Introduction

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

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

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

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

One in two postmenopausal breast cancer survivors experience aromatase inhibitor-associated arthralgia.

Clinical Presentation

Usually, the musculoskeletal symptoms include

Muscle and joint aches and pains
Joint stiffness
Joint swelling
Reduced muscle strength
Low stamina
Pins and needles
Fatigue

Diagnostic Procedures

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.

Secondary causes of arthralgia history should be considered, such as thyroid disease or vitamin D deficiency.

Management

Pharmacological Approaches

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

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.