Constipation after 40: your questions, answered

Constipation is one of those topics people rarely bring up, even with their doctor. Yet it's common, especially in women and in older adults (Suares and Ford, 2011), and it can make a bloated afternoon feel even worse.

Here are straight answers to the questions women ask most, based on guidelines and controlled trials rather than folklore.

How do I know if I'm actually constipated?

It isn't only about how often you go. Doctors use the Rome IV criteria for functional constipation. These count symptoms such as straining, lumpy or hard stools, a feeling of incomplete emptying, a sense of blockage and needing to use your fingers to help, each happening with more than a quarter of bowel movements. Fewer than three bowel movements a week also counts.

Two or more of these over the past three months, with symptoms that started at least six months earlier, meets the definition (Mearin et al., 2016).

Hard stools are usually described with the Bristol Stool Form Scale, where types 1 and 2 are separate hard lumps or a lumpy sausage shape. So if you go every day but regularly strain over hard stools, that can still count.

Is it really more common in women?

Yes. In a meta-analysis covering more than 261,000 people, about 14% of adults had chronic constipation. Women had about twice the odds of men, and rates rose with age (Suares and Ford, 2011).

Does fiber help, or does it just make me more bloated?

It can do both. A 2022 meta-analysis of 16 randomized trials with 1,251 adults found that 66% of people responded to fiber supplements, compared with 41% on control treatments. Psyllium and pectin showed the clearest effects, and benefits appeared mainly at doses above 10 grams a day and after at least four weeks (van der Schoot et al., 2022).

The same analysis found more flatulence with fiber. That's the practical catch: increase slowly, drink enough fluids and give any change a full month before you judge it.

Which laxatives have the best evidence?

In 2023, the American Gastroenterological Association and the American College of Gastroenterology published a joint guideline on medications for chronic constipation (Chang et al., 2023). It made:

• Strong recommendations for polyethylene glycol (PEG), sodium picosulfate, and the prescription drugs linaclotide, plecanatide and prucalopride
• Conditional recommendations for fiber, lactulose, senna, magnesium oxide and lubiprostone

A conditional recommendation means the evidence is weaker, or the balance of benefits and downsides depends more on the individual. Over-the-counter options are a reasonable place to start. Check with your doctor or pharmacist first if you have kidney or heart problems, take several medications, or find you need a laxative for more than a few weeks.

What if I strain even when my stools are soft?

That pattern can point to a coordination problem rather than a stool problem. In dyssynergic defecation, the pelvic floor and anal muscles don't relax properly when you try to have a bowel movement. It's diagnosed with specialized tests, such as anorectal manometry and a balloon expulsion test.

It's also treatable. In a randomized trial of 77 people with chronic constipation and dyssynergia, 69 of them women, biofeedback therapy was more likely to correct the dyssynergia than sham feedback or standard therapy with diet, exercise and laxatives. It also increased complete spontaneous bowel movements, and satisfaction with bowel function was higher than with sham feedback (Rao et al., 2007).

Could something else be causing it?

Sometimes. Constipation can be a side effect of medications or supplements, and it can come with conditions that slow the gut. If your constipation is new, bring a complete list of everything you take, including over-the-counter products, to your appointment.

It also helps to note when the change started, what your stools look like, and anything you've already tried. Those details help your doctor decide whether you need tests or a treatment trial first.

When should I see a doctor?

• Constipation that's new and lasts more than a few weeks, especially if you're 45 or older
• Blood in your stool, black stools or anemia
• Weight loss you can't explain
• Severe abdominal pain, vomiting or being unable to pass gas
• Narrower stools or a lasting change from your usual pattern
• A family history of colorectal cancer or inflammatory bowel disease
• No improvement after a month of consistent fiber, fluids and an over-the-counter option

Sources

1. Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol. 2011;106(9):1582-91. PMID 21606976
2. Mearin F, Lacy BE, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150(6):1393-1407. PMID 27144627
3. van der Schoot A, Drysdale C, Whelan K, Dimidi E. The effect of fiber supplementation on chronic constipation in adults: an updated systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr. 2022;116(4):953-969. PMID 35816465
4. Chang L, Chey WD, Imdad A, et al. American Gastroenterological Association-American College of Gastroenterology clinical practice guideline: pharmacological management of chronic idiopathic constipation. Gastroenterology. 2023;164(7):1086-1106. PMID 37211380
5. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. 2007;5(3):331-8. PMID 17368232

This article is for general information and isn't medical advice. Talk to your healthcare provider or pharmacist before using laxatives regularly, especially if you're pregnant, have kidney disease or take prescription medication.