Perimenopause Joint Pain: What the Research Actually Shows

By Dana Logan, DPT

Based on: Kruse C, McKechnie T, Dworsky-Fried J, et al. JB & JS Open Access. 2026; Hansen M, Kjaer M. Advances in Experimental Medicine and Biology. 2016; Hansen M, Kongsgaard M, Holm L, et al. Journal of Applied Physiology. 2009; Sander AM, Connizzo BK. Journal of Orthopaedic Research. 2025; Gilmer G, Crasta N, Tanaka MJ. American Journal of Sports Medicine. 2025.

Table of Contents

• What Is Perimenopause — and Why Does It Affect Your Joints?
• What the Research Found: 93,021 Women Tell a Clear Story
• The Biology Behind the Pain: Muscle, Tendon, Ligament, Cartilage
• Introducing the “Musculoskeletal Syndrome of Menopause”
• Implications for Active Women and Female Athletes
• The Gap in Clinical Practice
• What This Means for You
• Frequently Asked Questions
• The Bottom Line

If you’ve been experiencing joint pain, muscle aches, or a general sense that your body just doesn’t move the way it used to — and you’re in your 40s or early 50s — there’s a good chance perimenopause is playing a role. Yet for many women, these symptoms are dismissed as an inevitable part of aging, rather than recognized as a distinct and manageable feature of the menopausal transition.

A major new meta-analysis published in JB & JS Open Access (Kruse et al., 2026) is changing that conversation. Analyzing data from over 93,000 women, this large-scale study confirms that musculoskeletal symptoms are not only common during perimenopause — they are significantly elevated compared to other life stages, and they follow a clear biological pattern tied to hormonal decline. A growing body of mechanistic research now explains exactly why — and it implicates not just estrogen, but progesterone as well.

What Is Perimenopause — and Why Does It Affect Your Joints?

Perimenopause is the transitional phase leading up to menopause, typically beginning in a woman’s 40s and lasting several years. During this time, estrogen levels fluctuate unpredictably before eventually declining. Most people associate perimenopause with hot flashes and mood changes — but the hormonal shifts of this period affect nearly every system in the body, including the musculoskeletal system.

Estrogen’s influence on the musculoskeletal system is far more extensive than most people realize. Research by Hansen and Kjaer (2016) has shown that estrogen directly affects muscle contractile properties, tendon stiffness, ligament laxity, and cartilage integrity — making it a key regulator of structural and functional tissue health throughout a woman’s life.

As estrogen levels drop during the menopausal transition, women may experience increased joint inflammation, reduced muscle recovery, altered connective tissue properties, and decreased physical resilience — all of which contribute to pain and functional decline.

What the Research Found: 93,021 Women Tell a Clear Story

The meta-analysis by Kruse and colleagues is one of the largest studies to systematically examine the prevalence of musculoskeletal symptoms across the menopausal transition. The findings are striking:

Musculoskeletal symptoms are significantly elevated during perimenopause. Joint pain, muscle aches, and reduced physical function are among the most frequently reported complaints — yet they are consistently underrecognized in clinical settings.

Prevalence peaks during the menopausal transition and early postmenopause. This is not a random or gradual trend. The timing of symptom burden closely parallels the decline of estrogen, pointing to a direct hormonal mechanism rather than coincidental aging.

The pattern is consistent across a large, diverse sample. With over 93,000 women included, these findings carry significant statistical weight and are unlikely to reflect chance variation.

93,021 women. One clear pattern. MSK symptoms peak with hormonal decline.

The Biology Behind the Pain: What Estrogen and Progesterone Do to Muscle, Tendon, and Ligament

Understanding why perimenopause affects the musculoskeletal system requires a closer look at what sex hormones actually do to connective tissue — and what happens when they decline or fluctuate. While estrogen has received most of the attention, emerging research makes clear that progesterone plays a distinct and underappreciated role alongside it.

Muscles

Post-menopausal estrogen decline alters muscle fiber composition, reduces power output, and impairs neuromuscular coordination (Hansen & Kjaer, 2016). These are not subtle changes — they translate directly into the fatigue, weakness, and reduced physical capacity that many perimenopausal women report.

Tendons

Estrogen promotes collagen synthesis, which is essential for tendon health and integrity. However, its effects on tendons are complex: while estrogen supports collagen production, it paradoxically reduces tendon stiffness — with nuanced implications for athletic performance and injury risk (Hansen & Kjaer, 2016).

A landmark human in vivo study (Hansen et al., 2009) provided direct mechanistic evidence of this relationship. In postmenopausal women, estrogen therapy significantly increased peritendinous collagen synthesis rates. Women receiving estrogen also had greater tendon cross-sectional area and stiffness compared to untreated postmenopausal controls — indicating that estrogen deficiency contributes meaningfully to tendon structural deterioration after menopause.

Critically, the research also found that mechanical loading — that is, exercise — remained essential. Estrogen amplified exercise-induced collagen synthesis rather than replacing it, pointing to a combined approach of estrogen therapy and structured exercise as the optimal strategy for maintaining tendon health post-menopause (Hansen et al., 2009).

More recently, Sander and Connizzo (2025) have shed important light on the molecular mechanisms governing these effects. Both estrogen and progesterone act on tendon extracellular matrix (ECM) remodeling through distinct receptor-mediated pathways. Estrogen primarily promotes collagen synthesis and inhibits MMP-mediated degradation. Progesterone, meanwhile, modulates inflammatory signaling within tendon tissue, playing a protective role that has long been underappreciated.

Hormonal fluctuations across the menstrual cycle and menopause alter the balance between collagen production and breakdown in ways that shape both injury risk and repair capacity. The combined fluctuation of estrogen and progesterone drives unique patterns of tendon injury and recovery — findings with direct implications for how combined HRT formulations are designed and prescribed, and for understanding why women experience tendinopathy at different rates than men (Sander & Connizzo, 2025).

Ligaments

The relationship between sex hormones and ligament mechanics is one of the most clinically consequential areas of musculoskeletal research — and it is now substantially better understood thanks to a 2025 meta-analysis by Gilmer, Crasta, and Tanaka published in the American Journal of Sports Medicine.

Estrogen was consistently associated with increased ligament laxity across the studies reviewed — a dose-dependent effect observed across hormonal phases and in response to exogenous hormone administration. This explains why females face elevated ACL injury risk during certain phases of the menstrual cycle, when estrogen levels are at their highest (Hansen & Kjaer, 2016; Gilmer et al., 2025).

Importantly, the picture is more complex than estrogen alone. Progesterone partially counteracts estrogen-induced laxity, and the combined hormonal effect on ligament properties varies by cycle phase and by the anatomical site of the ligament in question. This means that a woman’s joint stability is not static — it shifts across her hormonal cycle in ways that have real implications for injury risk and athletic performance (Gilmer et al., 2025).

Post-menopausal ligament properties differ significantly from premenopausal norms. With declining estrogen and progesterone, ligaments show altered laxity patterns and reduced tensile strength — changes that affect joint stability and may contribute to the musculoskeletal symptoms so prevalent in this population (Gilmer et al., 2025).

Cartilage

Estrogen also plays a protective role in cartilage integrity. Its decline during and after the menopausal transition is associated with accelerated cartilage degradation, which may partly explain the increased prevalence of osteoarthritis in postmenopausal women.

Introducing the “Musculoskeletal Syndrome of Menopause”

One of the most important contributions of the Kruse et al. (2026) meta-analysis is the call to recognize what the authors term the “musculoskeletal syndrome of menopause” as a distinct clinical entity.

This framing matters for several reasons:

• It validates the experiences of women who have been told their joint pain is unrelated to their hormonal status
• It creates a framework for targeted clinical management, rather than generic pain management
• It places musculoskeletal health alongside vasomotor, psychological, and genitourinary symptoms as a core domain of menopause care
• It is now supported by mechanistic research demonstrating the direct biological pathways through which estrogen and progesterone decline drives MSK deterioration

Key insight: Joint pain and muscle aches during the menopausal transition are not a coincidence. They are a recognized, physiologically grounded syndrome — and they deserve to be treated as such.

Implications for Active Women and Female Athletes

The hormonal effects on the musculoskeletal system carry particular relevance for active women and female athletes navigating the perimenopausal transition. Hansen and Kjaer (2016) emphasize that understanding hormonal effects is essential for optimizing injury prevention and training strategies in female athletes across the lifespan.

The ligament data from Gilmer et al. (2025) adds important nuance: because estrogen-induced laxity is dose-dependent and varies by hormonal phase, a woman’s injury risk is not constant — it fluctuates with her hormonal cycle. For perimenopausal athletes experiencing irregular cycles and unpredictable hormone swings, this creates a particularly complex landscape for joint stability. Training loads and high-risk activities may warrant adjustment during phases of elevated laxity.

For tendons, Sander and Connizzo (2025) highlight that the interplay between estrogen and progesterone in ECM remodeling means that the timing of both hormonal fluctuations and exercise loading may influence tissue repair outcomes. Understanding the hormonal environment is no longer just background context — it is actionable information for clinicians and coaches.

Importantly, exercise remains a cornerstone of musculoskeletal health during this transition. The evidence from Hansen et al. (2009) is clear: estrogen amplifies the benefits of mechanical loading on collagen synthesis. This means that staying active is not just helpful — it is biologically synergistic with hormonal management strategies.

Why Perimenopause Joint Pain Is Underdiagnosed in Clinical Practice

Despite the prevalence of these symptoms and the growing mechanistic evidence to explain them, musculoskeletal complaints remain systematically underscreened in perimenopausal care. Women frequently report that their joint pain is attributed to stress, age, or lifestyle — without any consideration of hormonal context.

The research also raises important questions about how hormone replacement therapy is formulated and prescribed. Sander and Connizzo (2025) note that the distinct roles of estrogen and progesterone in tendon ECM remodeling have direct implications for combined HRT formulations. Similarly, Gilmer et al. (2025) highlight the clinical relevance of combined hormonal effects on ligament properties for surgical timing and joint instability management.

The authors of the Kruse et al. (2026) meta-analysis specifically call for:

• Systematic MSK screening as part of routine perimenopausal assessment
• Integration of musculoskeletal evaluation into standard menopause care protocols
• Clinician education on the hormonal basis of joint and muscle symptoms

This represents a significant shift in how menopause care should be structured — moving from a symptom-by-symptom approach to one that recognizes the musculoskeletal system as a core area of concern.

What This Means for You

If you are in the perimenopausal transition and experiencing joint pain, muscle soreness, or reduced physical function, here is what this research supports:

Your symptoms have a physiological basis. The hormonal changes of perimenopause directly affect muscle, tendon, ligament, and cartilage health. This is not “all in your head,” and it is not simply aging.

Tracking your symptoms matters. Keep a record of musculoskeletal complaints alongside other perimenopausal symptoms. Patterns over time are valuable clinical information.

Ask for a musculoskeletal assessment. If your provider has not discussed MSK health as part of your menopause care, bring it up. You have every right to request a thorough evaluation.

Exercise and hormonal management may work best together. The evidence suggests that estrogen therapy and structured exercise are synergistic — each amplifying the benefits of the other for tendon and muscle health. Discuss this with your healthcare provider.

Management options exist. From structured exercise programs and dietary interventions to hormone therapy and targeted physical therapy, there are evidence-based strategies that can meaningfully reduce the burden of MSK symptoms during this transition.

Getting Treatment for Perimenopause Joint Pain in Washington, DC

If you’re in the Washington, DC area and experiencing musculoskeletal symptoms related to perimenopause, specialized physical therapy can make a meaningful difference. At 

If you’re in the Washington, DC area and experiencing musculoskeletal symptoms related to perimenopause, specialized physical therapy can make a meaningful difference. At The PHYT Collective, our physical therapists work with active women navigating the menopausal transition — addressing joint pain, strength loss, and connective tissue changes with evidence-informed, individualized care.

We have two locations to serve you:

• Downtown DC
• H Street NE

Whether you’re a competitive athlete or simply someone who wants to stay active and pain-free through this transition, we’d love to talk. Learn more about our approach or reach out to schedule an evaluation.

Frequently Asked Questions

Can perimenopause cause joint pain?

Yes. Research from a meta-analysis of over 93,000 women confirms that joint pain is a common, hormonally driven feature of perimenopause — not simply a result of aging. Declining estrogen affects muscle, tendon, ligament, and cartilage health, contributing directly to pain and reduced physical function during this transition.

What does perimenopause joint pain feel like?

Perimenopausal joint pain is most commonly described as aching or stiffness in the hands, knees, hips, and shoulders. Some women also experience muscle soreness, reduced strength, and a general sense that their body doesn’t recover from activity the way it used to. Symptoms can come and go in ways that mirror hormonal fluctuation.

How long does joint pain last during perimenopause?

Joint pain tends to peak during the menopausal transition and early postmenopause, when hormonal fluctuations are most pronounced. For some women symptoms improve after menopause; for others they persist. The duration and severity vary, which is why tracking symptoms and seeking evaluation early is important.

Does estrogen help with joint pain in perimenopause?

The research suggests it can. Studies show estrogen therapy supports tendon collagen synthesis and may reduce joint inflammation. Evidence also indicates that estrogen and structured exercise are synergistic — each amplifying the other’s benefits for musculoskeletal health. Whether hormone therapy is appropriate for you is a conversation to have with your provider.

Should I see a physical therapist for perimenopause joint pain?

Yes — a physical therapist who understands the hormonal basis of musculoskeletal changes can help you build strength, reduce pain, and move better through the transition. The PHYT Collective in Washington, DC (Downtown and H Street NE) works with women navigating perimenopause with individualized, evidence-informed care. Reach out to schedule an evaluation.

The Bottom Line

The menopausal transition is a whole-body event — and the musculoskeletal system is no exception. A meta-analysis of over 93,000 women has confirmed what many women have long known from experience: perimenopause joint pain and muscle aches are a real, prevalent, and hormonally-driven feature of this life stage. Five converging bodies of research now explain precisely how estrogen and progesterone shape the health of muscles, tendons, ligaments, and cartilage — and what happens when those levels decline or fluctuate unpredictably.

The story is more nuanced than estrogen alone. Progesterone’s protective role in tendon ECM remodeling, its partial counteraction of estrogen-induced ligament laxity, and the combined hormonal effects on connective tissue repair and injury risk all point to a more sophisticated clinical picture — one that should inform how HRT is prescribed, how female athletes are managed, and how menopause care is structured.

Recognizing the musculoskeletal syndrome of menopause as a distinct clinical entity is a critical first step. Understanding the full hormonal biology — estrogen and progesterone together — is the next. Women deserve providers who screen for these symptoms, understand their hormonal basis, and offer targeted, evidence-informed management — not dismissal.

If you are experiencing these symptoms, know that the research is on your side.

References

• Kruse C, McKechnie T, Dworsky-Fried J, et al. JB & JS Open Access. 2026.
• Hansen M, Kjaer M. Advances in Experimental Medicine and Biology. 2016.
• Hansen M, Kongsgaard M, Holm L, et al. Journal of Applied Physiology. 2009.
• Sander AM, Connizzo BK. Journal of Orthopaedic Research. 2025.
• Gilmer G, Crasta N, Tanaka MJ. American Journal of Sports Medicine. 2025.

This blog post is for educational purposes only and does not constitute medical advice. Please consult a qualified healthcare provider for personalized guidance.