GERD in Women
GERD in Women
- Philip O. Katz, MD, and Jenifer K. Lehrer, MD
Clinical picture and management of this common gastrointestinal disease
- Philip O. Katz, MD, and Jenifer K. Lehrer, MD
Gastroesophageal reflux disease (GERD) is ranked as the fourth most prevalent gastrointestinal disease and the most expensive disease of the alimentary tract in the U.S.1 Heartburn (substernal burning rising from the epigastric region toward the neck), the most frequent symptom, is estimated to occur on a daily basis in 6% to 10% of the adult population and in up to 60% at least annually.2 An estimated 40% of the U.S. adult population use over-the-counter or prescription agents aimed at treating GERD symptoms more than twice a week.
Clinical Characteristics of GERD
In addition to heartburn, the characteristic presentations of GERD include regurgitation (the effortless return of gastric contents into the esophagus and oral cavity), chest pain, dysphagia, and dyspepsia. A number of extraesophageal symptoms, such as chronic cough or wheezing as well as chronic laryngitis and pharyngitis, have been associated with GERD. Other more serious problems include chronic adult asthma and pulmonary fibrosis. Although the majority of patients have little endoscopically visible mucosal damage, complications include erosive esophagitis, esophageal ulcers, stricture, and the premalignant transformation known as Barrett’s esophagus. The latter is a major risk factor for the development of esophageal adenocarcinoma, a cancer with rapidly rising incidence in the U.S. There is excellent medical therapy for GERD (see Table 1).3 The choice of treatment depends on the severity and frequency of symptoms.
Does GERD Exhibit Sex Differences?
Surprisingly, there are scant data addressing the features of GERD in women compared with men. The clinical impression from personal observations and the few existing studies is that the common presentations of GERD are similar regardless of sex.2,4 In a recent study of the features of GERD in women compared with men, the overall incidence of heartburn, regurgitation, dysphagia, non-cardiac chest pain, cough, and wheezing was similar for both sexes. Nonetheless, there was a trend toward a higher frequency and slightly increased severity of symptoms in women, although the clinical importance of these differences is unclear. The prevalence of hiatal hernia was similar in men and women.5 Though not seen in this study, sex differences have been observed for esophageal findings on endoscopy: Women who present with GERD are more likely to have non-erosive disease (i.e., heartburn and a normal endoscopy), whereas men are more likely to have erosive esophagitis. Some clinicians have suggested that this is due to differences in symptom sensitivity or patterns of healthcare-seeking behavior between the sexes; however, neither has been documented.
In the study by Lin et al, significantly more men (23%) than women (14%) with GERD had Barrett’s esophagus.5 The overall male-to-female ratio for esophageal adenocarcinoma is 8:1.6 The reasons for this dramatic difference in incidence are unknown. The prevalence of acid reflux episodes might be slightly higher in men, whether normal or symptomatic; however, this does not appear to be of clinical importance.7 There is no evidence that women respond any differently to antisecretory therapy or antireflux surgery than do men.3
We have become increasingly aware that overweight and obese persons are at increased risk for GERD. This relationship was assessed directly by investigators who studied the association between BMI and the severity, duration, and frequency of GERD symptoms in a cohort of participants from the Nurses’ Health Study.8 Compared with women having a BMI of 20.0–22.4, for women with a BMI >35, the likelihood of frequent GERD symptoms increased progressively to an odds ratio of almost 3. Notably, even in women with a normal BMI at baseline, weight gain resulting in an increase of >3.5 in BMI was associated with an increased chance of frequent reflux symptoms compared with women of stable weight.
Heartburn has been reported to occur in about 20% of pregnancies during the first trimester, 40% during the second trimester, and 70% during the third trimester.9,10 Anatomic changes such as a decrease in lower esophageal sphincter pressure, slowed gastric emptying, and higher intra-abdominal pressure from the enlarging uterus likely play a role. Some of these changes might be mediated by progesterone.10 Heartburn before pregnancy and multiparity also predict the likelihood of heartburn during pregnancy; however, no association has been found with ethnicity, pre-pregnancy BMI, or degree of weight gain during pregnancy.9 In most cases, heartburn resolves after delivery and has not been identified as a risk factor for long-term GERD.
Complications of reflux are extremely unusual during pregnancy, so upper endoscopy or other diagnostic tests are rarely needed. Dietary and lifestyle measures are common first-line treatment recommendations, although little evidence supports the efficacy of dietary interventions. Symptomatic treatment with antacids and sucralfate (FDA category B) are often recommended as early treatment interventions because of their lack of systemic absorption. Women should be aware that antacids have no FDA classification despite being generally considered safe for use in pregnancy. Sodium bicarbonate should be avoided because of the risk for maternal or fetal alkalosis and fluid overload.10 H2RAs, designated category B (except nizatidine, category C), are probably safe during pregnancy and do not appear to increase the rate of fetal malformations compared with controls. Proton-pump inhibitors (PPIs), the most effective and widely used medical therapy for GERD, have had limited study in pregnancy and are designated as category B (except omeprazole, category C).10 A recent study in 295 pregnant women exposed to omeprazole, lansoprazole, or pantoprazole during the first trimester demonstrated a similar rate of congenital anomalies compared with nonexposed women.11 This finding suggests that PPIs do not pose a teratogenic risk in humans.
GERD is common in both women and men. Regardless of the overall sex differences in the clinical picture of this disease, management principles are generally similar, and outcomes are excellent with proper therapy. Although women have a lower incidence of Barrett’s esophagus, they should discuss the option of screening for this condition with their healthcare providers. There is a clear relation between BMI and GERD in women. Reflux symptoms are common in pregnancy but can be safely and successfully managed.
Dr. Katz is Clinical Professor of Medicine, Thomas Jefferson University, and Chair of the Division of Gastroenterology, Albert Einstein Medical Center, Philadelphia, Pennsylvania.
Dr. Lehrer is in the Department of Gastroenterology, Frankford-Torresdale Hospital, Jefferson Health System, Philadelphia, Pennsylvania.