It Wasn’t Just a Weak Core: What I Understand Now About Back Pain in Perimenopause
I have an apology to the women I saw for back pain in 2018. I am sorry.
At the time, I was thinking about biomechanics, core stability, posture, stress, diet, inflammation, autoimmunity, and movement patterns. Those factors absolutely matter, and they are still part of how I practice today. But I did not yet fully understand how much fluctuating and declining estrogen in perimenopause and menopause can directly affect the musculoskeletal system.
Over the last several years, both clinical experience and research have shifted how I view pain in women in their late 30s, 40s, and 50s.
Estrogen and the Musculoskeletal System
Your muscles, tendons, ligaments, and joints are rich in estrogen receptors. Estrogen is not just a reproductive hormone. It plays a meaningful role in collagen production, tissue elasticity, inflammation, and recovery capacity. It influences how resilient your connective tissue is and how well you repair after physical load.
As estrogen begins to fluctuate and gradually decline, which can start years before a final menstrual period, many women notice changes such as:
Persistent or recurrent back pain
New joint stiffness, especially in the morning
Slower recovery from workouts
Increased tendon irritation
More muscle soreness than expected
A general sense that their body feels less resilient
At the same time, these musculoskeletal changes are often happening alongside other signs of perimenopause, including:
Worsening PMS
Increased anxiety or irritability
Brain fog or reduced mental clarity
Changing cycle lengths
Heavier or lighter periods
New sleep disruption
Night sweats or early hot flashes
When you step back and look at the full picture, the pattern often makes sense.
For some of the women I saw years ago, it was never just a weak core. And it was not a mysterious autoimmune process that no one could explain. It was a hormonal transition that we were not fully factoring into the treatment plan.
Asking Better Questions
Now, when a woman comes to see me with ongoing back pain, hip pain, or diffuse joint discomfort in this stage of life, I approach the assessment differently.
Of course, I still evaluate biomechanics, strength, posture, and movement patterns. But I also look carefully at:
Sleep quality and overnight blood sugar stability
Stress load and nervous system regulation
Strength training volume and recovery capacity
Nutrition adequacy, especially protein intake
Markers of inflammation and autoimmunity when clinically indicated
Hormonal patterns and whether menopausal hormone therapy may be appropriate
When we address the underlying drivers instead of focusing only on the symptom, the plan becomes more coherent. Women often feel validated simply by understanding that their pain has a physiological context. From there, we can build a strategy that supports tissue health, reduces inflammation, improves resilience, and when needed, supports hormones appropriately.
Why This Matters
Too many women are told that their pain is just aging, just stress, or just something they need to push through. That explanation is incomplete.
Perimenopause and menopause are significant biological transitions. They affect more than cycles and hot flashes. They affect connective tissue, recovery, body composition, and inflammation. When we acknowledge that, we can be more proactive and far more strategic.
I have spent the last year deep in the research on hormones and musculoskeletal health, and I am always happy to share key studies if you are interested in understanding the science behind this more fully.
If you have a friend who has been told her pain is just aging or just stress, share this with her. She deserves a more complete explanation. You can also direct her to my free Midlife Pain Lab Guide: Key Tests for Perimenopause and Menopause, where I outline important areas to assess during this transition.
Warmly,
Sarah Vosburgh, ND