Megan Miller-Zutshi, Lead Physiotherapist
In recent years, menopause has become a hot topic amongst health professionals, celebrities and the general population, but how does it affect us from a musculoskeletal pint of view?
Through life, women go through various different hormonal stages from being born, into puberty, their fertile years, then perimenopause and postmenopause. The menopause itself is actually only one day and it occurs once you have gone for one full year without a period. One year and one day without a period and you are postmenopausal. Perimenopause generally starts between the ages of 45-55 and can last for a few months up to a few years. Some people experience perimenopause before they are 40. This can be as a result of medical treatments, such as surgery to remove the ovaries, but sometimes there’s no cause.
It is estimated that more than 47 million women worldwide enter the menopause transition each year. Of this more than 70% will experience musculoskeletal symptoms during the transition from perimenopause to postmenopause and more than 25% will be severely affected by these symptoms. There are more than 35 symptoms associated with perimenopause and it should be considered a head to toe issue. Symptoms include hair thinning, skin changes, hot flashes, brain fog, anxiety, weight gain, fatigue, and sleep disturbances. However, musculoskeletal symptoms are less commonly recognised by health professionals. This collection of musculoskeletal symptoms is now being termed “The Musculoskeletal Syndrome of Menopause”, and includes but is not limited to, musculoskeletal pain, arthralgia, loss of lean muscle mass, loss of bone density with increased risk of fracture, increased tendon and ligament injury, adhesive capsulitis and a reduction in cartilage strength resulting in the progression of osteoarthritis (Wright et al., 2024).
So why do these musculoskeletal symptoms occur around this time? It is thought to be due to the drop in oestrogen that occurs during perimenopause. Oestrogen is the sex hormone responsible for the development and regulation of the female reproductive system, but it also helps regulate the maintenance of bone, muscle health, and control of inflammation. The rate of oestrogen decline varies based on the individual, levels can fluctuate and become unpredictable, but eventually production falls to a very low level. This means that symptoms can vary day to day, as can their intensity. When our oestrogen levels drop during perimenopause, it can lead to muscle weakness, joint pain and stiffness and bone loss.
Oestradiol, which is the most biologically active form of oestrogen, impacts nearly all types of musculoskeletal tissue including bone, tendon, muscle, cartilage, ligament and adipose tissue. The fall in oestradiol leads to five significant changes within the body: an increase in inflammation, sarcopenia (loss of lean muscle mass), a decrease in bone mineral density leading to osteopenia/osteoporosis, arthritis, and a decrease in the proliferation of satellite cells (muscle stem cells).
Inflammation
Oestrogen is known to be anti-inflammatory and mildly immunosuppressive and is the inflammatory regulator that plays a role in the prevention of generalized arthralgia, or joint pain. Arthralgia in perimenopause generally affects the neck, shoulders, elbows and knees. This pain often has no specific findings on imaging, and no secondary cause can be found, but there is some evidence to support increased reporting of arthralgia in postmenopausal women compared with premenopausal women
Sarcopenia
Sarcopenia also known as age-related loss of lean muscle mass, is the loss of Type II muscle fibres, a decrease in the number of motor units and increased intramuscular adipose (fat) tissue. All of these lead to a reduction in quality and strength of the muscle. Studies have found that women on average can lose 10 to 20% of lean body mass during perimenopause. A decrease in muscle strength can result in reduced mobility and an increased risk of falls. Additionally to this, a decrease in the number of muscle stem cells prevents the production of new muscle, further compounding the issue. Oestrogen also plays an important role in the production of collagen, which is vital for tendon health. The reduction in this alongside the decrease in skeletal muscle mass can put the tendon under increased stress. Because the normal cycle of tendon repair is taking longer than previously, it can increase the risk of developing tendinopathy.
Osteoporosis
Oestrogen deficiency during perimenopause is associated with significant bone loss increasing fragility and risk of fracture. Women have an average reduction of 10% in their bone mineral density during perimenopause, and between 30% and 50% of women suffer a clinical fracture in their life. Osteoporotic fractures can be extremely disabling and can result in chronic pain and deformity. The prevention of osteoporosis includes appropriate nutrition and exercise and the removal of risk factors.
Cartilage damage and osteoarthritis
The cells involved in the regulation of articular cartilage are partly controlled by oestrogen, and although other mechanical and biochemical factors are involved in the development and progression of osteoarthritis, it has been found that the incidence of osteoarthritis in women increases significantly around the time of perimenopause. Studies have suggested an association between perimenopausal oestrogen decline and the frequency of knee, hip and finger osteoarthritis and the severity of hip osteoarthritis.
Although there appears to be a strong correlation between oestrogen deficiency and “The Musculoskeletal Syndrome of Menopause”, a causal link is lacking as there have been few studies looking at symptomatic patients within this group. However, among the recommended prevention and treatment approaches associated with perimenopause, exercise is the only non-controversial modality. Again, there is a lack of concrete evidence regarding optimal weight training, but it is generally acknowledged that resistance training with heavier weights in lower repetition sets is more effective at increasing muscular power than lighter weights in higher repetition sets. Resistance training alongside dietary changes, including increased protein intake may be critical for perimenopausal and postmenopausal women to decrease their risk of falls and fractures.
If you are struggling with any musculoskeletal symptoms associated with perimenopause and would like further help or advice please contact the clinic on 01454838366 or CLICK HERE book an appointment with one of our practitioners.
Reference:
Vonda J Wright 1, Jonathan D Schwartzman 1, Rafael Itinoche 1, Jocelyn Wittstein 2 ; The musculoskeletal syndrome of menopause; Climacteric Volume 27, October 2024 – Issue 5, 466-472; Published online: 30 Jul 2024