The menopausal transition brings classic symptoms such as hot flashes, but it also is associated with symptoms that are less known and less discussed. “They’re not necessarily ‘esoteric’ symptoms,” said Francesca Turner, DO, an ob/gyn at Broadlawns Medical Center in Des Moines, Iowa. “Many are common but have received less attention.”

Part of the reason is that — unlike hot flashes — these lesser-known symptoms aren’t exclusively due to menopause, although menopause may affect them, said Turner, who is also adjunct assistant professor at The University of Iowa in Iowa City.

“But I’m cautious if someone has a new onset of symptoms — whether common, such as hot flashes or less common, such as tinnitus — very remote from the beginning of menopause,” Turner said. “These issues could certainly come from low estrogen levels, but we want to make sure to rule out other potential causes.”

No Single Presentation

Estrogen serves multiple functions, with estrogen receptors found in wide-ranging and often surprising parts of the body. Turner noted that almost every cell has estrogen receptors, including bones, ligaments, joints, surfaces such as the skin and mucosa, connective tissues, and glands (eg, the meibomian and salivary glands).

Musculoskeletal Syndrome of Menopause (MSM)

MSM is a “novel nomenclature” to describe the array of musculoskeletal symptoms that can arise during or after the menopausal transition. It affects an estimated 70% of midlife women, with 25% experiencing severe symptoms, though 40% will have no structural findings. Although common, it’s often not recognized by clinicians or patients, and can be “silent, devastating, and permanent” unless addressed.

MSM includes musculoskeletal pain, arthralgia, loss of lean muscle mass, loss of bone density (with increased risk for fracture), increased tendon and ligament injury, adhesive capsulitis, and cartilage matrix fracture, as arthritis progresses.

“Adhesive capsulitis — ‘frozen shoulder’ — can in part be attributed to reduced estrogen, with concomitant reduction in its anti-inflammatory effects on ligaments, cartilage, and muscles,” Turner said, although injury-related inflammation or overuse can also play a role.

Some research suggests that hormone therapy (HT) may mitigate symptoms or prevent adhesive capsulitis, although more research is needed. Additionally, treating the conditions themselves with physical therapy or surgery is important. Proper nutrition, resistance training, and vitamin intake may have a “substantial role” in quality of life, preventing falls, and decreasing frailty-related mortality.

Menopause and the Mouth

“Xerostomia, or dry mouth, is common in women over age 50. It can have many causes, including use of anticholinergic medications as well as cannabis,” Lauren Streicher, MD, professor of ob/gyn, Northwestern University Feinberg School of Medicine, Chicago, told Medscape Medical News.

But estrogen can play a role. “There are hormone receptors in the salivary glands, noted Streicher, founding medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause. “When estrogen drops, saliva production can decrease, and pH can change, similar to what happens in the vagina. There are often changes in the microbiome, bad breath, and a burning sensation.”

Adila Baig, DDS, director of Special Care and Geriatrics Clinic and clinical assistant professor in the Department of Oral Maxillofacial Surgery, University of Maryland School of Dentistry in Baltimore, elaborated. “In addition to the impact of declining levels of estrogen and progesterone on oral mucosa through causing dryness, estrogen deficiencies also affect the bone, and teeth are bones,” she said. Estrogen deficiency can lead to shifting of the teeth and jawbone, as well as tooth fracture, often starting with microfractures.

And menopause can indirectly affect oral health through its impact on sleep and mood. “Insomnia, disrupted sleep, fatigue, or anxiety, depression, and stress can cause bruxism, or grinding of the teeth,” Baig said. Bruxism can affect the stability of the teeth, the health of the gums, and can cause jaw pain.

She noted that prescription toothpaste is available to address the issue of dry mouth. And additional dental visits may also help. She advises patients to increase their dental cleaning schedule. Patients can also discuss potential HT with their physicians. She noted that the research is “inconsistent” regarding the impact of HT on teeth, but insofar as it may slow bone loss, it may also affect bone health in the mouth.

A multidisciplinary approach by physicians and dental professionals can help in creating a treatment plan for menopausal women experiencing dental problems.

The Genitourinary Connection

Genitourinary syndrome of menopause (GSM) “isn’t obscure — in fact, it’s very common, affecting between 13% and 87% of women,” said Stephanie Faubion, MD, MBA, Penny and Bill George Director of Mayo Clinic’s Center for Women’s Health and medical director of the Menopause Society.

GSM results from declining estrogen and androgen concentrations, she explained.

Symptoms include vulvovaginal dryness, burning, itching, or irritation; dyspareunia, dysuria; post-coital bleeding; decreased arousal, orgasm, or desire; urinary frequency, and urinary urgency as well as urinary tract infections, which can become recurrent, she said. Unlike vasomotor symptoms, which can self-resolve even without treatment, GSM symptoms “rarely improve without treatment and, in fact, tend to get worse over time.”

Moreover, Streicher added, the risks for urinary tract infections in older women are “greater than in younger women and include sepsis, hospitalization, altered mental status, and even death.”

The classic treatment for GSM consists of low-dose vaginal estrogen products, Faubion said. These include creams, inserts, or rings. Vaginal dehydroepiandrosterone may also be offered to patients with GSM to improve vulvovaginal dryness and/or dyspareunia. Ospemifene, an oral selective estrogen receptor modulator is FDA-approved for the treatment of vaginal dryness and moderate-to-severe dyspareunia, but the FDA warns against its use in patients with a history of breast cancer. Vaginal moisturizers or lubricants can be used too, either independently or together with other treatments, she added.

Turner said she offers vaginal estrogen to all menopausal patients. “And there’s almost no contraindication to vaginal estrogen, when used in appropriate doses,” she noted.

Ears, Eyes, and Nose

“Estrogen receptors in the cochlea protect the ear’s hair cells, which help conduct sound,” Streicher said. Before menopause, women typically hear better than men; but after menopause, when estrogen has declined, hair cells deteriorate, and women are at higher risk for hearing loss. Additionally, fluctuations or reductions in estrogen levels can destabilize auditory processes, potentially leading to increased auditory sensitivity and tinnitus.

Turner added that some patients also develop itchy ears. “This may be a function of the impact of low estrogen on the skin,” she suggested.

Tinnitus may similarly be related to falling estrogen levels, which affect neurotransmitters like serotonin and dopamine that contribute to auditory function. Some people develop tinnitus as a side effect of selective serotonin reuptake inhibitors, which lends credence to this hypothesis, but “no one knows for sure,” Streicher said.

She noted that data investigating the impact of HT on the ears is “lacking, with only a few poorly done studies.” More research is necessary to investigate mechanisms and determine if HT is a useful approach.

The nose is also susceptible to menopause-related symptoms. “Some women develop olfactory dysfunction, perhaps due to changes in the nasal mucous membranes,” Streicher said.

While this may be partially age-related, there appears to be a hormonal connection as well. Rhinitis and rhinosinusitis, which are inflammatory processes, may be affected by declining estrogen levels. Some research suggests that transdermal HT can be helpful, although intranasal HT may be superior in improving nasal function in postmenopausal women.

Don’t Ignore Sleep Apnea

“Many people associate obstructive sleep apnea (OSA) with overweight and snoring,” said Streicher. “But we can see increased sleep apnea in postmenopausal women, even if they’re not overweight and don’t snore.”

While OSA tends to be more common and severe in men, the disparity decreases after menopause, with declining estrogen playing an important role. Estrogen exerts a protective effect by modulating pharyngeal muscle tone, Streicher said. Lower estrogen levels contribute to “more lax, floppy muscles, which obstruct the airway, increasing apnea risk.” Morning headaches and frequent fatigue suggest the presence of OSA — especially if a partner reports snoring. Patients with suggestive symptoms may benefit from a sleep study.

The Role of HT

Current evidence continues to support HT as beneficial for sleep, quality of life, GSM, MSM, and other symptoms in appropriate candidates. Recent guidance emphasizes that, for healthy women younger than 60 years or within 10 years of menopause onset who have no contraindications, the benefits of HT generally outweigh the risks when treatment is initiated for symptom relief.

“When I’m talking about menopausal HT, I’m referring to a prescription estrogen product and, depending on whether the patient has a uterus, accompanying progesterone,” Turner said.

The HT decision should be revisited regularly and should be considered as one component of a comprehensive menopause management strategy that includes lifestyle measures as well.

Streicher reported being on the speakers bureau of Bayer. Turner, Faubion, and Baig report no relevant financial relationships.

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD.