The History of the Mystery :

In 1921 a French physician Charles-Pierre-Louis de Gardanne coined the term ‘menopause’. A fuse of meno, meaning ‘month’ – relating to the moon – and pause, as in the stopping of something. The word quite literally means the end of your monthly cycle. 

For a long time before that it was a huge source of confusion. Early physicians from the Greek and Roman era thought the loss of blood each month through menstruation  was a purging of toxins and poisons from the body and when that ended in menopause, a failure to release these toxins would drive a woman mad. Thus, over time the phrase ‘menopausal madness’ would vary from outrageous to inhumane and would include everything from using leeches to draw out toxins, to locking up women in asylums.

Thankfully, it’s 2024 and the explosion of social media over the past decade seems to have helped normalise the conversation, improving accessibility to support and provide a catalyst for those experiencing the symptoms of hormonal change to begin to openly share their experience with one another. Sympathetic listeners.

We are seeing a marked increase in information sharing, women not wanting to suffer in silence are helping one another, not just with their own experiences but with research strategies and guidance of where and who to go to for navigating this time of their lives. They are arriving at medical appointments more prepared and armed with information to push back for answers. 

There are many specialists on social media writing articles to illuminate menopause, encouraging readers to question the standards of care and demand better. Progress is being made but there is still room for improvement, not just on the menopausal journey but how we teach and train our providers to care for this cohort and in turn how society views and treats menopausal women in general. 

We may have moved on from leeches but there is still a great deal of flippancy around ‘menopausal’ woman.

Estrogen – and it’s non reproductive role

Estrogen is not just about eggs, periods and pregnancy. It is responsible for so much more. There are 3 major estrogens produced in the body, estradiol, estrone and estriol. They each have distinct functions around our body. Estradiol is the primary, its production almost entirely disappears after menopause (primarily reproduction based). It’s also the strongest of the estrogens. Estriol affects our bone health and lipid management. Estrone, the weakest of the estrogens, is produced in very small amounts by the ovaries. It may help with bone loss and aid in tissue maintenance but will never do the job of Estradiol. 

During menopause, estrogen levels begin to drop. There are estrogen receptors throughout almost every organ system in our body, and during menopause these cells begin to lose their ability to assist in maintaining health in other areas. This includes our heart, cognitive function, bone density, bone integrity and blood sugar balance. It is vital for the regulation of many processes in the body, including but not limited to insulin sensitivity, cholesterol levels, skin health, mental health, concentration and moods, focus, memory and finally, pelvic floor function. 

Women are more likely to be diagnosed with a range of diseases related to the body’s decline in estrogen – including stroke, heart disease, Alzheimer’s and type 2 diabetes – all which fall in the top ten causes of death. Whilst osteoporosis is not directly on the top ten list, it is another major concern for women. Because of bone loss from osteoporosis, one in two women will break a bone in their lifetime. Hip fractures alone are associated with a 15–20% increased mortality rate within one year of the break! 

Estrogen is broadly and profoundly protective of our overall health and its diminishing status or role through premenopausal and menopausal years is not be taken lightly. It should be treated accordingly.

Stages of Menopause : 

The menopausal journey can begin as early 35 years old, made up of 3 discrete medical stages: perimenopause, menopause and post menopause. The experience can feel very much the same through the 3 stages, but they all are caused by the deprivation of the sex hormones (estrogen, testosterone and progesterone) which will eventually lead to the end of ovulation. Normally it’s the severity and not the actual symptoms that can vary as you  transition through the stages. Let’s take a look.

Perimenopause 

This is the beginning of the end of the ovarian function, somewhat difficult to diagnose because there are many symptoms associated with that and it can start as early as mid thirties but normally 45-55 yrs. 

The most marked symptom is the irregular monthly cycle, longer or shorter in duration. This stage can last anything up to 2 -10 years.

This stage is the most difficult to diagnose, symptoms are varied and there are many, and there are no finite tests one can do to get correctly diagnosed. Listed below are just a few:

Hot flushes (which is the clearest symptom), night sweats, joint and muscular pain, pelvic floor dysfunction, weight gain, fatigue, bloating, skin changes, headaches. The list goes on. 

Menopause

You reach menopause when its been twelve months since your last period. To the day. This date will mark the end of your cycle and reproductive capabilities. This day is called menopause. Menopause is one moment in time. Its defined by a calendar date rather than a change in symptoms or a specific health sign. The day after is post menopause.

The average age for menopause is 51. Early menopause is defined if you reach this day before you are 45 and premature menopause if you are under 40.

Menopause is associated with so much more than reproductive aging. It initiates cellular aging and can be blamed for a decline in general health. This makes sense when you look at the role and importance of Estrogen in our bodies: when it diminishes there will be biological consequences. As stated by the American Heart Ass (2020) women who go through natural menopause later in life have been linked to having a higher bone density, longer life expectancy, greater joint longevity and reduced heart disease. 

Postmenopause

You are postmenopausal once you’ve hit the menopausal moment. This last stage includes the rest of your life after menopause. This doesn’t mean you will have symptoms forever, but common ones are reported to last anywhere between 4.5 and 9.5 years after your last menstrual cycle.

It is usual to have highest prevalence of vasomotor symptoms in this stage such as hot flushes, perspiration and heart palpitations. This stage can also find women mentally shifting and addressing how their life is travelling, becoming more self-focused, setting boundaries and prioritising themselves. 

Your journey towards menopause can be achieved 3 ways:

1. Biologically – naturally with influencing factors.

Both women who have never had children and women who started their cycle at age 11 or younger are more likely to go into early or premature menopause. If these two factors are combined, a woman is up to 5 times more likely to experience premature menopause and twice as likely to experience early menopause. This statistic is compared to a woman who has had 2 births and started her cycle at 12 years or older. The number of births may also influence how severe your menopausal symptoms are. More children means symptoms are generally more severe. Other factors can influence

menopause including genetics, race and ethnicity, body mass – being under weight as well as overweight. 

Cardiovascular health especially through premenopausal stages can speed up the journey to an early menopause. Early heart attacks, high cholesterol, high blood pressure and diabetes can cause a build up of plaque in the arteries, resulting in reduced blood flow through the body. If blood flow to the ovaries is compromised, it damages the tissues and cells needed for reproductive hormones. This in turn can speed up the process where the egg follicles don’t develop properly, causing the onset of an early menopause. 

Sadly, there is research published in 2022 in the Journal of Menopause* that highlighted a strong link between intergenerational abuse and age of menopause. This a worrying topic that has no definitive conclusion yet, but there is strong evidence to show that the effects of cumulative impact of stress and the body’s response to trauma accelerates and increases stress hormones that suppress the immune system and speed up reproductive ageing. 

2. Surgically – there is a chance that one can lose ovary function before their time is up. Mainly due to the removal of the ovaries before natural menopause. 

If the ovaries are spared through a hysterectomy, this can still disrupt blood flow, and one can expect to go into menopause 4.4 years earlier than a woman without a hysterectomy. The removal of both ovaries will thrust you into menopause immediately. This can be extremely traumatic and can come with dramatic changes in your hormones.

Removal of one ovary will impact when you start menopause. If this happens before you’re 40 years old you can expect an earlier menopause by 1.8 years. If you have an ovary removed earlier than 35yrs old it will vastly accelerate menopause because of the finite supply of eggs, losing half of whatever you have remaining. 

3. Treatment – clinically induced menopause can be caused by chemotherapy, radiation therapy or hormone suppressive treatment. Premature Ovarian Insufficiency (POI) occurs when the ovaries stop working before the age of 40. POI is caused by follicle dysfunction or depletion, and is said to be a hereditary condition but can also be brought about by:

    • Chemotherapy and radiation treatment
    • Auto-immune diseases, rheumatoid arthritis or thyroid diseases
    • Genetic disorders : Turners syndrome or Fragile X syndrome
    • Being born with a lower follicle count
    • Metabolic disorders

THE WIDER RISKS

As stated before, Estrogen is a  protective hormone and when it starts to diminish we lose a lot of this protection. Our stress hormones, such as cortisol and other pro-inflammatory actors become more prevalent and destructive. Menopause can be labelled as an inflammatory pathology or condition which leaves us at increased risk for several other things.

Broadly grouped together:

  • Musculoskeletal syndrome (joint and muscle health, sarcopenia, inflammation, arthritis)
  • Coronary heart disease
  • Insulin resistance and pre-diabetes (visceral fat gain) 
  • Osteopenia/osteporosis

 

Musculoskeletal System (Bones and Muscles)

During perimenopause, women have an average reduction of 10% in bone mineral density. Furthermore, there is an average of 0.6% loss in muscle mass per year after menopause. This is due to the decline in estradiol (the most active estrogen) which impacts all types of muscular skeletal tissues, including bone, tendons, muscle, cartilage, ligament and adipose. 

The fall in estradiol is the most impactful causing a rise in inflammation, a decrease in bone density increasing our risk of osteopenia/osteoporosis, arthritis, sarcopenia (loss of lean muscle) and a decrease in our muscle stem cells. 

Inflammation 

Estrogen is an inflammatory regulator that plays a role in the prevention of generalised arthralgia (joint pain). This pain experienced increases across the menopausal journey peaking in the early days of post menopause. These symptoms are also reported to be more evident in women who suddenly withdraw from hormone replacement therapy (HRT).  

 

Frozen shoulder, medically known as adhesive capsulitis. 

Frequently diagnosed in menopausal women aged between 51- 58. This pathology is identified with feelings of stiffness and pain in the shoulder joint. Women will literally present with this pain out of nowhere and the shoulder just seems to stop moving properly. As estrogen is a strong powerful anti-inflammatory and acts directly on the immune system, and without it doing its job to lower inflammation, the body can become hot and red inside. 

The shoulder capsule, which is the inside portion of the shoulder seems to be sensitive to this.* This complex but also quite poorly understood condition then progresses through 3 stages : the painful stage (we don’t want to move it because it hurts), the frozen stage (we can’t move it as the capsule literally contracts) which restricts range of movement, then the thawing stage (intervention of sorts is required). Our tendons and ligaments are reliant on estrogen for their health, so an increased amount of tendinitis will become more apparent through the menopausal years. 

 

Sarcopenia 

This is an age-related condition that’s characterised by the loss of lean muscle mass, skeletal muscle mass, strength and function. A combination of the atrophy of fast muscles fibers and the increase of intramuscular adipose tissue, this contributes to reduced physical performance and an increased risk of falls and fractures, thus affecting the overall quality of life. Estrogen helps muscle tissue regenerate and build, so when estrogen declines, tissue mass declines too. Losing muscle mass has a greater impact than what most people will realise: it results in a decrease in mobility and strength, increase of fat mass and also poorer metabolic health.

Resistance training and other exercise will improve muscle mass and strength but by the time sarcopenia is diagnosed it’s fairly advanced. In an ideal world, no one should wait to get a test to confirm the presence or the risk of sarcopenia. It is better to be educated and understand that muscle loss is inevitable with age, knowing that the sooner we build and maintain muscle, the better. 

 

Bone Density

Osteoporosis is a progressive bone disease characterised by brittle, weak bones. Our bone strength and mass will decrease over time, as a younger person the body will fight that degradation, renewing the bone strength and maintaining mass. As we age, the renewal slows down, but the degradation does not. One can develop osteopenia, which is the very early sign of bone density imbalance. 

Women are 4 times more likely to develop osteoporosis than men. Estrogen helps slow down the breakdown of bone, as their levels plummet during menopause this leaves women at risk to bone loss and bone weakness. This leads to increased fragility and risk of fracture. Osteoporosis is a serious problem when we look at the statistics. It is under diagnosed, preventable and treatable. Between 30% and 50% of women suffer a clinical fracture in their lifetime and 70% of hip fractures occur in women. These fractures are extremely detrimental since they lead to chronic pain, disability and even death. One in three adults aged 65 and over die within twelve months of suffering a hip fracture! The prevention of osteoporosis can include appropriate nutrition, and correct exercise and the removal of risk factors.

I will talk more about this in a bit. 

 

Arthralgia and Cartilage damage

Estrogen is critical for our health of the cartilage matrix. Cartilage is a spongy matrix that sits on the end of every bone and gives the smooth round edge allowing frictionless motion. Arthritis is the loss of cartilage. After the age of 50 women rapidly progress in arthritis. As the cartilage is starved of estrogen during menopause, it will break down more rapidly. 

Arthralgia is often the first signs of perimenopause, where the entire body and joints will be in pain. 80% of women will experience this at some point but scarily, 25% of women can be devastated by it. Taking a lot longer to diagnose correctly, compounded with other menopausal symptoms, this can be a long and uncomfortable road. 

As previously mentioned, there are ways to prevent  or minimise the impact of the changes that happen to our muscular skeletal system. 

DEXA scans measure muscle mass, bone density and visceral fat. It’s proactive to have these done on an annual basis. If you have a propensity to have develop osteporosis you can make some early life style changes that will take you out of the high risk zone, from fractures, falls and general fragility that has been discussed.

Be the correct body weight, our joints can bear 10 times our body weight. In short, if you’re carrying an extra 10lbs of body weight that is equivalent to 100lbs on your joints and cartilage.

Build more muscle. If you do nothing else, then lift heavy weights. Compound weights (progressive overload). Lifting heavy weights with fewer repetitions, 4-6 times for compound lifts such as bench press or pull ups for the upper body, and squats or deadlifts for the lower body. For accessory lifts that support the global muscles (biceps, triceps, lats, deltoids) we do the amount of weight we can until it will take you to fail after 8-10 reps.

    • We are lifting weights for longevity and power, so we age with minimal risk, open jars, get out of chairs. Its training for quality of life.

Building muscle will stimulate bone density. Muscle is connected to tendon which pull on our bones. It causes a biomechanical stimulus to make our bones stronger.

Now add plyometric exercises to our weekly workouts. Box jumps at the gym , jump board on the Reformer. Even skipping with a rope. 

Here are some benefits:

  • Impact exercises build stronger bone, it stimulates bone remodeling and enhances bone density putting us at a reduced risk of osteoporosis.
  • Plyometric exercise activates our fast twitch muscle fibers, improves our ability to move with speed.
  • Balance and co-ordination, these exercises refine our neuromuscular system which improves stability and precision in movement.

 

With regards to doing weekly exercise and movement, here is an acronym:

FACE

F – flexibility and mobility (pilates, yoga, walking , park your car far from the shops)

A – aerobic, lifting our heart rate ( running, swimming, rowing, biking, jumping )

C – carry load ( lift weights, pick up your grandchildren, carry your shopping)

E – equilibrium or balance (pilates, single leg standing, go up on your toes, walk bare

foot, try walking backwards)

 

Coronary Heart Disease

This is a specific type of cardiovascular disease that occurs when plaque made up of cholesterol and fats build up in the arteries, which reduce the flow of oxygenated rich blood to the heart. This can cause damage to heart function and risk for blood clots and heart attack. Heart disease still remains the leading cause of death for women, and we are at risk once we reach the age of 55, most women in the post menopausal stage. 

The overlap is not coincidental with menopause driving up cholesterol levels and triglycerides which are both risk factors for heart disease. You are at increased risk of coronary disease if you have:

  • Family history of heart disease
  • High cholesterol, diabetes or high blood pressure
  • Overweight 
  • Physically inactive
  • Coronary disease often goes undiagnosed. You can be proactive and seek out a CT scan (calcium score test) that looks at the level of calcium or plague build up around the coronary arteries. This will reveal the presence or risk of heart disease. 

 

Nutrition and Insulin Resistance

Muscle is an incredible metabolic organ, and it’s important for insulin sensitivity. The idea being that the more muscle we have, the more metabolically healthy we are, the less inflammation we will be exposed to and the stronger bones we have.

Insulin is a hormone our pancreas makes that allows our cells to use the food we eat as fuel. Its about as essential as it gets when it comes to metabolic function and basically keeps the engine of our body running. In short, we run like this:

  1. We eat, our stomach and small intestine convert the food to glucose
  2. The pancreas releases insulin to signal the cells to use the glucose as fuel
  3. Cells receive the signal and let the fuel be used, clearing glucose from the bloodstream
  4. The pancreas stops making insulin until you eat or drink again.

 

This entire process can be disrupted if we become less sensitive to insulin. Insulin resistance leads to high blood sugar levels, and if these remain high for an extended period this will lead to chronic low-grade inflammation. 

If we have excess glucose in our system, insulin will store this in our liver, muscles and fat cells. 

Because our estrogen levels decline during menopausal transition, we are more susceptible to developing insulin resistance. Estrogen plays an huge role in glucose metabolism and its absence can contribute to metabolic imbalance or dysfunction. 

It’s much easier to restore insulin sensitivity at an early stage before more serious conditions such as prediabetes or type 2 diabetes set in. Managing our glucose intake and nutrition are of paramount importance to minimise all risk. Jessie Inchauspe, the author of The Glucose Revolution, writes on how to manage glucose spikes through 10 lifelong hacks. I would highly recommend this book for anyone and everyone who wants to maintain minimal inflammation, optimal nutrition and overall good health.

Abdominal fat (visceral fat) and physical inactivity are key factors for developing insulin resistance this contributes to the gain of adipose weight around our midriff. Muscle mass does not cause redistribution of fat, this is hormonally driven. Muscle however, requires more calories just to sit in one place and be living than fat does! So building muscle mass will increase or basal metabolic rate (BMI) meaning the basic amount of calories we burn just to live without any exertion. The more muscle we have, the less fat we accumulate, as muscle is metabolically important and helps with insulin sensitivity.

Our percentage of body fat is far more relevant than what the scales read and what we weigh, again a DEXA scan will point you in the right direction. 19% – 28% is acceptable body fat for a woman. Focus on the percentages in increasing lean muscle mass. The more the better.

So nutritionally we need to feed our muscles with the correct food. Let’s avoid being ‘skinny fat’ the result of losing weight (fat) without gaining muscle. A change of thought to wanting ‘to be more lean’ from ‘needing to lose weight.’ We are building muscle for our metabolic health, our bone health, to recompose our body, to make us more insulin sensitive and to make our clothes feel better.

 

What should we eat then?

We need to move away from fast intense diets, rapid weight loss and starvation diets in the hope the scales move a kilo or two. These types of diets can make it harder to reach the 100 percent of key nutrients we need – protein, fibre and calcium. 

We need to be ‘consistently average.’ On average women between the ages of 45-55 gain 1.5kg per year. Food needs to be viewed as fuel for our bodies and not poison. 

Protein is essential for muscle tissue maintenance and muscle is crucial to helping us protect our bones. The recommended amount of protein is 1.5g- 2.2g of protein for every kilo that you weigh. So if you are 65kgs you need 98-143g of protein per day, preferably spread out and not loaded in one meal. Protein supplements are very acceptable, preferably animal based whey protein because they contain a higher level of leucin which is important for rebuilding and repairing muscles.  

We need an increase of fibre, a lot of dark green leafy green vegetables for fullness and density. We can’t eat enough fibre, not only for nutritional purposes but also for our digestive system.

Aim for a plant rich diet that has a strong emphasis on whole grains, nuts, seeds and legumes. Keep your fruit to a minimum, fruit is sugar. Eat fruit as a dessert and make it whole. 

Simple sugars are the number one culprit in increasing our risk of inflammation. If we want to decrease inflammation then simple sugar has to be cut from our diet. This includes juice, no simple carbohydrates (bread and pasta) and alcohol, which is full of sugar. 

We need the correct fuel comprised of complex carbohydrates, fibre and calcium with healthy fats such as olive oils, avocados or nut oils. Our meals should be balanced with: 

  • 50% plated salad or non starchy vegetables 
  • 25% plated protein (eggs, skinless chicken, tuna, lean meat)
  • 25% carbohydrates – this is our energy source! Don’t leave them out. Think sweet potato, quinoa, basmati or brown rice, sourdough or seeded bread.

Again, I suggest looking at the Glucose Goddess Method for guidance on how to eat and in what order we be eating to manage our glucose intake. 

 

 

MENTAL HEALTH

Mental health challenges that arise during menopause should never be approached with a  ‘grin and bare it’ attitude. Menopausal mood swings are impacted by sometimes rapid but ongoing change in our hormones. We need to be understanding of this and be more forgiving  with ourselves.

There are many support channels that we can look to :

  • Physician support – medications and hormone replacement therapy (HRT)
  • Physiological support – seek out support groups. A safe place to share your journey.
  • Supporting healthy movement and exercise
  • Aim for healthy nutrition – be ‘consistently average’ with your eating patterns
  • Support healthy sleep patterns 
  • Find social connections, educate yourself and find mindfulness through the channels on social media platforms that you choose to follow.

 

On a final note …

Among the various prevention and treatment approaches associated with menopause, exercise and movement is perhaps the one non-controversial modality. Decreasing estrogen is associated with loss of our muscle fibre and subsequently our power, which we need for everyday living. Along with dietary changes resistance exercise is critical for post menopausal women to decrease their risk of falls and fractures.

Make your HRT decision early, be in front of the change and not behind it. Find scientific research to help you make an informed decision. Whether you choose HRT or not, know what your options are. 

We are at maximum bone density by the age of 30 and we should be educating and talking about women’s health and menopause to young women in their early 20s. There is so much more to menopause than this article, I have barely scraped the surface. 

Symptoms I haven’t touched on include pelvic floor function and auto immune pathologies, sleep health. It’s an enormous medical topic that hasn’t really been given a true platform or voice to date. But this is changing. And gladly so, for our younger generation.

“Muscle is the Spanx of nature. It’s going to hold everything in” Dr. Vonda Wright. Dr. Vonda Wright.

 

An Article by Frances Chippeck

Dip. Professional Pilates Instruction 91491NSW

Faculty Educator, Central Coast, NSW – National Pilates Training

Owner of NPT Affiliate Studio- Pilates on the Lane, NSW

@pilatesonthelane  

 

Book References: 

Podcast References: 

 

Social References: 

  • @drvondawright – Dr Vonda Wright – Orthopeadic surgeon and women’s health advocate
  • @drmaryclaire – Dr Mary Claire – Peri and Menopausal Educator
  • @peterattiamd – Peter Attia – MD focussed on health longevity and science
  • @drgabriellelyon – Dr Gabrielle Lyon – Founder of Muscle-Centric Medicine
  • @heatherhirschmd – Heather Hirsch – Midlife and Menopause expert
  • @menopause-doctor – Dr Louise Newson – Physician and Menopause Specialist
  • @gotbuffbones – Rebekah Rotstein –  Educator – Osteoporosis and bone building through menopause
  • @edwinajennercoaching – Edwina Jenner – Health Coach for Menopausal women
  • @mitchlittleacademy – Mitchell Little – Fitness Trainer who teaches the art of staying ‘consistantly average’
  • @glucosegoddess – Jesse Inshaupe – French biochemist – teaches us about glucose intake
  • @menopausalmayhemmothers – Emma Skeates – writer and general sharer of uplifting menopause moments