Diverticulitis and Aging
Diverticulosis is a condition of the colon where small pouches bulge outward through weak spots in the colon wall. It becomes increasingly common as people age and is largely considered a disease of later life. As women age, questions about HRT and diverticulitis may also become increasingly relevant. Colon changes that come with aging, including alterations in the muscle layer and connective tissue of the bowel wall. These changes make the pouches more likely to form after the age of 50. Most people with diverticulosis never notice it. They are often only aware of it when their doctor sees it on a colonoscopy.
However, in a minority of cases, the pouches become inflamed or infected. This results in a painful and sometimes serious condition called diverticulitis. Because women tend to live longer than men and diverticular disease rises with age, it represents a meaningful and often underappreciated source of illness in older women. Researchers have noted that relatively little work has gone into understanding what actually drives it.
What the Research Shows About HRT and diverticulitis
The most direct evidence on hormone replacement therapy, or HRT, and diverticulitis comes from the Nurses’ Health Study. It is a large, long-running prospective cohort. Researchers followed over 65,000 postmenopausal women for more than two decades and tracked new cases of diverticulitis requiring antibiotics. Both current and past users of menopausal HRT had a higher risk of developing diverticulitis than women who had never used hormones. The risk was about 28% higher for current users and 35% higher for past users after adjusting for other factors. Interestingly, the risk did not increase with longer duration of use, and it held steady across different ages, body weights, and fiber intakes. The same research group had previously linked hormone therapy to a higher risk of inflammatory bowel disease (IBD). This suggests hormones may have a larger influence on gut inflammation than previously appreciated.
It’s worth noting this is observational data. It shows an association, not proof that HRT definitively causes diverticulitis. The authors themselves called for further research into the mechanism.
Plausible Biological Explanations
There are several reasons a hormonal link is believable, even if unproven. Estrogen receptors are present throughout the digestive tract. Estrogen is known to influence collagen production, connective tissue turnover, and smooth muscle function elsewhere in the body, such as in pelvic floor tissue. Diverticular disease itself is associated with structural changes in the colon wall — altered collagen cross-linking, thicker smooth muscle, and impaired motility in the affected segment. It is possible to believe, though not established, that circulating hormones could influence these same structural and motility pathways in the colon, or that they can cause low-grade gut inflammation or change the intestinal microbiome in ways that affect diverticular disease risk. None of these mechanisms have been confirmed as the explanation for the observed association.
Does Type or Route of Therapy Matter?
The Nurses’ Health Study found that the increased risk appeared similarly among women using estrogen alone and those using combined estrogen-progesterone therapy, suggesting the association isn’t limited to one hormone type. However, the available research has not clearly distinguished between delivery methods — oral pills versus transdermal patches, gels, or other routes — or between different doses and formulations. Since route of administration is known to matter for other hormone therapy risks, such as blood clots, this is a meaningful gap in current knowledge, and women shouldn’t assume that switching formulations changes their diverticulitis risk one way or another without better evidence.
What to Discuss With a Healthcare Provider
Women with a personal history of diverticulitis, or other diverticulitis risk factors, may want to raise this research explicitly when discussing hormone therapy options. Relevant topics include: the severity and frequency of any past diverticulitis episodes, whether other risk factors are already present, and how the modest increase in relative risk compares with the individual symptom relief and other benefits hormone therapy may offer for hot flashes, bone health, or quality of life. This is a shared decision that weighs a statistical association from one population against personal history and other menopause-related health needs, not a reason to avoid hormone therapy outright for most women.
Putting This Risk in Context
Hormone therapy is just one factor among many linked to diverticulitis. Established risk factors with stronger or longer-standing evidence include obesity, physical inactivity, smoking, a low-fiber and high-red-meat diet, and regular use of NSAIDs, opioids, or steroids. Genetics and simply growing older also play substantial roles. For most women, these modifiable lifestyle factors remain the more actionable targets for reducing diverticulitis risk, and the hormone therapy association (while real in the data) represents a comparatively modest piece of a much larger picture.
This article is for general informational purposes and is not a substitute for individualized medical advice. Women considering or currently using hormone therapy should discuss their personal risk factors with their healthcare provider.
Sources
- Jovani M, et al. “Menopausal Hormone Therapy and Risk of Diverticulitis.” American Journal of Gastroenterology, 2019;114(2):315-321.
- Strate LL, Morris AM. “Epidemiology, Pathophysiology, and Treatment of Diverticulitis.” Gastroenterology.
- “Etiopathogenetic Mechanisms in Diverticular Disease of the Colon.” Cellular and Molecular Gastroenterology and Hepatology, 2019.
- “Structural Alterations in Diverticular Disease.” PMC.
- “Multidimensional regulation of estrogen signaling in pelvic floor connective tissue homeostasis and remodeling.” PMC.
- UCHealth and Froedtert & the Medical College of Wisconsin patient education materials on diverticulitis risk factors.
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