Menopause and Musculoskeletal Health: Why it matters
Menopause is a natural phase in a woman’s life, but for many, it brings unexpected challenges that go beyond the commonly known symptoms such as hot flushes and fatigue. One of the lesser discussed yet impactful aspects of menopause is its effect on musculoskeletal (MSK) health.
GUEST POST
This month, we have our second guest blog from another of our Hip Academy members - Julia Gross, a highly experienced musculoskeletal physiotherapist, who has completed an MSc that involved a project on the experiences of menopausal women in the healthcare system. Julia also presented a masterclass for our membership on this topic earlier this year. You can read more about Julia at the end of this blog, and find out more about Hip Academy and our masterclasses below.
If you missed last month's guest post by Sonam Jethwa on Sex-Based Gaps in Musculoskeletal Clinical Practice, jump back and read it after you've finished this great blog.
As a musculoskeletal physiotherapist and educator, my interest in menopause was initially sparked by personal experience. Like many women, I noticed symptoms—fatigue, disrupted sleep, fluctuating moods and grumbling musculoskeletal pain. This made me curious about what other women were going through. It led me to reflect on the women I was treating in clinic—particularly those around midlife presenting with musculoskeletal pain. I began to ask simple questions about their menopausal journey, and the responses appeared to reveal a deeper connection between hormonal changes and musculoskeletal health than I had ever considered.
This blog draws from my Master's research, and the lived experiences of women navigating this transition. It explores how menopause affects musculoskeletal health, what this means for management, and why clinicians—especially physiotherapists—need to better understand and address these changes with empathy, clarity, and confidence.
This blog will cover the following topics:
- Understanding Menopause: An Overview
- Sex Hormones and The Musculoskeletal System
- Bone Health and Hormones
- Muscle Health and Hormones
- Tendon and Joint Pain and Hormones
- Considerations for Physiotherapy Practice
- What Women Can Do to Support Their Musculoskeletal Health
- Resistance Training
- Nutrition for Bone and Muscle Health
- Menopause Hormone Therapy (MHT)
- Stay Active
- Manage Stress and Sleep
- Call for Education and Empowerment
Understanding Menopause: An Overview
Menopause represents a significant transition in a woman’s life, accompanied by profound physiological changes driven by fluctuating and declining sex hormone levels, particularly oestrogens. Menopause marks the cessation of ovarian function and is defined as 12 consecutive months without a period. It typically occurs between the ages of 45 and 55 but varies greatly with perimenopause beginning in the early forties and early menopause being bought on by certain surgeries and types of cancer.1
With an increasing life expectancy, women can expect to spend more than one third of their lives in various stages of menopause.2 While hot flushes, night sweats, and fluctuating moods are widely recognised symptoms, the musculoskeletal consequences of menopause remain under-discussed and frequently under-addressed in clinical practice—despite their high prevalence and impact on quality of life.3
Up to 70% of women report musculoskeletal pain during menopause, often describing joint stiffness, widespread aches, tendon and back pain.4 For many, these symptoms are persistent, debilitating, and misunderstood — by both healthcare providers and women themselves. These symptoms are often dismissed or misattributed to ageing, highlighting the need for education for clinicians to recognise menopause as a contributing factor to musculoskeletal presentations.
Sex Hormones and The Musculoskeletal System
Declining oestrogens influence bone density, muscle mass, tendon health, and joint integrity—factors that are foundational to mobility, independence, and long-term health5. Yet, despite these well-established physiological changes, menopause is rarely considered within mainstream musculoskeletal assessment and rehabilitation frameworks.
Understanding these changes is essential for clinicians aiming to deliver effective, evidence-informed rehabilitation and conditioning interventions for women during the menopause transition.
Bone Health and Hormones
Oestrogen is key for more than reproductive health. Oestrogens play a central role in maintaining bone mineral density by regulating the dynamic process of bone remodelling.
Oestrogens and androgens modulate bone remodelling and growth, decreasing bone reabsorption and increasing matrix synthesis.6 Oestrogens inhibit osteoclast activity (cells responsible for bone resorption) and promotes osteoblast survival and function (cells responsible for bone formation).
The sharp drop in oestrogen at menopause accelerates bone turnover, favouring resorption over formation, which leads to net bone loss.7 Women can lose up to 10% of their bone mass within the first five years of menopause, significantly increasing the risk of osteopenia, osteoporosis, and fragility fractures and evidence suggests that 50% of postmenopausal women may develop osteoporosis.2
Muscle Health and Hormones
Sarcopenia—the age-related loss of skeletal muscle mass, strength and function—is accelerated by hormonal decline.8,9
Oestrogens, particularly oestradiol, enhance satellite cell activation, mitochondrial function, and muscle protein synthesis. Together with androgens, they increase myoblast proliferation and decrease cell apoptosis, allowing for increased muscle mass and contractility.6
With the onset of menopause, the decline in oestrogen and other anabolic hormones (e.g. testosterone) contributes to reduced muscle repair and regeneration. This results in diminished strength, power, and functional capacity, increasing the risks of falls and frailty in later life.8,9
Clinically, women may report early fatigue during functional activities such as stair climbing, lifting, or carrying. Impaired muscle performance also contributes to poor balance and increases injury risk.
Importantly, muscle loss is not just a strength issue; it also affects metabolic health, glucose regulation, and overall vitality. Resistance training has been shown to counteract these effects, with research supporting its role in maintaining and restoring muscle mass in postmenopausal women.10
Tendon and Joint Pain and Hormones
Though less widely studied than bone and muscle, tendon structure and function are also influenced by oestrogen. Emerging evidence suggests oestrogens modulate collagen synthesis, tendon elasticity, healing capacity and load adaptation.11
Declining oestrogen levels are associated with reduced collagen turnover and impaired tendon resilience, increasing susceptibility to tendinopathy and reduced healing capacity.6,12
During the menopausal transition, women often present with Achilles, gluteal, or rotator cuff tendinopathy, sometimes with no clear mechanism of injury.13 These presentations may be related to hormonal changes as well as altered biomechanics and reduced muscle strength.
In clinical practice, this highlights the importance of individualised load management, longer recovery timelines, and potentially slower rehabilitation progressions for women with tendinopathy who are navigating menopause.
Additionally, oestrogen and androgens play a role in maintaining joint lubrication and cartilage integrity by reducing articular cartilage matrix turnover and increasing type II collagen which improves cartilage thickness and mechanical properties.6 As hormone levels fall, some women experience increased joint stiffness, pain, and reduced range of motion.
These symptoms are often attributed to early osteoarthritic changes, which are more prevalent post-menopause.3,5 This can result in decreased participation in physical activity, contributing to a cycle of deconditioning and symptom exacerbation.
Many women in menopause report new or worsening joint stiffness, tendon pain, and conditions like frozen shoulder and plantar fasciopathy (plantar fasciitis). Women are twice as likely to develop frozen shoulder than men and emerging research suggests that withdrawal of oestrogens during perimenopause may be an important risk factor.14
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Considerations for Physiotherapy Practice around Menopause
Physiotherapists are ideally placed to help women manage the musculoskeletal impacts of menopause — but it is vital that we acknowledge the connection.
Unfortunately, menopause is often overlooked in physiotherapy assessments and many women report feeling that their pain is related to ageing or something sinister. Others report feeling dismissed or misunderstood by healthcare professionals.15 Understanding the hormonal context behind their symptoms could change the approach — and the outcome — of treatment.
Uncertainty
Uncertainty surrounding menopause—both in recognising symptoms and understanding their causes—can be a significant psychological stressor, affecting a woman’s engagement with physiotherapy and management of musculoskeletal conditions.
In my qualitative study on women’s experiences of physiotherapy whilst experiencing menopausal symptoms, participants reported fear and confusion as to where their symptoms were coming from.
Ambiguous symptoms often create fear, worry and doubt, particularly when symptoms such as musculoskeletal pain are not widely acknowledged as menopause-related.16, 17 This lack of clarity can lead to delayed help-seeking, misattribution of symptoms to ageing or sinister health issues, and reduced confidence in healthcare providers.
Higher levels of uncertainty are also associated with more frequent and disturbing symptoms and lack of knowledge perpetuates misinformation and contributes to health inequalities.16
For physiotherapists, this uncertainty presents a barrier to effective care: if menopause is not identified or discussed, underlying hormonal influences on bone, tendon, and muscle health may be overlooked. Moreover, uncertainty can heighten distress, contributing to increased pain sensitivity, fear-avoidance behaviours, and lower adherence to rehabilitation plans.17
By creating a safe, informed space to talk about menopause and educating women on the links between hormonal change and musculoskeletal health, physiotherapists can reduce uncertainty, build trust, and support more personalised, effective care.18
We must normalise asking about menopause in physiotherapy-especially when working with women experiencing persistent pain, fatigue, or functional decline. Direct questions, active listening with empathy and signposting to specialist services are all key skills for physiotherapists and highly valued by women with musculoskeletal pain and menopausal symptoms.
Importantly, we must educate ourselves. Physiotherapy training often lacks sufficient content on menopause, leaving clinicians underprepared to support this population.
What Women Can Do to Support Their Musculoskeletal Health
The good news is that there are evidence-based strategies women can use to support their musculoskeletal health throughout menopause.
Resistance Training
Weight-bearing and resistance exercises are essential for bone density, muscle mass, tendon and joint health. Strength training can slow bone loss, build strength, and improve posture and balance.10,19, 20
Aim for at least 2 sessions a week, focusing on major muscle groups. Start light and build gradually and consult a physiotherapist or trainer with experience in menopausal health.
Nutrition for Bone and Muscle Health
Optimising nutrition can be a valuable aid to menopausal health.21
- Calcium: Essential for bone strength. Found in dairy, leafy greens, almonds, and fortified foods.
- Vitamin D: Needed for calcium absorption. Get it through sunlight, mushrooms or supplements.
- Protein: Vital for muscle repair. Include a source in every meal (e.g., beans, lentils, eggs, fish, lean meats).
- Omega-3s: Can help reduce inflammation and joint pain. Found in walnuts, chia, flax and oily fish.
Menopause Hormone Therapy (MHT)
For some women, MHT (formerly known as HRT) may be appropriate to manage symptoms and reduce musculoskeletal risk. Evidence shows it can help preserve bone density, reduce fracture risk, and possibly benefit muscle and tendon health 22,23,24. It’s not suitable for everyone, so speak to your GP or menopause specialist.
Stay Active
Even light daily movement — like walking, yoga, swimming, or gardening — can help reduce stiffness, manage weight, and boost mood.25
Manage Stress and Sleep
Poor sleep and high stress levels can increase sensitivity to pain and inflammation.26 Mindfulness, sleep hygiene, and relaxation strategies may reduce symptom severity and improve overall well-being.
Call for Education and Empowerment
If you’re a physiotherapist or healthcare professional, consider what menopause training you’ve had. If you're a woman navigating menopause, know that help is available and you're not alone.
We need better education, more research, and open conversations about how menopause affects women’s bodies — especially their musculoskeletal health.
By bringing menopause into the physiotherapy mainstream, we can empower women to stay strong, active, and healthy during this life stage — and well beyond.
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This blog was written by Julia Gross
Julia (Jools) Gross is a British musculoskeletal physiotherapist with 10 years of clinical experience and a special interest in menopause and tendons.
She was working in a split role in musculoskeletal outpatients and Medical Education in the UK and is now working in Melbourne, Australia, practicing musculoskeletal physiotherapy, teaching yoga and reformer Pilates and finishing her MACP Masters degree.
Jools is a passionate voice for women and loves exploring and photographing wildlife in her spare time.
Julia is also a long term Hip Academy member, having presented a masterclass on this topic for members (recording available for members). If you'd like to benefit from the knowledge of the Hip Academy Brains Trust, get started today with a Hip Academy membership.
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References
- Turner, K., Crampton, J.S. and Dobbin, N., 2025. Physiotherapists’ perceptions on the management of musculoskeletal conditions in women of perimenopausal and menopausal age: a qualitative focus group study. Physiotherapy Theory and Practice, pp.1-14.
- Rostami-Moez, M., Masoumi, S.Z., Otogara, M., Farahani, F., Alimohammadi, S. and Oshvandi, K., 2023. Examining the health-related needs of females during menopause: A systematic review study. Journal of Menopausal Medicine, 29(1), p.1.
- Lu, C.B., Liu, P.F., Zhou, Y.S., Meng, F.C., Qiao, T.Y., Yang, X.J., Li, X.Y., Xue, Q., Xu, H., Liu, Y. and Han, Y., 2020. Musculoskeletal pain during the menopausal transition: A systematic review and meta‐analysis. Neural plasticity, 2020(1), p.8842110.
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- Karlamangla, A.S., Shieh, A. and Greendale, G.A., 2021. Hormones and bone loss across the menopause transition. In Vitamins and Hormones (Vol. 115, pp. 401-417). Academic Press.
- Buckinx, F. and Aubertin-Leheudre, M., 2022. Sarcopenia in menopausal women: current perspectives. International Journal of Women's Health, pp.805-819.
- Geraci, A., Calvani, R., Ferri, E., Marzetti, E., Arosio, B. and Cesari, M., 2021. Sarcopenia and menopause: the role of estradiol. Frontiers in endocrinology, 12, p.682012.
- Isenmann, E., Kaluza, D., Havers, T., Elbeshausen, A., Geisler, S., Hofmann, K., Flenker, U., Diel, P. and Gavanda, S., 2023. Resistance training alters body composition in middle-aged women depending on menopause-A 20-week control trial. BMC women's health, 23(1), p.526.
- McMahon, G. and Cook, J., 2024. Female tendons are from Venus and male tendons are from Mars, but does it matter for tendon health?. Sports medicine, 54(10), pp.2467-2474.
- Tarantino, D., Pellegrino, R., Di Iorio, A., Mottola, R., Saggini, R., Ruosi, C. and Aicale, R., 2024. UNDERSTANDING GLUTEAL TENDINOPATHY: DIAGNOSIS AND TREATMENT. A NARRATIVE REVIEW. Eur J Musculoskel Dis, 13(3), pp.47-59
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- Wang, Z., Li, X., Liu, X., Yang, Y., Yan, Y., Cui, D., Meng, C., Ali, M.I., Zhang, J., Yao, Z. and Long, Y., 2025. Mechanistic Insights into the Anti-Fibrotic Effects of Estrogen via the PI3K-Akt Pathway in Frozen Shoulder. The Journal of Steroid Biochemistry and Molecular Biology, p.106701.
- Barber K, Charles A. Barriers to Accessing Effective Treatment and Support for Menopausal Symptoms: A Qualitative Study Capturing the Behaviours, Beliefs and Experiences of Key Stakeholders. Patient Prefer Adherence. 2023; 17:2971-2980. Published 2023 Nov 15. doi:10.2147/PPA.S430203
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- Capel-Alcaraz, A.M., García-López, H., Castro-Sánchez, A.M., Fernández-Sánchez, M. and Lara-Palomo, I.C., 2023. The efficacy of strength exercises for reducing the symptoms of menopause: a systematic review. Journal of clinical medicine, 12(2), p.548.
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