-young of the Department of Gastroenterology, Professor Kim Byung-wook of the Department of Gastroenterology at Incheon St. Mary's Hospital, and Professor Bang Chang-seok of the Department of Gastroenterology at Hallym University Chuncheon Sacred Heart Hospital.
Peptic ulcer is a collective term for a condition in which the mucosa and muscle layers of the stomach or duodenum are damaged and hollowed out when the balance between aggressive factors, such as gastric acid and digestive enzymes, and the mucosa's defensive factors breaks down. A burning pain near the pit of the stomach is felt when fasting, and symptoms such as indigestion, loss of appetite, and vomiting may appear. In severe cases, it can lead to bleeding or perforation. The risk of such severe complications varies not only by sex but also by life cycle.
The research team planned the study after noting that existing clinical guidelines do not sufficiently consider changes in risk by age for men and women. To establish evidence to be reflected in new clinical guidelines, they examined sex differences in the incidence and complications of peptic ulcers, menopause, and drug response across various literature. As a result, the male-to-female patient ratio, which was previously around 2 to 1, has recently narrowed to nearly equal levels. Some domestic data show that the incidence of hemorrhagic peptic ulcers in women aged 80 and older has surpassed that of men in the same age group. The research team concluded that while the overall incidence and disease burden of peptic ulcers remain higher in men, the gap is gradually narrowing due to a larger decline.
The mortality rate was higher in women. According to nationwide data, the 30-day mortality rate for patients with hemorrhagic peptic ulcers was 3.20% for women, roughly double that of men (1.83%). For perforated peptic ulcers, the gap widened further, at 10.03% for women and 2.03% for men.
The researchers pointed to the decline of the hormone estrogen in elderly women as the background for this phenomenon. Estrogen, a representative female hormone, helps the defensive function of the mucosa in the stomach and duodenum. As women pass menopause and grow older, estrogen secretion decreases, so that protective effect disappears, increasing the risk of peptic ulcers. In fact, women who experienced early menopause due to surgery were reported to have about a 38% higher risk of peptic ulcers than premenopausal women of the same age. Another factor cited is the increase in women taking medications such as anti-inflammatory painkillers for conditions like joint disease after menopause. There are also survey results showing that about 75% of anti-inflammatory painkiller users among those aged 65 and older in Korea are women.
In other words, the research team's analysis suggests that the increase in peptic ulcers in women is likely the result of a complex interplay of hormonal changes during menopause, along with advanced age, comorbidities, and drug exposure. Sex differences were also found in various diagnostic and treatment areas, including Helicobacter pylori eradication therapy, proton pump inhibitors (PPI), and potassium-competitive acid blockers (P-CAB).
However, even when comparing 13 major international clinical guidelines on peptic ulcers, upper gastrointestinal bleeding, and gastric protection, none included sex or age-based menopausal or hormonal status in formal risk assessment. They only presented risk factors such as advanced age, a history of ulcers, and the use of anti-inflammatory painkillers and antithrombotic agents, without reflecting the possibility that risk and treatment response may differ in postmenopausal women. This study holds important significance in that it synthesized sex differences found in various peptic ulcer studies and pointed out gaps in current treatment guidelines that inadequately address them. It is also expected to serve as important evidence when clinical guidelines on the diagnosis and treatment of peptic ulcers are reestablished in the future.
Professor Kim Byung-wook, who serves as president of the Korean College of Helicobacter and Upper Gastrointestinal Research, said, "We are currently developing new clinical guidelines for drug-induced peptic ulcers," adding, "We are reviewing hormonal status, such as sex and menopause, as important variables."
Professor Kim Na-young stressed, "When elderly women use antiplatelet agents or anticoagulants, they are exposed to a high risk of severe progression and death." She added, "We need clinical guidelines that present gastric protection strategies, such as the use of acid secretion inhibitors, for women aged 70 and older, and that also evaluate differences in drug response by sex."
This study was supported by research funding for "Improvement of Sex-Based Diagnostic and Treatment Technologies for Digestive Diseases and Their Clinical Application" from the Korea Disease Control and Prevention Agency and the National Institute of Health, and was published in a recent issue of the international journal Gut and Liver.
