Yes, Menopause Can Cause Chronic Pain

Every year, the International Menopause Society highlights a different aspect of menopause care on World Menopause Day. This year’s theme is Chronic Pain in Midlife: From Recognition to Evidence-Based Care. I couldn’t be more thrilled! (Well … a focus on cardiovascular health would always win out, but that was done in 2023, so I’m good!)

As the spotlight on menopause has (thankfully) grown, more awareness, understanding, and support is hitting the mainstream. However, this isn’t necessarily widespread or consistent, and certain aspects of the menopause transition remain woefully underdiscussed. Pain is a very good example of this lapse.

In general, women are 50-70% more likely than men to suffer from chronic pain. Over the collective female life span, there are two distinct peaks of chronic pain: adolescence and older age, likely representing the conjunction of multiple factors (including hormonal) at these times.

Managing pain, especially chronic pain, is something health care doesn’t actually do that well overall. To say chronic pain is complicated is a massive understatement. And given the significant disparities in pain assessment and treatment in women vs men, advocacy for chronic pain management at menopause is fighting an uphill battle.

In the recently released Chronic Pain at Midlife by Mailis et al., we see this complexity described as follows: “Menopause may be one of the reproductive milestones modulating the clinical relevance of chronic pain. Estrogenic fluctuations and subsequent decline should be viewed as a central biological driver that interacts bidirectionally with musculoskeletal degeneration, neuro-immune sensitization, neuroendocrine response and other psychosocial vulnerability, collectively amplifying pain perception and maintenance.”

Yikes.

Anytime I read about chronic pain and menopause, my first takeaway is how important it is to validate the experience of those dealing with pain at this time. Whether it’s the appearance of chronic pain for the first time, or a worsening of existing pain (such as migraines, fibromyalgia, chronic pelvic pain, or arthritis), there is no doubt that there is a link to the menopausal transition for so many. This is understood and studied, even if how best to address it is not. And yet, when this pain is brought up, in clinics and appointments, menopause is rarely a part of the conversation, let alone a central component. Treatments such as physiotherapy or painkillers may be suggested, but more often than not, the pain is vaguely brushed off as a consequence of getting older, and just something we should put up with.

Naturopathic providers often fall into the same trap as well, recommending supplements like curcumin or boswellia, and touting anti-inflammatory or elimination diets, all the while hoping to land on that one technique that will make all the difference. I’ve been there.

And the thing is, physiotherapy, NSAIDs, curcumin, boswellia, and anti-inflammatory diets (among many other things) could all have a role to play in addressing chronic pain. But as previously mentioned, chronic pain is complicated and a hormonal shift like the menopause transition makes it more so. The solution must be multimodal, involving multiple strategies from multiple directions working together towards a common goal. It also involves understanding that this pain is neither unknown nor unmanageable.

Challenging? Yes. Stubborn? Definitely. Discouraging? Often.

But there are things to be done.

Where do we go from here? Although there are many things to discuss, here are the main items I want to share.

1. Hormone therapy and chronic pain

Can menopause hormone therapy (MHT) mitigate the pain that arrives or worsens during our menopause transition? It can … for some. Unfortunately, like many other menopause-related symptoms, just because the decrease in estrogen is often a major contributor to the symptom, it doesn’t mean that adding some back makes the symptom go away.

But sometimes it can. And since we don’t have a great way of identifying who will benefit, having a discussion with your prescriber about whether MHT is right for you and your pain is completely appropriate.

Side note 1:

Estrogen loss leads to decreased muscle quality and quantity. This, in turn, leads to joint instability and reduced muscle strength which predisposes us to more generalized joint pain, worsening arthritic pain, and lower back pain. Incorporating exercise and physical activity has more evidence for improving pain in this sphere than hormone therapy and should be prioritized.

Side note 2:

MHT can indirectly improve pain by addressing menopausal symptoms that are independent pain influencers. For example, poor sleep due to night sweats or significant mood and energy shifts can escalate pain in very real ways. If MHT reduces these symptoms, pain is less likely to take hold.

2. Both bottom-up and top-down pain management are required.

Whether you know it or not, you’re probably familiar with something called nociceptive pain. This is the body’s normal response to actual (or threatened) tissue injury or irritation such as a cut, a bruise, a sprain, a break, a burn, or even an arthritic joint. Specialized sensors called nociceptors detect the problem, the source is clear and the pain is local to the problem. If the underlying problem goes away in the relatively short term, the pain itself resolves. Put more technically, if the pain is input-dependent and reversible, this is nociceptive and settles once the input/trigger is removed. An example would be a one-off (or very occasional) tension headache due to poor ergonomics during a temporary work relocation.

If nociceptive triggers are repeated or sustained (e.g. those poor ergonomics continue in a new office and you’ve been unable to address them, or you develop arthritis of the knee but keep jogging through it) something called central sensitization can occur. Here the central nervous system turns up the volume, with nociceptive neurons in the spinal cord and brain becoming more excitable and harder to switch off, and descending pain-relieving “brakes” weakening. This maladaptive change means that even mild signals get amplified by the time they reach the brain, so pain can spread, things that shouldn’t hurt start to hurt, and systemic symptoms like fatigue, poor sleep, and difficulty concentrating can appear.

This central sensitization comes in two directions: bottom-up and top-down. In bottom-up, the sensitization is still being fed by a real peripheral source (e.g. the strained muscles or arthritic joint). Remove or treat that source and the amplified pain tends to settle. In the top-down form, the amplification has become self-sustaining in the central nervous system and persists even without ongoing peripheral input (e.g. this is the pattern seen in fibromyalgia).

Most real-world chronic pain involves both directions at once, which is why management usually has to address both the peripheral driver and the sensitized nervous system.

The good news is that this turned-up state can be calmed and, especially in the bottom-up form, even substantially reversed. Treatments aimed at the sensitized nervous system focus on sleep, stress management, (graded) exercise, neuroscience education (understanding pain actually helps pain) and even certain medications.

Side note 1:

I’ve somewhat oversimplified the description of chronic pain. The most common chronic pain picture is actually mixed, combining ongoing nociceptive pain (and sometimes neuropathic) with a nociplastic component. Nociplastic pain is pain that is out of proportion to any identifiable tissue or nerve damage, arising mainly from the central sensitization mechanism described above.

Side note 2:

Although nociplastic pain is often initially set off or fed by nociceptive input, it doesn’t typically respond in the same way. Whereas an NSAID might relieve the pain of an occasional tension headache, it’s unlikely to help in a chronic scenario. So in mixed chronic pain, we must address both the nociceptive driver (using tools like massage, physio, anti-inflammatories and more) and the centralized nociplastic component (focusing on central nervous system supports).

This may have given you more to think about chronic pain than you anticipated! But it’s so important to understand why I talk about things like sleep and stress when addressing your chronic pain.

It actually matters, a lot.

The International Menopause Society is suggesting calling this chronic pain associated with the menopause transition Musculoskeletal Syndrome of Menopause. I am here for it. As long as we don’t forget to address all the other non-hormonal components.

Mailis, A., Ang, S. B., Di Renna, T., Kazatsker, M. M., MacGregor, E. A., Misasi, G., … Nappi, R. E. (2026). Chronic pain at midlife. Climacteric, 29(5), 648–668. https://doi.org/10.1080/13697137.2026.2722558