Perimenopause: Insights for a Better Journey

Empower yourself with knowledge about perimenopause. Discover essential tips for managing this significant life transition.

Introduction

Perimenopause is a critical—yet often overlooked—transitional phase in a woman’s life, bridging reproductive vitality and menopause. While the hormonal fluctuations during this stage are well-known for causing hot flashes, mood swings, and menstrual irregularities, they also have a profound impact on the musculoskeletal system. As a nurse practitioner with two decades of experience in physical and functional medicine, I’ve seen firsthand how these hormonal changes contribute to chronic joint pain, decreased bone mineral density, and muscle mass loss.

In this comprehensive article, we’ll explore the physiological changes that occur during perimenopause, how they affect the musculoskeletal system, and the best evidence-based strategies to manage symptoms through a functional, integrative approach.

What Is Perimenopause?

Perimenopause refers to the years leading up to menopause, during which ovarian function declines and estrogen and progesterone levels begin to fluctuate erratically. It typically begins in a woman’s 40s but may start as early as the mid-30s for some.

This transitional phase can last anywhere from 4 to 10 years and is defined by noticeable changes in the menstrual cycle. According to Lega & Jacobson (2024), perimenopause officially begins when there’s a persistent difference in menstrual cycle length exceeding seven days. The phase concludes 12 months after a woman’s final menstrual period.

Recognizing the Symptoms of Perimenopause

Because estrogen plays a role in nearly every system of the body, symptoms are not limited to reproductive health. Many women report a constellation of systemic complaints that often go under-addressed:

Vasomotor Symptoms

• Hot flashes
• Night sweats

Neurocognitive and Mood Disturbances

• Memory lapses (“brain fog”)
• Difficulty concentrating
• Irritability, anxiety, and depression

Sleep Dysregulation

• Difficulty falling asleep
• Early morning awakenings

Urogenital Changes

• Vaginal dryness
• Urinary urgency and frequency

Menstrual Irregularities

• Heavier or skipped periods
• Spotting between cycles

Musculoskeletal Complaints

• Joint stiffness and pain
• Muscle soreness
• Increased risk for fractures

Importantly, many of these symptoms overlap with musculoskeletal disorders and inflammatory conditions, making differential diagnosis essential.

The Estrogen-Musculoskeletal Connection

Estrogen’s role in the musculoskeletal system is often underestimated. It is a key regulator of bone remodeling, collagen production, and muscle regeneration. As estrogen levels drop during perimenopause, several biomechanical and metabolic changes occur:

1. Decline in Bone Density

Estrogen helps regulate osteoclast and osteoblast activity. A decrease in estradiol leads to increased bone resorption and decreased bone formation, setting the stage for osteopenia and osteoporosis.

2. Loss of Muscle Mass (Sarcopenia)

Estrogen receptors are found in skeletal muscle. Declining estrogen impairs muscle protein synthesis, resulting in sarcopenia, especially in the lower extremities, leading to weakness and imbalance.

3. Increased Inflammation

Estrogen has anti-inflammatory properties. Its decline increases pro-inflammatory cytokines like IL-6 and TNF-α, which contribute to chronic joint pain, particularly in the neck, shoulders, and knees.

4. Altered Pain Perception

Estrogen modulates neurotransmitters such as serotonin and endorphins, which influence pain threshold. Fluctuating levels may lead to heightened pain sensitivity.

(Wright et al., 2024)

Common Musculoskeletal Conditions Exacerbated by Perimenopause

• Osteoarthritis flare-ups
• Fibromyalgia symptoms
• Myofascial pain syndrome
• Mechanical low back pain
• Rotator cuff tendinopathies

Assessing Hormone Therapy- Video

A Functional Medicine Approach to Managing Perimenopausal Musculoskeletal Symptoms

Perimenopause is not a disease—it’s a natural biological process. However, its symptoms can be debilitating. A proactive, integrative strategy that combines conventional treatments with evidence-based complementary therapies can dramatically improve quality of life.

1. Bioidentical and Traditional Hormone Replacement Therapy (HRT)

HRT remains the most effective treatment for vasomotor and musculoskeletal symptoms in eligible women. Estrogen replacement helps maintain bone density, alleviate joint pain, and improve mood.

Options Include:

• Oral conjugated estrogens
• Transdermal estradiol patches
• Bioidentical hormone creams or troches

Considerations:
Women with a personal history of breast cancer, thromboembolism, or stroke should be carefully evaluated. A risk-benefit analysis and shared decision-making approach are critical.

(Moustakli & Tsonis, 2023)

2. Nutritional Interventions for Hormonal and Skeletal Support

A nutrient-dense, anti-inflammatory diet can significantly reduce musculoskeletal pain and enhance hormone metabolism.

Key Nutrients:

• Calcium: 1,200 mg/day (dairy, leafy greens, almonds)
• Vitamin D3: 1,000–2,000 IU/day (sunlight, salmon, fortified foods)
• Magnesium: Relieves muscle cramps and supports sleep
• Protein: Vital for muscle preservation—aim for 1.0–1.2g/kg/day
• Omega-3 Fatty Acids: Reduce inflammation (flaxseeds, fish oil)

Functional Foods to Include:

• Tofu (phytoestrogens)
• Cruciferous vegetables (detoxify estrogen metabolites)
• Berries and turmeric (antioxidants)
• Bone broth (collagen and minerals)

(Erdélyi et al., 2023)

3. Exercise and Physical Rehabilitation

Physical activity is crucial for preserving musculoskeletal health during perimenopause. Exercise stimulates bone formation, reduces stiffness, and alleviates mood disorders.

Recommended Modalities:

• Weight-bearing exercises: Walking, resistance bands, light weights
• Tai Chi & Yoga: Improve balance, reduce fall risk, enhance joint mobility
• Pilates: Core stabilization and postural alignment
• Chiropractic care and physical therapy: Address joint dysfunction and improve mobility

(Li et al., 2023)

4. Mind-Body and Integrative Therapies

Complementary modalities help regulate the nervous system and reduce systemic inflammation.

Effective Options:

• Acupuncture: Modulates pain receptors and cytokine levels
• CBT and mindfulness-based stress reduction (MBSR): For anxiety, depression, and sleep
• Massage therapy: Relieves muscle tension and supports lymphatic flow
• Gua Sha therapy: Stimulates microcirculation and reduces myofascial restriction

(Zhao et al., 2023)

5. Lifestyle Optimization and Preventive Screening

• Sleep hygiene: Maintain consistent bedtime, minimize blue light
• Avoid smoking and alcohol: Both accelerate bone loss
• DEXA scans: Initiate baseline bone mineral density testing in mid-40s
• Pelvic floor therapy: For urinary and pelvic musculoskeletal concerns

Final Thoughts: Empowerment Through Education and Prevention

Perimenopause is not just about hot flashes—it’s a full-body transformation that deeply affects the musculoskeletal system. As healthcare professionals, we must recognize and validate the diverse experiences of women in this phase. With the right blend of clinical care, lifestyle interventions, and holistic support, we can offer women not just symptom relief but restored vitality.

By addressing perimenopause through a physical and functional medicine lens, we empower women to take control of their health, stay active, and live pain-free throughout midlife and beyond.

Injury Medical & Functional Wellness Clinic

We associate with certified medical providers who understand the importance of assessing individuals dealing with musculoskeletal issues related to perimenopause. When asking important questions to our associated medical providers, we advise patients to incorporate numerous techniques to reduce pain-like symptoms related to the musculoskeletal system. Dr. Alex Jimenez, D.C., uses this information as an academic service. Disclaimer.

References

Erdélyi, A., Pálfi, E., Tűű, L., Nas, K., Szűcs, Z., Török, M., Jakab, A., & Várbíró, S. (2023). The Importance of Nutrition in Menopause and Perimenopause—A Review. Nutrients, 16(1), 27. https://doi.org/10.3390/nu16010027

Lega, I. C., & Jacobson, M. (2024). Perimenopause. CMAJ, 196(34), E1169. https://doi.org/10.1503/cmaj.240337

Li, J., Guo, J., Wang, X., Zhang, X., Zhang, Y., Bu, M., Yao, X., & She, Y. (2023). Efficacy and safety of tai chi exercise on bone health: An umbrella review. Osteoporos Int, 34(11), 1853-1866. https://doi.org/10.1007/s00198-023-06830-7

Moustakli, E., & Tsonis, O. (2023). Exploring Hormone Therapy Effects on Reproduction and Health in Transgender Individuals. Medicina (Kaunas, Lithuania), 59(12). https://doi.org/10.3390/medicina59122094

Priyanka, H. P., & Nair, R. S. (2020). Neuroimmunomodulation by estrogen in health and disease. AIMS Neurosci, 7(4), 401-417. https://doi.org/10.3934/Neuroscience.2020025

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

Zhao, F.-Y., Zheng, Z., Fu, Q.-Q., Conduit, R., Xu, H., Wang, H.-R., Huang, Y.-L., Jiang, T., Zhang, W.-J., & Kennedy, G. A. (2023). Acupuncture for comorbid depression and insomnia in perimenopause: A feasibility patient-assessor-blinded, randomized, and sham-controlled clinical trial. Frontiers in Public Health, 11. https://doi.org/10.3389/fpubh.2023.1120567

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