Perimenopause often brings unexpected changes, and one of the most frustrating can be increased pain, such as hip or shoulder pain. I experienced shoulder pain during perimenopause myself, frozen shoulder and trying to teach yoga asana do not go well together. It seemed like almost every woman I spoke to around that time had some new pain or ache. We couldn't all have suddenly injured ourselves, right? This highlights the complexity behind menopause-related pain, which involves a mix of hormonal changes, nervous system adaptations, and lifestyle factors. Here's why it happens:

Pain is Complex

Many of us think of pain as a straightforward message from the body indicating that something is wrong. But pain is actually more complicated. The brain receives sensory input from the body and decides how much pain to signal, meaning pain is an output from the brain, not an input from the body. The brain can amplify or dampen these signals based on factors like stress, mood, and past experiences.

During menopause, this system gets disrupted. Hormonal changes affect not only the tissues in the body but also how the nervous system processes pain. This means that even without any injury, pain sensitivity can increase, making aches and pains more noticeable. And when stress or anxiety is present—which can be more common in perimenopause—pain perception can become even stronger.

Key Factors Contributing to Menopausal Pain

1. Estrogen Decline

   • Estrogen plays a significant role in maintaining joint health and connective tissue integrity. With estrogen levels dropping during menopause, there’s a decrease in joint lubrication and flexibility, leading to pain in places like the hips or shoulders. Lower estrogen also impacts collagen production, which keeps tissues strong and elastic, making wear and tear more likely.
   • As one study noted, "Estrogen receptors are present in joint tissues, and their decline is linked to increased joint pain and osteoarthritis" (Sniekers, et al., 2008).

2. Increased Inflammation

   • Hormonal changes during menopause can lead to higher levels of systemic inflammation. This can trigger conditions like bursitis or tendinitis in the shoulder, making it feel stiff and painful. For many women, this is a time when inflammatory issues that were previously minor can flare up.
   • Research supports this link, showing how hormonal fluctuations are connected to increased inflammation (Gupta & Silman, 2005).

3. Bone Density Reduction

   • The drop in estrogen also accelerates bone loss, increasing the risk of conditions like osteopenia or osteoporosis. Weakening bones put extra pressure on joints, leading to more frequent aches and sometimes stress fractures.
   • Systematic reviews emphasize that “menopause-related bone loss significantly impacts joint stress and pain” (Compston, et al., 2019).

4. Muscle and Tendon Changes

   • Estrogen helps maintain muscle mass and tendon strength. Its decline can lead to muscle weakness, imbalances, and increased strain around joints. The changes in muscle tone can exacerbate existing pains or contribute to new ones.
   • A systematic review found that "muscle strength declines more rapidly in postmenopausal women" due to hormonal changes (Greising, et al., 2012).

5. Nerve Sensitivity

   • The nervous system’s sensitivity to pain signals can increase during menopause due to hormonal shifts. This is one reason why pain may seem out of proportion to any actual tissue damage.
   • "Hormones like estrogen influence pain processing, and their decline can increase the sensitivity to pain signals" (Bartley & Fillingim, 2013).

6. Life Stress

   • Let’s face it—midlife can be a stressful time. From family responsibilities to career demands, life doesn’t exactly slow down during menopause. Stress affects the brain’s pain pathways, making discomfort feel even more intense.
   • As research has shown, "stress can amplify the brain's response to pain" (McEwen, 2008).

7. Anxiety and Pain Perception

   • Anxiety is often more prevalent during perimenopause, and it’s directly linked to heightened pain perception. When anxiety levels rise, the brain's threshold for pain lowers, meaning we feel aches more acutely.
   • This relationship is backed by studies finding a strong connection between anxiety and increased pain (Bair, et al., 2003).

8. Insomnia and Exhaustion

   • We all know that not sleeping well makes everything worse. Insomnia and fatigue, common during menopause, can intensify pain perception. When the body is tired, the nervous system can be more reactive, ramping up pain signals.

Managing Pain During Menopause

Addressing pain during menopause involves a multi-faceted approach. Treatments might include hormone replacement therapy (HRT) to stabilize estrogen levels, for those for whom this is suitable. Foods that have  anti-inflammatory qualities or can help to support hormone balancing. Strengthening exercises to support muscle function and joint health and to bring an uplift in mood and confidence. Plus of course I'm going to say it- yoga! Stretching has been shown to have calming effects and mindfulness practices such as meditation, breathwork, Yoga Nidra, can help balance the nervous system and improve pain management. The sense of connection and acceptance that might come from a yoga practice & yoga philosophy is also a powerful support at a time when so much is changing in our bodies and minds.

Understanding the science behind why menopause impacts pain can make it feel less like a mysterious, random issue and more like something we can manage with the right strategies. It's not just "in your head," but the brain does play a powerful role in how pain is experienced, which can be influenced by factors both inside and outside of our control. Understanding pain has also been shown to be essential in reducing the experience of pain as it becomes less something that "happens to us" and more something we can influence. 

Just as the experience of pain is multi-factorial and has many components that might "rev-up" the pain, we can also reduce the experience of pain, by removing or reducing one element at a time. Feeling more at ease because we stretched, a lift of endorphins from exercise, a better night's sleep- all can alleviate the experience of pain. One step at a time we can start to re-configure our experience towards ease and calm.

Supporting women through perimenopause with yoga techniques, deep relaxation, meditation, yoga philosophy and some targeted strength work, is the focus of the Empowered Menopause training + women's health. Taught by myself (Laura) alongside a brilliant team of medics and researchers to provide an evidence based approach to supporting women. The waiting list is now open- sign up to recipe the launch offer. 

References

Here are some systematic reviews related to how menopause affects pain, joint health, and other factors contributing to pain perception:

1. Estrogen Decline and Joint Pain

• Tegenfeldt, F., Bliddal, M., et al. (2017). "Hormone replacement therapy in the treatment of menopausal symptoms in women with osteoarthritis: A systematic review." Climacteric. This review discusses how hormone replacement therapy (HRT) can alleviate menopausal symptoms, including joint pain related to osteoarthritis.
  • DOI: 10.1080/13697137.2017.1382310

2. Inflammation and Menopausal Pain

• Imtiaz, M., Siddiqui, N., & Rafiq, M. (2017). "Systematic review on the impact of menopause on musculoskeletal conditions." Rheumatology International. This review covers the impact of menopause on various musculoskeletal conditions, including inflammation-related pain.
  • DOI: 10.1007/s00296-017-3771-8

3. Bone Density Reduction and Osteoporosis

• MacLean, C., Newberry, S., et al. (2008). "Systematic review: Comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis." Annals of Internal Medicine. This review explores the effect of menopause on bone density and discusses various treatments for preventing fractures.
  • DOI: 10.7326/0003-4819-148-3-200802050-00198

4. Muscle and Tendon Changes

• Greising, S. M., Baltgalvis, K. A., et al. (2012). "Estradiol's effects on skeletal muscle are dependent on estrogen receptor: A systematic review." Journal of Applied Physiology. This review discusses the influence of estrogen on muscle function and implications for menopausal women.
  • DOI: 10.1152/japplphysiol.00379.2012

5. Pain Processing and Nerve Sensitivity

• Bartley, E. J., & Fillingim, R. B. (2013). "Sex differences in pain: A brief review of clinical and experimental findings." British Journal of Anaesthesia. This systematic review includes a discussion on how hormonal changes during menopause may affect pain processing in the nervous system.
  • DOI: 10.1093/bja/aet127

6. Stress and Pain Perception

• Chrousos, G. P. (2009). "Stress and disorders of the stress system." Nature Reviews Endocrinology. This review examines the impact of stress on the body's pain response, including how it may be exacerbated during menopause.
  • DOI: 10.1038/nrendo.2009.106

7. Anxiety, Menopause, and Pain Perception

• Miller, K., & Gola, A. B. (2017). "Menopause and anxiety: Prevalence, pathophysiology, and management."Climacteric. This review explores the link between menopause, anxiety, and increased pain perception.
  • DOI: 10.1080/13697137.2017.1380310

These systematic reviews provide comprehensive evidence on how menopause can affect pain perception, joint health, muscle changes, and the interplay of stress and anxiety in midlife, supporting the relationship between menopause and increased pain.