Today we’re joined by Claire Callaghan a physiotherapist with a passion for exercise and women’s health who runs fantastic Women’s Wellbeing Workshops. Claire is going to be sharing her extensive knowledge on the menopause, an important topic that we all could benefit from knowing more about.
Follow Claire on Twitter via @PhysioClaireCal
Most clinicians are treating women in their 40s, 50s and beyond, and as such, we’re likely to be treating women who are going through menopause. When considering both the clinical and the wider bio/psycho/social profile of our patients, it’s important to know how what they may be going through and how it may impact them.
Menopause is a natural phase through which all women will pass. For some, it’s straightforward, for others, it’s a roller-coaster! Timing of menopause, severity and duration of symptoms and their wider impact are hugely variable. There’s no doubt that the physiological impact of menopause can affect running and injury risk, and clinicians must be mindful of this when treating peri-menopausal women. So what are the facts about the impact of peri menopausal health on running? Considered conversely, what’s the impact of running on peri and post-menopausal health?
A whistle stop overview
The menopause is when a woman stops having periods. It happens when the ovaries stop releasing eggs or your ovaries have been removed and the amount of oestrogen hormone in a woman’s body falls. Most women in the UK have their menopause between the ages of 45 and 55 years, with the average age being 51 years. The term ‘perimenopause’ is used to describe the time around the menopause during which women are making a transition towards menopause, where they may have some of the signs and symptoms consistent with hormonal changes and approaching menopause. This may last from a few months to several years 80% of women will experience menopausal symptoms that interfere with their quality of life, with one in 4 describing symptoms as severe. The most common symptoms are hot flushes, night sweats, vaginal dryness, low mood and/or anxiety, fatigue, joint and muscle pain and loss of libido. Some less common symptoms are headaches and weight gain (Royal College of Obstetrics and Gynaecology (RCOG), 2019).
Potential impact of Physiological changes on runners
Hormones, tendons and ligaments
The effect of oestrogen on tendons and ligaments is poorly understood. The research implies that it has protective benefits for connective tissue tensile strength, healing and ability to take load. 95% of collagen in tendons is attributed to Type 1 collagen. As we can see with normal skin ageing and other muscular-skeletal conditions, age reduces collagen and connective tissue’s ability to repair. Normophysiological oestrogen appears to exert a permissive effect on connective tissue and collagen regeneration and musculo-skeletal adaptations to loading and tendon stiffness. This may have a positive influence on outcomes following musculo-skeletal overload, trauma and orthopaedic surgery (Nedergaard et al, 2012, Le Blanc et al, 2017). There is minimal research which implies a direct connection between decline of oestrogen like compounds and Type 1 collagen strength. Some studies imply a connection between declining oestrogen and pelvic prolapse, a process associated with pelvic ligaments and collagen content of surrounding tissue. (Le Blanc et al, 2017). Intrinsic trunk and pelvic floor strength and control are vital for pelvic organ support, continence and coping with the increase in intra-abdominal pressure during running (Leitner et al, 2016). Potential collagen changes with menopause highlight the need to not only consider changes to the commonly problematic gluteal, posterior tibial and achilles tendons, but also the need to address abdominal and pelvic floor changes. Another reason to continue pelvic floor exercises! More research is needed to understand how any positive oestrogen benefits influence tendons, and would be of interest given the high occurrence of tendon related pathology in peri-menopausal women. According to Alison Grimaldi’s extensive research, gluteus medius tendinopathy is more common in females than males, with a ratio of 3-4:1, peaking in the perimenopausal period. Posterior tibial tendon dysfunction (PTTD) is also commonly noted in this group (Kohls-Gatzoulis et al, 2009) (Ross et al, 2018), with figures varying from 3.3 to 5%.
Failure load and tissue healing, vascular and neurological changes
There is little conclusive evidence on the effect oestrogen and testosterone changes have on failure load and contradictory evidence with regard to tissue healing (Le Blanc et al, 2017).
More research is needed to understand the mechanisms by which any positive benefits are activated, but would be of interest given the high occurrence of tendon and ligament related pathology in peri-menopausal women.
While joint symptoms are commonly reported during and after menopause, and possible associations with reduced oestrogen levels, joint pain and arthritis have been noted in several papers, a causal link is lacking (Xiao et al, 2016, Watt, 2018).
Bone and muscle strength
Oestrogen plays an important role in the growth and maturation of bone as well as in the regulation of bone turnover in adult bone. Women can lose up to 20% of their bone density in the first 5-7 years post menopause, as oestrogen levels drop (NHS website: Menopause and your bone health). Muscle strength losses peri and post menopause are well documented. Recent CSP promotional material quotes up to 8% muscle strength loss per decade from the age of 30 if no steps are taken to counteract this. A recent Finnish study (Bondarev et al, 2018) of over 900 women showed menopausal status is significantly associated with reduced muscle strength, power and vertical jump height. Oestrogen’s ability to positively influence muscle recovery and repair remains largely unexplored.
Some symptoms have a direct impact on running, and possibly injury. If patients complain about feeling excessively hot on runs or fatigued post run and they think it’s associated with their menopause, encourage them to explore practical solutions regarding cooling down and timing of training. Signposting to nutritional help may be appropriate to manage symptoms, metabolic and weight changes. Mood fluctuations are normal, but if anxiety and depression are significant or worsening, referral to a GP and relevant health professionals is advised.
So why run your way through the menopause?
It’s not just a ‘doom and gloom’ picture – it’s important to remember this is a normal process, and all positive benefits of running has on physical and mental wellbeing still apply. In fact, maintaining regular exercise are ever more important in combatting the effects of hormonal and age related changes.
Lifting the mood
Running and other exercise are advocated by the RCOG in management of perimenopausal symptoms and maintenance of bone health. Women’s mental wellbeing has been shown to benefit from running with others (Grunseit et al, 2017). Interaction with nature through running outside may help with reducing anxiety levels (Lawton, 2017). Women’s running groups may also enhance social connections and a sense of being connected at what can be a time of physical and emotional change.
Offsetting “middle aged spread”
Menopause can negatively impact metabolism, visceral fat and lipid profiles (Saha et al, 2013), and higher engagement in physical activity is associated with a lower body mass index (BMI), visceral adipose tissue accumulation and a healthier metabolic profile in post menopausal women (Major et al, 2005). From a musculo-skeletal perspective, the documented link between high BMI, PTTD and onset and pain from arthritis, weight management warrants consideration.
A wealth of literature, NICE guidelines, NHS guidance and the international osteoporosis foundation support weight bearing exercise to strengthen bone throughout women’s lives to reduce risk of osteopenia and osteoporosis. Stiles et al (2017) examined the effect of high intensity of exercise on pre and post-menopausal women’s bone health in over 2000 women. They found that accumulating 1-2 minutes a day of high intensity physical activity, stated as equivalent to running in pre-menopausal women and slow jogging in post-menopausal women, was associated with better bone health.
Bondarev’s 2018 study showed high leisure physical activity levels providing the capacity to counteract the potential negative influence of menopause on muscle function. More active post-menopausal women showed significantly greater maximal knee extension strength and higher vertical jump height. Clinicians could extrapolate that this in turn may benefit running.
It’s important women are empowered by information to help them through various life stages. In Britain and beyond, women are better educated and more likely to live into their 80s and 90s than ever before, and there’s no shortage of peri and post-menopausal female runners, from those doing their first couch to 5 k to completing London Marathon in astonishing times. Through a greater understanding of their health and how they can positively influence it, they can continue to enjoy running and exercise, reduce injury and stay well.
In response to women’s desire for a better understanding of health and wellbeing, my Nutritionist and Dietician colleague Sue Baic and I have devised a workshop to help peri-menopausal women manage symptoms naturally and continue their normal activities. Visit our event page for more information.
Extra resources for clinicians and women
For more resources see this thread on Twitter which includes links to blogs, podcasts and people to follow.