Is there a link between ankylosing spondylitis and female hormones?

Some scientists speculate that female hormones may play a role in ankylosing spondylitis, a condition that causes spinal inflammation. However, the link is largely unclear.
Most studies investigating the effect of female hormones on the condition consider the role of estrogen. To date, however, this research has not been able to determine whether estrogen may influence ankylosing spondylitis or vice versa.
This article considers the possible link between estrogen and ankylosing spondylitis.
Sex and gender exist on spectrums. This article will use the terms “male,” “female,” or both to refer to sex assigned at birth. Click here to learn more.
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Ankylosing spondylitis in females
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As a 2018 review explains, scientists historically considered ankylosing spondylitis a condition that predominantly affects males, but more recent data suggests it affects males and females equally.
2018 review
One reason for this change is that females are more likely to receive a delayed diagnosis.
The review also notes that the condition typically manifests differently in males and females. Females show higher rates of disease activity and a greater likelihood of developing extra-articular manifestations (EAMs). These are issues that do not affect the joints.
Examples of EAMs include:
psoriasis
psoriasis
inflammatory bowel disease (IBD)
inflammatory bowel disease (IBD)
enthesitis, which is inflammation of the entheses (tissues connecting bones to tendons or ligaments)
enthesitis
inflammation
In contrast, males are more likely to show higher rates of joint damage and progression on radiographs.
The review notes that the sex hormone estrogen may play a role in these differences since estrogen has an anti-inflammatory effect on ankylosing spondylitis.
estrogen
However, the authors add that research into the role of estrogen in the condition has provided conflicting results and requires further investigation.
Learn more about ankylosing spondylitis.
ankylosing spondylitis
Ankylosing spondylitis symptoms in females
Males and females may experience many of the same ankylosing spondylitis symptoms.
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD) states that the most common symptom of AS is pain or stiffness in the lower back or hip. For many people, the pain worsens after periods of rest or inactivity.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD)
Ankylosing spondylitis pain may also differ from person to person. Some may experience mild, intermittent pain, while others may experience severe, chronic pain.
Other possible symptoms include:
pain, inflammation, and stiffness in other joints
pain
stiffness
difficulty taking deep breaths due to inflammation of the connective tissues between the ribs
loss of appetite
loss of appetite
weight loss
weight loss
tiredness or fatigue
fatigue
According to the 2018 review, symptoms that appear to be more common in females include:
2018 review
psoriasis symptoms, such as:red or discolored skin patches with silvery-white scales that may itch or burndry, cracked skin that is prone to itching or bleedingnail thickening, ridging, or pitting
such as:
red or discolored skin patches with silvery-white scales that may itch or burn
dry, cracked skin that is prone to itching or bleeding
cracked skin
nail thickening, ridging, or pitting
nail thickening
IBD symptoms, such as abdominal pain and diarrhea
abdominal pain
diarrhea
enthesitis symptoms, such as atypical bone growths, pain, and stiffness, especially when moving
such as
Treatment and management of ankylosing spondylitis
As the NIAMSD explains, there is currently no cure for the condition.
NIAMSD
However, treatments can help delay or prevent fusion of the joints in the spine and alleviate symptoms.
The NIAMS outlines three main treatment approaches:
Physical therapy can help relieve pain, strengthen muscles, and improve posture and flexibility.
Physical therapy
Ankylosing spondylitis symptoms can worsen when a person is inactive, so it is important to exercise regularly.
A physical therapist will put together an exercise program, which may include one-on-one physical therapy and group exercises.
Some medications doctors may prescribe to treat AS include:
pain relievers, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)
acetaminophen
nonsteroidal anti-inflammatory drugs (NSAIDs)
biologics (medications derived from living organisms), such as anti-TNFs
biologics
Janus kinase (JAK) inhibitors
Janus kinase (JAK) inhibitors
corticosteroids
corticosteroids
disease-modifying anti-rheumatic drugs (DMARDs), which can help slow the progression of arthritic diseases
According to the United Kingdom’s National Health Service (NHS), most people with ankylosing spondylitis will not require surgery. Doctors typically reserve surgery for joints that are severely damaged and causing severe pain or disability.
National Health Service (NHS)
Learn more about the treatment and management of ankylosing spondylitis.
What are the treatments for ankylosing spondylitis?
What are the treatments for ankylosing spondylitis?
Biologics for ankylosing spondylitis and immunosuppression
Biologics for ankylosing spondylitis and immunosuppression
Home remedies for ankylosing spondylitis
Home remedies for ankylosing spondylitis
Ankylosing spondylitis and surgery
Ankylosing spondylitis and surgery
Outlook
As the NHS explains, the outlook for people with ankylosing spondylitis varies from person to person. Some find the condition improves following an initial period of inflammation, while others find it worsens over time.
NHS
A person may be able to continue most of their day-to-day activities, or they may develop severe disability due to fusion of the bones in their spine and damage to other joints.
With treatment, most people with the condition will have a near-typical life expectancy. However, the condition increases the risk of potentially life threatening health problems, such as:
spinal fractures
spinal fractures
cardiovascular disease
cardiovascular disease
osteoporosis
osteoporosis
Frequently asked questions
Below are some answers to common questions about ankylosing spondylitis.
It is not clear that ankylosing spondylitis has any direct effect on menstruation. However, a drug called adalimumab, which can help treat ankylosing spondylitis and other forms of inflammatory arthritis, may affect menstruation.
menstruation
can help
A 2023 review cites older research suggesting an association between adalimumab use and heavy menstrual bleeding.
2023 review
Some symptoms of ankylosing spondylitis, such as weight loss and reduced appetite, may also affect menstruation if they are severe.
Severe calorie restriction can stop periods and affect the production of hormones needed for ovulation.
Medical professionals generally consider estrogens to be pro-inflammatory. With menopause and decreased estrogen, joint pain and mild arthritis may develop.
If a person chooses estrogen replacement therapy, the joint pain can decrease in some people. However, studies have not explicitly noted this in cases of ankylosing spondylitis.
The Axial Spondyloarthritis Support Program (ASSP) of Australia explains that when estrogen levels drop during menopause, inflammation may increase, resulting in greater disease activity and worsening arthritis symptoms.
Axial Spondyloarthritis Support Program (ASSP)
However, the ASSP adds that there is insufficient research to properly determine the effect of menopause on ankylosing spondylitis.
A 2018 review suggests estrogen has an anti-inflammatory effect on ankylosing spondylitis. However, further research is necessary to understand the extent to which this hormone plays a role in the development or progression of the condition.
2018 review
Summary
Ankylosing spondylitis is an inflammatory form of arthritis that primarily affects the spine.
Some researchers have speculated that female hormones may play a role in ankylosing spondylitis, as it tends to manifest differently in people of different sexes. Certain symptoms appear to be more common among females than males.
Some studies suggest estrogen may help protect against inflammation in ankylosing spondylitis, but further research is necessary to better understand the role of estrogen in the development and progression of the condition.