Perimenopause and menopause are not just about hot flushes and periods stopping. Estrogen has receptors in nearly every tissue in your body, including your brain, your bones, your muscles, your tendons, your cartilage, your joints and the connective tissue of your pelvic floor. When estrogen levels decline, all of those tissues feel it, often at the same time.
During perimenopause your estrogen levels start to fluctuate and then drop significantly. By the time you reach menopause, your estrogen is around 90% lower than it was in your younger years. That drop is felt across every tissue estrogen touches.Most women are told about their bones. Far fewer are told about the rest.
Joint pain and inflammation
Many women reach perimenopause and find their joints have started hurting in ways they cannot explain. Aching, stiffness in the morning, pain that moves around without a clear cause. For many this is one of the earliest signs that perimenopause has begun, arriving before hot flushes and often before periods change noticeably.
If that sounds familiar, you are not alone and you are not imagining it. More than 70% of perimenopausal women experience musculoskeletal pain, and for many there is nothing visible on a scan to explain it. The pain is real and it is hormonal.
Estrogen is a natural anti-inflammatory. When levels drop, inflammation increases across your joints and soft tissues. That is what is driving what you are feeling.
Your muscles change too
Staying active is the most effective thing you can do for your muscles during perimenopause and menopause.
During perimenopause your muscles start to change before menopause even arrives. They respond differently to exercise and recover more slowly than they used to. Estrogen plays a role in maintaining muscle mass and strength, and as levels fall your muscles feel that change. You might find you tire more quickly, or that things that once felt easy require more effort.
After menopause, without regular exercise, women lose around 0.6% of muscle mass per year. This gradual change is called sarcopenia. It is not inevitable. It is something you can actively influence.
The good news is that many forms of movement count, and you do not need a gym or expensive equipment to make a difference. Walking is one of the most beneficial things you can do. Weights, resistance bands, bodyweight exercises, Pilates, yoga and running all work too. Stretching and mobilisation are just as important as strengthening, keeping your joints moving and your muscles flexible. The best exercise is the one that works for your life right now.
Your bones
Estrogen plays a central role in maintaining bone density. As your levels fall during perimenopause and menopause, bone loss accelerates. You can lose up to 10% of your bone density during the menopausal transition, which increases your risk of osteopenia, osteoporosis and fracture.
This is one of the most well understood effects of estrogen loss, and there is strong evidence that exercise, nutrition and in some cases medical treatment can make a real difference. We cover this in detail in our dedicated article on bone health in perimenopause and menopause.
Your tendons and connective tissue
Estrogen also plays a role in keeping your tendons and ligaments strong and springy. As levels fall, these tissues become less resilient and take longer to recover after exercise. You might notice this as a tendon that aches after activity in a way it never used to, or pain around a joint that is hard to explain. Giving your body more recovery time between sessions matters more now than it did before.
Your pelvic floor
Your pelvic floor is made up of muscles, tendons and connective tissue that support your bladder, bowel and uterus. Like so many other tissues in your body, it is affected by estrogen. As your levels fall, the muscles and connective tissue of your pelvic floor change, which is part of why leaking, urgency and pelvic discomfort become more common during this life stage.
Pelvic floor exercises can help at any stage, and if symptoms are affecting your life, support is available.
Your brain
Estrogen receptors are present in your brain too. This is why cognitive changes, brain fog, mood shifts and sleep disturbances are part of the perimenopause and menopause experience for many women, not separate issues, but part of the same hormonal transition. We cover this in more depth in a dedicated article.
What this means for you
Estrogen loss is not a single issue with a single solution. It affects your joints, your muscles, your bones, your tendons, your pelvic floor and your brain, often all at the same time. Understanding that picture is the first step to feeling less confused and more in control of what is happening to you.
The rest of this series goes deeper into each of these areas, what the evidence says, what helps, and where the research still has gaps.
References
Chidi-Ogbolu, N., & Baar, K. (2019). Effect of estrogen on musculoskeletal performance and injury risk. Frontiers in Physiology, 9, 1834. https://doi.org/10.3389/fphys.2018.01834
Juppi, H., Sipila, S., Cronin, N., et al. (2020). Role of menopausal transition and physical activity in loss of lean and muscle mass: a follow-up study in middle-aged Finnish women. Journal of Clinical Medicine, 9. https://doi.org/10.3390/jcm9051588
Nedergaard, A., Henriksen, K., Karsdal, M., & Christiansen, C. (2013). Menopause, estrogens and frailty. Gynecological Endocrinology, 29, 418-423. https://doi.org/10.3109/09513590.2012.754879
Pérez-López, F.R., Vieira-Baptista, P., Phillips, N., Cohen-Sacher, B., Fialho, S.C.A.V., & Stockdale, C.K. (2021). Clinical manifestations and evaluation of postmenopausal vulvovaginal atrophy. Gynecological Endocrinology, 37(8), 740-745. https://doi.org/10.1080/09513590.2021.1931100
Robinson, D. (2024). Oestrogens and lower urinary tract dysfunction chronicling a lifetime of research. Continence. https://doi.org/10.1016/j.cont.2024.101720
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
WHEN Position Statement: Resistance Training Across the Menopausal Transition (April 2026). Women’s Health Education Network. www.when.org.au
Developed by the WHEN Clinical Team
Clinically reviewed by the WHEN Clinical Governance Committee
Last reviewed: July 2026
