Estrogen Therapy and Gastroesophageal Reflux
Abstract & Commentary
By Malcolm Robinson MD, FACP, FACG, AGAF, Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City. Dr. Robinson reports no financial relationship to this field of study.
Synopsis: Estrogen treatment (but not estrogen given along with progestin) seems associated with gastro-esophageal reflux (GER) in postmenopausal women. Weight gain increases risk.
Source: Zheng Z, et al; Women's Health Initiative Investigators. Effects of estrogen with and without progestin and obesity on symptomatic gastroesophageal reflux. Gastroenterology 2008;135:72-81.
Hormonal elevations in pregnancy (estrogen and progesterone) have long been believed to be associated with GER. Studies of hormonal effects on GER have been inconclusive in the past. In this study, postmenopausal women were studied at 40 U.S. clinical centers. Women with hysterectomies (n = 10,739) were randomly assigned to 0.625 mg of conjugated equine estrogen (Premarin®) or placebo. Women without hysterectomies (n = 16,608) received either the same estrogen dose along with 2.5 mg medroxyprogesterone acetate daily (Prempro™) or matching placebo. More than 90% of women had available baseline data and data at one year on GER symptoms. After a year, 4.2% of women on estrogen had new moderate-to-severe symptomatic GER vs 3.1% receiving placebo (OR 1.35; 95% CI, 0.99-1.85). This strong trend implies a number needed to harm of 96 women. Estrogen plus progesterone had no effect on GER risk. Obese women (BMI > 40 kg/m2) had double the risk of incident moderate-to-severe symptomatic GER at one year with similar GER-promoting effects seen with both waist circumference and waist to hip ratio. Weight loss had a beneficial effect in terms of the reduction of incident symptomatic GER.
Commentary
As the authors themselves note, this study dealt only with oral hormone therapy in a single dosage. Only a single year was assessed in this data presentation. High levels of GER symptoms were present in all groups at baseline (42% in the estrogen trial and 35% in the women receiving estrogen and progesterone). This prevalence of GER is consistent with a number of previous epidemiologic studies. Increases in incident moderate-to-severe GER symptoms, even in the estrogen group, were modest at best. At baseline, moderate-to-severe heartburn was already present in 13% of those in the prospective estrogen arm and in 9% of the group which was to receive estrogen and progesterone or the matching placebo. In the past, most experts assumed that the culprit hormone causing GER in pregnancy was most likely to be progesterone. This study (the richly productive Women's Health Initiative or WHI) did not support this historical premise, and the conclusion that estrogen alone might be the basis for GER is at least gently supported. The most important finding from this portion of the WHI is the corroboration of other data that have strongly associated BMI and waist circumference with GER along with the premise that weight loss can significantly lower the risk of GER symptoms and the complications of gastroesophageal reflux disease. Perhaps future investigations will help elucidate the mechanisms for the effects of hormones on gastroesophageal function. Meanwhile, it seems reasonable to add the possible provocation of GER to the risk profile of estrogen therapy.
Estrogen treatment (but not estrogen given along with progestin) seems associated with gastro-esophageal reflux (GER) in postmenopausal women. Weight gain increases risk.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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