Despite the utilization of the random samples procedure during patient recruitment, predominant woman patients are detecting in the study population. Generally, the woman is much higher than man to incidence with CD and some studies shown that women were at increased risk for CD incidence, with an average ratio of women to men (2 : 1) (Kuja-Halkola et al., 2016 ; Ludvigsson et al., 2016 : Al-Toma et al., 2019) and with Mohtaʼs study that found the woman is (1.3–2.1) more than man to affliction with CD (Mohta et al., 2021) and this is in line with the publish results that is corresponding with as study involved 1,682 patients diagnosed with CD divulge (68.00) % are found to be women and (32.00) % are man, results which are usually observed as there is a prevalent rate of autoimmune disease among women (Dixit et al., 2014).
Other studies have also reported similar predominance with CD, for example, more than fifty percent of women in 249 celiac patients (Rubio-Tapia et al., 2013), and as a consequence, the findings of this study are comparable to the conclusion of a study of (Green and Cellier, 2007 ; Singh et al., 2018) which enumerated CD was 2 to 3 times more frequent in woman than in men patients.
Reasons suggested for woman's predominance to affliction with CD have not been well defined, but it proposed that women were at greater risk to develop immune-mediated diseases maybe the man Y-chromosome has a protective role against autoimmune diseases (Quintero, 2012). However, delay in presentation of clinical symptoms, short span of clinical manifestation as well as less frequency of diagnosis in men especially in early adulthood (Dixit et al., 2014), or associated with hormonal differences in women than men, or role of sex hormones as estrogen and androgens in immune response regulation which might explain sex differences or its complications as well as the nature of women's lifestyle, pregnancy, parturition, and menstruation (Quintero, 2012 ; Jansson-Knodell et al., 2019).
In many studies, a woman is more affected by CD than a man, but this disagrees with many studies that explained that CD seems to be more frequent in man than woman patients as a study was done in Iran (Mehrdad et al., 2012), and with a study conducted in the center for gastrointestinal diseases in Baghdad province that demonstrated the men were represented 51 of 93 patients whereas the woman was represented 42 of 91 patients because of this study didn’t include patients in all age and conducted on patients under 18 years (Arif et al., 2009), and also with a study that shown (62.20) % were man compared to (37.80) % of woman patients because this study conducted on under 12 years old celiac patients (Alshebani and Abdalhamza, 2018).
The results of the current study demonstrate that two steps serology testing approach represents good diagnostic tools for screening and monitoring patients with CD as these CD tests are manifested by high sensitivity, specificity, accuracy, and positive predictive values which agree with similar Iraqi studies were obtained by (Shorouq, 2020 ; Alaa, 2021 ; Majeed, 2021). Thus, based on the specificity and sensitivity of the study CD serology tests can be ranked in the order: Anti-tTG IgG > Anti-tTG IgA > Anti-GA IgG > Anti-GA IgA. The high frequency of patients with seropositivity to Anti-tTG IgG can be attributed to its high sensitivity and specificity in the existing study; thus, supporting it's diagnostic potency. The autoantibodies belong IgG class having a significantly higher specificity and sensitivity to CD, whereas the IgA class is related to a low rate of false negative results, so it is recommended to be used in patients with IgA deficiencies (Werkstetter et al., 2017).
The Anti-tTG and Anti-GA are considered the most important double diagnostic tests and the most common initial screening for CD (Brusca, 2015). It has been shown that Anti-tTG together with Anti-GA tests sensitive markers for the diagnosis of CD-suspected persons (Al-Kazraji, 2009). The findings of this study and other studies indicate the diagnostic potential of double diagnostic serology tests when conducting screening surveys for celiac patients (Aldaghi, 2016).
The results of the current study revealed that significant differences between celiac and healthy women groups (P < 0.05) are detected. The two steps serology testing approach represents a good diagnostic tool for screening and monitoring celiac patients as these CD tests show high sensitivity, specificity, accuracy, and (Al-Assaf et al., 2021) obtain positive predictive values that are compatible with similar results. The high frequency of patients with seropositivity to Anti-tTG IgG may be attributed to its high sensitivity and specificity in the existing study and thus supporting its diagnostic potency.