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Menopausal Arthritis and Bioidentical Hormones by Jeffrey Dach MD

Menopausal Arthritis
by Jeffrey Dach MD

This article is part one of a series.  For Part Two, Click Here,

Joyce is a 52 years old, post menopausal typist who came to see me in the office because of joint pain in her hands which keeps her up at night with aching, and interferes with her job as a typist. She was fine until about three years ago when she went into menopause and stopped her menstrual cycles. Since then, Joyce has made the rounds with a number of doctors and all the usual tests. Xrays of the hands were normal (left image), and blood tests for rheumatoid arthritis were negative. Her doctors told her she had early osteoarthritis and recommended the standard treatments listed here:

Conventional Treatment of Osteoarthritis:

1) NSAIDs. Over-the-Counter Aspirin, Acetaminophen (Tylenol), ibuprofen and naproxen,COX-2 inhibitors such as celecoxib. NSAIDS have adverse effects on the GI tract.

2) Injections.into the joint with medications such as steroids, hyaluronic acid, stem cells, platelet rich plasma etc.

3) Topical Creams for pain relief available over the counter. 

4)  Physical Therapy to keep the joint active.

6) Prosthetic Joint Replacement after irreversible joint damage causes pain an dimmobility.

Above left image: xray of normal hand without signs of arthritis. There is a fracture of the fourth metacarpal though. Courtesy of Wikimedia Commons.

Menopausal Arthritis

I explained to Joyce that she had fairly classical Menopausal Arthritis caused by an inflammatory response associated with declining estrogen levels.  I have noted this in many of my patients.  The inflammatory process is usually relieved by bio-identical estrogen as a topical cream. Joyce's lab panel showed low estrogen levels, and Joyce was started on her bio-identical hormone program. Six weeks later, Joyce reports complete relief of symptoms.  Her arthritis pains have gone. In addition, Joyce reports that she went off the bio-identical hormone cream for a week to see what would happen, and sure enough, the arthritis came back, only to be relieved again by resuming the hormone cream.  This is a fairly typical story that I have seen over and over again.

Doubts From A Colleague

In casual conversation with a rheumatologist friend of mine, I mentioned Joyce's story and the association of arthritis with declining estrogen levels relieved by bioidentical estrogen. To my surprise, my rheumatologist friend merely laughed and scoffed at the idea, saying he never heard of it and doubted the association between low estrogen levels and arthritis. As surprising as this might seem, there are many "denialists" doctors, possibly a result of not keeping up with the medical literature.

Association Well Documented in the Rheumatology Literature

As it turns out, the association of arthritic aches and pains with low estrogen levels is well documented in the mainstream rheumatology literature. 

For example, an article published in Sept 2005 in Arthritis & Rheumatism by Felson and Cummings entitled,"Aromatase Inhibitors and the Syndrome of Arthralgias With Estrogen Deprivation", showed that menopausal women treated with estrogen depleting medications tend to develop aches and pains in their joints. 

Another report in The Lancet Oncology,September 2008 by Sestak and Cuzick showed the same finding that estrogen depletion is associated with joint aches and pains.  They say "Joint symptoms (eg, arthralgia and arthritis) are a well-known side-effect of certain drugs that reduce estrogen levels.  Low estrogen levels and postmenopausal status are associated with the development of symptoms of arthralgias and arthritis."

Natural Treatments for Osteo-Arthritis

Althought bio-identical hormone therapy seems to work for most post-menopausal women for arthritis relief, there are a few women that still have arthritis and arthralgis in spite of the estrogen cream.  It just doesn't work for them.  What natural therapies do we have in our tool kit, that we can offer these women?

Doctor Yourself with Anti-Inflammatory Treatments

A Vegetable Juicing Diet is anti-inflammatory and can relieve arthritis:

The vegetable juicing diet is an effective lifestyle modification that is very effective for arthritis.  Credit and thanks goes to Andrew Saul MDfor bringing this to my attention in his book, "Doctor Yourself ", Page 36-38  (see image right) which is devoted to arthritis and the vegetable juicing diet.  This is certainly worth a try.

left image: Courtesy of Andrew Saul MD

Niacin Vitamin B3 is useful for osteoarthrits according to William Kauffman MD.

Weight loss is anti-inflammatory.  Fat in the "spare tire" of the abdomen produces inflammatory chemical mediators.  By reducing this fat depot, inflammation is reduced everywhere in the body.  This is certainly worth a try.

There are an number of anti-inflammatory herbs such as Boswellia, Ginger and Curcumin which can relieve the symptoms.

Omega 3 Fish Oil is anti-inflammatory and a number of studies reveal just as effective as NSAID anti-inflammatory medications for rheumatoid arthritis.

Treatments to Rebuild Cartilage

Cartilage is an important cushion material in the joints that often wears thin as osteoarthritis progresses.  Once cartilage loss is severe enough to show up on an x-ray, this usually indicates irreversible damage to the joint. Cartilage nutrients such as Glucosamine have been found to be effective at relieving arthritis.  Be patient, it takes about six weeks to get full relief.

Treatments to Rebuild Strong Bone and Collagen

In addition to cartilage, joints are made of bone material, so taking supplements to build strong bone makes sense.  Bone is made of collagen, so supplements that are required for strong collagen formation are ones we want here.

1) Vitamin C is a key vitamin for strong collagen.
2) Silica (BioSil) is a supplement that makes strong collagen.
3) Collagen is made from amino acids so, the amino acids-lysine, proline are useful.
4) Collagen strength comes from sulfer crosslinking, so the sulfer nutrient MSM is added.


Articles with Related Content:

Bioidentical Hormones for Menopausal Arthritis

Glucosamine and Chondroitin for Arthritis Pain

Bioidentical Hormones Prevent Arthritis

Nightshade Vegetables and Arthritis

Jeffrey Dach MD
7450 Griffin Rd Suite 180/190
Davie, FL 33314

Phone: 954-792-4663
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References and Links:

Menopause Arthritis

http://cme.medscape.com/viewarticle/512093

"Menopausal Arthritis" May Develop in Women Receiving Estrogen-Depleting Treatments
News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEd

Sept. 2, 2005 — Women receiving estrogen-depleting treatments may develop "menopausal arthritis," according to a review article published in the September issue of Arthritis & Rheumatism. The authors suggest that the symptoms are usually transient and resolve with estrogen therapy or when aromatase inhibitors are discontinued.

The authors review trial data showing that women treated with aromatase inhibitors often develop musculoskeletal and joint pain or aching sometimes leading to treatment discontinuation. They also review biologic mechanisms linking estrogen deprivation with joint pain, both in natural menopause and in pharmacologic estrogen deprivation.

Although estrogen is not known to specifically affect articular structures in a manner that would cause joint pain, it influences inflammation and neural processing of nociceptive input via tissue-specific effects on inflammatory cytokines and direct effects on opioid pain fibers in the central nervous system (CNS).

The best evidence that decreased estrogen production may cause arthralgias comes from trials of aromatase inhibitors for the treatment or prevention of breast cancer. Compared with women receiving placebo or tamoxifen, those receiving aromatase inhibitors have greater frequency of arthralgia.

When objective findings accompany arthralgias, this may result in an erroneous diagnosis of osteoarthritis or rheumatoid arthritis in women who might not otherwise be diagnosed.

Article: "Aromatase Inhibitors and the Syndrome of Arthralgias With Estrogen Deprivation,"
David T. Felson and Steven R. Cummings, Arthritis & Rheumatism, September 2005; 52:9; pp. 2594-2598.

http://www.emaxhealth.com/70/3606.html
Women treated with aromatase inhibitors often experience joint pain and musculoskeletal aching: severe enough, in some cases, to make them stop the treatment.

"Estrogen's effects on inflammation within the joint are not well known," Dr. Felson and Dr. Cummings observe. Yet, as they note, estrogen has well-established tissue-specific effects on inflammatory cytokines. Estrogen's role in joint inflammation could account for the increased sensitivity to pain that some women suffer with estrogen depletion. Citing studies of pharmacological suppression of estrogen and studies of natural menopause, the authors offer a look at compelling evidence associating estrogen deprivation with joint pain, including:

http://cme.medscape.com/viewarticle/579250
Anastrozole Associated With Joint Symptoms in Patients With Breast Cancer CME
News Author: Roxanne Nelson   Author: Charles Vega, MD

Joint symptoms are most prominent in women in the fifth decade of life, and women who are postmenopausal are more likely to experience joint symptoms vs premenopausal or perimenopausal women of the same age. Hormonal therapy with estrogen can relieve these joint symptoms, whereas third-generation aromatase inhibitors promote joint symptoms.

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(08)70182-7/abstract
The Lancet Oncology, Volume 9, Issue 9, Pages 866 - 872, September 2008

Risk factors for joint symptoms in patients enrolled in the ATAC trial: a retrospective, exploratory analysis

Ivana Sestak PhD a , Prof Jack Cuzick PhD a, Francisco Sapunar MD b, Prof Richard Eastell MD c, Prof John F Forbes FRACS d, Angelo R Bianco MD e, Aman U Buzdar MD f, on behalf of the ATAC Trialists' Group

Joint symptoms (eg, arthralgia and arthritis) are a well-known side-effect of aromatase inhibitors. Low oestrogen concentrations and postmenopausal status are associated with the development of these symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/17368903
Breast. 2007 Jun;16(3):223-34. 2007 Mar 21

Aromatase inhibitor-associated arthralgia syndrome. Burstein HJ.

Aromatase inhibitors (AIs) are widely used as an adjuvant endocrine treatment in postmenopausal women with early-stage breast cancer.  Clinical experience also suggests that AI therapy is associated with a novel musculoskeletal side effect consisting of an arthralgia syndrome. The actual incidence of AI-associated arthralgias or musculoskeletal symptoms is not known, though such symptoms are quite prevalent and appear more commonly with AI use than with tamoxifen. Arthralgias can be a reason for discontinuation of AI treatment.

NATURAL Treatment for Arthritis

1) anti-inflammation
Vegetable juicing diet-weight loss
Herbs- Boswellia, Ginger Curcumin
Aspirin, NSAIDs
Fish Oil

2) cartilage nutrients
glucosamine chondroitin MSM

3) bone nutrients-collagen fromation
Vitamin C
Silica (BioSil)
AMino acids-lysine, proline
Sulfer crosslinking -MSM

Fish Oil for Arthritis

http://www.jrheum.com/subscribers/06/10/1931.html
Collateral Benefits of Fish Oil Therapy for Rheumatoid Arthritis by CHAK SING LAU, MD, FRCP,Professor of Medicine, Division of Rheumatology & Clinical Immunology,

"Cod liver oil (n-3 fatty acids) as a non-steroidal anti-inflammatory drug sparing agent in rheumatoid arthritis," Galarraga B, Ho M, et al, Rheumatology, March 24 2008 [advance access published online]

James MJ, Cleland LG. Dietary n-3 fatty acids and therapy for rheumatoid arthritis. Semin Arthritis Rheum . 1997;27:85-97.

* Volker D, Fitzgerald P, Major G, et al. Efficacy of fish oil concentrate in the treatment of rheumatoid arthritis. J Rheumatol . 2000;27:2343-2346.

http://abcnews.go.com/Health/PainArthritis/story?id=4566412
Are There Any Vitamins Or Herbal Supplements That Can Be Used To Treat Pain Resulting From Osteoarthritis? Tieraona Low Dog, M.D., Director of Education, Program in Integrative Medicine, University of Arizona January 2, 2008

Glucosamine, Devil's claw - south african herb used in Europe. Clinical trials done concluded effective. Standardized extract.

Bromalain- pineapple digestive enzymes.
Commonly used in Europe.  Use enteric coated form to prevent break down from stomach acid.  May have blood thinner effect.

http://www.arthritis.org/media/newsroom/statements/GAIT_Statement_FINAL_2_21_06.pdf

Arthritis Foundation Statement on the Glucosamine/chondroitin Arthritis Intervention Trial

Summary ..The study did find that the combination of the two supplements provided significant pain relief for people with moderate-to-severe knee OA.

http://www.healingdaily.com/conditions/glucosamine.htm
Even JAMA admits glucosamine is effective against osteoarthritic pain.

McAlindon TE and others. Glucosamine and chondroitin for treatment of osteoarthritis: A systematic quality assessment and meta-analysis JAMA 283:1469-1475, 2000.

Reginster JY and others. Long-term effects of glucosamine sulfate on osteoarthritis progression: a randomized, placebo-controlled trial. Lancet 357:251-256, 2001.

Experimental Biology 2000 Conference San Diego April 18, 2000

Niacin and Osteoarthritis

http://www.doctoryourself.com/JOM1.html

Reprinted with permission from Saul AW. William Kaufman, B-3, and arthritis. J Orthomolecular Med, 2001. Vol. 16, No. 3, Third Quarter, 2001, p 189.  The world was still deep in the Great Depression when William Kaufman, MD, PhD, had already begun treating osteoarthritis with two to four grams of niacinamide daily. Now, over 60 years later, his pioneering work in orthomolecular medicine is receiving the recognition it so well deserves.

Jeffrey Dach MD
7450 Griffin Road Suite 190
Davie, Florida 33314
954-792-4663
http://www.drdach.com/
http://www.naturalmedicine101.com/
http://www.truemedmd.com/
http://www.bioidenticalhormones101.com/

Menopause identified as trigger for new type of arthritis

Author: Staff writer

A recent study has shed new light on a little-known type of arthritis known as ‘menopausal arthritis’, which effects women at the onset of the menopause and causes moderate to severe pain and swelling mainly in the fingers and wrists.

The study (1), carried out in September 2005, was on women who were taking oestrogen inhibiting drugs for breast cancer, found that the reduction in oestrogen production caused a rapid onset of arthritic symptoms.

The women experienced pain and swelling mainly of the finger and wrist joints, and sometimes in the jaw in a relatively short period following the start of a course of oestrogen blocking hormone therapy.

Until now little has been known about the effects of oestrogen on joint inflammation, but authors of the new study conclude it proves previously held suspicions that a sudden reduction of oestrogen production, such as at the start of the menopause or due to hormone therapy, can trigger a rapid onset of arthritic symptoms.

Evidence suggests that ’menopausal arthritis’ mainly affects the joints in the fingers. It is characterised by bony knobs visible on the fingers. Often small lumps will occur on either side of the joint. Doctors suggest it is not a destructive disease (and can be only temporary) and will respond well to anti -inflammatories both natural and medicinal.

Three ways to prevent menopausal-related Arthritis:

1. Control early aches and pains

Most people would not feel comfortable using regular NSAID’s (Non-Steroidal Anti-Inflammatory Drug) either as a cream or a tablet without having diagnosed and fairly advanced osteoarthritis.

However this study suggests that mild symptoms of bone and joint problems could begin before the menopause takes place. So using a natural non-drug anti-inflammatory cream on any small aches and pains may help delay the onset of menopausal related arthritis through gentle daily management of mild inflammation of the joints.

2. Take supplements to build stronger joints

A recent study found that the two supplements glucosamine and chondroitin sulphate help in preventing the onset of osteoarthritis. The study, carried out at the University of Utah in the US and published by the UK charity Arthritis Research Campaign, found that the two supplements worked best in combination.

The supplements are thought to work as joint cartilage contains both glucosamine and chondroitin and so taking additional supplementation of these two substances helps to build stronger bone cartilage to help guard against arthritis.

The study found the combination of supplements to be effective after several weeks or moderate knee pain caused by early onset osteoarthritis.

3. Eat more selenium

A new study published this week has found that low levels of selenium in people’s diets can increase the risk of osteoarthritis as the mineral acts as a protective antioxidant.

British women are particularly at risk because studies have shown that levels of selenium are very low in British soil compared to the US, meaning that many foods grown in the UK lack beneficial levels of selenium, which may be part of the reason why osteoarthritis is on the rise in the UK.

So incorporating more selenium-rich food sources into your diet in your early 50’s could help reduce women’s risks of getting menopausal-linked arthritis.

Selected food sources of selenium:

Food	Micrograms (μg)	Percent DV
Brazil nuts, dried, unblanched, 1 ounce	544	780
Tuna, light, canned in oil, drained, 3 ounces	63	95
Beef, cooked, 3½ ounces	35	50
Spaghetti w/ meat sauce, 1 serving	34	50
Cod, cooked, 3 ounces	32	45
Turkey, light meat, roasted, 3½ ounces	32	45
Roast beef, lean only, roasted, 3 ounces	23	35
Chicken Breast, meat only, roasted, 3½ ounces	20	30
Noodles, boiled, 1/2 cup	17	25
Macaroni, boiled, 1/2 cup	15	20
Egg, whole, 1 medium	14	20
Cottage cheese, low fat 2%, 1/2 cup	12	15
Oatmeal, instant, fortified, cooked, 1 cup	12	15
Rice, white, long grain, cooked, 1/2 cup	12	15
Rice, brown, long-grained, cooked, 1/2 cup	10	15
Bread, enriched, whole wheat, commercially prepared, 1 slice	10	15
Walnuts, black, dried, 1 ounce	5	8
Bread, enriched, white, commercially prepared, 1 slice	4	6
Cheddar cheese, 1 ounce	4	6

Case study:

Pauline Wright, 50, is a telephone customer relations officer from Edinburgh in Scotland with two grown up children.

Pauline says:

“I am currently going through the menopause, although I think I may have had symptoms for a few years before but it wasn’t diagnosed as I was quite young to be starting the menopause.”

“My symptoms were typical in that I started getting hot flushes mostly at night, I had some mild mood swings which I really noticed because I’ve never had that sort of thing before and my menstrual cycle became irregular.”

[quote]”But one of the symptoms of the menopause I had which actually caused me more pain than anything else was that the joints in my fingers and hands really started to ache and I’d often wake up I the mornings with swollen fingers.”[/quote]

“I had started to find it harder to grip things for the first few hours after I woke up for about a year before I went through the menopause, although there was no real pain, just a few minor aches. But it was the loss of action that I noticed first. Even doing up my skirt for work became a bit tricky.”

“Before the menopause began, the pain in my fingers was not immense so I didn’t really think to bother my doctor about it, although I did mention it once and he said it was most likely to be a minor sprain as I had it worse in one hand than the other and so that was the hand I showed him.”

“But with the onset of the menopause the pain increased and became first annoying, then quite chronic, it was like a nagging ache and the swelling was a problem because it prevented me from doing simple things like opening jars or putting my make up on.”

“My mother has arthritis and although she takes medication for it, for the last year she has been using this natural cream called Boswellia and Commiphora joint rub  on her hands and knees which she told me helps with the pain and swelling. She suggested I tried some, which I did, and within a week of using it the swelling and pain in my fingers had reduced quite noticeably. After a month I could barely notice it and was able to get my rings back on my fingers, which showed just how much the swelling had gone down. I ordered myself a pot of the cream from the internet for myself and I use it every day twice a day. I find it particularly helpful for the mornings as it brings the overnight swelling down within half an hour.”

[quote]”I only wish I had thought to use Boswellia and Commiphora Joint Rub earlier when I first noticed the swelling in my fingers and the lack of movement, and I would not have had to suffer so much pain for the last few years.”[/quote]

http://www.skinmagazine.co.uk/menopausal-arthritis_8