Burning mouth syndrome (BMS) is a long-term pain condition that can occur during the menopausal transition. It’s characterized by a persistent burning sensation in the tongue, lips, or other areas of the mouth, without visible clinical signs or abnormal laboratory results to explain the symptoms. Although its cause remains uncertain, BMS is believed to result from a combination of hormonal decline, nerve dysfunction (neuropathy), and psychological stress.(1)
Diagnosis is made only after other potential conditions have been excluded, which can make the process complex and time-consuming. Despite these challenges, early recognition and treatment can help individuals manage their symptoms effectively.
What is burning mouth syndrome?
BMS is a chronic pain disorder characterized by a persistent burning sensation in the mouth that typically lasts for at least four to six months. The discomfort most commonly affects the tongue, especially the tip and anterior two-thirds, but it may also involve the lips, palate, or other areas of the mouth. Individuals with BMS often describe the sensation as burning, tingling, scalding, or numbness, with symptoms that can fluctuate in intensity throughout the day.(1)
Clinical examination usually reveals no visible abnormalities, and laboratory findings are typically within normal limits. BMS is diagnosed only after other potential causes, such as infections, mucosal lesions, systemic illnesses, or nutritional deficiencies, have been excluded.
The condition occurs most frequently in women, particularly during the perimenopausal and postmenopausal stages, suggesting a possible hormonal component. BMS often presents as glossodynia, a chronic burning pain localized to the tongue, with or without the sensation of dry mouth (xerostomia). The reported prevalence of BMS in postmenopausal women ranges from 18% to 33%.(2)
BMS can be categorized into three types based on the daily pattern of symptoms.(1)
Type 1 is characterized by pain-free mornings, with symptoms gradually increasing in intensity throughout the day.
Type 2 involves constant pain that persists from morning through night.
Type 3 presents with intermittent symptoms, including pain-free intervals and the involvement of atypical sites like the floor of the mouth or the throat.
In addition to burning pain, many individuals suffering from BMS experience alterations in taste, such as a persistent bitter or metallic taste, and a sensation of dry mouth despite normal salivary output.
Causes of BMS During Menopause
The exact cause of BMS is not fully understood, but several contributing factors have been identified, especially in postmenopausal women.
Hormonal Fluctuations
Estrogen receptors are present in the tissues lining the mouth. Fluctuations in estrogen levels can cause these tissues to become thinner and more vulnerable to irritation. Many women also report dryness of the mouth, which may further aggravate BMS symptoms.(1)
Lower estrogen levels can also increase the excitability of sensory nerves, especially those involved in oral sensation, such as the trigeminal and glossopharyngeal nerves. This heightened nerve sensitivity can lead to normally harmless sensations, such as warmth or light touch, being perceived as burning pain.(1)
Psychological Factors
Many women going through menopause experience increased psychological distress, such as anxiety, irritability, or depression. These emotional changes can intensify how pain is felt, even if they aren’t the direct cause of BMS. Pain and emotional health are closely connected, and one can influence the other.(2)
Other Contributing Factors
Other factors, which may or may not be related to the menopausal transition, can increase the risk of BMS, including the following:(2)(3)
Nutritional Deficiencies: Low levels of certain nutrients, especially B vitamins, zinc, and iron, have been noted in some BMS patients.
Xerostomia (Dry Mouth): Many women with BMS experience dryness of the mouth, even though actual saliva flow may remain normal. This may be due to changes in the sympathetic nervous system, which controls automatic body functions like heart rate, digestion, and saliva production.
Taste Disturbances: Some individuals are “supertasters,” meaning they naturally have more taste buds and are more sensitive to certain flavors. This heightened sensitivity may make them more prone to oral pain if taste-processing nerves are affected.
Increased Sensitivity to Allergens or Irritants: Menopause may bring changes in immune response or tissue resilience, increasing sensitivity to certain dental prostheses, preservatives, or flavoring agents.
Medications: Certain drugs, especially angiotensin-converting enzyme (ACE) inhibitors, have been linked to the onset of BMS symptoms. These medications may increase levels of bradykinin, a molecule involved in inflammation and pain, potentially triggering burning sensations in the mouth. Other drugs associated with BMS include angiotensin receptor blockers, antiretrovirals (such as efavirenz and nevirapine), levothyroxine, and topiramate. In many cases, symptoms often improve after discontinuation of the suspected medication.
Reduced Fluid Intake: Inadequate hydration can affect the composition of saliva and reduce its protective function, increasing the risk of irritation and discomfort.
Oral Health Problems: Poor oral hygiene, dental diseases, and mucosal inflammation can aggravate symptoms or mimic BMS. Regular dental check-ups are important to rule out local causes of burning or pain and to maintain oral health.
How can individuals treat burning mouth syndrome in menopause?
BMS often requires a comprehensive, individualized approach to treatment. Since the condition has no single known cause, most individuals benefit from a combination of lifestyle changes, hormone therapy (when appropriate), and nonhormonal medications. Treatment is not always curative but aims to reduce pain, improve function, and enhance quality of life.
Lifestyle Modifications
Lifestyle strategies are often the first step in managing the frequency and intensity of symptoms. These include the following:
Dietary Adjustments: It’s recommended to avoid spicy, acidic, or very hot foods, as they can intensify the burning sensation. Tobacco, alcohol, and excessive caffeine may also worsen symptoms, so it’s best to avoid them. Sipping cold water or sucking on ice chips may offer temporary relief.
Hydration and Oral Care: Drinking plenty of fluids helps reduce the sensation of dry mouth. Using alcohol-free mouthwash and mild toothpaste (without foaming agents like sodium lauryl sulfate) can prevent additional irritation. It’s also recommended to avoid tongue thrusting, clenching the jaw, and excessive talking to reduce mechanical irritation of the oral tissues.
Stress Management: As psychological stress can amplify pain, techniques like deep breathing, meditation, yoga, or counseling, especially cognitive behavioral therapy (CBT), can help regulate mood and pain perception.
Hormone Replacement Therapy (HRT)
HRT works by replenishing declining hormone levels, particularly estrogen, which may help support nerve function and maintain oral tissue health.
Estrogen receptors are present in the oral mucosa, indicating a direct hormonal influence on these tissues. As estrogen levels fall during menopause, the oral lining may become thinner and more sensitive, and nerve pathways involved in pain perception may become more reactive.
Studies have shown that estrogen-based HRT can help reduce oral burning symptoms. In women with an intact uterus, progesterone is added to the regimen to lower the risk of endometrial hyperplasia, a condition that may lead to abnormal thickening of the uterine lining.(1)(4)
However, HRT is not prescribed solely for the treatment of BMS and should be considered only after consulting a healthcare provider.
Nonhormonal Medications
Pharmacological treatment for BMS often involves nonhormonal medications, which can be divided into two categories: local (topical) and systemic (oral).
Local (Topical) Medications
These are applied directly to the mouth and work at the site of pain:
Clonazepam (Oral Tablet Used Topically): Sucking on a low dose of this anti-anxiety medication can help reduce burning sensations. However, the effects may fade after the drug is discontinued, and side effects like drowsiness or dry mouth may occur. It’s also important to note that clonazepam is a controlled substance and should be used with caution under medical supervision.
Capsaicin: Derived from chili peppers, capsaicin can desensitize pain receptors by reducing substance P, a chemical that carries pain signals. It’s sometimes used as a mouth rinse or mixed with water (e.g., diluted hot pepper sauce). While it may help manage BMS symptoms, some individuals find the initial burning sensation too uncomfortable.
Aloe Vera Gel: This gel can be applied to the tongue several times a day and is often used with a tongue protector to keep it in place.
Topical Anesthetics: Products like lidocaine (a numbing agent) may provide short-term relief, but their effects are temporary and generally not suitable for long-term use.
Systemic (Oral) Medications
These medications affect the entire body and are taken by mouth:
Clonazepam (Oral Use): When swallowed, clonazepam may help reduce nerve-related pain and anxiety. However, prolonged use carries risks such as sedation, dependence, and dry mouth. As mentioned above, clonazepam is a controlled medication and should be used carefully under the guidance of a healthcare provider.
Tricyclic Antidepressants: Medications such as amitriptyline or nortriptyline are often prescribed in low doses to treat chronic nerve pain. They may also help improve mood and sleep. However, they can cause side effects like drowsiness and dry mouth.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): These include medicines like sertraline, paroxetine, and duloxetine. Originally developed for depression and anxiety, they can also help manage nerve pain in some individuals.(4)
Gabapentin and Baclofen: These medications are used to calm overactive nerves. Gabapentin is often prescribed for nerve-related pain, while baclofen is a muscle relaxant that may help reduce oral discomfort when used as part of a combination therapy. It’s important to note that gabapentin is a controlled medication and should be used with caution.
Alpha-Lipoic Acid: It’s a powerful antioxidant that can protect nerve cells. However, current evidence for its effectiveness in BMS remains limited and inconclusive.
Vitamin and Mineral Supplements: If lab tests reveal deficiencies in vitamin B12, folic acid, iron, or zinc, correcting these deficiencies with supplements may help ease symptoms.
Managing BMS During Menopause
BMS presents a unique clinical challenge, especially during the menopausal transition, where hormonal, neurological, and psychological factors often overlap. Although diagnosis can be complex and treatment isn’t one-size-fits-all, early recognition and a holistic treatment approach can significantly ease the burden of symptoms. Through lifestyle adjustments, pharmacologic support, and hormone therapy when appropriate, many women can achieve relief from BMS symptoms.
