My good friend (and 50-54 Individual Pursuit World Champion and former world record holder) Jayne Paine, once told me that at her age, the person who wins is often the one who is fending off the menopause the best! Little did I know that in not many years time, it would be something that I would also have to consider.
At 46 years of age, I have officially hit menopause. Menopause is defined as when a woman has not had a period for 12 consecutive months, with the ovaries stopping their production of hormones (mainly oestrogen) and eggs. The average age of menopause onset is 51 years and, whilst 45 is considered to be within normal ranges, it was earlier than I expected.
What also surprised me was that I had very little warning, with a short or non-existent peri-menopausal period. Peri-menopause typically starts in your mid-40’s and lasts on average 4 to 8 years. One of the first indications of peri-menopause is shortening of cycle length and then erratic periods, including a lengthening in the time between cycles, which is difficult to assess in women on a hormonal contraceptive (pill, IUD, injections etc). Other common symptoms are hot flushes, night sweats or sleep disturbance.
A reason for why I hardly experienced peri-menopausal symptoms could have been because I was on the combined contraceptive pill - and had been for over a decade. The only reason I stopped taking the pill was that I forgot to pack it on a racing weekend away (in early May 2022), and thought it might be a good chance to give my body a break from it. In the past when I had come off the pill, my period resumed within a month, but this time I never had a period ever again!
But, looking back, I suppose I did start having some very mild symptoms in the year preceding stopping the pill: an occasional hot flush (which occurs in 75% of women), and occasional sleep disturbance. But once I stopped, I did notice more changes - the main one being joint aching.
Being a competitive cyclist - and also a physiotherapist - made it hard to distinguish whether aches and pains were due to the high load I place on my body from training (and, to a lesser extent, my occupation), from overuse injuries, or from other causes.
One of the first symptoms I noticed was waking up in the middle of the night with finger stiffness, which I thought was highly unusual. Then came medial elbow tendon pain (pain on the inside of the elbow), as well as thumb and wrist pain whilst working - which I’d never had before. My upper and lower back felt chronically stiff. My knee cap joints ached more than usual, which I put down to a bit of patellofemoral overload from cycling. I also had some pelvic tendon pain, some of which turned out to be an actual cycling injury (it soon cleared up when I did some physiotherapy exercises for it!)
Not knowing that joint pain was a symptom of menopause (apparently it affects up to 40% of women), I started to worry that maybe I had some form of arthritis or autoimmune disorder, and went off to the GP for some blood tests looking for markers. At the same time, I had a number of other conditions tested, such as thyroid function, vitamin D, full blood count, and hormone levels.
My blood tests were all essentially normal, which helped to rule out REDs as a cause of the missing periods. However, all my hormones where at a menopausal level (low oestrogen and progesterone combined with high Follicle Stimulating Hormone (FSH) and Luteinising Hormone) - but with it having been only three months since coming off the pill, it was a case of wait and see.
Twelve months later and still no sign of a period, I decided to be proactive and see a GP who had more of an interest in women’s health issues. My main concern now, having hit menopause at what I considered an early age, was bone density and minimizing bone loss. As a competitive cyclist with a love of road and crit racing, it really is only a matter of time before I fall off my bike again!
The diagnosis of menopause is clinical in women over 45 years, based on a woman’s symptoms and changes in menstruation. Although measurement of FSH and other hormones are not usually indicated, my GP repeated these tests, which again showed menopausal levels. She also quizzed me about menopausal symptoms.
The list of symptoms can be long and vast, with only 20% of women reporting no menopausal symptoms.
Typical symptoms include hot flushes, night sweats, sleeping difficulties, headaches, bodily aches and pains, fatigue, dry skin, unwanted hair growth, vaginal dryness and atrophy, loss of libido, urinary frequency, gut issues, anxiety, depression, and mood and memory changes.
My GP also discussed management options, primarily Hormone Replacement Therapy (HRT), also known as Menopausal Hormonal Therapy (MHT). Despite my symptoms having a minimal effect on my quality of life, my priority was to prevent bone loss as best I could, and I was referred for a DEXA scan to assess my bone density status.
I’ve had DEXA scans in the past in the UK as part of being a volunteer for research studies conducted by Endocrinologist Dr Nicky Keay, who has a special interest in hormones, health and human performance. In 2018 my lumbar spine and hip bone mineral density were both excellent. In fact they were so good that Dr Keay questioned how that could be, considering I was a cyclist who mainly did non-weight-bearing exercise. So I was quite shocked to find that my recent DEXA scan showed my bone density had dropped so significantly that I was now considered osteopenic.
Unlike other menopausal symptoms which are more apparent, there is little indication of what your bone density is like unless you have a fracture - perhaps a stress fracture or one resulting from a crash. That didn’t apply to me, as I’ve been fortunate enough not to have crashed my bike in the last four years, despite the amount of racing I do.
This prompted me to do more research into menopausal bone loss and HRT. Bone density rapidly rises after puberty under the influence of oestrogen and peak bone mass is reached around age 30. After menopause, the drop in oestrogen levels results in accelerated bone loss, with the average woman losing up to 10% of her bone mass in the first five years after menopause. This figure can be up to 20% in some women.
Since low oestrogen levels are the main cause of post-menopausal bone loss, HRT is considered as the first choice for bone health and preventing osteoporosis. A number of studies have shown that MHT significantly increases bone mineral density.
The oestrogen in the combined pill is synthetic, which bone does not respond to. So whilst the pill may possibly disguise or dampen down other menopausal symptoms, it will not prevent a decline in bone stock.
My decision to start HRT was an easy one, despite my menopausal symptoms not being very severe or debilitating. Like most women, I had heard of the supposed increased risk of breast cancer from HRT, but it didn’t take much researching to discover that this wasn’t necessarily something to worry about.
HRT: are there risks?
Dr Keay is a strong advocate for the use of HRT for menopausal women. Whilst it may not be appropriate for those with a history of breast or other oestrogen-dependant cancer, or those with clotting disorders, for most women, it is a safe and effective form of treatment.
“There has been a lot of misinformation and scaremongering about HRT,” Dr Keay notes. “During the original trials in America some time ago, it seemed like a lot of women (on HRT) were getting breast cancer. But when it was looked into in more detail, the problem was that the women were started on HRT way after the menopause, in their 60’s. So if you are going to try HRT, I recommend to start it as soon as possible after your periods stop or your symptoms are getting bad”.
Since then, further research has shown the risk is much lower than originally stated. An article in the British Medical Journal in 2020 stated that whilst there is a slight increase in risk of breast cancer if taking HRT, it is 6 times more if you are overweight, not exercising, smoking, or drinking. Also HRT decreases overall mortality (risk of dying) from cardiovascular disease.
Another reason to commence HRT was to minimize muscle mass and strength losses, which of course could adversely affect cycling performance. Muscle mass in women tends to decrease gradually after 30 years of age, then shows an accelerated decline after 50 - which is known as sarcopenia. An article in the International Journal of Women’s Health in 2022 states that lean body mass decreases by 0.5% per year, while fat mass increases by 1.7% per year during menopause. The loss in estradiol (the most potent and abundant type of oestrogen) is believed to be the most important contributor in menopause-associated loss of muscle mass, due to its effect on satellite stem cells.
Fortunately for me, any loss in muscle mass due to menopause doesn’t seem to have resulted in a decline in my power numbers or cycling performance (yet!). In fact my 5sec, 1min and 5min maximum powers this year have been the highest since I started racing in 2012. Perhaps I have noticed a small change in body composition, and I don’t lift as heavy weights as I did 5-6 years ago, but this is by choice to lessen recovery time and minimize injury.
This was not the case for one of my fellow masters athletes and multiple Australian National Champion, Nicky Rolls, who swore to me that she “lost 100 watts overnight”. On looking through her Training Peaks data, it did seem that her maximum 5sec and 1min powers had dropped quite dramatically and suddenly between 2018 and 2019, the time when she started to experience peri-menopausal symptoms.
So, what does HRT actually entail? Transdermal oestrogen, such as a patch or gel, are recommended over oral forms as it will not need to be processed by the liver or gut and has fewer risks. Women with an intact uterus need to also take progesterone (coil or pills) to prevent build up of the uterine lining which increases the risk of endometrial cancer.
Dr Keay recommends taking oestrogen and progesterone that is less synthetic and as body identical as possible to our naturally occurring hormones, such as Estrogel and micronized progesterone (Prometrium/Utrogestan). Having been recommended exactly the same HRT by a friend who is a medical doctor and competitive masters cyclist, I knew I couldn’t go wrong with that.
Three months down the HRT track, and I have noticed a few slight improvements. My joints are aching far less, although this did tend to come and go anyway before I started HRT. I am sleeping a little better, which is usually attributed to the progesterone taken before bed. As for my bone density, the primary reason I started HRT, I will have to wait until next year for a repeat DEXA scan to assess what further bone losses, if any, have occurred.
However, menopause is not only managed through HRT. There are a number of lifestyle strategies that can be made to offset the effects of menopause especially in regards to nutrition and exercise, as described in Dr Keay’s book Hormones, Health and Human Potential. Important dietary considerations include timing of carbohydrates to fuel training, increasing protein intake, and ensuring sufficient Vitamin D, Calcium and Magnesium. In their book, Next Level, Selene Yeager and Stacey Sims outline the importance of heavy resistance training and high intensity training, more specifically sprint interval training, for off-setting the decline in bone health, muscle strength and body composition that occurs with menopause.
So, next season, the plan is for more strength training, including plyometrics, 2-3 times a week all year round. On the bike, I’m planning more 30sec sprints and 1min intervals, which isn’t a problem since I am naturally more of an anaerobic athlete. All this will likely mean less time on the bike, as older athletes also require more recovery, plus there are limited hours to train!
Finally, I will be telling all my female cycling friends and fellow competitors about menopause and HRT! I realized that I did not actually know much about the finer details of menopause, and assumed it was something to think about “in the future”, when in fact peri-menopause typically starts in our 40’s. Dr Keay agrees that awareness and education is essential to ensure early intervention and eliminate unnecessary suffering, for what is a natural process that every woman will experience in her life.
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