Male predominance in inflammatory bowel disease despite similar disease activity: A large retrospective cohort study

Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease (CD), exhibit clinical heterogeneity, with sex-related differences potentially influencing disease course and prognosis. This study investigates the impact of sex on IBD prognosis in a large cohort. Data were collected from patients diagnosed with IBD at our clinics between July 1993 and April 2025. Demographic, clinical, and treatment variables were analyzed, focusing on sex-based differences in disease onset, disease activity, extraintestinal manifestations (EIMs), treatment escalation, hospitalizations, and surgical interventions. A total of 1774 patients diagnosed with IBD were included in the study. A male predominance (61%) was observed in IBD, with higher male-to-female ratios in both ulcerative colitis (1.6:1) and CD (1.47:1). Female patients presented earlier with IBD (mean age 34.7 vs 37.0 years; P = .001) and had a higher frequency of EIMs, particularly peripheral arthritis and erythema nodosum (P < .001). No significant sex differences were observed in disease severity, hospitalizations, or need for treatment escalation. However, female patients with CD demonstrated higher disease activity at baseline, as measured by the Crohn's disease activity index. Both sexes exhibited similar rates of biologic therapy use, the number of biologic therapies, hospitalizations, and major surgeries. Despite the male predominance in IBD prevalence, sex-related differences in clinical outcomes were minimal, with both sexes experiencing comparable disease activity, treatment escalation, and need for surgery. However, female patients exhibited a higher frequency of EIMs, highlighting the importance of a sex-based approach in clinical management.