Menopause and arthritis: Is there really a causal connection?
So you've entered the perimenopausal years or perhaps you've stopped menstruating altogether. Just when you think your body will get a break from all that "change"—hormonal and otherwise—the pain kicks in. Maybe it's the hips or the knees, perhaps it's your fingers.
Now you're thinking: Menopause and arthritis, seriously? But is there an exact correlation between the two?
Online research on the subject produces conflicting information. Some studies indicate that drops in estrogen are linked to loss of synovial fluid, the gel-like substance that pads the joints. Low estrogen has also been linked to an increased perception of pain; for example, in women with depression. Other research states there is some connection between menopause and arthritis, but it's not clear exactly what it is.
We asked Blair S. Ashley, MD, an orthopaedic surgeon at Main Line Health, for her expertise on this subject.
"People start getting menopause symptoms in their late 40s and early 50s, so the age lines up with arthritis," Dr. Ashley says. "We don't have a great universal understanding of why osteoarthritis happens. It could be individual, from an injury or repetitive use, family history, or general aging resulting in wear and tear. I haven't seen anything in reputable journals that makes a good scientific link between menopause and arthritis."
Types of arthritis that might affect you in menopause
Osteoarthritis is commonly referred to as arthritis. This is joint pain, swelling, stiffness, and loss of mobility caused by loss of cartilage that protects the spine, hips and knees, for example.
Inflammatory arthritis, on the other hand, is a systemic disease associated with an overactive immune system. Rheumatoid arthritis (RA) is an example of inflammatory arthritis and symptoms may include swelling, pain and redness of the joints, but inflammatory arthritis often affects other organs and systems of the body.
"With inflammatory arthritis, you might get more inflammatory markers if you were to test the joints," explains Ashley. "We may use medications, called DMARDs, or disease-modifying antirheumatic drugs, for diseases like rheumatoid arthritis. That's why we don't see the severe RA we used to see, because the disease process is better controlled."
Osteoarthritis, however, doesn't respond to those medications, says Ashley.
Menopause and arthritis: The bare bones of it
"Osteoarthritis is very mechanical," Ashley emphasizes. "You've lost the cartilage in your joint because of wear and tear. Cartilage rubbing on cartilage is like ice rubbing on ice. It's smooth and easy. But it's bad at healing if you get a defect in the cartilage. Then it forms as fiber-cartilage, which is second-rate cartilage scarring, or worse, bone-on-bone. Once that process starts, there's no stopping. There's nothing to inject to help it regrow, nothing to resolve inflammation. It's a permanent problem that needs a permanent solution."
Ashley explains there are some isolated incidents, for example in younger patients who have very small defects in cartilage. In those cases, cartilage can be taken from other parts of the body and transposed into the damaged area.
What about menopause and arthritis and bone density?
Ashley points out that menopause does indeed affect women's bone density, but if anything, she says, there is a correlation between low bone density and less propensity for osteoarthritis.
Ultimately, she explains, "Arthritis and bone density are totally unrelated; they're two separate problems."
Put simply, one is a bone problem, and one is a cartilage problem.
Osteoporosis comes down to calcium and vitamin D. In later ages of life, whether you have good bone density is an indication of how well you did in your youth. Optimal bone density is generally when you're 25 or 30 years old. As you age, lack of calcium and vitamin D as well as inactivity can affect bone density.
Arthritis and bone density are totally unrelated; they're two separate problems. Put simply, one is a bone problem, and one is a cartilage problem.
"Arthritis may indirectly affect bone density. If you have a lot of pain from arthritis and you don't want to get up and move—and you're someone who's already at risk for osteoporosis—you may exacerbate your risk for osteoporosis because deconditioning and inactivity bad for bone health. adds Ashley. "But still, they're two separate processes."
Nonsurgical treatment for arthritis in menopause
Like other orthopaedic experts, Ashley takes a conservative approach to arthritis, starting with nonsurgical treatments. Patients usually come to her after they've "tried everything" to manage pain on their own.
She breaks down the nonsurgical treatments for arthritis as follows:
First-level treatment approach for hip and knee arthritis
- Avoid high-impact activity.
- Opt for walking, elliptical, biking, swimming.
- Take anti-inflammatories such as Aleve (ibuprofren).
- Take Tylenol if you're unable to take NSAIDs, but keep in mind that Tylenol is NOT an anti-inflammatory. It is a pain-reliever.
- Engage in physical therapy. Sometimes this helps; sometimes it makes it worse.
"If I think someone's a little deconditioned or not active at base line," explains Ashley, "a physical therapist can help with gait training and strengthening muscles around their joints. Again, can be a little plus/minus, depending on the type of arthritis the patient has and the severity of their arthritis."
Second-level treatment approach for hip and knee arthritis
- Steroid injections (anti-inflammatory) or cortisone injections (also called visco-supplementation or "gel shots") for knees
- Steroid injections for hips (no gel shot data to support relief for hips)
While Ashley may perform knee joint injections in the office, hip injections are often performed by pain management doctors or interventional radiologists using image guidance (ultrasound or x-ray).
Third-level treatment approach for hip and knee arthritis
- Surgery vs. live with it
"It often comes down to a patient deciding whether they're ready for surgery or if they're willing to live with the pain," explains Ashley. "How much is it affecting your life? How much have you given up due to pain that used to give your life meaning?"
Ashley may consider a patient a candidate for hip or knee arthroplasty based on their X-rays, but it always comes down to personal decision.
"I operate on people not on X-rays," she explains. "If that person is telling me, ‘I don't hurt every day,' well, I might say, put some ice on it or take some ibuprofen. Maybe it's not time for you. But if a person says, ‘I can't get up and down off the floor to play with my grandkids,' that's when it might be a problem that merits surgery."
As for menopause and arthritis, regardless of why it's happening, at some point it comes down to what are you going to do about it?
"People are making their best effort to come up with a biological solution," says Ashley. "But at the end of the day, [when so much pain is involved] surgery is my ultimate recommendation, and as of now metal and plastic are still the best solution for the treatment of arthritis."
Hip replacements and knee replacements: Are outcomes really 50/50?
If you're someone who's tried numerous treatments for arthritis hip pain or knee pain, you may be reluctant to consider hip replacement or knee replacement. Surgery and recovery seem like a big undertaking.
"Hip and knee surgery do deserve respect because they can have complications," says Ashley. "But you may be willing to risk complications vs. living the rest of your life with the pain."
In Ashley's experience with total hip replacements: About 95% of people are happy after a hip replacement. People generally do well with the hip.
About 95% of people are happy after a hip replacement.
About 85% of people are happy after a knee replacement.
- Blair S. Ashley, MD, Orthopaedic Surgeon
"Knees are a little less sunny," she says. "About 15% of people are not happy after a knee replacement."
One of the potential complications is persistent anterior knee pain.
"That's where some of the optimism with robotics in technology is coming into play. What's the exact right angle, the right balance, and how can we replicate that with the use of technology. Even though we can be very precise, we haven't figured out how to translate that into patient outcomes yet."
Menopause and arthritis pain: When it's time for surgery
If you're in your menopausal years and have been living with chronic arthritis pain—that is, pain that lasts a good six months or a year and is causing you difficulty—talk to your primary care provider (PCP). Your PCP can help determine if your arthritis is a chronic problem or an acute issue (comes on suddenly then goes away).
If you have tried with medications and activity modification to deal with arthritis pain, an X-ray may be the next step. This is always required before making an appointment with Ashley or another orthopaedic surgeon.
"If an X-ray shows there is arthritis there, we can talk about your options," says Ashley.