Q. Hello, Dr. C. My name is Mary. I am 56 years of age and have had trouble with constipation for probably 10 years. I have not seen a physician for this problem because it did not seem particularly significant. However, now I am having some abdominal discomfort and the over-the-counter laxatives have been less effective. I have seen ads on television and in magazines for prescription medications, and wonder if I should see a physician and have one of the prescription medications for constipation prescribed for my problem. I do not have a primary care physician and going to the emergency room does not seem warranted either. What should I do at this time?

A. Mary, thank you for your very important question. Constipation certainly is a common medical problem and since you have had it for an extended period of time it probably is a problem which is likely to stay with you or even become worse. Chronic constipation probably affects 40 million people in America, so you are certainly not alone. There are several important issues to discuss regarding your problem. First, given your age of 56 years, you do need to have your colon evaluated for anatomic problems that could be causing constipation, or certainly even if you had no symptoms you should have a colonoscopy to evaluate for pre-cancerous or even an evolving cancer in your colon. I am concerned while you have had constipation for a decade the abdominal pain component makes the issue a bit more concerning. It is certainly difficult in these times to find financially reasonable preventive health care programs, but I think it is essential that you find a clinic or a physician where you can obtain ongoing medical care. This issue of constipation and the evolving abdominal pain requires more attention than taking over-the-counter medications.

If we assume that you have not evolved any significant blockage of your bowel then you are probably like most Americans, you have a problem with motility of the colon or in fact you are simply not getting enough fiber in your diet. It is hard to believe that we have been talking about fiber and constipation for 50 years, yet it is still one of the leading problems in the American diet that with our fast food orientation, poor dietary habits, and evolving obesity, constipation is a major consequence of our dietary and sedentary lifestyle. The cornerstones for managing constipation are still the same. High fiber diet and regular exercise probably would correct most of the constipation problems for which patients take over-the-counter medications or even seek medical help. Having said that, there are medications approved by the Food and Drug Administration for the treatment of constipation. These medications include the following. Lactulose, polyethylene glycol 3350 commercially known as MiraLax, tegaserod commercially known as Zelnorm, and finally the new medication lubiprostone commercially known as Amitiza. These medications work differently. They are generally quite safe. They can be expensive. In practice the scientific data for these medications is very good for Zelnorm, good for Amitiza (the medication is very new and we do not have a great deal of data, but it is approved by the FDA), modest for MiraLax, and rather for lactulose. We use a great deal more of MiraLax in the office because it is quite safe, does not produce a great deal of gas, and has a very low side effect profile. On the other hand, Zelnorm which stimulates the motility of the GI tract resulting in increased peristaltic activity and improved stooling with the reduction of bloating as well, has the best scientific data for use in constipation.

In summary, in your age group it is particularly important for you to start with the basics. First, I would see a family physician and have a physical examination. Blood tests to exclude such disorders as adult onset diabetes and thyroid dysfunction should be carried out. A review of your diet and initiation of a high fiber program would be in order. Begin an exercise program. Try to walk 30 minutes or more five days per week. An occasional use of over-the-counter laxatives is certainly safe. Given your age, a screening colonoscopy is very important, not only for evaluation of constipation, but also to rule out an evolving partial blockage of the bowel due to colon cancer. Finally, when these steps have been taken and are adequately resolved or tested, the initiation of one of the four FDA approved prescription medications for constipation is certainly worth initiating at that time. I hope you find this answer satisfactory. Enjoy the holiday season.

Nicholas Costrini, MD, PhD provides his column Good for What Ails You every other week. He may be reached at georgiagi.com.