Menopause brings health changes for every woman, including hormone changes that can lead to bone loss and heart disease. But for women who also have rheumatoid arthritis (RA), the health changes that arrive with menopause may be even more complicated.

“We have no clear evidence that menopause positively or negatively affects RA,” says Vivian Bykerk, MD, a rheumatologist at the Hospital for Special Surgery in New York City.

Ongoing research continues to unravel clues about how menopause could affect you and your RA. Studies in 2012 and 2013 suggest that women with RA may go through early menopause that the age that menopause occurs may affect RA disease activity.

“In general, women undergoing early menopause may have less severe disease,” says Eric Matteson, MD, professor of medicine and chair of the division of rheumatology at the Mayo Clinic in Rochester, Minn. “The reasons for this are as yet unclear.”

There is no clear-cut answer to the RA-menopause relationship. What is clear, doctors say, is that women with RA at menopause and beyond need to keep their RA under control and protect their overall health.

Following are six ways that menopause may affect women with RA and steps for managing such changes.

1. Estrogen levels start to drop.

Estrogen is a female sex hormone that is made mostly by a woman’s ovaries. During menopause, the body slowly stops making this hormone, triggering significant physiological changes and often-bothersome symptoms, including hot flashes. But how and whether estrogen levels influence RA itself is a complicated topic.

A topic of debate is whether hormone-replacement therapy (HRT), used to ease menopause symptoms, might prevent or relieve RA symptoms. A 2011 study of 88 postmenopausal women with RA at the University of Gothenburg in Gothenburg, Sweden, found that HRT stabilized bone mineral density, which typically decreases after menopause. Previously, researchers at the same university found that two years of HRT lessened inflammation and disease activity, and slowed joint destruction.

“Estrogen both inhibits and stimulates [certain white blood cells that play a role in] RA inflammation.  So it is hard to say that estrogen is good for all women with RA,” says Mitra Pikwer, MD, PhD, a rheumatology fellow at Malar Hospital in Eskilstuna, Sweden who has co-authored studies on the topic.

Some doctors caution against the use of HRT in patients with RA, since it increases the risk for heart disease – and a person with RA already has about a 50 percent higher risk of heart attack than someone in the general population.

What you can do:

Ask your doctor if HRT is right for you.

2. Your heart needs more TLC.

RA combined with menopause plays a double-whammy on your cardiovascular system.  As mentioned, having RA already puts you at risk for heart disease. Regular, long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids adds to that risk. And so does menopause, says rheumatologist Nathan Wei, MD, director of the Arthritis Treatment Center in Frederick, Maryland.

In 2013, researchers at the University of Pittsburgh published results of a study involving 10,000 women with self-reported RA. They found that postmenopausal women who had RA plus anti-CCP antibodies (proteins found in the blood of many people with RA) had twice the mortality rate compared to women without those factors.  The main causes of death were heart disease, including stroke, and cancer.

What you can do:

·     Do not smoke
·     Eat a healthy, balanced diet
·     Get regular exercise
·     Maintain good control of RA
If you need long-term NSAIDs or high-dose corticosteroids, talk to your doctor about ways to reduce the risk of heart-related side effects.

3. Your bones become brittle and can break more easily.

Normally, the body constantly breaks down and makes new bone. But in menopause, declining estrogen levels cause the body to lose bone faster than the body can make it. This can lead to osteoporosis. If you have RA or use long-term corticosteroids to treat inflammation, you’re already at risk for this bone disease.

“Also, if your RA is [not controlled], and you walk less and have limited mobility, your bones won’t have the stimulus of exercise, and so there is consequent bone loss,” says Dr. Bykerk.  When muscles are challenged by exercise, they pull on the bones they’re attached to, stimulating bone growth.