Assessment of Oral and Emotional Health in Pre-Menopausal and Post-Menopausal Women: A Cross-Sectional Study

Abstract

Objectives

i) To assess the emotional health status and oral manifestations in pre-menopausal and post-menopausal women. ii) To evaluate the correlation between emotional health status and oral manifestations in pre-menopausal and post-menopausal women. iii) To assess the oral symptoms and emotional state of women in relation to the duration after cessation of menstruation.

Methods

A total of 68 women were included and categorized into pre-menopausal (n = 34) and post-menopausal (n = 34) groups. post-menopausal women were further subdivided into three groups based on the duration of cessation of menstruation. After the women provided written informed consent, a questionnaire with binary (yes/no) response options was used to document their emotional health, followed by a detailed case history and clinical examination to assess oral signs and symptoms.

Results

A statistically significant (P < 0.05) correlation was detected between women’s menopausal status and emotional health status. Burning mouth syndrome was more prevalent among post-menopausal women, with the highest prevalence in Group 2 (33.30%), whereas Group 3 had the highest mean periodontal index and number of missing teeth.

Conclusion

Post-menopausal women frequently experience oral discomfort, including xerostomia, burning mouth, gustatory changes, and hyposalivation, which are associated with changes in emotional health. The early diagnosis of oral alterations is crucial and should be evaluated alongside other systemic changes. This study aimed to enhance interspecialty cooperation and understanding to improve the health of post-menopausal women.

INTRODUCTION

Hormonal fluctuations are a natural part of women’s life, occurring at various stages such as menstruation, child birth and menopause. Among these transitions, menopause represents a substantial health change for women, with long-term consequences that extend beyond reproduction. The World Health Organization (WHO) defines menopause as the ‘cessation of cycles of menstruation,’ which typically occurs between the ages of 45 and 55 [1,2]. During this time, body undergoes a drop in estrogen levels which impacts wide range of systemic processes, including physiological and psychological alterations. These changes often manifest symptoms such as hot flushes, night sweats, irritability, anxiety, restless sleep, an increased risk of coronary artery disease, and melancholy [3].

The reduction in estrogen also has a profound effect on tissues throughout the body, including oral mucous membrane due to its placement of estrogen receptors in both vaginal and oral mucous membranes [4]. As a result, post-menopausal women may experience changes such as thinning of oral mucosa, alterations in oral microbiome, burning sensations, oral lichen planus (OLP), facial pain, etc. Additionally, the decline in estrogen can lead to decreased alveolar bone mineral density, increasing the risk of periodontitis [5]. These oral health problems can negatively affect women’s quality of life, as they are often accompanied by emotional distress, which in turn exacerbates the severity of oral symptoms.

The interplay between emotional health and oral health during menopause is significant, as chronic and emotional distress can activate the autonomic nervous system, potentially worsening existing oral conditions [3]. Given the complex nature of these changes, the current study was designed to evaluate oral and emotional health of pre- and post-menopausal women. By raising awareness of these interconnected health challenges, early identification and intervention can be promoted to mitigate the long-term impact of menopause on women’s overall health and well-being.

MATERIALS AND METHODS

The study was conducted in outpatient Department of Oral Medicine and Radiology at the Sibar Institute of Dental Sciences in Guntur, AP. Prior to starting the trial, ethical approval was obtained from the Institutional Ethical Committee (Pr.379/IEC/SIBAR/2024). Informed consent was taken from all of the participants after outlining the study protocol.

The sample size estimation was determined using G^*power software version 3.1.9.2 (Heinrich Heine University Düsseldorf) with effect size of 0.8, alpha error 0.05 and power of 0.90 (90%) with allocation ration of 1.

A total of 68 women were recruited and divided into:

• • Pre-menopausal group: women > 35 years with no history of irregular menstruation

• • Post-menopausal group: women < 65 years with good systemic health and natural cessation of menstruation for ≥ 12 months.

Subjects who were undergoing hormone replacement therapy (HRT), surgical menopause, radiation therapy, diabetes mellitus, and medication/diseases which effect the salivary flow were excluded.

Post-menopausal women were further categorized into three groups based on duration of cessation of menstruation:

• Group 1- History of menstrual cessation over the previous 1–5 years

• Group 2- History of menstrual cessation over the previous 6–10 years

• Group 3- History of menstrual cessation over the previous 11–15 years

Emotional health assessment

A standard questionnaire from the studies of MahendraRaj et al. [5] and Hunter [6] was distributed to each participant to evaluate their emotional well-being. The selected 13 questions were adapted from established questionnaires to focus on menopause-related emotional domains, which are most relevant to the study population. Verbal information in the patient’s native tongue was used to explain the questionnaire to the individuals. The questionnaire was designed with close-ended questions offering two possible answers “Yes” and “No” (Table 1).

Table 1. Denotes the questionnaire proforma.

Question	Yes	No
1. I get up early and have a restless night
2. I continue to enjoy the activities I used to
3. I have a good appetite
4. I am more irritable than usual
5. I have headaches
6. I often feel pins and needles in my hands and feet
7. I need to pass urine more frequently than usual
8. I have hot flushes
9. I suffer from night sweats and palpitations
10. I have difficulty in concentrating
11. I feel unattractive
12. I experience sudden panic attacks or extreme fear
13. My stomach feels bloated

Oral health assessment

A comprehensive case history, including the patient’s medical history, menstruation history, and a clinical examination were conducted to identify oral manifestations including dental caries, OLP, xerostomia, burning mouth, and Russell’s Periodontal Index was used to evaluate the patien’s periodontal health. Burning mouth syndrome (BMS) was diagnosed based on patient-reported burning sensation in the absence of clinically evident mucosal alterations. Periodontal status was evaluated using the Russell’s Periodontal Index, applying its standard scoring criteria (Table 2) [7]. OLP was diagnosed by the bilateral presence of Wickham’s striae, while xerostomia was identified based on patient-reported dryness, the appearance of stringy saliva, and adherence of the mouth mirror to the buccal mucosa.

Table 2. Denotes the Russell’s Periodontal Index.

Score	Criteria
0	Negative-no inflammation
1	Mild gingivitis
2	Gingivitis
6	Gingivitis with pocket formation
8	Advanced destruction with loss of masticatory function

RESULTS

There were 34 individuals in the post-menopausal women group across the three subgroups: Group 1 (n = 22), Group 2 (n = 5), and Group 3 (n = 7). The emotional health responses were compared across groups using chi-square analysis (Table 3). Statistical differences (P < 0.05) between pre-menopausal and post-menopausal participants were observed for symptoms such as restless sleep, irritability, needled and pins sensations, urinary frequency, difficulty concentrating, feeling unattractive, and panic attacks. Among the post-menopausal subgroups, Group 1 exhibited the highest proportion of affirmative responses for most significant questions, indicating that emotional disturbances were prevalent in early post-menopausal period. While, Group 3 showed the highest response for needles and pins sensation (Question 6).

Table 3. Distribution of emotional health symptoms across pre-menopausal and post-menopausal subgroups (showing “yes” responses only).

Question	Group				Total	P value
	Pre-menopausal	Post-menopausal (y)
		1–5	6–10	11–15
1. I get up early and have a restless night	4 (21.1)	10 (52.6)	3 (15.8)	2 (10.5)	19 (100.0)	0.019*
2. I continue to enjoy the activities I used to	24 (52.2)	14 (30.4)	5 (10.9)	3 (6.5)	46 (100.0)	0.437
3. I have a good appetite	33 (52.4)	20 (31.7)	4 (6.3)	6 (9.5)	63 (100.0)	0.055
4. I am more irritable than usual	10 (33.3)	11 (36.7)	3 (10.0)	6 (20.0)	30 (100.0)	0.036*
5. I have headaches	12 (46.2)	7 (26.9)	3 (11.5)	4 (15.4)	26 (100.0)	0.634
6. I often feel pins and needles in my hands and feet	4 (25.0)	4 (25.0)	3 (18.8)	5 (31.3)	16 (100.0)	0.003*
7. I need to pass urine more frequently than usual	3 (20.0)	7 (46.7)	5 (33.3)	0 (0.0)	15 (100.0)	0.000*
8. I have hot flushes	2 (25.0)	3 (37.5)	1 (12.5)	2 (25.0)	8 (100.0)	0.347
9. I suffer from night sweats and palpitations	8 (33.3)	8 (33.3)	4 (16.7)	4 (16.7)	24 (100.0)	0.103
10. I have difficulty in concentrating	5 (17.9)	11 (39.3)	6 (21.4)	6 (21.4)	28 (100.0)	0.000*
11. I feel unattractive	3 (12.0)	13 (52.0)	5 (20.0)	4 (16.0)	25 (100.0)	0.000*
12. I experience sudden panic attacks or extreme fear	1 (8.3)	6 (50.0)	2 (16.7)	3 (25.0)	12 (100.0)	0.013*
13. My stomach feels bloated	8 (33.3)	9 (37.5)	3 (12.5)	4 (16.7)	24 (100.0)	0.202

Data are presented as number (%).

^*P < 0.05 is considered as statistically significant.

Assessment of oral findings showed that BMS was reported most frequently in Group 2 (33.30%) (Fig. 1). Periodontal status and tooth loss differed significantly between pre-menopausal and post-menopausal women (P < 0.05), with Group 3 showing the highest mean Russell’s Periodontal Index scores and greatest number of missing teeth (Fig. 2). These findings indicate a cumulative effect of time since menopause on the severity of periodontal breakdown and tooth loss. Other findings included oral symptoms such as OLP and dental caries, which were found to be prevalent in post-menopausal women, but the results were not statistically significant.

Fig. 1. Prevalence of burning mouth syndrome across menopausal groups.

Fig. 2. Mean periodontal index scores and mean number of missing teeth across menopausal groups. ^*P < 0.05 is considered as statistically significant.

Further comparison revealed that post-menopausal women reporting two or more emotional symptoms demonstrated a higher occurrence of BMS, xerostomia, and elevated periodontal index scores than those with fewer emotional complaints. Although limited to unadjusted chi-square comparisons, these observations indicate an interrelationship between emotional symptoms and oral manifestations, particularly in the early and mid-menopausal years.

DISCUSSION

Menopause is characterized by the decline of ovarian function and a substantial reduction in estrogen and androgen levels, affecting systemic pathways and influencing both oral and emotional health. With an increasing number of Indian women spending a large proportion of their lives in the post-menopausal period, understanding menopause-related oral changes has gained clinical relevance. In the present study, significant differences were observed between pre and post-menopausal women in several emotional health domains and BMS emerged as the most common oral condition among menopausal women, followed by periodontitis, missing teeth, dental caries, and OLP.

MahendraRaj et al. [5] found BMS and periodontitis to be the most common conditions, associating them with anxiety, vasomotor symptoms, and sleep disturbances which align with the present study findings. Also, this study is similar to Hambire and Hambire [8], who reported the presence of estrogen receptors in the periodontium and salivary glands, contributing to a higher incidence of periodontal diseases. However, Hambire and Hambire [8] highlighted xerostomia and glossodynia being the most frequently reported oral symptoms. In contrast, our study found periodontitis and BMS to be predominant.

Rathod et al. [2] reported no correlation between menopause and quality of life in women with periodontitis, while our study found a significant association. Consistent with Park et al. [9] who noted increased periodontal risk in menopausal women and a protective role of HRT, our findings confirmed the prevalence of periodontitis among menopausal women (mean periodontal index score 14.88), supporting the notion that declining estrogen levels may exacerbate periodontal inflammation.

Ciesielska et al. [3] reported high prevalence even among healthy menopausal women, especially those with comorbidities. Although our study excluded systemic diseases, BMS prevalence remained notably high (63%). While Mahesh et al. [10] noted a significant reduction in salivary flow rates and improvement with HRT among post-menopausal women, we did not measure salivary flow objectively; however, subjective dry mouth was commonly reported, reinforcing the impact of estrogen deficiency on salivary function.

With respect to dental caries, previous studies by Shetty et al. [11] and Bhat et al. [12] identified elevated decayed, missing, and filled teeth scores in post-menopausal women. Although our study found higher prevalence of missing teeth in menopausal participants, the association with dental caries itself was not statistically significant.

Lichen planus has been documented as more common in post-menopausal women by Mohan et al. [13]. While our study also observed a higher frequency of OLP, the association was not statistically significant. Psychological and vasomotor symptoms are frequently reported during menopause. Ganapathy et al. [14] reported that 97.14% of menopausal women experienced at least five symptoms, including depression (69%), anxiety (64%), and vasomotor symptoms (60.7%). Although our findings also identified emotional symptoms, the prevalence was comparatively lower.

Kaur et al. [15] found that post-menopausal women had lower gustatory function compared to age-matched men. While Sumit et al. [16] concluded that menopause does not directly affect oral health, taste perception, or emotional well-being, suggesting they are more related to the aging process. In contrast, our study found an association between emotional well-being and menopause.

Overall, while several of our findings are consistent with existing literature, notable differences highlight the influence of demographic, cultural and methodological factors. The interplay between hormonal changes, oral manifestations, and emotional well-being in menopausal women appears complex and multifactorial, underscoring the importance of early recognition.

In conclusion, this study identified notable trends in oral and emotional health across menopausal stages. Post-menopausal women demonstrated higher frequencies of burning mouth symptoms, elevated periodontal index scores, and greater tooth loss, along with a higher proportion of emotional disturbances compared to pre-menopausal women. This study emphasizes the importance of early recognition of menopause-related oral changes within the dental practice. Although the findings are limited by sample size, the results highlight the need for interdisciplinary awareness and routine oral evaluation during the menopausal transition.