Hormone replacement therapy for chronic tinnitus in menopausal women: Our experience with 13 cases

Tinnitus is a common complaint among patients visiting an ENT clinic. It can cause severe annoyance and distress to some patients. Many treatment modalities are available for the management of tinnitus, with different degrees of effectiveness. 
 
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Hormone replacement therapy for chronic tinnitus in menopausal women: Our experience with 13 cases Dear editor, Tinnitus is a common complaint among patients visiting an ENT clinic. It can cause severe annoyance and distress to some patients. Many treatment modalities are available for the management of tinnitus, with different degrees of effectiveness 1 . Owing to the heterogeneity of tinnitus, it is very unlikely that an omnipotent therapy will cure all forms of tinnitus 2 . Therefore, treatment should be individualised and targeted at the possible cause. In our tinnitus special clinic, we encountered a special group of subjects: women in their menopausal period or in the immediate postmenopausal period, whose tinnitus responded exceptionally well to hormone replacement therapy (HRT). The effects of HRT on migraine-related vertigo have been previously reported, but no reports have documented its effects on chronic tinnitus 3 . In this study, we report our experience in treating this specific group of patients and provide another perspective to clinicians who treat tinnitus.

| METHODS
The study was a retrospective review of medical records and was approved by the institutional review board of the hospital. Between August 2015 and August 2016, we encountered in our tinnitus clinic 13 women in their menopausal period or immediate post-menopausal period who complained of experiencing chronic tinnitus for more than 1 year. Sequential patients were invited to enrol, and those reported here self-selected to try low-dose HRT as their tinnitus therapy after thorough discussion with our gynaecologist.  demographic data of these patients and their pre-treatment folliclestimulating hormone (FSH) levels are shown in Table 1. They underwent complete otological and audiological assessments, and ear diseases such as chronic otitis media, acoustic neuroma and Meniere's disease were ruled out. The severity and loudness of their tinnitus were evaluated using the Tinnitus Handicap Inventory (THI) and a visual analogue scale (VAS). The THI and VAS scores were evaluated between 3 weeks and 1 month, during their first follow-up visit.
Each patient also received a session of counselling and education after all assessments. No regular counselling, cognitive behaviour therapy or tinnitus retraining therapy sessions were offered to this group. All patients were requested to report any side-effects to our treatment team.

| RESULTS
The pre-treatment and post-treatment THI and VAS scores of the 13 patients are shown in Table 1. The average pre-treatment THI score was 58.5, and the post-treatment score was 12.6. The difference was statistically significant (paired t test, P<.001). The average pre-treatment VAS score was 8.2, and the post-treatment score was 2.5. The difference was also significant (paired t test, P<.001) (Figure 1). Nine of the 13 (69%) patients had THI scores below 10 after treatment, and five patients even had a THI score of 0, indicating almost complete disappearance of tinnitus. All patients also reported an improvement in other menopause-related symptoms, especially the sleep quality. In the THI questionnaire, the question number 7 and question number 20 are related to tinnitus and sleep. The added scores of these two questions were shown in Table 1 and Figure 1.
Marked improvement was found after HRT.
The averaged hearing thresholds before and after HRT are also shown in Table 1   We think the other possible mechanism involves sleep improvement. All patients reported poor sleep before treatment and much better sleep after treatment. Sleep disturbance is one of the most significant complaints of patients with tinnitus, and evidence shows that insomnia is associated with more distressing tinnitus 7 . A recent study summarised the role of hormones in the mechanism of chronic pain, which is often used as an analogue of tinnitus 8 . This field of research definitely warrants further investigation in the future.
The use of HRT for menopausal syndrome is still controversial.
However, emerging evidence shows that low-dose HRT does not increase the incidence to malignancies and can instead reduce composite deafness and heart failure 9 . It can also improve the sleep quality and prevent osteoporosis 10 . We emphasise here that, for this particular group of patients, their consent, close collaboration with gynaecologists and careful monitoring are all very important.
In conclusion, our preliminary 13 case series showed that menopausal women with chronic tinnitus could benefit by HRT. The treatment produces rapid, effective and safe results. However, HRT is not recommended as a standard treatment for chronic tinnitus now.
Further rigorous controlled trials and investigations on the underlying mechanism are needed to confirm our findings.

CONFLI CT OF INTEREST
None to declare.

| RESULTS
The patient characteristics are given in Table 1.
Patient preparation prior to surgery included cardiovascular optimisation and volume control, and haemodialysis up to 24 hours prior to parathyroidectomy. Patients were operated by the same surgeon (author 1), using standard surgical equipment. CORRESPONDENCE: OUR EXPERIENCE