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  • Deborah Thomas BPT MCSP MAPPI Chartered Physio

How do hormonal changes affect our muscles, joints, and whole musculoskeletal system?

We are all governed by our hormones, men, and women. Naturally, as women’s bodies have a cyclical pattern to the hormonal levels, as well as going through puberty, reproductive years, peri and post menopause, we see many more changes affecting women, than is obvious with men. Several medications and surgical interventions also affect our hormone levels. The menopause is a normal stage in life, and is influenced by a change in hormone levels, it is when a woman’s ovaries gradually stop producing eggs, therefor Oestrogen levels are low.


We need hormones to function well and to maintain a homeostasis (balanced function) between all our systems. But what happens when this delicate balance is altered? Many of the changes to hormone levels are normal, natural, and expected, and are not a part of a disease as such – so should we intervene? Which hormones can affect the musculoskeletal system?


As a physiotherapist I often get enquiries about a change in energy levels, fitness levels, ease to reach or maintain peak fitness, as well as people suddenly experiencing joint aches and pains, plantar fasciitis, back pain, stiffness and more similar symptoms.

I believe all women should understand how their body works, what is happening and why, and how they can help themselves, and then – what help is available that can be provided by physiotherapist specialising in Pelvic & Women’s health or by the medical team.


Let us discuss and explore a few of the key hormones that support the musculoskeletal system. We will look at normal changes throughout life, and specifically from age 35 onwards, and how these can affect our joints, muscles, and soft tissue. In future blogs, we will look at self-help advice and tips.


We know from statistics (2018), that women’s life expectancy is 82 years, and the average age of menopause is 51. So, we have 30 years of a life to live with high quality, enjoyment, and health. Statistically, The Osteoarthritis (OA) lifetime risk for women is 47% (Watt 2018), and Post-menopausal women have a higher prevalence of OA than age-matched men (Bay-Jensen 2012) , At the time of menopause, MSK pain is reported by >50% of women (Watt 2018) – and interestingly, Pain is the predominant menopausal symptom in 21% of women - so this is an issue to be aware of!


Which hormones are we talking about? Let us look at a few here.


I will focus mainly on their roles and how they affect the musculoskeletal system:


Oestrogen

This hormone is secreted mainly by the ovaries and has >400 roles in the female body. Oestrogen is a natural antioxidant and has a protective effect on skeletal tissue.

This hormone maintains our hair, skin, and nails’ health. It is directly related to the healthy structure and function of all the components of a joint (bone, cartilage, connective tissue, synovium, blood vessels). Oestrogen receptors are present in all musculoskeletal (MSK) tissues, including ligaments, tendons, and more. A great review in the literature was done by F Watt in 2018, where she explains how Oestrogen is known to be anti-inflammatory.

It is understood now that a low oestrogen environment, is an independent factor to deterioration (skin, bone, brain, heart, cardiovascular system…) beyond chronological ageing. Joint complaints double in the perimenopause period. Women complain of more stiffness and aching in joints and muscles.


Many of these tissues, are based on a collagen structure. Collagen is also the main support structure to pelvic organs. In menopause, many changes are due to the changes in collagen secondary to the reduction in oestrogen.


This is an exciting area in research, and the results can be sometimes confusing:

Research shows that Oestrogen deficiency seems to augment (increase) Osteoarthritis (OA) progression – (Anne C. Bay-Jensen 2012). We also know that Joint pain complaints double with perimenopause. Aches and stiff joints, common in postmenopausal women, are not necessarily indicative of radiological osteoarthritis – (Climacteric 2008). So, this means, that low levels of oestrogen may enhance deconditioning and OA in joints, however, there is also evidence that the pain levels themselves are higher, without necessarily any ‘evidence of damage’ on MRI.


Oestrogen receptors are abundant in skeletal muscles and Lack of oestrogen leads to rapid decrease in muscle mass & strength (Chidi – Ogbolu 2018)

When we look at bone strength and density, it’s important to know that your bones lose strength at a faster rate after the menopause. This is because levels of oestrogen decrease.

A reduction in bone density& strength in itself will not cause pain but can affect exercise choice and load tolerance.


Entering the menopause may be, for some, like constantly being in a ‘low-oestrogen’ part of the menstrual cycle: heightening pain experience for any given pathology (Watt 2018)


Progesterone

Progesterone is also secreted by the ovary, mainly, and has both systemic and local effects. Among it’s systemic effects, it relaxes smooth muscle cells (therefore it affects gut function, and so is related to constipation a topic for another blog, but definitely a condition we Pelvic Health Physio’s treat!). It also improves proliferation and differentiation of osteoblasts (bone cells) – and therefore is important for our bone health and density.


Testosterone

Testosterone is released by the ovaries and the adrenal glands; Women produce 3 times more testosterone than oestrogen! It is a main modulator of musculoskeletal health: It affects muscle mass & strength, cardiovascular function, and bone strength.


Cortisol

Our stress hormone! We have it always, but it is secreted more when we are stressed. It has many effects on the body, but we will focus on excess Cortisol as a contributor to arthritis, decreased metabolism, decreased immunity, chronic fatigue – all these of course will also affect the musculoskeletal system.


So, if we put all this together, we can see, that as a woman’s life goes through it’s natural cycles, the changes in hormone levels, and the balance between them all, can have a significant effect on muscles, joints, soft tissue, ligaments, our metabolism, energy levels, bone density and pain sensation to name but a few.


These can all contribute to changes & compensations in the musculoskeletal system, from your feet, all the way up to your head & neck. In the pelvis, due to these changes, we can also see changes in function and position of organs – incontinence, prolapse, pain - we’ll discuss these in another blog.


A Pelvic Health physio, who is a specialised musculoskeletal physio, will be able to assess weather your aches, pains, stiffness, tendinopathies are related to the above changes, and formulate a bespoke treatment plan to regain pain free movement, help return to exercise, so you can maintain bone and muscle strength, spinal flexibility, recover from tendon and fascia problems and enjoy a great quality of life.


References:

  1. F Watt 2018: Musculoskeletal pain and menopause

https://doi.org/10.1177%2F2053369118757537

  1. Chidi – Ogbolu 2018: Effect of Estrogen on Musculoskeletal Performance and Injury Risk

  1. M.A. Karsdal et al 2019: Biochemical markers in osteoarthritis with lessons learned from osteoporosis: Clinical and Experimental Rheumatology 2019 S-75

  2. Anne C. Bay-Jensen et al 2012: Role of hormones in cartilage and joint metabolism: understanding an unhealthy metabolic phenotype in osteoarthritis

DOI: 10.1097/GME.0b013e318274599

  1. C.E Szoeke et al 2007: The relationship of reports of aches and joint pains to the menopausal transition: a longitudinal study

https://doi.org/10.1080/13697130701746006


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