By Yuichi Hirase, MD

Hand surgeons know from experience that hand and finger disorders develop mainly during or after menopause, whereas clinicians often explain to patients with Heberden’s nodes or Bouchard’s nodes that the symptoms have been caused by aging or overuse, and that they cannot be cured. But hand surgeons should understand that there is a problem in the clinicians’ approach because joint degeneration is not caused by aging and overuse. Hand surgeons sometimes cannot sufficiently tell a patient why her left fingers hurt in spite of the fact that she is right hand dominant. They also cannot explain why there are women who do not complain of a hand disorders in the same generation as the patient.

It has been pointed out recently that such finger disorders may be deeply related to changes in female hormones, particularly estrogen.

Estrogen performs innumerable actions in every part of the body, but in order for it to exhibit its effects, it needs to bind to an estrogen receptor  (hereinafter refer to as “ER” ). There are two types of ERs, ERα and ERß. ERα exists in organs such as the uterus, ovaries, mammary glands, and kidneys. ERß exists in the bones, brain, liver, prostate gland, blood vessel walls, lung thyroid gland and bladder. An important point is that ERß is contained in large amounts in the synovia of the articular capsule, tendon sheath and ligaments^1,2). These organs are influenced by estrogen via ERß ^3-5). A decline of estrogen causes synovia to thicken during and after  menopause. Tenosynovitis tends to occur easily, and the risk of trigger finger increases. A long term trigger finger at the A1 pulley causes chronic traction of the PIP joint. The cartilage of the PIP becomes damaged gradually and  Bouchard’s nodes are established. Pressure on the median nerve due to  swelling of the synovial tissue in the carpal tunnel causes carpal tunnel syndrome. In addition, low estrogen levels over a long term lead to joint swelling, and wearing of joint cartilage. The wearing of the joint cartilage then induces narrowing of the joint space, causes the ligament to loosen, and increases the risk of subluxation. Subluxation often observed in a Heberden’s node or in thumb CMC joint osteoarthritis may be occurring through such process. In other words, it is strongly inferred that, if a low-estrogen state continues during or after menopause, it can cause swelling of the synovial membranes around joints or tendons, and this can develop into trigger finger, de Quervain disease, carpal tunnel syndrome, Heberden’s nodes, Bouchard’s nodes, or thumb CM joint osteoarthritis⁶⁾. In the postpartum lactation period, a low estrogen level can cause finger symptoms, but if the estrogen level improves after termination of breast-feeding, the finger symptoms gradually ease.

The estrogen level in a male does not greatly change during his life. However, in a female, the estrogen level decreases significantly during menopause. After menopause, the estrogen level in a female is lower than the estrogen level in a male, and it even becomes lower than the testosterone level. After menopause, the body of the woman suffers a predominance of male hormones⁷⁾.

When providing a consultation to a patient after menopause, not only a medical examination of the hand but also an understanding of the clinical background is necessary.

References

1 ) Engdahl C, Börjesson AE, Forsman H et al.  The role of total and cartilage-specific estrogen receptor alpha expression for the ameliorating effect of estrogen treatment on arthritis.  Arthritis Research & Therapy.  2014;16(4):R 150

2 ) Setchell KD   Dietary isoflavones: biological effects and relevance to human health  J. Nutr. 1999 ;129(3):758S-767S

3 ) Maffuli N, Waterston SW, Squqir J, Reaper J, Douglas AS . Changing incidence of Achilles tendon rapture in Scotland; a 15-year study. Clin J Sport Med1999 ;9:157-160

4 ) Hansen M and Kjaer M Sex hormones and tendon. Adv Exp Med Biol. 2016;920:139-49

5 ) Shen PC, Wang PH, Wu PT, Wu KC, Hsieh JL, Jou IM　The Estrogen receptor-β expression in De Quervain’s Disease.　 Int J Mol Sci. 2015;16(11):26452-62

6 ) HiraseY  Hands and Fingers Disorder as a Women’s Disease – Why my hands and fingers hurt or grow numb. Clinics in Surgery 2018;3:1-5 (Article 2170) open access

7 ) Khosla S, Melton LJ, Atkinson EJ, O’Fallon WM, Klee GE, Riggs BL Relationship of serum sex steroid levels and bone turnover markers with bone mineral density in men and women : A key role for bioavailable estrogen. J Clinical Endocrinology and Metabolism 1998; 83(7):2266-2274