Musculoskeletal Syndrome of Menopause – What You Need to Know

Have you heard of musculoskeletal syndrome of menopause (MSM)? This is a term to describe typical symptoms that are impacted by the estrogen flux and then precipitous drop in estrogen surrounding perimenopause/menopause.  The overall prevalence of musculoskeletal pain in perimenopausal women is approximately 71% with perimenopausal/menopausal  women demonstrating a higher risk for musculoskeletal pain than their premenopausal counterparts.  It has also been stated that up to a quarter of these women can be quite disabled by these symptoms.

It Includes but is not limited to:  musculoskeletal pain, arthralgia, loss of lean muscle mass (sarcopenia), increase tendon and ligament injury, adhesive capsulitis, cartilage matrix fragility with progression leading to osteoarthritis and loss of bone density that then leads to increased fracture risk.

The challenge for women, is to be aware and make your clinicians aware of your symptoms. The challenge to clinicians is to inquire adequately about these symptoms/issues, anticipate the onset and actively provide prevention and treatment strategies in a timely and safe manner.

More than 35 symptoms are known to be associated with menopause, including common ones such as vasomotor symptoms, genitourinary syndrome of menopause (GSM), sleep disturbances, brain fog, anxiety, and loss of libido; however, musculoskeletal symptoms are less commonly recognized by clinicians who are not as educated in menopause medicine and not yet in the minds of enough women to report to their clinicians. Not all MSM issues are obvious, and some are in fact quite silent until they aren’t, such as lower bone density and sarcopenia or a tendon/ligament injury.  Some of these can drastically change a woman’s life.

Here are some key reminders:

• The average age for onset of perimenopause is 47.5  The average age of menopause is 52.6 ± 2.5 years, with Hispanics having an onset approximately 2 years earlier.
• During perimenopause, women have an average reduction of 10% in bone mineral density In addition, women have a reduction of 0.6% in muscle mass per year after menopause. These musculoskeletal issues can be attributed to both aging and to the decline in estradiol, which impacts nearly all types of musculoskeletal tissue including bone, tendon, muscle, cartilage, ligament, and adipose.
• The fall in estradiol levels leads to five primary changes related to MSM: an increase in inflammation, a decrease in bone mineral density, osteoarthritis, sarcopenia and a decrease in the proliferation of satellite cells (muscle stem cells).

This clinical information should not lead to the conclusion that all perimenopausal and menopausal women need to be on systemic menopause hormone therapy (MHT).  What it does mean is that patients and practitioners should be aware of prevention and management approaches which may include the safe and appropriate prescribing of MHT.  MHT slows the rate of bone loss and reduces fracture rates in those with osteoporosis.  It also offers a possible modality to mitigate the estrogen withdrawal of menopause.

Nutrition (increased protein, whole grains, healthy fats, high fiber, plant dominant), exercise (aerobic and strength-resistance training) , avoiding nicotine and alcohol, nutrient collagen and muscular strength support and bone density/bone strength supplementation are all in the mix.  Guidelines recommend osteoporosis screening for women aged 65 years or older and for those aged 50–64 years who have certain risk factors, including a positive family history of osteoporosis.  Potential bone support supplements include vitamin D, calcium, magnesium Vitamin K2, and creatine. Potential muscle strength supplements include vitamin D and creatine.  Botanicals such as turmeric and Boswellia can reduce joint/muscle/tendon inflammation and improved recovery from injuries.  Vitamin C and amino acids from protein may help with collagen formation.

When midlife women present with symptoms of adhesive capsulitis or atraumatic joint pain, or describe recent loss of muscle or height, the wise and educated clinician should introduce the musculoskeletal syndrome of menopause and proceed to education and intervention options.  However, let’s don’t make assumptions just because a woman is perimenopausal or postmenopausal, as each woman needs an individual clinical evaluation.  A woman may have structural damage or other pathologies that may explain the presenting symptomatology and contribute to the overall picture, which may or may not be influenced by estrogen deficiency.  This approach can empower women and not just go the road of assuming that her life must become smaller and slower just based on age.

Practitioners need to be aware of the musculoskeletal syndrome of menopause and communicate optimal prevention and intervention strategies appropriate to the benefits and risks of each modality, especially the benefits and risks of MHT based on their age, age since menopause, as well as personal and family medical history.  The standard of care recommendations from all national and international societies regarding this issue is that if systemic MHT is indicated, for whatever reason, initiate systemic MHT within 10 years of their last menstrual period or before age 60 while also weighing the benefits and risks for each individual and continue this assessment ongoing.

Conclusions

The musculoskeletal syndrome of menopause is a newer and unique concept to describe the common musculoskeletal symptoms related to loss of estrogen levels, including joint pain, inflammation, sarcopenia, osteoporosis, and cartilage damage.  If we only consider each one of these issues in isolation, we are likely to proceed with a lack of appreciation as to the role of decreasing estrogen and the possible use of MHT, proper nutrition, resistance training, and nutrient supplementation.  This broader approach can offer a substantial strategy in quality of life, preventing falls and fractures, and decreasing age related frailty.

I look forward to future research on this issue, to better answer the remaining questions regarding mechanisms, the most effective and safe intervention, and prevention strategies.

Resource: Wright, V, Schwartzman, Iltinoche R, Wittstein J. The musculoskeletal syndrome of menopause.  Climacteric  2024 Oct;27(5):466-472