• Faire preuve de sensibilité culturelle et principes de soins tenant compte des traumatismes. Acknowledge prior healthcare experiences including dismissal or under-treatment of menopause symptoms, and the impact of reproductive history, gender identity, and lived experience on physical and mental health.
  
• Informations sociodémographiques : age, race or ethnicity, gender identity, language, occupation, and caregiving responsibilities (including for children, partners, and aging parents).
  
• Menopause stage and reproductive context:
  • Current life stage, using the STRAW+10 framework (Harlow et al. 2012) where helpful: late reproductive, early or late perimenopause, early or late post-menopause.
  • Menstrual history: cycle changes (frequency, duration, flow), last menstrual period (LMP), time since LMP, and any post-menopausal bleeding (always abnormal; see Red Flags).
  • Reproductive history: age at menarche, gravidity, parity, mode of births (vaginal, cesarean, instrumental, episiotomy), obstetric or pelvic injury, pelvic floor dysfunction (incontinence, prolapse, chronic pelvic pain), and breastfeeding or chestfeeding history.
  • Surgical or induced menopause: bilateral oophorectomy, hysterectomy with retained ovaries, chemotherapy, pelvic radiation, GnRH agonists, aromatase inhibitors.
  • Premature ovarian insufficiency (POI, under age 40) or early menopause (40 to 45): both warrant medical evaluation and typically MHT until the average age of natural menopause, given long-term cardiovascular, cognitive, and bone health risks (Panay et al. 2024).
  • Current or past use of gender-affirming hormone therapy. Do not assume reproductive or sexual history.
    
• Primary MSK concerns:
  • Location (hands and wrists, shoulders, neck, low back, hips, knees, or generalized), onset, and course.
  • Whether pain is localized or polyarticular and migratory.
  • Timing in relation to menstrual changes or other menopause-associated symptoms.
  • Change over time, including morning stiffness and its duration.
  • Aggravating and relieving activities.
  • Associated symptoms such as swelling, weakness, numbness, instability, locking, or radiating pain.
  • Impact on sleep, work, caregiving, intimacy, exercise, and valued activities.
    
• Menopause-specific symptom screening: consider the Menopause Quick 6 (MQ6) or equivalent to broaden the conversation beyond MSK: changes in periods, hot flashes or night sweats, vaginal dryness or sexual concerns, bladder symptoms, sleep, and mood.
  
• Revue des systèmes corporels : constitutional or general, neurologic, cardiovascular, genitourinary (including GSM, urinary symptoms, and pelvic floor dysfunction), gastrointestinal, musculoskeletal, bone health (fracture history, height loss, family history of osteoporosis), eyes, ears, nose, and throat, respiratory, skin, mental health (mood, anxiety, cognition), and reproductive and breast health.
  
• Santé, mode de vie et histoire : 
  • Pre-existing MSK conditions, prior surgeries, hypermobility, and inflammatory or autoimmune disease.
  • Current and recent medications and supplements: MHT (systemic or local), non-hormonal pharmacotherapy, osteoporosis treatments, and analgesics.
  • Physical activity history and current habits, including resistance, weight-bearing, aerobic, and balance activity.
  • Nutrition (protein, calcium, vitamin D, magnesium, vitamin K), alcohol, smoking, and substance use.
  • Sleep, fatigue, and VMS severity and frequency. Characterize night sweats in context, and consider systemic differentials (weight loss, persistent fever, drenching sweats independent of hot flashes) when the pattern does not fit menopause.
  • Falls history and risk factors.
    
• Functioning and participation:
  • Impact on work performance, attendance, and career.
  • Impact on caregiving, relationships, sexual functioning and intimacy, leisure, sport, and physical activity.
  • Use of supports or adaptive strategies, and activity avoidance.
    
• Déterminants sociaux de la santé:  employment, income, benefits and drug coverage, housing, food security, family and community support, access to rehabilitation, experiences of racism or discrimination in care, immigration status, and language. Documented inequities mean racialized and gender-diverse individuals experience higher symptom burden and lower access to evidence-informed care (Harlow et al. 2022).
  
• Traitements antérieurs et réponses : prior advice or treatment for menopause-associated MSK symptoms, perceived effectiveness, and any adverse effects.
  
• Croyances et attentes : understanding of menopause and MSK symptoms, recovery expectations, concerns about movement or specific interventions, cultural framing, and previous experiences of being dismissed.
  
• Considérations relatives aux drapeaux : identify red, orange, and yellow flags for potential referral.

​​Évaluations des résultats :  Prioritize measures aligned with the individual’s goals, life stage, and participation needs. The examples below are illustrative, not exhaustive.

• Douleur: NRS and body diagrams; pain interference (e.g., PROMIS Pain Interference).
• Functioning and Participation: PSFS, WHODAS 2.0; region-specific measures (Oswestry or RMDQ for low back, QuickDASH for upper limb, WOMAC, KOOS, or HOOS for hip and knee).
• Menopause-specific quality of life: MENQOL or the Greene Climacteric Scale.
• Dormir: PSQI or Insomnia Severity Index.
• Qualité de vie : SF-12 or EQ-5D.
• Falls and fracture risk: falls history; FRAX or CAROC; STEADI for falls screening.
• Physical activity: self-report or Godin Leisure-Time Exercise Questionnaire; resistance and balance frequency.
• Psychosocial and mood: PHQ-9, GAD-7, FABQ, PCS, and the Tampa Scale for Kinesiophobia.
• Work or school status: monitor participation in valued roles.
• Objectifs individuels : set Objectifs SMART aligned with what matters most to the patient and integrate patient feedback.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Prioritize safety, comfort, dignity, and relevance to functioning. Adapt the examination to the individual’s life stage, symptom presentation, and trauma history. Interpret findings in the context of physiological changes associated with menopause (reduced connective tissue load tolerance, possible sarcopenia or osteoporosis) without assuming symptoms are benign.

• Trauma-informed approach: offer choice at each step (positioning, draping, location of contact, pace, presence of a support person), explain each step before performing it, and invite ongoing consent. Confirm consent before examining the trunk, pelvis, hips, or breast region. Refer to a pelvic health provider for internal pelvic examination when indicated.
• Safety: take blood pressure where relevant, allow symptoms such as hot flashes to settle, and avoid prolonged static positions for those with significant VMS. Consider height compared with prior records and signs of kyphosis suggestive of vertebral fracture.
• Observation: posture, alignment, gait, movement behaviour, guarding, asymmetry, and use of supports.
• Amplitude du mouvement : active, passive, and resisted movement of the lumbar, thoracic, and cervical spine and the symptomatic regions, noting restriction, movement quality, and symptom reproduction.
• Palpation : tenderness, swelling, muscle tone, and temperature changes in relevant bones, joints, and soft tissues.
• Neurological examination (when indicated): motor and strength testing by myotome, sensory testing by dermatome, reflexes, and upper versus lower motor neuron patterns.
• Special or orthopedic tests: region-specific tests as clinically indicated, e.g., for adhesive capsulitis (capsular pattern), hand and wrist conditions (carpometacarpal osteoarthritis, distal and proximal interphalangeal osteoarthritis, de Quervain tenosynovitis, trigger finger, carpal tunnel syndrome), and hip or knee osteoarthritis and tendinopathy. Several of these are over-represented at midlife; screen for them when the history fits.
• Évaluation fonctionnelle : walking and standing tolerance, sit-to-stand (e.g., the 30-second sit-to-stand), lifting and carrying, single-leg loading and balance (single-leg stance, tandem stance), and stair negotiation. For those reporting falls or fear of falling, use the Timed Up and Go or a staged balance test.
• Imagerie : not routine. Reserve it for suspected serious pathology, an unsatisfactory response to care, or where the result would change management. Tell the patient when imaging is not needed.
• Repeat and adapt the examination over time to track recovery, progress conservative care, and identify when further assessment or referral is needed.

Presentations during the menopause transition are common, variable, and frequently multi-region. Risk of MSK pain rises across the transition (Lu et al. 2020). Interpret symptoms in the context of life stage, impact on functioning, and whole-person factors (sleep, mood, cardiometabolic status, social context) rather than as isolated regional problems. There is no validated menopause-specific classification; the groupings below are pragmatic.

Common menopause-associated presentations:

• Generalized arthralgia and myalgia: polyarticular, often migratory joint pain, stiffness (usually shorter in duration than inflammatory stiffness), and muscle aching; may predate other menopause symptoms.
• Adhesive capsulitis (frozen shoulder): insidious shoulder pain with progressive loss of active and passive range of motion; disproportionately affects women aged 40 to 60 (late perimenopause and early post-menopause), though the estrogen-decline link is biologically plausible and the evidence base remains limited (Wright et al. 2024).
• Hand and wrist conditions: carpometacarpal and interphalangeal (distal and proximal) osteoarthritis, de Quervain tenosynovitis, trigger finger, and carpal tunnel syndrome; overlapping presentations are common and over-represented at midlife.
• Low back and pelvic girdle pain: including persistent low back pain that may have started in pregnancy or postpartum and now overlaps with menopause-related change; sacroiliac and gluteal contributions are common.
• Hip and knee osteoarthritis: symptomatic presentation often emerges or accelerates at midlife.
• Tendinopathies: gluteal, rotator cuff, lateral elbow, and Achilles.
• Sarcopenia and reduced strength: loss of muscle mass and quality accelerates around and after menopause and contributes to falls, fragility fractures, declining functioning, and pain (Tan et al. 2023).
• Bone health: accelerated bone loss in perimenopause and early post-menopause increases the risk of osteopenia, osteoporosis, and fragility fracture (Morin et al. 2023).
• Pelvic floor and GSM-overlapping symptoms: pelvic pain, dyspareunia, and pelvic floor dysfunction (stress, urge, or mixed urinary incontinence, pelvic organ prolapse, defecatory dysfunction); often warrants pelvic health referral (Johnston et al. 2021).
• Amplification des symptômes liés au sommeil : night sweats and insomnia reduce restorative sleep, increase pain sensitivity, and reduce capacity to engage in active care (Shea et al. 2021).
• Mood and cognitive contributions: depressive symptoms, anxiety, and cognitive change can affect pain experience, functioning, and self-management (Shea et al. 2021).
• Cardiometabolic context: rising cardiovascular and metabolic risk shapes exercise recommendations and the case for sustained progressive activity (Abramson et al. 2021).
• Typical symptom behaviour:
• Pain and stiffness fluctuate with sleep, hormonal change, activity load, stress, and VMS severity.
• Symptoms often improve with graded, sustained physical activity and self-management (Money et al. 2024).
• Multi-region and overlapping symptoms are common and do not necessarily indicate serious pathology but warrant whole-person assessment.

Care is individualized, biopsychosocial, and delivered alongside medical care provided by other clinicians, with functioning, participation, sleep, mood, sexual health, and patient-defined goals as the targets, not pain reduction alone. It is trauma-informed, culturally safe, and equity-attentive, and delivered through shared decision-making. Active care and self-management are first-line.

First-line care

• Education and self-management: explain menopause as a normal transition with real physiological and whole-person consequences; cover biopsychosocial contributors (load, sleep, mood, cardiometabolic and bone health, social context); reassure that movement and graded activity are safe and beneficial in the absence of contraindications; and provide practical activity modification, pacing, load management, and progressive return to valued activities. Validate the patient’s experience, since many have been dismissed or under-treated (Menopause Foundation of Canada 2022). Discuss MHT and non-hormonal pharmacotherapy as options to raise with primary care or a menopause-trained clinician (Yuksel et al. 2021); early interpretations of the Women’s Health Initiative drove widespread fears about MHT that subsequent re-analyses have moderated, and clinicians should not steer the patient toward or away from MHT.
  
• Nutrition: encourage adequate protein, calcium, vitamin D, magnesium, and vitamin K, food first, and supplement when intake is inadequate or a deficiency is identified (Morin et al. 2023). Support neutral, non-shaming conversations about alcohol, smoking, and weight, and refer to a registered dietitian or primary care when more comprehensive nutrition care is needed.
  
• Thérapie par l'exercice : individualized, progressive, and multi-component.
  • Resistance training at least twice weekly, progressive load, targeting major muscle groups, to support bone mineral density, lean mass, and strength (Zhao et al. 2025).
  • Aerobic activity (at least 150 minutes per week of moderate, or 75 minutes of vigorous, intensity) to support cardiovascular and metabolic health, mood, sleep, and VMS (Money et al. 2024).
  • Weight-bearing and impact activity as tolerated for bone health (Morin et al. 2023).
  • Balance and mobility training for falls prevention, particularly in late perimenopause and post-menopause (Morin et al. 2023).
  • Mind-body movement (e.g., yoga or tai chi) for menopause symptoms (Money et al. 2024).
  • Region-specific exercise: progressive loading for tendinopathy, graded range of motion and loading for adhesive capsulitis, and pelvic floor training for pelvic floor dysfunction (Marcellou et al. 2025).
  • No single exercise mode is superior across goals; adherence, sustainability, and relevance to the patient’s life are central.

Adjunctive care (alongside active care, shared decision, time-limited)

• Evidence for adjunctive interventions in menopause-associated MSK care is limited overall. Use them as time-limited additions to active care, guided by shared decision-making and the patient’s response, not as stand-alone treatments.
  
• Thérapie manuelle : joint mobilization and manipulation, offered as an adjunct integrated with education and exercise, not as stand-alone care; obtain clear consent. It may modulate short-term pain and support engagement in active care (Espírito Santo et al. 2024). In confirmed or suspected osteoporosis, use high-velocity techniques with caution and prefer mobilization and soft-tissue approaches (Morin et al. 2023).
  
• Soft tissue techniques: massage, myofascial release, and trigger point techniques as a short-term adjunct integrated with active care, not as stand-alone care.
  
• Supports and ergonomic strategies: braces or supports in selected cases; ergonomic advice for daily and occupational tasks.
  
• Passive physical modalities: a short-term adjunct only, when they help the patient engage in active care.

Psychosocial and multidisciplinary care

• Screen for psychosocial contributors and mood or anxiety symptoms (distress, fear of movement, fear of fracture, low recovery expectations, caregiver burden, work stress, trauma), using the tools listed under Outcome measures.
  
• Sleep and behavioural strategies: sleep is foundational to MSK recovery, mood, and cognition; provide sleep hygiene education and refer for cognitive-behavioural therapy for insomnia (CBT-I) where indicated (Moon et al. 2025). Mindfulness and cognitive-behavioural approaches reduce hot-flush bother and improve mood and sleep (van Driel et al. 2019). VMS management sits outside the MSK scope but is supported through co-management.
  
• Pelvic health: pelvic floor muscle training reduces urinary incontinence symptoms in postmenopausal women (Marcellou et al. 2025); refer to a pelvic health provider when indicated. For GSM, refer to primary care to discuss options such as local vaginal estrogen (Johnston et al. 2021).
  
• Co-manage with primary care, mental health, pelvic health, rheumatology, sleep medicine, and menopause-trained clinicians as needed. Encourage the patient to bring questions about MHT, non-hormonal pharmacotherapy, perimenopausal contraception, and cardiovascular and bone screening to primary care, and provide a written summary if helpful.
  
• Equity-informed care: respond to documented inequities, since racialized and gender-diverse individuals experience higher symptom burden and lower access to care (Harlow et al. 2022); apply Indigenous cultural safety and humility principles when working with First Nations, Inuit, and Métis patients; and use inclusive, gender-affirming language.

Médicament

• Advise on and co-manage medication within your scope of practice, discussing over-the-counter options as appropriate. Short-term analgesia may support engagement in active care during symptom flares; discourage long-term opioid use. MHT and non-hormonal pharmacotherapy are prescribed and managed by other clinicians and discussed through co-management.

Not recommended

• Adjuncts (manual therapy, soft-tissue techniques, and passive physical modalities) used as stand-alone care in place of active care and self-management.
• Prolonged activity restriction or bed rest.
• Compounded “bioidentical” hormone therapy, which is not Health Canada-approved and not standard of care; if MHT is desired, refer to primary care to discuss pharmaceutical-grade products (Yuksel et al. 2021).
• Unsupported supplements marketed for menopause; encourage critical appraisal and a primary care discussion.

Monitoring and reassessment

• Reassess against the outcome measures recorded at baseline. Continue what helps, adjust or stop what does not, and reconsider the working diagnosis or referral if the patient is not improving as expected. Review sooner if symptoms worsen or red flags emerge. For bone health, follow the osteoporosis guideline for bone mineral density testing and reassessment intervals (Morin et al. 2023).

 Pronostic : generally favourable when care emphasizes functioning, sustained physical activity, sleep, mood, and whole-person support, with appropriate co-management (Money et al. 2024). Many symptoms improve over months to years with active management; some, such as GSM and bone loss, progress without ongoing treatment and warrant long-term strategies (Morin et al. 2023). Persistent, severe, or limiting symptoms should be actively addressed and not normalized as part of aging. The menopause transition is also an opportunity for preventive engagement across bone, cardiovascular, mental, and sexual health and sustained physical activity, which influences functioning for decades.

Factors associated with poorer outcome or delayed recovery:

• Prior or persistent MSK pain, including unresolved pregnancy or postpartum-related pain.
• Surgical or induced menopause, premature ovarian insufficiency, or early menopause (Panay et al. 2024).
• Higher symptom burden (multi-region pain, severe VMS, sleep disruption) (Lu et al. 2020).
• Low baseline physical activity, particularly limited resistance training (Money et al. 2024).
• Sarcopenia, low bone density, or prior fragility fracture (Morin et al. 2023).
• Sleep disorders, including untreated sleep apnea.
• Mental health symptoms (depression, anxiety, history of trauma).
• Activity avoidance, fear of movement or fracture, low recovery expectations, and beliefs that symptoms are untreatable.
• High caregiver burden and limited social support.
• Workplace inflexibility or stigma, including considering reduced hours or leaving the workforce.
• Major midlife transitions and chronic stressors.
• Healthcare dismissal and resulting disengagement from care (Menopause Foundation of Canada 2022).
• Structural inequities affecting access to care (Harlow et al. 2022).

Factors associated with recovery:

• Early, accurate, validating information about the menopause transition.
• Sustained physical activity, including resistance, weight-bearing, and balance work (Money et al. 2024).
• Strong social and community support.
• Timely access to appropriate medical, rehabilitation, mental health, and pelvic health care, including consideration of MHT when indicated (Yuksel et al. 2021).
• Workplace accommodations and supportive employment.
• Patient empowerment, self-efficacy, and shared decision-making.