Straight answers

Your joints ache and you don't know why. Could it be perimenopause?

You get up and your hands take a while to work. Your knees complain on the stairs. A shoulder aches and you can't remember doing anything to it. You haven't fallen, nothing in your routine has changed, and still something hurts. The obvious suspects are age, or arthritis. But there's another explanation almost nobody mentions, and it's worth keeping in mind.

It's more common than you'd think

When we think of perimenopause we think of hot flushes. But joint pain is one of the most common symptoms. In a survey of 1,750 Spanish women by the Spanish menopause societies (AEEM and FEEM), 51.7% reported joint pain. And a meta-analysis of 14 studies put it at around 71% of women in perimenopause, with more pain than women who hadn't reached this stage yet.

Some researchers now want to give it a name of its own. In 2024 a team of orthopaedic specialists, including Jocelyn Wittstein, who led the study on the frozen shoulder Penélope Cruz talked about, published a review in Climacteric grouping these symptoms under the term "musculoskeletal syndrome of menopause", precisely because neither patients nor many clinicians connect them with oestrogen.

Why joints ache in perimenopause

Oestrogen isn't only a reproductive hormone. According to an analysis by rheumatologist Fiona Watt at the University of Oxford, there are oestrogen receptors in every tissue of the joint: the cartilage, the bone beneath it, the ligaments and the lining around it. And it works on three fronts:

• Inflammation. Oestrogen has an anti-inflammatory effect. As it falls and fluctuates, that brake weakens.
• Cartilage. At normal levels it appears to help maintain cartilage and slow its breakdown.
• How pain feels. It acts on the nervous system too. Even across the menstrual cycle, pain is felt more when oestrogen drops. She puts it this way: entering menopause may be, for some women, like being permanently in the "low" part of the cycle.

Then there's everything else. Fatigue, poor sleep and mood changes, all common at this stage, turn up the feeling of pain, and pain in turn makes sleep and mood worse. It's a loop, which is why it's worth paying attention to.

One important caveat: a strong association doesn't prove that low oestrogen causes the pain. The analysis itself stresses that the studies are still missing. What is clear is that it's common and that it makes biological sense.

What it tends to feel like

There's no single pattern, but these come up again and again:

• Aches and stiffness in several places rather than one joint. The places musculoskeletal pain concentrates in general are the back, knees, hands, hips and shoulders.
• Hands in particular. Hand osteoarthritis rises clearly in women right around the age of menopause.
• It rarely comes alone. For most women the pain isn't the main symptom but part of a wider picture: hot flushes, insomnia, fatigue, changing periods. Only for about one in five is it the thing that bothers them most, according to the Oxford analysis.
• It's usually temporary. It often settles on its own. For a minority it lasts, so if it persists it's worth reviewing every so often.

What if it isn't perimenopause?

Being in your forties doesn't make every ache hormonal. In fact, the Oxford analysis stresses that "menopausal" joint pain is diagnosed after other causes have been ruled out. The ones worth keeping in mind:

• Osteoarthritis, wear in the joint. It hurts more with use and is more common after 45.
• Rheumatoid arthritis, an inflammatory disease. It most often starts between 35 and 55, the same window as perimenopause. It tends to affect the same joints on both sides of the body, with swelling and stiffness that's worse after rest. Catching it early makes a big difference to how it progresses.
• Thyroid problems, low vitamin D or anaemia, which can cause aches alongside tiredness.
• Some medicines. If you take something regularly and the pain started afterwards, mention it to your doctor, and don't stop it on your own.
• Fibromyalgia, when the pain is spread all over the body and comes with poor sleep and persistent tiredness.

Telling these apart is your doctor's job, and sometimes more than one applies. What you can do is arrive with information: which joints, since when, what time of day, and what other symptoms you have.

What you can do

The Oxford analysis admits there's little research specifically on menopausal joint pain. But the first-line measures it recommends are the same as for musculoskeletal pain in general, and they're well supported:

• Keep moving, even if it aches a bit. Regular exercise, both aerobic and exercises for the joint that hurts, is the foundation, and there's some evidence that moderate physical activity improves perimenopausal joint pain. The key is to build up gradually: doing too much too soon can make the pain worse and make you give up. As a benchmark, the WHO recommends 150 to 300 minutes of moderate activity a week, plus strength exercises on at least 2 days.
• Don't immobilise it. The NHS advises resting a painful joint but not stopping moving it completely. Cold, wrapped in a towel, can ease it.
• Manage your weight if you're overweight, as both the NHS and the Oxford analysis recommend.
• Sleep better and lower stress. This isn't filler advice: poor sleep and anxiety amplify pain. If you're sleeping badly, see what actually helps with tiredness and sleep.
• Avoid overloading the painful joint, for example with heavy lifting or very repetitive hand movements.

And if the pain is limiting you, you don't have to put up with it. There are treatments for the pain and for the other symptoms of this stage; which one suits you is a conversation to have with your doctor.

Keep reading: the full guide to perimenopause — what it is, when it starts and every symptom — or what frozen shoulder has to do with hormones.

Maia isn't a medical service and doesn't replace your healthcare professional. This article is informational and isn't a diagnostic tool: if joint pain worries you or isn't getting better, talk to your doctor.

Sources: on joint pain around menopause, its causes and management, Watt FE, "Musculoskeletal pain and menopause", Post Reproductive Health 24(1):34-43 (2018); on how common it is, Lu CB et al., "Musculoskeletal Pain during the Menopausal Transition: A Systematic Review and Meta-Analysis", Neural Plasticity (2020), and the AEEM-FEEM survey of 1,750 women (2024); Wright VJ et al., "The musculoskeletal syndrome of menopause", Climacteric 27(5):466-472 (2024); NHS, "Joint pain"; WHO, guidelines on physical activity (2020).