Menopause Associated Arthralgia
Original Editor - Habibu salisu Badamasi
Introduction[edit | edit source]
Musculoskeletal pain is reported by more than half of women at the time of menopause. Joint pain presentation is common in women between the ages of 45 and 55 years of age. Arthralgia, unlike arthritis or rheumatology disorders, is a subjective presentation describing pain in the joints. Arthritis is a pathological condition that damages the joints with associated joint pain symptoms and signs, and rheumatology disorder is an inflammatory condition. However, not all patients experiencing arthralgia during the time of menopause often do not have or develop associated arthritis. The pain may be associated with hormonal changes or secondary reversible conditions, which are essential to be ruled out. 
Prevalence[edit | edit source]
Arthralgia of menopause is a common complaint affecting close to 50% of all women at the time of menopause.  Joint pain is undoubtedly widespread during menopause, but the link between reported musculoskeletal complaints and menopausal transition is more difficult to establish. A study investigating menopausal symptoms found joint pain, joint stiffness or backache in 51–59% of women. Joint pains and muscular discomfort are most commonly reported symptoms by Nigerian women aged 40–60 and Spanish women aged 45–55 and in 21% of these women joint pain constitutes the most bothersome menopausal complaint. 
Aetiology[edit | edit source]
Causes of arthralgia in menopausal women:
- Primary/idiopathic (peri-menopausal)
- Secondary causes:
- Endocrine: Hypothyroidism, Hyperparathyroidism (primary or secondary), Vitamin D deficiency, Anaemia
- Drug-related: Statins and other lipid-lowering drugs, Aromatase inhibitors, Selective estrogen receptor modulators, Bisphosphonates (particularly intravenous), Thiazide diuretics
- Metabolic: Liver disease, Renal disease
- Rheumatic: Connective tissue disease (Lupus*, Scleroderma, Sjogrens*) Sarcoidosis*, Vasculitis, Hyperuricaemia, Hypermobility
- Infection: Parvovirus*, Hepatitis B*/C*/HIV*, Ross River virus*, Brucellosis*, Whipple’s disease*, Lyme disease*
- Malignancy: Disseminated bony malignancy, Paraneoplastic syndrome,  Multiple Myeloma 
*May be associated with arthralgia or arthritis.
Estrogen Deficiency Related Menopausal Arthralgia[edit | edit source]
Musculoskeletal system changes due to menopause have been studied for years, and more recent studies prove the relationship between estrogen deficiency and changes in bone and muscle metabolism. These changes include the rapid loss of density and strength of bone tissue and the deterioration of muscle mass.  In addition, cartilage metabolism is also affected by estrogen deficiency, and the presence of estrogen receptors on chondrocytes, which are cartilage tissue cells, supports this. 
Although arthralgia is a commonly reported musculoskeletal alteration in menopausal women, it has been less studied, therefore, the level of evidence for estrogen deficiency as a source of menopausal arthralgia is not strong. 
Aromatase-induced Arthralgia[edit | edit source]
Clinical Presentation[edit | edit source]
Usually, the musculoskeletal symptoms include
- Muscle and joint aches and pains
- Joint stiffness
- Joint swelling
- Reduced muscle strength
- Low stamina
- Pins and needles
Diagnostic Procedures[edit | edit source]
A detailed history should be carried out on a patient with joint pain. Usually, musculoskeletal pain does not always originate from the joint and does not refer to arthralgia. Because there are different causes of pain. Pain away from the joint may originate from bone, muscles, bursae, or entheses. 
A history of joint injury, occupation-related, past or family history of psoriasis, uveitis or inflammatory bowel disease, and a history of menopause should be investigated. 
Outcome Measures[edit | edit source]
Differential Diagnosis[edit | edit source]
Around menopause, women have a higher prevalence of osteoarthritis (OA), particularly in the hands, and rheumatoid arthritis (RA).  The decreasing levels of estrogen during menopause can result in joint synovium and cartilage damage, which is often misdiagnosed as RA, degenerative OA, or fibromyalgia.  One study  indicated that almost half of the people diagnosed with RA were misdiagnosed, while they had either menopausal arthralgia or menopausal OA.  Given them, differential diagnosis of the arthralgia of menopause, especially from RA, OA or other rheumatologic conditions that can mimic the arthralgia of menopause, should be provided.
For non-specialists, it is important to examine and assess joints by talking to the patient, observing and palpating the joints, and documenting the "3 S' " listed below. This can help to differentiate between arthralgia, pre-arthritis, or different types of arthritis. 
|RA||OA||Gout / Pseudogout|
|Does the patient have a joint-based site? (Single, or multiple? Symmetrical? Episodic vs. progressive? With activity?)||Multiple and symmetrical joint affection, progressive, activity related or not||Either single/multiple, and symmetrical/asymmetric joint affection, either progressive/episodic, activity-related||Typically single or few, and asymmetric joints affection, episodic|
|Is there early morning stiffness > 30 min?||Yes||No||Yes (flares)|
|Can I see joint swelling? (Are the joints red? Are the joints tender? Is there MCP joint swelling?)||Joint swelling occurs (MCP joint usually), joints are not red but tender||Joint swelling occurs (MCP joint occasionally), joints are not red but may be tender||Joint swelling occurs (MCP joint occasionally), joints are red and tender (flares)|
Management[edit | edit source]
Pharmacological Approaches[edit | edit source]
- Hormone Replacement Therapy (HRT): If arthralgia is severe and persisting, is insensitive to other treatment approaches, is temporarily associated with menopause, and significantly affects the quality of life, then the use of HRT could be tried.  Most studies indicate that HRT can relieve arthralgia in postmenopausal women. 
- Anti-inflammatory medications: Although drugs in this class have been traditionally used, to target inflammatory mediators for pain control, they may miss the root cause of arthralgia and have nothing to do with estrogen receptor influence on the joint itself. Although IL-6 and TNF alpha levels may increase with arthralgia and lead to physical disability, the decrease in estrogen levels before this affects joint cartilage and tendon functions. 
Non-Pharmacological Approaches[edit | edit source]
- Lifestyle changes: Non-pharmacological approaches include weight loss and exercise.  A clinical trial found that a complex intervention including dietary and exercise supervision reduced arthralgia.  There is evidence that moderate physical activity can improve arthralgia and other menopause-related symptoms.  Diets to regulate estrogen levels may help alleviate arthralgia. 
- Use of supplements: Soy isoflavone, which can be found in soy, legumes, and kudzu (also called Gen Ge or Puerain), is a supplement researched for the treatment of menopausal symptoms.  The significant improvement of the use of kudzu on bone mineral density, and cartilage degradation has been proven in both animal and randomized controlled studies.  Other supplements such as phytoestrogens, evening primrose oil, starflower oil, fish oils or ginseng are also reported used supplements for post-menopausal non-vasomotor symptoms, including arthralgia.  These alternative approaches may be helpful to control the menopausal symptoms but there is a lack of evidence for their effects, specifically on arthralgia. 
Additional Considerations[edit | edit source]
When planning an exercise programme, the following should be considered to not cause pain to get worse and loss of confidence and adherence. 
- Graded and gradual increase in the existence of a deconditioning event
- Avoidance of sudden overloading of the affected joints
- Avoidance of heavy lifting and repetitive joint use (for example it is often helpful in hand arthralgia)
Resources[edit | edit source]
References[edit | edit source]
- Magliano M. Menopausal arthralgia: Fact or fiction. Maturitas. 2010 Sep 1;67(1):29-33.
- Blumer J. Arthralgia of menopause-A retrospective review. Post Reproductive Health. 2023 Jun;29(2):95-7.
- Watt FE. Musculoskeletal pain and menopause. Post reproductive health. 2018 Mar;24(1):34-43.
- Geier KA, Benham AJ. Musculoskeletal Health in Menopause. Each Woman’s Menopause: An Evidence Based Resource: For Nurse Practitioners, Advanced Practice Nurses and Allied Health Professionals. 2022:307-46.
- Romero SA, Su HI, Satagopan J, Li QS, Seluzicki CM, Dries A, DeMichele AM, Mao JJ. Clinical and genetic risk factors for aromatase inhibitor-associated arthralgia in breast cancer survivors. The Breast. 2020 Feb 1;49:48-54.
- Gomez D, Saavedra-Martinez G, Villarreal L, Santos-Moreno P, Bello-Gualtero J, Giraldo V, Martinez P, Sanchez A, Sanchez M, Uribe E, Boon M. SAT0108 misdiagnosis of rheumatoid arthritis–the photography.
- Maltais ML, Desroches J, Dionne IJ. Changes in muscle mass and strength after menopause. J Musculoskelet Neuronal Interact. 2009 Oct 1;9(4):186-97.
- Geraci A, Calvani R, Ferri E, Marzetti E, Arosio B, Cesari M. Sarcopenia and menopause: the role of estradiol. Frontiers in endocrinology. 2021 May 19;12:682012.
- Messier V, Rabasa-Lhoret R, Barbat-Artigas S, Elisha B, Karelis AD, Aubertin-Leheudre M. Menopause and sarcopenia: a potential role for sex hormones. Maturitas. 2011 Apr 1;68(4):331-6.
- Xi S, Mao L, Chen X, Bai W. Effect of health education combining diet and exercise supervision in Chinese women with perimenopausal symptoms: a randomized controlled trial. Climacteric. 2017 Mar 4;20(2):151-6.
- Aparicio VA, Borges-Cosic M, Ruiz-Cabello P, Coll-Risco I, Acosta-Manzano P, Špacírová Z, Soriano-Maldonado A. Association of objectively measured physical activity and physical fitness with menopause symptoms. The Flamenco Project. Climacteric. 2017 Sep 3;20(5):456-61.
- Bihlet AR, Byrjalsen I, Andersen JR, Simonsen SF, Mundbjerg K, Helmer B, Riis BJ, Karsdal MA, Christiansen C. The efficacy and safety of multiple dose regimens of kudzu (pueraria lobata) root extract on bone and cartilage turnover and menopausal symptoms. Frontiers in pharmacology. 2021 Oct 22;12:760629.
- Luo Y, Zheng S, Ding Y, Dai Y, Zhou Y, Xiang R, Bay-Jensen AC, Karsdal MA, Qvist P, Zheng Q. Preventive effects of kudzu root on bone loss and cartilage degradation in ovariectomized rat. American journal of translational research. 2017;9(7):3517.
- Gartoulla P, Davis SR, Worsley R, Bell RJ, Gartoulla P, Davis SR, Worsley R, Bell RJ. Use of complementary and alternative medicines for menopausal symptoms in Australian women aged 40–65 years. Medical Journal of Australia. 2015 Aug;203(3):146-.