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Date of release: 28 September, 2009

Female sex hormones and osteoarthritis


Osteoarthritis or degenerative joint disease is characterized by the breakdown of articular cartilage, which leads to rubbing and friction of adjacent bones and consequent local inflammation, pain and impaired movement. Osteoarthritis is associated with aging and is more prevalent in menopausal women, suggesting a role for female hormone deficiency in its etiology [1]. A recent review by Christiansen’s group pointed at the direct and indirect effects of estrogen on articular cartilage, as well as the importance of hormone therapy for maintaining not only bone but also cartilage health in postmenopausal women [2]. However, another systematic review now published in Rheumatology concluded that there is no clear association between female sex hormones and osteoarthritis of the hand, hip and knee [3]. The review used the Medline and EMBASE search engines to search for articles that assess the association between osteoarthritis of the hand, hip or knee and female sex hormones. The determinants included endogenous hormones, age at menarche and/or menopause, duration of fertile period, menopausal status, years since menopause and surgical menopause.


 


Concerning age at menarche, only two studies [4, 5] have found that a younger age increased the risk of osteoarthritis, but other studies did not find such an association. There was no association between osteoarthritis and the duration of the fertile period. Endogenous early follicular phase estradiol concentration did not correlate with radiological knee osteoarthritis, but data are limited concerning the association of low blood estradiol levels and the incidence of knee osteoarthritis. There were conflicting data on the relation of age at menopause with hand osteoarthritis; for hip or knee osteoarthritis, there was overall moderate evidence suggesting no relationship. In addition, years since menopause did not correlate with knee or hand osteoarthritis. Interestingly, the data concerning surgical menopause are conflicting; those reported by Spector and colleagues indicated that the rate of hip osteoarthritis was lower in those women who had both ovaries removed [6], whereas the other report demonstrated a protective effect for radiological hip osteoarthritis following bilateral oophorectomy [7].

Comment

Osteoarthritis is the most common cause of locomotor disability in the elderly. It causes joint pain, bony and soft tissue swelling, tenderness, bony crepitus, peri-articular muscle atrophy, bony hypertrophy, deformity and marked loss of joint motion. It commonly affects the hands, feet, spine and large weight-bearing joints. It can present as localized, generalized or as erosive osteoarthritis [8]. The paper by de Clerk and colleagues confirmed no association between osteoarthritis and female sex hormones, but the fact remain that the burden of disease has a high impact on a woman’s life after menopause. Possibly, genetic predisposition plays an important role in the etiology.
 
The risk factors increase with age, especially in women over 45 years old [9, 10], resulting in a 45% less risk of incidence in men. Additional factors that increase the risk of developing osteoarthritis, especially of the knee, include excessive body mass [11], specific occupations, repetitive knee bending or heavy lifting. For osteoarthritis of non-weight-bearing joints like the hand, it is unclear whether the Herberden’s node plays any role.
 
The etiology of osteoarthritis is complex and many risk factors can be avoided. Even though this systemic review paper found no correlation between female sex hormones and osteoarthritis, all premenopausal women should be recommended to undertake appropriate lifestyle changes, receive education about behavioral interventions, take brisk walks, and perform low-impact aerobic exercises and exercises to strengthen the quadriceps, especially in cases of osteoarthritis of the knee. It is very important for overweight and obese women to lose weight and then to maintain their weight at a lower level. 
 
Pharmacological treatment can relieve the symptoms of pain. Minimal invasive surgery like joint lavage or intra-articular joint injection should only be considered by the specialist.

Comentario

Khunying Kobchitt Limpaphayom
President of Thai Menopause Society, Department of Obstetrics & Gynaecology, Faculty of Medicine, Chulalongkorn University, Thailand

    References

  1. Herrero-Beaumont G, Roman-Blas JA, Castaneda S, Jimenez SA. Primary osteoarthritis no longer primary: three subsets with distinct etiological, clinical, and therapeutic characteristic. Semin Arthritis Rheum 2009 Jul 7. [Epub ahead of print].
    http://www.ncbi.nlm.nih.gov/pubmed/19589561

  2. Tanko LB, Sondergaard BC, Oestergaard S, Karsdal MA, Christiansen C. An update review of cellular mechanisms conferring the indirect and direct effects of estrogen on articular cartilage. Climacteric 2008;11:4-16.
    http://www.ncbi.nlm.nih.gov/pubmed/18202960

  3. de Klerk BM, Schiphof D, Groeneveld FP, et al. No clear association between female hormonal aspects and osteoarthritis of the hand, hip and knee: a systematic review. Rheumatology 2009;48:1160-5. Published September 2009.
    http://www.ncbi.nlm.nih.gov/pubmed/19608726

  4. Kalichman L, Kobyliansky E. Age, body composition, and reproductive indices as predictors of radiographic hand osteoarthritis in Chuvashian women. Scand J Rheumatol 2007;36:53-7.
    http://www.ncbi.nlm.nih.gov/pubmed/17454936

  5. Liu B, Balkwill A, Cooper C, Roddam A, Brown A, Beral V. Reproductive history, hormonal factors and the incidence of hip and knee replacement for osteoarthritis in middle-aged women. Ann Rheum Dis 2009;68:1165-70.
    http://www.ncbi.nlm.nih.gov/pubmed/18957480

  6. Spector TD, Hart DJ, Brown P, et al. Frequency of osteoarthritis in hysterectomized women. J Rheumatol 1991;18:1877-83.
    http://www.ncbi.nlm.nih.gov/pubmed/1795326

  7. Nevitt MC, Cummings SR, Lane NE, et al. Association of estrogen replacement therapy with the risk of osteoarthritis of the hip in elderly white women. Study of Osteoporotic Fractures Research Group. Arch Intern Med 1996;156:2073-80.
    http://www.ncbi.nlm.nih.gov/pubmed/8862099

  8. Mahajan A, Tandon V, Verma S, Sharma S. Osteoarthritis and menopause. J Indian Rheumatol Assoc 2005;13:21-5.


  9. American Academy of Orthopedic Surgeons. The burden of musculoskeletal diseases in the United States. American Academy of Orthopedic Surgeons, 2008.
    http://www.aapmr.org/zdocs/member/bmus_executive_summary_low.pdf

  10. Felson DT. The epidemiology of knee osteoarthritis: results from the Framingham Osteoarthritis Study. Semin Arthritis Rheum 1990;20(3 Suppl 1):42-50.
    http://www.ncbi.nlm.nih.gov/pubmed/2287948

  11. Lievense AM, Bierma-Zeinstra SMA, Verhagen AP, van Baar ME, Verhaar JAN, Koes BW. Influence of obesity on the development of osteoarthritis of the hip: a systematic review. Rheumatology 2002;41:1155-62.
    http://www.ncbi.nlm.nih.gov/pubmed/12364636