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For millions of women entering menopause, hormone therapy (HT) can be a lifeline – relieving hot flushes, night sweats, and vaginal dryness. But a large new analysis suggests that relief may come with a hidden cost: a significantly increased risk of developing gastroesophageal reflux disease (GERD). Published in June 2023 in Menopause, the journal of The North American Menopause Society (NAMS), the study pooled data from five previous investigations involving over one million women without prior GERD diagnosis【1】. The findings are clear: women who use or have used hormone therapy to manage menopausal symptoms face a substantially higher likelihood of developing chronic heartburn, regurgitation, and other reflux symptoms.
The meta‑analysis revealed that current or past users of any form of hormone therapy had a 29% higher overall risk of developing GERD compared with non‑users. However, the risk varied depending on the type of hormone used:
Oestrogen‑only therapy was associated with a 41% increased risk.
Progesterone‑only therapy increased risk by 39%.
Combination therapy (oestrogen and progesterone together) raised risk by a more modest 16%【1】.
These differences likely reflect the distinct biological actions of each hormone. Oestrogen is known to increase gastric acid secretion and also raises levels of plasma nitric oxide, a neurotransmitter that relaxes the lower oesophageal sphincter (LES) – the muscular valve that normally prevents stomach contents from flowing back into the oesophagus【2】. Progesterone, on the other hand, directly relaxes oesophageal smooth muscle and the LES, further promoting reflux【1】. When both hormones are combined, their opposing or overlapping effects may partially counteract each other, explaining the lower risk observed with combination therapy.
Menopause itself is a time of significant hormonal change, and many women already experience new or worsening digestive symptoms. This study adds an important layer: the very treatment used to ease menopause may inadvertently trigger or exacerbate GERD. Dr Stephanie Faubion, NAMS medical director, notes: “Although additional research is needed, this study highlights the potential for the development of GERD symptoms with HT use.” She advises that women considering hormone therapy should review risk factors for GERD and adopt lifestyle strategies such as smoking cessation, maintaining a healthy weight, and avoiding lying down after heavy meals【1】.
For women already suffering from heartburn, regurgitation, or extra‑oesophageal symptoms like chronic cough or hoarseness, the decision around HT becomes more complex. However, it is important to remember that not all reflux symptoms are caused by GERD, and not all women on HT will develop problems. Accurate diagnosis is the first step toward personalised management.
Given the potential link between hormone therapy and reflux, women who experience new or worsening digestive symptoms after starting HT should seek objective confirmation. Relying solely on symptoms can be misleading – many people with LPR (laryngopharyngeal reflux) never feel classic heartburn.
Pepfast saliva kit offers a simple, non‑invasive reflux test that detects the presence of pepsin – a digestive enzyme produced only in the stomach. Pepsin should never appear in saliva. When it does, it is a direct biomarker of gastric reflux, proving that stomach contents have travelled up into the throat or airways. The test requires only a small saliva sample – no tubes, no scopes, no lab equipment. For menopausal women considering or already using HT, a Pepfast test can provide a clear, objective answer about whether reflux is occurring, helping both patient and doctor make informed decisions about continuing hormone therapy, adjusting lifestyle, or adding reflux‑specific treatments (such as alginate barrier therapy).
The study’s authors call for further research, but the existing evidence is strong enough to warrant clinical awareness. For healthcare providers prescribing HT, it may be prudent to:
Ask about reflux symptoms at follow‑up visits.
Counsel women on lifestyle measures to reduce reflux risk.
Offer non‑invasive testing (e.g., Pepfast) when symptoms arise, to distinguish true GERD from functional heartburn or other conditions.
For women who wish to continue HT but develop troublesome reflux, options include switching to a lower‑dose combination preparation, timing medication differently (e.g., morning vs evening), or adding a physical barrier therapy like alginates (Gasrelief) that blocks all gastric contents – including pepsin – from refluxing upwards.
1. Does hormone therapy always cause GERD?
No. The study found a 29% increased risk, meaning many women on HT will not develop GERD. However, the risk is real and higher with oestrogen‑only or progesterone‑only regimens. Individual susceptibility varies.
2. Why does combination therapy (oestrogen + progesterone) have a lower risk than either hormone alone?
The study did not fully explain this, but possible mechanisms include counteracting effects on the lower oesophageal sphincter or gastric acid secretion. More research is needed to understand this interaction.
3. Should I stop my hormone therapy if I have heartburn?
Do not stop without consulting your doctor. First, obtain an objective diagnosis – for example, with a Pepfast saliva test to confirm whether reflux is actually occurring. Then, discuss with your provider whether to adjust the type or dose of HT, add reflux medication (e.g., alginates), or implement lifestyle changes.
4. How can I be tested for reflux without undergoing an endoscopy?
Pepfast is a non‑invasive saliva test that detects pepsin, a direct biomarker of reflux. You collect a small saliva sample, apply it to the test cassette, and read the result in 15 minutes – no sedation, no tubes, no missed work.
【1】Richter JE, et al. The Association Between Menopausal Hormone Therapy and Gastroesophageal Reflux Disease: A Systematic Review and Meta‑Analysis. Menopause. 2023;30(6):612‑620.
【2】Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro‑oesophageal reflux. Gut. 2004;53(12):1730‑1735.
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