Exploring Estrogen-Related Atrophy Beyond the Genitourinary Tract
Submitted by Stefanie Varela, Ph.D, FNP-BC, WHNP-BC, Marcia Harris Luna, Ph.D, PNP-BC, FNP-C, Delfino Varela, Medical Student
While genitourinary syndrome of menopause (GSM) is widely recognized among providers, clinical discussions and interventions often remain narrowly focused on vaginal, urethral, labia minora, and labia majora atrophy. However, it is essential to expand our understanding of estrogen-related atrophy beyond the reproductive system. Estrogen receptors are distributed throughout various epithelial tissues, and the decline in estrogen during the perimenopausal and menopausal transition may have systemic effects, including changes in the upper gastrointestinal tract (Iijima & Shimosegawa, 2019).
One underrecognized manifestation of estrogen decline may be esophageal atrophy. Clinically, this may present as dysphagia, a burning sensation when swallowing, or the feeling of food getting stuck in the throat. These symptoms are often attributed to gastroesophageal reflux disease (GERD) or neuromuscular dysfunction.
However, in some cases, they may be rooted in estrogen deficiency. As a hormone specialist and a practitioner of bioidentical hormone replacement therapy, I have personally experienced these symptoms, and this observation has prompted further investigation into the connection between estrogen and esophageal integrity (Lenell et al., 2022).
Estrogen Receptors and Esophageal Epithelium
The esophagus is primarily lined by stratified squamous epithelium in the upper and mid-sections and transitions into simple columnar epithelium at the gastroesophageal junction. Estrogen receptors, particularly ERβ, have been identified in esophageal tissue (Iijima & Shimosegawa, 2019). These receptors are involved in cellular regeneration, anti-inflammatory modulation, and epithelial maintenance.
Estrogen’s protective effects on mucosal surfaces—well established in the vaginal and urogenital tissues—may similarly influence the esophageal lining, though data in this area remain limited.
Emerging hypotheses suggest that esophageal atrophy may develop secondary to chronic hypoestrogenism, contributing to non-specific upper gastrointestinal symptoms in peri- and postmenopausal women. Praveena and Nagashree (2024) demonstrated that reduced estrogen levels are associated with diminished lower esophageal sphincter (LES) tone and altered esophagogastric junction compliance, further supporting a systemic role of estrogen in gastrointestinal health.
This possible link warrants further investigation, as treatment with estrogen—particularly localized or systemic bioidentical formulations—may alleviate these symptoms if atrophy is the underlying cause. Conducting rigorous nursing research into these mechanisms will be essential to advancing our understanding.
Conclusion
There remains a critical gap in the literature regarding the systemic manifestations of estrogen deficiency. When women report hallmark menopausal symptoms—hot flashes, mood swings, night sweats, brain fog, lack of motivation, weight gain, anorgasmia, vaginal dryness, and burning—clinicians must look beyond the reproductive system.
If the vagina exhibits signs of atrophy, the next anatomical structures to assess should include the oral cavity and esophagus. Notably, tooth loss in menopausal women has been associated with declining estrogen levels, suggesting a need to reframe our understanding of menopause from a multisystemic perspective rather than a localized syndrome (Lenell et al., 2022).
Is it gingivitis or estrogen deficiency? Is it dysphagia or esophageal atrophy? These are the questions that must guide future inquiry. The reality is that until more women clinicians, researchers, and experts begin documenting these lived experiences, clinical frameworks will remain incomplete.
Hormonal optimization using bioidentical estrogen, progesterone, and testosterone—delivered at appropriate receptor-targeting doses—may hold therapeutic promise. As family nurse practitioners and women’s health specialists, we are uniquely positioned to identify and advocate for these patients. Similarly, understanding societal norms that silence women’s health concerns is essential to ensuring these symptoms are not dismissed.
Therefore, I strongly urge the research community to conduct randomized, double-blinded clinical trials assessing both symptomatic relief and objective biomarkers in women receiving bioidentical hormone replacement therapy. Only through rigorous evidence-based investigation can we validate the clinical intuition that so many providers and patients share—and ultimately close this persistent gap in women’s health.
References
Iijima, K., & Shimosegawa, T. (2019). The roles of estrogen and estrogen receptors in gastrointestinal disease. World Journal of Gastroenterology, 25(3), 2561–2570. https://doi.org/10.3748/wjg.v25.i3.2561
Lenell, C., et al. (2022). The relationship between menopause and dysphagia: A scoping review. Women’s Health, 18, 743–758. https://doi.org/10.1177/17455057221137116
Praveena, M., & Nagashree, R. (2024). Estrogen and gastroesophageal reflux disease dynamics in premenopausal and postmenopausal women. Journal of Clinical and Diagnostic Research, 18(6), CC18–CC21. https://doi.org/10.7860/JCDR/2024/59849.XX