Heartburn in Perimenopause

Heartburn in Perimenopause

By Suzanne Fenske, MD, FACOG, ABOIM, MSCP

Have you ever experienced a burning feeling in your chest after a large meal or when you lie down for the night? You probably know it right away as heartburn, but for many women, it appears suddenly in midlife, even if they’ve never experienced it before.

Heartburn isn’t the first perimenopause symptom you think of; hot flashes and insomnia probably come to mind first. Yet, heartburn affects almost half of women through the perimenopause transition, so it’s something we need to discuss.

Today’s article will explore heartburn, its relationship to perimenopause, and integrative strategies to feel better and address underlying contributors. Keep reading as we uncover:

• What is heartburn?
• Why heartburn occurs
• The perimenopause hormone connection
• Integrative strategies that work

What is Heartburn?

Also called indigestion or acid reflux, heartburn occurs when the lower esophageal sphincter (LES) isn’t working properly. The LES creates a barrier between the stomach and esophagus, and when working properly, it opens only during swallowing. When the LES function is impaired, acid from the stomach can move upwards, causing a burning sensation.

Heartburn may be an occasional symptom or a chronic condition, such as gastroesophageal reflux disease (GERD).

Why Heartburn Occurs

Conventional medicine treats heartburn like a high stomach acid (hydrochloric acid or HCl) problem and treats it with acid-suppressing medication. But most people with heartburn don’t have high stomach acid; they have low stomach acid. Heartburn tends to occur as people get older when stomach acid levels decline.

Low stomach acid can impair LES function, worsening symptoms. Other reasons for low stomach acid may include stress, micronutrient deficiencies (including zinc and vitamin B6), and estrogen decline. More on midlife hormones next.

Further, low stomach acid leads to poor protein breakdown, which impacts digestion and absorption of critical nutrients (like B6 and zinc). Stomach acid also creates an acidic environment in the small intestine, helping to keep this area clear of bacteria.

Without adequate acid, bacteria can grow in the small intestine (instead of the large intestine). Bacterial overgrowth means food is fermented in the wrong place, contributing to bloating and gas and creating upward pressure that leads to reflux, in a vicious cycle of digestive symptoms and feeling unwell.

Several factors, including age, sex, obesity, digestive function, infections such as H. pylori, hernias, nutrition, and environmental factors influence GERD development.

The Heartburn-Perimenopause Connection

Gender influences how heartburn shows up. In men, reflux esophagitis is more common, whereas symptomatic GERD is more common in women, with an increased risk during perimenopause.

Heartburn presents a global burden for perimenopausal women, and rates continue to rise. One often-cited study reports 42% of perimenopausal women and 47% of menopausal women experience reflux symptoms. Both groups are diagnosed with GERD at higher rates than premenopausal women, with menopausal women 2.9 times more likely to experience symptoms.

Like most things in women’s health, hormones help explain the disparity.

Estrogen and progesterone play a significant role in the digestive system, which takes its cues from the nervous system. Everything works less efficiently in an estrogen-deficient state.

Estrogen supports gut motility (movement of food through the GI tract), bile flow, gut integrity, and microbiome balance and diversity. Over the years of perimenopause, estrogen fluctuates and then declines, disrupting gut balance and health.

Additionally, research suggests that hormonal states influence LES pressure and function. In a normal menstrual cycle, reflux is more common in the luteal phase, the second half. Progesterone plays a role: higher levels may reduce LES pressure, which helps explain why heartburn is more common in pregnancy, a high-progesterone state. From this perspective, low progesterone in perimenopause might help reflux, but that doesn’t seem to outweigh the strong correlation between low estrogen and GERD.

Some research suggests that women taking hormone replacement therapy during perimenopause and menopause have more reflux. Still, overall data is lacking and hasn’t looked at safer, bioidentical options that we now use in practice.

Integrative Strategies

Conventional medicine often turns to acid-suppressing medications, including proton-pump inhibitors (PPIs), to reduce heartburn and GERD symptoms. They work because they significantly decrease acid levels, so there isn’t much to reflux back into the esophagus, but they don’t address the underlying causes of heartburn and can create new problems because acid is necessary for digestion and informs digestive health further down the tract.

Additionally, PPIs are intended as a short-term bridge, not a long-term solution. More than 70% of PPI users face long-term adverse effects, which include nutrient deficiencies calcium, magnesium, and vitamin B12), poor bone health and fracture risk, infections, dementia risk, and others.

From our integrative perspective at TārāMD, we see a place for medications, but we also offer many other tools. First, it’s important to work closely with your provider to identify and rule out underlying causes, such as a hiatal hernia, H. pylori infection, or bacterial overgrowth. It’s necessary to address these pieces when present.

Heartburn responds well to lifestyle changes, and we can often reduce symptoms quickly with targeted interventions, such as:

• Adjusting meal timing
• Adjusting meal composition
• Supporting the nervous system, especially around meals
• Evaluating and removing food triggers
• Ensuring regular bowel movements and avoiding constipation
• Drinking beverages between meals so as not to dilute stomach acid
• Supporting heartburn and low stomach acid with targeted supplements
• Managing stress

Heartburn isn’t a failure or a sign that perimenopause is “breaking” your body. Instead, think of heartburn as a signal from your digestive and nervous systems, asking for different support. If you’re struggling with heartburn or other perimenopausal symptoms, please reach out to TārāMD today for personalized, integrative care.

References

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