RECOGNIZING DIFFERENT WOMEN’S HEALTH

By Ann-Marie DePalma

As women, our bodies are constantly changing. From the moment we get our first period to menopause and beyond, our bodies are undergoing constant evolution. Whether for better or worse, hormones and other factors play a role in how we experience daily life. Let’s examine a few of these.

We know a lot about the effects of estrogen and progesterone on our reproductive system, but did you know that there are estrogen receptors in the temporomandibular joint? Numerous studies, particularly the OPPERA study, have shown that estrogen can influence the inflammatory response and pain modulation for TMD patients. Since many TMD patients are women in their childbearing years, this sheds light on a previously unknown connection.

As a TMD myself, I can attest to estrogen’s role – I often experience a “TMJ headache” prior to my period as well as during pregnancy when my symptoms decreased. The OPPERA study (Orofacial Pain: Prospective Evaluation and Risk Assessment) funded by the National Institute of Dental and Craniofacial Research set out to identify risk factors for the development of Temporomandibular Disorders (TMD). Beyond the findings on estrogen and its role in TMD, OPPERA opened the door to many other investigations that are still ongoing in the TMJ/TMD research arena.

Women also experience several autoimmune disorders ranging from rheumatoid arthritis to multiple sclerosis, to inflammatory bowel diseases to psoriasis. A recent study from Stanford University found that somewhere between 24 – 50 million Americans are affected by autoimmune disorders with as many as 4 out of 5 patients being women. There are an estimated 100 different types

of autoimmune disorders. Autoimmune diseases are a result of the body’s immune system overreacting, attacking and damaging the body’s own tissues. The exact causes of autoimmune disorders are unknown but there are theories as to what triggers them. Medications, genetics, and infections along with risk factors such as smoking, environment, or obesity are all indicated in the autoimmune disease development.

Depending on the autoimmune disorder the symptoms can be varied but common symptoms include fatigue, joint and muscle pain and/or swelling, and dermatological or digestive issues. One of the common antidotally found autoimmune disorders in women in dentistry is Hashimoto’s Thyroiditis or other thyroid disorders (hypo or hyperthyroidism or thyroid nodules). For example, with Hashimoto’s, patients can experience fatigue, constipation, weight gain, depression, dry skin, and sensitivity to cold. I have heard from several women in dentistry who have or are experiencing issues with their thyroid.

Another type of autoimmune disorder that I had never heard of until my own experience is polymyalgia rheumatica (PMR). PMR is an autoimmune, inflammatory disorder that can cause muscle pain and stiffness. This pain and stiffness is primarily seen in the larger muscle groups such as the shoulders or hips and appears on both sides of the body. The predominant patient population is Caucasian females after the age of 50. I began with shoulder and hip pain that didn’t resolve even with physical therapy. There were days when I had difficulty going up and down stairs or getting up from a seated position!

PMR symptoms can occur suddenly or come on slowly, mine were sudden onset with nothing definitive precipitating the pain. Like other PMR patients, the pain and stiffness were worse in the morning or after periods of inactivity although different than the pain of arthritis which has a similar appearance but involves the joints rather than the muscles. The physical therapist I saw felt it was more muscular than joint-related and therefore felt it wasn’t an arthritic situation. She advised contacting my primary care physician who ordered several blood tests including C-Reactive Protein (CRP – an inflammatory marker). This showed elevated inflammation, but CRP is only an indication that inflammation is occurring in the body and is not a specific diagnosis.

My PCP recommended a consult with a rheumatologist who also found an additional increase in CRP several weeks after the initial blood work. Inflammation was a problem, and he had several theories. One proved to be incorrect while another was PMR. There is no test for PMR however when a patient is given a dose of steroid, usually prednisone, the symptoms are reduced almost immediately. He started me on a dose of prednisone and sure enough, the symptoms subsided. Prednisone is a great medication for inflammation but also has numerous side effects. With PMR the patient is advised to remain on the initial dose for about a month and then a slow tapering process is begun. During the taper process symptoms of PMR can return and I experienced some recurrence and therefore had to increase the dosage again for a short time. I am still in the taper process but this time, symptoms seem to be less. PMR usually has an excellent prognosis for patients following treatment but sometimes can relapse if tapering has happened too quickly or at some point in the future if there is a trigger of some type.

Raynaud’s Syndrome or Raynaud’s Phenomenon causes spasms of the small arteries of the fingers or toes with fingers/toes turning white and eventually blue. Numbness and pain can also occur with pain, tingling, throbbing, and redness following the return of blood flow to the area. An episode of Raynaud’s vasoconstriction can last a few minutes or several hours. Women are prone to Raynaud’s more than men, with the age of onset between 15 and 30 years old.

There are two types of Raynaud’s, primary and secondary. Primary’s cause is idiopathic and not associated with another disease or condition other than a younger patient, climate, and genetics. Secondary Raynaud’s is usually associated with older patients, a connective tissue disorder such as lupus, an injury to the hand, prolonged use of vibration tools (think ultrasonic scaler), thyroid issues, smoking, and estrogen. Secondary Raynaud’s can cause severe tissue damage, but it is rare for ulcers to form.

Treatment involves keeping hands and feet warm in colder weather, even to the point of wearing mittens or gloves when taking food from the refrigerator or freezer or wearing socks to bed. Medications such as vasodilators (calcium channel blockers) or other blood pressure medications (angiotensin receptor blockers) and statins can be prescribed. Avoiding smoking/nicotine products, exercising regularly, acupuncture, biofeedback, and managing stress are also helping patients.

Vertigo is the sensation that objects around you or your surroundings are moving when no movement is occurring. Vertigo often feels like a spinning or swaying movement sometimes associated with nausea, vomiting, or difficulty walking. It often worsens when the head is moved. Vertigo can affect any individual, yet women experience vertigo attacks more frequently and more severely than men. It is theorized that hormonal fluctuations especially during perimenopause or menopause can increase the susceptibility to vertigo. There are also several other causes of vertigo including inner ear infections, head injuries, migraines, and even stress. A common cause of vertigo is benign paroxysmal positional vertigo (BPPV). BPPV has been shown to be caused by the crystals in the inner ear becoming dislodged and a movement, DixHallpike Maneuver, can alleviate the symptoms. The DixHallpike is considered controversial where the patient is moved from a sitting position to a supine position with the head turned 45 degrees to the right. After 20-30 seconds the patient is returned to the sitting position, and then the procedure is repeated to the left. Patients can experience vertigo during the procedure but often this helps realign the crystals within the inner ear. A physical therapist noted that BPPV is the one issue in physical therapy that can be resolved in only a few sessions!

Osteoporosis and its precursor osteopenia are bone diseases where the bone mineral density and bone mass decrease. Osteoporosis affects both men and women and is more common in non-Hispanic Caucasian women and Asian women. It usually begins to develop a year or two before menopause. Osteoporosis in men is more common in non-Hispanic Caucasian men, especially over age 70. Diet, medications such as corticosteroids, cancer medications, selective serotonin reuptake inhibitors (SSRIs), or proton pump inhibitors, certain medical conditions such as rheumatoid arthritis, gastrointestinal diseases, endocrine and other hormonal diseases, and lifestyle with a low level of physical activity all contribute to osteoporosis or osteopenia development. A DXA scan (Dual-energy X-ray Absorptiometry) is a non-invasive way of measuring bone mineral density to diagnose and follow the progression of osteoporosis/osteopenia. DXA scans are recommended for all women age 65 and older and for younger women at a higher risk of fractures due to risk factors. Men are advised to begin screening after age 70 or who have any of the high-risk factors. In dentistry, year-to-year comparisons of dental radiographs can provide an indication of low mineral bone density. Changes in the width of the inferior mandibular cortex and the texture of trabecular bone are early signs of low bone density and if found, a referral to a medical professional is recommended.

Nothing is constant in life except change. As women, we are constantly changing. Understanding and appreciating change at whatever stage of life you are in allows one to live her life to the fullest.

About the author:

Ann-Marie C. DePalma, CDA, RDH, MEd, FADIA, FAADH, FADHA is a graduate of the Forsyth School for Dental Hygienists, Northeastern University and the University of Massachusetts Boston. Ann-Marie is a Fellow and member of numerous professional organizations. She is an Esther Wilkins Distinguished Alumni of Forsyth Award recipient. Ann-Marie has been published in dental and dental hygiene publications and textbooks. She is a consultant dental hygiene examiner for CDCA/WREB/CITA.

Ann-Marie presents a diverse line-up of CE programs for dental teams after being employed in a variety of roles in dentistry/ dental hygiene.