Hormones and hypermobility
An overview of key sex hormones and their interactions with hypermobility.
Connective tissue disorders affect joint stability, skin elasticity, as well as other body systems. Recent research suggests that hormone fluctuations can play a role in variability of hypermobility related symptoms, especially for women. There is an increasing recognition of hypermobility-related disorders in the UK and a rise in use of hormone replacement therapy for perimenopausal symptoms. This should prompt a closer look at how hormonal factors can influence symptoms and quality of life for those affected by hypermobility. Currently there is very little research in this space.
Hormones are naturally present in everyone, men and women. They fluctuate throughout the course of life, particularly at puberty, midlife and into older age, as well as during menstruation, pregnancy and perimenopause. Some individuals with hypermobility syndromes (including, but not limited to hypermobility spectrum disorders, Joint hypermobility syndrome, Ehlers-Danlos syndromes, and symptomatic hypermobility) may experience variations in symptoms that relate to these hormonal changes.
For most men the hormone that is most impactful is testosterone. Understanding the impact of testosterone on joints/connective tissues/muscle may provide insights for improving the management of hypermobility disorders in everyone. Testosterone plays a key role in muscle mass and connective tissue strength. Lower levels of testosterone can lead to decreased muscle tone and further instability of hypermobile joints.
As a general rule, male puberty often brings a reduction in some of the hypermobility related issues as muscle mass is increased by their higher testosterone levels, while female puberty often brings a worsening of symptoms due to the higher progesterone levels that occur.
For women, there are generally more occasions for hormonal change and more hormones to consider. Oestrogen, progestogen, relaxin and testosterone all impact the body in ways that are relevant to hypermobility.
Table 1 below shows the impact of these hormones on the body, detailing how the effect of hormones extends beyond the reproductive system (this list could be expanded on but gives an overview of hormonal effects).
Table 1
Testosterone helps regulate libido (sex drive). In men it also regulates the production of sperm.
Oestrogen regulates the menstrual cycle, and is vital for fertility, pregnancy, and puberty in women.
Progesterone prepares the endometrium (uterus lining) for a fertilized egg to implant and grow.
Relaxin prepares the endometrium for implantation.
Note: This is not an exhaustive list.
Many hypermobile women report worsening of symptoms during specific hormonal phases including menstruation, pregnancy, and perimenopause. Fluctuations in progestogen and oestrogen levels play a part in all of these phases. In addition, relaxin induces an additional joint-loosening effect during pregnancy. . The role of hormones in exacerbating hypermobility syndromes, during these phases is often under-recognized.
Studies have indicated that oestrogen levels can affect joint laxity, particularly in women during pregnancy and post-menopause, where oestrogen levels decline sharply. There are questions about the impact of synthetic oestrogens as well, for example, in the combined pill with research showing that they may impact joint stability, particularly in individuals with hypermobility.
At the HMSA, these are two of the main issues we repeatedly encounter regarding hormones:
1. High levels of progestogen appear to be associated with increased joint laxity, with many hypermobile people experiencing worsening symptoms for the few days before, and the first few days after menstruation. It is also quite common for hypermobile people taking a progesterone-only version of birth control to experience an increase in symptoms – in which case it may be best to find an alternative.
2. Studies on female athletes have indicated that the increased risk of injury may be due to a combination of changes in joint laxity, and changes in coordination and muscle control. Given that hypermobile people already have lax joints and rely on muscle control to help stabilise those joints, it is not surprising that this effect can be amplified in some hypermobile people. It may be worth considering increased joint support of problematic joints when exercising during this part of their cycle, and/or adapting exercise routines.
The hormonal changes that happen at puberty, during the menstrual cycle, perimenopause and menopause, or with various other conditions such as polycystic ovarian syndrome or endometriosis, can cause a wide range of symptoms. The symptoms can include headaches, irritability, anxiety, low mood, mood swings, low self-esteem, poor concentration, migraines, reduced sex drive, vaginal dryness, bladder frequency, urgency, urinary leakage, worsening premenstrual syndrome symptoms, joint pain, increased ligament issues, tendonitis, hair changes, poor sleep, changes in body shape, increased allergy response, and hot flushes. The symptoms listed in bold are also often caused by or linked to hypermobility, and the combination of the two causes can amplify the severity of the symptoms.
Hormone replacement therapy (HRT) and contraceptive management can be used to support symptom management, especially in post-menopausal women or women who report worsening symptoms during their menstrual cycle. However, there needs to be consideration for the potential that hormones which we introduce to the body (e.g. contraception and HRT) may worsen hypermobility symptoms. A lot more research is needed in this area.
Supplements and lifestyle changes can also play a role in managing the combined symptoms of hypermobility and hormonal fluctuations, although the widespread lack of research into these aspects of women’s health means that the evidence base is mostly anecdotal or hypothetical.
As with many aspects of hypermobility management, it can take trial and error, and support from a relevant health care professional to find the right approach for each individual.
By the HMSA, with advice and guidance from Lexie Minter, BSc Nursing, BSc Midwifery, Nurse Prescriber, and Dr Colinette Margerison, GP with a special interest in gynaecology, BMS specialist and trainer, FSRH specialist and trainer.
Last updated 15/11/2024
Some blog posts relevant to hormones
You can find further information at:
https://www.nhs.uk/conditions/menopause/things-you-can-do/
www.minteretal.com/ More information from Lexi Minter and her colleagues on hormone health.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4282454/#:~:text=Relaxin%20is%20a%20hormone%20structurally The effect of relaxin on the musculoskeletal system - PMC (nih.gov)
https://pmc.ncbi.nlm.nih.gov/articles/PMC9958828/ Menstrual Cycle and Sport Injuries: A Systematic Review
https://pubmed.ncbi.nlm.nih.gov/26540261/ - Effects of Oral Contraceptive Use on Anterior Cruciate Ligament Injury Epidemiology - PubMed