Perimenopause and Menopause

Published January 1, 2026

What You Need to Know 

Perimenopause and menopause affect millions of women, influencing multiple body systems – including vasomotor, musculoskeletal, cognitive and integumentary functions. It is essential for physical therapists to understand the process of menopause and their clinical implications, as physical therapy can play a key role in both early intervention and long-term management.

• High prevalence: 1.3 million U.S. women enter perimenopause annually, and there will be 1.3 billion women in perimenopause or menopause by 2030.

• Multisystem changes: Estrogen decline affects vasomotor, musculoskeletal, genitourinary, sexual, cognitive, integumentary, and sleep systems.

• The role of physical therapy: Pelvic and general physical therapists often serve as first-line providers for symptoms such as joint pain, incontinence, and pelvic dysfunction, and play a central role in prevention, patient education, and long-term management.

1.3 million women per year enter perimenopause in the US, and there will be 1.3 billion women in perimenopause and beyond by the year 2030. (Peacock et al., 2023). The average age of menopause is fifty-one, with perimenopause symptoms starting often as early as age 40. Menopause is defined as one full year without menstruation and is preceded by declining levels of progesterone and estrogen. (Peacock et al., 2023). As estrogen levels drop during perimenopause, women experience a wide range of symptoms including vasomotor, musculoskeletal, genitourinary, sexual, psychological/cognitive, integumentary and sleep disorders. ( Santoro et al., 2021).It is extremely important for all physical therapists to understand the process of menopause and the implications on the various body systems, as the unmanaged effects of decreased estrogen have long-standing implications on the quality of life of the aging female from cognitive decline, cardiovascular disease, urinary incontinence, urinary tract infections, sarcopenia, risk for falls and hip fracture.  

The statistics are staggering. 60-80% of women experience hot flashes and night sweats with a median duration of over 7 years. (Sturdee et al., 2017). Women who experience longer durations of vasomotor symptoms are associated with higher risk of cardiovascular disease. (Zhu et al., 2020) 71% of women complain of musculoskeletal pain during menopause. (Lu et al., 2020). Declining estrogen receptors in the joints increase likelihood of inflammation and joint pain. (Blumer, 2023). Frozen shoulder or adhesive capsulitis affects 2-5% of people between ages 40 and 60, with women affected more than men. (Li et al., 2025). Research is looking at the potential protective effect of hormone therapy on the odds of getting frozen shoulder. (Saltzman et al., 2023). Bone density declines 7-10% during menopause, with some women losing 10-20%. (Ji & Yu, 2015). Improving bone density as early as possible is related to decreased chance of hip fractures post-menopause. During menopause, lean body mass decreases by 0.5% per year, while fat mass increases by 1.7% due to lowered estrogen. (Buckinx & Aubertin-Leheudre, 2022). 60-70% of women going through menopausal transition complain of weight gain, with visceral fat increasing from 5-8% to 15-20%. (Kodoth et al., 2022). 

Genitourinary symptoms often begin during perimenopause due to declining estrogen levels, with 32% of menopausal women complaining of urinary urgency, frequency, incontinence and pain. (Alperin et al., 2019). The thinning of the vaginal lining due to estrogen decline decreases the protective bacteria and leads to increased risk of UTIs and pain with intercourse. (Aggarwal & Leslie, 2025). 50-87% of women report pain during intercourse. (Heidari et al., 2019). Women with pelvic floor dysfunction show decreased sexual satisfaction, libido and orgasm compared to those with intact pelvic floors. (Zhuo et al., 2021). Major depression is 2-4 times more likely during menopause transition compared to before menopause. (El Khoudary et al., 2019). Other cognitive changes during menopause described as brain fog include higher anxiety, forgetfulness, trouble concentrating and poor memory. (Alblooshi et al., 2023; Maki & Jaff, 2022). 30% of skin collagen is lost within the first 5 years of menopause, followed by a 2% decline after that. (Kamp et al., 2022-a). 

Decreasing estrogen levels also causes hair follicles to shrink and new strands stop growing. (Kamp et al., 2022-b). 30-60% of postmenopausal women reported sleep disorders compared to 16-42%. (Kravitz & Joffe, 2011). As estrogen declines, so does increased time to fall asleep, increased awakenings, decreased sleep time. As progesterone declines, the woman experiences reduced sleepiness, increased anxiety, and worsened respiration. (Lee et al., 2019). Sleep disorders during menopause are significant as they are related to cardiovascular disorders, metabolic diseases, mental health disorders and cognitive disorders. (Spitschan et al., 2022). 

Pelvic and all physical therapists are often the first to see these women, with early complaints of joint pain, gluteal tendinopathy, frozen shoulder, urinary incontinence, pelvic organ prolapse, or dyspareunia. Occasionally, PTs are seeing these women with postpartum and perimenopause symptoms following childbirth in their late thirties or early forties. Pelvic therapists can manage the musculoskeletal issues associated with this period, as well as educating the patient to discuss options to manage hormonal changes with their practitioners. Early education on prevention of sarcopenia and osteoporosis through progressive resistive strength training (Watson et al., 2019; Kistler-Fischbacher et al., 2021a; Kistler-Fischbacher et al, 2021b ) and weight bearing exercise, such as walking, (Lan & Fen, 2022) is crucial to being as early as possible. The physical therapist can help the menopausal woman to prevent or manage visceral weight gain and prevent cardiovascular disease through lifestyle management including sleep hygiene, prioritizing protein, weight management and high-intensity interval training.(Nunes et al., 2019).The pelvic PT can provide education and physical therapy management of urinary symptoms, examination of vaginal tissues and communication with providers regarding vaginal tissue management including use of vaginal moisturizers, lubricants, and vaginal estrogen.(Kaufman et al., 2025). The pelvic physical therapist can help mitigate cognitive decline through education on aerobic activity and connecting patients with appropriate providers to address any mental health issues. (Maki & Jaff, 2022). For the postmenopausal woman who did not manage menopause with menopausal hormone therapy, interventions would likely need to focus on management of genitourinary symptoms, (Rubin et al., 2025) management of dyspareunia, increasing muscle strength, improving bone density (Kitagawa et al., 2022; Yin S et al., 2023) improving balance and preventing falls.  Understanding the symptoms associated with the menopause transition on the health of the woman is essential for the pelvic PT to make a lasting difference in the woman’s life throughout her lifespan, from perimenopause, through the menopause transition and beyond. 

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