Why Your Injuries Are Changing in Perimenopause (It's Not Just You)

Written By Lindsey Pope

A note on language: "women" in this article refers to menstruating people assigned female at birth. Not everyone this applies to identifies as a woman, you belong here too.

TL;DR

  • Estrogen isn't just about hot flashes, it directly affects your tendons, ligaments, bones, and muscle recovery.

  • When estrogen fluctuates or drops, connective tissue gets more lax and less efficient at transferring force → higher injury risk.

  • Adolescent female athletes are 2–8x more likely to tear an ACL than males, one of several proposed reasons is estrogen's effect on ligament laxity. (Female athletes also face higher ankle injury rates, though by a smaller margin.)

  • In perimenopause/menopause, declining estrogen is linked to a real, named condition: the Musculoskeletal Syndrome of Menopause (joint pain, sarcopenia, tendon issues, bone loss).

  • What can help: strength training, impact exercise, more recovery, and a handful of specific nutrients (protein, collagen + vitamin C, calcium + D, omega-3s, magnesium, creatine).

The Napheesa Collier Moment

Anyone catch Life in the W? Watching Napheesa "Phee" Collier talk about her string of injuries after having her daughter, after being someone who was rarely injured pre-pregnancy, sent me down a research rabbit hole.

My acupuncturist and I both have noticed similar patterns with our patients: and my period-tracking app literally has buttons labeled "old injury flare-up" and ‘injury’.

Turns out, estrogen could be the connective thread.

Estrogen 101: The Quick Version

During a normal cycle: Estrogen drops right before and during your period, rises to a peak before ovulation, dips briefly, then rises again for a smaller second wave in the second half of your cycle.

During pregnancy: Estrogen climbs the entire time and peaks in the third trimester. You'll produce more estrogen in one pregnancy than in the rest of your non-pregnant life combined.

We hear a lot about estrogen and bone health. We hear a lot less about this: Estrogen also affects your tendons and ligaments. Fluctuating levels can increase injury risk.

What Estrogen Actually Does to Connective Tissue

The good (muscle and bone):

  • Supports bone health

  • Supports muscle protein synthesis

  • Reduces exercise-induced muscle damage

  • Speeds up recovery

  • Helps preserve muscle mass with age

The trade-off (tendons and ligaments): Higher estrogen means more tissue laxity. Sounds flexible and good, but tendons and ligaments need stiffness to transfer force and stabilize your joints efficiently. Too much laxity can mean:

  • Less explosive power

  • Less efficient force transfer

  • Higher ligament injury risk

This is one theory behind why ACL tears spike around ovulation, when estrogen peaks.

Estrogen isn't the whole story, just an underappreciated piece of it. Female anatomy (pelvis width, ACL notch size), landing biomechanics, and neuromuscular differences all play a role alongside hormones. Research on female athletes and hormones is sparse but fortunately is a growing field of research. More is coming, but we're playing catch-up.

Then Menopause Happens

We generally think perimenopause means hot flashes, sleep issues, mood swings, and weight changes (and it does). What gets left out of the conversation is what declining estrogen does to your musculoskeletal system.

As estrogen drops:

  • Muscle mass decreases

  • Bone density decreases

  • Recovery slows down

  • Connective tissue properties shift

There's an actual clinical term for this now: the Musculoskeletal Syndrome of Menopause.

It includes:

  • Joint pain and morning stiffness

  • Bone density loss (osteopenia or osteoporosis)

  • Muscle loss and weakness (sarcopenia)

  • Faster progression of osteoarthritis

  • Tendon and ligament issues, such as frozen shoulder and rotator cuff issues, plantar fasciitis and Achilles problems, and general knee pain

The bottom line: lower estrogen means less collagen regulation, less tendon adaptability, less bone protection, and less muscle support. Your tendons and joints need more support in midlife, not less.

Your Best Defense: Muscle

The research keeps circling back to one thing: muscle is a protective organ. The more you have, the more protected you are.

Muscle:

  • Stabilizes joints

  • Protects bones

  • Reduces injury risk

  • Improves glucose metabolism

  • Supports long-term independence

You can't stop the hormonal shift. You can build the tissue that buffers you against it.

What To Do About It

Lifestyle

Strength train. Non-negotiable. (Portland folks, there are lots of options beyond bro-gyms, including functional-movement-focused studios and solid online programs if you're short on time.)

Focus on:

  • Squats and lunges

  • Deadlifts and hinges

  • Push movements

  • Pull movements

  • Progressive overload

Add impact exercise. Bone responds to load: hill walking, hiking, jump training, dancing, etc.

Take recovery seriously. Research points to slower tissue adaptation during this life stage.

Prioritize:

  • Sleep

  • Actual rest days

  • Mobility work

  • Managing total training volume

Fuel your body! Too little muscle and too little energy intake both raise injury risk. Under-fueling impairs hormones, recovery, and bone health.

Nutrition

Protein. Muscle loss accelerates in menopause.

  • Sources: eggs, Greek yogurt, fish, chicken, tofu/tempeh, beans, protein powder.

  • Spread across the day, and include it at breakfast.

Collagen + Vitamin C. Vitamin C is required to actually build collagen.

  • Sources: collagen powder with berries or citrus; bone broth with vitamin-C foods.

Calcium + Vitamin D. Estrogen decline speeds up bone turnover.

  • Sources: dairy, fortified alternatives, sardines, calcium-set tofu, leafy greens; sun, fatty fish, or supplement for D.

Omega-3s. May help regulate inflammation and support joints.

  • Sources: salmon, sardines, trout, walnuts, flax/chia.

Magnesium. Supports muscle function, sleep, and bone metabolism.

  • Sources: pumpkin seeds, nuts, dark chocolate, beans, leafy greens.

Creatine. Solid evidence for muscle strength and lean mass when paired with resistance training.

  • Dose: 3 to 5 grams per day, creatine monohydrate, taken consistently (timing doesn't matter).

The Takeaway

None of this is about chasing your 20's body back. It's about giving your tendons, joints, and muscles what they actually need right now, in the body you're in today. Start small: pick one nutrient from the list above you're probably under-consuming and build a habit around it this week. Pair it with a strength session and a hike, and you've already made more progress than most people do in a month of guessing.

If you're not sure where to start, or you want a plan that actually fits your body and your life, that's exactly what I help with. Book a free discovery call and let's talk through what nutrition and lifestyle support could look like for you.

Sources

  • Menstrual Cycle and Sport Injuries: A Systematic Review. PMID: 36833966

  • Effect of Estrogen on Musculoskeletal Performance and Injury Risk. PMID: 30697162

  • The Female ACL: Why Is It More Prone to Injury? PMID: 27053841

  • Sex Differences in Foot and Ankle Sports Injury Rates in Elite Athletes. PMID: 40949538

  • Creatine in Women's Health: Bridging the Gap from Menstruation Through Pregnancy to Menopause. PMID: 40371844

  • Impact of Creatine Supplementation on Menopausal Women's Body Composition, Cognition, Estrogen, Strength, and Sleep. DOI: 10.1080/15502783.2025.2533673

  • Creatine Supplementation in Women's Health: A Lifespan Perspective. PMID: 33800439

  • ISSN Position Stand: Safety and Efficacy of Creatine Supplementation. Kreider RB, et al., J Int Soc Sports Nutr. PMID: 28615996

  • The Musculoskeletal Syndrome of Menopause. e-arm.org/journal/view.php?number=4451

Lindsey Pope
Next

Why Your Neck Pain Might Start in Your Glute