Chronic pain at midlife.

Abstract

Chronic pain disproportionately affects women and reproductive milestones influence its clinical manifestation. Mechanistic pathways underlying pain are determined by numerous biopsychosocial factors, the most important being age, hormonal changes and mental health. Menopause-related changes in estradiol interact bidirectionally with musculoskeletal degeneration, neuro-immune sensitization, neuroendocrine responses and other intrapersonal and socio-cultural vulnerabilities, collectively amplifying pain perception and maintenance. Approximately half of midlife women experience chronic pain often with overlapping chronic pain syndromes (e.g. fibromyalgia, migraine, chronic pelvic pain) requiring an integrated management approach. The menopausal transition may coincide with an increased vulnerability to pain and vasomotor symptoms, sleep disruptions, mood disturbances, brain fog and fatigue, which may contribute overall to the pain experience. Chronic pain is a major health issue that is often under-recognized, underdiagnosed and inadequately treated. The aim of the 2026 International Menopause Society White Paper is to provide an overview of the current evidence on the most common midlife chronic pain syndromes causing significant disability and impairing quality of life. This article provides an updated synthesis of chronic pain in menopausal women, encompassing its neurobiological mechanisms and clinical management, and the influence of cultural factors, lifestyle interventions and hormonal therapies. The goal of the White Paper is to raise awareness of midlife women's pain experience and to support clinicians and policymakers in implementing culturally sensitive, personalized approaches. A proactive attitude is essential to guide women through multidisciplinary pathways of care that reflect the multidimensional nature of chronic pain, with the ultimate goal of promoting healthy longevity and gender equity. Chronic pain is common in women and may become particularly challenging during the menopausal transition. Changes in hormones, aging, sleep, mood, lifestyle, and other biological, psychological and social factors can influence how pain develops and is experienced. However, chronic pain in midlife women is often under-recognized, underdiagnosed and inadequately treated.The 2026 International Menopause Society White Paper reviews current knowledge about chronic pain at midlife, focusing on conditions such as fibromyalgia, migraine and chronic pelvic pain. These conditions frequently overlap and may share underlying mechanisms involving changes in the nervous system, immune system, hormones, musculoskeletal health and pain processing. Menopausal symptoms such as sleep disturbance, fatigue, mood changes and hot flushes may further affect the experience of pain.Gender stereotypes and inequalities in healthcare may contribute to women’s pain being insufficiently recognized and addressed. Cultural factors may also shape the experience and management of pain. A better understanding of these factors is therefore important to improve equity in pain care.The 2026 White Paper highlights the need for personalized and multidisciplinary care that considers the different factors contributing to pain in each woman. Lifestyle interventions, hormonal and non-hormonal treatments, and appropriate pain-management strategies may all have a role, depending on individual circumstances.Further research is needed to better understand how menopause and chronic pain interact, identify women at greater risk and develop effective treatments. Recognizing chronic pain as an important component of midlife health may help improve quality of life, clinical care and healthy aging in women.