There are a good number of research papers that make a connection between a woman’s low estrogen level and her chronic joint pain. Further, low hormone levels may contribute to other problems such as metabolic disorders such as obesity, high blood pressure, fatigue, general malaise, etc. These are all challenging conditions to manage. When we see menopausal or post-menopausal women, whether they are engaged in an active lifestyle, make good lifestyle choices, or not, and they have knee pain or hip pain, it is a worsening chronic condition that has, in many cases, suddenly escalated into a more acute type joint pain. This despite years of pain medications, anti-inflammatory medications, icing, braces, activity modification and physical therapy. This situation for many had become one of being told to prepare for the imminent and soon coming joint replacement recommendation.
For many decades doctors prescribed synthetic estrogen replacement to women who suffered from the symptoms associated with the “Change of Life.” A women would visit her doctor with “hot flashes,” “mood swings,” and “fatigue,” among other complaints and the doctor would simply give them estrogen. Then on July 12, 2002, the world of synthetic estrogen replacement abruptly collapsed and panic filled women across the world. The Journal of the American Medical Association (JAMA) reported that Hormone Replacement Therapy was too dangerous to research.
In the years since the effectiveness and safety of estrogen supplementation have been debated. Most recently researchers in the United Kingdom published their 2022 findings. (1) In estimating the effect of estrogen-only and combined hormone replacement therapy (HRT) on the hazards of overall and age-specific all-cause mortality in healthy women aged 46-65 at first prescription, the researchers found: Combined hormone replacement therapy was associated with a 9% lower risk of all-cause mortality and estrogen-only formulation was not associated with any significant changes.”
Estrogen is the primary female hormone. Research has shown that proper estrogen levels can work as an anti-inflammatory in conditions of degenerative joint and degenerative disc disease as demonstrated in the studies below. Equally, as estrogen levels decrease in perimenopause, menopause, and post-menopausal women, joint pain can be seen to increase due to an increase in inflammation, swollen joints, and bone breakdown.
Estrogen and joint pain controversies
The medical community is not in full agreement that low levels of estrogen contributes to or worsens osteoarthritis conditions in menopausal or post-menopausal women. In 2010 one paper (2) discussed this controversy:
“(Joint stiffness) is experienced by more then half of the women around the time of menopause. The causes of joint pain in postmenopausal women can be difficult to determine as the period of menopause coincides with rising incidence of chronic rheumatic conditions such as osteoarthritis. Nevertheless, prevalence of arthralgia does appear to increase in women with menopausal transition and is thought to result from reduction in (estrogen) levels. . . Hormone replacement therapy (HRT) has been shown to have some benefit in alleviating arthralgia associated with menopausal transition, and can be considered in women who report distressing vasomotor (night sweats, hot flashes, and flushes) symptoms. Simple analgesia, weight loss and physical exercise should be encouraged particularly in women with underlying osteoarthritis. Finally, other factors commonly associated with chronic pain and menopausal transition such as fatigue, poor sleep, sexual dysfunction and depression need to be addressed.”
The indication was that there is a connection between estrogen levels and joint pain, but the connection, if it existed, was unclear.
In 2013 researchers at Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center wrote (3):
“Although joint symptoms are commonly reported after menopause, observational studies examining exogenous (replacement therapy) estrogen’s influence on joint symptoms provide mixed results.” To demonstrate benefit or non-benefit of estrogen replacement therapy, the doctors followed over 10,000 postmenopausal women who have had a hysterectomy. The women were divided into groups. Those that received daily oral conjugated equine estrogens or a matching placebo.
At the start of the study, joint pain and joint swelling were closely comparable in the randomization groups (about 77% with joint pain and 40% with joint swelling). After 1 year, joint pain frequency was significantly lower in the estrogen-alone group compared with the placebo group, as was joint pain severity, and the difference in pain between randomization groups persisted through year three. However, joint swelling frequency was higher in the estrogen-alone group.
Conclusions: “The current findings suggest that estrogen-alone use in postmenopausal women results in a modest but sustained reduction in the frequency of joint pain.”
A 2018 study (6) explored the controversies surrounding the incidence of osteoarthritis after menopause and that the rising incidence of joint pain may be related to hormonal changes in women. Estrogen deficiency is known to affect the development of osteoarthritis the paper states. However, the relationship between knee osteoarthritis and menopausal hormone therapy remains controversial. In examining 4,766 postmenopausal women, hormone therapy helped with symptoms of knee osteoarthritis. The study stating: “The prevalence of knee osteoarthritis was lower in participants with menopausal hormone therapy than in those without menopausal hormone therapy.
Back pain and estrogen
A June 2016 paper (4) examined factors surrounding menopause as a potential cause for higher prevalence of low back pain in women.
“Female sex hormones play an important role in the etiology and pathophysiology of a variety of musculoskeletal degenerative diseases. Postmenopausal women show accelerated disc degeneration due to relative estrogen deficiency, resulting in narrower intervertebral disc space in women than age-matched men, increased prevalence of spondylolisthesis, and increased prevalence of facet joint osteoarthritis. Postmenopausal women also show higher osteoporosis related spine fracture rate, particularly at the thoracic-lumbar junction site.” The study’s author proposed the concept that low back pain is more prevalent in postmenopausal women than age-matched men and is associated with the physiological changes caused by the relatively lower level of sex hormones after menopause in women.”
In 2022 a paper further examined the role of estrogen and degenerative disc disease
In this paper (5) doctors examined women suffering from Premature ovarian insufficiency (the ovaries in women under 40 are no longer or have impaired functioning). As the research notes: (Premature ovarian insufficiency) is a condition associated with estrogen deficiency which leads to decreased bone mineral density and an increased risk of osteoporosis and fractures. Estrogen-based hormone therapy is an integral component of treatment; however, to date the ideal hormone formulation for optimizing bone health has not been established.
As many women can suffer from decreased hormonal output or more commonly referred to as Perimenopause, understanding how menopausal and post-menopausal women came to suffer from spine and joint pain is important in prevention and long-term understanding of hormone replacement therapy recommendations. This paper’s main point was to assess the effects of estrogen-based oral contraceptives (OCP) versus hormone therapy (HT) on bone mineral density (BMD) in women with Premature ovarian insufficiency. The findings were inconclusive. To quote: “While two studies reported increased lumbar spine Bone mineral density with hormone therapy, this result was not consistently found across studies.”
Estrogen degenerative disc disease and osteoporosis
In May of 2019, doctors published a study (7) of the role of estrogen, osteoporosis and degenerative disc disease. What the researchers found controversial was not so much the role of estrogen and back pain, but the role osteoporosis plays in degenerative disc disease. What they wanted to show was that hormones could help with spinal vertebral fractures, and that helping the fractures could help with the the problems of degenerative disc disease.
This was an animal study conducted on female rats. The study’s highlights revealed:
- Microstructures of C5 vertebral body were weakened significantly after ovariectomy, while restored effectively with estradiol supplementation.
- Damage to the spinal facet joints led to significant Intervertebral Disc Degeneration because of spinal instability. (Doctors will need to independently address the spinal instability issue).
- In addition, the estrogen supplement acted as an anti-inflammatory and reduce pain.
The conclusion? Estrogen deficiency exacerbated Intervertebral Disc Degeneration induced by spinal instability, while estrogen supplementation alleviated the progression of disc degeneration related to osteoporosis.
References for this article
1 Akter N, Kulinskaya E, Steel N, Bakbergenuly I. The effect of hormone replacement therapy on the survival of UK women: a retrospective cohort study 1984− 2017. BJOG: An International Journal of Obstetrics & Gynaecology. 2021 Nov 12.
2Magliano M. Menopausal arthralgia: Fact or fiction. Maturitas. 2010 Sep;67(1):29-33.
3 Chlebowski RT, Cirillo DJ, Eaton CB, Stefanick ML, Pettinger M, Carbone LD, Johnson KC, Simon MS, Woods NF, Wactawski-Wende J. Estrogen alone and joint symptoms in the Women’s Health Initiative randomized trial. Menopause (New York, NY). 2013 Jun;20(6).
4 Wang YX. Menopause as a potential cause for higher prevalence of low back pain in women than in age-matched men. Journal of Orthopaedic Translation. 2017 Jan 1;8:1-4.
5 Fine A, Busza A, Allen LM, Kelly C, Wolfman W, Jacobson M, Lega IC. Comparing estrogen-based hormonal contraceptives and hormone therapy on bone mineral density in women with premature ovarian insufficiency: a systematic review. Menopause. 2022 Mar 1;29(3):351-9.
6 Jung JH, Bang CH, Song GG, Kim C, Kim JH, Choi SJ. Knee osteoarthritis and menopausal hormone therapy in postmenopausal women: a nationwide cross-sectional study. Menopause. 2019 Jun 1;26(6):598-602.
7. Liu Q, Wang X, Hua Y, Kong G, Wu X, Huang Z, Huang Z, Liu J, Yang Z, Zhu Q. Estrogen Deficiency Exacerbates Intervertebral Disc Degeneration Induced by Spinal Instability in Rats. Spine. 2019 May 1;44(9):E510-9. —