Menopause and Musculoskeletal Health: Why Your Joints, Muscles and Tendons May Feel Different

Every so often, a patient who has always been active comes in and says something like:

“I haven't changed what I'm doing. So why am I suddenly getting injured?”

Maybe you've been running for 30 years and your Achilles tendon has suddenly become a problem. Or you've always skied hard and your knees aren't recovering the way they used to.

There is another version of this story. A woman who has been relatively sedentary reaches midlife, decides it's time to get moving, and starts walking, lifting weights, running or taking classes. She feels great, until something hurts.

These women are starting from very different places, but they share a common issue: how much activity your body can tolerate depends partly on the capacity you've built in your muscles, tendons, joints and bones. That capacity changes over time, and perimenopause and menopause can be part of the story.

The question is how to adjust to those changes without giving up the things you love.

Menopause affects more than your bones

When we talk about menopause and musculoskeletal health, bone usually gets most of the attention. That's appropriate. Bone loss accelerates around menopause. In the Study of Women's Health Across the Nation (SWAN), women lost an average of about 7% of bone density at the spine and 6% at the femoral neck during the roughly three years from one year before through two years after the final menstrual period. I've written more about Menopause and Bone Loss: What's Happening and What You Can Do About It.

But bone is only one part of the musculoskeletal system.

Estrogen receptors are found in skeletal muscle and in connective tissues, including tendons and ligaments. Estrogen appears to influence things like collagen turnover, muscle protein metabolism, and how connective tissues respond to mechanical stress.

The biology of estrogen in muscle, tendon and joint is complicated, but it's reasonable to think that changing hormone levels are one reason aches and a different response to training become more noticeable around menopause.

Joint and muscle aches are common in midlife, and body composition, strength and physical function often change as well. It's hard to separate how much of that comes from menopause and how much comes from aging, health, sleep and activity. We shouldn't blame every ache on estrogen. But we also shouldn't ignore menopause when we're trying to understand why something that used to feel easy suddenly doesn't.

Sometimes it isn't possible to separate menopause from aging

Here's the reality for those of us who have been active for decades: by midlife, our bodies have a history. If you've spent 30 or 40 years running, skiing, cycling, hiking, playing sports or lifting weights, your joints and connective tissues have experienced a lot of mechanical demand. By your 50s or 60s, a joint may reflect the effects of age, an old injury, arthritis or the particular demands of the activities you've done for decades. At the same time, menopause brings another set of changes. Estrogen levels decline, body composition and muscle function often change, and the way your tissues respond to loading may be different.

So when your knee starts hurting, there may not be one neat answer. Is it an old injury? Your current training? Arthritis? A change in strength? Menopause? Often, it's some combination. You may simply have less room to get away with the things that used to work for you, particularly if your strength, recovery, sleep or injury history has changed.

Why active women may notice this first

Very active women may notice these changes before someone who isn't asking as much of her body.

Exercise is one of the best things you can do for your health as you age, but skiing all day, trail running, mountain biking, climbing or hiking for several hours puts very different demands on your body than a leisurely walk around the neighborhood.

Muscles get stronger when you progressively challenge them. Tendons and bones also respond to mechanical loading. Your ability to tolerate a particular activity depends partly on the capacity you've built and partly on what you're asking that capacity to handle right now.

Sometimes the answer isn't to do less. It may be to build more capacity.

If you're starting from a sedentary baseline, the answer is different

Consider two 57-year-old women. One has been skiing for 40 years. The other has spent most of the last 20 years sitting at a desk. If the second woman decides she's ready to get in shape and immediately starts running five miles three times a week, she may feel capable of the aerobic effort before she has built tolerance for that amount of repeated impact. That doesn't mean she shouldn't run. She needs to build toward it.

Start where you are. Give your muscles, tendons, joints and bones time to adapt. Increase the workload gradually. Strength training can begin at your current level. You don't have to get “fit enough” before you start lifting weights.

This is one reason I don't love generic prescriptions that simply say, “Lift three times a week.” That's not very helpful if you don't know what you should actually do on Monday morning.

Does menopause cause tendon and joint injuries?

This is where I think we need to be careful about how we talk about menopause. Hormonal changes can affect the biology of connective tissues, and aches in muscles and joints are common at this stage of life. But we know much less about whether menopause itself increases the risk of a specific tendon problem or an acute sports injury.

I'm not going to tell you that you tore your Achilles tendon because your estrogen dropped. That's far too simple.

An acute injury still has a trigger. You landed awkwardly, bumped up your mileage, pushed off hard or fell skiing. But the trigger usually lands on a body that was already tired, carrying an old injury, or short on the capacity to handle it.

Chronic joint pain, tendinopathy, and changes in muscle strength also tend to have several contributors: how much you load your tissues, how well you recover, your injury history, your general health and your hormones. You don't have to identify one culprit to recognize that your body may need a different approach.

Think prehab, not just rehab

I don't want you to wait until something hurts before you start thinking about how to prepare your body for the activities you love. That doesn't mean spending 30 minutes stretching before every workout. Stretching can feel good, and flexibility matters for some activities, but stretching alone isn't a particularly compelling general strategy for preventing sports injuries. Programs that combine strength, balance and movement skills have much better support, and strength is the foundation.

Resistance training is one of the most useful things you can do to maintain strength as you move through menopause, and studies in postmenopausal women consistently show that it improves strength and physical function. You can read more about training strategies in Why Exercise Feels Different in Menopause And What to Do About It.

Your tendons need loading too, because they adapt to mechanical stress. If you want to run, ski, jump, climb or lift, your training should gradually prepare those tissues for the forces they're going to experience. Depending on what you do, that may mean working on single-leg strength, balance, landing mechanics or the ability to decelerate. If you ski steep terrain, for example, your quads spend all day controlling your descent, which is very different work from simply lifting your body uphill. Running downhill, landing from a jump and controlling a heavy weight make the same kind of demand.

Before a demanding session, warm up with movement specific to the activity and build the intensity gradually. A warm-up won't prevent every injury, but it's a sensible way to get ready.

Recovery matters here too. If most of your workouts land at the same moderately hard effort, you pile up fatigue without getting much easy recovery or the truly hard sessions that drive adaptation. Endurance coaches call this the "gray zone."

Fueling matters as well. Protein and overall nutrition support training, especially if you're increasing activity or trying to build strength. You don't need a complicated menopause diet, but consistently under-eating or skimping on protein doesn't pair well with hard training. For more information about nutrition, check out my article: Eat to Stay Strong: Rethinking Nutrition for the Active Woman During Menopause.

All of this points to the same goal: a body that can tolerate the activity you want to do.

You may not be able to do it the same way anymore

This may be the hardest part for women who have always been active.

You may not be able to train exactly the way you did at 35, but you can still get stronger, and you may even get better at your sport if you're willing to change how you train. Maybe you need more strength work. Maybe you need a more deliberate warm-up. Maybe you need more easy aerobic days and fewer workouts that live in that gray zone of moderately hard. Maybe you need more recovery between hard efforts.

These changes can actually make you a better athlete. Adding strength work may make you a better skier. Backing off one hard workout may leave you stronger for the next one. Changing how you warm up may make a long ride feel better.

Sometimes you get better because you finally stop insisting on doing everything the way you've always done it.

Your training partner may not be your training partner anymore

This is another place where menopause can force you to get a little more analytical about your training.

Your running buddy might not be the right training partner for you anymore. Your cycling group may be pushing a pace that no longer makes sense for your training. Your ski friends may want to ski hard every day when your body needs something different. And sometimes, frankly, your friends may be holding you back.

If you're constantly pushing to keep up, ending every workout exhausted and going into the next one under-recovered, you may be following someone else's training plan without realizing it.

The question isn't always, “Can I still keep up?” Sometimes it's, “Is keeping up actually helping me get better?”

There is no single menopause workout

I'm skeptical of anyone who tells you there is one exact exercise prescription for every woman after menopause. The 57-year-old who has skied for 40 years needs something different from the 57-year-old who is just beginning to exercise, and even two lifelong skiers may need different things depending on their previous injuries, strength, fitness, biomechanics, sleep, medications, training history and goals.

The same is true of menopause more broadly. Your friend may swear by a particular diet. Someone else may tell you that a certain supplement changed everything. Another woman may have a fantastic experience with menopause hormone therapy. Those experiences are worth listening to. They're just not prescriptions for you. Your friend's menopause is not your menopause.

I think there is a lot of value in approaching this period of life with some curiosity. Try something. Pay attention to what happens. Give it enough time to know whether it's helping, then adjust. That's not failure. It's information.

Does menopause hormone therapy (MHT) help joint pain?

It's a reasonable question. Estrogen acts directly on joint tissues, and in the Women's Health Initiative (WHI), women taking hormone therapy reported less joint pain and stiffness than women on placebo. But the difference was modest. In the estrogen-alone arm, 76% of women on estrogen reported joint pain after a year, compared with 79% on placebo. Some women also noticed more joint discomfort after they stopped.

The evidence gets thinner when it comes to osteoarthritis. The Menopause Society's position statement says there's no clearly observed association between MHT and osteoarthritis, and that results from trials of estrogen have been inconsistent enough that it can't draw strong conclusions. In the WHI, MHT also didn't clearly reduce the need for hip or knee replacement.

That's why I don't think of MHT as a treatment for arthritis or tendinopathy, and I wouldn't start it just because your knees or Achilles tendon are bothering you. If you have another good reason to use it, like hot flashes, less joint pain may be a bonus.

When pain needs more than a training adjustment

Not every musculoskeletal problem is something you should try to work around on your own. A hot, red or visibly swollen joint, especially with fever or feeling ill, needs prompt medical evaluation. Significant night pain, sudden loss of function, a pop or snap with an injury, or pain after a fall that makes it difficult to bear weight also deserve evaluation. If pain isn't improving after a few weeks of an appropriate training adjustment, it's worth getting checked.

Sometimes the right answer really is a medical diagnosis or physical therapy, not another change to your workout.

Putting it together

If you take one thing from this, I'd want it to be that your body is giving you information, and it's worth listening to.

For one woman, the answer might be more strength work. For another, it might be more thoughtful recovery, a different training group, a slower progression or a better warm-up. Nutrition, sleep, and treatment for your other menopause symptoms belong somewhere in the conversation too.

You won't get your 35-year-old body back. But a well-trained 57-year-old body can do a lot. The goal is to figure out what works for the body you have now, and then train that body well.