Reflux does not always mean too much stomach acid

Let’s start here, because it changes everything that follows:

We used to assume reflux was always excess stomach acid. That assumption is why antacids became the automatic answer, and why so many people end up managing a symptom for years without anyone asking how or why it started.

But acid in the wrong place is not the same thing as too much acid.

Slowed motility, meaning food moving too slowly through the digestive tract, causes fermentation and gas build-up. That gas creates upward pressure, and pressure pushes stomach contents past the valve at the top of the stomach and into the oesophagus. You feel burning. But the total amount of acid may be perfectly normal, or even low.

In fact, women with hypochlorhydria, which means low stomach acid, very commonly experience reflux symptoms. It is one of the great counterintuitive facts of digestive health, and almost nobody is told about it.

And even when acid genuinely is excessive, that did not come from nowhere. Gut infections, inflammation and excess body fat can all drive overproduction. Which is why I am rarely satisfied with suppressing it and moving on.

How common is reflux in perimenopause?

Much more common than most women realise, and much more common than it is talked about.

Research presented at the 2025 Annual Meeting of The Menopause Society surveyed almost 600 women aged 44 to 73. 94% reported digestive symptoms. Acid reflux affected 49%, alongside bloating at 77%, constipation at 54% and stomach pain at 50%.

The number that stopped me: 82% said their digestive symptoms either began or got worse at perimenopause or menopause.

And yet only a third had ever received a formal diagnosis. Of the women who did seek professional help, 58% found the support they got inadequate. More than half said their symptoms had a significant or regular impact on their quality of life.

So if you have felt fobbed off about this, you are not imagining it, and you are very much not alone.

Why perimenopause brings on reflux

Several things happen at once, which is why it can feel like it arrives out of nowhere.

Oestrogen affects stomach acid and bicarbonate. Bicarbonate is your body’s own neutralising agent. When the balance between the two shifts, reflux symptoms increase.

Oestrogen helps protect the mucosal layer lining your stomach. As oestrogen falls, that protective layer can thin, leaving the tissue more vulnerable.

Digestion slows down. Lower oestrogen reduces muscle tone and peristalsis, the wave-like movement that carries food along. Stomach acid and enzyme production also decline with age. Both feed straight back into the fermentation and gas picture from the first section. This is the clearest illustration of why reflux does not equal high acid: the problem is often too little digestive capacity, not too much.

And higher oestrogen can cause it too. Lower oestrogen speeds gut transit, higher oestrogen slows it. Which is why plenty of women starting menopausal hormone therapy notice reflux appearing or worsening. That is not a reason to stop, but it is worth knowing so you can name it rather than panic about it. If it is a persistent problem, the dose and the route are both worth discussing with your prescriber.

You can see why this is rarely a one-cause problem.

Where GLP-1 medications fit

GLP-1 medications such as semaglutide and tirzepatide work partly by slowing gastric emptying. Food sits in the stomach for longer, which is exactly the mechanism we have just been describing. So reflux is a known and expected effect rather than a surprise.

A 2025 meta-analysis of placebo-controlled trials in Gastroenterology found GLP-1 medications roughly doubled the risk of reflux disease compared with placebo, and modestly increased the risk of gallstones. In absolute terms that worked out at about 4 extra cases of reflux per 1,000 people and 2 extra gallstone cases per 1,000. Notably, the same analysis found no increase in other gut or biliary problems.

So: real, expected, and for most people not dramatic. But if you are on a GLP-1 and reflux has appeared or worsened, it is not in your head, and it is worth raising rather than quietly enduring. Smaller meals, less fat in a single sitting, staying upright after eating and not eating close to bed all help more on a GLP-1 than they do otherwise, because the stomach is emptying more slowly to begin with. For more on my thoughts on GLP-1 medications, read here.

What about acid-suppressing medication?

Proton pump inhibitors, the medications ending in "prazole", work by shutting down acid production. They can be genuinely valuable, and for some conditions they are exactly the right treatment. If you have been prescribed one, this is not a reason to stop.

Two things are worth understanding, though.

The first is that if your reflux is being driven by slow digestion and low acid rather than excess acid, suppressing acid further may relieve the burning without touching the cause. Symptoms return when you stop, so the prescription continues, and years pass.

The second is that stomach acid is not the enemy. You need it to break down protein and to absorb several nutrients properly. Long-term acid suppression is associated with lower absorption of vitamin B12, magnesium and iron. In perimenopause, when many women are already short on iron from heavy bleeding, that matters. It is one of the reasons red meat can become harder to digest too, which I have written about in the meat intolerance post.

Please do not stop a PPI abruptly. Acid production can rebound above where it started, symptoms come back worse, and people conclude they needed the medication after all. If you want to come off one, it is done gradually and with your GP.

What I would say is this: if you have been on acid suppression for years without anyone revisiting why, that is a conversation worth having. And in the meantime, there is a great deal that can be done nutritionally and herbally.

There are some wonderful herbal and nutritional medicines for reflux that work by supporting and soothing the digestive tract rather than switching it off, which means they do not carry the nutrient absorption trade-off. Demulcent herbs like slippery elm, marshmallow root and licorice coat and calm irritated tissue. Bitters taken before meals encourage your own digestive secretions rather than suppressing them. Deglycyrrhizinated licorice, zinc carnosine and glutamine all support the integrity of the gut lining. Which of these suits you depends entirely on what is driving your reflux, which is why this is worth working through with a practitioner rather than guessing at the health food shop.

What actually helps

• Slow down and chew properly. Unglamorous, and the single highest-yield change most women make. Digestion starts in the mouth and works best when you are not eating at your laptop.
• Eat your largest meal earlier and leave two to three hours before lying down.
• Smaller portions, more often rather than one large evening meal sitting on a slow stomach.
• Bitters before meals. Rocket, radicchio, lemon in water, apple cider vinegar. These prompt your own digestive secretions instead of suppressing them.
• Support motility with fibre, hydration and movement. A short walk after dinner does more than it sounds like it should.
• Notice your triggers, but do not build a life around them. Coffee, alcohol, chocolate, tomatoes, spice and fatty meals are the usual suspects. Reduce them while you address the cause, rather than avoiding them forever.
• Manage the stress load. Digestion happens in a parasympathetic state. Three slow breaths before you eat is not a soft suggestion.
• Consider mechanical contributors. I know when the thoracic region of my spine goes out of alignment, reflux is not far behind. Manual therapists can help with some of this. Hiatus hernia is also worth ruling out if symptoms are stubborn.
• Work with your healthcare team. Your GP for diagnosis and to rule out anything that needs ruling out, and a naturopath for the holistic side.

The bottom line

Reflux in your 40s is not something you have to accept as part of getting older. It is a signal that digestion is not working the way it used to, and digestion is very responsive to the right changes.

The question is not "how do I neutralise this acid?" It is "why has my digestion slowed down, and what does it need?"

If reflux has crept into your 40s along with everything else, the good news is that digestion responds quickly when you give it what it needs.

That is a lot of what PerimenoGO is: four weeks of eating and living in a way that suits a perimenopausal body, with the plan and the recipes done for you. Let’s PerimenoGO.

And if your reflux has been going on for years, or you are on long-term medication and want to understand what is actually driving it, that is a bigger conversation. My free Clarity Call is 20 minutes to work out what would help most. Book a Clarity Call here.

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