Prz Menopauzalny. 2015 Sep; 14(3): 203–207.

Published online 2015 Sep 30. doi: 10.5114/pm.2015.54347

PMCID: PMC4612559
PMID: 26528111

Low back pain in women before and after menopause

Mateusz Kozinoga, 1,2
Marian Majchrzycki,3 and Sylwia Piotrowska4
Low back pain is a massive problem in modern population, both in social and economic terms. It affects
large numbers of women, especially those aged 45-60. Going through a perimenopausal period is
associated with many symptoms, including low back pain.

As their life expectancy increases, contemporary women live a third of their

life in menopause [1]. Chronic pain is more prevalent in women than in men,
and it increases with age [2–4]. According to Whelan et al., even 80% of
women suffer from various symptoms (including pain) in the perimenopausal
period (which is usually defined as the age range of 45-55) [5].
Going from a premenopausal period to a postmenopausal one is a result of
slower production of female hormones by ovaries. This process is gradual
and spread over time, and a natural part of aging. Numerous symptoms
associated with the perimenopausal period have been identified. Physical
ones can include spine and joint pain, hot flashes, night sweats, chronic
tiredness; psychological symptoms can include irritation and anxiety, mood
swings, depression and sleep disorders. The analyzed studies showed an
association between the menopausal period and depression, hot flashes and
sleep disorders but little attention was paid to pain (in spine and peripheral
joints) as an equally prevalent symptom associated with this period of life
Most studies [1, 10–12] divided women into five groups:
1. Premenopausal women who had had a regular period in the past three
months.
2. Early perimenopausal women who had an irregular period in the past
three months.
3. Late perimenopausal women who had menstruated irregularly in the
last 12 months but not in the last 3 months.
4. Postmenopausal women who had not menstruated in the last 12
months.
A separate group of women who have hormone replacement therapy.
All analyzed studies showed that women who are experiencing or
experienced menopause suffered from increased joint and spine pain.
According to Dugan et al. [10], 61% of women in the study group of 2218
reported lumbar spine pain. Back pain experienced at least once in two
weeks prior to the study was reported by 56% of 294 women in group 1
(premenopausal), 65% of 856 women in group 2 (early perimenopausal),
59% of 137 women in group 3 (late perimenopausal) and 61% of 152 women
in group 4 (postmenopausal). Additionally, an association between increased
BMI and increased pain was observed, which probably is a result of increased
mechanical loading of the spine. Mitchell and Woods [12] divided their study
subjects into similar groups. In group 1 (late reproductive stage), of 196
women, 81.6% reported pain; in group 2 (early transition stage), of 171
women, 77.8% reported pain; in group 3 (late transition stage), of 106
women, 83% reported pain; in group 4 (early postmenopause), of 67 women,
80.6% reported pain

What causes lower back pain?

The vast majority of low back pain is mechanical in nature. In many cases,
low back pain is associated with spondylosis, a term that refers to the
general degeneration of the spine associated with normal wear and tear that
occurs in the joints, discs, and bones of the spine as people get older. Some
examples of mechanical causes of low back pain include:

 Sprains and strains account for most acute back pain. Sprains are caused
by overstretching or tearing ligaments, and strains are tears in tendon or muscle.
Both can occur from twisting or lifting something improperly, lifting something
too heavy, or overstretching. Such movements may also trigger spasms in back
muscles, which can also be painful.

 Intervertebral disc degeneration is one of the most common mechanical

causes of low back pain, and it occurs when the usually rubbery discs lose
integrity as a normal process of aging. In a healthy back, intervertebral discs
provide height and allow bending, flexion, and torsion of the lower back. As the
discs deteriorate, they lose their cushioning ability.

 Herniated or ruptured discs can occur when the intervertebral discs

become compressed and bulge outward (herniation) or rupture, causing low back
pain.
 Radiculopathy is a condition caused by compression, inflammation and/or
injury to a spinal nerve root. Pressure on the nerve root results in pain,
numbness, or a tingling sensation that travels or radiates to other areas of the
body that are served by that nerve. Radiculopathy may occur when spinal
stenosis or a herniated or ruptured disc compresses the nerve root.

 Sciatica is a form of radiculopathy caused by compression of the sciatic

nerve, the large nerve that travels through the buttocks and extends down the
back of the leg. This compression causes shock-like or burning low back pain
combined with pain through the buttocks and down one leg, occasionally
reaching the foot. In the most extreme cases, when the nerve is pinched between
the disc and the adjacent bone, the symptoms may involve not only pain, but
numbness and muscle weakness in the leg because of interrupted nerve
signaling. The condition may also be caused by a tumor or cyst that presses on
the sciatic nerve or its roots.

 Spondylolisthesis is a condition in which a vertebra of the lower spine slips

out of place, pinching the nerves exiting the spinal column.

 A traumatic injury, such as from playing sports, car accidents, or a fall can
injure tendons, ligaments or muscle resulting in low back pain. Traumatic injury
may also cause the spine to become overly compressed, which in turn can cause
an intervertebral disc to rupture or herniate, exerting pressure on any of the
nerves rooted to the spinal cord. When spinal nerves become compressed and
irritated, back pain and sciatica may result.

 Spinal stenosis is a narrowing of the spinal column that puts pressure on

the spinal cord and nerves that can cause pain or numbness with walking and
over time leads to leg weakness and sensory loss.

 Skeletal irregularities include scoliosis, a curvature of the spine that does

not usually cause pain until middle age; lordosis, an abnormally accentuated arch
in the lower back; and other congenital anomalies of the spine.

Low back pain is rarely related to serious underlying conditions, but when
these conditions do occur, they require immediate medical attention. Serious
underlying conditions include:

 Infections are not a common cause of back pain. However, infections can
cause pain when they involve the vertebrae, a condition called osteomyelitis; the
intervertebral discs, called discitis; or the sacroiliac joints connecting the lower
spine to the pelvis, called sacroiliitis.

 Tumors are a relatively rare cause of back pain. Occasionally, tumors begin
in the back, but more often they appear in the back as a result of cancer that has
spread from elsewhere in the body.

 Cauda equina syndrome is a serious but rare complication of a ruptured

disc. It occurs when disc material is pushed into the spinal canal and compresses
 the bundle of lumbar and sacral nerve roots, causing loss of bladder and bowel
control. Permanent neurological damage may result if this syndrome is left
untreated.

 Abdominal aortic aneurysms occur when the large blood vessel that
supplies blood to the abdomen, pelvis, and legs becomes abnormally enlarged.
Back pain can be a sign that the aneurysm is becoming larger and that the risk of
rupture should be assessed.

 Kidney stones can cause sharp pain in the lower back, usually on one side.

Other underlying conditions that predispose people to low back pain include:

 Inflammatory diseases of the joints such as arthritis, including

osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of
the vertebrae, can also cause low back pain. Spondylitis is also called
spondyloarthritis or spondyloarthropathy.

 Osteoporosis is a metabolic bone disease marked by a progressive decrease

in bone density and strength, which can lead to painful fractures of the
vertebrae.

 Endometriosis is the buildup of uterine tissue in places outside the uterus.

 Fibromyalgia, a chronic pain syndrome involving widespread muscle pain

and fatigue.

Beyond underlying diseases, certain other risk factors may elevate one’s risk
for low back pain, including:

Age: The first attack of low back pain typically occurs between the ages of
30 and 50, and back pain becomes more common with advancing age. As
people grow older, loss of bone strength from osteoporosis can lead to
fractures, and at the same time, muscle elasticity and tone decrease. The
intervertebral discs begin to lose fluid and flexibility with age, which
decreases their ability to cushion the vertebrae. The risk of spinal stenosis
also increases with age.

How is low back pain diagnosed?

X-ray is often the first imaging technique used to look for broken bones or an
injured vertebra. X-rays show the bony structures and any vertebral
misalignment or fractures. Soft tissues such as muscles, ligaments, or
bulging discs are not visible on conventional x-rays.
Computerized tomography (CT) is used to see spinal structures that
cannot be seen on conventional x-rays, such as disc rupture, spinal stenosis,
or tumors. Using a computer, the CT scan creates a three-dimensional image
from a series of two dimensional pictures.

Myelograms enhance the diagnostic imaging of x-rays and CT scans. In this

procedure, a contrast dye is injected into the spinal canal, allowing spinal
cord and nerve compression caused by herniated discs or fractures to be
seen on an x-ray or CT scans.

Discography may be used when other diagnostic procedures fail to identify

the cause of pain. This procedure involves the injection of a contrast dye into
a spinal disc thought to be causing low back pain. The fluid’s pressure in the
disc will reproduce the person’s symptoms if the disc is the cause. The dye
helps to show the damaged areas on CT scans taken following the injection.
Discography may provide useful information in cases where people are
considering lumbar surgery or when their pain has not responded to
conventional treatments.

Magnetic resonance imaging (MRI) uses a magnetic force instead of

radiation to create a computer-generated image. Unlike x-ray, which shows
only bony structures, MRI scans also produce images of soft tissues such as
muscles, ligaments, tendons, and blood vessels. An MRI may be ordered if a
problem such as infection, tumor, inflammation, disc herniation or rupture, or
pressure on a nerve is suspected. MRI is a noninvasive way to identify a
condition requiring prompt surgical treatment. However, in most instances,
unless there are “red flags” in the history or physical exam, an MRI scan is
not necessary during the early phases of low back pain.

Electrodiagnostics are procedures that, in the setting of low back pain, are
primarily used to confirm whether a person has lumbar radiculopathy. The
procedures include electromyography (EMG), nerve conduction studies
(NCS), and evoked potential (EP) studies. EMG assesses the electrical activity
in a muscle and can detect if muscle weakness results from a problem with
the nerves that control the muscles. Very fine needles are inserted in
muscles to measure electrical activity transmitted from the brain or spinal
cord to a particular area of the body. NCSs are often performed along with
EMG to exclude conditions that can mimic radiculopathy. In NCSs, two sets of
electrodes are placed on the skin over the muscles. The first set provides a
mild shock to stimulate the nerve that runs to a particular muscle. The
second set records the nerve’s electrical signals, and from this information
nerve damage that slows conduction of the nerve signal can be detected. EP
tests also involve two sets of electrodes—one set to stimulate a sensory
nerve, and the other placed on the scalp to record the speed of nerve signal
transmissions to the brain.

Bone scans are used to detect and monitor infection, fracture, or disorders
in the bone. A small amount of radioactive material is injected into the
bloodstream and will collect in the bones, particularly in areas with some
abnormality. Scanner-generated images can be used to identify specific areas
of irregular bone metabolism or abnormal blood flow, as well as to measure
levels of joint disease.

Ultrasound imaging, also called ultrasound scanning or sonography, uses

high-frequency sound waves to obtain images inside the body. The sound
wave echoes are recorded and displayed as a real-time visual image.
Ultrasound imaging can show tears in ligaments, muscles, tendons, and
other soft tissue masses in the back.

Blood tests are not routinely used to diagnose the cause of back pain;
however in some cases they may be ordered to look for indications of
inflammation, infection, and/or the presence of arthritis. Potential tests
include complete blood count, erythrocyte sedimentation rate, and C-
reactive protein. Blood tests may also detect HLA-B27, a genetic marker in
the blood that is more common in people with ankylosing spondylitis or
reactive arthritis (a form of arthritis that occurs following infection in another
part of the body, usually the genitourinary tract).