The Musculoskeletal Syndrome of Menopause: A Conversation with Orthopedic Surgeon Dr. Jocelyn Wittstein

"Why do my joints suddenly hurt?" "Is this frozen shoulder connected to my hot flashes?" If you're a woman in your 40s or 50s experiencing mysterious joint pain, you're not alone‚ and it's not just aging. In this conversation, host Catherine Isaac delves into the hidden connection between menopause and joint pain with Dr. Jocelyn Wittstein, orthopedic surgeon and sports medicine specialist at Duke Health. They uncover the surprising truth about the "musculoskeletal syndrome of menopause" that affects millions of women but remains largely unrecognized in clinical practice.

Understanding Musculoskeletal Changes During Menopause

As women transition through perimenopause and menopause, the decline in estrogen levels triggers significant changes in the musculoskeletal system that many women‚ and even healthcare providers‚ may not recognize as being connected to hormonal shifts.

Dr. Wittstein explains that these changes fall into three main categories:

1. Increased Inflammation: Women experience more painful, inflamed joints and an accelerated rate of arthritis development. A prime example is frozen shoulder (adhesive capsulitis), which almost exclusively affects women aged 40-60.
2. Accelerated Bone Density Loss: During menopause, the rate of bone density loss increases from 1% to 2% annually, significantly raising the risk of osteoporosis and fractures.
3. Muscle Mass Challenges: With declining estrogen levels, it becomes more difficult to maintain and build muscle mass, leading to sarcopenia (muscle loss).

The Menopause-Arthritis Connection

Dr. Wittstein describes what she calls "menopause arthritis" as existing somewhere between mechanical wear-and-tear osteoarthritis and purely inflammatory arthritis. The combination of aging joints and increased inflammation creates a unique scenario where women have a 30% higher risk of developing osteoarthritis around age 50‚ a risk men don't experience until about age 80.

Estrogen receptors exist in the synovium (the tissue lining joints), and studies show that estrogen withdrawal increases inflammation while estrogen therapy can reduce joint pain and inflammation. Interestingly, Dr. Wittstein notes that even though 77% of women in the Women's Health Initiative reported joint pain, and hormone therapy reduced both the number and severity of painful joints, joint pain is not currently an FDA-approved indication for menopausal hormone therapy.

Frozen Shoulder: The "50-Year Shoulder"

Frozen shoulder deserves special attention as it disproportionately affects women during the menopausal transition. Dr. Wittstein explains that this condition:

• Usually occurs without injury or trauma
• Begins with aching that progresses to significant pain and stiffness
• Can take up to two years to resolve completely
• Is so common in menopausal women that some cultures have termed it the "50-year shoulder"

The condition is so strongly associated with hormonal changes that when Dr. Wittstein sees a man with frozen shoulder, she screens him for diabetes, as that's typically the only context where men develop this condition.

Treatment Approaches

For frozen shoulder, Dr. Wittstein emphasizes early intervention:

• Steroid injections into the joint can be "magical" when administered within the first three months of symptom onset
• Physical therapy may worsen symptoms if attempted during the painful inflammatory phase
• For severely "frozen" shoulders that limit daily activities, surgical intervention may be necessary

Dr. Wittstein also discusses the complex relationship between menopause and musculoskeletal health, emphasizing two factors under individual control:

1. Exercise: A balanced approach that includes:
   • Strength training (resistance exercises) to support muscle and bone health
   • Cardiovascular activity for heart and brain health
   • Impact exercises (like jumping) to stimulate bone density
   • Balance training to prevent falls
2. Diet: An anti-inflammatory approach focusing on:
   • Minimizing red meat, fried foods, and processed foods
   • Including at least 25 grams of fiber daily from whole grains
   • Consuming a variety of fruits and vegetables for their antioxidant properties
   • Incorporating omega-3 fatty acids from fish, walnuts, and chia seeds

Resources for Further Learning

For those looking to learn more about maintaining musculoskeletal health during menopause, Dr. Wittstein recommends:

1. The Complete Bone and Joint Health Plan - Dr. Wittstein's own book co-authored with registered dietician Sydney Nitskorsky, providing comprehensive guidance on nutrition and exercise for bone and joint health.
2. The Musculoskeletal Syndrome of Menopause - A medical paper co-authored by Dr. Wittstein and Dr. Vonda Wright, available through the journal Climacteric.
3. The Science of Joint Health: How to Keep Your Bones Strong for Life - Dr. Wittstein's recent appearance on Gabby Lyon's podcast (Episode 147).
4. The M Factor - A recommended film about menopause that provides additional context and education.
5. Ortho Info - A patient-friendly resource from the American Academy of Orthopedic Surgery offering guidance on various orthopedic conditions.

The Takeaway

This episode highlights how the musculoskeletal impacts of menopause remain underrecognized despite affecting millions of women. Dr. Wittstein's expertise sheds light on why women experience particular joint, bone, and muscle challenges during this life stage and offers practical strategies for maintaining musculoskeletal health through the menopausal transition and beyond.

By understanding these connections and taking proactive steps with exercise, nutrition, and appropriate medical interventions when needed, women can better navigate the musculoskeletal challenges of menopause and maintain mobility and function for years to come.