Strength Training & Perimenopause
When to Start, How to Start Safely, and What "Heavy" Actually Means. Written By Abi Jettner, Physiotherapist at Hatched House
Somewhere in your late 30s to 40s, the exercise advice changes; lift heavy weights.
It is a reasonable thing to feel unsure about. Heavy lifting has not historically been recommended to women in midlife, and for a long time it was actively discouraged for anyone with low bone density. That advice has changed, and it has changed because of good quality Australian research.
In short: loss of bone density does not begin at menopause. It begins roughly one year before your final period and is fastest over a three-year window either side of it, at around 2.5% per year at the spine. Strength training is the most effective form of exercise for protecting bone, but the load matters: research consistently shows low-intensity exercise does very little for bone, while training at 80–85% of your maximum, for around five to eight repetitions, twice a week, does. "Heavy" means a weight you could only lift a few more times with good technique, not a weight that feels unsafe. Most women should begin with eight to twelve weeks building technique before load, and anyone with existing pelvic floor symptoms, a fracture history, or diagnosed osteoporosis should start with supervision rather than avoidance.
Below, we answer the questions we hear most often from clients about strength training, perimenopause, and bone.
Why Does Perimenopause Affect My Bones?
Oestrogen is one of the main regulators of bone turnover. Bone is living tissue that is constantly being broken down and rebuilt, and oestrogen slows the breaking-down side of that equation. As oestrogen falls through the menopause transition, bone is removed faster than it is replaced.
The timing is the part most women are not told. The large, long-running Study of Women's Health Across the Nation followed women through the transition and found something specific: there is no measurable decline in bone density in the years leading up to the transition, loss begins about one year before the final menstrual period, runs rapidly for around three years, and slows — but does not stop — roughly two years after. Researchers named that three-year window the transmenopause. During it, women in the cohort lost an average of around 2.5% of bone density per year at the spine and 1.8% at the hip.
The consequence is straightforward. The fastest bone loss of a woman's life happens while she is still having periods, still being told she is "not there yet," and usually years before anyone suggests a bone density scan. The Australasian Menopause Society estimates that the average woman loses up to 10% of her bone mass in the first five years around menopause.
When Should I Start Strength Training in Perimenopause?
Start before the rapid loss phase begins, which in practice means your late thirties or forties, rather than waiting for a symptom, a diagnosis, or a scan result.
There are two reasons for this. The first is that you cannot recover bone as easily as you can protect it. Exercise is much better at slowing loss than reversing it, so the women who benefit most are the ones who enter the transition already strong and already loading their skeleton. The second is technical: heavy lifting requires a skill base. Building that base takes a few months, and it is considerably easier to learn deadlift and squat technique at 42 than to begin learning it at 62 with a T-score you are worried about.
If you are already in the transition, or through it, the answer does not change, it just becomes more urgent rather than less relevant.
Is It Too Late If I'm Already Postmenopausal?
No. The strongest evidence for high-intensity training and bone actually comes from postmenopausal women with already-low bone density.
The LIFTMOR trial, run at Griffith University and led by Professor Belinda Beck, recruited 101 postmenopausal women with low bone mass, average age 65. Half completed eight months of supervised heavy resistance and impact training twice a week, for thirty minutes, completing five sets of five repetitions at more than 85% of their maximum. The other half did a home-based, low-intensity program.
The training group gained 2.9% in spine bone density while the comparison group lost 1.2%. At the femoral neck (the top of the thigh bone), the training group essentially held steady while the comparison group lost 1.9% bone density. They also got measurably stronger, moved better, and gained slightly in height. Attendance averaged 92%, and across the whole trial there was one adverse event: a minor episode of lower back spasm.
That last detail matters, because the reason heavy lifting was withheld from this population for decades was a presumed fracture risk that the trial did not find.
What Are the Benefits Beyond Bone?
Bone tends to dominate this conversation, but it is rarely the benefit women notice first.
Resistance training preserves muscle mass and strength, both of which decline through midlife independently of how active you are. It improves balance and lower-limb power, which is what actually determines whether a stumble becomes a fall and whether a fall becomes a fracture. The Australasian Menopause Society notes that resistance training also lowers resting heart rate and blood pressure, and improves lean body mass alongside bone density.
Clinically, the change women report most often is a sense of capability returning, carrying, lifting, and moving through a day without negotiating with their body about it. That is not a trivial outcome, and it arrives well before any scan would show a change.
What Does "Heavy" Actually Mean… when we are told to lift heavy weight?
Heavy means a load you could manage for only a few more repetitions with good technique. It does not mean maximal, and it does not mean unsafe.
In the research, high intensity has a specific definition: around 80–85% or more of your one-repetition maximum, performed for roughly five to eight repetitions per set. In practical terms, if you finish a set of five and could comfortably have done ten, that is not a bone-loading stimulus, it is a fitness stimulus, which is worthwhile but different.
A useful way to judge it without formal testing is to work by repetitions in reserve. Aim to finish each set feeling you had about two good repetitions left. The final repetition should be genuinely effortful, your technique should not deteriorate, and you should not be holding your breath through it or gritting through pain.
For most women, this is heavier than they expect and heavier than the dumbbells they have been using, and still a long way from what they were imagining.
What Intensity and Load Does Bone Actually Need?
This is where the evidence is unusually clear, and it is worth being direct about it.
A comprehensive review of one hundred exercise trials in postmenopausal women found that low-intensity exercise was not an effective stimulus for bone at all. Moderate intensity produced modest benefit. High intensity produced the largest effect, and the combination of high-intensity resistance training with impact loading was the most effective of anything examined. The accompanying meta-analysis found the effect on spine bone density from high-intensity training was roughly two to three times that of low or moderate intensity training.
The same review also found that fewer than one in ten of the trials conducted had actually used high intensity protocols. For decades, we studied the intensity we assumed was safe rather than the intensity bone responds to.
Bone responds to strain that is large in magnitude, applied quickly, and unfamiliar. That gives three practical requirements:
Load. Progressive resistance training at 80% or more of maximum, for fewer than eight repetitions, with the load increasing as you get stronger. Exercises that load the hip and spine — squat, deadlift, overhead press variations — matter most, because those are the sites that fracture.
Impact. Landing forces, where appropriate. Jumping, hopping, skipping, stair descent, drop landings. Impact is the other half of the stimulus and is not interchangeable with load.
Novelty and progression. Bone adapts to what is unfamiliar. Doing the same weight for two years is, to your skeleton, the same as doing nothing new.
Exercise and Sports Science Australia's position statement on osteoporosis makes an additional point worth knowing: the women who see the greatest bone response are those with the lowest bone density or the least previous exposure to loading. If your bone density is currently average or better, the realistic goal through the transition is to protect what you have and build strength — not to expect a dramatic rise on a scan.
Isn't Walking Enough? What About Pilates, Swimming and Yoga?
Each of these is genuinely valuable, and none of them is a substitute for progressive load.
Walking is weight-bearing and excellent for cardiovascular and metabolic health, but if you have been walking for years it is no longer an unfamiliar load, so it provides very little osteogenic stimulus. Swimming and cycling, because they remove body weight from the skeleton, have little to no effect on bone.
Pilates and yoga develop control, mobility, balance and a strong foundation of technique, and balance work has its own independent role in fracture prevention: fewer falls means fewer fractures. Clinical Pilates is often the ideal place to begin, particularly if you are managing pelvic floor symptoms, back pain, or a long gap since you last trained. What it does not do, at the loads typically used, is generate the strain magnitude bone requires.
The most sensible position is not to choose. Use Pilates and balance work to build the platform and add progressive load on top of it.
How Do I Start Safely?
By spending the first eight to twelve weeks on technique and exposure, not on weight.
This is exactly how the LIFTMOR trial was run. The first month used body weight and light-load versions of each exercise, with the focus purely on learning the movement patterns. Every participant (women in their sixties with low bone density), was performing all four core exercises competently within two months. Safety in that trial came from progression and supervision, not from avoidance.
A reasonable pathway looks like this:
Get assessed first. A physiotherapist or exercise physiologist should screen for fracture history, pelvic floor symptoms, existing joint or back problems, and what your current capacity actually is.
Learn the patterns unloaded. Hip hinge, squat, press, pull, carry. Technique before load, every time.
Add load gradually, then keep adding it. Progressive means progressive. If the weight has not changed in six weeks, the program has stalled.
Train twice a week, thirty to forty minutes. Healthy Bones Australia recommends at least one full day of recovery between resistance sessions. Australia's physical activity guidelines recommend muscle-strengthening activity on at least two days a week as a baseline for all adults.
Layer in impact and balance once you are moving well. Both should progress to genuinely challenging, not stay comfortable.
Be supervised early. Australian guidance recommends supervised exercise for anyone with diagnosed osteoporosis, and it is a reasonable standard for anyone starting heavy lifting for the first time in midlife.
One specific caution from the ESSA position statement: loaded spinal flexion (weighted sit-ups, loaded forward bends, repeated or end-range rounding and twisting under load) is not recommended for people with low bone density. This is a technique consideration rather than a reason to avoid lifting.
How Long Before It Makes a Difference?
Strength and function change quickly. Bone does not.
You will likely notice strength gains within four to six weeks, largely from your nervous system learning to recruit muscle more effectively. Bone remodelling operates on a much slower cycle, and meaningful change on a DXA scan takes at least a year. Healthy Bones Australia suggests thinking in terms of six to twelve months of consistent training for bone benefit.
There is an important corollary: bone adaptation is not banked. If you stop training, the benefit is lost. This is best understood as something you take up rather than something you complete.
Is Lifting Heavy Safe for My Pelvic Floor?
For most women, yes, and for women with existing pelvic floor symptoms, it is a question worth answering properly rather than guessing at.
Heavy lifting raises intra-abdominal pressure, which is why the concern exists. Kari Bø's group in Norway tested this directly, measuring pelvic floor muscle strength, resting pressure and resting activity in strength-trained women before and after an hour of heavy squats and deadlifts. They found no significant change in any measure. They also found that how much a woman could squat or deadlift told you nothing about how strong her pelvic floor was. General strength and pelvic floor strength are separate capacities, which is precisely why both need training.
Two honest limitations. That study was conducted in young women who had not given birth and who were already experienced lifters, so it does not answer the question for a 47-year-old returning to training potentially numerous decades after two vaginal births. Research is now extending into parous women, but the evidence is still developing. And separately, stress urinary incontinence is genuinely common among female powerlifters and weightlifters, reported at rates between roughly a third and a half.
The reasonable reading of that is not that lifting damages the pelvic floor. It is that a high-pressure task will expose a pelvic floor that is not managing pressure well, in the same way running exposes a knee that is not tracking properly. The answer is assessment and training, not avoidance.
What If I Leak, or Feel Heaviness or Bulging?
These are reasons to be assessed, not reasons to stop.
Leaking with lifting, a sense of heaviness or dragging, bulging, or pressure that worsens through a session all indicate that pressure management needs attention. A pelvic health physiotherapist can assess pelvic floor function directly, look at how you are breathing and bracing under load, and modify your program in the meantime rather than pausing it. Bø's group has also trialled pelvic floor muscle training specifically in women who lift, including in functional fitness and strength sport populations.
What we would ask you not to do is quietly stop lifting, or quietly keep lifting while symptoms escalate. Both are common, and both are avoidable.
Do I Need a Bone Density Scan Before I Start?
Not to begin sensible strength training, no. But a scan is worth discussing with your GP if you have risk factors.
Those include a fracture after minimal trauma, a parental hip fracture, early menopause, long-term corticosteroid use, low body weight, coeliac disease or other malabsorption conditions, and certain medications and cancer treatments. In Australia, a DXA scan is Medicare-rebatable under specific criteria, which your GP can confirm for your situation. A scan is also genuinely useful as a baseline if you are entering the transition and want to track what happens next, rather than discovering the outcome a decade later.
Your decision to start strength training, though, does not need to wait on a scan result.
What If I Already Have Osteopenia or Osteoporosis?
Then progressive loading becomes more important, and supervision becomes non-negotiable.
This is the population LIFTMOR was designed for, and the finding was that appropriately progressed, supervised high-intensity training improved bone density and physical function without the adverse events that had been feared. Australian guidance recommends supervised programs delivered by a physiotherapist or exercise physiologist for anyone with diagnosed osteoporosis, with attention to fracture site, technique, and the spinal flexion caution above.
If you are on bone medication, exercise is complementary to it rather than an alternative. Both are worth having.
Will Strength Training Make Me Bulky?
No. Building substantial muscle mass requires years of specific, high-volume training and a sustained calorie surplus, and it becomes harder rather than easier as oestrogen declines.
What twice-weekly heavy training in perimenopause typically produces is preserved lean mass, more strength, and better function. Many women find their body composition shifts in ways they are pleased with, but the primary outcome is capability.
What Else Supports Bone Alongside Training?
Bone adaptation depends on having the raw materials available. The ESSA position statement is explicit that exercise programs for bone should be accompanied by sufficient calcium and vitamin D.
The Australasian Menopause Society recommends 1,300 mg of calcium daily for postmenopausal women, preferably from food and spread across the day. Vitamin D status is worth checking with your GP, particularly through a Victorian winter. Adequate overall energy and protein intake matters too. Under-eating while training heavily works against both bone and muscle. Reducing smoking and moderating alcohol both have independent effects on bone.
Menopausal hormone therapy also reduces bone loss, and whether it is appropriate for you is a conversation for your GP or a menopause specialist. It is not an either/or with exercise.
Supporting Women Through Perimenopause at Hatched House
We see the consequences of the gap in this advice regularly: women who did everything they were told, walked daily, attended their classes, and were never told that the fastest bone loss of their lives was already underway. We also see how quickly that changes when loading is introduced properly: with technique first, progression that continues, and pelvic floor symptoms addressed rather than worked around.
If you are in perimenopause and unsure where to begin, an assessment is the first step. We can screen your pelvic floor and musculoskeletal function, establish where your current capacity sits, and build a pathway from Clinical Pilates through to progressive loading that suits your body and your history.
References
Australasian Menopause Society. (2023). Maintaining your weight and health during and after menopause. https://www.menopause.org.au/health-info/fact-sheets/maintaining-your-weight-and-health
Australasian Menopause Society. (2024). Lifestyle and behavioural modifications for menopausal symptoms. https://menopause.org.au/health-info/clinical-guides
Australian Government Department of Health, Disability and Ageing. (2021). Physical activity and exercise guidelines for all Australians: Adults (18 to 64 years). https://www.health.gov.au/topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians/for-adults-18-to-64-years
Beck, B. R., Daly, R. M., Fiatarone Singh, M. A., & Taaffe, D. R. (2017). Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. Journal of Science and Medicine in Sport, 20(5), 438–445. https://doi.org/10.1016/j.jsams.2016.10.001
Bø, K., Lillegård, R. H., & Skaug, K. L. (2024). Pelvic floor muscle training on stress urinary incontinence in power- and weightlifters: A pilot study. International Urogynecology Journal, 35(6), 1291–1298. https://doi.org/10.1007/s00192-024-05801-8
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Greendale, G. A., Sowers, M., Han, W., Huang, M.-H., Finkelstein, J. S., Crandall, C. J., Lee, J. S., & Karlamangla, A. S. (2012). Bone mineral density loss in relation to the final menstrual period in a multiethnic cohort: Results from the Study of Women's Health Across the Nation (SWAN). Journal of Bone and Mineral Research, 27(1), 111–118. https://doi.org/10.1002/jbmr.534
Healthy Bones Australia. (2024). Exercise and bone health (2nd ed.). https://healthybonesaustralia.org.au/your-bone-health/exercise-bone-health/
Healthy Bones Australia. (2024). Exercise prescription to support the management of osteoporosis. https://healthybonesaustralia.org.au/wp-content/uploads/2024/02/hba-ex-presc-final-compressed.pdf
Kistler-Fischbacher, M., Weeks, B. K., & Beck, B. R. (2021). The effect of exercise intensity on bone in postmenopausal women (part 1): A systematic review. Bone, 143, Article 115696. https://doi.org/10.1016/j.bone.2020.115696
Kistler-Fischbacher, M., Weeks, B. K., & Beck, B. R. (2021). The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis. Bone, 143, Article 115697. https://doi.org/10.1016/j.bone.2020.115697
Skaug, K. L., Engh, M. E., & Bø, K. (2024). Acute effect of heavy weightlifting on the pelvic floor muscles in strength-trained women: An experimental crossover study. Medicine & Science in Sports & Exercise, 56(1), 37–43. https://doi.org/10.1249/MSS.0000000000003275
Skaug, K. L., Engh, M. E., & Bø, K. (2024). Pelvic floor muscle training in female functional fitness exercisers: An assessor-blinded randomised controlled trial. British Journal of Sports Medicine, 58(9), 486–493. https://doi.org/10.1136/bjsports-2023-107365
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