Muscle and Joint Pain in Menopause

What's up with that?

Muscle and joint pain are common concerns in the menopause transition and menopause. They seem to peak closer to the final menstrual period and right after menstruation stops. As muscle pain and joint pain also increase with age, teasing out what is menopause and what is aging or other medical conditions is important so people can get the right therapy and so important medical conditions don’t go undiagnosed.

If you are between ages 45 and 55, muscle and joint pain are more common in general. However, if we look at a 49 year old who is still having her period regularly compared to a 49 year old whose last period was 3 months ago, the one who is just entering menopause is is more likely to have muscle and joint pain than the one who is still having regular periods. Muscle and joint pain appear to be about twice as common around the final menstrual period than they are at other age-matched times, so there is definitely a menopause component.

We know that changes in estrogen clearly have a role in developing muscle and joint pain. For example, muscle and joint pain are very common side effects experienced by people taking aromatase inhibitors for breast cancer, and these drugs result in dramatic reductions in estrogen levels. We also know that when the ovaries are removed before menopause, and estrogen levels drop dramatically, there is a subsequent negative impact on cartilage.

Even so, the role of estrogen, and the other hormones that change during menopause, is complex and not fully understood. Estrogen is anti-inflammatory which may have a role in protecting joints, but this is complicated. For example, estrogen can reduce flares of rheumatoid arthritis, an autoimmune condition that causes joint pain and damage, but it can flare lupus, another autoimmune condition that can cause arthritis. 

Joint tissue, such as cartilage, ligaments, synovium, and subchondral bone, all have estrogen receptors, and estrogen is even made locally in some of these tissues. The fact that many tissues make estrogen locally is often forgotten in discussions about menopause.

Estrogen can also impact pain tolerance, either by direct effects on the nervous system, or via sleep disturbances due to hot flashes, or possible via other mechanisms.

There are a few factors associated with an increased risk of muscle and joint pain around menopause: anxiety, stress, higher body mass index, and poor sleep. It’s important to point out that none of these are related to estrogen levels. Basically, it’s complicated.

So if you have muscle or joint pain and are in your 40s or early 50s, what is the first step?

The first thing is to look for causes of muscle and/or joint pain other than menopause. Attributing muscle or joint pain to menopause is what we call a diagnosis of exclusion, meaning we have to rule out other causes first. Some of the more common causes of muscle and/or joint pain include the following:

• Fibromyalgia, pain should be widespread and muscles should also be tender

• Polymyalgica rheumatica, this is almost always seen in people ages 50 and older.

• Rheumatoid arthritis, an autoimmune condition that causes inflammatory arthritis and the peak incidence is ages 35-55. It is typically associated with multiple painful joints that are often swollen (most typically in the hands, wrists, and knees) and morning stiffness. 

• Osteoarthritis, the most common type of arthritis, often thought of as “wear and tear” on the joints.

• Thyroid disease

• Gout, an inflammatory arthritis in the United States caused by elevated levels of uric acid that lead to deposits of monosodium urate (MSU) monohydrate crystals in the tissues. 

• Another illness, for example liver disease and kidney disease and cancer can all be associated with muscle pain.

• Vitamin D deficiency

• Medications (Note: Don’t include statins in the medication list, they are not actually a cause of muscle pain or joint stiffness. You can read more about that here.)

• Depression, pain and depression have a shared neurological pathway although the link between the two is not fully understood. 

• Infections, such as HIV and hepatitis C. 

Vitamin B12 deficiency per se doesn’t usually cause muscle or joint pain, but when severe it can cause numbness, tingling, weakness, fatigue and balance problems and some of those may be misinterpreted as muscle or joint problems. Vitamin B12 deficiency increases with age, and is more common for people taking acid-blockers, among vegetarians and vegans, for people with inflammatory conditions of the small bowel, and for people who have had bariatric surgery. 

Most non-menopause causes of muscle and/or joint pain can be diagnosed or ruled out with a combination of a thorough medical history, a physical exam, a formal screening for depression, and blood work. It’s important to ask about sleep during the medical history, and if there are any concerns for sleep apnea an evaluation is indicated, as sleep apnea is associated with increased levels of pain.

Two important considerations: 

• It’s always possible that more than one thing could be causing your pain.

• In general, after treatment is started it may take several months to improve. 

To start narrowing down the possible causes of joint pain, typical initial blood work you should expect to have performed includes the following:

• CBC (general blood count)

• Thyroid stimulating hormone (TSH, a screen for overactive or underactive thyroid)

• Vitamin D

• A screening test for HIV and hepatitis C

• Tests that evaluate the health of the liver and kidneys

Other testing will depend on your history and what your provider finds on the exam. Given the menopause transition and early menopause overlap with the peak time for developing rheumatoid arthritis, a work up for this condition may be indicated initially.

So it’s nothing else…what next?

Standard therapies for joint and muscle pain related to menopause, and not due to one of the causes listed above, include non steroid anti inflammatory medications (NSAIDS), focusing on a healthy diet, and paying attention to any sleep issues. For those who want to learn more about sleep and insomnia, please check out this episode of my podcast, Body Stuff.

Increasing physical activity as tolerated is also important. I have a lot of patients with muscle and joint pain who do very well with water-based exercises, be it walking in the water, water aerobics, or swimming. Tai-chi is also another consideration. When muscles hurt, it’s natural to stop moving, but that can paradoxically increase pain because when we are inactive muscles shorten and then the next time we move, that amplifies the pain.

There may be a modest impact of menopausal hormone therapy (MHT) on muscle and joint pain, and I’m the first to admit that is a generous description. For example, in the Women’s Health Initiative (WHI) 47% of women who took estrogen and a progestin (MHT) reported improvement in joint pain and stiffness versus 38% who took placebo. In the WISDOM trial, 57% of women taking hormones reported joint aching and muscle pain versus 63% on placebo. For postmenopausal women in the HERS study, estrogen had no impact on knee pain related to osteoarthritis. 

If your sleep is disrupted by hot flashes and there are no contraindications (meaning you are not at high risk for heart disease and don’t have breast cancer), then MHT may well help by improving sleep. Muscle and/or joint pain is not an indication for MHT under current guidelines, but studies tell us it can have an impact for some people. As long as people are counseled that the effect is moderate at best, I believe it is worth considering for those who are interested, especially as it may provide enough of an improvement that it is easier to engage in an exercise program. If anyone tells you that all you need are hormones, get up and get another opinion. 

References

The 2017 hormone therapy position statement of The North American Menopause Society. Menopause 2017;24:728-753.

Watt, FE. Musculoskeletal pain and menopause. Post Reprod Health 2018;24:34-43.

Other references are embedded throughout the document.