Reframing Perimenopause: Why Physical Therapy Matters More Than Ever

Introduction

Perimenopause is a critical yet often underrecognized phase where physical therapists can make a meaningful impact on long-term health.

The (M) Factor 2: Before the Pause [Perimenopause], a documentary released in March 2026, brings much-needed attention to women’s health during this transition. The film features perspectives from medical experts, researchers, perimenopausal women, and their partners, offering a multidimensional view of this often misunderstood life stage.

Perimenopause refers to the transitional period leading up to menopause, which is defined as 12 months after a woman’s final menstrual period. This phase is often described as a “zone of chaos” due to fluctuating hormone levels.1 These hormonal shifts affect multiple body systems and contribute to symptoms such as hot flashes, night sweats, and cognitive changes like brain fog. Many women describe a pervasive sense of “not feeling like myself” (NFLM).1

As physical therapists and physical therapist assistants, we regularly work with perimenopausal and postmenopausal women across most settings, especially in pelvic health. Our role, however, extends far beyond symptom management. As movement experts, we are uniquely positioned to support cardiovascular, musculoskeletal, and sexual health during this critical transition.

Heart Health: A Missed Opportunity for Prevention

Declining estrogen during perimenopause and menopause is associated with an increased risk of cardiovascular disease, which is the leading cause of death in women.1 Yet many women are not adequately screened or educated about this risk.

Physical therapists can play a key role in bridging this gap. First, we can promote awareness by encouraging patients to understand their family history and pursue appropriate cardiovascular screening. A cardiologist in the film states that 90% of heart disease is preventable through lifestyle modifications, even in individuals with significant genetic risk.1

Second, we can integrate aerobic conditioning into our treatment plans. Guiding patients toward sustainable, enjoyable forms of exercise is essential for long-term adherence. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous activity per week, ideally spread throughout the week.2

By embedding these principles into routine care, we shift from reactive treatment to proactive prevention.

Bone Health: Beyond “Avoiding Fractures”

Estrogen decline also accelerates bone loss, increasing the risk of osteopenia, osteoporosis, and fragility fractures, particularly in the spine and hips.

Physical therapists are well-equipped to intervene. High-intensity resistance and impact training (HiRIT) has emerged as an effective strategy for improving bone mineral density.3 The LIFTMOR trial demonstrated that a supervised HiRIT program significantly improved lumbar spine and femoral neck bone density, as well as functional performance, in postmenopausal women with low bone mass without adverse events.3

Our role is critical in ensuring safe and effective implementation. This includes:

• Teaching proper mechanics
• Progressing exercises appropriately
• Individualizing programs based on patient tolerance and risk

In addition, we can provide general education on nutrition within our scope of practice. This may include discussing adequate protein intake for active individuals and highlighting key nutrients such as magnesium, vitamin D, B vitamins, iron, and omega-3 fatty acids.1

Rather than focusing solely on fall prevention, we can help patients actively build stronger, more resilient bones.

Sexual Health: Addressing What Often Goes Unspoken

Genitourinary syndrome of menopause (GSM) includes a range of symptoms such as vaginal dryness, recurrent urinary tract infections, urinary urgency or frequency, and pain with sex. Pelvic health physical therapists are in a unique position to identify and address these issues. A thorough evaluation should include:

• Screening for GSM-related symptoms
• Observing tissue quality and color changes in the perineal region
• Asking about current treatments, including vaginal estrogen use

When a hormonal component is suspected, we can help patients understand the range of available treatment options and support them in seeking individualized care from appropriate medical providers.

For patients already prescribed vaginal estrogen, we can provide education on proper application techniques. For those who are hesitant, often due to lingering concerns from the 2002 Women’s Health Initiative, we must approach the conversation with empathy and respect.

With patient consent, we can provide evidence-based resources to support informed decision-making, including updates from the U.S. Food and Drug Administration (FDA) and the 2025 AUA/SUFU/AUGS guidelines on GSM, which help clarify the safety and use of local hormone therapy.4,5

Addressing sexual health is not optional; it is fundamental to overall health and well-being.

Conclusion: Expanding Our Role in Women’s Health

Perimenopause is not simply a hormonal transition; it is a whole-body experience that affects cardiovascular, musculoskeletal, and urogenital health.

Physical therapists and physical therapist assistants have an opportunity and a responsibility to expand our role. Through targeted education, evidence-based exercise prescription, and collaborative care, we can help patients navigate this phase with confidence.

With greater awareness and earlier intervention, we are not just managing symptoms but also improving long-term health outcomes and quality of life.

References

1. Barbini C, ed. The (M) Factor 2: Before the Pause [Perimenopause]. PBS; 2026.
2. American Heart Association. American Heart Association recommendations for physical activity in adults and kids. Published January 19, 2024. Accessed May 3, 2026. https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults
3. Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018;33(2):211-220. doi:10.1002/jbmr.3284
4. U.S. Food and Drug Administration. HHS advances women’s health, removes misleading FDA warnings on hormone replacement therapy. Published November 10, 2025. Accessed May 3, 2026. https://www.fda.gov/news-events/press-announcements/hhs-advances-womens-health-removes-misleading-fda-warnings-hormone-replacement-therapy
5. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause. J Urol. Published online 2025. doi:10.1097/JU.0000000000004589

About the Author

Yuhang "Doris" Cai, PT, DPT

APTA Pelvic Health's California State Representative

Yuhang “Doris” Cai, PT, DPT, is a physical therapist and site supervisor practicing in an outpatient clinic in the Bay Area, California, where she provides care in orthopedic, pelvic health, and neurologic conditions. She is an active advocate for pelvic health and has volunteered with the Academy of Pelvic Health since 2023. Doris was recognized as one of the Top 3 State Representatives at the 2026 Combined Sections Meeting. She is passionate about advancing pelvic health for people of all genders through education, clinical practice, and community outreach.