The Hidden Ache: Understanding Chronic Pain in Perimenopause and Menopause
- Vanessa Weiland
- Jul 29
- 7 min read
Updated: 4 days ago
Menopause is often associated with hot flashes and mood swings, but for many it brings another, less talked-about challenge: chronic pain. If you're experiencing new or worsening aches and discomfort during perimenopause or menopause, you're not alone. Research increasingly points to a significant link between the menopausal transition and an increased burden of chronic pain.

Pain on the Rise: What the Research Says
Multiple studies confirm that as women transition through perimenopause and into postmenopause, they are more likely to experience various types of pain. This includes:
Musculoskeletal pain: Aches in muscles and bones are particularly common, with some cohorts reporting prevalence as high as 71% in perimenopausal women (1-2). The risk of musculoskeletal pain is significantly higher in perimenopausal women than in premenopausal women, and postmenopausal women are at even greater risk for moderate to severe musculoskeletal pain compared to both premenopausal and perimenopausal women (1-2).
Joint pain: Stiffness and discomfort in joints can become more pronounced (3-4).
Headaches: The frequency and severity of headaches can increase (3-4).
Generalized bodily aches: A pervasive feeling of discomfort throughout the body (3-4).
Why the Increase? The Multifaceted Causes
The reasons behind this surge in chronic pain are complex, involving a delicate interplay of hormonal shifts, psychosocial factors, inflammation, and neuroimmune interactions.
1. The Hormonal Connection: Estrogen, Progesterone, and Testosterone
The fluctuating and eventually declining levels of key hormones play a significant role:
Estrogen: This hormone modulates pain sensitivity through effects on both the nervous and immune systems. Estrogen can have both pro-pain and anti-pain effects, depending on its concentration, receptor subtype activation, and tissue context. During perimenopause and menopause, fluctuating and declining estrogen levels are associated with increased pain sensitivity and a higher prevalence of chronic pain conditions, likely due to altered interactions between the nervous system and immune system, as well as increased inflammation. Estrogen also influences mast cell activity and histamine release, which can contribute to neurogenic inflammation and pain amplification (5-7).
Progesterone: Generally, progesterone exerts pain-relieving and anti-inflammatory effects. However, high levels—such as those seen in the luteal phase—can paradoxically enhance pain sensitivity. In perimenopause and menopause, declining progesterone may reduce its protective effects, contributing to increased pain perception. Progesterone also modulates immune cell function and may influence histamine pathways (5-7).
Testosterone: This hormone is consistently associated with reduced pain sensitivity and has anti-inflammatory properties. Lower testosterone levels in aging women may contribute to increased pain vulnerability during and after the menopausal transition (5-7).
It's important to note that while some evidence suggests that declining estrogen may reduce pain sensitivity, the overall burden of chronic pain increases, likely due to the interplay of hormonal, psychological, and lifestyle factors.
2. Beyond Hormones: Psychosocial Factors and Inflammation
It's not just about hormones. Other elements significantly contribute to the pain experience:
Psychosocial Factors: Mood disorders, sleep disturbances, perceived stress, and lower self-rated health further exacerbate pain perception and chronicity (3-4).
Inflammation and Histamine: Ovarian hormones regulate immune cell activity, including mast cells, which release histamine and other pro-inflammatory mediators. Estrogen can enhance, while progesterone and testosterone can suppress, inflammatory and histaminergic responses, thereby modulating pain thresholds. This interplay is particularly notable for those affected by Mast Cell Activation Syndrome (common in Ehlers Danlos and other hypermobility syndromes). The net effect in perimenopause and menopause is a shift toward increased inflammation and pain sensitivity due to the loss of hormonal modulation (5-7).
Menopausal Symptom Burden: There is a strong association between the burden of menopausal symptoms (e.g., vasomotor, mood, cognitive) and the likelihood of chronic pain diagnoses (3-4).
Treatment Options: Finding Relief
Chronic pain, increased pain sensitivity, inflammation, and histamine-related symptoms during perimenopause and menopause are complex issues, often driven by the decline in ovarian hormones—primarily estrogen, progesterone, and testosterone—which modulate neuroimmune and neuroendocrine pathways (1-7). Understanding these underlying mechanisms helps guide treatment approaches.
1. Hormonal Treatment Options
Menopausal Hormone Therapy (MHT): This is considered the most effective intervention for common menopausal symptoms like hot flashes (vasomotor symptoms) and can also improve some musculoskeletal pain and inflammatory symptoms (8-9). Estrogen therapy, with or without progestogen, is indicated for symptomatic women without contraindications, particularly those under age 60 or within 10 years of menopause onset.
Testosterone Therapy: This has shown potential benefit for pain and sexual dysfunction in select women with documented androgen deficiency, but more robust evidence and regulatory approval are still needed (10).
It's crucial to remember that individualized risk-benefit assessment is essential for any hormonal treatment, considering potential cardiovascular, blood clot, and cancer risks.
2. Nonhormonal Pharmacologic Therapies
For women with contraindications to MHT or those who prefer to avoid hormones, several nonhormonal pharmacologic options are available:
Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) are the mainstay of treatment for chronic pain and inflammation. Although prolonged, high-dose NSAIDS may contribute to kidney and heart disease, topical NSAIDS, such as diclofenac, are a safer alternative for joint pain.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptators (SNRIs): These medications have demonstrated efficacy for vasomotor symptoms and may also provide benefits for chronic pain and sleep disturbances (8-9).
Gabapentin and Pregabalin: These medications are also effective for vasomotor symptoms and can help with chronic pain and sleep issues (8-9).
When considering these options, potential side effects such as dry mouth, nausea, sedation, and sexual dysfunction should be discussed to ensure the best fit for each patient.
3. Complementary and Lifestyle Interventions
Regular Physical Activity and Anti-Inflammatory Diet: These lifestyle changes may help reduce inflammation and improve pain (8-9). Menopause-knowledgeable physical therapists and personal trainers can become important members of your healthcare team.
Herbal and Alternative Therapies: While many options exist, strong clinical evidence for their efficacy or safety in managing menopausal pain is not considered sufficient for guideline recommendations. The following may be particularly beneficial, according to current evidence:
Palmitoylethanolamide (PEA) has demonstrated efficacy in reducing chronic pain, including neuropathic and inflammatory pain, in several double-blind randomized controlled trials and meta-analyses. PEA appears to be well tolerated, with no major side effects reported, and may improve quality of life and functional status (11).
Boswellia, glucosamine, curcumin, and capsaicin are widely used for musculoskeletal and inflammatory pain. Boswellia and curcumin have anti-inflammatory properties and may provide modest benefit for osteoarthritis and joint pain, but high-quality evidence for their use in menopause-related chronic pain is lacking (12).
Cannabis has been studied for gynecologic pain conditions, including chronic pelvic pain and endometriosis. Systematic reviews indicate that a majority of women report subjective pain relief with cannabis use. However, the quality of evidence is limited by heterogeneity in cannabis formulations, delivery methods, and dosages, as well as a lack of standardized outcome measures (13).
Cognitive Behavioral Therapy (CBT): This therapeutic approach is effective for managing anxiety, sleep disturbances, and even vasomotor symptoms, all of which may contribute to chronic pain (3, 8-9).
Hypnosis has demonstrated efficacy for reducing vasomotor symptoms and may provide benefit for pain management. Clinical hypnosis is recommended by the North American Menopause Society and other guidelines for vasomotor symptoms, with some evidence for improvement in pain and sleep disturbances (14).
Most of these interventions have favorable safety profiles, but long-term safety data and regulatory oversight are lacking for many supplements and herbal products.
Gaps in Evidence and Future Directions
There's a continuous need for more research, particularly concerning the role of testosterone therapy, histamine-targeted interventions, and individualized approaches for perimenopausal women, as most studies have focused on postmenopausal populations.
What Does This Mean for You?
In summary, perimenopause and menopause are associated with an increased risk and burden of chronic pain, particularly musculoskeletal pain, due to hormonal changes and interacting psychosocial and health-related factors.
If you're experiencing persistent or worsening pain during perimenopause or menopause, it's crucial to discuss it with your healthcare provider. Understanding the multifactorial nature of this pain is the first step toward effective management. While hormone therapy may modulate pain perception, its use must be individualized and is not universally indicated for pain management.
The good news is that by understanding the interconnectedness of hormones, inflammation, and lifestyle factors, healthcare professionals can work with you to develop a comprehensive approach to managing chronic pain during this significant life stage.
Pain During Menopause. Strand NH, D'Souza RS, Gomez DA, et al. Maturitas. 2025;191:108135. doi:10.1016/j.maturitas.2024.108135.
Musculoskeletal Pain During the Menopausal Transition: A Systematic Review and Meta-Analysis.
Lu CB, Liu PF, Zhou YS, et al.
Neural Plasticity. 2020;2020:8842110. doi:10.1155/2020/8842110.
Gibson CJ, Li Y, Bertenthal D, Huang AJ, Seal KH.
Menopause (New York, N.Y.). 2019;26(7):708-713. doi:10.1097/GME.0000000000001312.
Aras SG, Grant AD, Konhilas JP.
Scientific Reports. 2025;15(1):640. doi:10.1038/s41598-024-84208-3.
Athnaiel O, Davidson N, Mangat J, Nasr NF, Knezevic NN.
Cells. 2025;14(2):123. doi:10.3390/cells14020123.
Lenert ME, Avona A, Garner KM, Barron LR, Burton MD.
Endocrinology. 2021;162(8):bqab109. doi:10.1210/endocr/bqab109.
Athnaiel O, Cantillo S, Paredes S, Knezevic NN.
International Journal of Molecular Sciences. 2023;24(3):1866. doi:10.3390/ijms24031866.
Management of Menopausal Symptoms: A Review.
Crandall CJ, Mehta JM, Manson JE.
JAMA. 2023;329(5):405-420. doi:10.1001/jama.2022.24140.
Chang JG, Lewis MN, Wertz MC.
American Family Physician. 2023;108(1):28-39.
Gonadal Hormone Changes With Aging and Their Impact on Chronic Pain.
Athnaiel O, Davidson N, Mangat J, Nasr NF, Knezevic NN.
Cells. 2025;14(2):123. doi:10.3390/cells14020123.
Lang-Illievich K, Klivinyi C, Lasser C, et al.
Nutrients. 2023;15(6):1350. doi:10.3390/nu15061350.
Management of Chronic Pain Using Complementary and Integrative Medicine.
Chen L, Michalsen A.
BMJ (Clinical Research Ed.). 2017;357:j1284. doi:10.1136/bmj.j1284.
Medical Cannabis for Gynecologic Pain Conditions: A Systematic Review.
Liang AL, Gingher EL, Coleman JS.
Obstetrics and Gynecology. 2022;139(2):287-296. doi:10.1097/AOG.0000000000004656.
The 2023 Nonhormone Therapy Position Statement of the North American Menopause Society.
Menopause (New York, N.Y.). 2023;30(6):573-590. doi:10.1097/GME.0000000000002200.
Comments