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Musculoskeletal Syndrome of Menopause

How the menopausal transition and oestrogen withdrawal drive joint, tendon and muscle symptoms — arthralgia, tendinopathy, frozen shoulder, greater trochanteric pain and myalgia — and the evidence on hormone therapy.

Overview

The perimenopause is a state during which women are particularly predisposed to develop musculoskeletal pain [1]. Arthralgia is experienced by more than half of women around the time of menopause [2]. The prevalence of arthralgia appears to increase during the menopausal transition [2]. This increase likely results from reduction in oestrogen levels [2].

Low back pain is more prevalent in postmenopausal women than in age-matched men [4]. The higher prevalence of low back pain in postmenopausal women is associated with physiological changes caused by relatively lower levels of sex hormones after menopause [4]. The prevalence of sarcopenia is 31% in community dwelling outpatient postmenopausal Hungarian women [3].

The prevalence of asymptomatic full-thickness rotator cuff tears is increased in the postmenopausal period [5]. There is an association between asymptomatic full-thickness rotator cuff tears and metabolic disorders in postmenopausal women [5]. There is limited evidence for a protective effect of unopposed oestrogen use for the incidence of hip replacement or joint replacement [7]. There is a protective trend for unopposed oestrogen use for incident radiological osteoarthritis of the knee [7].

Background & Causes

The perimenopausal period is a state of heightened predisposition to musculoskeletal pain [1]. Arthralgia affects more than half of women around the time of menopause, with prevalence increasing during the menopausal transition [2]. This rise in arthralgia likely results from reduced oestrogen levels [2]. Low back pain is more prevalent in postmenopausal women than in age-matched men, a difference associated with physiological changes from relatively lower sex hormone levels after menopause [4].

Estrogen and muscle stiffness share a negative relationship in females, and correlations exist between muscle properties and reproductive hormones [10]. In older men, total estradiol (E2) levels positively relate to muscle mass but adversely affect muscle strength [14]. In ovariectomized mice, combined treatment with estradiol (E2) and progesterone (P4) restored physical activity, predominantly driven by E2, and protected soleus muscles against fatigue [12]. The prevalence of sarcopenia is 31% in community-dwelling outpatient postmenopausal Hungarian women [3].

Osteoporotic osteoarthritis is defined by reduced bone mineral density related to high remodeling in subchondral bone [6]. Estrogen and selective estrogen receptor modulators (SERMs) may be particularly favorable for postmenopausal patients with early-stage osteoarthritis or osteoporotic osteoarthritis [6]. Significant associations exist between lower baseline serum estradiol and developing knee osteoarthritis in middle-aged women, as well as between lower baseline urinary 2-hydroxyestrone and the same condition [17].

The prevalence of asymptomatic full-thickness rotator cuff tears is increased in the postmenopausal period [5]. There is an association between asymptomatic rotator cuff tears and metabolic disorders in postmenopausal women [5]. Aging and estrogen deficiency affect extracellular matrix-related gene expression in rotator cuff tendons through distinct mechanisms [16]. Estrogen receptors (ERs) and progesterone receptors (PR) are present in the supraspinatus tendon of patients with rotator cuff tears, suggesting a role for sex hormones in the pathogenesis of rotator cuff disease [19].

Women not receiving hormone replacement therapy (HRT) had greater odds of adhesive capsulitis compared to those receiving HRT [18]. The association between HRT and reduced risk of adhesive capsulitis did not reach statistical significance due to limited sample size, but the 95% confidence interval supports the hypothesis that HRT may be protective against adhesive capsulitis [18].

Symptoms & Presentation

The perimenopause is a state during which women are particularly predisposed to develop musculoskeletal pain [1]. Arthralgia is experienced by more than half of women around the time of menopause [2]. The prevalence of arthralgia appears to increase during the menopausal transition [2]. This increase is likely resulting from reduction in oestrogen levels [2].

Low back pain (LBP) is more prevalent in postmenopausal women than age-matched men [4]. The higher prevalence of LBP in postmenopausal women is associated with physiological changes caused by relatively lower levels of sex hormones after menopause [4]. Long-lasting use of systemic MHT, in particular therapy based on oestrogen only, is associated with greater risk of chronic LBP [8].

The prevalence of asymptomatic full-thickness rotator cuff tears is increased in the postmenopausal period [5]. There is an association between asymptomatic rotator cuff tears and metabolic disorders in postmenopausal women [5]. Estradiol supplementation was associated with better outcomes in postmenopausal women undergoing rotator cuff repair (RCR) [9]. The differences in VAS and SSV outcomes with estradiol supplementation did not meet the minimal clinically important threshold [9].

Estrogen and muscle stiffness have a negative relationship in females [10]. Correlations exist between muscle properties and reproductive hormones [10]. Oestrogen fluctuations had no significant effect on anterior knee laxity over the 28-day cycle [20]. The effects of oestrogen fluctuations on musculotendinous stiffness over the 28-day cycle were considerable [20]. Female hormone levels are related to increased knee joint laxity and decreased stiffness at ovulation [22].

Management

Musculoskeletal pain is particularly prevalent during the perimenopausal transition [1]. Arthralgia affects more than half of women around the time of menopause, with prevalence increasing during the menopausal transition due to reduced estrogen levels [2]. Low back pain is more prevalent in postmenopausal women than in age-matched men, associated with lower sex hormone levels after menopause [4]. The prevalence of asymptomatic full-thickness rotator cuff tears is increased in the postmenopausal period and is associated with metabolic disorders [5].

Hormonal Therapy: Estrogen and selective estrogen receptor modulators (SERMs) may be favorable for postmenopausal patients with early-stage osteoarthritis or osteoporotic osteoarthritis, defined by reduced bone mineral density and high subchondral bone remodeling [6]. There is limited evidence for a protective effect of unopposed estrogen use on the incidence of hip or joint replacement [7]. Unopposed estrogen use shows a protective trend for incident radiological osteoarthritis of the knee [7]. Long-lasting use of systemic menopausal hormone therapy (MHT), particularly estrogen-only therapy, is associated with a greater risk of chronic low back pain [8]. Estradiol supplementation was associated with better outcomes in postmenopausal women undergoing rotator cuff repair, although differences in Visual Analog Scale (VAS) and Simple Shoulder Test (SSV) scores did not meet the minimal clinically important threshold [9].

Exercise and Rehabilitation: The combination of proprioceptive neuromuscular facilitation (PNF) exercises and strength training is more effective than strength training alone for reducing disability and pain, and improving mobility and strength in postmenopausal women with thumb carpometacarpal osteoarthritis [11]. For postmenopausal women with a BMI <25, MHT combined with any exercise plus education was superior to placebo in managing greater trochanteric pain syndrome [15].

Key Considerations

The perimenopausal period is a state of heightened predisposition to musculoskeletal pain [1]. Arthralgia affects more than half of women around the time of menopause, with prevalence increasing during the menopausal transition [2]. This rise in arthralgia likely results from reductions in oestrogen levels [2].

Low back pain is more prevalent in postmenopausal women than in age-matched men [4]. This higher prevalence is associated with physiological changes caused by relatively lower levels of sex hormones after menopause [4]. However, long-lasting use of systemic menopausal hormone therapy is associated with a greater risk of chronic low back pain [8]. Specifically, therapy based on oestrogen only is associated with a greater risk of chronic low back pain [8].

Sarcopenia prevalence is 31% in community-dwelling outpatient postmenopausal Hungarian women [3]. The prevalence of asymptomatic full-thickness rotator cuff tears is increased in the postmenopausal period [5]. There is an association between asymptomatic full-thickness rotator cuff tears and metabolic disorders in postmenopausal women [5].

Hormonal Therapy Effects: * Osteoarthritis: Estrogen and SERMs may be particularly favorable for postmenopausal patients with early-stage osteoarthritis or osteoporotic osteoarthritis [6]. Osteoporotic osteoarthritis is defined by reduced bone mineral density related to high remodeling in subchondral bone [6]. * Joint Replacement: There is limited evidence for a protective effect of unopposed oestrogen use for the incidence of hip replacement or joint replacement [7]. There is a protective trend for incident radiological osteoarthritis of the knee with unopposed oestrogen use [7]. * Rotator Cuff Repair: Estradiol supplementation was associated with better outcomes in postmenopausal women undergoing rotator cuff repair [9]. The differences in VAS and SSV scores with estradiol supplementation did not meet the minimal clinically important threshold [9].

Surgical Alternatives: * Trapeziometacarpal Arthrosis: The Epping resection arthroplasty technique is a valuable alternative procedure to treat idiopathic postmenopausal trapeziometacarpal arthrosis after a midterm follow-up period [21].

Key Evidence

  • [L1] The perimenopause is a state during which women are particularly predisposed to develop musculoskeletal pain. (10.1155/2020/8842110)
  • [Paper] Arthralgia is experienced by more than half of women around the time of menopause, and prevalence appears to increase during menopausal transition, likely resulting from reduction in oestrogen levels. (10.1016/j.maturitas.2010.04.009)
  • [L4] The 31% prevalence of sarcopenia in the studied post-menopausal women highlights the need for adequate assessment of the condition in the elderly. (10.1186/s12891-022-05167-2)
  • [L5] I propose the concept that low back pain (LBP) is more prevalent in postmenopausal women than age-matched men and is associated with the physiological changes caused by the relatively lower level of sex hormones after menopause in women. (10.1016/j.jot.2016.05.012)
  • [L4] The prevalence of asymptomatic full-thickness tears is increased in the postmenopausal period, and there is an association between tears and metabolic disorders. (10.1097/gme.0b013e31829638e3)
  • [L4] Estrogen and SERMs may be particularly favorable for postmenopausal patients with early-stage OA or osteoporotic OA, a phenotype defined by reduced bone mineral density related to high remodeling in subchondral bone. (10.1186/s13075-016-1045-7)
  • [L1] Limited evidence was seen for a protective effect of unopposed oestrogen use for incidence of hip replacement/joint replacement, and a protective trend for incident radiological OA of the knee. (10.1093/rheumatology/ken390)
  • [L2] Long-lasting use of systemic MHT, in particular therapy based on oestrogen only, is associated with greater risk of chronic LBP. (10.1186/s12891-023-06184-5)
  • [L3] Estradiol supplementation was associated with better outcomes in postmenopausal women undergoing RCR; however, these differences in VAS and SSV did not meet the minimal clinically important threshold. (10.1016/j.xrrt.2025.100642)
  • [L3] Correlations exist between muscle properties and reproductive hormones. (10.1007/s00167-011-1577-y)
  • [L1] The combination of PNF exercises and strength training is more effective for reducing disability pain and improve mobility and strength in post-menopausal women with CMC OA than a programme based solely on strength. (10.1016/j.jht.2022.07.005)
  • [Paper] Combined treatment of E2 + P4 in OVX mice restored physical activity, predominantly driven by E2, and protected soleus muscles against fatigue. (10.1016/j.exger.2018.11.003)
  • [L4] Total E2 level, though related to muscle mass positively, affected muscle strength adversely in older men. (10.1530/eje-10-0952)
  • [L1] For women with a BMI <25, MHT with any exercise plus education was better than placebo. (10.1177/03635465211061142)
  • [L5] These results suggest that aging and estrogen deficiency affect ECM gene expression through distinct mechanisms. (10.1016/j.jseint.2025.05.021)
  • [L2] There were significant associations of lower baseline serum estradiol and urinary 2-hydroxyestrone with developing knee OA in middle-aged women. (10.1002/art.22005)
  • [L3] Women not receiving HRT had greater odds of adhesive capsulitis, though the association did not reach statistical significance due to limited sample size; the 95% confidence interval supports the hypothesis that HRT may be protective. (10.1177/2325967123s00174)
  • [L3] These results reveal that ERs and PR are present in the supraspinatus tendon of patients with RC tears, suggesting a role of sex hormones in the pathogenesis of the disease. (10.1186/s12891-021-04778-5)
  • [L3] Oestrogen fluctuations had no significant effect on anterior knee laxity, however, the effects on musculotendinous stiffness over the 28-day cycle were considerable. (10.1007/s00167-006-0143-5)
  • [L4] The Epping procedure has proven to be a valuable alternative procedure to treat idiopathic postmenopausal trapeziometacarpal arthrosis after a midterm follow-up period. (10.1097/01.sap.0000143607.46558.7a)
  • [L3] Female hormone levels are related to increased knee joint laxity and decreased stiffness at ovulation. (10.1177/0363546508326713)

References

[1] Musculoskeletal Pain during the Menopausal Transition: A Systematic Review and Meta-Analysis. Neural Plasticity. 2020. DOI: 10.1155/2020/8842110

[2] Menopausal arthralgia: Fact or fiction. Maturitas. 2010. DOI: 10.1016/j.maturitas.2010.04.009

[3] Prevalence of sarcopenia in community dwelling outpatient postmenopausal Hungarian women. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05167-2

[4] Menopause as a potential cause for higher prevalence of low back pain in women than in age-matched men. Journal of Orthopaedic Translation. 2017. DOI: 10.1016/j.jot.2016.05.012

[5] Prevalence of and risk factors for asymptomatic rotator cuff tears in postmenopausal women. Menopause. 2014. DOI: 10.1097/gme.0b013e31829638e3

[6] Are estrogen-related drugs new alternatives for the management of osteoarthritis?. Arthritis Research & Therapy. 2016. DOI: 10.1186/s13075-016-1045-7

[7] Limited evidence for a protective effect of unopposed oestrogen therapy for osteoarthritis of the hip: a systematic review. Rheumatology. 2008. DOI: 10.1093/rheumatology/ken390

[8] Menopausal hormone therapy, oral contraceptives and risk of chronic low back pain: the HUNT Study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06184-5

[9] Does estradiol supplementation improve rotator cuff repair outcomes in postmenopausal women?. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100642

[10] Estrogen and muscle stiffness have a negative relationship in females. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1577-y

[11] Effectiveness of proprioceptive neuromuscular facilitation therapy and strength training among post-menopausal women with thumb carpometacarpal osteoarthritis. A randomized trial. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2022.07.005

[12] Effects of ovarian hormones and estrogen receptor α on physical activity and skeletal muscle fatigue in female mice. Experimental Gerontology. 2019. DOI: 10.1016/j.exger.2018.11.003

[14] Testosterone but not estradiol level is positively related to muscle strength and physical performance independent of muscle mass: a cross-sectional study in 1489 older men. European Journal of Endocrinology. 2011. DOI: 10.1530/eje-10-0952

[15] Does Menopausal Hormone Therapy, Exercise, or Both Improve Pain and Function in Postmenopausal Women With Greater Trochanteric Pain Syndrome? A 2 × 2 Factorial Randomized Clinical Trial. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211061142

[16] Impact of aging and estrogen deficiency on extracellular matrix-related gene expression in rotator cuff tendons: in vitro and in vivo rat model. JSES International. 2025. DOI: 10.1016/j.jseint.2025.05.021

[17] Estradiol and its metabolites and their association with knee osteoarthritis. Arthritis & Rheumatism. 2006. DOI: 10.1002/art.22005

[18] Poster 188: Is Hormone Replacing Therapy Associated with Reduced Risk of Adhesive Capsulitis in Menopausal Women? A Single Center Analysis. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00174

[19] The role of estrogen and progesterone receptors in the rotator cuff disease: a retrospective cohort study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04778-5

[20] Effects of menstrual‐cycle hormone fluctuations on musculotendinous stiffness and knee joint laxity. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0143-5

[21] Treatment of Idiopathic Postmenopausal Osteoarthrosis of the Trapeziometacarpal Joint With the Epping Resection Arthroplasty Technique. Annals of Plastic Surgery. 2005. DOI: 10.1097/01.sap.0000143607.46558.7a

[22] Changing Hormone Levels during the Menstrual Cycle Affect Knee Laxity and Stiffness in Healthy Female Subjects. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546508326713

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