How to help a Perimenopausal Patient with Joint Pain.

In the last session before lunch, Fiona Watt took us through different musculoskeletal conditions and their links with MHT as well as tips on how to treat perimenopausal patients with joint pain.

Musculoskeletal pain is more prevalent in women than men, with prevalence increasing with age for both genders. The pain is so significant that 33% of people over the age of 45 will visit their doctor about discomfort caused by musculoskeletal pain. Arthralgia, more commonly known as joint pain, is reported by 50% of women during the menopause. This joint pain has associations with muscle pain, fatigue, mood change, sleep disturbance, raised BMI and anxiety and stress. Improving some of these associations, such as reducing hot flushes and improving quality of sleep can in turn result in a reduction in joint pain.  Arthralgia is more common during menopause, particularly in perimenopausal women where Szoeke et al. have reported that up to 41% of women experience joint related pain in this phase.

Osteoarthritis (OA) is also a common cause of joint pain. Hand osteoarthritis in particular is very common in women, who have a 5% lifetime risk of developing the condition. This often affects hand function and quality of life. Data available from Prieto-Alhambra et al. has shown that the onset of OA is linked to the menopausal phase, which explains why between 80-90% of individuals in secondary care clinics with hand OA are female. The meta-analysis shows that hand osteoarthritis has a different pattern to other forms of osteoarthritis, with a peak of incidence in the fifth decade which implicates that menopause may have a role in the onset of the condition.  Watt DE et al. have also shown that over 50% of patients experience onset of osteoarthritis within 4 years of the onset of menopause. This is compounded with data by H. L Ma et al. which suggests that estrogen deficiency is involved in the pathogenesis of osteoarthritis.   

So we think menopause plays a role in the onset of hand osteoarthritis, but what effect does MHT have on musculoskeletal symptoms? Data gathered from the WHI post-hoc analysis (Chlebowski, R.T., et al.) suggests modest reduction in joint pain and stiffness in women on MHT compared to those on placebo. In an Australian study (Welton AJ et al.) joint ache and myalgia were also significantly reduced in women using MHT.

Literature suggests that current MHT use appears to be protective of knee OA and has a reduced risk of total join arthroplasty in the hip.  When it comes to the hand however, studies have mixed results, currently there are only a few prospective studies and no RCTs so more research is needed to decipher the role of MHT in hand OA.

With the data collected, Fiona suggests evaluating the following questions when dealing with peri-menopausal patients with joint pain:

  1. Does the patient have joint-based pain?
  2. If yes, where is this pain?
  3. Multiple or single joints? Are they symmetrical?
  4.  Does the patient have prolonged early morning stiffness?
  5. Can you see joint swelling?
  6. Are the joints tender?
  7. Are there firm modules suggesting Osteoarthritis?
  8. Is there MCP joint swelling suggesting RA?

Literature has shown that musculoskeletal pain increases during and after perimenopause. Those who are in perimenopause will have an increased risk for osteoarthritis (particularly hand) and rheumatoid arthritis. We still need more data to be collected in order to see if MHT can be beneficial for osteoarthritis as we await studies in well-defined populations of symptomatic OA patients, but current data should be considered when evaluating the best source of treatment for perimenopausal women with joint pain.

References:

1.       Szoeke et al. Climacteric 2008;11, 55-63

2.       Prieto-Alhambra et al. Ann Rheum Dis 2014;73, 1659-1663

3.       H. L Ma et al, Osteoarthritis and Cartilage, Volume 15, Issue 6, 2007, 695-700

4.       Chlebowski R.T. et al. Menopause, 2013; 20, 600-8

5.       Welton AJ et al. BMJ. 2008; 337:a1190