Perimenopause, Menopause, and Bone Health
Reviewed by Cheryl Long, AHPC-registered physiotherapist, Goji Physio
Perimenopause and menopause bring significant changes to the musculoskeletal system, pelvic floor, and bone density — changes that are often attributed to ageing rather than recognised as hormone-driven and, in many cases, addressable. Physiotherapy at this life stage focuses on building and maintaining the physical reserves — bone density, muscle strength, pelvic floor function, and joint health — that protect quality of life in the decades ahead.
What changes during perimenopause and menopause?
Oestrogen has wide-ranging effects on the musculoskeletal system. As levels decline during perimenopause (the transition phase, which begins several years before periods stop) and menopause (defined as 12 consecutive months without a period), women may notice:
Joint pain and stiffness: oestrogen has anti-inflammatory properties. Its decline is associated with increased joint pain, particularly in the hands, knees, and spine. Some women are newly diagnosed with arthritis during this period; others find pre-existing joint conditions worsen.
Muscle strength and mass changes: muscle protein synthesis slows. Without targeted resistance exercise, women lose lean muscle mass at an accelerating rate from perimenopause onward — a process called sarcopenia.
Bone density: oestrogen regulates bone remodelling. The most rapid period of bone loss occurs in the 5–7 years around menopause. Women lose an estimated 10–20% of bone density in this window. Osteoporosis risk increases significantly, particularly in Asian women who have lower baseline bone density on average.
Pelvic floor changes: oestrogen supports the health of vaginal, urethral, and pelvic floor tissue. Its decline causes tissue atrophy (genitourinary syndrome of menopause, or GSM), contributing to vaginal dryness, discomfort, urinary symptoms, and increased pelvic floor vulnerability.
Why is bone health a physiotherapy issue?
Weight-bearing and resistance exercise are the most evidence-supported modifiable factors for maintaining bone density. Walking alone is insufficient — the bones require specific mechanical loading (impact and resistance) to stimulate bone formation. The right exercise programme, designed around your bone density status and physical capacity, is one of the most impactful things you can do during and after menopause for long-term skeletal health.
Physiotherapy also addresses the balance, coordination, and strength that reduce falls risk — and falls are the primary mechanism through which osteoporosis leads to fractures. Exercise that reduces falls risk is as important as exercise that builds bone.
What about pelvic floor symptoms at menopause?
Urinary incontinence, urgency, pelvic organ prolapse, and pain with intercourse all commonly appear or worsen around menopause. The reduction in tissue oestrogen is a major contributing factor, and topical oestrogen (prescribed by a GP or gynaecologist) is often appropriate alongside physiotherapy. Pelvic floor rehabilitation at this life stage follows the same principles as at any other age, with the added consideration of tissue quality and hormonal context.
What does a session at Goji involve?
Your first session is a broad assessment of where you are in the menopause transition and what your priorities are. Our physiotherapist will ask about your symptoms, your current activity level, your bone density results (if available), and what you want to be able to maintain or improve. The assessment may include:
Musculoskeletal screen: joint mobility, muscle strength and symmetry, balance
Pelvic floor assessment (if relevant to your symptoms)
Exercise and load tolerance assessment: what you are currently doing and how to progress it safely and effectively for bone and muscle goals
From this, a programme will be designed that is specific to you — not a generic "women over 50" exercise class. The focus is on doing the right kind of load, progressively, in a way that you can sustain.
Frequently asked questions
I have been told I have osteopenia. What exercise should I be doing?
Osteopenia (low bone density that has not yet reached the threshold for osteoporosis) is a common finding in perimenopausal and postmenopausal women. The evidence supports a combination of weight-bearing impact exercise (e.g. jumping, jogging, stair climbing) and progressive resistance training. The specific programme should be tailored to your bone density, fitness, and any joint or mobility limitations. Our physiotherapist will design this for you following assessment.
Is it too late to improve bone density after menopause?
It is never too late to slow the rate of bone loss or reduce falls risk through exercise. The evidence for fracture risk reduction with resistance and balance training persists into older age groups. Bone density itself is more difficult to meaningfully increase after peak loss has occurred, but preventing further decline and reducing falls risk remain achievable goals.
I have joint pain. Does that mean I should exercise less?
Usually not. Joint pain in the perimenopause and beyond is often partly driven by reduced muscle support and inflammation, both of which respond to graduated exercise. Complete rest tends to worsen joint stiffness and muscle deconditioning. Our physiotherapist will help you identify which movements aggravate your joints and how to load progressively without increasing pain.
My pelvic floor symptoms started after menopause. Is it too late for physio?
No. Pelvic floor physiotherapy is effective at any life stage. Postmenopausal pelvic floor dysfunction is often multifactorial — hormonal, structural, and neuromuscular — and physiotherapy addresses the neuromuscular components directly. Your GP or gynaecologist may also recommend topical oestrogen to support tissue health alongside physiotherapy.
Should I have a DEXA scan before seeing a physio?
A DEXA scan (which measures bone density) is helpful context for designing an appropriate exercise programme, but it is not a prerequisite for physiotherapy. Many women do not have access to recent DEXA results. Our physiotherapist will design an appropriate programme based on your risk profile, and may suggest you request a DEXA scan from your GP if results would meaningfully change the programme design.
Can physiotherapy help with the joint pain and fatigue of perimenopause?
Yes — for the musculoskeletal and physical capacity components. Joint pain often responds to targeted load management and progressive exercise. Fatigue is multifactorial and includes hormonal, sleep, and psychological contributors that are outside the scope of physiotherapy alone. Our physiotherapist will address what is addressable and be clear about when a GP or specialist review is appropriate.
Tell us where you are in your menopause journey and what is affecting you most — we'll help you figure out what physiotherapy can offer at this stage.
Reviewed by Cheryl Long, BSc (Hons) Physiotherapy, AHPC-registered
Clinical Director, Goji Physio — Women's and Family Physiotherapy, Lentor, Singapore
Related conditions:
Urinary Incontinence | Pelvic Organ Prolapse | Pelvic Pain & Dyspareunia
