The Musculoskeletal Syndrome of Menopause

Without question one of the most common complaints I hear from midlife women is that they feel like they’ve aged a decade overnight or that they are falling apart. That they wake up one day and feel like they’ve been run over by a truck. If this describes you, I see you. I hear you. I’ve been you.

When I was about 47, I also felt like I’d been run over. My whole body hurt, and I felt like a shadow of the woman whose office is lined with athletic medals. I hobbled out of bed every morning. I’d also gained thirty pounds and, at 34 percent body fat, was technically in the danger zone for metabolic health.

When you think about menopause, you likely think of the stereotypical symptoms, like hot flashes, night sweats, brain fog, and mood swings. But from where I sit as an orthopedic surgeon, one of the most devastating consequences of menopause is a cluster of symptoms I call the musculoskeletal syndrome of menopause.

Musculoskeletal syndrome of menopause is just as common as hot flashes and wreaks even more havoc on a woman’s health. Evidence shows that more than 70 percent of menopausal women will experience musculoskeletal symptoms, and 25 percent will be disabled by them through the transition from perimenopause to postmenopause.

Estrogen has a profound effect on the musculoskeletal system, and as mentioned previously, unless you take action, when it is no longer being produced, you can lose bone density (up to 20 percent in the years immediately following menopause), lose muscle, and have a rise in inflammaging.

This destructive syndrome shows up, again, as conditions that we have traditionally written off as “just getting older,” like osteopenia and osteoporosis. Lower levels of estrogen mean that our osteoclasts, the cells that break down bone, work without regulation and outpace our osteoblasts, the cells that build and repair the skeletal system, resulting in a net loss of bone density. Osteoporosis still doesn’t get the attention that cancer or heart disease does, despite its affecting more than 200 million postmenopausal women worldwide.

Sarcopenia, or involuntary muscle loss, is another musculoskeletal symptom that we used to just chalk up to getting old. This is something we need to combat with every weapon available, because loss of muscle robs women of their strength and contributes to reduced physical function and increased risk of falls.

While some muscle loss is inevitable with age, what happens around menopause isn’t. Estrogen receptors are present in muscle tissue; therefore, estrogen influences muscle mass and strength. The decline in estrogen during menopause leads to decreased muscle protein synthesis and increased protein degradation. Women will often say it feels like they lost their muscle “overnight,” and while it’s certainly not in 24 hours, there can be a relatively rapid decline during the menopause transition.

Animal studies bear this out. In one experiment, 24 weeks of estrogen deficiency resulted in a 10 percent decrease in strength that corresponded with an 18 percent decrease in what’s called fiber cross-­sectional ­ area — a measure of muscle size. In another experiment, with mice, the researchers suggested that without enough estrogen, muscle is more prone to injury and growth is limited.

It comes down to muscle stem cells (also called satellite cells). Estradiol (our primary form of estrogen) helps activate and grow satellite cells in our muscles. These cells have estrogen receptors, and some of the strength our muscles produce appears to come from estradiol binding to these receptors. When we lose that stimulation, our muscle strength and ability to repair our muscles is impaired. Again, we see it in animal studies, where mice who had their ovaries removed had 30 to 60 percent fewer satellite cells; the amount of reduction was associated with how long they were without estrogen.

As a side note, because many women are losing muscle and gaining fat during this period, they’ll also start dramatically restricting their food intake, which is not good for muscles or bones. Both need fuel — especially enough ­ protein — to repair and rebuild. Denying them that protein makes matters much worse.

As we know, estrogen has anti-­inflammatory (and therefore anti-inflammaging) properties, which means it also helps maintain the health of joint tissues, including cartilage. The decline in estrogen during the menopause transition can lead to increased inflammation and degradation of joint cartilage. The rate of osteoarthritis increases dramatically around the time of menopause. In one comprehensive review, researchers suggested a potential association between menopausal estrogen decline and the frequency of knee, hip, and finger osteoarthritis as well as the severity of hip osteoarthritis.

The impact of estrogen decline is something I see every day. Many women report increased joint pain, stiffness, and swelling during and after menopause, which can affect the knees, hips, hands, and other joints. For some women this presents as total body pain, known as arthralgia, as well as frozen shoulder (which predominantly affects women between the ages of 40 and 60 —­ prime menopause transition time) and increased arthritis.

Active women can find themselves increasingly sidelined with injury during the menopause transition because estrogen influences the metabolism and mechanical properties of tendons and ligaments. As tendons and ligaments become less elastic, they are more prone to injuries such as tendinitis and ligament tears. It’s worth noting that all of the changes and symptoms of menopause can lead to pronounced weight gain (again, in my own case 30 pounds) in a relatively short period of time, which places more load on the joints. By some estimates, every pound of excess weight we carry puts an additional four to ten pounds of pressure on our knees. That means losing just 10 pounds if you’re overweight can take 40(!) pounds of pressure off those joints and make you much less likely to experience joint pain.

Putting it all together, it’s no wonder so many women in menopause feel like they’re falling apart! The loss of muscle obviously makes us weaker, so we move less. The loss of bone makes us more prone to fragility, so we’re afraid to move. And the rest of it puts us in pain, so we don’t even want to move because it hurts! So, we gain weight and move less and hurt more, putting us in the path of those time bombs and leading to shortened healthspan. I frequently see women living in pain who have gone to multiple doctors and been told they’re “fine” because everything looks “normal” on an X-­ray or an MRI (our research finds that 40 percent of women have no structural abnormalities that show up in screening). So they go untreated, just live in pain, and slowly but surely recede from their active lives. It’s a vicious cycle.

What’s crazy is that the medical community often wrings its hands about how postmenopausal women become more sedentary. In fact, they have the audacity to blame these women for not exercising enough and point to their “just not moving enough” as the reason behind all their woes. But they never actually explore why. It’s not like midlife women have suddenly become lazy! It’s that we are often in pain because we’re suffering musculoskeletal syndrome of menopause. This is all completely avoidable.

Many of the potentially devastating end stages of the musculoskeletal syndrome of menopause can be prevented if they are recognized as real early in menolescence — my name for the transition women undergo from their reproductive years into the rest of their lives. We can continue to be healthy, vital, active, and joyful. We just need to be proactive. That means practicing the exercise, lifestyle, and nutrition advice found in the pages of my book. It also means attending to your hormonal health, which I also address in my book.

I hope you are now equipped with the knowledge of why mobility is the key to healthspan and longevity and the motivation to act. If you are raring to go, you are welcome to do it now! Take a walk, lift a weight, and then turn the page as we build a mindset for your success.

Excerpted from UNBREAKABLE by Vonda Wright, MD. Copyright © 2025 by Vonda Wright, MD. Used by permission of Rodale Books, an imprint of Random House, a division of Penguin Random House LLC, New York.  All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.