Menopause is often discussed in relation to vasomotor symptoms, urogenital changes and bone loss. However, many patients first present to a physiotherapist or musculoskeletal clinic with joint pain, stiffness, reduced strength, tendon symptoms or an unexplained decline in physical capacity. The term 'musculoskeletal syndrome of menopause' (MSM) was proposed to bring these overlapping problems into one clinical framework (Wright et al., 2024).

MSM is a useful emerging concept rather than a formally established diagnosis. It has no universally accepted diagnostic criteria, and menopause should not become a shortcut explanation for every new pain in midlife. Its value lies in prompting clinicians to consider reproductive ageing alongside mechanical, inflammatory, metabolic and psychosocial contributors.

What Does the Syndrome Include?

The proposed syndrome describes musculoskeletal symptoms and disorders that may emerge or worsen during the menopausal transition as ovarian oestrogen declines. Its suggested spectrum includes arthralgia, loss of muscle mass and strength, reduced bone density, tendon and ligament problems, adhesive capsulitis, osteoarthritis progression and increased injury risk (Wright et al., 2024).

The symptom burden is clinically important. A 2026 systematic review and meta-analysis involving 93,021 women found that those transitioning through perimenopause had greater odds of muscle or joint pain than premenopausal women (Kruse et al., 2026). Earlier evidence also found musculoskeletal pain to be more common during perimenopause than before menopause (Lu et al., 2020). These associations do not prove that hormonal change is the only cause, but they support asking about menopause stage during a midlife musculoskeletal assessment.

Common presentations include:

diffuse joint or muscle aching, often with morning stiffness;
shoulder pain or adhesive capsulitis;
tendinopathy, reduced load tolerance or slower recovery;
declining grip strength, lower-limb strength or exercise capacity;
pelvic-floor symptoms occurring alongside general musculoskeletal complaints; and
fragility risk, particularly when early menopause or other osteoporosis risks are present.

Why Can Menopause Affect Musculoskeletal Tissues?

Oestrogen receptors are present in bone, skeletal muscle, cartilage, synovium, tendons and ligaments. Oestrogen influences bone remodelling, muscle protein turnover, connective-tissue collagen, inflammation and pain processing. Therefore, fluctuating and eventually lower oestrogen exposure offers a biologically plausible explanation for part of the clinical pattern (Watt, 2018; Wright et al., 2024).

Bone loss accelerates around the final menstrual period because resorption begins to exceed formation. In muscle, menopause overlaps with age-related anabolic resistance, reduced physical activity and changes in body composition. Tendons may show altered collagen turnover and mechanical properties, although direct clinical evidence remains less complete than that for bone. Sleep disruption, vasomotor symptoms, mood change, weight gain and reduced activity can further increase pain sensitivity and diminish recovery.

This is therefore a multifactorial model. Chronological ageing, previous injury, occupational load, obesity, diabetes, thyroid disease, vitamin D deficiency, inflammatory disease and medication effects may coexist with hormonal change. A good assessment identifies the relative contribution of each rather than attributing symptoms to oestrogen alone.

Clinical Assessment: Connect the Timeline Without Anchoring

Begin with the usual musculoskeletal history, then add a reproductive-ageing lens. In people aged 45 years or older with typical symptoms, perimenopause and menopause are usually identified clinically from menstrual and symptom history rather than routine ovarian-hormone testing (National Institute for Health and Care Excellence [NICE], 2024).

Objective examination should remain presentation-specific. It may include joint and neurological screening, muscle strength, functional tasks such as sit-to-stand, gait and balance, and graded tendon-loading tests. Consider fracture-risk assessment and referral for bone-density evaluation when indicated; menopause alone does not mean that every patient requires dual-energy X-ray absorptiometry.

Avoid diagnostic anchoring. Persistent synovitis, prolonged morning stiffness, unexplained weakness, neurological deficit, systemic illness, significant night pain or a suspected fragility fracture requires medical investigation. New pain can still represent rheumatoid arthritis, polymyalgia rheumatica, hypothyroidism, malignancy, infection or another condition unrelated to menopause.

Management: Build Capacity and Coordinate Care

Management should be matched to the dominant impairment and the patient’s goals. Education can validate that musculoskeletal symptoms are common during the transition while reinforcing that tissues remain adaptable. The physiotherapist’s central role is to restore capacity, confidence and sustained physical activity.

Progressive resistance training should target major muscle groups at least twice weekly, beginning at a tolerable dose and advancing load as technique and recovery permit. Weight-bearing and impact exercise should be included according to bone health, symptoms and previous training. Aerobic exercise supports cardiometabolic health, sleep and general function, while balance work becomes increasingly important with age. A symptomatic tendon or joint still requires condition-specific rehabilitation; a menopause label does not replace graded loading, activity modification or appropriate manual and educational strategies.

Recovery factors matter. Adequate dietary protein, calcium and vitamin D should be addressed through dietetic or medical input where necessary. Sleep, smoking, alcohol intake and fear-driven activity avoidance may all influence outcomes. A pelvic-health referral is appropriate when urinary leakage, prolapse symptoms, pelvic pain or sexual dysfunction restrict exercise.

A practical rehabilitation sequence is the following:

Screen and classify → establish baseline capacity → select symptom-specific loading → add resistance, weight-bearing and aerobic exercise → monitor immediate and next-day response → progress or refer.

Where Does Menopausal Hormone Therapy Fit?

Physiotherapists should understand hormone therapy (HT) sufficiently to communicate accurately, but prescribing decisions belong to an appropriately qualified menopause clinician. HT is an evidence-based option for bothersome vasomotor symptoms and genitourinary symptoms and can prevent bone loss and reduce fracture risk in suitable patients. Individual risks, age, time since menopause, uterine status and patient preference must guide the decision (NICE, 2024; The Menopause Society, 2024).

HT should not currently be presented as a proven stand-alone treatment for general musculoskeletal pain. A recent systematic review of 57 studies found no significant pooled effect of ever using HT versus never using it on generalised musculoskeletal pain; evidence for osteoarthritis and inflammatory conditions was heterogeneous and conflicting (Overton et al., 2026). The Menopause Society (2024) similarly advises against using HT specifically to manage conditions such as osteoarthritis, joint pain or frozen shoulder. Clinicians should refer for an individual menopause consultation when broader symptoms or bone-health considerations make HT discussion appropriate without promising pain relief.

Viva-Ready Summary

The musculoskeletal syndrome of menopause is an emerging umbrella concept, not a validated standalone diagnosis.
It links the menopausal transition with arthralgia, muscle decline, bone loss and possible tendon, ligament and joint problems.
Oestrogen change is biologically relevant, but age, activity, sleep, metabolic health and existing disease also contribute.
Assessment must combine menopause history with a complete musculoskeletal examination, bone-risk screen and differential diagnosis.
Progressive resistance, weight-bearing, aerobic and balance exercise form the rehabilitation foundation.
HT may be appropriate for recognised menopause indications and bone protection, but current evidence does not justify prescribing it solely for musculoskeletal pain.

One-line recall point: In a midlife patient with new musculoskeletal symptoms, connect the menopause timeline – but still assess the tissue, screen bone health and exclude alternative pathology.

References

Kruse, C., McKechnie, T., Dworsky-Fried, J., Sardar, A., Hacker, G., Rattansi, S., Fang, E., Sprague, S., Shea, A. K., & Bhandari, M. (2026). Musculoskeletal manifestations of perimenopause: A systematic review and meta-analysis of 93,021 women. JBJS Open Access, 11(1), e25.00254. https://doi.org/10.2106/JBJS.OA.25.00254

Lu, C.-B., Liu, P.-F., Zhou, Y.-S., & Meng, F.-C. (2020). Musculoskeletal pain during the menopausal transition: A systematic review and meta-analysis. Neural Plasticity, 2020, 8842110. https://doi.org/10.1155/2020/8842110

National Institute for Health and Care Excellence. (2024). Menopause: Identification and management (NICE Guideline NG23). https://www.nice.org.uk/guidance/ng23

Overton, R., Amini, P., Chew, A., Babatunde, O., Mason, K. J., Rathod, S., Welsh, V., & Burton, C. (2026). The effect of hormone replacement therapy on musculoskeletal pain in menopausal women: A systematic review and meta-analysis. Post Reproductive Health, 32(1), 52–68. https://doi.org/10.1177/20533691251403087

The Menopause Society. (2024). Misinformation surrounding hormone therapy. https://menopause.org/wp-content/uploads/for-women/Misinformation-Surrounding-Hormone-Therapy.pdf

Watt, F. E. (2018). Musculoskeletal pain and menopause. Post Reproductive Health, 24(1), 34–43. https://doi.org/10.1177/2053369118757537

Wright, V. J., Schwartzman, R. J., Itinoche, R., & Clark, A. L. (2024). The musculoskeletal syndrome of menopause. Climacteric, 27(5), 466–472. https://doi.org/10.1080/13697137.2024.2380363