Joint pain, swelling, stiffness, fatigue; all part of the normal ageing process, right? Combine that with the mood changes, hot flashes and sleep disruption of menopause and it can become a nightmare situation, writes medical researcher and female health advocate, Dr. Emily Handley.

What is arthritis?

Arthritis is an umbrella term for over 100 conditions that share inflammation of the joints, mostly affecting cartilage where two or more bones meet. Most commonly, this occurs in the wrist, hands, fingers, knees and ankles. The causes of arthritis aren’t well known but are generally thought to be due to immune system defects that cause the body to attack tissue and joints, in combination with environmental factors.

In Australia, nearly 4 million people have some form of arthritis, affecting 12% of females and 6.8% of males in 2018 – and prevalence increases from the age of 45 onwards, coinciding with the reduction in female sex hormones in women. The three most common forms of arthritis are osteoarthritis; rheumatoid arthritis; and gout.

Osteoarthritis occurs when the joint between bones is worn down due to cartilage damage, and often affects women. The condition can be heritable – that is, it can run in the family – and being overweight or sustaining previous injuries increases your risk of it developing. Usually, osteoarthritis occurs in fingers and larger joints such as lower spine, hips, ankles and knees. These joints may appear enlarged, and pain is often worse in the morning or after a period of being sedentary, improving with use. The condition develops slowly over a period of several years.

Rheumatoid arthritis is a less common condition, causing joint and organ inflammations. It is considered an auto-immune disease and occurs when the immune system attacks the body’s tissues. Tissue surrounding the joint – known as the synovial membrane – then thickens and becomes inflamed, secreting liquid that causes swelling. Women are three times more likely to develop the condition, and to do so between the ages of 25-50. Swelling and pain appears rapidly, and the disease creates fatigue and a general sense of feeling unwell.

Gout is an incredibly painful form of arthritis and occurs after increased levels of uric acid in the body. These cannot be excreted normally – through urination or bowel movements – and tiny crystals of uric acid form in the joints. This results in extreme pain and inflammation, and usually affects one joint at a time. Typically, it will begin in the big toe, and can go onto affect the ankles, knees and hands. Women are less likely to develop gout; yet when they do, it is generally after menopause.

Other forms of arthritis include ankylosing spondylitis; lupus; scleroderma; and juvenile arthritis.

How does menopause impact arthritis?

There is no doubt that the changes occurring in female hormones during menopause impact our health and development of different diseases and conditions. During menopause, the female sex hormone estrogen goes into decline and joint symptoms – pain, aches, swelling – are reported by at least 50% of women with menopausal symptoms. While some of these symptoms resolve themselves by post-menopause, they can also be a sign of arthritis – a condition postmenopausal women most commonly develop, with a rapid onset of symptoms. Adding to the complexity, some forms of arthritis have overlapping symptoms with menopause – making diagnosis confusing.

The increased prevalence of arthritis in women after menopause, along with arthritic symptoms during menopause, has been further validated by the increase in arthritis in women who have had a hysterectomy. The severity of arthritis, particular in lower limbs, has also been linked to the genes that control estrogen and its actions. As early as 1938, scientists have even observed that pregnancy can reduce symptoms of rheumatoid arthritis, while conversely symptoms worsen before menstruation.

But why would estrogen – a reproductive hormone – have such an impact on our joints? Receptors for estrogen – working together as a lock and key mechanism – can be found in the synovium of joints (the soft tissue lining the inner surface). The loss of active estrogen from the joint may then give rise to this pain and stiffness. Additionally, estrogen has a number of effects on our immune system, and arthritis is considered an auto-immune disease. Forms of estrogens and their receptors control pathways in the body that act to combat disease and damage, and during periods of time where estrogen is reduced (such as during menopause), the ability of estrogen to trigger these pathways is also reduced. Importantly, while it is increasingly clear estrogen impacts arthritis, much more research is needed before we understand the complex pathways that contribute to the condition.

Risk factors for arthritis

While we have evidence for the roles of estrogen and the immune system in arthritis, we still don’t fully know what causes the condition. Instead, we can target risk factors for arthritis onset, progression and severity, including:

• Obesity
• Repetitive joint movements
• Previous joint damage
• Family history of arthritis
• Nutritional deficiency in omega-3-fatty acids, or vitamins C and E
• Diabetes
• Smoking

Addressing these factors can reduce the chance of arthritis developing, and mitigate the severity of symptoms.

Women’s reproductive conditions can also worsen the risk of arthritis forms, including endometriosis and polycystic ovary syndrome (PCOS) – further validating the link between female sex hormones and arthritis. If you are reaching peri-menopause and have any of these risk factors in your environment, it is important to take note of changes in your joint mobility and the presence or absence of pain. Understanding the increased risk of arthritis during menopause, particularly in conjunction with any of these risk factors, will make it easier to diagnose arthritis as separate from overlapping menopausal symptoms.

Can estrogen be a therapeutic?

With such close ties to estrogen levels, using hormone replacement treatments has long been thought to hold promise in treating arthritis. Selective estrogen receptor modulators (SERMS) act as ‘fake’ estrogen in the lock and key mechanism at receptors. While SERM treatment has shown some promise in animal studies, this has yet to fully translate to humans, with difficulty in figuring out which specific SERMS are effective in different parts of the body. Still the treatment does appear to have protective effects at joints, as well as having a pain-killing effect and protecting the synovium. In post-menopausal women struggling with arthritic symptoms, it is certainly worth discussing the use of SERMS with your doctor.

Other estrogen-related drugs may also target disease-modifying pathways in arthritis; particularly in late stages of the disease. These therapeutics act on the bone and cartilage, being especially effective in osteoarthritis. Additionally, estrogen-related drugs can indirectly protect cartilage and surrounding bone-tissue, maintaining joints as a whole. It is crucial to note that estrogen treatments can result in treatment-related adverse effects at a significantly higher rate than SERMS.

New estrogen drugs – such as tissue-selective estrogen complexes – combine estrogen and SERMs, and have high potential for treating post-menopausal arthritis. In theory, this would take the best effects from both of these therapies, and these could be a candidate for the most effective drugs in future. Clinical trials are ongoing, with the hope that these therapies can target the necessary pathways in our bodies.

How can arthritis symptoms be managed?

The number one way to ease symptoms of menopause and of arthritis is – drumroll – to work closely with your doctor. Always, this is the best way to keep track of whether any joint pain is worsening in conjunction with menopausal symptoms, and to find a treatment plan that suits your unique, individual circumstances and health. Alongside this, there are the usual suspects of eating healthy, quitting smoking and drinking, and – perhaps surprisingly – exercising more.

Exercising regularly keeps bones strong and joints flexible, as well as fighting fatigue; all symptoms of arthritis. It may seem counterintuitive to seek out exercise when joints are swollen and inflamed, yet exercise reduces joint stiffness, pain and tension and maintains mobility. A good fitness program that attends to the joints combines:

• Movement such as swimming, tai chi, golf, yoga, Pilates all can help improve strength, posture and flexibility.
• Aerobic exercise that strengthens the heart, such as cycling, badminton, tennis or fast walking/hiking.
• Strengthening muscles through weight training, either with your own body weight or with gym equipment, to support your joints.

A strenuous exercise program is not the goal here – instead, look for a program of moderate exercise to strike the balance between rest and activity, and avoid further degeneration of joints.

Additionally, eating well is not only great for your overall health; maintaining a healthy weight also will relieve your joints. Work with your doctor and dietician to find a diet that suits your needs and health.

Dietary elements that can ease arthritis symptoms include:

• A Mediterranean style diet that is full of fish, nuts, omega-3 fatty acids, fruit and vegetables
• Reduced saturated fats, which can be found in red meat and dairy.
• Reduced fatty and sugary foods found in processed products.
• Healthy levels of calcium products, such milk, cheese, yoghurt, seeds and fish.

Additionally, making use of therapies such as physiotherapy; massage; acupuncture; and mindfulness techniques can also provide benefits in managing pain. Hot and cold treatments – such as heat packs and warm baths, or ice packs – can be used throughout the day to prevent swelling and ease sore muscles.

How do I live with arthritis?

While we don’t know all the causes of arthritis, we do know that some of these cannot be prevented. Addressing the risk factors of arthritis can still go a long way to giving yourself the highest quality of life for a longer period of time. The management treatments mentioned above should be attended to throughout life, proving to be beneficial preventative measures. Eating well, exercising and maintaining regular wellbeing appointments in combination can ease the symptoms of both menopause and arthritis, improving sleep and overall mood and outlook.

If you have arthritis, also consider protecting yourself by modifying your home, making daily tasks easier without making your pain worse. Your doctor can refer you to an occupational therapist, who will work to adapt your home to your needs. Some tasks for which there is equipment available target movement such as getting from sitting to standing in chairs or in the bathroom; reaching for objects; turning doorknobs; getting dressed; and performing household chores. Arthritis can affect the large joints of the legs, leading to a loss of balance that also increases the risk of falls. Adapting your home and daily routine can protect from the injury and keep you healthy for longer.

It is also important to note that some forms of arthritis come with the added risk of lung cancer, diabetes and heart disease. The lack of physical activity the condition can bring also can result in a loss of independence, fatigue, depression and anxiety: all outcomes that overlap with menopause. Again, maintain your doctors’ appointments will empower you to know when these symptoms creep up, and to treat these as soon as possible before they can worsen any other conditions.

At the end of the day, while menopausal arthritis may seem to be a recipe for disaster, there are many ways to ease symptoms, and therapeutic medications are just on the horizon. Always stay in tune with yourself and the symptoms you are feeling, to help health professionals diagnose you accurately and differentiate between overlapping symptoms. With the progress being made in research and treatment, you don’t have to let arthritic symptoms stop you from being active and fully engaging with life.

Disclaimer: This article provides general information only, and does not constitute health or medical advice. If you have any concerns regarding your health, seek immediate medical attention.