For the Ladies

Gentlemen, while this post may be “one for the ladies”, you might just want to stick around too, learning about this might just win you some brownie points one day! Ladies, if you’ve ever felt like some days everything hurts (when there’s “no reason”) and a few days later all is fine and well, it may be worth seeing if those sore days seem to coincide with certain days of your cycle - or on a larger scale, at a certain time in your life. While things like mood, energy levels and genitourinary symptoms have long been appreciated as being impacted by hormonal changes; the impacts on the musculoskeletal system (muscles, joints, connective tissue and bone) are perhaps less commonly discussed. To better understand the importance of hormones on these structural components of the body, we can look at correlations of musculoskeletal pain and injury to the natural fluctuations of hormones throughout a woman’s cycle each month, and of course as she goes through the joys of the hormonal storms of perimenopause and menopause. Both the monthly hormone fluctuations and the sharp decline in mid-life have effects on our muscles, joints and bones and may just be one of the things you can curse on your sore days! Let’s look at just a couple examples of hormones impacting our aches and pains. 

If you follow any of the WNBA or women’s college basketball, you may have noticed that the amount of players with ACL injuries (past or present) seems rather high compared to men - and not just slightly higher either…a lot higher! The ACL is an important ligament in the knee, preventing the shearing motion between the femur on top and the tibia below. It is thought a variety of factors may lead to the higher rate of injury to this ligament in women compared to men. We’ve got some well established strength and biomechanical factors that may predispose women to more ACL injuries than men, and more recently, we’re also realizing there may be some hormonal factors to consider as well. More specifically, the importance of the fluctuation in hormones and their impact on ligaments and muscle. 

It appears that ACL injuries in female athletes are more common during the mid to late luteal phase (roughly days 21-24 of their cycle), a time when the hormone relaxin is at higher levels (Parker et al, 2024). Relaxin increases ligament laxity by impacting the collagen fibres that make up our ligaments. Because all women are different, as are all of their cycles, it can be hard to put a finger on the exact timing of when they may be at higher risk of experiencing injury or muscle and joint pain driven by hormone changes. In addition, as the ladies know, everyone experiences hormone fluctuations differently; some can be thrown right out of sorts and others may not even notice when a change occurs. Because of this, the extent of hormone contribution to injury is individual and so it may or may not be appropriate to consider some preventative measures. 

Some suggest that women who experience increased musculoskeletal pain during certain days of their cycle may want to avoid higher-risk activity during those few days, in an effort to reduce the risk of ligament injuries. This strategy is obviously not feasible for athletes, nor is it a relevant preventative measure for all women. But for some, there just may be something to be said for listening to your body and choosing lower impact activities on the days you aren’t feeling as spry. Another strategy that has some limited support is that oral contraceptives may offer some protection, but clearly the risk-benefit ratio should be discussed on an individual basis with a qualified healthcare provider. Due to the other factors at play that may predispose women to ACL injuries, the variable has the biggest impact it is likely to vary between individuals! 

Now, to touch on the increased musculoskeletal pain some women experience during perimenopause and menopause… It is “a thing”. In fact, it’s “a thing” for A LOT of women, so much so that it is now being referred to as the musculoskeletal syndrome of menopause (Wright et al., 2024). At least 70% of women experience musculoskeletal concerns stemming from hormonal changes during the time frame from perimenopause to postmenopause (Lu et al. 2020) and estrogen is thought to be the main culprit behind this observation. Estrogen levels fluctuate during the menstrual cycle and begin a sharp decline sometime during perimenopause. We know that this decline in estrogen is associated with a loss of bone density and is one of the reasons why it’s especially important for women to participate in strength and weight-bearing activity. 

Perhaps not quite as common knowledge as its importance in maintaining bone density, estrogen is also involved in maintenance of muscle mass and strength as well as being protective from inflammation. Estrogen inhibits the release of pro-inflammatory cytokines (messengers) and can also modulate anti-inflammatory signals as well. This combination means that when estrogen levels are low, women can experience more inflammation. Cartilage structure and health is also affected by estrogen levels leading to possible increased risk of arthritis and painful joints during this time frame. To add one more cherry on top, we also think estrogen can affect pain perception, with lower levels leading to increased sensitivity to pain. While these findings are primarily in reference to the larger decline of estrogen beginning at perimenopause, it is plausible that estrogen may be at play in women who experience muscle and joint pain or inflammation at certain stages during their regular cycles as well.

Apart from hormone replacement therapy (also requiring an individual conversation with a doctor), because the decline of estrogen is a fairly non-modifiable risk factor for musculoskeletal pain, it’s important for women to be cognizant of the modifiable factors. This means as we start to reach middle age, we may need to pay more attention to things like diet, exercise and mindfulness. Ensuring a healthy diet rich in anti-inflammatory foods like fruits and vegetables and less in inflammatory processed foods and sugar becomes even more important. Pay special attention to leafy greens for maintaining vitamin D and calcium levels too. Exercise, especially weight bearing and strength training is important for maintaining bone density and muscle mass and should be done 2-3 times per week if possible. Activities like yoga, pilates and stretching can help with strength, balance and maintenance of flexibility as well. Swimming and aqua therapy can offer a more gentle form of exercise for those with painful joints and also offers an excellent way to maintain and improve cardiovascular fitness; because there is less impact on the joints getting in the pool is a great starting point or supplement to existing exercise programs.

So while the discussion of hormones and women’s health can fill entire books and should one day fill entire libraries, I hope this gave you just a little baby toe dip into the waters of realization that hormone fluctuations are involved in a whole lot more than just a chocolate craving or two!