Journal
of
Coloproctology
w w w . j c o l . o r g . b r
Original
article
Prevalence,
repercussion
and
factors
associated
with
intestinal
constipation
in
women
in
Florianópolis
Cinara
Sacomori
∗,
Camila
Silveira,
Fabiana
Flores
Sperandio,
Fernando
Luiz
Cardoso
UniversidadedoEstadodeSantaCatarina,Florianópolis,SC,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received23May2014
Accepted11August2014
Availableonline4September2014
Keywords:
Intestinalconstipation
Qualityoflife
Bodyimage
Physicalactivity
a
b
s
t
r
a
c
t
Theobjectiveofthisstudywastodeterminetheprevalenceofintestinalconstipationand
itsassociationwithsociodemographicandhealth-relatedfactorsin605adultwomenof
metropolitanFlorianópolis/SCwhounderwentscreeningtestsforcervicalcancer.Thisis
across-sectionalstudyinwhichintestinalconstipationwasevaluatedbyRomeIIIcriteria.
WeusedPoissonregressionconsideringp<0.05.
Results:TheprevalenceofintestinalconstipationaccordingtoRomeIIIwas25.1%.
Approx-imately80%ofwomenwithconstipationreportedthattheproblemcausedmedium/high
interferenceintheirlives.Inunivariateanalysis,constipationwasassociatedwith:income
percapitalowerthan1minimumwage,apoorhealthstate,bodydissatisfaction,physical
activityduringpersonalcommutingandself-reportofhemorrhoids.Inmultivariateanalysis
andfollowingahierarchicalmodel,theassociationpersistedonlyforself-reportof
hemor-rhoids(PR=4.45,CI=3.49–5.68).Copingstrategiesforintestinalconstipationinthehealth
careofwomenaresuggested.
©2014SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All
rightsreserved.
Prevalência,
repercussões
e
fatores
associados
à
constipac¸ão
intestinal
nas
mulheres
em
Florianópolis
Palavras-chave:
Constipac¸ãointestinal
Qualidadedevida
Imagemcorporal
Atividadefísica
r
e
s
u
m
o
Oobjetivofoiverificaraprevalênciadeconstipac¸ãoesuaassociac¸ãocomfatores
sociode-mográficoserelacionadosàsaúdeem605mulheresadultasdagrandeFlorianópolis/SCque
realizaramexamesderastreamentodecâncerdecolouterino.Esteéumestudotransversal
emqueaconstipac¸ãofoiavaliadapormeiodoscritériosRomaIII.Utilizou-seregressãode
Poissonparap<0,05.
∗ Correspondingauthor.
E-mail:csacomori@yahoo.com.br(C.Sacomori).
http://dx.doi.org/10.1016/j.jcol.2014.08.006
Resultados:aprevalênciadeconstipac¸ãosegundoRomaIIIfoi25,1%.Aproximadamente80%
dasmulherescomconstipac¸ãoreferiramqueamesmatinhamédia/grandeinterferência
emsuasvidas.Naanáliseunivariada,estiveramassociadosàconstipac¸ão:rendapercapita
menorque1saláriomínimo,estadodesaúderuim,insatisfac¸ãocomocorpo,realizar
ativi-dadefísicanodeslocamentopessoaleauto-relatodehemorróidas.Naanálisemultivariada
eseguindoomodelohierárquico,somenteaassociac¸ãocomoauto-relatode
hemorrói-dasfoipreservada(RP=4,45;IC=3,49-5,68).Sugerem-seestratégiasdeenfrentamentoda
constipac¸ãonoâmbitodeatenc¸ãoàsaúdedamulher.
©2014SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.
Todososdireitosreservados.
Introduction
Unliketheoldmyththatconstipationisnormalforwomen,
this problem, when chronic, can cause health and
qual-ity of life impairment, besides facilitating the appearance
ofinjuries, e.g.prolapseofpelvicorgans,hemorrhoidsand
stress urinary incontinence.1,2 Functional constipation is
definedbased on Rome III diagnostic criteria: sensation of
abdominalbloating,feelingofincompleteevacuation, need
ofdigitalfacilitationfordefecation,needforstraining,
pass-ing hard stools and occurrence of less than three bowel
movements per week, in addition to the regular use of
laxatives.3
Studiesaimedatunderstandingthisphenomenonusually
involvespecificgroups, withthemostvariedprevalence.A
systematicreviewshowedthepresenceofdistinctdiagnostic
criteria,resultinginwidevariationsintheprevalencereported
ininternationalstudies,from0.7%to79%inadults.4InBrazil,
population-basedstudiesconductedinthesouthofthe
coun-tryreportedaprevalenceof23%inbothmenandwomen5and
of37%inwomen.6
Thereis evidencethat the prevalenceofintestinal
con-stipationishigherinwomenthaninmen,duetohormonal
factors.7 Theminorityofwomenwhosufferfrom
constipa-tionlookforhealthservicesforadiagnosisortreatmentof
theircondition.Thisunderestimationofdata,aswellasthe
lackofadiagnosticandtherapeuticstandardization,8makes
itdifficulttodeterminetheactualprevalenceofconstipation.
In general, constipationcan be treated at primary care
levelwithcost-effectivecontrolofsymptoms.9Inthewomen’s
healthcareservice,screeningtestsforcervicalcancerstand
out.Epidemiologicalstudieshaveshownthatthecoverageof
thesetestsissatisfactoryinBrazil.10,11Itisunderstoodthatit
wouldbeopportunetoinvestigatethepresenceof
constipa-tioninwomenlookingfortheseexamsandtoadoptstrategies
forthisdisease.
Of those factors associated with constipation, eating
habits,physicalinactivity,socioeconomicstatus,
psycholog-icalissues, medication use and increasing age stand out.7
Giventheimportanceofthisissueandthesocialsignificance
offemalebodyappreciationasaconstituentofsatisfaction
andwell-being,this researchaimstoverify the prevalence
ofintestinalconstipationand its association with
sociode-mographicfactors and other health-related issuesin adult
women who perform routine screening tests for cervical
cancer.
Methods
Thisisanobservationalcross-sectionalstudy,withdata
col-lection conducted from September 2011 until April 2012.
Participantswere605womenwhoattendedtheWomen’s
Net-work Against Cancer in Florianópolis (SC). The institution
servesapproximately4200womenperyear,beingreference
tothepreventionandcareofbreastandcervicalcancerfor
womenofdifferentsocioeconomicclassesoftheregion.The
assessmentsoccurredonTuesday,ThursdayandFriday
after-noons,giventheavailabilityofaroomreservedforthisstudy.
Thepatientsshowedupwithnoscheduledtimeforthe
exam-ination.
ThestudywasapprovedbytheethicscommitteeofUDESC
under protocol n.15/2011 and was conducted within the
ethical standards ofthe Declarationof Helsinki (1964) and
accordingtoResolution196/96oftheMinistryofHealth.
Inclusion criteriaconsistedofwomenwho attended the
institutionforcervicalcancerscreeningtestandagreedto
par-ticipateinthestudybysigningafreeinformedconsentform.
Exclusioncriteriawere:pregnantwomen,womenwith
cog-nitiveimpairmentorneurologicalillness,physicaldisability
limitingambulation,andwomenunder18yearsofage.
Instruments
Demographicdatawereobtainedthroughaformcontaining
questionsofinterest:age,ethnicity,education,maritalstatus,
familyincome(inminimumwages)andhealthstatus(levels:
verygood,good,fair,poorandverypoor).
Anthropometric data (weight, height,waist and hip
cir-cumference) were obtained with a digital scale and a
measuringtape.Forclassificationofabdominalobesity(using
the waistcircumference,measured justbelowthelast rib),
weusedcutoffpointsinrelationshiptotheriskofdeveloping
metaboliccomplications,being categorizedinto inadequate
(≥80cm)andappropriate(<80cm).12
The physical activity was assessed through questions
obtainedfromastudy ofIBGE.13Womenwho saidthat“in
thelastthreemonthsIhavepracticedsomeformofphysical
exerciseorsport”wereconsideredasactiveinleisure.Women
who“usedtowalkorbikefromhometowork”were
consid-eredactiveintheirjourneytowork.Activewomenatwork
correspondedtothosewho“walkedatworkmostofthetime,
carried weightordidsomeother activity requiringintense
thehousewherethosewhosaidthat“usedtodothe(heavy)
cleaningathome.”
Bodyimage was assessedwith the silhouettes’ scale of
Stunkard.14 To evaluate satisfaction with body image, the
actualbodyappearancewassubtractedfromtheidealbody
appearance.Whenthevariationwas=zero,thewomanwas
classifiedassatisfied;withanon-zerovalue,shewasclassified
as dissatisfied.If the difference was positive, the
dissatis-factionwasbyanexcessofweight;andwhennegative,the
dissatisfactionwaswithleanness.Bodysatisfaction,inturn,
wasidentifiedwithaquestion:“towhatdegreeareyou
sat-isfiedwithyourbody?”(verysatisfied, moderatelysatisfied,
neithersatisfiednordissatisfied,moderatelydissatisfied,very
dissatisfied).
Inordertoassessconstipation,inadditiontoself-reportsof
womenweusedRomeIIIcriteria,thankstotheirwide
accep-tanceanduseinstudiesonthistopic.3,4,15RomeIIIconsists
ofobjective(numberofevacuations,needformanual
maneu-verstodefecate)andsubjective(strainingwhendefecating,
incompleteevacuation,sensationofobstruction,hardstools)
criteria.Tocharacterizetheconstipation,twoormoreofthese
criteriamustbeachieved.15
Finally,aself-report controlquestionregardingthe
pres-enceofhemorrhoidswasincluded,aswellasanevaluation
ofhowthe presenceofconstipationinterfered with
every-daylife.Withthisinmind,avisualanalogscalewithscores
rangingfrom0(doesnotinterfere)to10(interferesalot)was
used.
Procedures
Theinformationwascollectedatthetimeduringwhichthe
womenwereinthewaitingroom,waitingtotheirscreening
examforcervicalcancer.Theywereinvitedtoparticipatein
thestudybeforetheexam,whenweexplainedthepurposeof
thestudyandtheconfidentialityofidentification.
Datawerecollectedbyaphysiotherapistandtwo
under-graduatestudents (all women, all previouslytrained) from
PhysiotherapyCourse.Datacollectiontookplaceonprivacy
andduringthewaitingtimeforthescreeningtest.Veryfew
womenrefusedtoparticipate,becausetheirparticipationdid
notentailfurtherlossoftime.First,thecharacterizationdata
ofthesamplewerecollected,followedbytheapplicationof
otherresearchinstruments.
Dataanalysis
Dataobtainedwere tabulatedwithSPSSstatisticalprogram
and analyzed using descriptive (frequency, mean, median
andstandarddeviation)andinferentialstatistics.Inorderto
analyzetheassociationsamongtheoutcome(constipation)
andindependent(sociodemographicandhealth-related)
vari-ables,wecompletedaPoissonregressionanalysiswithrobust
variance toobtain crude and adjusted estimates of
preva-lenceratios,consideringp<0.05.For adjustedanalyzes,we
adoptedtheorderofahierarchicalmodeltodeterminethe
outcomesinwhichwereincludedthosevariablespresenting
p<0.25incrude analyses.16 Thelevel 1(sociodemographic)
variableswereadjustedamongthemselves,beingkeptinthe
modelthosewithp<0.25,foradjustmentofvariablesinthe
Table1–Prevalenceofself-reportedconstipation accordingtoRomeIIIobjectivecriteriaandhow constipationinterfereswitheverydaylife.
Criteriaofconstipation n % Self-report 148 24.5 DiagnosedaccordingtoRomeIII 152 25.1 Sensationofanalblock 138 22.8 Needfordigitalfacilitation 9 1.5 Sensationofincompleteevacuation 123 20.3 Passageofhardstools 134 22.1 Strainingnecessity 134 22.1 Occurrenceoflessthan
threebowel movements/week
119 19.7
Regularuseoflaxatives 31 5.1
Hemorrhoids 51 8.4
Interferenceineverydaylife(0–10)a
0–Nointerference 458 75.7
1 1 0.2
2 5 0.8
3 8 1.3
4 10 1.7
5–Mediuminterference 25 4.1
6 11 1.8
7 14 2.3
8 20 3.3
9 11 1.8
10–Highinterference 37 6.1
a Fivewomendidnotrespondtothisquestion.
subsequent level. Next, level 2 (behavioral) variables with
p<0.25inthecrudeanalysiswereincluded,alongwiththose
oflevel1,foradjustmentofvariables.
Results
AscanbeseeninTable1,theprevalenceofintestinal
constipa-tionaccordingtotheself-reportwassimilartothatobtained
with Rome III criteria. Most women exhibited noneof the
establishedobjectivecriteriaand25.1%hadatleasttwo
crite-ria,consistentwiththediagnosis ofconstipationaccording
to Rome III. Regarding the interference of constipation in
women’severydaylives,measuredwithavisualanalogscale,
approximately80%ofwomenwithconstipationreportedthat
thisproblemhadamedium/highinterferenceintheirlives.
The mean age of participants was 40.5 (SD=13.2,
median=40) years. About 70% ofwomen were dissatisfied
withtheirbodyimage,mainlyduetoanexcessbodyweight.
Prevalenceratiosobtainedforthevariable“constipation”in
womeninthisstudy,accordingtoapre-established
hierarchi-calmodel,aregiveninTable2.Asforcrudeanalysis,income
percapitalessthan1minimumwage,poorhealthstate,body
dissatisfaction,physicalactivityinpersonalcommutingand
self-reportedpresenceofhemorrhoids.
Afterintra-andinter-leveladjustments,onlythepresence
ofhemorrhoidswasassociatedwithconstipation,sothatthe
prevalenceofconstipationinwomenwithhemorrhoidswas
Table2–SociodemographicandhealthvariablesassociatedwithfemalebowelconstipationevaluatedbyRomeIII criteria.
n(%)a RawanalysisPR(CI) AdjustedanalysisPR(CI)
Notconstipated(n=453) Constipated(n=152)
Level1–sociodemographicvariables
Education p=0.178 p=0.269
Fundamentalcomplete/incomplete 195(74.7) 66(25.3) 1.69(0.92–3.11) 1.66(0.89–3.10) Mediumcomplete/incomplete 200(73.5) 72(26.5) 1.77(0.97–3.25) 1.59(0.87–5.93) Superiorcomplete/incomplete 57(85.1) 10(14.9) 1 1
Incomepercapita p=0.045 p=0.120
Upto1minimumwage 261(72.1) 101(27.9) 1.36(1.01–1.85)b 1.29(0.94–1.77)
Morethan1minimumwage 183(79.6) 47(20.4) 1 1
Agegroup p=0.065 p=0.062
<44years 265(72.2) 102(27.8) 1.33(0.98–1.80) 1.36(0.98–1.88)
≥45years 178(79.1) 47(20.9) 1 1
Maritalstatus p=0.476
Withnopartner 133(76.9) 40(23.1) 0.89(0.65–1.22) c
Withpartner 320(74.1) 112(25.9) 1
Ethnicity p=0.712
Caucasian 354(75.3) 116(24.7) 0.96(0.66–1.33) c
Black/mulatto/yellow 81(73.6) 29(26.4) 1
Level2–health-relatedvariables
Stateofhealth p<0.001 p=0.069
Fair/poor/verypoor 170(67.7) 81(32.3) 1.66(1.26–2.19)b 1.34(0.98–1.83)
Good/verygood 282(80.6) 68(19.4) 1 1
Hemorrhoids p<0.001 p<0.001
Yes 6(11.8) 45(88.2) 4.56(3.75–5.56)b 4.45(3.49–5.68)b
No 447(80.7) 107(19.3) 1 1
Urinaryincontinence p=0.051 p=0.660
Yes 143(70.1) 61(29.9) 1.32(0.99–1.74) 1.07(0.79–1.46)
No 310(77.3) 91(22.7) 1 1
BMIclassification p=0.106 p=0.423
Excessbodyweight 209(72.6) 79(27.4) 1.27(0.95–1.71) 1.13(0.84–1.52)
Normalweight 215(78.5) 59(21.5) 1 1
Abdominalobesity p=0.476
Inappropriate(waist≥80cm) 201(79.4) 52(20.6) 1 c
Appropriate(waist<80cm) 175(76.8) 53(23.2) 1.13(0.81–1.58)
Bodysatisfaction p=0.013 p=0.925
Unsatisfied 114(67.5) 55(32.5) 1.54(1.15–2.06)b 1.05(0.73–1.48)
Neithersatisfiednordissatisfied 44(71) 18(29) 1.37(0.88–2.15) 0.94(0.57–1.55)
Satisfied 291(78.9) 78(21.1) 1 1
Satisfactionwithbodyimage p=0.066 p=0.382
Satisfied 131(80.4) 32(19.6) 1 1
Unsatisfied 319(72.8) 119(27.2) 1.38(0.98–1.96) 1.19(0.81–1.75)
Physicalactivityatwork p=0.345
Inactive 251(76.5) 77(23.5) 0.87(0.66–1.15) c
Active 202(73.2) 74(26.8) 1
Physicalactivitypersonalcommuting p=0.005 p=0.124
Inactive 333(78) 94(22) 1 1
Active 120(67.4) 58(32.6) 1.48(1.12–1.95)b 1.26(0.94–1.71)
Domesticphysicalactivity p=0.655 c
Inactive 39(72.2) 15(27.8) 1.11(0.70–1.75)
Active 410(75) 137(25) 1
PR,prevalenceratio;CI,confidenceinterval.
a Validpercentageswereusedduetosomemissingdataforsomevariables.
b Significantatp<0.05.
c VariablesnotincludedinmultiplePoissonmodelfornotpresentingp<0.25.
Discussion
Thisstudyidentifiedahighprevalenceofconstipation(25.1%)
in adult women visiting a public health service to
per-formscreeningtestsfor cervicalcancer. Theprevalenceof
self-reported constipationwas similar tothat according to
Rome III diagnosticcriteria (24.5%and 25.1%,respectively).
Asimilarpopulation-basedstudyconductedinPelotas,RGS,
reachedaprevalenceof37%usingRomeIIIcriteria.6Itis
previousstudiesduetodifferentdiagnosticcriteria,
consid-eringthattheestablishmentofRomeIIIcriteriaoccurredin
2006.15Theinformationontheprevalenceofconstipationin
developingcountriesisscarce.4
Inthe present study, it wasidentified that constipation
affects the everyday lives of adult women, since
approx-imately 80% of patients with this condition reported a
medium/high interference in their lives. Although
consti-pationreally affecteveryday life, many constipatedpeople
minimizesuchdiscomfort,notconsideringitsbowelhabits
asabnormal,andbelievingthattheycansolvetheproblem
ontheirown.4
Theresultsofthisstudy–highprevalenceofconstipation
andinterferenceofthisconditionineverydaylivesofwomen
–indicatetheneedtointroducemethodstocorrectthe
prob-leminordertopreventitscomplicationsintheshortandlong
term.Overtheyears,thepresenceofconstipationincreases
theriskoffecalincontinence,17cardiovascularevents,18
prob-lems inhemorrhoids and anal fissure,19 prolapse ofpelvic
organs,andstressurinaryincontinence.1,2,20
Therefore, there is a need to develop health education
programswhich advise on strategiesforconstipation care,
including improved eating behaviors and bodily practice
incentives(e.g.games,dance,gymnasticsandsports).Itis
sug-gested,asaspacetodevelopsuchactions,theuseofwomen’s
serviceofhealthcareinthosetimeswhenwomenareseeking
thescreeningtestforcervicalcancer.
Inthisstudy,theprevalenceofconstipationinwomenwho
had incomesper capitalower than 1minimum wage was
1.36timestheprevalenceinwomenwithincomespercapita
higher than 1 minimum wage. However, after adjustment
withthevariables“education”and“age”,thisassociationdid
notkeepstatisticalsignificance.Itwaspreviouslydescribed
thatlowsocioeconomic status/educationlevelwere
associ-atedwithhigher prevalenceofconstipation.4,6,7 A possible
explanationforthisfindingistherelationshipwithdifferent
dietaryhabitsandlifestylesofindividualsindifferent
socio-economicconditions.7
Furthermore, the prevalence of constipation in women
withself-assessmentimplyingaworsehealthstatuswas1.66
timeshigher than thatfound inwomenwithgood health,
butthisassociationwasnotmaintained,whenadjustedfor
theothervariablesofthehierarchicalmodel.Inthisregard,a
reviewoftherecentliterature19indicatesthatintestinal
con-stipationmaybesecondarytomanydiseases,andalsotothe
useofmedications.Possibly,thesymptomsofconstipationare
elementsthatreducetheperceptionofhealth,initsbroadest
sense.
The prevalenceof body image dissatisfaction was high
(72.9%) and mainly attributed to excess body weight. The
manifestation of dissatisfaction with body image usually
beginsingirlsfrom 6yearsofage(pre-adolescence),when
the child beginto assimilate the culturalcontexts ofbody
andesthetics.21Dissatisfactionwithbodyimageisrelatedto
depressivesymptomsandpoorerself-esteeminthefemale
population.22SlevecandTiggemann(2011)23explainthatthe
factors responsible for dissatisfaction with body image in
middle-agedwomenare similartothose inyoungwomen,
whethertheyarebiological(suchasBMI),psychological
(inter-nalizingtheslendernessideal)andsocio-cultural(e.g.bullying
relatedtobodyweight).Furthermore,accordingtotheauthors,
thefactors“menopause”and“anxietyrelatedtoaging”
con-tributetothisfeelingofdissatisfactionwithbodyimagein
middle-agedwomen.
ItisunderstoodthatthelackofcomfortofBrazilianwomen
intheeliminationofflatus,duetoaculturalnormestablishing
thatitspubliceliminationisunpleasant,alongwiththehigh
demandfordomesticchoresandworkingactivitiesandalso
withthepoorhygieneinpublicrestroomsingeneral,willlead
toanincreasedrepressionofintestinalgasesandsolidcontent
elimination,withconsequentinhibitionofdefecationreflex
–whichisatriggeringfactorforchronicconstipation.Such
behaviorprovidesevidenceofapossiblerelationshipbetween
poorbodyperceptionandconstipation.
Thisstudy found thatthe prevalenceofconstipationin
womendissatisfiedwiththeirbodywas1.54timesthe
preva-lencefoundinwomenshowingsatisfactionwiththeirbody.
However, when the adjustment with the other variables
was made, the association between body satisfaction and
constipationdidnotlast.Itwasverifiedthatwomenwith
con-stipationhadgreaterpsychologicalmorbidity,manifestedby
anxiety,depressionandsocialdysfunction,andbyanaltered
perceptionoffeminineidentity.24 Therelationshipbetween
constipationandsatisfactionwiththebody,includingthe
per-ceptionofbodyimage,hasnotyetbeensufficientlyexplored.
Theperception,thatis,themeaningattributedtothebody,
undergoeschangesthroughoutlife,sincetheconstructionof
thisimagecanbeinfluencedbycultural,socialand
psycho-logicalcontexts.25
There was no association between variables related to
excessbodyweight(BMIandwaistcircumference)with
con-stipation.Furthermore,asystematicreview4identifiedseveral
studiesdescribingtherelationshipbetweenobesityand
pres-enceofconstipation.
Unlikestudiesdescribingthatexercisepracticestimulates
bowelfunction,sincethedesiretodefecateisoftenreported
duringandafterexercise,26ourstudydidnotidentifysuchan
associationafteranadjustedanalysis,possiblybecausethe
measuringinstrumentofphysicalactivitythroughself-report
doesnotofferenoughprecisiontodetectthisassociation.
In thisstudy,the presenceofhemorrhoids wasthe
fac-tormostassociatedwithconstipation(PR=4.45), evenafter
adjustment.Hemorrhoidthrombosismaybethecauseor
con-sequenceofconstipation,19 andthereforeshouldbefurther
investigatedinthefemalepopulationingeneral.
Conclusion
Weobservedhighprevalenceofintestinalconstipationandof
dissatisfactionwithbodyimageforwomenseekingscreening
testsforcervicalcancerinFlorianopolis.Thefactors
associ-atedwithconstipationinunivariateanalysiswereanincome
percapitalessthan1minimumwage,apoorhealthstate,body
dissatisfaction,physicalactivityinpersonalcommutingand
self-report ofhemorrhoids.Inmultivariateanalysis,
follow-ingahierarchicalmodel,onlytheself-reportofhemorrhoids
remainedassociatedwithconstipation.
Thisstudyisimportantforidentifyingthatconstipation
justifiesthedevelopmentofhealtheducationactivitiesand
bodilypracticesinthecontextofprimarycareencouraging
betterbodyperceptionand knowledge,besidesthe offerof
therapeuticandpreventivecareforconstipationand
hemor-rhoids.
Consideringthe limitationsofthisstudy,it issuggested
thatfutureresearchusepopulationbasedsurveysand
prefer-ably continue adopting Rome III criteria for evaluation of
constipation.Furthermore,itissuggestedthatother
impor-tantfactors,asthoseofobstetric(parity,complicationsand
typeofdelivery),hormonal(menopause),nutritional,
psycho-logicalandofmedicalnaturebecontrolled.Inaddition,the
relationshipbetweenconstipationandbodilyissuesneedto
befurtherexplored.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
We would thank the group of women volunteers of the
Women’sNetworkAgainstCancer,Florianópolis,SC,forthe
opportunitytoconductthisstudy.
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