Perimenopause and after
Keep the training and its intensity, add heavy lifting with impact twice a week because bone loss starts about a year before the last period, keep protein at the sport target, and leave hormone therapy to her and her clinician: it treats symptoms and bone, kept no muscle in trials and is not a performance tool; no trial has studied trained endurance women
The question it answers
A woman who trains, usually in her 40s or 50s, reports symptoms she links to the menopause transition, or asks what she should change in training, food and recovery now, whether to take hormone therapy, or whether her changing periods mean she is under-fuelled. What does she keep, what does she add, what does she refer, and what can the assistant honestly say?
Short answer: keep the training and its intensity; add twice-weekly heavy lifting with impact, starting in the transition; keep protein at the sport target and fuelling intact; protect sleep; send symptoms that stop training, hormone therapy and changing bleeding to a clinician.
The assistant never diagnoses perimenopause or menopause, never advises on hormone therapy or any medication, and never explains every bad week by hormones.
What this guide owns and what it leaves
| Owns (decided here) | Leaves to |
|---|---|
| What changes in the transition that a coach can act on (bone, strength, symptoms), what to add (heavy lifting with impact, protein), what to refer | The menstrual cycle and contraception → SYNTH-37; pregnancy, the year after birth and leaking at any age → SYNTH-95 |
| Hormone therapy as a clinician's decision: what the base can and cannot say | Masters training load and recovery in general → SYNTH-35; strength programming → SYNTH-43, SYNTH-44; supplements → SYNTH-67 |
| A changing or missing period in the 40s | The REDs screen and weight loss → SYNTH-54; sleep → SYNTH-07; heat → SYNTH-04; bone-like pain → SYNTH-94, SYNTH-73 |
Default — the decision, in order (what to prescribe first)
Not from a study; the base's own practice for the order and every step not given a source:
Ask what she feels and what else changed before naming hormones. In 187 endurance athletes aged 40-60, sleep problems (88%) and exhaustion (83%) were the commonest symptoms, and joint and muscle discomfort, weight gain, sleep problems and exhaustion were the ones perceived to hurt training most; hot flushes (65%) were not among them (REF-731, B, self-report survey). Check load, sleep, fuelling and life before attributing a bad block to the transition (practice).
Keep the endurance training and its intensity. Keeping the intensity is the base's masters stance (SYNTH-35; practice); no trial in the base tests any change of training through the menopause transition in trained endurance women.
Add heavy lifting with impact, twice a week, from the transition on. Bone loss at the spine and hip starts about a year before the last period and is fastest for the next three years (REF-1404, B+, 862 women who were not athletes); in 101 postmenopausal women with low bone mass, 8 months of twice-weekly, 30-min supervised lifting at 5 sets of 5 above 85% of 1RM with impact training raised spine density 2.9 ± 2.8% against a 1.2 ± 2.8% fall with light home exercise (REF-1405, A-, abstract, aged 65 ± 5); bone answers impact and heavy loads, not riding or swimming hours (PHYS-37, established principle).
Starting in the transition rather than after it is the base's inference from REF-1404's timing; building up to those loads under a coach is practice.
Expect strength to keep responding. Free-weight training raised 1RM in middle-aged women whatever their menopause status, while muscle grew only before menopause at 6-8 sets a muscle a week, and the authors infer that more volume is needed after it (REF-523, B+, non-athletes); over 50, women gained more relative lower-body strength than men on identical programmes (REF-532, A), and loads of 70% of 1RM or more built more leg strength than lighter loads (REF-1086, A).
Protein at the sport target, toward its upper end, spread through the day; food intact. About 1.8 g/kg a day (SYNTH-69, B), the same requirement in endurance-trained women and men (REF-725, B+), 1.6-2.1 g/kg with the upper end in energy-restricted periods and for masters athletes, on account of anabolic resistance (REF-748, A; SYNTH-69 gives masters the same upper band) — the base holds no menopause-specific number (REF-582, C+: no sex-specific guideline).
Do not cut food against a weight change before the energy screen in SYNTH-54 (practice; the base holds no entry on body composition through the transition).
Heat: the same rules as for anyone (SYNTH-04); the base holds no study of exercise heat tolerance in peri- or postmenopausal athletes, so there is no menopause-specific heat rule (gap).
Symptoms that stop training, and hormone therapy, go to a clinician. Hormone therapy is the most effective treatment for hot flushes and night sweats and prevents bone loss and fracture, with the benefit-risk balance, for bothersome hot flushes and bone loss, favourable under 60 or within 10 years of menopause onset without contraindications, and treatment individualised (REF-1406, A, abstract); in randomised trials it did not keep lean mass (REF-1407, A-); no entry tests it for performance.
The assistant states this and neither recommends, discourages, doses, starts nor stops it.
A changing or missing period in the 40s is a doctor's question, not a label. Irregular cycles were the normal run-up to the last period, and most women were still early perimenopausal in the year their bone loss began (REF-1404); the energy-related cause, functional hypothalamic amenorrhoea, is largely a diagnosis of exclusion, made once pregnancy, thyroid and other causes are ruled out (REF-1399, A, written for premenopausal women); reading it as REDs or as "just menopause" by default is wrong either way (the base's inference).
Very heavy or prolonged bleeding → an iron check and a doctor (REF-573, B; PHYS-36).
When to see a clinician
None of these is a diagnosis; each goes to a doctor (a GP or a menopause clinic) or the named professional:
Decision table by stage
"(practice)" marks a call that is not from a study; the base's own practice. Every training and nutrition row transfers from non-athletes.
| Stage or question | What changes (evidence) | Train | Eat | Ask | Refer |
|---|---|---|---|---|---|
| Early perimenopause: cycles starting to change | Bone loss had not started 1-5 years before the last period (spine −0.02% a year), and most women were still classed as early perimenopausal in the year it began, so bleeding patterns did not signal it (REF-1404, B+) | Keep the intensity (SYNTH-35; practice); start heavy lifting with impact now (inference from REF-1404; the tested shape is REF-1405) | Protein at the sport target (SYNTH-69); food intact (practice) | Sleep, exhaustion, joints and weight first (REF-731); bleeding pattern | Very heavy or prolonged bleeding → iron and a doctor (REF-573); missed periods with weight loss or a hard block → SYNTH-54 and a doctor (REF-1399) |
| From a year before to two years after the last period | Fastest loss: spine −2.46% and femoral neck −1.76% a year; 7.38% of the spine's 10.6% ten-year loss falls in these three years (REF-1404, B+, women not using hormone therapy at entry) | Twice-weekly heavy lifting with impact (REF-1405, A-; PHYS-37); strength still rises (REF-523, B+) | Do not diet against a weight change before the screen (SYNTH-54; practice) | Hot flushes, night sweats, sleep, mood | Symptoms that stop training → a GP or menopause clinic (REF-1406; practice) |
| Postmenopause | Loss slows but does not stop: about 1.1% a year at the spine and hip from 2 to 5 years after the last period (REF-1404) | The same; for muscle, more weekly sets than 6-8 a muscle (the authors' inference in REF-523) | The same; creatine optional for muscle (REF-530, B+, narrative), not for bone (see the creatine row) | Leaking, joint pain | Leaking → a pelvic-health physiotherapist (SYNTH-95) |
| Known low bone mass or osteoporosis | Supervised 5 sets of 5 above 85% of 1RM with impact, twice a week for 8 months: spine +2.9 ± 2.8% vs −1.2 ± 2.8%, femoral neck +0.3 ± 2.6% vs −1.9 ± 2.6%, one minor adverse event (a back spasm) (REF-1405, A-, abstract, 65 ± 5 years, T-score below −1.0) | That programme's shape, built up under a qualified coach (practice; tested only supervised) | — | Past fractures, the doctor's view | The doctor's agreement before heavy loading (practice) |
| "I'm a cyclist or swimmer — are my bones at risk?" | Adult road cyclists had low spine density; road cycling does not appear to build bone (REF-896, A-); bone answers impact and heavy loads (PHYS-37) | Lifting with impact outside the sport (practice; PHYS-37's own line; the dose shape is REF-1405) | — | Previous fractures; any impact sport | A doctor for a bone-density question (practice) |
| "Should I take HRT? Will it help my performance or keep my muscle?" | Most effective treatment for hot flushes and night sweats; prevents bone loss and fracture; benefit-risk favourable for these under 60 or within 10 years of menopause onset without contraindications, less favourable later (REF-1406, A, abstract); users lost 0.06 kg less lean mass than controls (95% CI −0.05 to 0.18), no evidence of a difference (REF-1407, A-, 12 RCTs, low certainty) | Training is the lever for strength and muscle (REF-523; REF-1086) | — | — | Her decision with her clinician; the assistant neither recommends nor discourages it (practice) |
| "I've put on weight around the middle" | No entry in the base measures body composition through the transition; weight gain was among the symptoms perceived to hurt training (REF-731) | Keep lifting; it is the muscle lever (REF-523) | No deficit before the REDs screen and the conditions in SYNTH-54 (practice) | Sleep, alcohol, load, food (practice) | A dietitian for a weight goal (practice) |
| "Creatine for my bones?" | Not a bone treatment: a 2-year RCT in 237 postmenopausal women and a meta-analysis of 5 RCTs, neither in the base (Chilibeck 2023, Forbes 2018), found no effect on bone density (the RCT reported better femoral-neck geometry, a marker); the narrative claim of a bone benefit is REF-530 (B+) | Loading is the bone stimulus that was tested (REF-1405) | Creatine for muscle is optional (SYNTH-67) | — | — |
| Hot days, hot flushes, night sweats | No study in the base of exercise in the heat in peri- or postmenopausal athletes; no entry tests whether training changes hot flushes | The same heat rules as anyone (SYNTH-04) | Fluids as usual (SYNTH-68) | Night sweats with fever or weight loss | Night sweats with fever or weight loss → a doctor, not put down to the transition (practice); bothersome flushes → a clinician (REF-1406; practice) |
Key Findings — what the evidence shows
Bone loss is timed to the last period. In 862 midlife women followed with yearly scans from 5 years before to 5 years after the final period, loss began about a year before it and slowed, without stopping, two years after; the spine lost 10.6% and the femoral neck 9.1% over the 10 years; higher body mass went with slower loss (REF-1404, B+, not athletes, density not fractures).
Heavy lifting with impact raised bone density. LIFTMOR's supervised 5 × 5 above 85% of 1RM with impact, twice a week for 8 months, raised spine and femoral-neck density against light home exercise and improved every functional test, with one minor adverse event (REF-1405, A-, abstract, 101 women aged 65 ± 5 with low bone mass).
In adults over 50, loads of 70% of 1RM or more built more leg strength than lighter loads with no difference in bone density (REF-1086, A) — a different comparison, with no impact component. Road cycling does not appear to build bone (REF-896, A-; PHYS-37, established).
Strength still responds after menopause. 1RM rose in every group of middle-aged women; muscle mass grew only before menopause at 6-8 sets a muscle a week (REF-523, B+); over 50, women gained more relative lower-body strength than men (REF-532, A).
Hormone therapy is a clinical treatment for symptoms and bone. Most effective for hot flushes, night sweats and the genitourinary syndrome; prevents bone loss and fracture; its risks depend on type, dose, duration, route, timing and progestogen; individualised and re-evaluated (REF-1406, A, abstract; the grades are in its full text, unread).
Hormone therapy did not keep muscle. In 12 RCTs (4,474 women, mean age 59.0), women on hormone therapy lost 0.06 kg less lean mass than controls (95% CI −0.05 to 0.18; I² 0%), with no subgroup by type, dose, duration or time since menopause differing; low certainty, half the trials at high risk of bias, signs of publication bias (REF-1407, A-). Strength, power and endurance were not tested.
What athletes report. Sleep problems 88%, exhaustion 83%, hot flushes 65%; joint and muscle discomfort, weight gain, sleep problems and exhaustion perceived to hurt training most; severity like the general population's (REF-731, B, 187 endurance athletes aged 40-60, self-report).
A missing period is worked up, not assumed. The 2025 Triad guideline treats functional hypothalamic oligo/amenorrhoea, the energy-related cause of missing or infrequent periods, as largely a diagnosis of exclusion and covers girls and premenopausal women only (REF-1399, A); in the transition, irregular bleeding preceded the final period in most women (REF-1404).
It does not show: any training, recovery or nutrition trial through the menopause transition in trained endurance women; the bone response of athletes, of perimenopausal women or of women with normal density to heavy lifting with impact (REF-1405); fracture outcomes; whether hormone therapy changes strength, endurance or training response; whether exercise changes hot flushes or menopausal sleep; heat tolerance in peri- or postmenopausal athletes; how body composition changes through the transition; recovery by menopausal status.
Conflicts and how they are resolved
Practical Application — how the assistant says it
What NOT to do
Evidence gaps
Limitations
How this entry was checked and changed
(the direction — load bone with heavy lifting and impact, start in the transition, expect strength to keep responding, and refer symptoms and hormone therapy — rests on an A- randomised trial of heavy lifting with impact REF-1405, an established principle PHYS-37, a B+ cohort that times the bone loss REF-1404, A and B+ resistance-training evidence after 50 and after menopause REF-532 REF-1086 REF-523, an A position statement REF-1406 and an A- meta-analysis of hormone therapy and lean mass REF-1407. Held at B, not higher, because every one of them is in women who are not athletes, mostly older or with low bone mass, no trial has studied training or nutrition through the transition in trained endurance women, the timing of the bone work is the base's inference from a cohort, the protein number transfers from general endurance athletes SYNTH-69 REF-725, and the intensity stance, the sleep, heat and weight handling and the referral lines are the base's practice)