Menopause-Related Changes to the Oral Cavity

Defined by the American College of Obstetricians and Gynecologists as the significant change in a woman’s life when the menstrual cycles naturally come to an end, menopause affects more than 1.5 million women annually in the United States.^1,2 Menopause occurs when the ovaries stop producing estrogen, the hormone that helps control and maintain the menstrual cycle.

Research shows that systemic health conditions, including menopause, can signficantly impact oral health.^1–3 Oral health status can be indicative of a patient’s overall well-being, as signs and symptoms of underlying conditions manifest there first, exhibited in increased inflammation, xerostomia, and caries, to name a few.^1,4

Menopause has a direct cause-and-effect relationship on oral health, as estrogen receptors are present in the oral mucosa.^1,3 The various stages of a woman’s life—such as puberty, menstruation, pregnancy, and menopause—all impact both systemic and oral health conditions.

During menopause, women may experience hormonal fluctuations and biological changes, primarily affecting their production of estrogen and progesterone. If at least 12 consecutive months have passed without a menstrual cycle, menopause has occurred, marking the end of the reproductive years.^1,5

Perimenopause

Many women will experience symptoms of perimenopause, which refers to the years leading up to menopause. Perimenopause can begin as early as a few years or as late as a few months before menopause.

During a woman’s 30s and 40s, the amount of estrogen generated by the ovaries begins to fluctuate. Menstrual cycle abnormalities are a frequent perimenopause symptom. The menstrual flow may become heavier or lighter, and gaps in monthly cycles are likely to occur. Many women do not realize these symptoms are signs of perimenopause; they are often overlooked.^2,5

Onset of Menopause

The average age of menopause is the early 50s; however, the age at which menopause actually begins is influenced by a number of factors.^1–3 Family history, past oral contraceptive use, ethnic origin, and body mass index are among these factors.

Early or premature menopause is when menopause happens before age 45; it can occur on its own for no apparent reason. Early menopause may also be due to underlying health conditions, medication use, or prior surgeries. Some of the most common reasons for early or premature menopause are family history, history of cancer-related chemotherapy or radiation treatments, and the presence of autoimmune diseases (eg, chronic fatigue syndrome).^1–4

Studies show that women who have never had children or started their menstrual cycle prior to age 11 may go through menopause sooner than other women. Additionally, smoking can cause women to enter menopause up to 2 years earlier than those who do not smoke.^4,5

Another factor that can influence when menopause begins is if a woman undergoes a hysterectomy, the removal of the uterus. While a hysterectomy will result in the ending of the menstrual cycle, the onset of menopause will not take place unless the ovaries are also removed.^1,3,4 If the ovaries are not surgically removed, the onset of menopause will likely still occur in the early 50s.

Evidence has shown that some women may experience menopause at a later than average age. This is seen in women who are overweight or obese, as these women typically have fewer symptoms than women who are slim or average weight.^1,3 This delay in natural menopause and reduced symptoms are due to adipose tissue expansion, which can increase the amount of synthetic estrogen stored in the tissues.^3,4

Furthermore, a history of pregnancy and breastfeeding has been linked to a delayed onset of menopause. Although studies have not definitively determined the reason, pregnancy and breastfeeding usually both halt ovulation, so experts surmise the decrease in egg loss may delay menopause.^5,6

The range of symptoms accompanying menopause are often complex and can vary in severity depending on hormonal fluctuations. Some of these symptoms include insomnia, joint pain, fatigue, decreased libido, and vaginal dryness. Most women will also have some degree of vasomotor symptoms—more commonly known as hot flashes and night sweats—during their menopausal transition.^4–6

Effects on the Oral Cavity

Menopause can also affect oral tissues. Alterations in the oral cavity are due to hypoestrogenism and normal aging. The oral mucosa mirrors vaginal mucosa in its histology, and sex hormone receptors have been detected in each. Due to these similarities, estrogen will affect the oral mucosa as it would vaginal mucosa.^2,6

During menopause, changes in the oral cavity and oral discomfort are possible and may be related to the aging of oral tissues as well as hormone alterations. The primary oral menopausal conditions include xerostomia, burning mouth syndrome, and candidiasis, which can increase the development of oral mucosal and dental diseases, and may cause severe pain.^1,7,8 The incidence of periodontitis, dysesthesia, taste alterations, atrophic gingivitis, and osteoporotic jaws also increases.^2,7,8 Dental professionals are critical in advising patients on the oral and systemic symptoms of menopause and proper management.

Xerostomia is one of the most common oral manifestations seen in menopausal women. Numerous studies have shown that the menopause-related fluctuations in saliva composition are due to the change in concentration of salivary proteins and calcium, which normally provide protective mechanisms.^7–9

Hormone replacement therapy has been effective in increasing salivary flow rates impacted by menopause, however, this treatment has not proven to be effective in improving the pH of the saliva or electrolyte and calcium concentrations. Therefore, dental professionals should recommend the use of alternative adjunct therapies to neutralize the oral pH. ^9–11

Menopausal women may be given hormone replacement therapy or other medications to treat their symptoms.¹² One of the most common causes of xerostomia is medication use.^9,10 Additionally, considering the age group of women affected by menopause, they may also be in treatment for other medical conditions. This increases the likelihood for polypharmacy, or taking multiple medications simultaneously, a known risk factor for xerostomia.¹²

Managing xerostomia may include a combination of nonpharmacologic and pharmacologic drugs. Dental professionals must consider the specific needs of the patient when providing recommendations. Some at-home remedies may involve repeated sipping of water throughout the day, xylitol tablets, sugar-free gums and lozenges, artificial salivary substitutes, and self-administered fluoride supplements.^3,7–9

Advising patients to come in for frequent recare visits along with proper self-care to manage their plaque control and preventing oral disease through nutritional counseling can reduce xerostomia risk. An evidence-based approach to managing xerostomia during menopause should focus on providing suitable recommendations to relieve the symptoms of dry mouth and prevent oral manifestations.

Some women choose to try alternative options such as homeopathic remedies, herbal treatments, and acupuncture. ^3,9,10 These treatments may also have side effects. Furthermore, evidence supporting alternative treatments or natural remedies to alleviate menopausal symptoms affecting the oral cavity is lacking.^4,7–9

Conclusion

Menopause strikes the average American woman in her early 50s. Oral health professionals need to recognize and address the possible oral health issues associated with menopause. The dental hygienist may be one of the first healthcare professionals to recognize the signs of menopause.

Xerostomia can be detected during routine appointments, and when identified, the dental hygienist should discuss with the patient to determine possible causes and management options. A referral to the patient’s gynecologist or primary care physician may be deemed appropriate if hormonal changes are suspected.

References

1. American College of Obstetricians and Gynecologists. The Menopause Years. Available at: acog.o/​g/​womens-health/​faqs/​the-menopause-years. Accessed March 14, 2023.
2. Suri V, Suri V. Menopause and oral healthJ J Midlife Health. 2014;5:115–120.
3. Mutneja P, Dhawan P, Raina A, Sharma G. Menopause and the oral cavity. Indian J Endocrinol Metab. 2012;16:548–551.
4. United States Department of Health and Human Services Office on Women’s Health. Menopause Basics. Available at: womenshealth.gov/​menopause/​menopause-basics#1. Accessed March 14, 2023.
5. Santoro N, Epperson CN, Mathews SB. Menopausal symptoms and their management. Endocrinol Metab Clin North Am. 2015;44:497–515.
6. Parakh D, Garla B K, Dagli R, Solanki J, Thareja P, Vyas D. Evaluation of the effect of menopause on saliva and dental health. Int J Oral Health Dent. 2016;2:71–76.
7. Rothmund WL, O’Kelley-Wetmore AD, Jones ML, Smith MB. Oral manifestations of menopause: an interprofessional intervention for dental hygiene and physician assistant students. J Dent Hyg. 2017;91:21–32.
8. Meurman JH, Tarkkila L, Tiitinen A. The menopause and oral health. Maturitas. 2009;63:56–62.
9. National Institute on Aging. What is Menopause? Available at: nia.nih.gov/​health/​publication/​menopause#menopause. Accessed March 14, 2023.
10. Dutt P, Chaudhary S, Kumar P. Oral health and menopause: a comprehensive review on current knowledge and associated dental management. Ann Med Health Sci Res. 2013;3:320–323.
11. Plemons JM, Al-Hashimi I, Marek CL; American Dental Association Council on Scientific Affairs. Managing xerostomia and salivary gland hypofunction: executive summary of a report from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2014;145:867–873.
12. Col NF. The impact of risk status, preexisting morbidity, and polypharmacy on treatment decisions concerning menopausal symptoms. Am J Med. 2005;118:155–162.

From Dimensions of Dental Hygiene. April 2023; 21(4):22-24.