The Musculoskeletal Syndrome of Menopause

Wright el al. have recently published a review article on the musculoskeletal syndrome of menopause – a complex issue that affects millions of women worldwide. 

The Role of Estrogen in Musculoskeletal Health

Estrogen plays a crucial role in maintaining bone density, muscle mass and tendon structure. It helps to:

• Stimulate bone formation: Estrogen promotes the activity of osteoblasts, cells responsible for building new bone tissue.
• Inhibit bone resorption: It reduces the activity of osteoclasts, cells that break down bone tissue.
• Maintain muscle mass: Estrogen helps to regulate muscle protein synthesis and breakdown, preventing excessive muscle loss.
• Maintain tendon structure and function: It influences collagen metabolism and maintains optimal tendon stiffness.
• Maintain healthy joints: Estrogen helps decrease inflammation and maintain joint structure.

When estrogen levels decline during menopause, these processes become imbalanced, leading to bone loss, increased risk of fractures, muscle atrophy, joint pain and stiffness, and increased predisposition to tendinopathies and risk of tendon ruptures.

Risk Factors for Musculoskeletal Syndrome of Menopause

Several factors can increase a woman’s risk of developing musculoskeletal issues during or after menopause:

• Genetics: A family history of osteoporosis or other bone disorders can increase susceptibility.
• Lifestyle factors: Smoking, excessive alcohol consumption, and a sedentary lifestyle can contribute to bone loss and muscle weakness.
• Nutrition: Inadequate intake of calcium and vitamin D can impair bone health.
• Medical conditions: Certain conditions, such as autoimmune diseases or thyroid disorders, can affect bone metabolism.

Treatment and Prevention Strategies

While there is no cure for the musculoskeletal syndrome of menopause, effective management strategies can help alleviate symptoms and improve quality of life. These include:

• Hormone replacement therapy (HRT): When used appropriately, HRT can help maintain bone density and reduce the risk of fractures. However, it’s important to discuss the potential risks and benefits with a healthcare provider.
• Lifestyle modifications: Regular exercise, especially weight-bearing activities, can help strengthen bones and muscles. A balanced diet rich in calcium, vitamin D, and protein is also crucial.
• Medications: In some cases, medications like bisphosphonates or selective estrogen receptor modulators (SERMs) may be prescribed to treat osteoporosis.
• Supplements: Calcium and vitamin D supplements can be beneficial for maintaining bone health.

By understanding the causes, risks, and treatment options for the musculoskeletal syndrome of menopause, women can take proactive steps to protect their health and well-being during this important life stage.

Meditation and the Brain

Meditation can be defined as “a family of mental training practices aimed at monitoring and regulating attention, perception, emotion and physiology” (Fox and Cahn, 2019). As with other forms of learning, meditation has the potential to change the brain (neuroplasticity). Fox and Cahn (2019) reviewed decades of meditation research in a paper entitled “Meditation and the brain in health and disease”. Here are some of their findings. The table below summarises the areas of the brain that have been implicated in meditation.

Brain Region	Function
Insula	Awareness of internal environment (breathing, heartbeat, abdominal sensations, etc.)
Somatosensory Cortex	Awareness of external environment (touch, pain, etc.)
Rostrolateral Prefrontal Cortex	‘Higher’ thinking ability
Anterior Cingulate Cortex	Emotional awareness and regulation
Hippocampus	Memory
Corpus Callosum	Integration of information between the 2 hemispheres

Although “psychologically distinct meditation practices show correspondingly diverse neural correlates”, most practices modulate activity in the insula. Given that awareness of breathing or other body sensations is central to most forms of meditation, and the insula’s role in the awareness of the internal environment, it’s not surprising that meditation leads to a change in structure and function of the insula.

Some interesting discoveries have been made regarding pain. The experience of pain is the combination of the purely sensory aspect of pain with feelings of distress, thoughts relating the pain to the self and various negative emotional interpretations of the experience. “These cognitive-affective elaborations appear to be dissociable from, and temporarily subsequent to, the purely sensory aspects of pain – and what’s more, they may contribute significantly to the subjectively experienced unpleasantness of nociceptive experience (Rainville et al., 1997)”. Meditators were found to have lower pain sensitivity. This may be due to their decreased functional connectivity between primary sensory pain areas and secondary affective-elaborative areas. This supports the idea that seasoned meditators remain focussed on purely sensory aspects of pain whereas non-meditators dwell on emotional and cognitive associations of pain.

Other fascinating discoveries are the impact of meditation on aging. There is usually a decrease in function (glucose metabolism) and structure (amount and density of grey matter) of the brain with aging. However, studies show that meditation may help stave off the effects of aging. In fact, some studies have found no age-related decline in function and/or structure!

But, the limitations of current research must be acknowledged:

• It’s a new field of inquiry
• Agreement amongst researchers is the exception rather than the norm
• Few studies control for factors that may exist between meditators and controls e.g. Diet, stress, sleep, personality, etc.
• Publication bias (the preferential publication of only positive studies)

Pain and Sleep

A few days ago, Krause et al. from the University of California (Berkeley), published the results of their research on the relationship between pain and sleep. They found that poor sleep quality was linked to increases in pain experience, whereas better sleep quality decreased pain. Krause notes that “the results clearly show that even very subtle changes in nightly sleep – reductions that many of us think little of in terms of consequences – have a clear impact on your next-day pain burden”. In the laboratory, they were able to identify that sleep deprivation amplifies the reactivity in parts of the brain (somatosensory cortex) responsible for the perception of pain. Whilst deactivating the responses from some pain relieving centres (insula and nucleus accumbens).

The irony is that pain often disrupts sleep, and thus the pain experience gets magnified and a vicious cycle is created.

How Does Cannabis Relieve Pain?

The use of cannabis to relieve pain is controversial, not just for legal reasons but also because of the conflicting research findings with regards to its efficacy. A recent study by Martin De Vita et al., from Syracuse University in New York, looked into the effects of cannabis on pain. They selected, reviewed and analysed studies that had researched the effect of cannabis on experimentally induced pain. De Vita et al. conclude that “although the cannabinoids examined in this review may prevent the onset of laboratory-induced pain by increasing pain thresholds, they do not appear to reduce the intensity of experimental pain that is already being experienced. Instead, these substances make experimental pain feel less unpleasant and more tolerable, suggesting a notable influence on affective processes. The cumulative research synthesized in this review has helped characterize how cannabis and cannabinoids affect different dimensions of pain reactivity.”

There are 2 components to pain: the purely sensory component and the affective (emotional) component. It’s been known for a while that opioids and our endogenous opioid pathways play an important role in sensory pain perception. It now appears that cannabis and our endogenous cannabinoid pathways play a part in the emotional dimension of pain. Interestingly, mindfulness meditation, which has proven effects on pain relief, doesn’t use opioid pathways. In fact, the mechanisms underlying mindfulness meditation’s pain-relieving effects are as yet unknown. Could it be possible that they employ cannabinoid receptors and pathways?

Acceptance and Commitment Therapy Helpful for Chronic Pain

Yu et al recently published the results their study on the effects of acceptance and commitment therapy (ACT) in people with chronic pain. The article appeared in last month’s issue of Journal of Pain. ACT “is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to “move toward valued behavior”. Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoiding situations where they are invoked” (Wikipedia).

The study involved over 400 hundred adults referred to a pain management clinic. Treatment significantly improved pain acceptance, pain-related interference, work and social adjustment and depression. This was true immediately post-treatment as well as at a 9-month follow-up. ACT also changed something known as “self-as-context” (SAC). SAC can be described as “the you that is always there observing and experiencing and yet distinct from one’s thoughts, feelings, sensations, and memories” (Wikipedia). Of note was the fact that positive changes in “self-as-context” were associated with positive changes in outcomes.

It’s really interesting how acceptance and commitment therapy has incorporated Buddhist principles and techniques such as mindfulness, acceptance and the self. In fact, it seems that the use of Buddhist philosophy and principles are becoming more common within therapy nowadays.

Chronic Pain Linked to Memory Decline and Dementia

A study by Whitlock et al from the University of California, published in this month’s Jama Internal Medicine, looked into the relationship between persistent pain, memory decline and dementia. Over 10,000 senior citizens (median age of 73 years) from the Health and Retirement Study were followed for 12 years.

At baseline, persistent pain affected 11% of participants and was linked with more restrictions in daily activities and more symptoms of depression. Those with persistent pain had a greater risk (9%) of having a more rapid memory decline than those without pain. They also had a smaller increase in risk (2%) of developing dementia. These changes significantly increased the chances of being unable to manage medications (16%) or finances (12%).

What’s the causal connection between chronic pain, memory decline and dementia? The authors believe the severity of pain can decrease attention capacity and impair memory consolidation. Additionally, pain leads to stress, and stress has been shown to promote cognitive decline, mainly through hypotrophy of the hippocampus. In my opinion, the disruption of sleep can also contribute to poor memory and a decline in cognitive ability because, as we know, sleep is involved in memory processing and consolidation.

Fortunately, physiotherapy, rehabilitation, relaxation and mindfulness meditation are effective at addressing chronic pain.

Shared Reading Improves Mood and Decreases Pain

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Earlier this year Billington et al. from the University of Liverpool published the results of their study looking at the effects of shared reading (SR) on people with chronic pain. The shared reading model they used was the one employed by the charity “The Reader“. “The Reader is an award-winning charitable social enterprise working to connect people with great literature through shared reading. We’re here to bring books to life, creating welcoming environments in which personal feeling is recognised and valued, forming vital connections between people and literature through which everyone can feel more alive.”

The researchers concluded “Qualitative evidence indicates SR’s potential as an alternative or long-term follow-up or adjunct to CBT in bringing into conscious awareness areas of emotional pain otherwise passively suffered by patients with chronic pain. In addition, quantitative analysis, albeit of limited pilot data, indicated possible improvements in mood/pain for up to 2?days following SR. Both findings lay the basis for future research involving a larger sample size.”

The preliminary findings are encouraging. There may be other factors such as distraction, social bonding and the benefits of having regular scheduled activities that may also play a part in improving the well-being of the participants.

“When touched with a feeling of pain, the uninstructed run-of-the-mill person sorrows, grieves, and laments, beats his breast, becomes distraught. So he feels two pains, physical and mental. Just as if they were to shoot a man with an arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows.”

Buddha

Persistent Pain Associated With DNA Changes In Brain And Immune Systems

Renaud Massart et al from McGill University have recently published an article in Scientific Reports on the effects of chronic pain on the body. “Chronic pain” is pain that has lasted for 6 months or more. The study was performed on rats with induced nerve injuries.

The results showed epigenetic changes in the DNA of the prefrontal cortex and in the DNA of T cells. Their findings support the notion that persistent pain affects multiple biological systems. It’s possible that future research will show changes to other systems as well.

Why Do Statins Sometimes Cause Muscle Problems?

Statins are widely used to lower cholesterol and reduce the risk of cardiovascular disease. Like a lot of drugs, statins come with some side effects. Myopathy, in the form of muscle weakness, pain and cramps is one of the most important adverse effects. A group of researchers from Radboud University Medical Center in the Netherlands may have found out why statins can sometimes cause muscle problems. Their findings are published in this month’s issue of Cell Metabolism.

They found that statins can significantly inhibit mitochondrial (complex III) activity. This effect is primarily from statin lactones rather than the acid forms. These findings could lead to new classes of cholesterol-lowering drugs without the unwanted muscle effects.