Can hormone therapy ease arthritis after early menopause?

Question

Hello doctor,

My 43-year-old wife has had rheumatoid arthritis for seven years, but her condition has worsened significantly since she went through early menopause at age 41. Her morning stiffness now lasts more than three hours, and her hands become so swollen that she cannot even hold a coffee cup on some days.

The joint pain is most severe in her wrists, knuckles, and toes, but it has now spread to her shoulders and hips as well. She was previously on Methotrexate 20 mg weekly, which helped for a few years, but her liver enzymes (ALT 95 and AST 87) increased, so the dose had to be reduced.

She also takes folic acid and Prednisone 10 mg daily, but the steroids have caused weight gain and osteoporosis. Her rheumatologist has recommended starting Humira injections, but insurance is delaying approval and requiring her to try other medications first. Her sed rate is 89, and CRP is 67, both indicating significant inflammation from rheumatoid arthritis.

She used to be very active, but now she can barely walk up the stairs without severe pain. Could hormone replacement therapy help improve arthritis symptoms after menopause, and how concerned should we be about the risk of infections from immunosuppressive medications?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

She has long-standing rheumatoid arthritis, flaring worse after early menopause. That is expected since an estrogen drop can aggravate autoimmune diseases.

The Probable causes are hormone changes post-menopause and inadequate RA (rheumatoid arthritis) control (Methotrexate cut down, steroids side effects).

I suggest the following investigations:

DEXA (Dual-energy x-ray absorptiometry) scan (for osteoporosis).
Mammogram.
Pelvic USG (ultrasound) if considering HRT (hormonal replacement therapy).
Repeat LFTs (liver functional tests) before starting any new drug.

The differential diagnosis is either osteoarthritis on top of RA or steroid-induced bone pain, and the probable diagnosis is rheumatoid arthritis flares post early menopause.

The management of rheumatoid arthritis is HRT. Sometimes helps with menopausal symptoms, but it will not really control RA inflammation, so it is not the main solution. Safer to discuss non-hormonal options for bone and menopausal issues. Weight-bearing exercise and calcium or vitamin D supplementation. For RA control, rheumatologists need to decide on biologics like Humira, and insurance has to be worked out. Minimize long-term steroids if possible.

Please share her bone scan and hormone profile. I can guide on whether HRT is reasonable for menopausal symptoms, but RA treatment must stay under rheumatology.

To prevent RA:

Regular breast or gynec screening if on HRT.
Check if vaccinations are updated before biologic therapy.
Maintain a healthy weight, avoid smoking or alcohol.

I hope this helps.

Please follow up if you have any further concerns.

Thank you.