Menopause and Rheumatoid Arthritis: Are we asking enough? Save

Pain, fatigue and poor sleep are common concerns for people living with rheumatoid arthritis (RA). In women approaching or experiencing menopause, however, we should also consider whether some of these symptoms relate to the menopause. Joint and muscle pain, mood changes and sleep difficulties are recognised menopause-associated symptoms. Yet, how often does menopause feature in our assessment of a woman with RA whose symptoms have worsened?

What did the study find?

A study from Mayo Clinic at this year’s ACR Convergence, abstract 1849 examines menopause symptom burden in women with and without RA. Using two research datasets, Kristen Young and colleagues conducted a cross-sectional analysis of 9,356 women aged 40-65, of whom 215 had RA. The investigators used the validated 11-item Menopause Rating Scale (MRS), which assesses somatic, psychological and urogenital symptoms.

Women with RA reported greater menopause symptom severity. Using the investigators’ threshold of MRS ≥12, 72.1% of women with RA had clinically significant symptom burden, compared with 56.5% of women without RA. The association persisted in multivariable analysis, with approximately twice the odds of reaching this threshold in women with RA (OR 1.96, 95% CI 1.44-2.67).

Interestingly, systemic hormone therapy use did not differ significantly between groups. Obesity was more common in women with RA, affecting 38.1%, compared with 29.9% of those without RA. The authors concluded that RA was associated with greater menopause symptom burden independently of age, obesity and hormone therapy use. 

Why does this matter in clinical practice?

The difference in symptom burden is stark. It also raises a practical question: are we asking enough about menopause when assessing symptoms in our patients with RA?

The MRS includes symptoms such as joint and muscle discomfort, exhaustion, sleep problems and psychological symptoms. These are relevant to a rheumatology consultation, but the questionnaire does not assign their cause. In practice, we need to understand how symptoms have changed, their relationship to the menstrual history, and their impact on daily life. The conversation must also be individualised to the patient, given the variation in symptoms that can arise during the menopause.

What can rheumatologists do?

A woman may describe worsening fatigue and pain while her joints remain quiescent. We should still assess for inflammatory disease activity, but this is also an opportunity to ask about sleep, menstrual changes, night sweats and other menopause-associated symptoms. Equally, recognising menopause should not become a reason to dismiss new symptoms or overlook active RA. Both need to be considered.

There is a role for rheumatologists here, even where menopause treatment is usually managed elsewhere. We can open the discussion, identify symptoms that need further assessment, and help patients access appropriate care through primary care or menopause services. Where treatment is considered, management should take account of the patient’s preferences, medical history and individual risks, alongside advice on bone health and maintaining muscle strength.

We routinely ask whether RA treatment is controlling inflammation. We should also ask what else may be contributing to the patient’s symptoms, particularly when the clinical assessment does not explain how unwell a person feels. Menopause is one part of that assessment. Including it in the conversation could help us give more useful advice and direct patients towards support they might otherwise miss.