Getting to grips with menopausal pain
Menopause and Musculoskeletal Pain: What's the Connection?
Menopause is a natural phase in a woman's life, marking the end of menstrual cycles. While hot flashes and mood swings often steal the spotlight, many women are surprised to experience musculoskeletal pain—aching joints, muscle stiffness, or general body discomfort. In the paper by Wright and colleagues (2024), it's pointed out that musculoskeletal pain in perimenopausal women is about 71% (citing Lu et al., 2020) and higher than in pre-menopausal women. Given that women's experiences of pain can be dismissed (Loscar, 2018; Prego-Jiminez, 2022; Wilford, 2022) and that stereotypes may be applied to women when they seek help (Wratten et al., 2019), it is essential to raise awareness.
“Every person who menstruates will, if they live long enough, stop menstruating. The impact of hormone changes over the course of our lives is enormous, and it seems to have more of an effect on musculoskeletal pain than we've considered. Women are disproportionately represented in chronic pain statistics (Mills et al., 2019; Zimmer et al., 2022), and female nociceptive systems are not the same as males (Osborne & Davis, 2022)
-Bronnie Lennox Thompson, March 2025
Our clinical team was interested in reading this article by Bronnie Lennox about menopausal pain, as we treat people with persistent pain. I sat down with Maxine Haylock, one of our Specialist Occupational Therapists, who discussed this further. Maxine stated that the majority of clinical research is conducted on men. So the role of hormones is seldom considered. Women's experience of pain is often different due to hormonal changes, which are not adequately considered in research and medication development. Some women can be misdiagnosed as having Fibromyalgia, for example, rather than their symptoms being considered as part of a menopausal profile.
A gender pain-gap?
As someone who has had MECFS for over twenty years, I discussed how with peri- menopause (I am 54 shortly), the nature of my cognitive fatigue and my pain were different. I never thought I would succumb like my ex-mother-in-law to finding it hard to find words and indeed to say the wrong words frequently, something which to my twenty-year-old self at the time seemed so unfathomable. How is it possible to say a word you don’t mean, I wondered then? My memory is worse, and my capacity to process information has slowed down markedly with menopausal changes. Pain-wise, the type of pain I am experiencing in my joints is quite different to any pain I have had with my ME/CFS profile. Maxine shared that for her, she has some of the symptoms that you might expect with menopause, but not all of them, and this again muddles the diagnostic picture. There isn’t a convenient test either that can be taken other than measuring testosterone levels, which some GPs may be willing to do. Maxine mentioned a Nurofen advert and a related report highlighting a "gender pain gap" where women experiencing menopause-related pain often have their concerns dismissed or face significant delays in diagnosis. This study is an interesting observation of positive changes in the media about the awareness of pain in women’s health in general.
“Some commentators have called for the pain people experience around and after menopause to be called ‘the musculoskeletal syndrome of menopause’ to help clarify what is going on, raise awareness of the issues, and help focus research efforts in this area. The hallmark paper is by Wright et al., (2024) where they argue that by recognising these issues as a specific diagnostic entity there will be increased awareness - similar to the term ‘genitourinary syndrome of menopause’ which has enhanced awareness of and better care for people experiencing genital symptoms such as vaginal dryness, burning and irritation, dysuria and recurrent urinary tract infections.”
Why can pain be exacerbated with menopausal changes?
Bronnie writes, ‘Hormonal shifts, particularly the decline in oestrogen, play a key role. Oestrogen helps maintain joint and bone health, so when levels drop, inflammation can increase, cartilage may break down more quickly, and bones may lose density. This can lead to:
Joint pain (especially in the knees, hands, shoulders, and neck)
Muscle aches or stiffness
Increased risk of osteoporosis and fractures
In her paper called “Menopause and musculoskeletal pain, Bronnie Lennox Thompson develops this list to include potential causes, such as:
Increased inflammation related to the loss of oestrogen, which usually regulates inflammation.
Sarcopenia (loss of muscle mass in older people) involves loss of fast muscle fibres, type II fibres, reduced motor units and more intramuscular fat tissue. Sarcopenia increases the risk of falls, frailty, and poorer bone density, and treatment often involves increasing nutrition, including proteins, vitamin D, and creatine, as well as resistance training. Interestingly, oestrogen influences energy in cells through changes in mitochondrial function, increased mitochondrial H202 production, reduced antioxidant proteins, and insulin sensitivity because oestrogen is involved in cellular redox and glucose homeostasis in skeletal muscle.
Satellite cell proliferation - these cells promote plasticity and regeneration in muscle fibres, and particularly activate after injury or in chronic inflammatory situations. Estradiol stimulates the production of these cells through oestrogen receptors, and when oestrogen is not present (and therefore not binding to oestrogen receptor alpha), recovery after injury is impaired.
Bone density has long been seen as a post-menopausal problem; it's often underdiagnosed, and yet it's both preventable and treatable. Oestrogen deficiency is associated with bone loss.
Cartilage changes accelerate in menopausal women, with some studies demonstrating that oestrogen modulates cartilage and bone remodelling (in rats!) but also in humans, when it's been found to influence intervertebral disc height (Muscat Baron et al., 2007).
What Can Help?
“Some commentators have called for the pain people experience around and after menopause to be called 'the musculoskeletal syndrome of menopause' to help clarify what is going on, raise awareness of the issues, and help focus research efforts in this area. The hallmark paper is by Wright et al., (2024) where they argue that by recognising these issues as a specific diagnostic entity there will be increased awareness - similar to the term 'genitourinary syndrome of menopause' which has enhanced awareness of and better care for people experiencing genital symptoms such as vaginal dryness, burning and irritation, dysuria and recurrent urinary tract infections.”
Treatment and Individual Assessment
Maxine shared that the treatment approach for pain and fatigue, whether related to menopause, fibromyalgia or ME/CFS, often involves an individual assessment of symptom severity and how it impacts a person's life. She noted that there isn't a specific medication for fibromyalgia, for example, and interventions focus on managing symptoms. Maxine mentioned that when working with new clients, she now considers the client's age and potential menopausal symptoms as a possible contributing factor to their fatigue or pain.
Managing musculoskeletal pain during menopause involves, according to Bronnie’s article, a holistic approach:
Stay active: Low-impact exercises, such as walking, swimming, and yoga, help keep joints flexible and muscles strong. In our programmes, our team explicitly examines the nature of how a level of activity can be supportive, depending on the specific conditions of an individual's lifestyle and the nature of the pain experienced.
Eat for your bones: Include calcium, vitamin D, and anti-inflammatory foods in your diet. Our specialist dietitian and nutrition consultant has extensive experience in the relationship between diet and fatigue and pain.
Talk to your doctor: Hormone replacement therapy (HRT) or other medications may be appropriate in some cases, and Maxine says that it can help as the process of diagnosis with symptoms of fatigue or pain that persist, is often via exclusion.
Bronnie says, “Dismissing a person's report of pain as 'because menopause' and pointing them to counselling or dealing with anxiety is insufficient and inadequate management. Understanding the link between menopause and musculoskeletal pain is the first step toward finding relief and reclaiming your comfort.” Both Maxine and I noted in our discussion that the nature of our anxiety is different with menopausal changes, and again, looking at the role of emotional fluctuations and perhaps their impact on the quality of sleep, is again something our multi-disciplinary approach considers to inform symptom management.
You're Not Alone
If you’re navigating menopause and struggling with aches and pains, know that you’re not imagining it, and you’re not alone. If persistent pain is a debilitating issue in your life, perhaps interfering with your ability to sustain work, please do book a 15-minute call with us so we can share more about how our programmes can help.
Written following a discussion between Katherine Sewell and Maxine Haylock.
Resources
Bronnie Thompson: Menopause and pain