Unexplained Pain During Menopause? You're Not Alone

Menopause is having a moment—and it's about time! Considering 51% of humans are born with ovaries, and 47 million women across the globe1 enter menopause each year, it's exciting that menopause is hitting the mainstream in all its realness.

While hot flashes, night sweats, and weight gain get most of the attention, menopausal symptoms are much more extensive (there are actually more than 35). 

One area that I'm particularly passionate about educating women and physicians on is the presence of musculoskeletal symptoms, which will impact 70% of menopausal women and leave 25% of them disabled2 due to the severity. You can imagine how easily some of these women are dismissed despite their severe pain.

In my work as a double board-certified orthopedic sports medicine surgeon, I've had the pleasure of working with thousands of women. I've also seen the significant need for menopausal advocacy, education, and destigmatization, as so many women deal with symptoms like pain as a normal part of life. 

My team and I recently published a paper3 introducing the new term "musculoskeletal syndrome of menopause" to describe the collective musculoskeletal signs and symptoms associated with this phase of life and its associated estrogen loss. 

The musculoskeletal syndrome of menopause includes but is not limited to:

• Musculoskeletal pain
• Joint pain
• Stem cell devitalization
• Loss of lean muscle mass
• Loss of bone density with increased risk of fracture
• Increased tendon and ligament injury
• Progression of osteoarthritis

When ovaries gradually begin to make less estrogen, perimenopause is present. As estrogen begins to walk out the door, all the above symptoms are invited in. 

This is because estradiol (the most biologically active form of estrogen) impacts nearly every type of musculoskeletal tissue in the body, including bone, tendon, muscle, cartilage, ligament, and fat.

Most people don't realize that estrogen regulates inflammation, as it can inhibit pro-inflammatory cytokines, which can degrade muscle proteins. So when estrogen declines during perimenopause and menopause, inflammation is able to slowly but surely creep in.

This explains why many women struggling with musculoskeletal symptoms of menopause often have inconclusive imaging findings, despite very real pain.

More than half of perimenopausal women4 report joint pain (a sign of inflammation) and women have higher rates5 of inflammation, osteoarthritis, and clinical pain and decreased cartilage volume. 

Many women report increased joint pain at the withdrawal of menopausal hormone therapy (MHT). You may be more familiar with the phrase "hormone replacement therapy," or HRT, which MHT has now replaced in regard to menopause for greater specificity.

Sarcopenia is the fancy word for age-related muscle loss, which also comes with increased intramuscular adipose tissue. Think of the marbling you see in meat at the store.

Estrogen serves an important role in muscle function and strength, with decreasing levels associated with declining mitochondrial function6 (our cellular energy production), reduced insulin sensitivity, and declining levels of antioxidant proteins.

More than 200 million postmenopausal women struggle with osteoporosis, and up to 50% of women will experience a clinical fracture7 at some point in their life. 

While the musculoskeletal syndrome of menopause is most certainly not a picnic to look forward to, understanding the clinical evidence behind it and the root cause common to each symptom—estrogen deficiency—allows us to seek solutions.