‘Menopause and Muscles (and bones, and tendons): Maintaining fitness during Menopause.’
Dr Colm McCarthy

When talking about Menopause we can talk about Perimenopause which is ages 45-55. We can find post-menopausal which is the time after menopause so really fitness and exercise in menopause we are talking about a large part of a woman’s life. If the average age of a woman is 84 then menopause will be about 1/3 of your life. If we are talking about perimenopausal age 45 that would be considered as mid-life and this is an opportunity at this stage in our life when you look at the choices you make in terms of activity and how that will help your ability to do things and move on into the future.

First of all, defining what is exercise and what is activity? They can be easily interchanged but physical activity is any activity you do in daily life and that could be gardening, housework, or playing with children, whereas exercise is a planned physical activity that keeps you fit or makes you fitter.

Exercise has always been a part of life right through to older ages. The Grandparent Hypothesis looks into how societies that flourish rely on the older members of society to be active and healthy and have the ability to help out in physical activity in order to keep the community going. We are genetically programmed to be able to keep fit and strong right into later life.

Exercise has been strongly proven through epidemiological studies to reduce the risk of getting seven of the most common cancers including breast, colon and endometrial cancer and this is in the realm of about a 20% reduction when comparing people who are physically active to people who aren’t.

There is a pretty big change in terms of a womens cardiovascular risk and that’s the risk of heart disease and that’s comparing before menopause and after. Oestrogen has quite a protective effect on the heart and so in the absence of oestrogen then for a number of reasons the risk of getting cardiovascular disease goes up by a factor of 2.6 between pre-menopause and post-menopause. On the left are the main contributors to this such as worsening insulin resistance, higher blood pressure, higher cholesterol, reduced sleep quality, and mood changes can also have an effect.

Exercise can improve every single one of the risk factors. Exercise can also help improve your mental health with strong evidence from studies that follow women through menopause such as the Swan study in the United States, following a group of women for 20 years through menopause with clear evidence showing women who were physically active reporting better mental health and better quality of life, while reducing symptoms of depression anxiety and stress.

Something quite topical at the moment is whether exercise can improve symptoms of the perimenopause transition? The classic symptom being hot flushes but there are many other symptoms associated with perimenopause which is a period that can negatively impact a woman’s health and well-being.

There have been studies done on how exercise can potentially help some of these symptoms. One of the interesting studies looks into the relationship between musculoskeletal pain and menopause. Musculoskeletal pain has been proven to be one of the most common menopausal symptoms causing pains and aches in muscles or joints causing about 1.6 times the amount of aches and pains to premenopausal which is a big increase. There has also been good evidence from these studies that people who are active and take regular exercise reported less headaches, less joint pain, and less heart palpitations. This evidence that symptoms such as difficulty sleeping, mood changes, low energy, heart palpitations, headaches or migraines, and joint/muscle aches can be positively affected by exercise. The jury is still out on whether exercise has a significant effect on hot flushes. There is a theory that as we know that exercise increases your parasympathetic tone is upregulated so this may help with hot flushes although we don’t have strong evidence for this.  There is good evidence from studies that keeping physically active will also help maintain a healthy body composition, maintain your muscle mass, and reduce the amount of central adiposity or visceral fat which is the weight you carry around your middle. This increases after menopause so maintaining good activity and exercise can help offset this and has health benefits as carrying weight around the middle has effects on cardiovascular health, and insulin resistance.

The main musculoskeletal effect that we see in menopause such as the decline of oestrogen. Oestrogen is not just a reproductive hormone it has effects on lots of body symptoms and has a really strong effect on our muscular system and on our bones, this can have a big knock-on effect on a woman’s health. Oestrogen helps to maintain muscle mass, it helps with muscle’s response to exercise and also helps with making new muscle fibres. There is an increased risk of sarcopenia in menopause but really that comes about when you combine inactivity with a lack of oestrogen. Osteoporosis then is when you get a decrease in bone density which causes an increased risk of fractures which later in life can have a devastating effect on a person’s independence. This drawing in the top right is what is meant by sarcopenia, where you have muscle in the dark red over the years if you have a lack of oestrogen and a lack of exercise have the combined effect and cause the muscle to get smaller and the fat mass to get bigger. In the absence of oestrogen and bone breakdown starts to exceed bone formation so our bones get thinner and a lack of mechanical stress can breakdown bone. This is why exercise is so important to maintain bone health.

When talking about sarcopenia and the loss of muscle it is something you definitely want to avoid and it is because muscles are so much more to our bodies than a piece that just moves us. Muscles can send messages to other parts of the body and it is an endocrine organ. Substances released from muscles are called myokines which can have effects on the brain, the gut, the kidney, the pancreas and bones. When you have muscle and maintain muscle it sends all these positive messages out to the body which decreases inflammation, decreases immunity and this is where the decrease 9in cancer risk comes from. It helps you metabolise your food better, makes you happier, makes your bones stronger so muscles really are such an important organ in your body rather than just being something that moves us

Is menopause a one-way ticket to sarcopenia and osteoporosis? The answer is no and the reason is that it is possible to maintain your muscle mass and function to keep your bones strong with the magic pill and that magic pill is exercise.

Exercise, a combination of aerobic and resistance exercise in other words getting out of breath and lifting heavy things will keep your muscle mass and muscle function. In terms of osteoporosis, menopause is not a one-way ticket to osteoporosis. If you are maintaining and currently doing impact activity or taking up impact activity now then that loading effect on the bone will maintain bone density and perhaps even improve it. The impact is basically jumping, landing and things like running and in fact it actually does not take a lot to get a good stimulus of the bone and 50 jumps a day would be enough to maintain your bone and that is something that all of us can do right up to the elderly ages with the right advice and modifying what sort of impact they do.

In terms of what exercise to do, there are plenty of science-backed recommendations on what’s the best mix to do. Interestingly, I came across this in the paper and in certain states in Germany it has been mandated that people who own dogs must walk them twice a day for at least half an hour so an hour exercise for dogs because if not then it would be considered as cruel.

There are bodies such as the World Health Organisation (WHO) who come up with recommendations that are all pretty similar and this is for adults in general not specifically women in peri-menopause or menopause because the same advice would be true for a man or any healthy adult and there is importance on the bone loading part of this for menopausal women. The advice is 3-5 days a week of moderate to vigorous aerobic exercise at 30-60 minutes each time. To make sure that some of those are bone-loading or impact-type work and then a really strong recommendation is to do two days a week of resistance training. It is also worth doing some flexibility and balance work.

So first of all you have some moderate aerobic exercise which is exercise which feels somewhat hard the best way to think about is as exercise where you can talk but you can’t sing a song so something like brisk walking where you are a little out of breath, swimming, jogging, cycling or also team sports or racket sports can all be considered moderate aerobic exercisers.

What is bone loading/ impact? Not all moderate aerobic exercises can be considered bone loading, walking doesn’t have enough impact to consider it bone loading neither does swimming or cycling. You need something in which you are jumping or hitting the ground a little harder for example tennis would be an excellent bone-loading activity It is multi-directional, your running forward and back all those things give novel stresses, so changing messages to the bones and that’s what really stimulates them to get strong. Dance is a really good form impact exercise, the picture on the left is Zumba which has been shown to be really good in terms of bone loading because of the jumping and sideways movements. Team sports are great, the picture there is Gaelic football but really any sport where you are changing directions, and the other benefit for this is that they can be really fun and social. As mentioned just simply jumping, jumping off a box hitting the ground that’s the impact. Needs to be a little thought around the safety of that for an older person or a person with osteoporosis but they can all be modified. Getting impact loading in two/three times a week so not just walking, cycling or swimming.

Strength or resistance training is basically where your making your muscles work hard and get tired, so again there is lots of different ways to do this, certainly gyms, gym classes, anything with lifting weights is good. Things like Pilates are also a form of resistance exercise, your body weight Is a from of resistance. Things that work your big muscle groups like your glutes and your quads like squats or lunges are really excellent.  Lots of different ways to achieve two days of strength work, it could be through something like a class or going to the gym or it could be in your own living room with some weights and there is some pretty good YouTube workouts if you are looking for inspiration. Obviously going to see a professional to develop a program for you would be optimal, some good online things and some good apps as well. Big benefits by doing resistance training twice a week in terms of strength function and maintaining that muscle mass, which is so important for your overall health.

The best exercise is one which you enjoy and you keep doing so if you can find something you can enjoy that’s always going to be the best.

Menopause and Tendons are really quite complex, we are kind of a bit unsure on how the decline in oestrogen effects tendons, well we know it reduces collagen formation, increases the stiffness but again if you keep your tendons strong through exercise that’s the best way of keeping them strong and avoiding injury.

Quick word on MHT (menopausal and hormonal therapy. In terms of taking HRT or MHT that’s going to replace the oestrogen that you would otherwise be losing through menopause. It’s been shown pretty clearly to help maintain muscle mass and function and it also has a positive effect on bone. This coupled with exercise is going to give the best results in terms of maintaining muscle and bone mass.

If there are any elite athletes or anyone who competes as opposed to just keeping fit, there are a few studies which show that the MHT or HRT can help with performance more so the adaptation to training, it’s not like it makes you run faster on the day you take it, its more in terms of being able to maintain muscle mass. There is also a bit of evidence around recovery from exercise sessions so probably something worth thinking about for elite athletes but that’s not necessarily promoting it to so people can keep winning races but there is some science there.

In terms of training and the effect on muscles and bones it’s pretty clear that it is a positive influence, it’s a little less clear in terms of oestrogen supplementation or oestrogen replacement on tendons. So the best advice that through good strength training that you maintain your tendons in good condition.

The final thing is some conditions which commonly occur in postmenopausal and perimenopausal women, the first being Knee osteoarthritis which is really common in the general population but it is twice as common for women as it Is for men. The advice for managing Knee Osteoarthritis is really clear from all the major medical bodies that deal with it, both the medical rheumatological surgical and this little graph here is good from the Osteoarthritis research Society International and that’s that everybody who has Knee arthritis should receive education about activity, exercise and weight management, because this is what makes the biggest impact on the osteoarthritis so maintaining a healthy weight as best a possible, keeping good strength in the muscles around the knee and keeping the knee moving. Exercise is good for Knee Osteoarthritis, in the old days people might have thought that rest was the answer but that’s been shown to actually make things deteriorate because of some of the metabolic effects, the negative metabolic effects that being inactive have, so again exercise therapy is really the mainstay of managing osteoarthritis. Some people may benefit from medications or injections and very few need surgery but in our clinic we manage the vast majority of people with exercise and it works well.

Another common and really annoying and painful issue is a pain at the side of the hip, it’s mainly the gluteus Medius and Minimus tendons which come down the side of the hip and attach onto the Bony part of the outside of the hip called the greater trochanter, that’s the bit that kind of sticks out when you lie down and so it can often be quite uncomfortable to lie on, it can be really debilitating, stopping people from running or walking even so that’s something we would see a good bit of, again the management of that there has been some really good interest into it, and specific exercise and strength along with some simple advice on some postures to avoid can be quite effective for this. That doesn’t mean it’s a quick fix it takes a while but it’s been shown that exercise and education beats injections for improving gluteal tendinopathy. Sometimes we would use injections or shock wave therapy but good strength work is the way to both prevent and treat Gluteal Tendinopathy.

A few of my patients have mentioned to me whether HRT might help their Gluteal Tendinopathy and there has only been one study on it so not a lot of evidence, but that did show a combination menopausal hormonal therapy in the form of oestrogen combined with an exercise program was better than an exercise program alone. Only one study but potentially promising.

Finally, exercise can bring its own problems in terms of picking up injuries so simple advice to try and minimise that risk. So Festina Lente is latin for make haste slowly, that’s the single best piece of advice, whatever your doing, if your starting from a low base just build up slowly, if you’re already doing a lot don’t add a lot suddenly just build up slowly and let your body adapt to it. Before you do impact work like running make sure that your muscles are strong, and make sure that you get good recovery. It takes a little longer to recover once you go past the age of 40 that goes for men and women, so a day off in between hard sessions, make sure you eat well, and get some expert advice if you are embarking on a training program.

Bursitis doesn’t burn itself out in the same way that frozen shoulder does over a long time maybe 2 years. Eventually, frozen shoulder burns out but bursitis doesn’t particularly do that in the same way so something has to change to relieve that bursitis whether that is better movement patterns in the shoulder or treating the inflammation that goes with the bursitis. The other thing to say is that with night time pain that is often an inflammatory issue and the other thing to think about there is that although it may be bursitis on the MRI it is not necessarily the bursitis causing the pain it could be something else. Although there may be fluid in the bursa on the MRI that still may not be the thing causing the pain. The rotator cuff tendons may be causing the pain or the Acromioclavicular joint (AC). You may even have pain coming from the neck and I know you said the person in question has had a steroid injection if that has not worked then maybe they should look into getting it checked again to see if it would be re-diagnosed as it may be something else. Sometimes, if it does look like bursitis a second injection would help even if it is under ultrasound as it can target a small area.

If it is gluteal tendinopathy which is pain on the outside of the hip then there is a high likelihood that it is gluteal tendinopathy. The tendons are the bit that is sore but the muscles that are attached to the tendons are on the side of the hip and they can feel it and be really tight and sore and this can work it’s way up to the buttock area and it feels as though you should stretch it but it actually does not help it. It might be detrimental by pulling the tendon across the outside of the hip. Gluteal tendinopathy is something where stretching should be avoided.