I had a hysterectomy almost three years ago and have been on 2mg of estradiol daily since then. My doctor now suspects I have GERD, and I am taking two doses of ranitidine HC 150mg per day. My friends tell me estradiol can cause GERD and I should consider taking natural estrogen. Is this true?

J.P.

Gastroesophageal reflux disease (GERD) is caused by a reflux of stomach contents, including acid, into the lower esophagus resulting in heartburn, regurgitation and a sour taste in the back of the throat.

Research into the causes of GERD has found that the sphincter that separates the lower esophagus from the stomach tends to relax spontaneously at times, allowing stomach contents to back up into the esophagus. Although these relaxations typically occur at random, certain factors can lead to worse reflux. Among the dietary factors that can aggravate GERD by relaxing the sphincter are alcohol, peppermint, chocolate and foods high in fats. Some medications also impair the function of the lower esophageal sphincter. These include calcium-channel blockers that are commonly used to treat high blood pressure; certain painkillers, such as meperidine (Demerol) and morphine; and sedatives, such as diazepam (Valium).

Hormones normally found in the body also act on this sphincter to either increase or decrease its function. Progesterone has been found to lower the pressure in the esophageal sphincter, leading to more reflux. In fact, it is probably the effect of progesterone early in pregnancy (before the uterus has enlarged enough to push up on the stomach) that accounts for the high frequency of GERD at this stage of pregnancy. Some researchers have questioned whether this effect may also be due in part to the effects of estrogen, but this has not been conclusively determined.

It is interesting that you noted GERD symptoms after starting estradiol. If this estrogen replacement therapy did lead to your symptoms, it may be related to the possible effects on the lower esophageal sphincter, as is hypothesized in pregnancy. However, in practice, gastroenterologists do not typically find that estrogen-replacement drugs lead to a higher incidence of GERD. I wonder if the effect of progesterone (which many women take after menopause along with estrogen) might account for your discomfort. If you are not taking progesterone, obviously the scenario would not apply. To answer your specific question, I am not aware of any reduced tendency to GERD among women who opt for natural estrogens.

Keep in mind that your symptoms (which you did not describe) may stem from something other than GERD. The ranitidine prescribed by your doctor is sometimes used to treat symptoms associated with other upper gastrointestinal illnesses. I would recommend a consultation with a gastroenterologist to further evaluate your condition before modifying your hormone-replacement therapy.