Joint Pain in Perimenopause and Menopause
I am an OBGYN and Lifestyle Medicine physician who is also a Menopause Society Certified Practitioner. I have also been competing as an amateur age-group triathlete for the past 13 years, and I am several years post-menopause. I am not an orthopedic surgeon or sports medicine physician or an exercise physiologist, but I certainly have accessed the care and expertise of these providers over the years, and I love the fact that there has been an intersection of these specialties as perimenopause and post-menopause symptoms and management have come to the forefront. It’s all connected and that’s why whole person health is so important.
And I do want to highlight that Dr. Vonda Wright, who is an orthopedic surgeon, has done research and published on this topic and specifically coined the term Musculoskeletal Syndrome of Menopause.
How do declining estrogen levels in menopause affect joints?
So first - when we think about joint health and estrogen’s impact, we need to consider the anatomy of a joint and the structures to which they are connected, namely muscles and bones which together make up the musculoskeletal system.
Joints are comprised of ligaments, tendons, cartilage, and synovium which produces synovial fluid to keep the joints lubricated. The knee joint also has a specific type of cartilage called the meniscus.
The joints that people commonly have issues with as we age are knees, hips, ankles, shoulders, the spine, hands and feet but really any joint can be affected. What is the role of a joint in the body? It’s any part of the body that allows our body parts to rotate, bend such as in flexion and extension, abduct (move away from the body), adduct (move toward the body), and pivot.
Estrogen levels decline significantly after menopause and affect joint health by:
decreasing muscle mass through increasing cell death of skeletal muscle cells and other mechanisms that cause a reduction in muscle mass and strength
decreasing bone density by increasing osteoclast or bone resorption activity and worsening osteoarthritis due to wearing down cartilage in the joints
accelerating cartilage breakdown and increasing production of inflammatory cytokines which are basically chemical messenger proteins in the immune system which leads to chondrocyte degeneration. (Chondrocytes are the primary cell type in cartilage)
So, the entire musculoskeletal system is affected – the components of the joint are directly affected by the loss of estrogen as are the supporting structures.
What does menopause joint pain tend to feel like? How does it compare to other common types of joint pain?
Menopause joint pain is not distinct from joint pain that is not related to menopause. And to be clear, the causes of joint pain are multifactorial and the decline in estrogen levels with menopause is just one component of many factors that lead to joint pain. And pain is also somewhat subjective, so what a person feels will depend on the location and underlying cause of the joint pain as well as individual pain threshold and pain perception. A meniscus tear in the knee will feel different from a ligament tear vs. loss of cartilage and lubrication of a joint for example.
The symptoms of frozen shoulder (adhesive capsulitis) are the same whether it’s related to menopause or not although the condition is more prevalent in women than men and more common during perimenopause and postmenopause. Even things like the fact that women have wider hips compared to men due to the shape of our pelvis, which changes the hip to knee alignment, predisposes women to a higher incidence of knee problems such as ACL injuries. So, it’s not really that the pain is different per se, but the predisposing factors and prevalence are different.
Does menopause joint pain persist through the entire menopause experience? Does it resolve once hormone levels stabilize?
So again, the causes of joint pain are multifactorial, but not all hope is lost after menopause. In addition to declining levels of estrogen after menopause, you do need to consider other factors that affect joint health like age, physical activities, body weight, injury, certain medical conditions like autoimmune diseases, infection, and smoking. You can’t just chalk it all up to menopause. You do need to assess for other underlying causes.
But there are ways to mitigate joint pain, and treatment will depend on the underlying cause. I will say that I am the poster child for mitigating joint pain because I have severe bilateral knee osteoarthritis. I’ve done all the things including kinesiotape, PRP, hyaluronic acid, and cortisone injections, acupuncture, genicular nerve block, sports massage therapy, shock wave therapy, and even in desperation at the time of a race, I had a team physician injecting a long-acting numbing medication called bupivacaine into my knee joint just to get me through the race. Of course, he had to caution me that bupivacaine is chondrocyte toxic in animal studies. And I’m thinking, Buddy, menopause is chondrocyte toxic! And yes, I do take menopause hormone therapy.
So, things like maintaining a healthy weight, doing strength training, mobility and balance exercises are extremely important. I like to say “Motion is Lotion” for the joints. And sitting is the worst for your joints! As a Lifestyle Medicine physician, I highlight all the lifestyle factors with my patients that can impact overall health such as good nutrition with a whole food plant predominant diet, avoiding ultra-processed foods and added sugar, getting regular physical activity and incorporating strength training, getting sufficient and good quality sleep, managing stress and having a social support system, and avoiding risky substances. And yes, hormone therapy can help.
What are the best tools to ease joint pain in menopause? Do you recommend the following, and if yes, how do they help?
I will say that I’m not a big proponent of supplements for a couple of reasons: 1. Most people can get all the nutrients they need from following a healthy diet. There are dietary reference intake recommendations for certain vitamins and minerals and certain individuals can have deficiencies due to things like dietary restrictions or problems with intestinal malabsorption. Some women, particularly during the reproductive years, have iron deficiency anemia due to having heavy menstrual cycles. So, there is certainly a role for supplementation of some vitamins and minerals in certain situations.
A second reason is that the supplement industry is not FDA regulated, and they are not held to the same standards when it comes to quality control. In fact, supplements specifically cannot state that they are for treatment, prevention, diagnosis or cure of disease. However, there are ways to help ensure that you are purchasing a quality supplement. You want to know if a supplement has undergone neutral 3rd party lab testing and/or has a certification label to ensure quality standards have been met such as USP (US pharmacopeia), NSF (National Sanitation Foundation), BSCG (banned substance control group), or Informed Choice label or has been vetted by a company called Consumer Lab which contracts with neutral 3rd party labs. You need to be an informed consumer when it comes to buying supplements. And just because some amount or dose may be good for you, more is not necessarily better and can cause harm. And there are a number of supplements that are sold at much higher doses than are typically recommended. Buyer beware.
Heat/ice
Both can definitely help. Ice is used for acute injury and swelling in the initial couple of days after injury and heat is typically applied later.
Over-the-counter pain relievers
Ibuprofen and Tylenol for sure. You do need to be careful about ibuprofen if you have high blood pressure, and also excessive intake on an empty stomach can cause GI issues. You can also overdose on Tylenol which in excessive doses can be toxic to the liver. I do like a topical nonsteroidal medication called diclofenac gel.
Low-impact exercise
The downside of low or non-impact activities is that they don’t help with bone density, but activities such as swimming and cycling certainly have their benefits for joint health and may be necessary for cross-training in the setting of injury or to help prevent overuse injury. People do experience overuse injuries with excessive levels of activity and intensity so it’s always important to balance activity with recovery and cross-training as well as being diligent about doing strength and mobility work.
Physical therapy
I have said many times that physical therapists are the unsung heroes! Nothing against sports medicine or orthopedists - they certainly diagnose and treat musculoskeletal problems, but the Physical Therapists are the ones who help you know what exercises to do to prevent and recover from injury. Anyone who has ever been to a physical therapist for injury recovery knows how important it is to continue to do those exercises once you are healed to help prevent the injury from recurring.
Dietary changes or supplements
I do take creatine for muscle, bone and cognitive health, and if I could recommend any one supplement, it would be creatine. Creatine is a naturally occurring substance made up of amino acids (arginine, glycine, methionine) found in muscle and brain and made by the liver, kidneys and pancreas. It is present in higher amounts in men compared to women and in carnivores compared to vegetarians and vegans. I have also personally taken turmeric and curcumin and collagen supplements to try to help mitigate my joint pain but with limited personal success. There is some evidence to support taking some of these supplements and others, but again the buyer must beware in terms of what you are choosing to purchase.
As for diet, I think the best general strategy is consuming whole foods in the form of fresh fruits and vegetables, healthy whole grains, healthy fats and lean protein. I do personally follow a plant predominant diet because compared to animal protein, plant sources are a good source of fiber and are low in saturated fat. Staying away from ultra-processed foods and added sugars which promote inflammation is also important.
Weight loss
Maintaining a healthy weight for sure is going to be key to decrease the weight impact on your joints especially in your spine, hips, knees, ankles and feet. And I will say that although rucking with a weighted vest has become an increasingly more popular activity, I would just be careful because the added weight can put stress on your joints.
Hormone replacement therapy
While I am an advocate for hormone therapy, it is not a panacea! But we also know that fewer than 5% of women who are candidates for hormone therapy are prescribed it. Partly from the backlash of the WHI study, and also due to the lack of providers who have the knowledge and ability to counsel women on the indications, risks, benefit and alternatives.
The FDA indications for hormone therapy include treatment of vasomotor symptoms - hot flashes and night sweats, prevention of osteoporosis, and treatment of genitourinary syndrome of menopause, which includes vaginal dryness, pain with intercourse and urinary symptoms, such as urinary frequency and recurrent UTIs.
However, we know that perimenopause and menopause due to estrogen deficiency is associated with an entire spectrum of symptoms that extend beyond those for which hormone therapy is FDA approved, and this includes symptoms related to joint pain. So yes, if you have no contraindications to hormone therapy, and you have a constellation of symptoms that suggest estrogen deficiency, then hormone therapy should absolutely be discussed and offered as a treatment option.