Menopausal arthralgia: Fact or fiction

The musculoskeletal syndrome of menopause

Fifty-one percent of humans are born with ovaries. As the ovarian production of estrogen diminishes in midlife and ultimately stops, it is estimated that more than 47 million women worldwide enter the menopause transition annually. More than 70% will experience musculoskeletal symptoms and 25% will be disabled by them through the transition from perimenopause to postmenopause. This often-unrecognized collective of musculoskeletal symptoms, largely influenced by estrogen flux, includes arthralgia, loss of muscle mass, loss of bone density and progression of osteoarthritis, among others. In isolation, it can be difficult for clinicians and patients to adequately appreciate the substantial role of decreasing estrogen, anticipate the onset of related symptoms and actively treat to mitigate future detrimental processes. Thus, in this review we introduce a new term, the musculoskeletal syndrome of menopause, to describe the collective musculoskeletal signs and symptoms associated with the loss of estrogen. Given the significant effects of these processes on quality of life and the associated personal and financial costs, it is important for clinicians and the women they care for to be aware of this terminology and the constellation of musculoskeletal processes for which proper risk assessment and prophylactic management are of consequence.

Climacteric and fibromyalgia: a review

Fibromyalgia (FM) and climacteric conditions share common epidemiological and clinical features, with FM symptoms often beginning during menopause. Musculoskeletal pain, arthralgia, myalgia and other symptoms are frequently seen in both conditions. Some research suggests a link between the cessation of sex hormones and FM symptoms. Women with FM tend to experience more severe symptoms after menopause, and the severity of FM symptoms can worsen in women who have had a hysterectomy with or without oophorectomy. Despite these similarities, it is essential to treat FM and climacteric conditions separately and follow established guidelines for management. However, it is also important to recognize that both conditions can coexist in the same patient. It is crucial to note that there is limited evidence supporting the effectiveness of menopausal hormone therapy for primary FM management. Therefore, menopausal hormone therapy should not be recommended for FM unless the patient also has climacteric syndrome.

Individual and additive-effect relationships of menopausal symptoms and subjective cognitive decline among nurses during menopausal transition: a cross-sectional study

OBJECTIVE

This study aimed to examine the individual and additive-effect relationships between menopausal symptoms and subjective cognitive decline among nurses during menopausal transition.

METHODS

Between February and September 2019, a convenience sampling strategy was used, involving 1,335 Chinese nurses undergoing menopausal transition. A general information survey that included the Subjective Cognitive Decline Scale and the Menopause Rating Scale was completed. Based on a cut-off point of the subjective cognitive decline score of 7.5, the overall sample was divided into mild and severe groups. Propensity score matching was performed to balance covariates of mild and severe subjective cognitive decline. The individual and cumulative effects of menopausal symptoms and subjective cognitive decline were analyzed using binary logistic regression and the Cochran-Armitage trend test, respectively.

RESULTS

After propensity score matching, none of the parameters showed significant differences between the groups. Logistic regression analysis revealed that four menopausal symptoms were closely associated with severe subjective cognitive decline. The Cochran-Armitage trend test indicated odds ratios linking the presence of these symptoms with increased severe subjective cognitive impairment. In addition, nurses simultaneously experiencing two or more core menopausal symptoms were over six times more likely to have severe subjective cognitive decline than nurses experiencing none or one core menopausal symptom during menopausal transition.

CONCLUSIONS

Individual and additive numbers of menopausal symptoms significantly influenced subjective cognitive decline in nurses during their menopausal transition. These findings suggest that interventions aimed at enhancing the cognitive performance of nurses experiencing menopause should consider menopausal symptoms.

A Cohort Study to Evaluate Genetic Predictors of Aromatase Inhibitor Musculoskeletal Symptoms: Results from ECOG-ACRIN E1Z11

PURPOSE

Aromatase inhibitor (AI)-associated musculoskeletal symptoms (AIMSS) are common and frequently lead to AI discontinuation. SNPs in candidate genes have been associated with AIMSS and AI discontinuation. E1Z11 is a prospective cohort study designed to validate the association between 10 SNPs and AI discontinuation due to AIMSS.

PATIENTS AND METHODS

Postmenopausal women with stage I to III hormone receptor-positive breast cancer received anastrozole 1 mg daily and completed patient-reported outcome measures to assess AIMSS (Stanford Health Assessment Questionnaire) at baseline, 3, 6, 9, and 12 months. We estimated that 40% of participants would develop AIMSS and 25% would discontinue AI treatment within 12 months. Enrollment of 1,000 women with a fixed number per racial stratum provided 80% power to detect an effect size of 1.5 to 4. SNPs were found in ESR1 (rs2234693, rs2347868, and rs9340835), CYP19A1 (rs1062033 and rs4646), TCL1A (rs11849538, rs2369049, rs7158782, and rs7159713), and HTR2A (rs2296972).

RESULTS

Of the 970 evaluable women, 43% developed AIMSS and 12% discontinued AI therapy within 12 months. Although more Black and Asian women developed AIMSS than White women (49% vs. 39%, P = 0.017; 50% vs. 39%, P = 0.004, respectively), the AI discontinuation rates were similar across groups. None of the SNPs were significantly associated with AIMSS or AI discontinuation in the overall population or in distinct cohorts. The OR for rs2296972 (HTR2A) approached significance for developing AIMSS.

CONCLUSIONS

We were unable to prospectively validate candidate SNPs previously associated with AI discontinuation due to AIMSS. Future analyses will explore additional genetic markers, patient-reported outcome predictors of AIMSS, and differences by race.

The role of exercise in aromatase inhibitor-induced arthralgia

Aromatase inhibitors are prescribed in breast cancer due to their associated lower rate of cancer recurrence compared to tamoxifen. However, aromatase inhibitor-induced arthralgia (AIIA) is one of the leading causes of treatment nonadherence, increasing the risk of cancer recurrence. The pathophysiology of AIIA is poorly understood, and although current recommendations for AIIA include lifestyle changes and analgesics depending on the severity of symptoms, there is no established effective treatment. The aim of this study is to explore the presentation and mechanism of AIIA and investigate the feasibility and efficacy of different exercise interventions (aerobic, resistance, aerobic and resistance combined, and yoga or tai chi) in patients with AIIA to guide the development of formal exercise prescription guidelines. Findings indicate that a mixed-modality regimen of aerobic and resistance exercises is feasible and safe and may serve the most benefit in improving joint pain, functionality, and quality of life. More specifically, the weekly regimen should consist of 150 min of aerobic exercise with two sessions of at least six resistance exercises, 8 to 12 repetitions, three sets each. Supplementary yoga and tai chi may be recommended twice a week depending on a patient's target symptoms. Yoga was associated with improved physical functionality, whereas tai chi was related to improvements in mental health. However, the feasibility and impact of combined aerobic and resistance exercise protocols with yoga or tai chi in our target population were not investigated in this review. The use of large, randomized controlled trials is recommended for future studies.

Associations between the severity of menopausal symptoms and musculoskeletal pain in postmenopausal Portuguese women

OBJECTIVE

To analyze the association of the severity of the menopausal symptoms with musculoskeletal pain in Portuguese postmenopausal women.

METHODS

A cross-sectional, observational study was conducted on 167 women (63.85 ± 9.36 years). The Menopause Rating Scale was used to evaluate the menopausal symptoms severity, while the Nordic Musculoskeletal Questionnaire was employed to assess the localization of the musculoskeletal pain, and multi-located pain was determined if two or more body regions were affected. Depression (Hospital Anxiety and Depression Scale), age, body mass index (BMI) and physical activity level were considered as potential confounders.

RESULTS

A greater severity of the somato-vegetative menopausal symptoms was related to the prevention from usual activities because of pain in the neck, shoulders, elbows, wrists/hands and knees (R2 of Nagelkerke = 0.064, 0.043, 0.074, 0.045 and 0.045, respectively). Associations were also observed between greater age and pain in the knees, ankles and feet (R2 of Nagelkerke = 0.036 and 0.034, respectively), and being physically inactive with upper back pain (R2 of Nagelkerke = 0.060). Higher depressive symptoms were linked to pain in the hip/thighs and knees (R2 of Nagelkerke = 0.067 and 0.085, respectively), as well as being physically inactive was related ton in the neck (R2 of Nagelkerke = 0.053). Only a greater BMI was related to multi-located pain in the last 7 days (R2 of Nagelkerke = 0.041).

CONCLUSIONS

The findings of our study showed that, taking into account possible confounders, greater severity of the menopausal symptoms at a somatic-vegetative level was associated with more anatomical regions with musculoskeletal pain.

Arthralgia in midlife Singaporean women: the Integrated Women's Health Program (IWHP)

OBJECTIVE

Arthralgia is a common menopausal complaint in midlife women, and its causes remain unclear. We examined the prevalence of menopausal arthralgia with various factors including sleep quality, depression/anxiety, muscle strength and physical performance among midlife Singaporean women.

METHODS

The Integrated Women's Health Program (IWHP) comprised 1120 healthy, community-dwelling women of Chinese, Malay or Indian ethnicities (aged 45-69 years) attending well-women clinics at the National University Hospital, Singapore. Sociodemographic, menopausal, reproductive and health data were obtained with validated questionnaires. Muscle strength, physical performance and dual-energy X-ray absorptiometry were measured. Women with moderate to very severe symptoms using the Menopause Rating Scale were classified as having arthralgia. Multivariable logistic regression analyses examined risk factors for arthralgia.

RESULTS

One-third of the participants reported arthralgia, and 12.7%, 16.2% and 71.2% were in the premenopausal, perimenopausal and postmenopausal period, respectively. Menopausal symptoms, such as vaginal dryness (adjusted odds ratio [aOR]: 2.64, 95% confidence interval [CI]: 1.64, 4.24) and physical/mental exhaustion (aOR: 2.83, 95% CI: 1.79, 4.47), were independent risk factors for arthralgia. Poor muscle strength (aOR: 2.20, 95% CI: 1.29, 3.76), obesity (aOR: 1.94, 95% CI: 1.13, 3.32) and rheumatoid arthritis (aOR: 7.73, 95% CI: 4.47, 13.36) were also independently associated with arthralgia after adjustment for confounders.

CONCLUSIONS

Arthralgia in midlife Singaporean women was associated with menopausal symptoms of vaginal dryness and physical and mental exhaustion. Women with poor muscle strength were more likely to experience menopausal arthralgia.

Ovariectomy induces hyperalgesia accompanied by upregulated estrogen receptor α and protein kinase B in the rat spinal cord

Hormone supplementation is one of the common therapies for menopause-related disorders. Among different tools, the ovariectomy (OVX) rodents are widely accepted as an appropriate menopausal pain model. Our previous study has showed that OVX produces a significant pain facilitation in both acute pain and tonic pain, however, the underlying mechanisms remain unclear. In this study, we examined the effects of OVX treatment and estradiol (E2) supplementation on formalin-induced nociceptive responses, and explored the associated spinal mechanisms. Female Sprague-Dawley rats underwent bilateral OVX, and E2 supplementation was given subcutaneously from the 5th week after surgery (30 μg/day for 7 days). Our results showed that formalin-induced nociceptive behaviors did not differ between diestrus and proestrus stages of the estrous in intact rats. However, OVX exacerbated formalin-evoked inflammatory pain, especially in the late phase at 4-5 weeks but not 2 weeks post-surgery. E2 supplementation significantly reversed the OVX-triggered hyperalgesia. Double immunofluorescence staining revealed that both ERα and ERβ in the spinal dorsal horn were co-labeled with the neuronal markers, but not with markers of astrocytes or microglia. The spinal ERα (but not ERβ) expression significantly increased in the OVX group, which was reversed by E2 supplementation. Moreover, the OVX individuals showed an increased protein kinase B (AKT) level in lumbar spinal cord, and E2 supplementation diminished the AKT expression in OVX rats. Finally, intrathecal injection Wortmannin, an inhibitor for AKT signaling, effectively reduced the nociceptive behaviors in the late phase and the number of c-fos positive cells. Together, our findings indicate that E2 supplementation alleviates the OVX-induced hyperalgesia, which might be involved in spinal ERα and AKT mechanisms.

Fat quantification in the sacroiliac joint syndesmosis: a new semi-automatic volumetric approach

Fat is physiologically embedded within the interosseous ligaments in the posterior part of the sacroiliac joint (PSIJ). This composite of fat and ligaments is hypothesized to serve a shock-absorbing, stabilizing function for the sacroiliac joint and the lumbopelvic transition region. Using a novel Python-based software (VolSEQ), total PSIJ volume and fat volume were computed semi-automatically. Differences within the cohort and the viability of the program for the quantification of fat in routine computed tomography (CT) scans were assessed. In 37 CT scans of heathy individuals, the PSIJ were first manually segmented as a region of interest in OSIRIX. Within VolSEQ, 'fat' Hounsfield units (- 150 to - 50 HU) are selected and the DICOM file of the patient scan and associated region of interest file from OSIRIX were imported and the pixel sub volumes were then automatically computed. Volume comparisons were made between sexes, sides and ages (≤ 30, 31-64 and > 65 years). PSIJ volumes in both software (VolSeq vs. OSIRIX) were non-different (both 9.7 ± 2.8cm3; p = 0.9). Total PSIJ volume (p = 0.3) and fat volume (p = 0.7) between sexes were non-different. A significant difference in total PSIJ volume between sexes (p < 0.01) but not in fat volume (p = 0.3) was found only in the ≥ 65 years cohort. Fat volume within the PSIJ remains unchanged throughout life. PSIJ volume is sex-dependent after 65 years. VolSEQ is a viable and user-friendly method for sub-volume quantification of tissues in CT.

Arthralgia in female Masters weightlifters

BACKGROUND

Arthralgia or joint pain is a heterogeneous condition including organic and nonorganic joint pain. It is common in older populations, particularly in females. There is evidence that menopausal changes are associated with increased prevalence of arthralgia. While physical activities have been recommended to mitigate osteoarthritis (OA) and arthralgia, sport participation also carries risk factors due to excessive loading of some joints and possible injuries. The aim was to evaluate the association of training patterns, prior injuries, and severity of menopausal symptoms with arthralgia in female Masters weightlifters.

METHODS

Competitive female Masters weightlifters (n=868, 30-78 years) from 30 countries completed an online survey including joint pain for different anatomical sites, weightlifting training and performance, sport history, and menopausal symptoms. Logistic regression models were used to estimate the association of training patterns, prior sport participation, and menopausal symptom severity with arthralgia separately for shoulders, spine, hips, knees, ankles, elbows, and hands.

RESULTS

Arthralgia was most reported in knees (38.8%), shoulders (29.8%), hands/wrists (28.8%), and hips (24.9%). The prevalence of arthralgia was 51.5% in pre-menopausal women, 62.4% in women post natural menopause and 73.3% in women post medical or surgical menopause. Lifting heavier weights was associated with arthralgia in hips (OR=1.05, p=0.03), knees (OR=1.06, p=0.01), and hands/wrists (OR=1.05, p=0.04), but prior strength training was protective for arthralgia in the shoulders (OR=0.66, p=0.02). Prior injuries and psychological menopausal symptom severity were associated with an increased risk for arthralgia (p<0.01).

CONCLUSIONS

Arthralgia was common in competitive female weightlifters. Training frequency was not associated with arthralgia, but lifting heavier weights relative to age and body mass was. Prior injuries and menopausal symptoms were associated with arthralgia, but prior strength training was protective of arthralgia in the shoulders. Athletes, coaches and sports medicine professionals should be aware that prevalence of polyarthralgia increases in post-menopausal athletes.

Arthralgia of menopause - A retrospective review

Arthralgia is a common complaint around the time of menopause in many women. It is estimated that over 50% of women experience arthralgia or arthritis at the time of menopause. The complex of symptoms has been linked to the joint and tendon response to the decline in sex hormones as well as sarcopenia, or loss of muscle volume associated with aging. The diagnosis of "arthritis of menopause" has been identified since 1925, but treatments have been symptomatic at best.^1,2 Joint synovium and cartilage interaction with estrogen is well documented. This article reviews the literature regarding the current approaches to treatment of arthralgia menopause.

The role of diet in managing menopausal symptoms: A narrative review

Menopause is a natural stage that occurs when women stop menstruating, during which many women experience physical and psychological symptoms that can affect their quality of life and ability to work. Dietary modifications and food supplements may be explored by some women as alternatives to hormone replacement therapy, although existing reviews and expert position statements have given this limited consideration. This narrative review summarises the current evidence for dietary patterns, and botanical and food supplements, in the management of common menopausal symptoms, including vasomotor symptoms (VMS; hot flushes; night sweats), changes in bodyweight and composition, psychological symptoms (depression; anxiety; cognitive changes), sleep disturbances, joint pain, skin changes and urogenital symptoms. Soy isoflavones may reduce the frequency and/or severity of VMS, although results are inconsistent, and it is unclear whether dietary and supplemental sources have comparable effects. Adopting a healthier dietary pattern may support a healthy bodyweight and benefit VMS. However, evidence suggesting dietary patterns may benefit depression, anxiety, and cognition remains largely observational. While some botanicals, such as black cohosh and St John's Wort, have been reported in some studies to alleviate symptoms (such as VMS and depression), these are not currently recommended due to uncertainty about the appropriate dose and preparation, and potential safety concerns. Evidence for other symptoms is currently too limited to draw conclusions. While further trials at different menopausal stages are needed, adopting a healthier dietary pattern in accordance with dietary guidelines is likely to help support women's health before, during and after the menopausal transition.

Visualization of the location and level of pain in common wrist pathologies using color-coded heatmaps

BACKGROUND

Pain of the hand and wrist affects a large patient population. If the onset is unrelated to recent trauma, the first medical contact is rarely established with a specialized hand surgeon.

OBJECTIVE

The objective of this investigation was to (1) visualize the localization of hand pain using pain-related heatmaps in common wrist pathologies, (2) to test whether differences between these pathologies exist with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major patient-reported complaints associated with the pathologies.

METHODS

This observational cross-sectional study included patients suffering from: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Patients marked the location of maximum pain projection on hand graphics depicting the outline of the palmar and dorsal hand. Color-graded frequency heat maps were generated for the wrist pathologies investigated. Daily life impairments were assessed and clustered into groups of functions/activities.

RESULTS

120 patients with a mean age of 44.3 years were investigated. The diagnostic groups showed significant differences regarding the level and location of pain, as well as daily life impairments. Patients with CMC-1-OA presented with increased pain levels compared to patients with dorsal wrist ganglions and TFCC tears. Daily life impairment was rated highest when household chores were adversely affected, and sport activities were symptomatic/painful. All groups showed significant skin surface pain projection, which was visualized in heatmaps. While general trends in pain localization were visible, pain levels were also reported distal/proximal and palmar/dorsal to the pathology.

CONCLUSIONS

Knowledge of main demographic parameters, pain projection, and degree of impairment in daily activities can help physicians to narrow differential diagnosis of wrist pain during first patient contact. Patients should then be referred to hand surgeons for specialist examination, to further differentiate the origin of the pain.

Effects of Obesity on Severity of Menopausal Symptoms in Urban and Rural Women

Background

According to the WHO, obesity is an epidemic and is quantified by obesity indices. Menopause is a crucial period with a tendency toward weight gain and has profound implications on the morbidity and mortality of women. This study provides a greater insight into the aggravating adverse effects of obesity on the lifestyles of urban and rural women during their menopausal phase. Hence, this cross-sectional study aims at analyzing the effects of obesity indices on the severity of menopausal symptoms in urban and rural women.

Objectives

1. To compare the obesity indices in rural and urban women and to study the severity of menopausal symptoms in them. 2. To assess the influence of the area and body mass index (BMI) on menopausal symptoms.

Materials and Methods

This cross-sectional study comprised 120 women, of which 60 healthy women volunteers between the age group of 40 and 55 years from the urban area and 60 age-matched healthy women volunteers from the rural area were recruited. The sample size was calculated based on stratified random sampling. After obtaining informed consent anthropometric measurements were recorded and the Menopausal Rating Scale was used for assessing the severity of menopausal symptoms.

Results

A positive correlation was observed between the severity of menopausal symptoms and BMI as well as waist circumference in urban women. The problems related to menopausal symptoms were milder in rural women.

Conclusions

Our study concludes that obesity worsens the severity of several menopausal symptoms which is greater among obese urban women owing to the urban lifestyle and increased stress levels.

Vitamin D levels and menopause-related symptoms in postmenopausal women

Background

Menopause is an important period in women’s life. It is characterized by many symptoms that affect women’s quality of life. This study aimed to the evaluation of the relation between vitamin D levels and menopause-related symptoms. 

Results

Vitamin D insufficiency was noted in 52.4% of the studied population. There was no statistically significant difference in any of the menopausal rating scale dimensions, psychological symptoms (p = 0.16), somato-vegetative symptoms (p = 0.45), or urogenital symptoms (p = 0.59), between vitamin D sufficient and insufficient groups. The severity of the menopausal symptoms was affected by the presence of medical illness (p < 0.001).

Conclusion

Vitamin D deficiency is an alarming issue among postmenopausal women. It was not associated with menopause-related symptoms.

The effect of self-care education program on the severity of menopause symptoms and marital satisfaction in postmenopausal women: a randomized controlled clinical trial

Background

Physiological and psychological changes during menopause can affect the quality of marital satisfaction. The aim of this study was to evaluate the effect of self-care education program on the severity of menopause symptoms and marital satisfaction in postmenopausal women.

Methods

In this randomized controlled clinical trial, 70 postmenopausal women who referred to the gynecology clinic of Baqiyatallah and 502 Artesh hospitals in Tehran, Iran, and met the all inclusion criteria were randomly allocated into two equal groups (intervention and control groups) using block randomization. The intervention group received self-care training program in physical, psychological, social and sexual dimensions in 5 sessions during a week. The control group also had 5 sessions exactly the same as the intervention group, except that they received only routine care and training. Data were collected pre- and post-intervention using Menopause Symptoms' Severity Inventory (MSSI-38) questionnaire and the Revised Dyadic Adjustment Scale (RDAS) questionnaire.

Results

In the control and intervention groups before the intervention, socio-demographic characteristics (P > 0.05), the mean scores of MSSI-38 (P = 0.388) and RADS (P = 0.476) were not statistically significant. However, in the intervention group the mean scores of MSSI-38 (49.88 ± 3.3 vs. 39.33 ± 3.7, P < 0.001) and RADS (35.15 ± 4.3 vs. 49.48 ± 3.2, P < 0.001) after the intervention changed significantly and this change were statistically significant compared to the control group. Significant inverse correlation between severity of menopausal symptoms and marital satisfaction was observed with r = -0.461, P < 0.001.

Conclusion

Our findings indicate that self-care training has a positive effect on the severity of menopause symptoms and also improves marital satisfaction in postmenopausal women. Therefore, we recommend that more attention be paid to providing self-care educational content to improve the marital satisfaction in postmenopausal women.

Clinical trial registration Iranian Registry of Clinical Trials; https://www.irct.ir/trial/49225 (IRCT20200624047910N1), registered (10/11/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01653-w.

Effect of Tart Cherry on Aromatase Inhibitor-Induced Arthralgia (AIA) in Nonmetastatic Hormone-Positive Breast Cancer Patients: A Randomized Double-Blind Placebo-Controlled Trial

BACKGROUND

Aromatase Inhibitor induced Arthralgia (AIA) can cause noncompliance leading to decreased breast-cancer survival. Effective interventions for AIA are limited. Tart cherry (TC) showed beneficial effect on musculoskeletal pain. 48 patients (Pts) randomized to TC versus placebo over 6 weeks, TC (23pts) had 34.7% mean pain decrease versus 1.4% in Placebo (25pts). TC can improve AIA in nonmetastatic breast-cancer patients.

METHODS

Randomized, placebo-controlled, double-blind trial. Eligible patients with NMHPBC on AI for at least 4 weeks were randomized to TC concentrate [50 tart cherries] vs. placebo (P) [syrup] in 1:1 model. Patients instructed to consume 1 Oz of concentrate in 8 Oz water daily for 6 weeks, and document their pain intensity at baseline, weekly and at study completion in a diary using Visual Analog Scale (VAS), with 0 mm indicating no pain, and 100 mm indicating highest pain.

RESULTS

Sixty patients were enrolled. Two patients did not complete the study due to diarrhea, and 10 patients were noncompliant. Forty-eight patients were included in the final analysis. TC group (23 pts) had 34.7% mean decrease in pain compared to 1.4% in P group (25 pts). This difference was statistically significant (Mann-Whitney U Test, P = .034).

CONCLUSIONS

Tart cherry can significantly improve AIA in nonmetastatic breast cancer patient.

Understanding the Impact of Sex and Gender in Osteoarthritis: Assessing Research Gaps and Unmet Needs

Osteoarthritis (OA) affects more than 300 million individuals globally, with higher prevalence in women than in men. In addition, OA affects women and men differently, with women demonstrating both increased disease severity and disability. The Society for Women's Health Research (SWHR) convened an interdisciplinary group of expert researchers and clinicians for a roundtable meeting to review the current state of the science on OA and to identify knowledge gaps in the scientific literature, especially as they relate to the topics of sex and gender. The current review summarizes discussions from the roundtable and prioritizes areas of need that warrant further attention in OA research, diagnosis, care, and education. Improvements in basic and clinical research, clinical practice, patient education, and policy are needed to allow for better understanding as to the pathogenesis of sex- and gender-related disparities in OA.

Comparison of various menopausal symptoms and risk factor analysis in Korean women according to stage of menopause

OBJECTIVE

To determine the prevalence and severity of menopausal symptoms and their related risk factors among middle-aged Korean women according to their reproductive stages.

METHODS

This cross-sectional study included 3039 Korean women, aged 45-65 years, who attended their routine health checkup. Their scores from the Menopause Rating Scale (MRS) were compared and participants were categorized into four groups according to stage of menopause: premenopause, early menopause (≤2 years from their last menstruation), mid-menopause (2-8 years), and late menopause (>8 years).

RESULTS

The mean age of the participants was 52.81 ± 5.39 years, and 98.5 % of them reported one or more symptoms included in the MRS. The most common symptom was physical/mental exhaustion, experienced by 86.7 % of participants. The prevalence of moderate to severe symptoms, including vasomotor symptoms, heart discomfort, sleep problems, sexual problems, vaginal dryness, and joint/muscular discomfort, increased in the early menopausal period. This increased in the late menopausal period compared with its prevalence at premenopause. The prevalence of moderate to severe psychological symptoms, heart discomfort, and sleep problems followed a U-shaped trend after menopause: high at early menopause, low at mid-menopause, and high again at late menopause. A low level of physical exercise was an independent risk factor for a high total MRS score; however, the menopausal stages, age, and weight were also variously associated with menopausal symptoms.

CONCLUSIONS

Several menopausal symptoms remain severe, or are aggravated, until the late menopausal period among Korean women. More attention is warranted to manage these symptoms in postmenopausal women.

Menopause symptoms and chronic pain in a national sample of midlife women veterans

OBJECTIVE

Women are more likely than men to suffer chronic pain, with the highest rates seen in midlife. The symptoms that characterize menopause broadly affect health and well-being, but their contribution to chronic pain risk during this period is poorly understood. To address this gap in knowledge, we examined relationships between indicators of menopause symptoms and chronic pain among midlife women veterans, a population with prevalent chronic pain diagnoses and elevated risk for bothersome menopause symptoms.

METHODS

This is a cross-sectional analysis of national Veterans Health Administration medical and pharmacy records. Using national medical and pharmacy records from women veterans aged 45 to 64 with at least one VA encounter during 2014 and/or 2015 (n = 200,901), we developed multivariable logistic regression models to examine associations between menopause symptoms (defined by menopause symptom-related diagnoses on ≥2 encounters and/or menopause hormone therapy use) and chronic pain outcomes, adjusting for age, race, body mass index, mental health diagnoses, and substance use disorders.

RESULTS

In this national sample of midlife women veterans (mean age 54.3 ± 5.4), 13% had menopause symptoms, 52% had chronic pain, and 22% had ≥2 distinct chronic pain diagnoses. In multivariable analyses, women with menopause symptoms had nearly two-fold odds of chronic pain (odds ratio 1.84, 95% confidence interval 1.79-1.90, P < 0.001) and multiple chronic pain diagnoses (odds ratio 1.79, 95% confidence interval 1.74-1.83, P < 0.001).

CONCLUSIONS

These findings raise the possibility within this vulnerable critical period, midlife women with a higher menopause symptom burden may be most vulnerable for chronic pain.

Muscle and joint pains in middle-aged women are associated with insomnia and low grip strength: a cross-sectional study

Background: Although muscle and joint pains are among the most common symptoms in menopausal transition, their underlying mechanisms are not precisely known. This study aimed to investigate the factors associated with myalgia and arthralgia in middle-aged women.Methods: We analyzed in a cross-sectional manner the first-visit records of 305 Japanese women aged 40-59 years who enrolled in a health and nutrition education program at a menopause clinic. The prevalence of muscle and joint pains was estimated according to the participants' responses to the Menopausal Health-Related Quality of Life Questionnaire. Background characteristics including age, menopause status, body composition, cardiovascular parameters and physical fitness, as well as other menopausal symptoms including vasomotor symptoms, insomnia, depression and anxiety, were assessed for associations with daily myalgia and arthralgia.Results: The percentage of women who were bothered by muscle and joint pains almost every day of the previous week was 56.1%. Characteristics associated with these symptoms were: low stature; high body fat percentage; low grip strength; and high vasomotor, insomnia, depression and anxiety symptom scores. Multivariate logistic regression analysis revealed that independently associated factors (adjusted odds ratio [95% confidence interval]) for daily myalgia/arthralgia were low hand-grip strength (kgf) (0.92 [0.87-0.97]) and insomnia symptom score (1.20 [1.07-1.34]).Conclusion: Muscle and joint pains are highly prevalent in Japanese middle-aged women. Low grip strength and insomnia are independently associated with these symptoms. Treatment of insomnia in this population might improve myalgia/arthralgia, and in turn, help restore grip strength, or treatment of hand pain might conversely reduce insomnia in addition to improvement in grip strength.

Knee osteoarthritis and menopausal hormone therapy in postmenopausal women: a nationwide cross-sectional study

OBJECTIVE

The incidence of osteoarthritis (OA) increases after menopause, and may be related to hormonal changes in women. Estrogen deficiency is known to affect the development of OA, and menopausal hormone therapy (MHT) is suggested to be related to the development of OA. However, the relationship between knee OA and MHT remains controversial. The association between knee OA prevalence and MHT was investigated using large-scale national data.

METHODS

Data were collected from 4,766 postmenopausal women from the Korea National Health and Nutrition Examination Survey (2009-2012). MHT was defined as regular hormone medication for ≥1 year, and demographic and lifestyle variables were compared between the MHT and non-MHT groups. Knee OA was defined according to symptoms and radiographic findings.

RESULTS

In the multiple logistic regression models, the OA odds ratio was 0.70 for the MHT group (95% confidence interval 0.50-0.99), compared with the non-MHT group.

CONCLUSIONS

The prevalence of knee OA was lower in participants with MHT than in those without MHT.

Quantification of fat in the posterior sacroiliac joint region: fat volume is sex and age dependant

Fat is appreciated as a structural component of synovial joints. It may serve a shock-absorbing function for the incongruent surfaces, vessels and ligaments, but has not been investigated in the posterior sacroiliac joint (PSIJ). Sixty-six cadaveric hemipelves were serially-sectioned and photographed. The amount of visible fat in the PSIJ was quantified using a modified version of Cavalieri’s method. Total volume, fat volume and fat percentage of the PSIJ were calculated in predefined sub-regions. Fat is consistently present in the PSIJ (1.9 ± 1.3 cm³). Fat volume correlates with the PSIJ total volume (p < 0.0001; r = 0.73) and age (p = 0.024; r = 0.24), and is smaller in males (1.4 ± 0.8 cm³) than females (2.4 ± 1.5 cm³). Fat volumes in the middle and inferior sub-regions of the PSIJ show side- (p < 0.0001) and sex-differences (p = 0.013 females, middle sub-region). Age and PSIJ total volume correlate between sexes in various sub-regions (p = 0.05 females superior sub-region; males inferior sub-region). Fat percentage differs between sexes and sub-regions (p = 0.018 females, superior sub-region) but is independent of age and sides. The presence of fat within the PSIJ is a normal finding and shows sex-dependant and age-related differences. It is unclear whether fat is linked to age-related degeneration or has a shock-absorbing role in stress- and load-dissipation in the PSIJ.

Menopausal Symptoms and Higher Risk Opioid Prescribing in a National Sample of Women Veterans with Chronic Pain

BACKGROUND

The greatest increases in long-term opioid use and opioid-related overdose mortality in recent years have been among women in midlife. Common menopausal symptoms broadly affect health and health care utilization in midlife, but their contribution to chronic pain management during this period is unknown.

OBJECTIVE

To examine relationships between menopausal symptoms and long-term opioid prescription patterns among midlife women with chronic pain.

DESIGN

Cross-sectional analysis of national Veterans Health Administration medical and pharmacy records (2014-2015).

PARTICIPANTS

Women Veterans aged 45-64 with ≥ 1 outpatient visit and chronic pain diagnoses spanning ≥ 90 days.

MAIN MEASURES

Long-term opioids (prescribed oral opioids for ≥ 90 days), high-dose long-term opioids (> 50 mg average morphine equivalent daily dose), and long-term opioids co-prescribed with central nervous system depressants (benzodiazepine and non-benzodiazepine sedative-hypnotics, gabapentin/pregabalin, muscle relaxants). Multivariable logistic regression models were used to examine associations between outcomes and menopausal symptoms (menopausal symptom-related diagnoses (i.e., "symptomatic menopausal states") on ≥ 2 encounters and/or menopausal hormone therapy, adjusting for race, age, body mass index, and mental health and substance use disorder diagnoses.

KEY RESULTS

In this national sample of 104,984 midlife women Veterans with chronic pain (mean age 54.5, SD 5.4 years), 17% had evidence of menopausal symptoms, 51% were prescribed long-term opioids, 13% were prescribed high-dose long-term opioids, and 35% were co-prescribed long-term opioids and central nervous system depressants. In multivariable analyses, women with menopausal symptoms had increased odds of long-term opioids (OR 1.21, 95% CI 1.18-1.26), high-dose long-term opioids (OR 1.08, 95% CI 1.02-1.13), and long-term opioids co-prescribed with central nervous system depressants (sedative-hypnotics OR 1.25, 95% CI 1.22-1.30; gabapentin/pregabalin OR 1.23, 95% CI 1.20-1.27; muscle relaxants OR 1.24, 95% CI 1.20-1.28).

CONCLUSIONS

Among midlife women Veterans with chronic pain, evidence of menopausal symptoms was associated with potentially risky long-term opioid prescription patterns, independent of known risk factors.

Type 2 Diabetes and Musculoskeletal Symptoms Among Midlife Women

PURPOSE

The purpose of this study was to describe the association between type 2 diabetes and musculoskeletal symptoms among midlife women from 4 major racial/ethnic groups in the United States.

METHODS

This is a secondary data analysis using the data from 164 participants aged 40 to 60 years of 2 larger survey studies (62 with type 2 diabetes and 102 without type 2 diabetes). In the original studies, the participants completed multiple questionnaires on background characteristics, health status, menopausal status, and musculoskeletal symptoms. The Musculoskeletal Symptom Index for Midlife Women was used to determine the number and severity of musculoskeletal symptoms. For data analysis, independent t tests, Mann-Whitney U tests, and multiple regression analyses were used.

RESULTS

The mean number of musculoskeletal symptoms was significantly higher in women with vs without type 2 diabetes as was the mean severity score. In subgroup analyses, among each menopausal stage and non-Hispanic white women, there were significant differences in the numbers and total severity scores between those with type 2 diabetes and without type 2 diabetes. When background characteristics, health status, and menopausal status were controlled, having diagnosis of type 2 diabetes was positively associated with the numbers and total severity scores of musculoskeletal symptoms.

CONCLUSION

Study findings supported significant associations of type 2 diabetes with musculoskeletal symptoms among midlife women. Further studies are recommended to confirm relationships in larger populations.

Musculoskeletal pain and menopause

Musculoskeletal pain, arthralgia and arthritis are all more common in women, and their frequency increases with age and in some appears to be associated with the onset of menopause. The clinical assessment, investigation and management of women presenting with musculoskeletal pain, arthralgia or arthritis at the time of menopause are reviewed. Common causes of arthralgia and arthritis in this population are discussed. The epidemiological and trials evidence for the effects of hormone replacement therapy on musculoskeletal pain and arthritis (primarily from RCTs of HRT for other menopausal symptoms) are discussed. Lastly, the possible underlying aetiological roles of sex hormones including estrogen, and their deficiency, in predisposing to musculoskeletal pain and arthritis are overviewed. Although the association appears strong, a causal link between estrogen deficiency and musculoskeletal pain or different types of arthritis is lacking; there have been few studies specifically within this group of symptomatic patients, and there is much still to understand about musculoskeletal pain and arthritis at the time of the menopause, and about how we might prevent or treat this.

Associations between endogenous sex hormones and MRI structural changes in patients with symptomatic knee osteoarthritis

OBJECTIVE

To investigate the longitudinal association between endogenous sex hormones and knee osteoarthritis (OA) structures and pain.

METHOD

We examined 200 participants (mean age 63.0 ± 7.3 years) from a clinical trial of vitamin D supplement for symptomatic knee OA. Serum levels of estradiol, progesterone, testosterone and sex hormone binding globulin (SHBG) were analyzed at baseline and 24 months later. Magnetic resonance imaging (MRI) scans of selected knee were obtained at both baseline and follow-up for the measurement of cartilage volume, cartilage defects, bone marrow lesions (BMLs) and effusion-synovitis volume. Knee pain was assessed using a 100 mm visual analogue scale (VAS). Longitudinal data were analyzed using linear mixed-effects model.

RESULTS

One hundred and seven males and 93 females were included in this study. For females, after adjustment for age, body mass index (BMI), and vitamin D level, progesterone was positively associated with cartilage volume (β = 0.12 mm³ per quartile, P < 0.01). Estradiol levels were associated with lower grades of BMLs (β = -0.46 per quartile, P = 0.03), while estradiol (β = -1.28 per quartile, P = 0.04), progesterone (β = -1.56 per quartile, P < 0.01) and testosterone (β = -1.51 per quartile, P = 0.01) were inversely associated with effusion-synovitis volume. Testosterone was inversely associated with knee pain. No consistent associations were observed for males.

CONCLUSION

In women but not men, low serum levels of endogenous estradiol, progesterone and testosterone are associated with increased knee effusion-synovitis and possibly other OA-related structural changes. This may contribute to observed sex differences in knee OA.

Prevalence of aromatase inhibitor-induced arthralgia in breast cancer: a systematic review and meta-analysis

BACKGROUND

Although aromatase inhibitors have proven to be an effective treatment of hormone receptor-positive breast cancer in postmenopausal women, aromatase inhibitor-induced arthralgia (AIA) is an adverse event associated with low compliance with treatment. The aim of this literature study is to assess the prevalence of AIA and to provide an overview of significant predictors for the development of AIA.

METHODS

A systematic review was conducted using PubMed, Cochrane Library and Web of Science. A meta-analysis was performed and heterogeneity has been investigated by moderator analyses. The meta-analysis was repeated with studies that were considered as best evidence, i.e. studies with an above-average score on the STROBE checklist.

RESULTS

Twenty-one studies (13,177 participants) were included. Prevalence rates ranged from 0.200 to 0.737. Meta-analysis resulted in a pooled estimate of 0.459 (95% CI = [0.397-0.520) with a high heterogeneity (I ² = 98%). Moderator analysis showed no differences regarding heterogeneity. Predictors for the development of AIA included a body mass index of 25-30 kg/m² (OR = 0.33), taxane-based chemotherapy (OR = 4.08), stage III cancer (OR = 0.32) and a duration of menopause of 5-10 years (OR = 1.10) or >10 years (OR = 0.44-3.29) (An OR <1 indicates a predictor of lower risk of AIA).

DISCUSSION

Despite the established benefits of AI, an important portion of the patients experiences AIA. More research is needed to investigate the efficacy of treatments such as exercise therapy for AIA.

Effects of physical exercise on the cartilage of ovariectomized rats submitted to immobilization

Objective

To analyze the effects of physical exercise on cartilage histomorphometry in osteoporosis-induced rats subjected to immobilization.

Methods

We used 36 Wistar rats that were separated into six groups: G1, G2 and G3 submitted to pseudo-oophorectomy, and G4, G5 and G6 submitted to oophorectomy. After 60 days at rest, G2, G3, G5 and G6 had the right hind limbs immobilized for 15 days, followed by the same period in remobilization, being free in the box to G2 and G5, and climb ladder to G3 and G6. At the end of the experiment, the rats were euthanized, their tibias bilaterally removed and submitted to histological routine.

Results

There was significant increase in thickness of the articular cartilage (F(5;29)=13.88; p<0.0001) and epiphyseal plate (F(5;29)=14.72; p<0.0001) as the number of chondrocytes (F(5;29)=5.11; p=0.0021) in ovariectomized rats, immobilized and submitted to exercise. In the morphological analysis, degeneration of articular cartilage with subchondral bone exposure, loss of cellular organization, discontinuity of tidemark, presence of cracks and flocculation in ovariectomized, immobilized and free remobilization rats were found. In ovariectomized and immobilized remobilization ladder rats, signs of repair of the cartilaginous structures in the presence of clones, pannus, subcortical blood vessel invasion in the calcified zone, increasing the amount of isogenous groups and thickness of the calcified zone were observed.

Conclusion

Exercise climb ladder was effective in cartilaginous tissue recovery process damaged by immobilization, in model of osteoporosis by ovariectomy in rats.

Aromatase inhibitor induced musculoskeletal syndrome: a significant problem with limited treatment options

BACKGROUND

Aromatase inhibitor induced musculoskeletal syndrome is experienced by approximately half of women taking aromatase inhibitors, impairing quality of life and leading some to discontinue treatment. Evidence for effective treatments is lacking. We aimed to understand the manifestations and impact of this syndrome in the Australian breast cancer community, and strategies used for its management.

METHODS

A survey invitation was sent to 2390 members of the Breast Cancer Network Australia Review and Survey Group in April 2014. The online questionnaire included 45 questions covering demographics, aromatase inhibitor use, clinical manifestations and risk factors for the aromatase inhibitor musculoskeletal syndrome, reasons for treatment discontinuation and efficacy of interventions used.

RESULTS

Aromatase inhibitor induced musculoskeletal syndrome was reported by 302 (82 %) of 370 respondents. Twenty-seven percent had discontinued treatment for any reason and of these, 68 % discontinued because of the musculoskeletal syndrome. Eighty-one percent had used at least one intervention from the following three categories to manage the syndrome: doctor prescribed medications, over-the-counter/complementary medicines or alternative/non-drug therapies. Anti-inflammatories, paracetamol (acetaminophen) and yoga were most successful in relieving symptoms in each of the respective categories. Almost a third of respondents reported that one or more interventions helped prevent aromatase inhibitor discontinuation. However, approximately 20 % of respondents found no intervention effective in any category.

CONCLUSION

We conclude that aromatase inhibitor induced musculoskeletal syndrome is a significant issue for Australian women and is an important reason for treatment discontinuation. Women use a variety of interventions to manage this syndrome; however, their efficacy appears limited.

Confronting the challenges of the menopausal transition

Canada’s Generation X is now entering the menopausal transition and pursuing effective therapy for bothersome vasomotor symptoms. They do so at a time when confusion about the safe and appropriate use of menopausal hormone therapy (MHT) has never been greater. Misplaced fears among women and their health care providers about MHT have, in many circumstances, led them to abandon this most effective therapy. This review discusses the physiology of the menopausal transition, the nature of symptoms related to withdrawal of ovarian estrogen production, and the potential benefits and risks of MHT. It is now clear that for most recently menopausal women the benefits of MHT outweigh the risks. The rationale for choosing different dosages, formulations, and regimens is reviewed.

Hand osteoarthritis, menopause and menopausal hormone therapy

Hand osteoarthritis (OA) is one of the commonest musculoskeletal conditions, primarily affecting women over the age of 50, typically around the age of the menopause. Symptomatic disease can give rise to substantial pain, impairment of hand function and quality of life, leading to significant socioeconomic cost. There is currently no disease-modifying therapy, representing a huge unmet clinical need. The evidence for a relationship between hand OA and the menopause is summarised. Whether there is evidence for an effect of menopausal hormonal therapy on the incidence, prevalence or severity of symptomatic hand OA is critically reviewed, and gaps in our knowledge identified. Lastly, the potential mechanisms by which estrogen, or newer agents such as SERMs, might act to interfere with disease pathogenesis are overviewed. The need for specifically designed, controlled trials of agents in cohorts with symptomatic hand OA, refractory to standard symptomatic management is highlighted.

Safety of aromatase inhibitor therapy in breast cancer

INTRODUCTION

Aromatase inhibitor (AI) therapy is the current preferred choice of endocrine therapy in postmenopausal estrogen receptor-positive breast cancer patients thanks to their improved effectiveness compared to tamoxifen. Despite the absence of increased endometrial pathology and deep venous thrombosis seen in tamoxifen-users, the safety profile of AIs consists of a variety of bothersome side effects negatively influencing daily functioning.

AREAS COVERED

Besides the well-known adverse effects on joints and bone and the vasomotor system, more neglected and latent toxicity like cognitive problems and vulvovaginal atrophy will be discussed. Concern has been raised in terms of increased risk of fractures and cardiovascular events with chronic AI use.

EXPERT OPINION

Placebo-controlled long-term studies carefully monitoring these adverse events, together with more extensive research in the etiologies, are warranted.

Postmenopausal Symptoms in Female Veterans with Type 2 Diabetes: Glucose Control and Symptom Severity

BACKGROUND

While type 2 diabetes mellitus (DM) is a common condition of midlife women, few studies have examined its influence on the symptom features of menopause. To explore this relationship, we conducted a study of symptom patterns of diabetic patients using a random sample of female veterans receiving care in the Veterans Affairs Healthcare system.

METHODS

A cross-sectional comparison was conducted with three groups of postmenopausal respondents (ages 45-60 years) to a mailed national survey who also consented to clinical data access: no diabetes (n=90), diabetes with better glucose control (hemoglobin A1c [HbA1c]≤7%, n=135) and diabetes with worse glucose control (HbA1c>7%, n=102).

RESULTS

Respondents, on average, were obese (body mass index: 33.9±0.4 kg/m(2)), 11.30±0.2 years postmenopause, with more than one chronic illness. Despite higher body mass index and increased comorbidities in women with diabetes compared with nondiabetic women, measures of mental health (anxiety, depressed mood, stress) were similar across groups. The pattern of menopause symptoms did not differ by group. Muscle aches/joint pain was the most prevalent symptom (78.6%), followed by vasomotor symptoms (74.4%). Respondents with elevated HbA1c demonstrated higher total menopausal symptom severity scores (DM-HbA1c>7: 15.4±0.8 vs. DM-HbA1c≤7%: 12.2±0.8 vs. No diabetes: 12.3±0.8; p=0.006) than the other two groups.

CONCLUSIONS

In postmenopausal female veterans with diabetes, glucose control is associated with the severity of those symptoms commonly attributed to menopause. Joint pain is an important part of the postmenopausal symptom complex in this population.

Activation of GPR30 attenuates chronic pain-related anxiety in ovariectomized mice

Estrogen regulates neuroendocrine and inflammatory processes that play critical roles in neuroinflammation, anxiety, and chronic pain. Patients suffering from chronic pain often complain of anxiety. However, limited information is available regarding the neural circuitry of chronic pain-related anxiety and the related function of estrogen. Hindpaw injection of complete Freund's adjuvant (CFA) and chronic constriction injury (CCI) of the sciatic nerve induced notable pain sensitization and anxiety-like behavior in ovariectomized (OVX) mice. We found that the level of G-protein-coupled receptor 30 (GPR30), a membrane estrogen receptor, was significantly increased in the basolateral amygdala (BLA) of ovariectomized (OVX) mice suffering from chronic inflammatory and neuropathic pain. Subcutaneous injection or BLA local infusion of the GPR30 agonist G1 significantly reduced anxiety-like behavior in CFA-injected and CCI-OVX mice; however, this treatment did not alter the nociceptive threshold. GPR30 knock down by shRNA in the BLA of OVX mice inhibited the anxiolytic effects of GPR30 activation. G1 administration reversed the upregulation of GluR1 subunit in AMPA and NR2A-containing NMDA receptors and the downregulation of GABAA receptors in the BLA of CFA-injected and CCI-OVX mice. Electrophysiological recording revealed that GPR30 activation could prevent imbalance between excitatory and inhibitory transmissions in the BLA synapses of CFA-injected OVX mice. In conclusion, GPR30 activation induced anxiolytic effects but did not affect the nociceptive threshold of mice under chronic pain. The anxiolytic effects of GPR30 were partially due to maintaining the balance between excitatory and inhibitory transmissions in the BLA.

Articular cartilage chondrocytes express aromatase and use enzymes involved in estrogen metabolism

Introduction

Sex hormones, especially estrogens, have been implicated in articular cartilage metabolism and the pathogenesis of postmenopausal osteoarthritis. The conversion by aromatase (CYP19A1) of androstenedione into estrone (E1) and of testosterone into 17β-estradiol (E2) plays a key role in the endogenous synthesis of estrogens in tissue.

Methods

We analyzed the expression of aromatase (CYP19A1) in immortalized C-28/I2 and T/C-28a2 chondrocytes, as well as in cultured primary human articular chondrocytes and human articular cartilage tissue, by means of RT-PCR, Western blotting and immunohistochemistry. By means of quantitative RT-PCR and enzyme-linked immunosorbent assay, we also determined whether the aromatase inhibitor letrozole influences estrogen metabolism of cultured chondrocytes in immortalized C-28/I2 chondrocytes.

Results

Aromatase mRNA was detected in both immortalized chondrocyte cell lines, in cultured primary human chondrocytes, and in human articular cartilage tissue. By means of Western blot analysis, aromatase was detected at the protein level in articular cartilage taken from various patients of both sexes and different ages. Cultured primary human articular chondrocytes, C-28/I2 and T/C-28a2, and human articular cartilage tissue reacted with antibodies for aromatase. Incubation of C-28/I2 chondrocytes with 10⁻¹¹ M to 10⁻⁷ M letrozole as an aromatase inhibitor revealed significantly increased amounts of the mRNAs of the enzyme cytochrome P4501A1 (CYP1A1), which is involved in the catagen estrogen metabolism, and of the estrogen receptors ER-α and ER-β. Concomitantly, synthesis of estrone (E1) was significantly downregulated after incubation with letrozole.

Conclusions

We demonstrate that human articular cartilage expresses aromatase at the mRNA and protein levels. Blocking of estrone synthesis by the aromatase inhibitor letrozole is counteracted by an increase in ER-α and ER-β. In addition, CYP1A1, an enzyme involved in catabolic estrogen metabolism, is upregulated. This suggests that articular chondrocytes use ERs functionally. The role of endogenous synthesized estrogens in articular cartilage health remains to be elucidated.

Menopause in multiple sclerosis: therapeutic considerations

While the onset of multiple sclerosis (MS) typically occurs during the childbearing years, many women living with MS are of perimenopausal age. There is frequent overlap between menopausal and MS-related symptoms and co-morbidities (e.g. sexual dysfunction, mood disorders and bladder function). Furthermore, some MS symptoms may be exacerbated by perimenopausal changes such as hot flashes or sleep disturbance. The MS neurologist may frequently be the first to become aware of these symptoms and to play a role in monitoring and managing them. In this review, we describe immunological and neurologic changes at menopause as they may impact MS. We then review common symptoms, including fatigue, depression, sexual function, pain and insomnia, and provide both behavioral and pharmacological suggestions for their management. Next, we discuss the need for osteoporosis and cancer screening in perimenopausal women with MS. Finally, we highlight important research gaps, including what effect, if any, the menopausal transition may play on MS disease course as well as the potential modulatory role of hormone replacement therapies.

Estrogen alone and joint symptoms in the Women's Health Initiative randomized trial

OBJECTIVE

Although joint symptoms are commonly reported after menopause, observational studies examining exogenous estrogen's influence on joint symptoms provide mixed results. Against this background, estrogen-alone effects on joint symptoms were examined in post hoc analyses in the Women's Health Initiative randomized, placebo-controlled, clinical trial.

METHODS

A total of 10,739 postmenopausal women who have had a hysterectomy were randomized to receive daily oral conjugated equine estrogens (0.625 mg/d) or a matching placebo. The frequency and severity of joint pain and joint swelling were assessed by questionnaire in all participants at entry and on year 1, and in a 9.9% random subsample (n = 1,062) after years 3 and 6. Logistic regression models were used to compare the frequency and severity of symptoms by randomization group. Sensitivity analyses evaluated adherence influence on symptoms.

RESULTS

At baseline, 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 (76.3% vs 79.2%, P = 0.001), as was joint pain severity, and the difference in pain between randomization groups persisted through year 3. However, joint swelling frequency was higher in the estrogen-alone group (42.1% vs 39.7%, P = 0.02). Adherence-adjusted analyses strengthen estrogen's association with reduced joint pain but attenuate estrogen's association with increased joint swelling.

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.

Aromatase inhibitor-induced arthralgia: a review

Though aromatase inhibitors (AIs) are an essential part of estrogen receptor-positive (ER+) breast cancer therapy, many patients discontinue the medicine before their adjuvant therapy is completed because of the arthralgia which often accompanies the medicine. Up to half of women on AI therapy experience joint pain, and up to 20% will become non-compliant with the medicine because of the joint pain. Yet, very little is known about what causes AI-induced arthralgia (AIA), and there is no established, effective treatment for this difficult problem. It compromises survivors' quality of life and leads to non-compliance. This paper will discuss AIA in depth, including potential etiologies, clinical significance, risk factors, and possible management solutions. Of note, this article presents one of the first proposed algorithms which clearly lays out a treatment plan for AIA, incorporating a variety of interventions which have been proven by the available literature.

Prospective study to assess fluid accumulation and tenosynovial changes in the aromatase inhibitor-induced musculoskeletal syndrome: 2-year follow-up data

BACKGROUND

Aromatase inhibitors (AIs) frequently lead to the AI-induced musculoskeletal syndrome (AIMSS). Looking into its pathophysiology, 6 months of AI therapy thickens the tendon sheath with intra-articular fluid (IAF) retention and loss of grip strength. We here report 24-month follow-up data.

PATIENTS AND METHODS

A prospective cohort study of 33 postmenopausal breast cancer patients received adjuvant endocrine therapy; 27 received an AI and 6 received tamoxifen. At baseline, 6 and 24 months patients had a rheumatologic examination, including a grip strength test, and magnetic resonance imaging of both hands and wrists. The primary end point was tenosynovial changes; secondary end points were changes in morning stiffness, grip strength and IAF.

RESULTS

Twenty-three AI and 5 tamoxifen patients completed all investigations. Between month 6 and 24, IAF further increased in AI users (P = 0.04) but not in tamoxifen users, and grip strength further decreased in both groups. The worsened tenosynovial changes were strongly correlated with a decrease in grip strength. At 24 months, morning stiffness continued to be present in over a third of AI users.

CONCLUSION

AIMSS represents a substantial problem in breast cancer patients. It is associated with tenosynovial changes, IAF retention, joint stiffness and loss of grip strength that do not improve with prolonged use.