Menopause and Joint Pain an Integrative Approach

With the menopause transition many women begin to feel an increase in aching, stiffness and joint pain. For some this can be quite a shock, as it is perhaps less noted than many of the other more well-known menopause symptoms. If there are pre-existing joint injuries or back problems, often the pain from these can become worse too.

As well as HRT, using an integrative approach can also be effective and offers a wide toolbox to reach into. The aim is always to start with a foundation of optimum nutrition, followed by using botanical or nutritional supplements, herbal medicine, yoga or acupuncture. These support the body and can reduce inflammation; ensure there are the correct amount of nutrients to meet the extra demands on the body; help to improve circulation and lymphatic flow; reduce muscle tension and spasm, and provide symptom relief for pain. All of these can also be used safely alongside HRT or BHRT.

Supporting the body through this transition using nourishing food, movement and botanicals also provide the resources for us to move into the next stage of life in an optimum state. Hormone replacement is often a very beneficial part of a treatment plan, but it is important not to focus solely on it as the only option.

Joint pain, aching and stiffness or arthralgia during menopause are actually very common. There is no direct evidence that the loss of oestrogen during menopause leads to painful joints, however it is thought the decline is somehow responsible. A similar syndrome has been found to occur following sudden withdrawal of hormone replacement therapy or treatment with aromatase inhibitors which block oestrogen in the body, so doctors conclude that oestrogen is an important factor. Oestrogen receptors are found in the synovium of joints and the decline in levels of oestrogen can cause swelling of the synovial membranes around joints or tendons.

Various interactions between sex hormones and pain processing pathways, immune cells and chondrocytes (the cells responsible for cartilage formation) have also been demonstrated but further research is needed to clarify exactly what these are. Interestingly it is also known that when oestrogen levels drop it can heighten the pain experience.  Additionally, hormonal changes make women more susceptible to dehydration, which may also have an effect on joints.

Food is always the foundation of an integrated approach, and adapting your diet is a great place to start. Focusing on a Mediterranean style diet provides a very well researched approach which is anti-inflammatory and includes a wide range of antioxidant fruit and vegetables; healthy oils and fats; high quality protein; complex carbohydrates or wholegrains and functional foods which support our heart, brain function, energy and mood as well as joints. Adding phytoestrogens, calcium and magnesium rich foods strengthens bones and taking plenty of water and herbal teas hydrates the joints.

Try out these delicious additions which can all help promote healthy joints:

• Omega 3 oils found in oily fish such as sardines, mackerel, wild salmon, as well as nuts and seeds such as, walnuts and almonds, chia seeds, linseeds and pumpkin seeds.
• Herbs and spices such as turmeric, cayenne pepper, parsley, garlic, rosemary and ginger. Ginger is a powerful anti-inflammatory herb and has shown positive effect in reducing pain and inflammation associated with osteoarthritis.  Clinical trials indicate that ginger extract and ibuprofen were comparable in efficacy in the treatment of pain.
• Colourful vegetables are antioxidant and phytonutrient rich. Phytonutrients are crucial for reducing the effects of free radicals - one of the main elements that cause cartilage degradation.  Include a range of different colourful vegetables daily such as blueberries, pomegranates, pineapple, yellow peppers, squash, spinach and beetroots. 

Try to aim for a prominently plant- based diet which includes nutrient dense wholefoods.  

Try to avoid these foods which can promote inflammation in the body:

• Hydrogenated fats found in many processed foods such as margarines, commercial breads and biscuits, or those generated by frying foods in unstable oils at high temperatures. Cook with extra virgin olive oil, coconut or avocado oil if you must fry food.
• Sugar can drive blood sugar imbalances, increasing cortisol which can aggravate inflammation. Refined grains should be avoided for the same reason so choose wholegrains over refined and don’t eat more than 30g of free sugar a day.
• Arachidonic acid is best kept to a minimum, it is commonly found in intensively produced meats and dairy products.
• Beef, pork, soya, peanuts, gluten, dairy and egg may cause issues for some people. Under guidance they can be eliminated for a short period of time to restore immune balance through an elimination diet. Gluten sensitivity in particular may contribute to muscle and joint aching. It is important to see a qualified nutritionist if you are looking to attempt this level of diet restriction.

These wonderful functional foods can also be added:

• Bone broth is rich in vitamins and minerals and is a direct source of collagen, chondroitin and glucosamine, which can help reduce inflammation and pain, as well as increase joint mobility.
• Cruciferous vegetables such as broccoli, cabbage and kale contain sulphur which is necessary for the building of healthy joints. Add some in daily, ideally lightly cooked or steamed for the best nutrient absorption.
• Vitamin C rich foods are powerful antioxidants and essential for collagen production in the body. Consuming a diet rich in vitamin C can prevent accelerated joint damage in osteoarthritis, as well as protecting against free radical damage. Food sources include blackcurrants, broccoli, brussels sprouts, citrus fruit, guava, parsley, pawpaw, strawberries and tomatoes.

Reducing stress, ensuring plenty of sleep, movement, exercise and natural sunlight also contribute to reducing inflammation  and pain in the body. Optimising Vitamin D throughout the winter months with a supplement can often ease muscle aches and pains too.

Using botanicals or herbs to support the body can be an additional benefit:

• Turmeric is a powerful anti-inflammatory with a large body of research behind its use. Turmeric’s major active constituent is curcumin which inhibits the inflammatory COX-2 prostaglandins and leukotrienes. Using a micronized curcumin supplement, rather than just taking turmeric in food or as a supplement gives a much more powerful effect and has higher bio-availability meaning your body absorbs it better and can utilise the powerful anti-inflammatory effects.
• Devils Claw is a traditional South African herb used in arthritis, rheumatic and joint inflammation, with studies supporting it’s use in degenerative disorders of the musculoskeletal system. Devils claw extract inhibits the synthesis of prostaglandins; TNF-alpha and may also inhibit the COX-2 enzyme system which are all responsible for inflammation in the body. It is antioxidant and there are numerous trials studying the effect of Devils Claw in back pain and musculoskeletal pain which show significant improvements in pain outcome and mobility, in particular with knee and hip arthrosis.

Other herbs used traditionally for joint and muscle pains in menopause are Black cohosh, Willow bark, Boswellia, Celery seed and Guaiacum bark. Consulting with a qualified medical herbalist is the safest and most effective way to use herbal medicines; and look for registration with the NIMH or CPP for a qualified practitioner.

Acupuncture

Pilot studies of acupuncture show beneficial effects on women suffering with joint pains taking aromatase inhibitors for breast cancer. Positive trends were observed in stiffness and physical function at 12 weeks using electroacupuncture. In addition the ACOM study into acupuncture found it produced a fast and significant reduction in moderate-to-severe menopausal symptoms during a six-week intervention in a group of 70 women in a Danish primary care setting. As part of an integrated approach acupuncture can offer a very safe option for women unable to take HRT or preferring an alternative.

HRT

Studies into HRT, joint pains and aching show in general a positive effect. The Chingford Study which looked at 1003 women with OA ( osteoarthritis) in hand and knees found there was a significant protective effect of HRT for knee OA and a weaker effect on the hand joints.

Other studies have shown women taking HRT have a lower prevalence of spinal OA; but data supporting protection against hip OA is unclear. The decision to take oestrogen replacement is a personal choice and the type of HRT one chooses is also unique to each individual. There is a choice between conventional HRT, body-identical or bio-identical. This needs to be discussed with your medical practitioner to see if it is the right choice for you.

The Women's Health Initiative (WHI) trial which analysed 10,000+ post-menopausal women found 77% of these women reported join pain and 40% experienced joint swelling. After one year, frequency of joint pain was lower among women who received oestrogen- only therapy, compared to women who were in the placebo group. After three years, the subset of women who received oestrogen continued to have joint pain less frequently. However, joint swelling frequency was higher in the oestrogen-alone group.  The conclusion was that oestrogen-alone used in postmenopausal women resulted in a modest but sustained reduction in the frequency of joint pain.

In practice I find general muscle aching, pain and stiffness do improve with bio-identical oestrogen therapy, but I would always use it alongside nutrition and lifestyle advice to ensure the body is in an optimum state, and for safety progesterone always needs to be added to protect the womb lining in women who have not had a hysterectomy.

Dr Sally Moorcroft