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 Women, Back Pain, and Hormones
Ross Hauser,
M.D.
During pregnancy, a woman's body secretes a hormone called relaxin which causes
ligament to loosen in preperation for birth.
Ligament
laxity is normal during
pregnancy.
Relaxin's effects include the production and remodeling of
collagen, increasing
the elasticity and relaxation of muscles,
tendons, and
ligaments.
The point is that relaxin has a direct negative effect on the strength of
collagen. Relaxin is secreted by all females, the highest levels being during
the middle of the luteal phase (ovulation) of the menstrual cycle (days 20-23).
Because of the double whammy of estrogen and relaxin, women have increased
ligamentous
laxity and flexibility compared to men. This excessive laxity is the reason
that there is an increased incidence of
patellar subluxations and ligament sprains seen in female athletes. (Glick,
J. The female knee in athletics. Physician and Sports Medicine. 1973;
1:35-37.;Powers, J. Characteristic features of injuries in the knees of women.
Clin. Orthop. Rel. Res. 979; 143:120-124.) This laxity is especially present
during pregnancy when the risk of
ankle sprains and ligamentous injuries is
highest. (Lutter, J.M., Lee, V. Exercise in pregnancy. In Pearl AJ, (ed.), The
Female Athlete in Human Kinetics. Champaign, IL: 1993; p. 81-86.) If this was
not bad enough,
articular cartilage see also
Articular
Cartilage Growth
(see research paper)
has estrogen receptors located on it. Like ligamentous
tissue, estrogen has a direct negative effect on cartilage growth and repair. (Rosner,
I. Estradiol receptors in articular cartilage. Biochem. Biophys. Res. Commun.
1982; 106:1378-1382.)
The net effect of all of this is that the joints of females, even females who
have no pain whatsoever, are not normal. They cannot possibly be normal because
of all the negative effects of estrogen as the prime instigator and relaxin as a
lessor instigator. The turnover time (or half-life) of
ligaments and cartilage
is about one to two years. This means that about half of the cartilage or
ligaments is regenerated about every 300 to 700 days. This is a very, very slow
rate. Fibroblastic cells, which make collagen, and
chondrocytes that make cartilage tissue, are stable cells in the fact that
they do not proliferate easily. They need to be stimulated to proliferate.
Injury to tissue stimulates them to some degree, but exercise does not
noticeably change this rate. The primary way to stimulate the
fibroblasts and
chondrocytes (see research paper) is by direct proliferative therapy (Prolotherapy).
Prolotherapy injections are given right where the fibroblasts and chondrocytes
are located-at the
fibro-osseous
junction. This is where ligaments attach to
bone or directly on the outside of the cartilage. This causes a massive
stimulation of fibroblastic and chondrocyte growth, with the net effect being
ligament and cartilage growth. It is this treatment that offers the only hope to
women to not only get rid of their
chronic pain, but also cure their sports injuries
Jan Brynhildsen and colleagues from the Department
of Obstetrics and Gynecology, Faculty of Health Sciences, University Hospital,
Linkoping, Sweden, sent questionnaires to 1,324 women who were in menopause.
This questionnaire included questions about current hormone replacement
treatment, previous and current
back pain, medical care for back
problems, parity, exercise and smoking habits, and occupation. The questionnaire
was returned by 85 percent of the women. There was a significant positive
association between current use of hormone replacement treatment and
low back pain. Previous back problems
during pregnancy was a strong risk factor for current back pain, whereas neither
current smoking nor regular physical exercise was a risk factor (nor was
exercise protective). Their conclusion was that women receiving hormone
replacement treatment had a significantly higher prevalence of current back pain
than non-users, which could not be explained by differences in occupation,
smoking habits, or current physical activity. (Brynhildsen, J. Is hormone
replacement therapy a risk factor for
low back pain among postmenopausal women?
Spine. 1998; 23:809-813.) They speculated that hormonal effects on joints and
ligaments may be involved.
Others have also speculated that oral contraceptive pills are a risk factor for
low back and pelvic pain among women. The theory proposes that estrogen steroid
hormones affect joints and ligaments, leading to
pubic symphysis weakening and low back pain. In our opinion, this is not
theory, but fact. Estrogen negatively affects collagen growth with only one
result emerging, and that result is not good. Many general practitioners,
gynecologists,
orthopedic, midwives, and physiotherapists (at least in Sweden)
believe there is an association between the use of these estrogen pills and the
development of back problems. Approximately one-fourth of the active
professionals in Sweden recommend that some women with back problems abandon
their use of oral contraceptives. (Brynhildsen, J. Oral contraceptives and low
back pain: Attitudes among physicians, midwives and physiotherapists. Acta.
Obste. Gynecol. Scan. 1995; 74:714-717.) Many believe the oral contraceptives
increase the risk of back problems, just like what occurs during pregnancy. As
many as 50 percent of all women experience back problems during pregnancy.
Because back problems develop so early during pregnancy, they cannot be
explained as related only to the increased mechanical stress from the weight
gained in the front of the body; therefore, hormonal factors have been proposed
as the cause. Sex hormones are thought to affect ligaments and increase
flexibility in the
pelvis. This increased flexibility, or laxity, then leads to
the low back pain.
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