1. Menopause accelerates muscle mass loss 

The menopause transition is associated with a significant decline in oestrogen, which contributes to accelerated loss of skeletal muscle mass and increased fat mass. 

This shift in body composition is independent of aging alone (Greendale et al 2019). 

Longitudinal studies show that women may lose up to 1–1.5 per cent of muscle mass per year during menopause, with a concurrent increase in visceral adiposity (El Khoudary et al 2020). 

These changes are linked to decreased resting metabolic rate, reduced physical function and increased cardiometabolic risk.

Physiotherapists are well placed to identify and address early signs of muscle mass loss in midlife women. 

Through tailored assessment and prescription of progressive resistance training, physiotherapists can help maintain or improve lean mass, strength and function during and after menopause (Sipilä et al 2020). 

Exercise programs that incorporate strength, balance and functional components not only preserve musculoskeletal health but also reduce the risk of falls, frailty and associated disability later in life. 

A proactive physiotherapy approach supports healthy aging and empowers women and other people going through menopause to maintain independence and quality of life. 

2. Postmenopausal oestrogen decline increases fracture risk 

The decline in oestrogen following menopause results in accelerated bone turnover, with resorption outpacing formation. 

Women may lose up to 20 per cent of their bone mineral density in the five to seven years following menopause, significantly increasing their risk of osteoporotic fractures (Greendale et al 1997, National Institutes of Health 2023). 

These fractures—commonly affecting the spine, hip and wrist—can lead to loss of independence, chronic pain and increased mortality. 

Physiotherapists play a crucial role in early intervention and prevention of osteoporosis-related complications. 

During the perimenopausal years, physiotherapists can provide targeted education on modifiable risk factors including physical inactivity, poor posture and falls risk. 

Tailored exercise programs that include weightbearing and resistance-based training have been shown to slow bone loss and enhance skeletal strength, particularly when implemented early (Watson et al 2015). 

In addition to exercise prescription, physiotherapists contribute to fracture prevention through balance training, home hazard assessment and postural correction— particularly in people already experiencing vertebral changes. 

By empowering women with knowledge and practical strategies, physiotherapists can significantly reduce the impact of osteoporosis and support healthy aging through menopause and beyond. 

3. Menopause impacts tendon, ligament and joint health

The hormonal changes caused by menopause can affect connective tissue integrity, increasing the vulnerability of tendons, ligaments and overall musculoskeletal function. 

This is commonly referred to as musculoskeletal syndrome of menopause and is experienced by more than 70 per cent of women (Wright et al 2024). 

Oestrogen plays a key role in maintaining the health and flexibility of connective tissues and when it decreases in menopause, collagen production is reduced, which leads to lower tensile strength, elasticity and hydration of tissues. 

This in turn makes tendons and ligaments more prone to stiffness, micro tears and injury (Chidi-Ogbolu & Baar 2019), increasing the risk of tendinopathies and joint instability (Frizziero et al 2014). 

The decline in oestrogen also affects tendon healing, slows down the repair process, potentially limits mobility and can cause pain (Frizziero et al 2014). 

Hormone replacement therapy has been explored as a potential way to mitigate some of these effects, although its use must be carefully evaluated on an individual basis (Calleja-Agius & Brincat 2009). 

In addition to medical management, physical activity focused on strength, flexibility and stability can help maintain tendon and ligament health (Cowan et al 2022). 

4. Genitourinary symptoms are common in menopause 

Genitourinary symptoms, commonly referred to as the genitourinary syndrome of menopause, affect more than 50 per cent of postmenopausal women and arise due to the decrease in oestrogen and other sex hormones during menopause, which triggers structural, histological and functional changes in the genitals and urinary tract (Gandhi et al 2016). 

The genitourinary syndrome of menopause can include genital and vulval symptoms such as vaginal dryness, which affects up to 75 per cent of women; burning or itching in the vagina; and vaginal shortening and narrowing (Mili et al 2021). 

Potential sexual symptoms include pain with sexual intercourse, which affects up to 40 per cent of women, as well as reduced lubrication, arousal or libido (Cox et al 2023). 

Urinary symptoms can include frequency and urgency, incontinence, pain with urination and recurrent urinary tract infections (Reed 2024). Vaginal prolapse associated with the sensation of a vaginal bulge, heaviness or dragging sensation may also occur due to reduced pelvic floor muscle function. 

These symptoms can be particularly impactful, leading to genital, sexual and urinary dysfunction that will continue to progress without management (Gandhi et al 2016). 

They can also result in psychological, body image and relationship issues (Rogers et al 2018). 

However, genitourinary symptoms can be addressed effectively through lifestyle modifications; pelvic physiotherapy to provide targeted pelvic floor muscle rehabilitation, bladder training and bladder and bowel management; and medical management with vaginal oestrogen (Mercier et al 2023, Nappi et al 2021). 

5. Menopause affects mental health

Menopause has a significant impact on mental health, with hormonal fluctuations contributing to sleep disturbances, fatigue, anxiety, depression, mood changes and cognitive symptoms such as ‘brain fog’ (Greendale et al 2010, Hogervorst et al 2022). 

These changes are partly driven by declining oestrogen levels (Freeman 2015). 

Cognitive difficulties such as reduced attention, working memory and executive function can directly affect physiotherapy engagement and motor learning (Hogervorst et al 2022). 

Sleep disruption and persistent fatigue may reduce exercise tolerance, increase pain sensitivity and compromise rehabilitation outcomes (Saghafi et al 2021), while anxiety and depression during menopause have been shown to correlate with poorer physical function and lower motivation for physical activity (Thurston et al 2008). 

Physiotherapists can support people through this transition. 

Early recognition of menopause-related mental health concerns, appropriate screening and tailored exercise prescription can greatly enhance outcomes. 

Physical activity remains a cornerstone of management, with evidence supporting its role in improving both mood and cognition (de Rezende et al 2014). 

Through multidisciplinary collaboration and a compassionate, informed approach, physiotherapy can play a vital role in improving quality of life during menopause. 

>>Sarah Myles APAM is an advanced physiotherapist (pelvic health) at Townsville Hospital and Health Service. Sarah holds a Graduate Certificate in Physiotherapy (Pelvic Floor Physiotherapy) from the University of Melbourne. She is a member of the APA Women’s, Men’s and Pelvic Health national group and a former chair of the group’s Queensland branch. 

>>Rebecca Tapiolas APAM is a senior physiotherapist (pelvic health) at Townsville Hospital and Health Service. Rebecca holds a Master of Physiotherapy (Pelvic Health) from the University of Melbourne. She is a member of the Women’s, Men’s and Pelvic Health group. 

>>Kathy Jennings MACP is an APA Titled Women’s, Men’s and Pelvic Health Physiotherapist working as a senior physiotherapist in Sydney. Kathy is a member of the Women’s, Men’s and Pelvic Health group. 

>>Lauren Neill MACP is an APA Titled Women’s, Men’s and Pelvic Health Physiotherapist working as a senior physiotherapist in Mackay, Queensland. Lauren is the chair of the Queensland branch of the Women’s, Men’s and Pelvic Health group. 

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