Pilates for women over 40: strength, bones and the pelvic floor, perimenopause, how often, the evidence, and a class

Pilates suits your 40s, as one part of the week

The NHS lists Pilates among the activities that strengthen muscles, and it builds control, trunk and hip strength and flexibility. On its own it adds little muscle and hasn't been shown to build bone, so pair it with load you keep increasing, a little impact if it suits you, brisk walking and daily pelvic floor exercises. NICE (the National Institute for Health and Care Excellence) asks clinicians to explain "the importance of maintaining muscle mass and strength through physical activity" around the menopause.

Sources 1, 2, 3

What changes from 40 is real, and gradual

Through the menopause transition, the rate of fat gain doubled and lean mass dipped slightly in 1,246 US women, while weight rose a steady 0.25 kg a year. Finnish women lost some muscle through the transition, and the more active kept more. Bone loss sped up from about a year before the final period.

Sources 4, 5, 6

The Pilates trials in midlife women are few and small

No trial has recruited women in perimenopause only, and one registered trial hasn't reported. In women after the menopause, 6 to 8 weeks of Pilates lowered self-rated symptom scores against no exercise (30 to 74 women, unblinded), and did no better than aerobic exercise.

Sources 7, 8, 9, 10, 11, 12

Pilates hasn't been shown to build bone; heavier lifting and impact have

Pooled Pilates trials found no significant change in bone density. In the one head-to-head trial, 8 months of supervised heavy lifting and impact raised spine density 1.9% against 0.1% with a Pilates-based programme, in 115 women with low bone mass.

Sources 13, 14, 15

Your pelvic floor needs its own training

Pelvic floor muscle training made a cure of stress leaking about 8 times more likely than no treatment, and NICE recommends at least 3 months of supervised training first. Pilates on its own isn't that training: it helped as much only when women squeezed deliberately during it.

Sources 16, 17, 18, 19

Hot flushes: exercise hasn't been shown to stop them

A Cochrane review and two large trials found no reliable effect on hot flushes, though exercise does ease low mood and anxiety a little. NICE recommends HRT (hormone replacement therapy) for flushes, with menopause-specific CBT (cognitive behavioural therapy) as an option.

Sources 20, 21, 22, 23, 2

Perimenopause and the menopauseStrong evidence

The NHS says: "Perimenopause happens when your periods become irregular and menopause is when your periods stop altogether." It "usually affects women between the ages of 45 and 55, but it can happen earlier", and symptoms "usually last for 7 to 9 years, sometimes longer". For most women, the 40s are the perimenopause years. It's still possible to get pregnant, so the NHS says you still need contraception. Our Pilates for menopause guide covers this stage in depth.

Sources 24, 25

Muscle changes slowlyStrong evidence

On MRI (magnetic resonance imaging) scans of 468 adults, muscle mass didn't fall noticeably until about 50, and the loss was mostly in the legs. Through the menopause transition, lean mass dipped by about 0.2 kg in 1,246 US women; in 234 Finnish women aged 47 to 55, muscle fell through the transition, and physical activity went with keeping more. The UK guidelines put the natural decline in muscle and bone "from around 50 years of age".

Sources 26, 4, 5, 3

Fat and weightStrong evidence

In the same US study, "At the start of the MT, rate of fat gain doubled, and lean mass declined" (MT is the menopause transition): fat gain went from about 1% to 1.7% a year. Weight rose a steady 0.25 kg a year, with no speed-up at the menopause.

Source 4

Bone loss speeds up around the final periodStrong evidence

In 862 women, the spine lost 10.6% of its density over 10 years, and 7.38% of that went in the years from about one year before the final period to two years after it. That's why the 40s are a good time to build the habits that load bone, rather than waiting for a scan (our reading).

Source 6

Leaking is common, and treatableStrong evidence

About 3 in 10 Norwegian women aged 40 to 64 reported some leaking, mostly slight, and stress leaking (when you cough, sneeze, lift or jump) was commonest in the 40s. Pelvic floor training treats it well (below).

Sources 27, 28, 16

Why Pilates alone isn't enough at this ageEmerging evidence

The NHS says Pilates focuses on balance, posture, strength and flexibility, and is suitable for all ages. On a mat the load is your body weight; on a reformer, springs. Neither gets harder by itself over the weeks, and muscle and bone respond to load that keeps rising and to impact: higher-intensity exercise did more for the spine after the menopause across 53 trials, and impact with resistance work did best before it. The Royal Osteoporosis Society describes gradually heavier strength exercise and moderate impact, if they suit you.

Sources 29, 30, 31, 32, 33

Very few are in women in their 40sStrong evidence

Of 12 studies in a 2026 review of Pilates in adult women (about 540 women), only about 5 were in women of roughly 37 to 59, and the authors say the "findings warrant cautious interpretation given heterogeneity in study design, intervention protocols, and methodological quality". We found no Pilates trial in women in perimenopause only; one registered trial in women over 40 hasn't reported.

Sources 34, 7, 8

Menopause symptom scores: lower, in small studiesMixed evidence

Against no exercise, 6 to 8 weeks of Pilates lowered self-rated menopause symptom scores in women after the menopause. The largest, a Korean study of 74 women aged 45 to 60, had unequal groups (45 and 29) that weren't matched at the start, and a review classes it as non-randomised. A Turkish trial of 30 women also improved quality of life and sexual function scores, and a Turkish trial of 40 women doing online Pilates lowered the total score but "had no significant effect on urogenital symptoms or sexual quality of life". Women rated their own symptoms and knew which group they were in.

Sources 9, 34, 10, 11

No better than aerobic exerciseEmerging evidence

In 30 women, 8 weeks of clinical Pilates did no better than aerobic exercise for symptoms, mood, sleep or quality of life: "No significant between-group differences were observed".

Source 12

Quality of life: some areasEmerging evidence

Across 11 trials in women after the menopause, Pilates improved 5 of 9 areas of quality of life (bodily pain, physical functioning, social functioning and two role scores), more with 48 or more sessions and with equipment, but "no analysis showed high certainty of evidence".

Source 35

Sleep and mood: unclear for Pilates itselfMixed evidence

Pooled, Pilates "showed no significant impact on sleep quality for healthy individuals over 40 years old and for postmenopausal women" (6 trials), and in 108 Iranian women aged 40 to 60, 6 weeks did no better than the control group. In 53 Greek women before the menopause (not randomised), insomnia scores improved with 16 weeks of Pilates. Mind-body exercise more widely (11 trials, 1,005 women, 3 of them Pilates trials) improved sleep, anxiety, low mood and tiredness.

Sources 36, 37, 38, 39

Leaking: one small trialEmerging evidence

In 53 Korean middle-aged women with urinary symptoms, 8 weeks of Pilates on a mat or with a foam prop eased symptom scores against a control group. Pelvic floor training has much stronger evidence (below).

Source 40

Weight and waistEmerging evidence

Pilates trials in women found small drops in weight (about 4 kg) and body mass index against no exercise, but no change in body fat percentage, waist or lean mass. In 18 Korean women with obesity, a Pilates circuit and a weight circuit lost similar weight over 8 weeks, which the authors say "should be interpreted cautiously due to the exploratory design and small sample size". Our Pilates for belly fat guide explains why no move takes fat off one place.

Sources 34, 41

What each buildsEmerging evidence

In 60 Spanish women aged 60 to 80, Pilates did better on held (isometric) hip and trunk strength, and resistance training on strength through movement; lean mass rose in both. In older adults overall, Pilates wasn't better than other exercise for strength (24 trials). Pilates builds control and trunk endurance; load builds strength.

Sources 42, 43, 44

The head-to-head trialStrong evidence

In MEDEX-OP, 115 women with low bone mass (average age 63.6) trained twice a week for 8 months. Supervised heavy lifting and impact raised spine bone density 1.9% against 0.1% with a low-intensity Pilates-based programme, and built more leg and back strength; both groups improved in everyday function. The LIFTMOR trial found the same pattern (2.9% up against 1.2% down, 101 women). Both trials come from one Australian group and were in women after the menopause with low bone mass.

Sources 15, 45

Free weights around 50Emerging evidence

In a small German study, 10 weeks of free-weight training twice a week raised squat and bench press strength in all groups of women around 52, with no injuries. "Hypertrophy effects were found exclusively in pre-menopausal women" (muscle grew only before the menopause), and the authors suggest more sets afterwards. It had no separate control group. Across 12 trials after the menopause (452 women), resistance training improved function with no serious adverse events, though the certainty was very low to low.

Sources 46, 47

How heavy, and how oftenStrong evidence

The Royal Osteoporosis Society says: "Try to do 8 to 12 repetitions of each activity." If you can't do 8 with good technique, use a lighter weight; if you can do 12 and keep going, a heavier one; build up to 3 sets. The NHS asks for strengthening activities that work all the major muscle groups on at least 2 days a week, and the UK guidelines say strength work "should be considered as important as achieving 150 minutes" of moderate activity.

Sources 32, 1, 3

Doing both

Pilates can count as a strength day if you make it hard enough; weights or bands on the other, or our class below, which puts both in one session. The UK guidelines say strength training in middle age is "particularly important for adults at the upper end of the 19 to 64 age range". Our Pilates for strength guide shows how to make Pilates harder, and our guide to building muscle over 40 covers weights.

Source 3

Pilates on its own: no change in bone densityEmerging evidence

Across 3 trials of 6 months or more in women after the menopause, Pilates didn't significantly change bone density, and in 591 women aged 45 to 78, Pilates or yoga didn't either. The trials were few and mostly low in quality. A 2026 review of leisure activities, including Pilates, found no significant rise in bone density after the menopause, "yet may help maintain bone mass".

Sources 13, 14, 48

Heavier lifting and impact: the stronger recordStrong evidence

In two trials in women after the menopause with low bone mass, supervised heavy lifting and impact raised spine density (MEDEX-OP and LIFTMOR, above). Across 53 trials after the menopause, higher-intensity exercise did more for the spine than low or moderate intensity, though not for the hip.

Sources 15, 45, 30

Before the menopause: a littleMixed evidence

In trials before the menopause, exercise raised hip and spine bone density a little, and impact combined with resistance work did best. A 2026 analysis found no significant effect in its two trials before the menopause (112 women). So in your 40s, build the habit without expecting a big change on a scan.

Sources 49, 31, 50

Impact, if it suits youStrong evidence

The Royal Osteoporosis Society says to "Aim to build up to 50 moderate-impact exercises on most days of the week", such as jumps, skips or hops, and that "Most people with osteoporosis can exercise safely." Heel drops are an easy way to start (our suggestion). If you leak or have a prolapse, train your pelvic floor first and bring impact in gradually. Our Pilates for osteoporosis guide covers bone in depth.

Sources 33, 51

Train it directlyStrong evidence

Women with stress leaking who did pelvic floor muscle training "were eight times more likely to report cure" than women who had no treatment (56% against 6%; high-quality evidence). NICE recommends a trial of supervised training of at least 3 months as the first treatment for stress or mixed leaking, with "at least 8 contractions performed 3 times per day".

Sources 16, 17

Pilates isn't the same thingEmerging evidence

In a 2026 Brazilian trial, "Pelvic floor muscle training was superior to Pilates in reducing the impact of urinary incontinence and improving pelvic floor muscle function, regardless of the inclusion of voluntary pelvic floor muscle contraction." In 40 women after the menopause with stress leaking, Pilates matched pelvic floor training (except for strength) only when women squeezed their pelvic floor during it. A Cochrane review found direct pelvic floor training did better than general exercise without squeezes (low certainty).

Sources 18, 19, 52, 53

Squeeze first, then moveEmerging evidence

In 20 women, a direct pelvic floor squeeze lifted the pelvic floor 11.2 mm against 4.3 mm with a deep tummy draw-in, and 30% pushed the pelvic floor down with the draw-in. In another 20, core and plank positions raised pelvic floor activity, and "No position inhibited a conscious contraction". Pilates mat and reformer moves raised pressure inside the abdomen no more than standing up from a chair; only roll-ups held it longer.

Sources 54, 55, 56

Lifting and impact are allowed, built up graduallyEmerging evidence

In MEDEX-OP, 8 months of heavy lifting and impact didn't worsen pelvic floor quality of life against Pilates-based exercise in women after the menopause with low bone mass, and in 47 young women who lift, an hour of heavy squats and deadlifts didn't change pelvic floor function. That reassurance rests on these two studies. Athletes do leak more ("female athletes are about three times more likely to have urinary incontinence compared to controls"), and the evidence on hard exercise and prolapse is inconsistent. So train the pelvic floor first, squeeze before each lift or landing, and build up.

Sources 57, 58, 59, 60

Hot flushes: not shownStrong evidence

A Cochrane review found "no evidence was found of a difference between groups in frequency or intensity of vasomotor symptoms" (hot flushes and night sweats), and a UK trial of 261 women concluded that "women should not be advised that exercise will relieve their vasomotor menopausal symptoms". Twelve weeks of aerobic exercise didn't ease flushes in 248 US women either.

Sources 20, 21, 22

One strength trial is the exceptionEmerging evidence

In 58 Swedish women after the menopause, 15 weeks of resistance training 3 times a week cut moderate to severe flushes by 43.6% against 2.0%. The difference was still there at 6 months but "not maintained after two years". Our Pilates for menopause guide covers the Pilates studies of symptoms.

Sources 61, 62

Low mood, anxiety and sleep: a littleEmerging evidence

Across 21 trials, physical activity eased low mood and anxiety in women around and after the menopause, and low to moderate intensity helped. Exercise eased how bad insomnia was, but not overall sleep quality.

Sources 23, 63

What treats hot flushesStrong evidence

NICE recommends HRT for hot flushes and night sweats, with menopause-specific CBT as an option. Talk to your GP about what suits you; our Pilates for menopause guide has more.

Sources 2, 64

Osteoporosis or a past spinal fracture

Swap the hundred, curl-ups, roll-ups and rolling moves for head-down versions, and bend from your hips rather than rounding your back; the move pages and our Pilates for osteoporosis guide explain which moves to keep. The Royal Osteoporosis Society says "Most people with osteoporosis can exercise safely." Most women in their 40s don't know their bone density, and without a diagnosis you don't need these swaps.

Source 51

A prolapse, or leaking

Train your pelvic floor first, bring impact in gradually and keep lifts lighter until you're confident, as the heel drop and Romanian deadlift pages say. If you feel heaviness, dragging or a bulge, ease off and get checked (below).

Pregnancy

The NHS says: "It's possible to get pregnant during perimenopause. You still need contraception". If you're pregnant, follow the move pages' pregnancy notes, and see our Pilates in pregnancy guide.

Source 25

High blood pressure

Breathe out on each effort and don't strain against a held breath, as the squat and deadlift pages say. Our Pilates for high blood pressure guide has more.

Hot flushes in class

Light layers, a fan and a cold drink help, and stopping to cool down is fine (our suggestion).

After a hysterectomy

Follow your surgical team's advice on when to start, and see our Pilates after a hysterectomy guide.

Contact your GP if

The NHS suggests contacting your GP if:

• you think you have symptoms of menopause or perimenopause and want to know your options
• you have a fast or noticeable heartbeat (palpitations)
• you still have periods but you're bleeding more than before, not less
• you have any vaginal bleeding 12 months or more after your last period

Source 25

Palpitations

A faster or more noticeable heartbeat is a common symptom around the menopause. If palpitations come with chest pain, breathlessness or fainting, use the 999 lines below. An irregular pulse can be atrial fibrillation, which our Pilates for atrial fibrillation guide covers.

Sources 25, 65

Bleeding after the menopause

See a GP about any bleeding from the vagina after your menopause, even if it's only a small amount or has only happened once. It's not usually serious, but it needs checking, and you shouldn't have to wait more than 2 weeks to see a specialist.

Source 66

A bulge or heaviness

See a GP if you have a lump in or around your vagina or other signs of prolapse, such as heaviness or pressure. With prolapse, the NHS advises avoiding activities that strain the pelvic floor, like heavy lifting, running and trampolining.

Source 67

Leaking

If leaking isn't improving, see a GP or a pelvic health physiotherapist: NICE recommends supervised pelvic floor training for at least 3 months first.

Source 17

Leaking when you lift or jump

If you leak when you lift or jump, keep exercising, lighten or change what sets it off, and see a GP or pelvic health physiotherapist; if you feel a bulge or heaviness, get checked before heavy lifting or running.

Sources 59, 16, 17, 68

Chest pain or fainting while exercising: call 999

Call 999 if:

• You get sudden pain or discomfort in your chest that doesn't go away; it can feel like squeezing or pressure, burning or indigestion.
• The pain spreads to your left or right arm, or your neck, jaw, stomach or back.
• You have chest pain and feel sweaty, sick, light-headed or short of breath.
• Someone faints while exercising, can't be woken within 1 minute, or has chest pain or a pounding, fluttering or irregular heartbeat.

Sources 69, 70, 71

Unusual breathlessness

Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.

Source 72

Stop the session if

You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.

Source 29

Before you start

The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.

Source 29

"After 40 you should stick to gentle exercise"Emerging evidence

Supervised heavy lifting and impact raised spine bone density in women after the menopause with low bone mass, with one minor back spasm in 101 women, and beat a Pilates-based programme for bone and strength. Harder programmes did more for the spine across 53 trials, and women around 52 lifted free weights with no injuries. Build up gradually.

Sources 45, 15, 30, 46, 3

"Pilates builds bone"Emerging evidence

Pooled trials found no significant change in bone density with Pilates; heavier lifting and impact did more.

Sources 13, 14, 15

"Heavy weights and jumping will ruin your pelvic floor"Emerging evidence

Eight months of heavy lifting and impact didn't worsen pelvic floor quality of life in one trial in women after the menopause, and an hour of heavy lifting didn't change pelvic floor function in young lifters. But athletes leak more, and with a prolapse the NHS advises avoiding heavy lifting, running and trampolining. Train the pelvic floor first and build up.

Sources 57, 58, 59, 67

"Pilates is pelvic floor training, so you don't need the squeezes"Emerging evidence

Pelvic floor training beat Pilates, with or without squeezes, in a 2026 trial, and it cures stress leaking far more often than doing nothing. Pilates matched it only when women squeezed deliberately.

Sources 18, 16, 19

"Pilates balances your hormones, so the menopause weight comes off"Emerging evidence

Pilates trials in women found small drops in weight and no change in waist or body fat, so there's no sign of a hormone effect on weight. Our workout plan for women over 40 explains why short rises in the stress hormone cortisol after hard exercise are normal.

Source 34

"Exercise will stop your hot flushes"Strong evidence

Exercise hasn't been shown to reduce them. One strength training trial is the exception, and its effect had gone by 2 years. HRT and CBT are the treatments NICE recommends.

Sources 20, 21, 61, 62, 2

"It's too late to change much after 40"Emerging evidence

Free-weight training raised strength in women around 52, resistance training improved function after the menopause, and people who became active in midlife had death rates like those active all along (an association).

Sources 46, 47, 73

"Lifting weights will make you bulky"Emerging evidence

In women around 52, 10 weeks of free weights raised strength, and muscle grew only in the women before the menopause. Our exercise for women guide answers this in full.

Source 46

"You need a reformer for real Pilates"Emerging evidence

Mat and apparatus Pilates gave similar gains in function in women about 65, and both helped in a small trial after the menopause. Equipment went with more quality-of-life gains in one review, at very low to moderate certainty.

Sources 74, 75, 35