Menopause discussions are often centred on weight gain and hot flashes, however there are many varying symptoms experienced through this life stage. Removing the stigma around menopausal ‘changes’ provides an opportunity to understand and implement meaningful strategies for overall health. This article aims to break-down menopause, the associated physical and psychological changes and interventions available.
What is Menopause?
Menopause is defined as the permanent cessation of a period (menstrual cycle) for at least 12 months. It is a normal event that occurs for most women at age 50, where the number of primary ovarian follicles reduces and subsequently impacts on the reproductive hormones. Oestrogen which is our primary sex hormone, declines during this time period and subsequently impacts our bone health, reproductive organs, weight, height, psychological changes and vasomotor responses such as hot flashes, migraines and palpitations.
We can further breakdown menopause into three stages: pre-menopause, peri-menopause and post-menopause which becomes more important in the context of exercise and training. As menopause is marked by only one day, the phases either side; peri and post menopause are vital to understand.
Pre-menopause is when cycle length is regular with ovulation and timeframe between bleeds remaining consistent. For most women this occurs during adolescence and the return to ovulation after having children- if that is a decision made.
Peri-menopause occurs with altered flow or cycle length (shorter or longer) and the onset of typical menopausal symptoms. This can begin 5-10 years before the last menstrual cycle however the length of time is varied for each individual.
Post-menopause occurs the day after 12 months post-menstrual cycle and hosts a range of changes psychologically and physically which will be further explained below.
Menopausal changes within the body
To understand Menopause, let’s go back one step to the menstrual cycle itself. Within the cycle there is the follicular phase, ovulation and the luteal phase which lasts from 27-35 days. During this cycle there are increases and decreases in oestrogen and progesterone. These hormonal fluctuations have a varying effect on mood, performance, libido, lethargy and more.
During peri-menopause, the frequency of ovulation reduces and eventually ceases. This is caused by the gradual reduction in the amount of oestrogen produced by the ovaries. This reduction in the level of oestrogen in the body is what is largely triggers the cascade of symptoms.
Hot flashes and weight gain garner the most amount of traction as they effect close to 75% of women during the peri menopause phase. A study completed this year, showed women in the peri menopause phase had greater fat mass and less lean muscle mass than pre and post-menopausal women. The cause of weight gain during this time can be attributed to multiple causes including but not limited to: genetic predisposition, nutrition, low physical activity and hormone fluctuations.
Close to 50% of women also experience mood changes such as anxiety, depression, anger or irritability, reduction in confidence, sleep disturbances and reduced concentration. To continue this wonderful list of symptoms, bone health is impacted, vaginal dryness presents, breast size decreases and blood pressure increases.
The reduction in systemic oestrogen levels seen during menopause have a direct correlation with the reduction in lean muscle mass. It is the reduction in lean muscle mass which is most hazardous, as muscle mass has great protective benefit to bone and general health. With less lean muscle mass, there is the converse increase in fat mass which represents the .5-2kg gained each year during the menopausal transition window. This typically affects the abdominal area, with most fat mass gained here.
During menopausal transition physical activity has been shown to slow the loss of skeletal muscle mass with a specific focus on resistance training and high intensity interval training. Lifting weights can be a daunting progression from nothing so engaging a Physiotherapist, Exercise Physiologist or Personal Trainer is vital to support you moving forward.
Bone health is maintained by an equal relationship between reabsorption of old bone and production of new bone. During Menopause with the reduction in oestrogen and subsequent muscle mass, there is more absorption without the production. This reduces the strength of the bone and increases the risk of osteoporosis.
Osteoporosis rates are highest in post-menopausal women with 1 in 3 women in this stage experiencing a fracture due to bony fragility. Even more concerning, mortality risk is as high as 25% in the year following a hip fracture. The type of training that is most effective for the osteoporotic population is resistance training and weight bearing exercises.
For greatest increases in bone mass density, high intensity and heavy resistance training is the most effective. This may look like low repetition, heavy lifting accompanied by higher heart rate intensity training. This ‘power’ training for strength needs to work towards repetition maximum lifts and the rate at which these are performed for skeletal health.
Metabolic health very simply is the conversion of food to energy which involves multiple systems. Metabolic changes may present in the form of body mass, insulin resistance and glucose/lipid disturbances. The relevance to menopause, is that most of these metabolic factors increase during the menopausal transition. We see this manifest through obesity, diabetes, diet and lifestyle behaviours which have a direct link with cardiovascular disease (CVD) risk. Poor sleep has even been shown to increase the risk of subclinical cardiovascular disease. The menopausal drop in oestrogen impacts blood vessels, fat mass distribution, temperature regulation and may create barriers to participating in healthy lifestyle choices.
Your healthcare provider may suggest menopause hormone therapies which in appropriate populations- age 60 or within 10 years of starting menopause, have been associated with reduced CVD risk. It is recommended to working closely with your General Practitioner (GP) to work towards a therapeutic management plan in conjunction with lifestyle modifications such as diet and exercise.
Over half of menopausal women experience urogenital symptoms which includes changes externally, reproductive organs and the urinary system. Aforementioned changes to the reproductive organs include reduction in ovarian size however the most impactful symptoms occur at the vagina itself. There is muscle atrophy at the mucosal muscle layer which results in thinning and dryness. Externally, the pubic hair thins, the labia reduces in size and loss of the labial fat pad. Similarly with the urethra which is the exit pathway from the bladder, atrophies and thins which can lead to urinary incontinence or increased frequency and urgency.
This can cause burning, pain and the dryness and increase the risk of urinary tract infections. Additionally there is a reduction in libido so with dryness and a reduction in desire for intercourse that is likely to be painful, it is often shameful to discuss. Fortunately, your women’s health Physiotherapist in conjunction with your GP can point you in the right direction. With note of your general health, topical oestrogen creams and the use of menopausal hormone treatment can assist with both libido and urogential changes. Hormonal therapy is an option that needs to be discussed with your Doctor due to the varying combinations, applications and duration of treatment that varies dependent on the individual. The effects additionally have a positive effect on bone health and vasomotor symptoms discussed above.
Menopause management is as varied as the hormonal transition itself. Intervention application is structured dependent on the severity of symptoms, impact to quality of life and general health including additional risk factors.
Across the board, lifestyle changes in the form of diet and exercise are recommended to aid the reduction of menopausal specific risk factors and mitigate the prevalence of specific symptoms. Utilising hormonal therapy as discussed, has the capacity to greatly assist with the maintenance of a healthy weight, bone and muscle mass as well as optimise urogenital health.
Physiotherapy plays a role from an exercise and women’s health perspective. Pelvic floor strengthening addresses muscle loss in the pelvic floor as well as strategies for constipation, continence dysfunctions and advice regarding topical creams or pessary’s or vaginal rings. Your Physiotherapist can assist in structuring an exercise program that incorporates updated recommendations for bone health and muscle mass.
Don’t hesitate to enquire about any of these options discussed with your treating Physiotherapist for more information.