How Estrogen, Sleep and Mood Combine to Amplify Pain in Midlife Women

Aches and pains in your 40s and 50s are often written off as a normal part of getting older. According to the International Menopause Society (IMS), that explanation leaves many women without the care they need.

The IMS 2026 White Paper, released for World Menopause Day under the theme “Chronic Pain at Midlife,” found that women are up to 70% more likely than men to have chronic pain. Almost three in four women have joint or muscle pain during perimenopause. Rossella Nappi, M.D., Ph.D., professor of obstetrics and gynecology at the University of Pavia in Italy and IMS president from 2024 to 2026, spoke with The Educated Patient about why pain becomes so common at this stage of life and how women can make sure they are heard.

Several changes happen at once

“Pain becomes more common at midlife because several changes happen at once,” Nappi said. “Falling estrogen, aging and other menopause symptoms all affect how pain develops and how it is felt.”

According to the white paper, about half of midlife women live with chronic pain. It is often complicated because women may have several types of pain at once, such as joint pain, migraine and pelvic pain. These conditions can share causes in the nervous system, the immune system and shifting hormones.

Falling estrogen affects nerves, joints and muscles. It also changes how the nervous system processes pain signals and how the immune system responds. Hot flashes, poor sleep, low mood and fatigue can make pain feel worse, and the effects run both ways. “Poor sleep increases sensitivity to pain, and pain disrupts sleep,” Nappi said.

Over time, the nervous system can become more sensitive and amplify pain signals, a process called central sensitization. “This is a real, physical change in how pain is processed, not a sign that the pain is imagined,” she said.

When aches are blamed on age

When menopause-related pain is blamed on aging, it often goes untreated, Nappi said. The reverse can happen too. Not every symptom at midlife comes from menopause, so other causes should be checked. For example, bladder pain and urinary symptoms after menopause are often treated as repeated infections. Women may get several rounds of antibiotics while the real cause, such as bladder pain syndrome or endometriosis that continues after periods stop, goes untreated.

Nappi said a woman should talk with her provider if her pain has lasted or kept coming back for more than three months, is new or has changed in a worrying way, or keeps her from work, exercise or sleep. Other reasons to speak up include pain in several places along with fatigue or poor sleep, pelvic pain, pain during sex, bladder discomfort, first-time migraine aura or a sense that her pain is not being taken seriously.

“A woman knows her body best,” she said.

Normal results should not end the conversation

Normal test results do not mean pain is not real, Nappi said. Because the nervous system can amplify pain, what a woman feels does not always match what tests show.

She suggested women ask questions such as whether their pain could be connected to menopause, whether more than one condition could be involved, whether poor sleep, hot flashes or low mood could be making it worse, what nonhormonal options exist, and whether a referral to a physical therapist or pain specialist makes sense.

“Being heard and taken seriously is often the first step,” she said.

A simple pain record helps spot patterns

Tracking pain does not need to be complicated. Nappi recommends a short note each time pain happens: when it started, how long it lasted and what made it better or worse. Notes on sleep, energy and mood also help. For women with migraine, timing matters, because some find attacks come a few days before or after their period starts during perimenopause.

At an appointment, how pain affects daily life matters as much as where it is or how bad it feels, she said. A clear record can show patterns, such as pain tied to the menstrual cycle or to poor sleep, which is especially useful when tests are normal.

Treatment usually takes more than one approach

“There is no single treatment that works for everyone,” Nappi said. Programs that bring different professionals together have been shown to improve daily function and quality of life.

Regular exercise, especially strength training, has the strongest evidence of any lifestyle change for women over 40. Good sleep, stress management and maintaining a healthy weight also help. Physical therapy can ease joint, muscle and pelvic pain, and cognitive behavioral therapy can help women manage how pain affects daily life.

Menopausal hormone therapy (MHT, also called HRT) can ease many menopause symptoms, but the evidence does not show that it reliably treats chronic pain. A cautious trial may be considered for some women whose pain started around menopause, after discussing the limited evidence, the possible risks and the need for careful follow-up. Nappi also stressed that decisions about MHT should be made individually for women with a history of endometriosis or migraine, because MHT can make migraine worse for some women and the type and dose need to be chosen carefully.