Menopause and pain, hormones and exercise: a beginning ∞

Dr. Louise Tulloh in an editorial about menopause for a new exercise-focused issue of the British Journal of Sports Medicine:

Despite a renaissance in menopause awareness, the over-medicalisation of women’s midlife health threatens to eclipse foundational interventions like physical activity.

And, she warns, women are trapped between the devil of over-medicalization and the deep blue sea of misinformation spewing from “influencers” online.

What does this mean for women with chronic pain?

This post is for the men too

This post is the seedling for an article on this topic. To get started, I am writing about Dr. Tulloh’s editorial — rather than a new study, say — because every deep dive starts with a shallow one. Her perspective has helped me figure out early which myths to avoid perpetuating, where to focus my attention, and what primary research to read and cite as I proceed.

For women, much of this will be old news. But many men (especially male healthcare professionals) need to start here with me. And maybe some younger women! I remember how surprised both my wife and I were by a lot of “basics” about menopause that we didn’t know about until she was living with them.

So …

Basics: menopause isn’t just hot flashes (“vasomotor symptoms”)

Menopause has quite the wide array of symptoms: bad sleep, bad moods, mood swings, brain fog, bladder trouble, headaches, and — of particular interest to my readers — musculoskeletal troubles like joint pain, frozen shoulder, tendinitis, and osteoarthritis.

There’s a term for this: “musculoskeletal syndrome of menopause.” (Kind of awkward, needs workshopping. Widespread Irritating Menopause Pains, or WIMP?)

Yet another item on a long list of so many ways to hurt.

It’s unclear exactly how it works. For instance, slow muscle loss (sarcopenia) is one of the things that defines aging, for men and women, but evidence is wishy-washy on whether it’s accelerated by menopause. But there is emerging evidence that peri-menopause is pro-inflammatory (McCarthy), which would explain a lot.

Some of the aches and pains may respond to menopause hormone therapy (MHT, formerly HRT), but many do not.

Major myths about the power of hormones, good and bad

Early research exaggerated the risks of MHT, specifically and infamously breast cancer — a drama that started just down the road from me at the University of British Columbia. Many women quit MHT on their own initiative or were cut off paternalistically. That left a vacuum that was filled by the advice of influencers and celebrities, who eventually powered a hormones-fix-everything backlash and a lot of unrealistic expectations.

If only hormones were “a panacea capable of reversing ageing, restoring athleticism and eliminating all symptoms.” In reality, MHT can help with some symptoms, and probably reduces fracture risk, but it’s no magic bullet, and the risks and benefits vary greatly from person to person. Tulloh emphasizes: hormones are not a universal cure, and MHT should be limited “primarily to symptomatic management and fracture prevention,” and not even that for everyone.

What is a solid, broadly effective intervention? “Trust the muscle not the myth”

The alternative to unrealistic expectations of MHT is … realistic expectations of exercise. Do I really need to say that women can, of course, do both? It seems obvious, but it’s probably wise to emphasize. 🙂 This is not about MHT or exercise. They are obviously both valuable for many women. And they also very likely reinforce each other.

But this is about exercise versus MHT as a miracle cure.

Exercise actually delivers much more of what people hope MHT will deliver. Exercise isn’t the answer to all problems, and it will fail with many kinds of pain. But it may work for menopausal pain, and it definitely delivers many more benefits than MHT alone.

It’s just more work, of course. The good answers are never easy.

Elaine Robertson in her garage gym in Beith, Scotland, where she’s been lifting for about a decade. Her husband runs a strength and fitness coaching business (Instagram @strengthforhealth), and he got her into the sport after she finally overcame the objections many women have, like the “wildly-overstated risk of becoming bulky.” But now she can “blithely carry fully-laden suitcases up flights of stairs” and, much more importantly, “lift my 82 year-old, frail, osteoporotic mum after a fall from which she was unable to get up. A key driver for my strength training is avoiding following her into frailty.”

What kind of exercise? Hint: not endless cardio

Exercise is more work than taking hormones, but this isn’t about long, tedious cardio workouts. In fact, “intense aerobic activity can transiently worsen vasomotor symptoms [hot flashes] and the traditional emphasis on ‘cardio for weight loss’ should be rebalanced towards strength training for muscle.” Tulloh makes a strong case for strength. Resistance training specifically (lifting weights) should be a top priority for midlife women, because it has a whole bunch of benefits (and the confidence level is good to great on most of these):

• improves many musculoskeletal symptoms more reliably than hormones
• helps maintain bone mineral density (critical for preventing fractures)
• improves balance, lowering fall risk (also critical for fracture prevention)
• combats age-related muscle loss (sarcopenia)
• reduces high blood sugar and cholesterol
• protects cognitive function

Not bad for something so accessible.

Plus it would be nice to score a point against the myth of feminine fragility, wouldn’t it?

And I will add that building strength is easier than most people realize, especially for beginners — it’s so easy that gym memberships are not required. This makes the option way more appealing to many women who are reluctant to spend time around a lot of fit young people. Specifically, it’s easy because it’s efficient! A little goes a surprisingly long way — a point I’ve supported with a lot of research over many years.

Carpe the midlife opportunity

“Menopause represents a critical ‘window of opportunity’ for risk modification,” Tulloh writes. Women deserve clear, evidence-based guidance — which supports MHT for symptoms and fracture prevention, but activity, exercise, and especially lifting weights for practically everything else. Put your trust in muscle, not myths.