Menopause & Musculoskeletal Health

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before discussing reproductive, sexual or gender-related health, and adapt communication to the patient’s language, identity, culture, disability and previous experiences of care (Public Health Agency of Canada, 2018).
• Patient and contextual information: age; sex and gender when clinically relevant; pronouns and preferred terms; language and communication needs; work or school; caregiving; and activities, roles, cultural practices and community connections important to the patient.

Primary concerns

• Menopause and reproductive context: menstrual-cycle change and date of last menstrual period; vasomotor, genitourinary, sleep, mood or cognitive symptoms; hysterectomy or oophorectomy; pregnancy possibility and contraception when relevant; premature or early menopause; cancer treatment or other treatment-induced menopause; and use or change of hormonal contraception, menopausal hormone therapy or gender-affirming hormones. Do not assume menstrual history alone establishes the stage when hormonal treatment or surgery changes bleeding.
• Relevant reproductive and pelvic history: pregnancies and births; pelvic or obstetric injury; pelvic, abdominal, breast or chest surgery; breastfeeding or chestfeeding; and urinary, bowel, prolapse, pelvic pain or sexual concerns when these may affect the presenting concern, bone health or care plan.
• Musculoskeletal symptoms: onset, course, location, intensity, quality, irritability and pattern of pain, stiffness, swelling, weakness, cramps, numbness or tingling; single-region or multisite symptoms; recent trauma, illness or activity change; and whether symptoms are improving, stable, fluctuating or worsening.
• Functioning and participation: effects on mobility, transfers, self-care, household tasks, work or school, caregiving, sleep, physical activity, exercise, recreation, sexual activity, relationships, social roles and community participation.
• Sleep, fatigue and vasomotor symptoms: frequency, severity, triggers and night-time pattern of hot flashes or night sweats; sleep quality and duration; fatigue; effects on functioning; and whether night sweats are persistent or drenching, occur independently of hot flashes, or accompany fever, unexplained weight loss or other systemic symptoms.
• Body systems review: constitutional symptoms; neurological; cardiovascular and peripheral vascular; respiratory; genitourinary and gastrointestinal; reproductive and breast; musculoskeletal and bone health; immune, infectious or inflammatory; endocrine or metabolic; skin; haematologic or bleeding; sleep; cognition; and mood symptoms that may change safety, the differential diagnosis, medication decisions or referral.
• Health and safety context: cardiovascular or thromboembolic disease; cancer; inflammatory or autoimmune disease; osteoporosis, low-trauma fracture, falls or family fracture history; diabetes; thyroid, kidney, liver or gastrointestinal conditions; pelvic health concerns; migraine; pregnancy history; recent surgery or immobilization; and current medicines and supplements, including corticosteroids, anticoagulants and medicines that affect balance or bone health.
• Physical activity, muscle and bone context: current and preferred activity; resistance, aerobic, weight-bearing and balance activity; recent change in capacity; falls confidence; nutrition, including food sources of protein and calcium; vitamin D context; smoking; alcohol or substance use; and readiness for change without assuming these factors explain the symptoms.
• Social and access context: work or school demands and support, caregiving, income, housing, food security, transportation, discrimination, safety, social support, access to primary care or menopause-informed care, technology and suitable space or equipment (Public Health Agency of Canada, 2026).
• Previous care and responses: education, activity change, exercise, rehabilitation, pelvic health care, hands-on care, medication, hormone therapy, mental-health care, other medical care and culturally grounded approaches tried; benefits, adverse effects, burden and reasons care was difficult to use or continue.
• Patient perspective: understanding of menopause and musculoskeletal symptoms; concerns about ageing, hormones, damage or serious illness; priorities, preferences, cultural context, expectations, strengths and what a meaningful improvement would look like.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess when symptoms, bleeding, neurological status, mood or general health change.

Optional menopause conversation aid

• The Menopause Quick 6 (MQ6) can help broaden discussion across period changes, hot flashes or night sweats, vaginal dryness or sexual concerns, bladder symptoms, sleep and mood. It is a conversation and screening aid, not a diagnostic or outcome measure, and it does not replace clinical history or medical assessment.

Outcome measures

• Choose a small set that reflects the patient’s goals and can be repeated. Add a region-specific measure only when it helps answer a clinical question.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF or another suitable validated measure.
• Menopause-specific quality of life: the Menopause-Specific Quality of Life Questionnaire (MENQOL) can track vasomotor, psychosocial, physical and sexual domains when these matter to the care plan. Check current access and licensing requirements before distributing the questionnaire (Hilditch et al., 1996).
• Physical performance: a repeatable task such as sit-to-stand, walking, stairs, carrying or balance can be added when it reflects the patient’s goals. Record the test conditions and symptom response.
• Individual goals and recovery: agree on patient-defined goals and how progress will be recognized. A global rating of change or recovery can support review when useful.

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.

Select examination elements that answer a clinical question or may change safety, the working presentation, care or referral. Adapt positioning, pace, exposure and loading to symptoms, comfort, consent, trauma history, mobility, balance and other health conditions.

• Ongoing consent and comfort: explain each step, provide choices, ask permission before touch or exposure, offer a chaperone according to policy and patient preference, and stop or modify the examination when requested.
• Immediate safety and general observation: observe general appearance, posture, gait, transfers and spontaneous movement; record vital signs when systemic, cardiovascular, respiratory or vascular concerns are present; and inspect for trauma, swelling, skin change, muscle wasting or asymmetry.
• Regional musculoskeletal examination: examine the symptomatic region using active and passive movement, resisted testing, palpation and focused tests only when results can change the working presentation or care. Compare sides when useful and record symptom response, strength, movement quality and capacity.
• Neurological and vascular examination: assess strength, sensation, reflexes, coordination, neural tension or upper motor neuron findings when indicated. Assess pulses, perfusion and limb swelling when vascular concern is plausible.
• Muscle, mobility and physical performance: select meaningful measures of strength, balance, gait, transfers, walking, stairs, carrying or another patient-prioritized task. Record symptoms, confidence, quality, assistance and the test conditions.
• Bone and falls context: assess falls history, balance, mobility, environmental or medication contributors and signs of fracture or height loss. Formal fracture-risk assessment may include Canada-specific FRAX, which is preferred, or CAROC; bone-density testing and interpretation sit within appropriate medical care (Morin et al., 2023).
• Pelvic health context: ask permission for symptom screening. A pelvic floor examination is completed only by a clinician with appropriate competence, consent and scope, or through referral.
• Investigations and imaging: tests are not routine solely because symptoms occur during menopause. Imaging, laboratory testing or medical investigation follows the regional presentation, Red Flags, fracture risk, systemic findings and whether the result is likely to change care.
• Reassessment: repeat the findings and tasks needed to review progress, revisit the working presentation, identify adverse effects and decide whether further assessment or shared care is appropriate.

Working clinical presentations

Use these as working clinical descriptions rather than fixed stages or a diagnosis caused by menopause. Presentations can overlap or change, and a usual regional diagnosis or a serious condition can coexist.

• Menopause-associated multisite muscle or joint symptoms: pain, stiffness, aches or reduced activity occur alongside a menopausal transition and may fluctuate with sleep, vasomotor symptoms, mood, activity or other health factors. The association does not establish a single tissue cause (Kruse et al., 2026).
• Regional musculoskeletal presentation: symptoms and examination findings fit a regional condition such as shoulder, spine, hip, knee, tendon or hand and wrist disorder. Use the relevant condition-specific pathway and retain the menopause context when it changes goals, loading, bone health or shared care.
• Muscle strength or physical-performance presentation: reduced strength, endurance, balance, confidence or activity affects transfers, walking, work, caregiving, exercise or participation, with or without regional pain.
• Bone health, falls or fracture-risk presentation: osteoporosis risk, a low-trauma fracture, recurrent falls, height loss or a possible vertebral fracture changes loading, exercise safety and the need for medical shared care.
• Pelvic health or genitourinary overlap: urinary or faecal incontinence, pelvic floor symptoms, pelvic organ prolapse symptoms, pelvic pain or pain with sexual activity affects movement, exercise, sleep, confidence or quality of life.
• Broader symptom and participation presentation: vasomotor symptoms, sleep disruption, mood or cognitive concerns, cardiometabolic health, caregiving, workplace conditions or access barriers substantially influence symptom burden and participation.
• Alternative or systemic presentation: the pattern fits an inflammatory, neurological, endocrine, vascular, malignant, infectious, traumatic or other condition better than a menopause-associated musculoskeletal presentation. Revisit Red Flags and arrange appropriate assessment.

Develop care with the patient. Choices reflect the working presentation, safety, goals, preferences, culture, access, reproductive and hormone context, other health conditions, previous responses and the burden of care. Respect the patient’s right to accept, decline, limit or stop any part of care.

Education, self-management and participation

• Understanding symptoms: validate the patient’s experience and explain that joint and muscle symptoms can occur during the menopausal transition, while avoiding claims that hormones alone caused a regional condition. Discuss the variable course and the reasons for reassessment or shared care (National Institute for Health and Care Excellence, 2026; Kruse et al., 2026).
• Daily activity and participation: pacing, task variation, brief recovery periods, sleep-supportive routines, workplace or caregiving changes and gradual return to valued activity can reduce avoidable disruption without making rest the main strategy. Prolonged bed rest or activity restriction is not used unless required for a specific medical reason.

Physical activity and exercise

• Graded activity and exercise: options include resistance, aerobic, weight-bearing, impact and balance activity, with regional mobility or motor-control work when relevant. Type, dose and progression reflect goals, current capacity, symptom response, bone and pelvic health, falls risk, comorbidities and access (Morin et al., 2023; Tan et al., 2023).
• Menopause symptom context: physical activity can support general health and participation, but evidence does not identify one best exercise mode for menopause symptoms. Yoga, aerobic exercise or other preferred activities can be used when acceptable and safe, then reviewed against the patient’s goals (Money et al., 2024).
• Protection and optimal loading: temporary protection, an aid, task modification or reduced loading can be useful after injury, with fracture risk or during a marked flare. Progress toward tolerable, meaningful loading as safety and symptoms allow; protection is not required solely because a person is experiencing menopause.

Bone, muscle and falls support

• Bone and muscle health: resistance and balance exercise, appropriate weight-bearing or impact activity, adequate dietary protein and calcium, and individualized vitamin D and fracture-risk follow-through can be coordinated with medical and nutrition care. Avoid high-risk spinal or impact loading when fracture risk or a possible fracture has not been clarified (Morin et al., 2023).
• Falls and mobility: balance practice, strength work, gait or mobility-aid review, home and community changes, vision or footwear follow-through and medication review can be combined according to the identified risks and the patient’s goals.

Hands-on and symptom-relieving care

• Hands-on care: regional mobilization, soft-tissue techniques or massage can accompany exercise and activity when a short-term goal is to improve comfortable movement or support participation. Purpose and response are reviewed rather than using hands-on care alone.
• Comfort strategies: heat, cold, relaxation, breathing practices or another acceptable strategy can support movement, sleep or activity when safe. Protect skin and circulation and review whether the approach is helping the agreed goal.

Psychological, social and interdisciplinary support

• Sleep, mood and coping: sleep routines, cognitive behavioural approaches, pain-coping skills, stress support and mental-health care can be integrated when sleep, mood, anxiety, cognition or distress affects functioning and these options match the patient’s priorities (Shea et al., 2021).
• Persistent sleep disruption: medical assessment can address vasomotor symptoms and possible primary sleep disorders. Cognitive behavioural therapy for insomnia can form part of shared care when insomnia persists (Ontario Health, 2025).
• Social and culturally grounded support: workplace or caregiving changes, community services, peer support and traditional, Indigenous, spiritual or community-based approaches identified by the patient can be integrated when safe, acceptable and within scope.

Pelvic and genitourinary shared care

• Pelvic floor rehabilitation: pelvic floor muscle training, bladder or bowel strategies and graded return to activity can be used for a relevant continence or pelvic floor presentation by a clinician with appropriate competence and scope. Medical assessment addresses bleeding, recurrent urinary symptoms, vulvovaginal symptoms or other concerns outside rehabilitation scope (Marcellou et al., 2025).

Medication and menopause medical shared care

• Menopause management: decisions about menopausal hormone therapy, non-hormonal medicines, contraception and treatment of vasomotor or genitourinary symptoms sit with an authorized medical provider. Shared care includes the patient’s goals, symptom pattern, health risks, current medicines, benefits, adverse effects and monitoring needs (National Institute for Health and Care Excellence, 2026; Yuksel et al., 2021).
• Hormone products and supplements: questions about custom-compounded hormone products, supplements and natural health products are reviewed with an authorized prescriber or pharmacist. Discuss available evidence, product authorization, interactions, adverse effects, cost and duplication. Custom-compounded “bioidentical” hormone therapy is not Health Canada-approved or standard care when an authorized pharmaceutical product can meet the clinical need (Ontario Health, 2025; Government of Canada, 2026).
• Pain medication: medication review sits with an authorized prescriber or pharmacist and includes intended benefit, adverse effects, sedation, falls risk, kidney, liver, gastrointestinal and cardiovascular health, other medicines, polypharmacy and the patient’s priorities.

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, symptom course, safety, goals, the options being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review symptoms, sleep, activity tolerance, strength, balance, task performance, functioning, participation, confidence, benefits, adverse effects, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit Red Flags, the working presentation, differential diagnosis, investigation, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: menopause-associated muscle and joint symptoms vary. They can improve, remain stable, fluctuate or persist, and there is no single recovery timeline. A regional condition follows its own expected course, while bone health and fracture risk can need ongoing review (Kruse et al., 2026; Morin et al., 2023).
• Factors associated with a less favourable course: greater or multisite symptom burden, reduced strength or activity tolerance, sleep or mood disruption, low bone density or fracture, falls, relevant comorbidity, and barriers to supportive care may be associated with more persistent effects. These are group-level associations and contextual factors, not certain causes or individual predictions (Kruse et al., 2026).
• Potential supports for recovery: validating information, feasible physical activity and exercise, gradual loading, attention to strength, bone and falls health, sleep and mood support, suitable social and workplace supports, access to menopause-informed care and timely shared care may support functioning and participation.
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using goals, repeated outcomes and the observed response over time. Do not use age, menopause stage, hormone status or a single score as a fixed prediction.