Pulsatile Tinnitus And Menopause

Introduction

The potential mechanisms underlying the link between pulsatile tinnitus and menopause are unclear. However, many scientists believe low circulating oestrogen levels to be the main factor contributing to pulsatile tinnitus in menopausal and postmenopausal individuals assigned female at birth (AFAB).

Eager to find out how and why menopause may influence hearing? Prick up your ears and keep reading!

Overview of tinnitus

Tinnitus, widely referred to as “ringing in the ears’’ is an inescapable symptom (not a disease in itself) that causes an affected person to perceive sounds in the absence of external auditory stimuli.¹ 

Besides ringing, some patients also report hearing buzzing, swooshing, and whistling sounds from one ear (unilateral), both ears (bilateral), or even from inside the head.²

Types of tinnitus 

Tinnitus is a very broad term that encompasses a wide variety of signs, symptoms, and causes. It has therefore been categorised into two main types:^2,3

• Pulsatile tinnitus: People with pulsatile tinnitus perceive a rhythmic pulsing sound that matches their heartbeat—hence the name. This type of tinnitus is relatively rare, affecting less than 10% of individuals with tinnitus
• Non-pulsatile tinnitus: This form of tinnitus presents as a continuous sound that does not follow the heartbeat’s rhythm. It is the most common type and is often associated with age-related hearing loss (presbycusis)

Understanding pulsatile tinnitus

Causes

Pulsatile tinnitus has two main causes and is therefore categorised into two primary types:¹ 

• Vascular Pulsatile Tinnitus, which can be further divided into:
  • Arterial causes: This is the most common cause of pulsatile tinnitus and typically occurs when the normal laminar (linear) blood flow through the arteries becomes turbulent (disrupted and irregular). This turbulence is often due to the narrowing of the carotid arteries, a condition known as atherosclerotic carotid disease
  • Venous causes: The most common venous cause of pulsatile tinnitus is idiopathic intracranial hypertension (IIH). This condition leads to pulse-synchronous sounds being perceived in both ears (bilaterally) due to increased pressure (“hypertension”) within the skull (“intracranial”) caused by cerebrospinal fluid buildup
• Non-Vascular Pulsatile Tinnitus: This type may occur during pregnancy due to an increase in circulating blood volume (cardiac output)

Diagnosis and evaluation methods 

To diagnose pulsatile tinnitus, a healthcare provider will begin with a thorough medical and family history assessment, focusing on otologic (ear-related) symptoms, family history of autoimmune conditions such as Takayasu disease, and medication use.¹ Certain drugs, including antibiotics and aspirin, can contribute to or worsen tinnitus symptoms due to their ototoxic effects.

A physical examination follows, starting with an otoscopy, which checks for structural abnormalities or tumours like paragangliomas. Tympanometry is used to evaluate middle ear function and distinguish between pulsatile and non-pulsatile tinnitus. A full head and neck examination is also performed, along with a cardiac assessment, where the provider uses a stethoscope on the neck and head rather than the chest.⁴ This helps determine whether the tinnitus pulses in sync with the heartbeat. If the sound is audible to the provider, it is classified as subjective pulsatile tinnitus; if only the patient hears it, it is objective pulsatile tinnitus.

Further evaluation methods 

To determine the cause of pulsatile tinnitus, healthcare providers may use advanced imaging techniques based on the patient’s symptoms, medical history, and physical examination findings. These tests help assess both vascular and non-vascular origins of the condition:^1,4

• Doppler Ultrasound: This test uses sound waves to create images of blood flow in the neck, particularly within the carotid arteries. It is useful for identifying arterial turbulence caused by conditions like atherosclerotic carotid disease
• Magnetic Resonance Venography (MRV): MRV uses a magnetic field and radio waves to generate detailed cross-sectional images of veins in the ears and neck. This test is particularly helpful in diagnosing venous causes of pulsatile tinnitus, such as idiopathic intracranial hypertension (IIH)
• Computed Tomography Angiography (CTA): If arterial causes beyond the carotid arteries are suspected, a CTA scan may be performed. This imaging technique combines X-rays and computer technology to produce high-resolution, three-dimensional images of the blood vessels in the head and neck, aiding in the detection of aneurysms or vascular malformations

Menopause and its impact 

Overview of menopause 

Throughout approximately 30 years of life, the ovaries continuously release eggs and produce the sex hormones oestrogen and progesterone, which are essential for female reproductive health.⁵ However, as most women and AFABs reach their mid-40s and transition into perimenopause, the release of eggs and production of these hormones (particularly oestrogen) declines significantly.^5,6 By their 50s, oestrogen levels drop to an all-time low, leading to the complete cessation of menstruation.

Menopause is officially diagnosed when a person has gone 12 consecutive months without a menstrual period.⁶ It is considered a natural part of ageing for individuals between the ages of 45 and 55, provided there are no underlying medical conditions. However, menopause can also occur due to medical interventions such as hormonal birth control, radiotherapy, or oophorectomy (surgical removal of the ovaries).

Symptoms of menopause 

Beyond their role in fertility, reproduction, and menstruation, oestrogen and progesterone also influence mood, energy levels, and the health of the brain, heart, and bones.⁵ As these hormone levels decline during menopause, many individuals experience a range of symptoms, including:⁶

• Fatigue (extreme tiredness)
• Hot flashes, characterised by sudden waves of heat throughout the body—one of the most common menopausal symptoms
• Night sweats
• Cognitive difficulties, such as trouble concentrating or memory issues
• Sleep disturbances, including insomnia or difficulty falling asleep
• Vaginal dryness and/or itching
• Mood changes, such as anxiety or depression
• Weight gain
• Hair thinning or hair loss
• A racing heart (palpitations)

These symptoms often begin 8 to 9 years before menopause (perimenopause) and typically lessen after menopause (postmenopause). However, some individuals may continue to experience menopausal symptoms for more than a decade after menopause.

Additionally, menopause and postmenopause are linked to a higher risk of osteoporosis and heart disease due to declining oestrogen levels.

Exploring the potential link between pulsatile tinnitus and menopause

Although a connection between pulsatile tinnitus and menopause has long been suggested, the exact mechanisms behind this link remain unclear.⁷

The most plausible explanation points to hormonal fluctuations, particularly in oestrogen levels.^8,9 While oestrogen is primarily associated with the female reproductive system, it is also present in various organs, including the brain, skin, liver, and colon, playing a crucial role in overall health.¹⁰ Notably, oestrogen receptors are found in parts of the inner ear, such as the spiral ganglion cells, which transmit hearing signals from the cochlear hair cells to the brain.¹¹ Another key structure in the inner ear, the stria vascularis, which ensures adequate blood flow to the cochlea, also contains oestrogen receptors.

Some studies have reported lower oestrogen levels in individuals AFAB with tinnitus compared to those without, leading researchers to speculate that reduced circulating oestrogen may contribute to tinnitus by impairing blood flow to cochlear hair cells.¹¹

Further supporting this theory, research has found that hormone replacement therapy (HRT), which supplements declining oestrogen and progesterone levels, may reduce tinnitus prevalence in menopausal and postmenopausal individuals.^12,13 However, findings on HRT and tinnitus remain inconclusive. While some studies suggest HRT negatively affects hearing, others report no significant impact or even a protective effect.^11,14 There have also been cases where HRT has been linked to sudden hearing loss in some individuals.¹⁵

Beyond hormonal changes, other possible contributors to both pulsatile tinnitus and menopause include:¹⁶

• Sleep disturbances, such as insomnia
• Increased anxiety

Managing pulsatile tinnitus during menopause

As mentioned earlier, HRT can be helpful in alleviating menopausal symptoms, including pulsatile tinnitus.^12,13 However, due to the associated risks, such as sudden hearing loss and an increased risk of certain cancers, many menopausal and postmenopausal individuals choose non-hormonal alternatives.^6,13 These approaches can help reduce the severity of pulsatile tinnitus without the potential risks and may include:⁶

• Regular exercise
• Mental wellness therapies, such as Cognitive Behavioral Therapy (CBT) or group therapy
• Relaxation techniques

Summary 

Pulsatile tinnitus is a type of tinnitus where sounds, without external stimuli, pulse in sync with the heartbeat. These sounds, which can be perceived as ringing, buzzing, or whooshing, may be heard in one or both ears or even inside the head.

The primary cause of pulsatile tinnitus is often changes in blood flow within the inner ear (cochlea) or nearby blood vessels, such as those in the neck or skull. This condition is commonly associated with medical issues like atherosclerotic carotid disease.

In addition to such conditions, menopause is another factor thought to influence pulsatile tinnitus. The decrease in oestrogen levels during menopause is believed to affect blood flow to the cochlea, as oestrogen receptors are present in structures involved in regulating this blood flow. While scientists speculate that low oestrogen may contribute to pulsatile tinnitus, the exact role of the hormone in hearing and tinnitus remains unclear.

Further research is needed to fully understand the potential link between pulsatile tinnitus and menopause.