Perimenopause represents a significant physiological transition for many women, yet its implications for exercise prescription, musculoskeletal health and long-term physical function are still not always given the attention they deserve.

For Exercise Physiologists working with women in midlife, understanding the physiological changes associated with perimenopause and menopause can help inform more targeted, individualised exercise interventions.

Resistance training, in particular, has an important role to play. Beyond improving strength and physical function, resistance training may help address several key health considerations associated with the menopause transition, including changes in lean mass, body composition, metabolic health and musculoskeletal function.

This article explores why resistance training should be an important consideration when supporting women through perimenopause and beyond.

Understanding Perimenopause and Its impact on muscle health

The menopause transition is associated with significant hormonal changes, particularly fluctuations and eventual reductions in oestrogen.

Estrogen has important effects throughout the musculoskeletal system, including skeletal muscle, bone, connective tissue and other tissues involved in physical function.

As women transition through perimenopause and into postmenopause, changes in hormone status may contribute to alterations in muscle mass, strength and body composition. These changes occur alongside the natural effects of ageing, reduced physical activity and other lifestyle and health factors.

This is where Exercise Physiologists can play an important role. Rather than viewing perimenopause purely as a symptom-management issue, it is also an opportunity to assess a woman's current physical capacity and develop strategies that support strength, muscle mass, metabolic health and long-term function.

Resistance training provides a practical and evidence-based intervention for addressing many of these areas.

The challenge is ensuring exercise prescription is individualised and appropriately progressed according to the woman's health history, training experience, symptoms, goals and current physical capacity.

Vasomotor symptoms and lean body mass

Vasomotor symptoms, including hot flushes and night sweats, are among the most commonly recognised symptoms associated with the menopause transition.

However, women may also experience disrupted sleep, palpitations, anxiety, chills and other symptoms that can affect quality of life and participation in physical activity.

A 2020 study using data from the Study of Women's Health Across the Nation explored the association between lean body mass and vasomotor symptoms in women transitioning through menopause.

The researchers found that higher lean body mass was associated with a lower probability of developing vasomotor symptoms.

Importantly, this research demonstrates an association rather than proving that increasing muscle mass through resistance training directly prevents hot flushes or other vasomotor symptoms.

However, it provides an interesting area for Exercise Physiologists to consider. Supporting women to maintain or build lean mass through appropriately prescribed resistance training may have benefits that extend beyond strength and body composition alone.

For women who are unable to use, choose not to use or are considering menopausal hormone therapy, exercise may form one component of a broader multidisciplinary approach to supporting health during the menopause transition.

The decline in muscle mass and strength

Age-related declines in skeletal muscle mass, strength and physical function are important considerations for all Exercise Physiologists working with midlife and older adults. The menopause transition may add another layer of complexity.

Recent literature has described a broader "musculoskeletal syndrome of menopause", highlighting the potential effects of oestrogen deficiency on muscle, bone, joints and other musculoskeletal tissues.

Loss of muscle mass and strength can have important implications for physical function, falls risk, frailty and long-term independence.

Sarcopenia is no longer defined simply by a reduction in muscle mass. Current definitions place particular emphasis on muscle strength, with reduced muscle quantity or quality used to confirm the diagnosis and physical performance used to identify severe sarcopenia. This distinction is important for Exercise Physiologists. Our assessment and intervention should not focus exclusively on body composition. Strength, function, movement capacity and the ability to perform meaningful daily activities are equally important outcomes. Resistance training remains one of the most effective interventions available to support muscle strength and physical function across the lifespan.

A 2023 controlled trial by Isenmann et al demonstrated that free-weight resistance training was safe and effective for improving strength in middle-aged women. Interestingly, the study also highlighted potential differences in body composition responses between premenopausal and postmenopausal women, reinforcing the importance of considering training volume, intensity and individual response when prescribing exercise.

For Exercise Physiologists, this is a useful reminder that women in midlife may require more than a generic "menopause exercise program". Progressive overload still matters, appropriate volume still matters, and individual response to training still matters.

Changes in adiposity, metabolic health and inflammation

Changes in body composition are among the most common concerns women report during perimenopause and menopause. Many women describe an increase in abdominal adiposity despite reporting little change to their exercise or dietary habits.

While changes in body composition are influenced by multiple factors, including ageing, hormone status, physical activity, sleep and nutrition, the menopause transition can influence fat distribution and metabolic health.

For Exercise Physiologists, this creates an opportunity to shift the conversation away from weight alone. Rather than focusing exclusively on the number on the scales, we can help women understand the importance of:

• preserving or building muscle

• improving strength and physical capacity

• supporting metabolic health

• reducing sedentary behaviour

• improving cardiorespiratory fitness

• supporting sustainable changes in body composition

Research has also explored the effect of resistance training on inflammatory and metabolic markers in postmenopausal women.

Ward and colleagues investigated a 15-week resistance training intervention in postmenopausal women and reported changes in several circulating adipokines.

Other research suggests resistance training can positively influence body composition and metabolic risk factors in older and postmenopausal women.

The important message for clinicians is that resistance training should not be positioned purely as a tool for changing appearance. It is a powerful intervention for improving strength, preserving physical function and supporting long-term metabolic and musculoskeletal health.

Practical considerations for Exercise Physiologists

When working with women in perimenopause and menopause, resistance training programs should be individualised rather than based on a one-size-fits-all approach.

Please consider the following:

Training history: Is the woman new to resistance training, returning after a period of inactivity or already an experienced lifter?

Current symptoms: Poor sleep, fatigue, joint pain, vasomotor symptoms and psychological stress may influence recovery, exercise tolerance and adherence.

Health status: Consider existing conditions, including osteopenia, osteoporosis, cardiometabolic disease, musculoskeletal injuries and other relevant health factors.

Strength and function: Assessment should extend beyond body weight and appearance. Grip strength, functional capacity, movement quality, muscular strength and other clinically relevant measures may provide valuable information.

Progressive overload: Women in midlife still need an appropriate training stimulus to develop strength and maintain or build muscle.However, progression should be individualised and consider recovery, symptoms, training experience and tolerance.

Multidisciplinary care: Exercise is only one component of menopause care. Exercise Physiologists can play an important role alongside GPs, menopause specialists, dietitians, physiotherapists, psychologists and other allied health professionals. Understanding when to work collaboratively and when to refer is an important part of providing high-quality care.

A broader opportunity for Exercise Physiologists

Supporting women through perimenopause and menopause represents a significant opportunity for Exercise Physiologists.

Women are often looking for help because their bodies feel different. They may report that the exercise strategies that previously worked no longer seem as effective. They may be concerned about weight change, reduced strength, joint pain, fatigue or declining confidence.

This is where Exercise Physiologists can provide real value. Not by offering another generic weight-loss program. But by helping women understand their changing physiology and develop an individualised strategy to support:

✔️ Muscle
✔️ Bone
✔️ Metabolic health
✔️ Strength
✔️ Function
✔️ Healthy ageing

Resistance training is not simply about aesthetics. For women navigating midlife, it can be an important tool for building physical capacity and supporting health for decades to come.

My final thoughts

Perimenopause and menopause should not automatically be viewed as a period of physical decline. They can also represent an important window for preventative health intervention.

For Exercise Physiologists, this means looking beyond symptom management and considering the broader musculoskeletal and metabolic changes occurring during midlife. Appropriately prescribed resistance training can help women build strength, improve physical function and support healthy ageing.

The key is moving away from generic advice and towards individualised, progressive and clinically informed exercise prescription.

As Exercise Physiologists, we are uniquely positioned to help women understand what is happening to their bodies and, importantly, what they can do about it. The goal should not simply be to help women get through menopause, it should rather be to help them build the physical capacity and confidence to thrive long after it.

References

European Working Group on Sarcopenia in Older People 2 (EWGSOP2). (2019). Sarcopenia: Revised European consensus on definition and diagnosis. Age and Ageing, 48(1), 16–31. https://doi.org/10.1093/ageing/afy169

Isenmann, E., Kaluza, D., Havers, T., Elbeshausen, A., Geisler, S., Hofmann, K., Flenker, U., Diel, P., & Gavanda, S. (2023). Resistance training alters body composition in middle-aged women depending on menopause: A 20-week control trial. BMC Women's Health, 23, 526. https://doi.org/10.1186/s12905-023-02671-y

Ward, L. J., Nilsson, S., Hammar, M., Lindh-Åstrand, L., Berin, E., Lindblom, H., Spetz Holm, A.-C., Rubér, M., & Li, W. (2020). Resistance training decreases plasma levels of adipokines in postmenopausal women. Scientific Reports, 10, 19831. https://doi.org/10.1038/s41598-020-76901-w

Woods, R., Hess, R., Biddington, C., & Federico, M. (2020). Association of lean body mass to menopausal symptoms: The Study of Women's Health Across the Nation. Women's Midlife Health, 6, 10. https://doi.org/10.1186/s40695-020-00058-9

Wright, V. J., Schwartzman, J. D., Itinoche, R., & Wittstein, J. (2024). The musculoskeletal syndrome of menopause. Climacteric, 27(5), 466–472. https://doi.org/10.1080/13697137.2024.2380363