Balance and Falls Risk in Perimenopause: What Changes and How to Stay Safe

Suddenly Feeling Unsteady When You Never Were Before

You misjudged a curb and stumbled. You reached for something in the dark and grabbed the wall instead. You stood up too quickly and had to wait for the room to stop tilting. You are tripping over things you used to step over without thinking.

Balance changes in perimenopause are not talked about nearly as much as hot flashes or mood swings. But they are real, they are hormonal in origin, and they carry consequences that deserve attention.

A fall that would have been embarrassing at 30 can be significantly damaging at 48, particularly if bone density has already started to decline. Understanding why balance changes happen and how to address them proactively is one of the more practical investments you can make in your long-term physical independence.

How Estrogen Affects Proprioception and Vestibular Function

Proprioception is your body's ability to sense where it is in space. This information comes from receptors in your muscles, joints, and connective tissue, and it is processed by your cerebellum to constantly adjust your posture and movement. This system operates mostly below conscious awareness.

Estrogen receptors are present in the inner ear, which houses the vestibular system responsible for balance and spatial orientation. Estrogen supports the health of the vestibular hair cells that detect movement and gravity. When estrogen fluctuates and declines during perimenopause, vestibular function becomes less stable and less accurate.

Estrogen also affects the sensitivity of muscle spindles and joint mechanoreceptors, the sensors that feed proprioceptive information to the brain. Reduced receptor sensitivity means you get less accurate information about where your limbs are and how your body is oriented. The brain must work with noisier, less reliable data to make postural adjustments.

The result is subtle but measurable. Studies using force plate measurements show that balance in women declines measurably during perimenopause, beyond what is explained by age alone. This is a hormonal contribution, not just an aging one.

Dizziness and Its Connection to Balance

Dizziness is among the most common and least explained perimenopause complaints. It takes several forms: a spinning sensation (vertigo), a feeling of lightheadedness or faintness (presyncope), or a more vague sense of unsteadiness or disconnection.

Benign paroxysmal positional vertigo (BPPV) is significantly more common in perimenopausal women than in age-matched men. BPPV occurs when calcium crystals in the inner ear become dislodged and float into the wrong canal, triggering a spinning sensation with position changes, particularly lying down, rolling over in bed, or looking up. The hormonal connection is thought to involve estrogen's role in calcium metabolism and vestibular hair cell health. BPPV is highly treatable with specific head repositioning maneuvers (the Epley maneuver) performed by a physical therapist.

Estrogen-related vestibular instability can also produce more generalized unsteadiness that is not quite BPPV. This may feel like a constant mild disconnection from your environment, difficulty with busy visual environments (crowded stores, traffic), or a tendency to feel worse on certain hormonal days in your cycle.

Hot flash-related drops in blood pressure can also produce brief dizziness when they occur. The vasodilatory response of a hot flash can transiently lower blood pressure, particularly when you are upright, producing presyncope.

Muscle Weakness and Falls Risk: Why the Combination Is Dangerous

Balance is not just a neurological issue. It is also a muscular one. Your ability to recover from a stumble, to catch yourself before you fall, depends on the speed and strength of your muscle response to a perturbation.

Declining muscle mass during perimenopause reduces the reactive strength available for these recovery movements. A strong hip abductor can counter a lateral stumble. A strong ankle can correct a misstep on uneven ground. When these muscles are weaker, the same stumble that a stronger system would have recovered from becomes a fall.

Leg strength, particularly single-leg stability, is one of the strongest predictors of fall risk. The ability to stand on one leg for 10 seconds, a task that is simple for most adults under 40, declines significantly in the 40s and 50s in women who are not specifically training balance and leg strength.

A simple test you can do right now: stand near a wall or chair for safety, lift one foot, and see how long you can balance without touching down or touching the wall. Ten seconds on each leg without wobbling is a reasonable target. If you cannot reach ten seconds, your balance training priority is clearly defined.

The Fracture Cascade: Why Falls in Perimenopause Matter So Much

A fall that results in a fracture when bone density is already reduced can trigger what physicians call a fracture cascade. A first fracture, particularly a hip or vertebral fracture, significantly increases the probability of a second fracture. Each fracture worsens spinal alignment, reduces mobility, increases deconditioning, and further raises fall risk.

Hip fractures specifically are associated with a substantial decline in independence and quality of life in older women. The process begins, silently, with the bone density loss of perimenopause and the balance changes that make falls more likely.

Addressing balance during perimenopause is, in a real sense, protecting yourself from a fracture cascade that might not materialize until your 60s or 70s. The investment is long-term but concrete.

If you have not had a DEXA scan to assess your current bone density, and you are 45 or older or have risk factors for low bone density, this is worth prioritizing in your next healthcare visit. Knowing your current bone density baseline tells you how urgently the falls prevention work needs to happen.

Balance-Specific Exercises That Actually Work

General fitness helps, but specific balance training produces more targeted improvements. Several types of exercise have strong evidence for improving balance in midlife and older women.

Single-leg work is the foundation. Single-leg deadlifts, single-leg squats, and step-ups train the stabilizing muscles of the hip, knee, and ankle while also providing proprioceptive challenge. Starting with support (a wall or chair nearby) and progressively reducing support as stability improves is the appropriate progression.

Unstable surface training adds proprioceptive challenge beyond flat-floor single-leg work. Balance boards, BOSU balls, foam pads, and even pillows add sensory instability that trains the nervous system to make faster, more accurate postural corrections. Even standing on one leg on a folded yoga mat while brushing your teeth adds meaningful daily proprioceptive challenge.

Tai chi has among the strongest evidence of any exercise modality for falls prevention. Multiple systematic reviews have found that regular tai chi practice (two to three sessions per week) reduces fall incidence by 20 to 45 percent in older adults. The benefits apply in perimenopause too. Tai chi specifically trains weight shifting, controlled movement, and the reactive balance responses that prevent falls.

Ankle strengthening is often neglected but critical. The ankle is the first line of defense against balance loss on uneven surfaces. Heel raises, toe raises, and ankle circles train the muscles responsible for the fastest postural corrections. Including these as part of a daily routine takes three to five minutes.

Footwear, Home Safety, and Practical Prevention

Balance training addresses the internal capacity for postural control. Reducing environmental fall hazards addresses the external risks. Both matter.

Footwear is directly relevant to balance. High heels raise your center of gravity and reduce the sensory feedback from your foot, both of which worsen balance. Flat shoes with a wide toe box and thin, firm soles provide more proprioceptive feedback from the ground. Soft, thick-soled shoes, while comfortable, reduce ground sensation and can worsen balance in women who already have reduced proprioception.

At home, the highest-risk areas for falls are bathrooms, stairs, and any area with loose rugs or poor lighting. Grab bars in the shower and next to the toilet are one of the highest-return safety investments available. Non-slip bath mats, adequate nighttime lighting on the path to the bathroom, and securing or removing loose rugs reduce friction between environment and function.

Checking your medications is also worthwhile. Certain medications including sedatives, some blood pressure medications, antihistamines, and muscle relaxants increase dizziness and impair balance. If you are on any of these and have noticed balance changes, this is worth discussing with your prescriber.

When Balance Changes Need Neurological Evaluation

Most perimenopause-related balance changes are vestibular and musculoskeletal in origin and respond to the approaches described above. But some balance changes require more thorough evaluation.

Seek evaluation promptly if you experience: sudden onset of severe vertigo with hearing loss or tinnitus in one ear (possible Meniere's disease or vestibular neuritis), balance loss accompanied by double vision, severe headache, facial numbness, or arm weakness (possible neurological cause), falls that occur without any warning sensation, or progressive balance worsening that is not responding to exercise.

A baseline conversation with your provider about your balance changes is appropriate even without these red flags, particularly if the changes are significant enough to affect your daily activity. An audiologist or vestibular physical therapist can do specific vestibular function testing and determine whether your balance changes are inner ear related, musculoskeletal, or central nervous system in origin. This distinction guides the most effective treatment approach.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.