During the transition through menopause, many women experience a decline in muscle mass and strength, especially after age 50 (Rathnayake et al., 2021; Tan et al., 2023). This change is often linked to lower estradiol levels, which may reduce satellite cell activity and increase inflammation in skeletal muscle (Menzies et al., 2026). Reduced estrogen is also associated with metabolic changes that may increase the risk of osteosarcopenia—the loss of both bone density and muscle mass—which can raise the risk of frailty (Nishikawa et al., 2021). Other factors, including anabolic resistance and chronic inflammation, can further limit muscle repair and protein synthesis (Tu et al., 2025; Zhang et al., 2023).
Still, menopause may not be the sudden “breaking point” for muscle loss that it was once thought to be. Long-term observational studies suggest that the average decline in lean mass during the menopausal transition may be more modest than previously expected. Even so, estrogen loss can reduce the muscle’s ability to repair and adapt. Estradiol signaling through ERα and ERβ helps regulate metabolism and activate satellite cells (Geraci et al., 2021; Li et al., 2025). It also supports the activity of Pax7 and MyoD, transcription factors involved in muscle cell renewal and adaptation (Gharahdaghi et al., 2021).
Muscle preservation in mid-life
Hormone replacement therapy may provide small benefits for muscle strength by reducing the activity of atrogenes, but the clinical evidence is mixed because studies have used different doses and treatment schedules (Nuccio et al., 2023). For this reason, nutrition and regular exercise remain key strategies during perimenopause, when fat gain often begins to accelerate (Smith‐Ryan et al., 2022). Maintaining muscle strength is especially important because low strength is linked to a higher risk of death from any cause in this population (Peyton et al., 2023).
Future studies should look beyond lean mass alone. They should also examine how hormonal changes affect sarcopenia risk compared with factors such as inactivity, aging, and anabolic resistance (Juppi et al., 2025; Shu et al., 2023). Starting resistance training during perimenopause may be particularly helpful, since waiting until several years after menopause could reduce some of the muscle and cardiovascular benefits of exercise (Hansen et al., 2025).
Increasing protein intake may help address the anabolic resistance often seen in older women. However, it is still unclear whether protein recommendations need to be adjusted according to menstrual-cycle phase. Resistance training can increase muscle mass in premenopausal women, but muscle growth may be smaller after menopause. Training volume and intensity may therefore need to be adjusted to account for age-related changes (Isenmann et al., 2023).
Peptides and collagen peptides may also support muscle and connective-tissue health by promoting extracellular matrix production and tendon integrity. This may help women tolerate the mechanical demands of continued resistance training (Viecelli & Ewald, 2022). Soy isoflavones combined with resistance training have also been shown to increase quadriceps cross-sectional area and maximal isometric strength.
In the long term, combining resistance training with regular aerobic exercise remains one of the best approaches for improving strength and physical function (Hu et al., 2025). Moderate- to high-quality evidence also suggests that supplements such as leucine-rich protein may improve grip strength and physical function more than exercise alone (Aragón-Espinosa et al., 2026; Mao et al., 2025). High-intensity resistance training can further improve bone and muscle density while reducing the risk of disability and injurious falls (Izquierdo et al., 2021). These combined approaches may even restore muscle health after periods of inactivity (Trezise et al., 2025).
Muscle-to-fat ratio as a predictor of longevity
The muscle-to-fat ratio may be a better indicator of metabolic health than BMI because it gives a clearer picture of changes in body composition linked to physical decline (Radaelli et al., 2021; Thomas et al., 2021). Higher levels of fat within muscle are associated with poorer muscle quality and weaker neuromuscular function, even when total muscle mass is relatively stable. High-intensity physical activity may help limit these age-related changes and preserve mitochondrial function (Grevendonk et al., 2021). Excess body fat can also weaken strength adaptations, so managing body weight while following a progressive resistance-training program may be the most effective way to improve muscle quality (O’Bryan et al., 2022).
Lifestyle changes
Lifestyle strategies for preventing sarcopenia should include an individualized protein plan and at least two resistance-training sessions per week at 60–80% of one-repetition maximum (Ma et al., 2025). Training should also include balance, mobility, and functional exercises to support physical resilience and quality of life (Shen et al., 2023). Anti-inflammatory dietary patterns and targeted supplements may provide additional support by helping control the inflammation associated with muscle loss (Araújo et al., 2025).
Supplements
Evidence for specific drug treatments remains limited. However, nutritional supplements may support resistance training by improving muscle mass and function. Leucine-rich protein may help stimulate muscle growth and reduce some of the metabolic barriers to strength gains in older women (Cacciatore et al., 2024). Omega-3 fatty acids may help regulate inflammation and support muscle protein synthesis, although their specific effects on sarcopenia are still uncertain (Palmer & Jensen, 2022). L-citrulline combined with high-intensity interval training may also support mitochondrial biogenesis and fusion, which could improve muscle quality in older adults (Burtscher et al., 2024).
Conclusion
Proactive management of sarcopenia necessitates a paradigm shift from passive observation to active intervention, focusing on the synergy between progressive resistance training and optimized protein intake (Fang et al., 2023; Wannamethee & Atkins, 2023). By identifying individuals at risk for malnutrition early and tailoring nutritional counseling to address specific dietary habits, clinicians can establish a robust foundation for long-term musculoskeletal resilience (Liu et al., 2023).
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