Contribuția factorului hormonal și vascular la tinitusul din perioada sarcinii: un review sistematic al literaturii

1. Introduction

Tinnitus, the perception of phantom sounds such as ringing or buzzing in the ears, can arise or worsen during pregnancy due to significant physiological changes. Among the primary contributing factors, there are hormonal fluctuations, increased blood volume, and pregnancy-related conditions such as preeclampsia and migraines⁽¹⁾. The vascular and neurological shifts that accompany pregnancy can influence auditory perception, leading to varying presentations of tinnitus, including pulsatile and non-pulsatile forms. While pulsatile tinnitus is often linked to increased intracranial pressure or vascular anomalies, non-pulsatile tinnitus is generally associated with sensorineural factors and auditory dysfunction⁽²⁾. The distinction between these forms is crucial for understanding the underlying causes and for developing targeted management strategies.

The influence of hormonal fluctuations, particularly estrogen and progesterone, on tinnitus is a subject of ongoing research. These hormones play a critical role in fluid regulation, neurotransmitter balance and vascular function, all of which are implicated in tinnitus pathophysiology⁽³⁾. Studies indicate that estrogen dominance may contribute to increased susceptibility to tinnitus by affecting neural excitability and auditory processing, while progesterone has been suggested to have a protective effect by modulating inflammatory responses and cochlear function⁽⁴⁾. The hormonal shifts in pregnancy, particularly during the second and third trimesters, may therefore alter tinnitus severity, with some women experiencing temporary relief while others report exacerbation⁽⁵⁾. Additionally, hormonal replacement therapy (HRT) used postpartum or during menopause has been linked to tinnitus onset, further supporting the hypothesis of hormonal influence⁽³⁾.

A key area of distinction in tinnitus during pregnancy is the difference between pulsatile and non-pulsatile tinnitus. Pulsatile tinnitus is often associated with increased blood volume, hypertension and vascular disorders such as fibromuscular dysplasia, conditions that are heightened during pregnancy⁽⁶⁾. On the other hand, non-pulsatile tinnitus is more closely tied to sensorineural hearing loss, which can be exacerbated by progesterone fluctuations and structural auditory changes during pregnancy⁽⁷⁾. The distinction between these two forms is vital in clinical management, as pulsatile tinnitus often warrants vascular investigation to rule out underlying cerebrovascular disorders, while non-pulsatile tinnitus may require audiological and neurological assessments. The current literature indicates a need for further research on how hormonal fluctuations specifically affect these subtypes and whether pregnancy-related tinnitus has long-term implications for auditory health⁽²⁾.

2. Materials and method

This study employed a systematic review methodology to analyze the available medical literature on tinnitus in pregnancy, particularly focusing on pulsatile and non-pulsatile tinnitus, and their potential links to hormonal fluctuations involving estrogen and progesterone. Additionally, studies referencing hearing assessments such as tonal audiograms were included to examine whether pregnancy-related auditory changes could be objectively measured.

2.1. Search strategy

A structured search was conducted using major academic databases, including PubMed, Google Scholar, SpringerLink and ScienceDirect, to gather relevant literature published in the last 10 years (2014-2024). We used keywords and search combinations to refine the results. Primary Search Terms were: “tinnitus AND pregnancy”, “pulsatile tinnitus AND pregnancy”, “non-pulsatile tinnitus AND pregnancy”, “tinnitus AND estrogen”, “tinnitus AND progesterone”, “hormonal tinnitus AND pregnancy”, “pregnancy AND audiogram”, “pregnancy AND hearing loss”, “pregnancy AND sensorineural hearing loss”. To minimize bias and ensure scientific rigor, we included peer-reviewed journal articles, systematic reviews and clinical case reports from 2014 onward, focusing on studies with human subjects rather than animal models.

2.2. Inclusion and exclusion criteria

We chose to employ inclusion criteria, as follows:

• Studies published between 2014 and 2024.
• Articles focused on pregnant individuals experiencing tinnitus (pulsatile or non-pulsatile).
• Studies discussing the hormonal role of estrogen and progesterone in auditory changes.
• Research incorporating audiometric testing (audiogram) or other clinical evaluations.
• Studies published in English for accessibility and standardization.
• We also used exclusion criteria:
• Studies focusing solely on tinnitus in non-pregnant individuals.
• Articles discussing general tinnitus mechanisms without pregnancy-specific insights.
• Animal studies or laboratory-based research with no direct clinical application.
• Non-peer-reviewed sources such as blog posts or anecdotal reports.

Data extraction and analysis were performed by means of manually screening, and key data points were extracted, including: the design of studies (case study, cohort study, review, clinical trial), primary findings related to tinnitus type (pulsatile versus non-pulsatile) and pregnancy outcomes, association with estrogen and progesterone fluctuations, hearing assessment results (audiograms or clinical evaluations). A qualitative synthesis was performed, categorizing findings into hormonal and vascular changes; idiopathic intracranial hypertension and pregnancy; sudden sensorineural hearing loss and tinnitus during pregnancy; migraine and tinnitus during pregnancy; betahistine use for tinnitus during pregnancy; nonpharmacological treatments for tinnitus during pregnancy; preeclampsia, headaches and tinnitus, and common hearing tests used in tinnitus studies on pregnant patients. Data were compared across multiple studies to identify patterns or inconsistencies. A report and review were further developed in order to see if we could come up with a guideline for tinnitus develop during pregnancy.

3. Results and discussion

3.1. Hormonal and vascular changes during pregnancy and their link to tinnitus

Pregnancy is associated with profound hormonal fluctuations and vascular changes, both of which may contribute to the onset or exacerbation of tinnitus. The rise in estrogen and progesterone during pregnancy affects multiple physiological systems, including the auditory pathway, cerebral circulation and cochlear function, all of which play a role in tinnitus perception⁽³⁾. Estrogen has been shown to influence blood flow and neural excitability, potentially heightening auditory sensitivity and increasing the likelihood of experiencing non-pulsatile tinnitus⁽⁵⁾. Conversely, progesterone has been suggested to protect cochlear structures by reducing inflammation and stabilizing the inner ear environment, though its exact role in auditory processing remains a subject of investigation⁽²⁾.

In addition to hormonal effects, the vascular system undergoes significant modifications during preg­nancy. Increased cardiac output and blood volume lead to greater vascular pressure, which can manifest as pulsatile tinnitus – a rhythmic sound synchronized with the heartbeat⁽⁴⁾. Carrera and Southerland⁽⁶⁾ indicate that this type of tinnitus is often linked to pregnancy-induced hypertension, preeclampsia or vascular anomalies such as fibromuscular dysplasia.

These combined hormonal and vascular alterations provide a plausible mechanism for the increased prevalence of tinnitus during pregnancy, with different pathways influencing pulsatile and non-pulsatile tinnitus. Further research is needed to clarify whether tinnitus in pregnancy is transient or indicative of underlying vascular or neurological conditions, as well as to explore potential treatment strategies that take hormonal balance into account⁽⁷⁾.

3.2. Idiopathic intracranial hypertension and pregnancy

Idiopathic intracranial hypertension (IIH) is a neurological disorder characterized by increased cerebrospinal fluid (CSF) pressure in the absence of an identifiable mass or obstruction. The condition has been increasingly recognized in pregnant individuals, with pulsatile tinnitus being one of its most common symptoms, alongside headaches, transient visual obscurations and papilledema, as Colman, Boonstra and Nguyen defined in 2024⁽⁸⁾.

Pregnancy-related hormonal and vascular changes may exacerbate IIH by affecting CSF dynamics, particularly due to estrogen-induced fluid retention and increased intracranial pressure⁽⁹⁾. A case study by Tyndel et al. in 2022⁽¹⁰⁾ reported a pregnant woman with fulminant IIH who exhibited pulse-synchronous tinnitus, blurred vision, and a dangerously elevated CSF opening pressure of 43 cm H₂O. The study highlights the necessity of early diagnosis and CSF pressure monitoring in high-risk pregnancies and possible indications for an emergency cesarean section.

Idiopathic intracranial hypertension during pregnancy is commonly associated with pulsatile tinnitus, as turbulent blood flow in compressed venous sinuses produces an audible pulsation synchronized with the heartbeat⁽¹¹⁾. This can be misdiagnosed as an ear-related disorder if CSF pressure is not assessed. Another study, by Karmaniolou et al.⁽¹²⁾, emphasized the anesthetic considerations for IIH patients during labor, as CSF leakage from epidural anesthesia can worsen symptoms or even precipitate sudden hearing loss⁽¹²⁾.

While some studies suggest that pregnancy does not significantly alter IIH progression, others indicate that weight gain and hormonal fluctuations may contribute to worsening symptoms, requiring careful monitoring and possible medical intervention⁽¹³⁾. Toscano et al.⁽¹⁴⁾ conclude that more research is needed to determine whether pregnancy-induced IIH has long-term consequences on auditory health, particularly in patients who continue experiencing pulsatile tinnitus postpartum.

3.3. Sudden sensorineural hearing loss and tinnitus during pregnancy

Sudden sensorineural hearing loss (SSNHL) is a rare but serious condition that can develop during pregnancy, often presenting with tinnitus and balance disorders. SSNHL is defined as a rapid-onset hearing loss of at least 30 dB in three contiguous frequencies over 72 hours, typically affecting one ear⁽¹⁵⁾. While SSNHL is uncommon, pregnancy-induced hormonal and circulatory changes may increase susceptibility to cochlear dysfunction, triggering auditory symptoms including tinnitus, as shown by Tampa, Matei and Loreta in 2024⁽¹⁶⁾.

Hormonal influences, particularly fluctuations in estrogen and progesterone levels, are thought to impact the vascular supply to the inner ear. Estrogen increases blood viscosity and coagulability, which can lead to microvascular thrombosis and ischemia in the cochlear structures, a hypothesized mechanism for SSNHL⁽¹⁷⁾. Additionally, progesterone, which modulates vascular permeability and inflammation, may influence fluid balance within the cochlea, potentially exacerbating or alleviating SSNHL symptoms⁽¹⁸⁾. Some studies have identified pregnancy-related cardiovascular changes, such as increased blood volume, cardiac output and venous congestion, as potential contributors to hearing loss and tinnitus⁽¹⁹⁾.

Circulatory abnormalities, including hypertension and preeclampsia, have also been implicated in pregnancy-related SSNHL. In a population-based study, Eom et al.⁽²⁰⁾ found that pregnant patients with hypertension had a higher incidence of SSNHL compared to non-pregnant women. This suggests that vascular instability and cochlear hypoxia may play a role in the pathogenesis of pregnancy-related SSNHL. Moreover, a systematic review by Qian and Yang⁽²¹⁾ found that pregnant women with SSNHL often experienced concurrent tinnitus, likely due to altered cochlear fluid dynamics and increased intracranial pressure.

The management of SSNHL in pregnancy is challenging due to limited treatment options. Standard SSNHL treatments, such as systemic steroids, are used cautiously due to potential fetal risks. Intratympanic steroid injections (ITS), which deliver medication directly to the cochlea while minimizing systemic absorption, have been explored as a safer alternative for pregnant patients with SSNHL in a study by Lyu et al. in 2020⁽²²⁾. Without a stabile guideline through the literature, further research is more likely needed to determine long-term outcomes of SSNHL in pregnancy, particularly in individuals with persistent tinnitus postpartum⁽²³⁾.

3.4. Migraine and tinnitus during pregnancy

Migraines during pregnancy are frequently associated with tinnitus, particularly in individuals experiencing hormone-driven migraines. The hormonal fluctuations that occur during pregnancy, especially shifts in estrogen and progesterone levels, can impact cerebrovascular tone and neurotransmitter function, both of which contribute to migraine pathophysiology and associated tinnitus symptoms⁽²⁴⁾. A case study documented by Castillo-Guerrero et al.⁽²⁴⁾ highlighted a pregnant woman diagnosed with ophthalmoplegic migraine, experiencing intense nausea, vomiting, photophobia and tinnitus at peak migraine intensity. These findings suggest that pregnancy-related hormonal changes can significantly influence migraine patterns and their associated auditory manifestations.

Another study, by Vargas-Abonce et al., from 2024⁽²⁵⁾, examined the connection between hypertension, migraines and tinnitus in pregnant individuals. The research found that preeclampsia-related hypertensive episodes often co-occur with migraines and pulsatile tinnitus, indicating a vascular component in the development of auditory symptoms. Additionally, increased blood volume and changes in blood viscosity during pregnancy may contribute to intracranial pressure fluctuations, which can intensify both migraine severity and tinnitus perception. The literature suggests that while some women experience migraine relief during pregnancy due to higher estrogen levels, others face worsened symptoms, particularly in the third trimester.

Further research is necessary to determine whether pregnancy-induced migraines have long-term implications for tinnitus persistence postpartum, especially in individuals with preexisting auditory conditions or vascular susceptibility. The term of vascular susceptibility is still being researched into, as clear diagnostic criteria to connect it with audiological symptoms have not been published.

3.5. Betahistine use for tinnitus during pregnancy

Betahistine is a histamine analog commonly used to manage vertigo and tinnitus associated with Ménière’s disease. However, its safety profile in pregnant individuals remains uncertain, as clinical studies evaluating its teratogenic effects are lacking in solid results⁽²⁶⁾. While betahistine works by increasing cochlear and vestibular blood flow, concerns have been raised about its potential impact on fetal circulation and histamine receptor interactions during pregnancy and further use has been limited.

A review by SalisPharm (2024) examined available pharmacological data on betahistine exposure during pregnancy and concluded that no controlled human studies have definitively assessed its risk-to-benefit ratio. Some animal studies suggest that betahistine does not exhibit strong teratogenic effects, but species differences in metabolism mean these results may not be directly applicable to humans⁽²⁶⁾. In clinical practice, betahistine is often avoided in pregnant women due to insufficient safety data and potential concerns regarding fetal development.

Furthermore, tinnitus during pregnancy may be multifactorial, with causes ranging from vascular changes and fluid retention to hormone-induced neural excitability. Some researchers recommend alternative treatment approaches for pregnancy-induced tinnitus, such as sound therapy, vestibular rehabilitation, and dietary modifications rather than pharmacological interventions⁽²⁷⁾. Future research is needed to determine whether betahistine could be safely used in cases of severe tinnitus during pregnancy or if its benefits outweigh potential risks in select patients.

3.6. Nonpharmacological treatments for tinnitus during pregnancy

Given the uncertain safety profile of pharmacological treatments, including betahistine, pregnant individuals with tinnitus often turn to nonpharmacological management strategies. These approaches focus on reducing tinnitus perception, minimizing distress and improving quality of life without medication-related risks^(27,28).

One widely recommended approach is sound therapy, which involves using background noise or specialized sound generators to mask tinnitus perception and retrain the auditory system⁽²⁸⁾. This can be particularly useful for pregnant individuals experiencing heightened auditory sensitivity due to hormonal changes. Pandarakalam (2016)⁽²⁹⁾ suggests that cognitive behavioral therapy (CBT) can be effective in managing tinnitus-related anxiety and stress, which can otherwise exacerbate symptoms.

Additionally, acupuncture has been explored as a potential treatment, particularly for individuals who experience migraine-associated tinnitus. A study by Kwok⁽³⁰⁾ suggested that acupuncture may help regulate blood flow and neurological activity linked to tinnitus perception, although further research is needed to confirm its efficacy. Dietary modifications, including avoiding excessive sodium and caffeine, have also been associated with improvements in tinnitus severity, particularly for those with pregnancy-induced Ménière’s disease⁽²⁸⁾.

Overall, nonpharmacological interventions such as sound therapy, relaxation techniques and dietary adjustments remain the preferred management strategies for tinnitus during pregnancy, providing relief without compromising maternal or fetal health.

3.7. Preeclampsia, headaches and tinnitus

Preeclampsia is a serious hypertensive disorder of pregnancy that is characterized by elevated blood pressure, proteinuria and systemic vascular dysfunction. It is often associated with neurological symptoms, including headaches, visual disturbances, dizziness, and tinnitus. Vargas-Abonce et al.⁽²⁵⁾ demonstrate that vascular instability and endothelial dysfunction, which are hallmarks of preeclampsia, can contribute to cerebral hypoperfusion and increased intracranial pressure, potentially leading to pulsatile tinnitus and migraine-like headaches in affected individuals. The same study detailed a pregnant woman diagnosed with preeclampsia who presented with headache, tinnitus and dizziness. Her arterial blood pressure was significantly elevated, and further assessment revealed vascular dysfunction as a contributing factor to her auditory symptoms. Following a diagnosis of severe preeclampsia, the patient underwent an emergency cesarean section to mitigate risks for both maternal and fetal complications⁽²⁵⁾.

The underlying pathophysiology connecting preeclampsia to tinnitus is thought to involve vascular dysregulation, increased cerebrospinal fluid pressure and endothelial damage, all of which contribute to altered cochlear blood flow and auditory disturbances. Increased intracranial pressure in preeclamptic patients may compress venous sinuses, leading to pulsatile tinnitus, while systemic hypertension can cause cochlear microvascular ischemia, triggering non-pulsatile tinnitus^(18,25).

3.8. Hearing tests used in tinnitus and pregnancy research

Various audiological assessments have been utilized in studies examining tinnitus in pregnancy, helping to differentiate between vascular, neurological and sensorineural causes of tinnitus. The most frequently used tests include pure-tone audiometry (PTA), tympano­metry, otoacoustic emissions (OAE) and auditory brainstem response (ABR) testing, each providing insights into the potential underlying mechanisms of tinnitus⁽³¹⁾.

PTA remains the gold standard for detecting sensorineural hearing loss (SNHL), which is often associated with pregnancy-related SSNHL and tinnitus. Studies such as those by Mukhtar-Yola et al.⁽³²⁾ used PTA to confirm mild to moderate sensorineural deficits in pregnant patients with tinnitus. Tympanometry is widely used to assess middle ear function and rule out conductive hearing loss in patients with pregnancy-related ear pressure or fluid retention. This test has been particularly useful in cases of preeclampsia-induced tinnitus, where vascular instability may lead to changes in middle ear pressure⁽³³⁾.

OAE testing has been used to evaluate cochlear function in pregnancy-related tinnitus cases. Studies show that reduced otoacoustic emissions correlate with tinnitus severity, particularly in hormonally influenced SNHL cases⁽³⁴⁾.

ABR has been employed in studies focusing on neurological causes of tinnitus, such as idiopathic intracranial hypertension (IIH) and migraine-associated tinnitus. It helps in evaluating auditory nerve function and ruling out retrocochlear pathologies that could be exacerbated during pregnancy⁽³⁵⁾ without the need for magnetic resonance or other imagining tests. Some researchers, like Ghiselli et al.⁽³⁶⁾, suggest that combining OAE and ABR tests provides a more comprehensive analysis of auditory function during pregnancy, particularly in distinguishing between hormonal and vascular influences on tinnitus, but this study topic warrants more investigation before being included in a guideline.

4. Conclusions

Tinnitus during pregnancy appears to be influenced by hormonal, vascular and neurological factors, with evidence suggesting a strong connection to estrogen and progesterone fluctuations. Increased intracranial pressure, vascular instability and cochlear dysfunction contribute to both pulsatile and non-pulsatile tinnitus, particularly in conditions such as preeclampsia, idiopathic intracranial hypertension and sudden sensorineural hearing loss (SSNHL). Migraines, which often accompany tinnitus in pregnancy, further suggest the importance of cerebrovascular involvement in auditory disturbances.

While betahistine remains a controversial, currently non-indicated treatment due to lack of studies, safer nonpharmacological alternatives, such as sound therapy, cognitive behavioral therapy and dietary adjustments, are preferred. Steroids are to be considered only when facing a complete diagnosis of SSNHL. Audiological assessments, including PTA, OAE, tympanometry and ABR testing, are crucial for determining the underlying cause of tinnitus in pregnancy, as imagining is not readily available for pregnant individuals. Further research is needed to establish evidence-based guidelines for managing pregnancy-associated tinnitus, ensuring safer maternal and fetal outcomes. In the absence of such guidelines, the custom multi-treatment approach, tailored for each individual and situation, is still the most recommended method in clinical practice. Monitoring of pregnant patients with tinnitus where hearing loss is diagnosed should be carried out at least 12 months after delivery for monitoring potential negative outcomes.

Autor corespondent: Andrei Osman E-mail: andrei.osman@umfcv.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.