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• Posted July 3, 2023

Hormone Replacement Therapy May Raise a Woman's Risk for Chronic Reflux

Some women take hormone replacement therapy (HRT) to combat the hot flashes and night sweats that accompany menopause, but a new study review suggests hormone therapy may increase a woman's risk for developing heartburn.

Women who take or have ever taken hormones are at greater risk for developing gastroesophageal reflux disease or GERD, which is marked by heartburn, difficulty swallowing and chest pain, the analysis of five previous studies found. It was published June 27 in Menopause, journal of the North American Menopause Society.

This isn't the first time that HRT has been linked to side effects. Long-term use fell from grace in 2002 after the Women's Health Initiative study found hormones increased the risk of strokes, and breast and ovarian cancer. These days, short-term use of hormone therapy is deemed safe for some women who have severe menopausal symptoms.

"The main message is that hormone therapy use can be associated with GERD and that women who are at risk should be counseled accordingly," said Dr. Stephanie Faubion, medical director of the North American Menopause Society and director of the Mayo Clinic Center for Women's Health in Rochester, Minn.

At-risk women include those who are obese, smoke, have moderate to high alcohol consumption and lack of regular physical activity, she said. Vigorous physical activity after meals may also put a woman at risk.

Previous research has shown that the risk for GERD is higher during pregnancy when hormones are surging and also when women take birth control pills.

Hormones may weaken the lower sphincter, or muscle, that connects the esophagus with the stomach, allowing acid easy access up the food pipe. Estrogen may also increase stomach acid production, according to Faubion.

For the new review, a team led by Dr. Wafa Aldhaleei of Johns Hopkins Bloomberg School of Public Health in Baltimore, examined five studies that included more than 1 million women. None had been diagnosed with GERD when the studies began.

Women in the studies who took estrogen or a combination of estrogen plus progesterone had a greater risk for developing GERD compared to those who didn't, the analysis showed.

Women who took a combined estrogen-progestogen formulation had a lower risk of GERD than women who took either hormone alone.

Women who still have a uterus must take progesterone with estrogen as taking estrogen alone increases the risk of cancer of the uterine lining (endometrium).

Faubion's advice is the same for all women with GERD regardless of whether they take hormone replacement therapy.

“These recommendations include maintaining a healthy body weight, stopping smoking, reducing or eliminating alcohol intake, avoiding larger, heavier meals [especially near bedtime], avoidance of caffeine, regular physical activity [but not vigorous activity right after a meal],” she said.

Dr. Margaret Nachtigall is a clinical associate professor of obstetrics and gynecology at NYU Grossman School of Medicine in New York City. She hasn't noticed an increase in GERD symptoms in her patients who are on HRT.

“This is an interesting study, but it's based on five studies, and therefore, I don't think that I would change my practice in prescribing hormone therapy," said Nachtigall, who reviewed the findings.

The majority of studies included in this review looked at women taking oral hormones, she pointed out.

“It's possible that any oral medication could be an irritant to the stomach and that might be an explanation [for the increase in GERD]," Nachtigall said, suggesting future research investigate whether hormones delivered via skin patches or other routes increase the risk for GERD.

If you develop GERD, see your doctor to find out what's causing it, she advised.

"If it [becomes] known that oral hormone therapy was causing GERD, then I might convert or consider changing to a [patch] route, and if there is not another source for the GERD, it might be worth considering a trial without the hormone therapy to see if that were the cause," Nachtigall said.

Hormone therapy during and after menopause needs to be personalized, she said.

“I think that it is important for people to be evaluated to see if hormone therapy would be beneficial for them,” Nachtigall added.

More information

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases has more on heartburn.

SOURCES: Stephanie Faubion, MD, medical director, North American Menopause Society, director, Mayo Clinic Center for Women's Health, Rochester, Minn.; Margaret Nachtigall, MD, clinical associate professor, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York City; Menopause, June 27, 2023