Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

In this article, we will explore the challenges menopausal and post-menopausal women face with knee pain and possible treatment options. Many women contact our office with knee pain challenges. They will tell us that they have led an active lifestyle for decades. They also have a long history of sports participation, and some have very physically demanding lines of work or jobs where they have to stand on their feet all day.

They also tell us about their knee pain and a somewhat lengthy medical history, including low back pain, chronic hip pain, ankle, and foot pain as well. Some women report an acute injury, a torn meniscus, while skiing, for instance. Some have knee pain because part or all of their meniscus was removed following a sports-related injury decades ago. Some will tell us about an even more extensive arthroscopic knee surgery history and the recommendation for a new surgery because their knee gave out suddenly and is causing them a lot of pain. This “giving out” or “knee-buckling” event followed a routine activity they enjoyed, such as a simple jog, a mountain hike, a pickleball or softball game, and, of course, tennis, and the front knee collapse and pain of the golfer.

We also hear from the women with significant and severe post-traumatic osteoarthritis in their knees from ACL sports-related injuries that occurred many years and decades ago. Some women had the ACL Rupture, the ACL reconstruction, and then the ACL Revision surgery. Some women then repeated this with an ACL re-rupture two or three years after the original, soccer or lacrosse, or other sport-related ACL rupture. Many women who contact us are still in their early 40s but tell us that they “walk like an old lady” and are plagued by swelling, limited or lost range of motion, and “bone on bone” knees. Further, some of these young women, in their 40s, are being prepped for total or partial knee replacement and are going down the checklist of Hyaluronic acid and cortisone injections and other knee pain conservative methods that will need to fail, so knee replacement at a young age can be justified. For many, an exercise bike or cycling is the last activity they can perform, and while many can enjoy this activity, it is the other activity that they want to return to. They are not confident in the knee replacement and its ability to get them back to the sport.

This article is a companion piece to our article Hormone replacement therapy and degenerative joint disease. In this article, we discuss:

• The controversies surrounding hormone levels and osteoarthritis.
• There is a connection between painkillers and hormone replacement therapy that makes the pain worse
• The role of estrogen in joint pain. Does estrogen deficiency make “bone on bone”?

More than simple knee pain.

An April 2025 study in the Indian Journal of Orthopaedics (1) compared pain perception between female and male patients, over the age of 50, with knee osteoarthritis. The researchers asked the patients to perform a series of physical activities and measured pain and functional response. They found in this study of  111 patients (50 males and 61 females), females had significantly more pain and stiffness than males following the measured physical activity. The researchers concluded that females experienced greater pain, stiffness, and reduced physical functions despite similar radiological knee osteoarthritis grading.

A March 2025 study (2) in the International Journal of Molecular Science looked at fluctuating perimenopausal estrogen levels, which often trigger a range of knee osteoarthritis symptoms. In this paper, researchers summarized earlier research in describing how knee osteoarthritis can be impacted by estrogen levels. “Changes in estrogen levels among perimenopausal women are closely linked to the onset of knee osteoarthritis, and decreased estrogen levels can trigger pain associated with knee osteoarthritis. Estrogen plays a protective role in maintaining bone and cartilage health, and reduced levels can lead to the degeneration of articular cartilage and contribute to the development of arthritis, worsening knee osteoarthritis.  Women tend to experience the onset of knee osteoarthritis at a younger average age compared to men, and the severity of their condition is often greater. Additionally, postmenopausal women make up a larger proportion of knee osteoarthritis cases.”

Obesity, inflammation, and joint pain

Many women will go to the orthopedist or physical therapist, and the sole focus of their treatment will be on the knee pain. A March 2018 study in the Public Library of Science One (3) suggested that doctors go beyond that. Here is what they wrote:

“Women without knee osteoarthritis tended to report increasing knee pain with increasing age. BMI (Body Mass Index – weight) is considered a significant controllable factor in knee pain in women, regardless of the presence of radiographic knee osteoarthritis. The presence of depressive symptoms may aggravate knee pain in women with knee osteoarthritis. Attention needs to be focused on concomitant musculoskeletal problems such as lumbar spinal and hip diseases in women with knee pain.”

What these doctors are suggesting is what we look for in our patients. Do they have a supportive family? Do they have hip and back pain as well? Treating a meniscus tear or some other abnormality as seen on MRI may not be sufficient in understanding knee pain in menopausal and post-menopausal women.

The problem with opioids

An October 2019 study in the Journal of General Internal Medicine (4) was published by doctors at the San Francisco VA Health Care System and the University of California, San Francisco. In this paper, these doctors examined the problem of opioid abuse in middle-aged women vets.

“Among midlife women Veterans with chronic pain, those with evidence of menopausal symptoms had increased odds of long-term opioids, high-dose long-term opioids, and long-term opioids co-prescribed with Central Nervous System depressants, independent of known demographic and clinical risk factors.” In other words, opioids are prescribed without clearly knowing the impact of these post-menopausal service veterans.

“Although rates of opioid use and opioid-related mortality have risen dramatically among midlife women over the past two decades, drivers of increased risk in this vulnerable population had not been previously identified.” In other words, prescriptions are being given, and there is no clear reason why, except for pain management beliefs.

“These findings raise the possibility that menopausal symptoms are an under-recognized indicator of risk among midlife women with chronic pain, influencing treatment decisions that enhance the risk for opioid-related disability and mortality. Safe and effective comprehensive care for midlife women with chronic pain should include recognition of the potential role of menopause in pain experience and management and the possibility that pharmacological treatments for menopausal symptoms may inadvertently put women with chronic pain treated with long-term opioids at increased risk for opioid misuse and overdose.”

Comment: In middle-aged women, there can be types of prescriptions at play, including those to help alleviate hormonal problems. It is not clear whether the combination of hormones and painkillers is causing more problems than they are helping. We address the complexity of this subject in our article: Hormone replacement therapy and degenerative joint disease.

Hormones and knee pain

In July 2017, researchers published in the journal Osteoarthritis and Cartilage (5) findings to suggest: “In women but not men, low serum levels of endogenous estradiol, progesterone and testosterone are associated with increased knee effusion-synovitis and possibly other osteoarthritis-related structural changes.”

The different types of diagnosed knee pain in the menopausal, post-menopausal woman

Many people who contact us have a very good understanding of what is going on in their knees beyond the umbrella term “knee pain.” In fact, the emails that we receive at our center are usually detailed and contain parts of an MRI report. This is generally an indication that this person has taken an active role in determining their knee pain treatments. It is equally indicative that they have taken a more active role out of frustration for lack of progress in getting help for their knee or a recommendation to a knee surgery that they do not want. Here are some of the more common diagnoses of knee pain and general thoughts.

Diagnosis of Iliotibial band syndrome – runner’s knee or jumper’s knee

We have a more extensive article on our website: Iliotibial band friction syndrome – Sports-related knee pain. We are presenting a summary of that article here

Women who do a lot of running and have knee pain may have been told that they have a “runner’s knee.” If you are involved in a sport where you do a lot of jumping or lunging, or upward motion, as in “jumping jacks you may have been told that you have a “jumper’s knee.”

For many women, the conservative care treatments (anti-inflammatories, rest, ice, physical therapy) can be helpful; the woman with a physically demanding job will have their immediate knee pain reduced. However, like most runners or active people, or people with demanding lines of work, you kind of get used to nagging knee injuries, and you always manage to work or get yourself through them as best you can.

There are a few theories of how Iliotibial Band Syndrome develops, but most are in agreement that there is a component of high or irregular compression forces between the iliotibial band and the lateral femoral condyle (the lower bony part of the thigh bone that connects to the shin bone), which causes the irritation and inflammation of the tissue. It is this location that also gives IT Band Syndrome, and it may be easier to understand the name “Runner’s Knee.” There are two distinct problems labeled “runner’s knee.” For problems that relate to Chondromalacia Patella – Patellofemoral Pain Syndrome, please see that article.

Diagnosis: Patellar Tendinopathy

We have a more extensive article on our website, Patellar Tendinopathy Surgery and Treatment Options. We are presenting a summary of that article here:

Treatment guidelines – Exercise and physical therapy

A 2020 study published in the Journal of Back and Musculoskeletal Rehabilitation (6) examined women with knee osteoarthritis, seeking to determine the impact of aerobic exercise on functional limitation, exercise tolerance, and other performance tests on the quality of life. To do this, researchers enrolled 50 women (aged between 48-78) with grade 2-3 knee osteoarthritis. Osteoarthritis-specific physical performance tests were then administered, including a fast walk pace test, a test for standing and walking after getting out of a chair, and a stair climb test. The women’s ability to perform these tests was then assessed. Then the women were divided into treatment or non-treatment groups. The treatment group received additional aerobic exercise training along with a combined physiotherapy program for six weeks. The aerobic exercise program was carried out by the same physiotherapist every weekday (five days) for six weeks. The control group only received a combined physiotherapy program for six weeks.

Results: The post-treatment comparisons of the two groups showed the exercise group had reduced pain and disability scores and performed better in the fast walk test. Consequently, this study provides an insight into the efficacy of the aerobic exercise program applied along with a combined physiotherapy program in postmenopausal women with knee osteoarthritis.

Treatment guideline – aquatic resistance training

All forms of exercise can be very beneficial. When research is published questioning the efficiency of a certain form of exercise, many people who benefited from it may write to us saying how much they were helped. A general rule is that if something is helping you and you know it is helping you, it is a good thing.

A June 2020 study in the Scandinavian Journal of Medicine and Science in Sports (7) conducted an analysis to study the effects four months of aquatic resistance training has on self-assessed symptoms and quality of life in postmenopausal women with mild knee osteoarthritis after the completion of the study and after a 12-month follow-up period.

• A total of 87 post-menopausal volunteer women, aged 60-68 years, with mild knee osteoarthritis, were recruited in a randomized, controlled, four-month aquatic training trial and randomly assigned to a control group or an exercise group. The exercise group participated in 48 supervised aquatic resistance training sessions over 4 months while the control group maintained their usual level of physical activity.

Results: After 4 months of aquatic resistance training, there was a significant decrease in knee stiffness scores in the aquatic resistance training group compared to the controls. After the aquatic resistance training was stopped, this benefit was no longer observed during the 12-month follow-up.

Conclusions: The results of this study show that participation in an intensive aquatic resistance training program did not have any short- or long-term impact on pain and physical function or quality of life in women with mild knee osteoarthritis. However, a small short-term decrease in knee stiffness was observed.

Treatment guideline – Bone Mineral Density and Osteoporosis in knee osteoarthritis

An August 2021 study in the journal BioMed Central Musculoskeletal Disorders (8) found that women who suffer from varus deformity (being bow-legged) were at greater risk for developing osteoporosis. Here are the summary learning points of this research:

• Varus deformity of the knee is a common pathological characteristic in knee osteoarthritis, and not enough attention has been given to the relationship between knee varus deformity and the state of systemic bone mass.
• The purpose of this study was to evaluate the potential relationship between bone mineral density and varus deformity in postmenopausal women with knee osteoarthritis.

What is being suggested are the important topics of bone mineral density and knee osteoarthritis. Now, let’s see how the connection was made to osteoporosis.

• A total of 202 postmenopausal women with more advanced arthritis were examined. Those women with varus deformity or bowed legs were compared to women who had normal limb alignment

Results: Bone mineral density within the knee varus deformity group was lower than that of the normal limb alignment group, and the prevalence of osteoporosis was higher. Osteoporosis should be a major risk factor for varus deformity in postmenopausal women with knee osteoarthritis.

Treatment guideline – Vitamin D

In our article Vitamin D and Knee Osteoarthritis, we cite several studies on the possible benefits of vitamin D supplementation for knee pain.

Doctors writing in the Archives of Osteoporosis (9) noted that:

• Low vitamin D status in knee osteoarthritis patients is often reported to be associated with increased pain and locomotor dysfunction (reduced ability to walk).
• Despite the growing evidence of the effect of vitamin D on the development and progression of knee osteoarthritis, vitamin D’s role remains conflicting. They concluded: “Vitamin D insufficiency may have an adverse effect on muscle power function.”

The effects of vitamin D supplementation on pain are controversial

In The Clinical Journal of Pain (10), researchers suggested:

• Because of the strong association between 25-hydroxyvitamin D levels and knee osteoarthritis pain, it is reasonable to think that vitamin D supplementation may help reduce pain associated with the condition.
• While some studies suggest that vitamin D does not regrow cartilage, vitamin D supplementation did improve physical function assessed by a timed 20-meter walk and chair-rise test. In another study, vitamin D supplementation in veterans was demonstrated to significantly decrease pain level, number of pain sites, use of pain medication, as well as improve sleep and health-related quality of life.
• The effects of vitamin D supplementation on pain in individuals with knee osteoarthritis are open to interpretation and warrant further investigation.

There is no general consensus on the effects of vitamin D on osteoarthritis; some results seem promising

As the above research points out, vitamin D does have a place in helping a patient with knee osteoarthritis. Vitamin D supplements are readily available, and food rich in vitamin D is plentiful. These include salmon, herring, and sardines, for non-fish lovers, spinach, and kale. Of course, sunshine helps a lot too.

A study in the Orthopaedic Journal of Sports Medicine (11) concludes on what vitamin D may do: “Some studies have investigated the effect of vitamin D on osteoarthritis progression and pain management; however, while there is no general consensus on the effects of vitamin D on osteoarthritis, some results seem promising. Vitamin D supplementation may be a safe method to treat and prevent osteoarthritis, but future research is required to define the specific pathway and ultimate efficacy.”

Treatment guideline – Prolotherapy

Comprehensive Prolotherapy to the knee involves multiple injections of a dextrose-based solution directed at the affected tendons, ligaments, and other affected structures of the knee. This causes a mild and localized inflammatory response, which triggers the immune system to initiate repair of the injured tendons and ligaments. Blood supply dramatically increases in the injured area. The body is alerted that healing needs to take place, and reparative cells are sent to the treated area of the knee that needs healing. The body also lays down new collagen in the treated areas, thereby strengthening the weakened structures. Once the tendons and ligaments are strengthened, the joint stabilizes, and the tendonitis or tendinosis condition resolves.

Platelet Rich Plasma Therapy is the use of a patient’s blood platelets and healing factors to stimulate the repair of a tendon. It is considered when tendon damage is more severe.

What causes osteoarthritis, and why Prolotherapy makes sense as a first-line treatment:

Ross Hauser, MD, explains why osteoarthritis develops in one joint and not another, why certain athletes who run get arthritis and others don’t, and why certain regenerative injection treatments may work better than others.

More articles

Prolotherapy Knee Injections : Prolotherapy is a non-surgical injection treatment that introduces small amounts of an irritant solution (simple dextrose) into the knee with the goal of helping the immune system rebuild the soft connective tissue of the knee ligaments and knee tendons to restore stability to the knee and alleviate pain and improve function. The research is well documented and will be presented below. Prolotherapy does not work for every patient.

Questions about our treatments?

If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

 

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References: 

1 Ratan R, Basak M, Pal D, Dwivedi M, Haq RU. Females with Knee Osteoarthritis have Greater Pain and Reduced Physical Function but Similar Radiological Grading at Presentation: A Cross-sectional Observational Study. Indian Journal of Orthopaedics. 2025 Apr 15:1-9. [Google Scholar]
2 Zhao H, Yu F, Wu W. The Mechanism by Which Estrogen Level Affects Knee Osteoarthritis Pain in Perimenopause and Non-Pharmacological Measures. International Journal of Molecular Sciences. 2025 Mar 7;26(6):2391. [Google Scholar]
3 Lee KM, Kang SB, Chung CY, Park MS, Kang DW, Chang CB. Factors associated with knee pain in 5148 women aged 50 years and older: A population-based study. Plos one. 2018 Mar 8;13(3):e0192478. [Google Scholar]
4 Gibson CJ, Li Y, Huang AJ, Rife T, Seal KH. Menopausal symptoms and higher risk opioid prescribing in a national sample of women veterans with chronic pain. Journal of general internal medicine. 2019 Oct;34(10):2159-66. [Google Scholar]
5 Jin X, Wang BH, Wang X, Antony B, Zhu Z, Han W, Cicuttini F, Wluka AE, Winzenberg T, Blizzard L, Jones G. Associations between endogenous sex hormones and MRI structural changes in patients with symptomatic knee osteoarthritis. Osteoarthritis and cartilage. 2017 Jul 1;25(7):1100-6. [Google Scholar]
6 Kilic F, Demirgüç A, Arslan SA, Keskin ED, Aras M. The effect of aerobic exercise training on postmenopausal patients with knee osteoarthritis. Journal of Back and Musculoskeletal Rehabilitation. 2020 Jan 1(Preprint):1-8. [Google Scholar]
7 Munukka M, Waller B, Häkkinen A, Nieminen MT, Lammentausta E, Kujala UM, Paloneva J, Kautiainen H, Kiviranta I, Heinonen A. Effects of progressive aquatic resistance training on symptoms and quality of life in women with knee osteoarthritis: A secondary analysis. Scandinavian journal of medicine & science in sports. 2020 Jun;30(6):1064-72. [Google Scholar]
8 Zhang C, Zhuang Z, Chen X, Li K, Lin T, Pang F, Zhang Y, He W, Wei Q. Osteoporosis is associated with varus deformity in postmenopausal women with knee osteoarthritis: a cross-sectional study. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-0. [Google Scholar]
9 Levinger P, Begg R, Sanders KM, Nagano H, Downie C, Petersen A, Hayes A, Cicuttini F. The effect of vitamin D status on pain, lower limb strength and knee function during balance recovery in people with knee osteoarthritis: an exploratory study. Archives of Osteoporosis. 2017 Dec 1;12(1):83. [Google Scholar]
10 Glover TL, Goodin BR, King CD, Sibille KT, Herbert MS, Sotolongo AS, Cruz-Almeida Y, Bartley EJ, Bulls HW, Horgas AL, Redden DT. A Cross-sectional Examination of Vitamin D, Obesity, and Measures of Pain and Function in Middle-aged and Older Adults With Knee Osteoarthritis. The Clinical journal of pain. 2015 Dec;31(12):1060-7. [Google Scholar]
11 Garfinkel RJ, Dilisio MF, Agrawal DK. Vitamin D and its effects on articular cartilage and osteoarthritis. Orthopaedic journal of sports medicine. 2017 Jun 20;5(6):2325967117711376. [Google Scholar]