RESEARCH

The prevalence and pattern of gastroesophageal reflux symptoms

in perimenopausal and menopausal women
Mary Infantino, PhD, ANP, BC (Associate Professor)

Keywords
Women’s health; menopause; perimenopause;
GERD.
Correspondence
Mary Infantino, PhD, ANP, BC, Department of
Nursing, C.W. Post/L.I.U., Brookville, NY.
Tel: 516-628-1714 (home), 516-551-6763 (cell),
516-299-2320 (work); Fax: 516-299-2352;
E-mail: minfan2379@aol.com
Received: October 2006; accepted: April 2007
doi:10.1111/j.1745-7599.2008.00316.x
Abstract
Purpose: To determine the prevalence and describe the pattern of gastroesoph-
ageal reflux disease (GERD) symptoms in premenopausal-, perimenopausal-,
and menopausal-age women.
Data sources: Three tools were used to collect data: the Menopause Rating
Scale, a standardized, self-administered 11-item scale that assesses the presence
of menopausal symptoms and their impact on quality of life; the Gastrointestinal
Symptom Rating Scale, a standardized, self-administered 15-question survey
that inquires about both lower and upper gastrointestinal (GI) symptoms; and
the Reflux Disease Questionnaire (RDQ), a self-administered 14-question sur-
vey currently being evaluated in the United States as a specific diagnostic tool for
GERD that specifically addresses upper GI symptoms of discomfort. Additionally,
GERD were correlated with vasomotor, vaginal, genitourinary, and other
menopausal symptoms using multiple regression analysis to assess the relation-
ships between GERD and menopausal symptoms.
Conclusions: Approximately 497 women between the ages of 25 and 60 years
completed the surveys. The prevalence of GERD symptoms was high in this
sample. Almost 42% of perimenopausal and 47% of menopausal participants
complained of upper GI symptoms. Although perimenopausal and menopausal
women had higher percentages of GERD diagnosis as compared to premeno-
pausal women, 80% of the perimenopausal and menopausal groups had never
been diagnosed with an upper GI disorder. A post hoc analysis of RDQ results
demonstrated that patients with menopause had significantly more upper GI
discomfort. Overall, this study found that menopausal women were 2.9 times
more likely to have GERD symptoms.
Implications for practice: These findings are strongly suggestive of a hormonal
link between perimenopausal and menopausal states and increasing GERD
symptoms. Women of all ages should be screened for symptoms of GERD,
especially in the perimenopausal and menopausal population of women because
diagnosis of GERD is often not made or misdiagnosed. The impact on the quality of
life of women experiencing GERD symptoms cannot be underestimated.

carcinoma. Symptoms may include heartburn, dysphagia,

Introduction
Gastroesophageal reflux disease (GERD) is a constellation
of signs and symptoms that reflect ongoing esophageal
damage from gastric contents related to changes in lower
esophageal sphincter pressure (LESP) and pH. GERD can
lead to esophagitis, Barrett’s esophagus, and esophageal
chest pain, regurgitation, dyspepsia, and in some cases,
coughing and wheezing. Diagnosis is usually made empir-
ically or by endoscopy (Campion & Richter, 2006).
GERD affects both genders with only a slight preference
for men. While there is a wealth of literature on the
pathology, patterns of presentation, and treatment of

266 Journal of the American Academy of Nurse Practitioners 20 (2008) 266–272 ª 2008 The Author(s)
Journal compilation ª 2008 American Academy of Nurse Practitioners
M. Infantino
GERD in men, there is little information on the presenta-
tion, pathology, prevalence and patterns, and treatment in
women. Studies have demonstrated that men and women
experience GERD symptoms differently (Heitkemper &
Jarrett, 2001; Ter, 2000; Toner & Akman, 2000) and have
suggested the role of hormones as the variable responsible
for the difference.
Menopause is defined as the cessation of menses for a
least 1 year (Triadafilopoulos, Finlayson, & Grellet, 1998)
and can be confirmed by laboratory measurements that
confirm the depletion of ovarian hormones. This change
generally occurs between the ages of 50 and 55 years and is
preceded by a period of perimenopause. Perimenopause is
a term used to describe the time surrounding menopause,
which usually begins about the age of 35 years when
changes begin occurring that indicate a time of transition
(i.e., changes in menstrual cycle, sleep disturbance, sexual
problems, bladder problems). Perimenopausal and men-
opausal states in women are accompanied by a variety of
symptoms related to hormone depletion (Birnbaum,
2006) including gastrointestinal (GI) symptoms, which
are attributed to hormonal changes. For the purposes of
this study, premenopause is defined as being between the
ages of 23 and 34 years, having regular menstruation
patterns, and the absence of perimenopausal or meno-
pausal symptoms.
Studies have demonstrated that estrogen and proges-
terone modulate contractile function of lower GI segments
in humans and that symptoms are highest when these
hormones are at the lowest levels (Heitkemper, Jarrett,
Caudell, & Bond, 1993). Research exploring the role of
fluctuating ovarian hormones and the menstrual cycle’s
relationship to lower GI symptoms demonstrated that
lower GI symptoms increase during menses, when both
hormone levels are dropping (Heitkemper et al.). There is
limited information surrounding GI function and meno-
pausal states. However, previous findings would suggest
that as women experience menopausal symptoms related
to low estrogen and progesterone levels, GERD-related
symptoms would increase (Heitkemper et al.).
Literature review
GI symptoms across the menstrual cycle
Literature has documented some of the relationships
between GI symptoms and the menstrual cycle. Heitkem-
per et al. (1993) found that irritable bowel syndrome (IBS)
symptoms increased, across women’s menstruating life
span, during menses when both estrogen and progester-
one levels are low. The researchers also found that per-
ceptions of stress aggravate symptoms. Although women
in the study between the ages of 40 and 60 years reported
GERD symptoms in women
IBS symptoms (i.e., diarrhea alternating with constipation,
bloating), the researchers did not know whether the
women developed these GI symptoms during perimeno-
pause and menopause or before. It was suggested that
prospective studies aimed at describing GI pathologies in
relation to reproductive cycling, and the cessation of
cycling, in this population of women be performed.
Heitkemper and Jarrett (1992) studied the relationship
between the menstrual cycle and bowel patterns in a con-
venience sample of menstruating women with and with-
out functional bowel distress (FBD). FBD is a term that is
often used interchangeably with IBS in the literature. The
women rated their GI and premenstrual symptoms on
a daily basis across two menstrual cycles. They also had
serum estrogen and progesterone levels assessed during
the two menstrual cycles. The researchers found that while
both groups had an increase in bowel symptoms during
menses, the group with FBD reported more severe symp-
toms. There were no significant differences in serum
estrogen or progesterone between the two groups, but
women without FBD did have higher levels of progester-
one at menstruation compared with women with FBD. In
conclusion, the authors report an increase in GI symptoms
in healthy menstruating women and in menstruating
women with FBD during menstruation, suggesting a hor-
monal link to increased GI symptoms in menstruating
women, which remains to be determined.
In another study exploring GERD symptoms across the
normal menstrual cycle, 19 women had 24-h monitoring
of esophageal pH and serum progesterone levels for 2
months. Researchers found that despite fluctuation in
progesterone levels throughout the menstrual cycle, no
significant differences in LESP or esophageal pH were
observed. The researchers concluded that in healthy men-
struating women, progesterone did not predispose them to
GERD symptoms (Alvarez-Sanchez, Rey, Achem, & Diaz-
Rubio, 1999).
One study explored bowel dysfunction in perimeno-
pausal and menopausal women (Triadafilopoulos et al.,
1998). A total of 228 perimenopausal and menopausal
women were evaluated prospectively by a survey designed
to evaluate symptoms of IBS. Thirty-eight percent of
menopausal women reported IBS-type symptoms com-
pared with 14% of perimenopausal women (p < .0001).
These results suggest that perimenopausal and meno-
pausal women have a prevalence of IBS-type symptoms
that should be carefully assessed related to hormone status.
In a meta-analysis of nine studies exploring GI symp-
toms and their relationship to the menstrual cycle,
researchers found that one third of asymptomatic women
experienced GI symptoms at the time of menses and that
50% of women with IBS experienced an increase in their
IBS symptoms just prior to and during their menses.
267
GERD symptoms in women
Additionally, researchers reported that women who expe-
rienced dysmenorrhea were more likely to also suffer from
FBD and IBS (Moore, Barlow, Jewell, & Kennedy, 1998).
More recently, Lee, Mayer, Schmulson, Chang, and
Naliboff (2001) explored gender-related differences in
IBS symptoms. In an analysis of 714 men and women
with IBS, the researchers found that all the subjects
reported similar levels of symptom severity. Women
reported more symptoms, however, and 40% of the
women reported worsening of the symptoms around
the time of menses. According to the researchers, few
differences were found between premenopausal and men-
opausal women, making it unlikely that gender differences
observed were hormonally related.
Much of the research describing GI symptoms in rela-
tionship to the menstrual cycle is confusing and contra-
dictory. While many studies seem to agree that the
menstrual cycle affects GI function, findings seem to raise
more questions than they answer.
Research on the effects of hormones on GI function
The effects of hormones, especially progesterone, on the
GI system are not well-known. Animal studies have dem-
onstrated that estrogen and progesterone do modulate
contractile function of the GI tract (Heitkemper et al.,
1993). Many authors (Abulafia, Eliakim, & Sherer,
2000; Case & Reid, 1998) believe that GI disorders and
other disorders (i.e., migraines, asthma, epilepsy) are
attributable to the fluctuations in hormones, particularly
during the luteal phase and during menstruation. Abulafia
et al. assert that LESP and delayed gastric emptying are
affected by estrogen and progesterone as evidenced by the
increase in GERD symptoms during pregnancy, affecting
70% of pregnant women; by an increase in LESP in
women taking combination oral contraceptives; and by
animal studies that have noted LESP in animals given
hormones. This suggests that increasing hormone levels
affect the GI system, not decreasing levels, as suggested by
Heitkemper et al.
Biochemical studies have suggested that progesterone
may be responsible for alterations in GI function. van
Thiel, Gavaler, and Joshi (1977) have suggested that
although progesterone may have the predominant effect
on GI function, the estrogen effect is required before pro-
gesterone can have any effect at all. Rameshkumar (1997)
stated that the presence of estrogen and progesterone
receptors in the GI tract suggests an underlying common
hormonal pathway between the GI system and the repro-
ductive system. Estrogen and progesterone decrease and
change the acid mucin content in the GI tract. Mucin acts
as a protective barrier to physical and enzymatic assaults
on the mucosa. GI symptoms, therefore, are caused by
268
M. Infantino
variations in the mucin content within the mucosa, which
are directly related to variations of estrogen and proges-
terone. If this is so, then GERD and other GI symptoms
would be expected to appear or worsen during the hor-
mone fluctuations associated with the perimenopausal
and menopausal phases of life.
GI symptoms, especially GERD, have not been ade-
quately or systematically described or analyzed in women,
particularly the perimenopausal and menopausal popula-
tion. The GI symptoms these women suffer are not life
threatening. They do, however, impact quality of life by
limiting functional activities and enjoyment of life. They
also increase the use of healthcare resources. It is impor-
tant that research focuses on surveillance and patterns that
characterize these symptoms in this population and exam-
ines the role of hormones in the experience of these GI
symptoms.
Purpose
The purpose of this study was to determine the preva-
lence and describe the pattern of GERD symptoms in
premenopausal-, perimenopausal-, and menopausal-age
women. The specific aims of this study include (a) to
describe the pattern of GERD symptoms in premeno-
pausal, perimenopausal, and menopausal women aged
25–60 years; (b) to clarify the prevalence of GERD symp-
toms in this same population of women; and (c) to corre-
late GERD symptoms with menopausal symptoms.
Methods
Study design
This was a descriptive study of premenopausal, perime-
nopausal, and menopausal women which explored the
pattern and prevalence of GERD symptoms across the life
span. Participants between the ages of 25 and 60 years who
were premenopausal, perimenopausal, or menopausal
were recruited primarily through word of mouth. Flyers
describing the study and the need for volunteers were
hung in clinics, private medical offices, libraries, and
community centers around Long Island and Greater
New York. Institutional review board approval was
obtained; all information was confidential, and no iden-
tifying data were placed on the participant questionnaires.
After giving informed consent, the participants com-
pleted a demographic data sheet. Participants completed
three questionnaires in addition to the demographic data
sheet. These included the Menopause Rating Scale
(MRS), the Gastrointestinal Symptom Rating Scale
(GSRS), and the Reflux Disease Questionnaire (RDQ).
The MRS is a standardized self-administered scale of
M. Infantino GERD symptoms in women

menopausal complaints with established validity and
reliability, aimed at comprehensively assessing the suf-
fering from psychological symptoms, somatovegetative
symptoms, and urogenital symptoms. The scale consists
of 11 symptoms and uses a Likert-type scale ranging
from none (0 = asymptomatic) to very severe (4 = highest
degree of discomfort). The total score may range from 0 to 44
(highest degree of complaints; Schneider, Heinemann,
Rosemeier, Potthoff, & Behre, 2000). The MRS is a prac-
tical and rapid tool to measure symptoms of menopause
and the impact on quality of life related to those symp-
toms.
The GSRS developed by Wiklund, Junghard, and Grace
(1998) has well-documented reliability and validity. This
scale assesses the presence or nonpresence of GI symp-
toms. It is a 15-item, self-administered, and easily com-
pleted survey that asks questions about both lower and
upper GI symptoms. Each question is scored on a 7-point
Likert-type scale ranging from no discomfort at all to very
severe discomfort.
The RDQ is a self-administered 14-question survey that
specifically addresses upper GI symptoms of discomfort
during the last 4 weeks. It uses a 6-point Likert-type scale
ranging from Did not have this symptom in the last four weeks to
Experiencing this symptom daily. Although it has been pre-
viously validated to assess discomfort, it is currently being
reevaluated in the United States as a diagnostic tool aimed
at assisting the healthcare provider in making the diagnosis
of GERD.
Based on the reply to the questionnaires and age of the
participants, participants were placed into one of the six
groups: premenopausal women with upper GI symptoms,
premenopausal women without upper GI symptoms, peri-
menopausal women with upper GI symptoms, perimeno-
pausal women without upper GI symptoms, menopausal
women with upper GI symptoms, and menopausal women
without upper GI symptoms.
Data collection and analysis
Approximately 497 women between the ages of 25 and
60 years completed the surveys. Of the 457 participants
enrolled in the study, 110 were premenopausal, 180 were
perimenopausal, and 162 were menopausal. Fifty-three
percent of the participants were married, 48% were Cau-
casian, and 60% were college educated. Single, separated,
and divorced women were represented in the sample as
were African American, Hispanic, Asian, and Native
American women. The highest income levels were repre-
sented in the older, menopausal group (23.8%). Only 5%
of the participants were currently on hormone replace-
ment therapy or hormonal birth control. Eighty percent of
the participants who complained of upper GI symptoms
had never been diagnosed with any GI disorder.
Analysis of data was performed using Pearson chi-
square, analysis of variance (ANOVA) with Tukey analysis,
and logistic regression. Table 1 correlates patient charac-
teristics with menopausal states.
Results
Chi-square analysis suggests that there are differences
among these three groups (premenopausal, perimeno-
pausal, and menopausal) based on the baseline variables.
Most notably, perimenopausal and menopausal women
have higher percentages of both GERD symptoms (p =
.001) and GERD diagnosis (p = .036) than premenopausal
women. Increased weight (p > .001) and alcohol usage
(p > .009) among perimenopausal and menopausal
women were also significant. Interestingly, the percentage

Table 1 Participant characteristics

Measure Premenopausal Perimenopausal Menopausal p Valuea

Upper GI symptoms (%) 25.5 41.7 46.9 .001*

Upper GI diagnosis (%) 14.7 18.5 26.9 .036*
Median age group 25–29 41–45 51–55 <.001*
Caucasian (%) 33.6 62.3 66.5 <.001*
Median weight 121–140 141–160 141–160 <.001*
Married (%) 53.6 68.0 70.4 <.001*
Smoking (%) 7.3 15.2 9.3 .070
Alcohol use (%) 19.1 35.4 33.5 .009*
College education (%) 76.4 74.3 73.3 .313
Median income group 20–40,000 60–80,000 60–80,000 <.001*
Hormonal birth control (%) 27.3 14.1 1.9 <.001*
Hormone replacement (%) 4.5 2.3 10.6 .004*
Gastric ulcer surgery (%) 8.3 15.0 30.1 <.001*
a
Pearson chi-square analysis.
*Significant.

269
GERD symptoms in women M. Infantino

(30.1%) of menopausal women having had some form of Table 3 RDQ survey results for base dimensions (mean scores)
gastric ulcer surgery was also significant (p > .001). p
ANOVA demonstrated that the symptoms of acid reflux Base dimension Premenopausal Perimenopausal Menopausal Valuea
(p = .023) and nausea (p = .023) were the most common
Pain behind 0.52 0.49 0.26 .06
GERD-related complaints, and they increased significantly breastbone
between the premenopausal and menopausal groups on Burning center 0.96 0.86 0.51b,c .01*
the GSRS survey (Table 2). Diarrhea (p = .013) and loose Painful center 0.81 0.71 0.39b,c .01*
stools (p = .018) were also significant, but because these are Acidic mouth 0.92 0.54d 0.38b .001*
Unpleasant 0.75 0.54 0.37b .03*
lower GI symptoms, they would suggest a lower GI prob-
upward flow
lem. Acid reflux and nausea are common symptoms of
a
GERD. Interestingly, cough, often considered an atypical ANOVA with Tukey post hoc analysis.
b
Statistically significant comparison between premenopausal and men-
symptom of GERD in women, was not included in the
opausal.
GSRS survey dimensions. c
Statistically significant comparison between perimenopausal and
The 14-item RDQ survey was placed into five base menopausal.
domains for analysis: ‘‘Pain Behind Breastbone,’’ ‘‘Burning d
Statistically significant comparison between premenopausal and peri-
Center,’’ ‘‘Painful Center,’’ ‘‘Acidic Mouth,’’ and ‘‘Unpleas- menopausal.
ant Upward Flow.’’ Analysis demonstrated that patients *Significant.
with menopause scored higher on four of the five base
domains (Table 3). In post hoc analysis, Burning Center strongly suggestive of a relationship between GERD and
(p = .01) and Painful Center (p = .01) were significantly menopause.
different between both the premenopausal and meno- In this analysis, using logistic regression, when all other
pausal groups and the perimenopausal and menopausal variables were controlled for, participants in menopause
groups. Acidic Mouth (p = .001) and Unpleasant Upward were 2.9 times more likely to have GERD symptoms than
Flow (p = .03) also demonstrated significance between the participants not in menopause.
premenopausal and the menopausal groups. Because the
RDQ survey is specific for reflux disease, these findings are
Discussion
This study had three specific aims: (a) to clarify the
prevalence of GERD symptoms in perimenopausal and
Table 2 GSRS survey results (mean scores)
menopausal women aged 35–60 years, (b) to describe
p the pattern of GERD symptoms in this same population
Dimension Premenopausal Perimenopausal Menopausal Valuea
of women, and (c) to correlate GERD symptoms with
Pain or 1.83 1.85 1.57 .084 menopausal symptoms. The prevalence of GERD symp-
discomfort toms is high in this sample. Almost 42% of perimenopausal
Heartburn 1.73 1.72 1.63 .706
and 47% of menopausal participants complained of upper
Acid reflux 1.76 1.49 1.42b .023*
Hunger pains 1.77 1.84 1.85 .822
GI symptoms. Interestingly, although perimenopausal and
Nausea 1.59 1.50 1.28b .023* menopausal women had higher percentages of GERD
Rumbling 1.86 1.84 1.86 .984 diagnosis as compared to premenopausal women, 80%
Bloating 2.28 2.21 2.05 .393 of this group had never been diagnosed with an upper GI
Burping 1.82 1.76 1.61 .265
disorder. This is consistent with literature, suggesting that
Gas 2.42 2.29 2.18 .378
Constipation 1.85 1.67 1.75 .533
GERD is often underdiagnosed or misdiagnosed in this
Diarrhea 1.32 1.46 1.18c .013* population of women.
Loose stools 1.30 1.57d 1.33 .018* Heavier women and women who used alcohol com-
Hard stools 1.50 1.62 1.73 .328 plained of more GERD symptoms. This is not surprising
Urgent need 1.39 1.55 1.38 .265
because alcohol is a known GI irritant and recent research
Not emptying 1.79 1.78 1.91 .581
suggests that even moderate weight gain is associated with
a
ANOVA with Tukey post hoc analysis. an increase in GERD symptoms. Barclay and Nghiem
b
Statistically significant comparison between premenopausal and men- (2006) found that compared with no weight changes,
opausal.
c
an increase in body mass index (BMI) of more than 3.5,
Statistically significant comparison between perimenopausal and
menopausal.
even in women with a normal baseline BMI, was associ-
d
Statistically significant comparison between premenopausal and peri- ated with increased GERD symptoms (n = 10,545). Symp-
menopausal. toms increased as BMI increased. The findings in this study
*Significant. appear to support Barclay and Nghiem’s research.

270
M. Infantino
Gastric ulcer surgery in the menopausal group of par-
ticipants was also associated with GERD symptoms. Past
biochemical studies have documented estrogen and pro-
gesterone receptors in the GI tract, which are related to
variations in the mucin content of the mucosa. With
depletion of hormones, the mucin content is altered
potentially, decreasing the protective barrier to enzymatic
and physical assaults on the GI tract and possibly causing
gastric ulcer problems. It is unknown whether participants
had gastric ulcer surgery before or after menopause.
Although weight and alcohol use were associated with
GERD symptoms, the two most common symptoms that
this sample displayed were acid reflux and nausea. While
these symptoms are almost expected, this is not consistent
with literature, suggesting that men and women experi-
ence GI dysfunction and GERD differently (Heitkemper &
Jarrett, 2001; Ter, 2000; Toner & Akman, 2000).
The GSRS used to obtain data is a generalized tool and
not specific to GERD symptoms. It did not include some of
the more atypical symptoms that women may experience,
such as coughing and wheezing. Diarrhea and loose stools
were also common GI complaints but are usually associ-
ated with lower GI problems such as IBS and would not be
considered atypical symptoms of GERD. It is, however,
consistent with findings in the literature (Triadafilopoulos
et al., 1998), which found that menopausal women also
have a higher prevalence rate of IBS symptoms that need
to be explored in relationship to hormone status.
More importantly, the RDQ, which is specific for reflux
disease, demonstrated a very strong relationship between
GERD symptoms and menopause. The menopausal group
demonstrated significance between both the premeno-
pausal and the perimenopausal groups, scoring higher
on four of the five base domains. This is suggestive of
a hormonal link between GERD and the hormonal
changes of menopause.
A limitation of this study is that only women in the Long
Island and Greater New York area were asked to partici-
pate. This study represents results from only one area
within the United States, and the findings may not be
generalized to women in other parts of the country. Also,
this study did not explore the effects of diet or stress on
symptom development or progression. These could have
significant impact on GERD symptoms unrelated to
changes in hormones.
Implications for practice
GERD was underdiagnosed or misdiagnosed in all three
groups of women (premenopausal, perimenopausal, and
menopausal). The prevalence of GERD is highest, how-
ever, in the perimenopausal and menopausal groups and
should be screened regularly, especially because some
GERD symptoms in women
women will display atypical symptoms such as coughing,
wheezing, or hoarseness, which may not be recognized by
the patient as GI symptoms. Surveys used in practice to
assess GERD symptoms often do not address these atypical
symptoms. While nurse practitioners may elicit these
symptoms in their review of system’s portion of the patient
history, they may still be missed because according to the
findings of this study, 80% of perimenopausal and men-
opausal women went undiagnosed despite the presence of
GERD symptoms. Because women often do present with
atypical symptoms of GERD, perhaps a written tool to
assess GERD symptoms specific to women should be
developed.
The findings of this study strongly suggest a hormonal
link between perimenopausal and menopausal states and
increasing GERD symptoms. Studies exploring this link
between hormones and GERD need to be conducted to
both further confirm this link and find the etiology, or
etiologies, causing these symptoms so that they may be
managed appropriately. While preventing and reversing
mucosal damage are primary, the impact on the quality of
life in these groups of women cannot be underestimated.
Acknowledgment
Funded by Astrazeneca Pharmaceuticals.
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Conflict of interest disclosure
No relationship exists between the author and any com-
mercial entity or product mentioned in this article that
might represent a conflict of interest. No inducements
have been made by any commercial entity to submit the
manuscript for publication.

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