Stacey Pfeffer

Women go through so many changes throughout their life cycle. From pregnancy for those who choose to conceive to the post-partum phase, hormones can increase a woman’s likelihood of certain injuries. The fluctuating hormones in perimenopause and then a sharp decline of estrogen in menopause can cause a variety of musculoskeletal issues as well. Inside Press spoke with Chappaqua resident Dr. Corrinne Menn, an OBGYN and menopause specialist to gain a better understanding of how hormones and other factors at different stages of a woman’s life can make her more prone to injury. We also spoke with two local physical therapists who have decades of treating women of all ages for these various injuries, Armonk’s Michele Berliner at Focal Physical Therapy in Armonk and Pleasantville’s Caron DuBois at New Castle Physical Therapy in Millwood.

Pregnancy

The pregnancy hormone relaxin surges during pregnancy in order to prepare the body for delivery. This important hormone helps loosen muscles, joints and ligaments to help the body stretch and prepares the pelvis for delivery. Unfortunately, it can also make pregnant women more prone to injury as their ligaments loosen. With added weight gain causing a women’s center of gravity to shift, it is not surprising that many women experience muscle aches and pains during their pregnancy. According to the American Pregnancy Association, the number of pregnant women who experience back pain is somewhere between 50 to 70 percent.

Dr. Menn says back pain is one of the top reasons she has referred pregnant women to physical therapy (PT). Both Berliner and DuBois agree that back pain is one of the most common ailments they treat in pregnant women, particularly in the third trimester. But other women seek out physical therapy due to pelvic girdle pain (PGP) and even pain in the rib cage. PGP can cause pain in the hips, buttocks, thighs and the sacrum and it is estimated to affect up to 70 percent of pregnant women in the US. PGP can also persist in the post-partum phase with nearly 40 percent of women reporting ongoing PGP and pelvic weakness 12 weeks after delivery.

Besides addressing pain, Berliner works a lot on core strength and helping women recruit their abdominal muscles properly so that they can recover quickly in the post-partum phase. From lifting a heavy car seat to placing a baby in a crib, using core muscles effectively is key to injury prevention.

Just as many expectant moms take classes about newborn care, DuBois wishes that all pregnant women could have at least one physical therapy session prior to delivery. PT could teach them proper lifting mechanics and how to strengthen their pelvic floor to aid in delivery.

Post-Partum

Dr. Menn believes that historically there has been an undereducation in the wider medical community of how physically traumatic the delivery process can be for some women. The tide is slowly turning with medical groups such as the International Society for the Study of Women’s Sexual Health (ISSWSH) highlighting data on episiotomies, vaginal tears, perineum and nerve pain following delivery. Women can even break their coccyx bone or hip during childbirth.

Diastasis recti is the separation of the abdominal muscles during pregnancy and is more common in women who deliver via caesarean. The condition not only affects body posture but also leads to core dysfunction which can cause low back pain, urinary incontinence and a reduced quality of life. “Before a woman resorts to surgery for it, physical therapy can help narrow the separation and fix many of the problems associated with it,” explains Berliner.

“When you give birth, your life changes dramatically and your body is challenged in different ways,” adds Berliner. Movements such as holding the baby, feeding or nursing it, placing them in a car seat or crib are repeated throughout the day. “PT can help with postural awareness to help address any weaknesses and prevent injury,” adds Berliner. Relaxin, which loosens the ligaments still remains in the body post-partum. Some sources say it can take up to a year for relaxin levels to return to pre-pregnancy levels. The ligaments and joints can still be loose in this phase, so an exercise program needs to be done cautiously. “Women need guidance in the post-partum period to educate them on the best body mechanics for doing these activities, so they don’t hurt themselves,” explains DuBois.

Many times, when a woman visits her ob-gyn for a six-week post-partum check-up, pain is attributed to the weight gain of pregnancy or a difficult delivery. “If you are having pain anywhere in your body that is lasting more than two weeks and affecting your daily life, you have to be the squeaky wheel with your doctor. Find a physician who acknowledges the problem and ask for a referral to a pelvic floor therapist or an orthopedist with expertise in pregnancy-related issues,” urges Dr. Menn.

Perimenopause

In 2024, Dr. Vonda Wright an orthopedist in Florida along with other researchers published a seminal study in the journal Climacteric titled the “Musculoskeletal Syndrome of Menopause”. While many women are familiar with the decline in bone health at this stage, the musculoskeletal syndrome of menopause (MSM) also includes joint and muscle pain. “The loss of estrogen affects every system in the body,” notes Dr. Menn. Doctors are becoming more aware of MSM as the study was widely covered in the media.

Perimenopause is a period in woman’s life when her estrogen levels are constantly fluctuating. “From a physiologic standpoint, perimenopause symptoms can start 10 years prior to a woman’s last period. For example, if the normal range of menopause is 46-56, let’s say someone transitions into menopause at 49, that woman can start having symptoms of perimenopause starting at 39 with abrupt fluctuations and unpredictable estrogen levels,” explains Dr. Menn. The most rapid bone loss begins during the late perimenopause, approximately 1-2 years before the final menstrual period (FMP), and continues through the first few years of postmenopause. During this critical window, bone mineral density can decline by 2.5% per year or more.

Dr. Wright’s study found that more than 70% of women will experience musculoskeletal symptoms and 25% of women will be disabled by a musculoskeletal issue through the transition from perimenopause to postmenopause. This often-unrecognized collective of musculoskeletal symptoms, largely influenced by estrogen fluctuations, includes joint pain, loss of muscle mass, loss of bone density and progression of osteoarthritis.

With approximately 40–50% of women at age 50 having osteopenia, which is a precursor to osteoporosis, and approximately 20% of women over 50 years of age having osteoporosis, baseline bone density tests are critical. Bone density scans are usually recommended at age 65 for women. Dr. Menn, a breast cancer survivor, would argue that there are a lot of risk factors that women need to know about that would make them an ideal candidate to have a baseline DEXA bone density scan done earlier, starting at age 50. These include but are not limited to women who had chemotherapy, having a parent who had an osteoporotic fracture, smoking, ongoing steroid or SSRI use, having celiac disease or autoimmune diseases or an eating disorder at some period in their lives. “If insurance denies it, the cash price is about $100 and it is worth it,” she advises.

Berliner sees many patients in perimenopause. A common refrain she hears from them is “I’m now in my 50s. I never had so much pain and used to bounce back quicker.” One of the most difficult conditions both Berliner and DuBois treat in this population is frozen shoulder which is significantly more common in women during perimenopause and menopause (ages 40-60) due to hormonal shifts, particularly the drop in estrogen, which affects joint lubrication, inflammation, and connective tissue elasticity, making the shoulder capsule prone to stiffness and thickening. “It is such a painful and frustrating condition, and it takes a lot of diligence in treating with stretching and home exercises. It can take 6-12 months to heal. If you are having shoulder pain, the sooner you start working on it with PT the better. The same is true for nagging back pain during pregnancy. Don’t delay treatment,” says Berliner.

Menopause

According to the International Osteoporosis Foundation, approximately 30% of women age 65 or older will have osteoporosis. “We have clear data that 1 in 2 women with osteoporosis will have a fracture in their lifetime. If they have a hip fracture, close to 30% of those patients die within a year and a vast majority of them will never return to the independent functioning they had prior to that hip fracture,” says Dr. Menn.

So many women think that if they eat enough vitamin D or take calcium supplements, they think that they won’t have bone loss but that’s simply not true points out Dr. Menn. “You can’t ignore the elephant in the room. Once you stop producing estrogen, you will have bone loss and need to take an all-hands-on deck approach with hormone replacement therapy (HRT) for those who are a good candidate for it plus weight bearing exercises and resistance training.

Dr. Menn is a proponent of HRT. “The FDA has approved estrogen for more than two decades for the prevention of bone loss and osteoporosis. One of the primary indications of HRT is for the prevention of bone loss. The FDA sets a very high standard to get a drug approved for the prevention of a disease. Even if a woman isn’t experiencing symptoms like hot flashes or night sweats, I still recommend it.”

“A lot of women assume they aren’t good candidates for hormone therapy but if a doctor says that, ask them, “why am I not a good candidate?” so they don’t lose out on the benefits of HRT for osteoporosis prevention,” she adds. Dr. Menn suggests seeing a specialist if you choose not to take HRT or are not a good candidate for it, as there are non-hormonal options for osteoporosis available.

Physical therapists can develop a supervised and safe strength training program for menopausal women. “Physical therapy used to be viewed as a tool for those suffering from an injury or people in the pre-or post-surgery phase but with people living longer, they are now using it on a semi-regular basis and for injury prevention,” notes Berliner.

DuBois agrees and also noted that she has many elderly female patients who stopped exercising during COVID. They were afraid to go to the gym, and they need to work on strength training with guidance. Those who are frail especially need a supervised tailored approach to an exercise program.

Many studies show that weight bearing exercises such as vigorous walking can improve osteopenia and osteoporosis. “Other exercises such as glute bridges, planks, squats and lunges are extraordinarily beneficial,” says Berliner. In addition to strength training, physical therapists work a lot on balance exercises for fall prevention with many of their elderly clients.

Part of the therapist’s job is to build a home exercise program that is realistic for each individual and addresses the client’s needs. “If a client says she only has 10 minutes to exercise at home, then I will build a short program tailored to her needs within that time frame,” says Berliner. She also suggests “exercise snacks” for time pressed individuals who may have trouble carving out 30 minutes of consecutive exercise, they can break up sessions into 10 or 15 minute chunks a few times a day.

“Although a diagnosis of osteopenia and osteoporosis can be alarming, we do have good solutions to address this,” says Dr. Menn. Acknowledging that other therapies such as acupuncture and functional medicine can help women at this stage or at other periods throughout their life, Berliner wants women to view PT as a way to meet their goals. “Whether you hope to get stronger, more flexible or have less pain, I am here to listen to you and I view myself as a tool to build you a program to help you achieve that. You are not alone –
let me help you to feel better,” sums up Berliner.