The effect of hormone replacement therapy and the experience of chronic musculoskeletal pain in post-menopausal women: A systematic review 

Problem

Around 13 million people, equivalent to a third of the entire UK female population are currently peri or menopausal. Fluctuating oestrogen levels of the perimenopause and the subsequent oestrogen deficiency of the menopause result in a plethora of symptoms. These symptoms include the typical vasomotor symptoms of hot flushes and night sweats. However, women frequently report non-vasomotor symptoms such as mood changes, cognitive dysfunction, sleep disturbance, fatigue, loss of libido and musculoskeletal pain. Musculoskeletal pain, arthralgia and arthritis are all more common in women, and their prevalence increases with age and in some, appears to be associated with the menopause. For example, the prevalence of osteoarthritis rises exponentially in women over men at the age of menopause. It has been hypothesised that oestrogen has pain the pathogenesis of common MSK conditions. However, evidence is often conflicting. This living systematic review aims to summarise evidence of associations between hormone replacement therapy (HRT) and its effect on the experience of chronic musculoskeletal pain. 

Approach

A comprehensive search of seven databases (e.g., Medline, Embase) from inception until May 2023 was conducted. The search, including terms for HRT and musculoskeletal pain was run in tandem with a search including terms for menopause and musculoskeletal pain. Inclusion criteria: studies reporting the effects of non-contraceptive hormone replacement on outcomes relating to chronic painful musculoskeletal conditions in women experiencing the peri / menopause. Title, abstract and full text screening were conducted independently by two reviewers. Data extraction and risk of bias assessment was by one reviewer with independent verification. Risk of bias was assessed using the JBI critical appraisal tool appropriate for the study type. Data is beings synthesised narratively, with meta-analysis to estimate the pooled-effect of HRT on specific painful musculoskeletal conditions, where appropriate. The protocol is registered on PROSPERO CRD42023467911.

Findings

28929 titles, published from database inception to May 2023, have been identified. 346 full texts have been screened and 70 studies included. These papers examine the association between HRT and musculoskeletal conditions including osteoarthritis, rheumatoid arthritis, temporomandibular joint disorder, greater trochanteric pain syndrome, gout, carpel tunnel, fibromyalgia, back and neck pain and chronic upper extremity pain. At the conference we will present the results of this systematic review to help guide clinical practice and guidelines on the use of HRT, particularly for menopausal women whose predominant symptom is musculoskeletal pain.

Consequences

To our knowledge, this is the most comprehensive systematic review examining the association between HRT and chronic musculoskeletal pain in menopausal women. It extends to conditions including osteoarthritis, rheumatoid arthritis, gout, carpel tunnel, fibromyalgia and generalised joint and muscle pain. This evidence will help guide clinical practice and guidelines on the use of HRT, particularly for menopausal patients whose predominant symptom is musculoskeletal pain, as well as future research into this area.