Mile 27 Coach Cathy Duffy discusses the impact of menopause on female athletes and what she has learnt whilst navigating her own perimenopause journey. She wants to start a discussion about this time in every woman’s life which can be challenging and confusing, but can also be a time of change and discovery.

I recall one night sleeping in my campervan in the Blue Mountains before heading out for a long run the next morning. It was the middle of winter and beside me my husband was rugged up in full winter attire, under multiple bed covers “freezing”. There I lay in a t-shirt and underwear, with no bed covers, feeling like the Sahara Desert would be a cooler option.

It is difficult to describe the unbearable wave of volcano-like heat that envelopes your body – where one moment you feel like you are dying inside and the next when the heat dissipates, you are diving under the bed covers as your body responds to the temperature around you. Imagine this over and over and over again. In my busy life I did not notice subtle changes until one day I paused and found myself sleep deprived, with brain “fog”, living in a body that just ached, and as a bonus I scored my first injury in ten years. Was I just getting old and my body could not handle running like it used to, or was something else going on?
On reflection, I had never been taught or learnt about menopause. In an attempt to rectify this, I opened my computer, yet found the contradicting information confounding. Even a discussion with my doctor, who informed me they did not deal with hormone replacement therapies, left me bewildered and none the wiser. So, I did two things. Firstly, I attended a Women in Sport Congress, which highlighted the current 100-year research gap between males and females. Thankfully, science is forging ahead with a vast array of dynamic and curious groups intent on carving out information pertaining to women. Secondly, I enrolled in a science-based menopause course (Dr. Stacy Sims | Menopause 2.0 Course (drstacysims.com) to plug my learning deficit. As I progressed through the course I was impressed at the scientific fortitude of the presenting information, which perhaps highlighted why there is so much confusion in Google-land. It is a complex topic and can be hard to tease out simple, yet accurate, information.

As a perimenopausal ultra-trail athlete, this is what I have learnt, and what I would like to share with others.

Let’s talk about it

Think about your relationship with menopause. In your social arena, is it something that is readily spoken about? Do you talk about menopause with your running buddies? If so, how is it framed? The reality is that society has come a long way from considering a menopausal woman a witch or mentally incapacitated, but society still has a long way to go towards ensuring access to robust information, with open dialogue and acceptance, that menopause is not a curse.

So what is menopause

Menopause is used by many as an umbrella term to describe the transition from perimenopause to post-menopause. In reality, menopause is one day on the calendar, which marks 12 menstruation-free (without a period) months and occurs on average at age 51.
Leading up to this specific point in time is perimenopause, which can last up to 10 years. It is during this time the ratios between two main hormones start to shift, which can result in a myriad of symptoms, often highlighting entry into this stage of life.
After menopause you enter post-menopause which is the new biological state for a female. For some, symptoms experienced during perimenopause can persist for years.

Key hormones

Understanding the intricacies of female hormones is complex. There are multiple key hormones influencing the reproductive years, with the main stars of the show being estrogen and progesterone. These hormones have a reciprocal relationship to provide balance in the female body. For example, estrogen promotes inflammation, whilst progesterone has anti-inflammatory properties, creating balance. This symbiotic relationship is akin to ensuring your ultra-training program includes a balance between running and recovery to optimise your athletic potential.

What happens to your hormones during perimenopause
A lot happens. To (over) simplify a very complex topic, these are the key takeaways:

• Estrogen is a dominant female hormone.
• Estrogen receptors are in almost every system of the body, so the presence or absence of estrogen impacts the whole body.
• Progesterone is another female hormone. Progesterone works with estrogen to provide balance in the body.
• During perimenopause, estrogen and progesterone levels change, and the ratio between these hormones also changes, which can result in varying symptoms.
• After menopause, estrogen and progesterone levels flatline. This is the new biological state for the female.
• Do not forget other hormones impact the female body. For example, testosterone also works with estrogen and generally has a slow rate of decline with age (unlike the faster rate of decline of estrogen and progesterone). For some, however, it can decline at a faster rate, further impacting the female body.

To follow on from the example regarding inflammation, during perimenopause estrogen can become more dominant relative to progesterone, thus increasing inflammation. Is that why I’m always achy and it is not just the training?!
Given that the estrogen and progesterone relationship changes and then flatlines, what is the impact of this? As these hormonal powerhouses impact the muscle, bone, brain and metabolic systems, the impact can be significant.

Our muscles – we need you strong
I think we can all agree our muscles are important, not only as endurance athletes, but as we age. As our body progresses towards its new biological state, the impact on the muscles is significant:

• Muscles break down easier (catabolism).
• It becomes harder to build lean muscle mass (how much muscle you have).
• The strength of muscle contractions and number of muscle fibres reduces.
• The muscles’ response to previous training stimulus is reduced.

This is yet another example of how ratios are important in the body. During perimenopause muscles begin to breakdown more quickly than they are built, making it harder to maintain and increase lean muscle. Reflect on this for a moment. In a physical activity that relies heavily on the strength and endurance of our muscles, what does this mean for our longevity in the sport? Do we need to adjust our ultra-training?

One of my biggest learnings, where the proverbial hammer hit me hard, was the training stimulus once used to promote muscle growth and repair was now less sensitive. We now need new ways to build lean muscle and strength.

Our bones – don’t fracture this relationship
Are you prone to stress fractures? Did you have a fall on the trail that didn’t seem like a big deal but ended with a fracture? Bone health is exceptionally important. During perimenopause our bone mineral density can decrease making our bones weaker and more susceptible to break and osteoporosis more of a risk.

Our brain – what was I thinking
As ultra-endurance athletes we pride ourselves on the strength of our minds. As the adage goes, a large proportion of ultra success relates to mental fortitude and the ability to keep going despite physical discomfort. So what happens when our brain has other plans?
Our brain is powerful and controls many things. Some of the changes that can be experienced during perimenopause include:

• A decrease in serotonin (‘happy hormone’) uptake. This impacts many things including mood, digestion and sleep. Think about that for a moment. This one pathway alone can increase your risk of depression, anxiety, brain fog and gut issues.
• The temperature control centre in the brain (hypothalamus) is impacted. Did someone say, “hot flush”?! You may also find you heat up faster and your ability to cool down changes. You may also sweat later in a training session.
• Pain tolerance levels change.
• Appetite regulation is also impacted.

Metabolic changes – how we use fuel

Numerous metabolic changes occur during perimenopause, with many of these altering your body composition, including:

• Decreased lipid (fat) removal rate resulting in increased body fat with a focus on visceral or “belly fat”. Where you once may have stored fat on the hips and thighs, it is now stored in your belly which can increase your risk of cardiovascular and fatty liver diseases.
• Decreased insulin sensitivity/increased insulin resistance leading to increased circulating blood glucose. As your blood glucose levels entertain the proverbial highs and lows life can offer, this can leave you feeling hungry, fatigued and storing more fat.
• Decreased reliance on carbohydrates for fuel. The body does not use glucose (for fuel) like it used to; it now wants to store more of it as belly fat.

For ultra-athletes this can now challenge the way we fuel our bodies, not only during training (did someone says gels-a-plenty) but day to day.

As an added bonus
It is worth noting that many of the above can lead to:

• Increased total body inflammation.
• Increased injury risk.
• Increased sympathetic drive (fight or flight response) which leaves you feeling ‘tired but wired’.
• Altered gut microbiome diversity. This is a big one impacting so much in the body:
  • In the gut are a bunch of microorganisms (bugs). These microbes are important as they help digestion, improve energy, help brain tissue growth, impact body composition, plus many more benefits.
  • As your hormones decline, these microbes seep through the intestinal wall increasing systemic inflammation whilst decreasing the diversity of the bugs left in the gut. So now you are left with digestion problems, fatigue, impaired brain tissue growth and changes to body composition (to name a few)

In a nutshell
As time marches on, the female ultra-endurance athlete may find:
They are more prone to injury.
It is harder to maintain or build lean muscle mass.
Their body changes with it now storing weight around the belly.
Motivation for training is low due to sleep deprivation, depression, anxiety or body aches.
Training during the warmer months, or for hotter events, now feels harder.
Energy levels during and outside training are lower.
They have an unhappy gut.

What now
The menopause path is crossed by us all. Whether personally (yourself or someone you know) or professionally (perhaps you are coaching female athletes) it pays to engage and work with health professionals (eg doctor, sports dietitian) that understand menopause and available treatment options.
Whilst some of the above can seem overwhelming, it is important to note that knowledge is power. Just like you train differently for different running distances, different physiologies also require different attention. So, it is not necessarily bad; it is just different.

Interventions

Some enter menopause without any symptoms, while others experience symptoms which have a significant impact on their life, causing them to hang up their running shoes. There are things we can do to assist with the symptoms of perimenopause and beyond. These include menopausal hormone therapy (hormone replacement therapy), non-hormonal prescription medications and complementary alternatives (adaptogens).
The correct and safest path is highly individual and needs the help of a professional. This is why it is important to establish appropriate health relationships early to minimise impacts throughout the menopause journey.

So what does menopause mean for training for an ultra

Muscles and Bone 
The way we train to optimise lean muscle, maintain bone density and body composition looks different when you enter perimenopause. Where you could once rely on estrogen and its counterparts (including testosterone) to maintain the integrity of our musculoskeletal system, we now need to apply external stressors for the same effect. We can do this by performing high intensity interval training, plyometric exercises and heavy lifting sessions. Does this mean all sessions have to fit this? Definitely not, but those high intensity and strength sessions your coach wants you to do become even more important.
It is worth noting that functional strength/plyometric programs, which include multidirectional movements (mirroring trail running), not only promote strength to ensure optimal trail prowess (as we jump over logs and hop from one rock to the next), but they also improve our bone strength, as the application of force on the bone is varied. So, if you struggle with consistently completing strength programs (I may have been guilty of this in the past), bump it up the priority list and reap the rewards of stronger bones.

Nutrition
During perimenopause your macronutrient (think carbohydrates, protein and fats) requirements may change. Your body does not utilise carbohydrates like it used to, your gut microbiome is altered and the protein you ingest is used less effectively, therefore what you eat and when you eat becomes more important.

So, what do we then eat? As an ultramarathon coach I am not an expert in nutrition for menopausal women, so I consulted with Sylvia Pfeffer (Accredited Sports Dietitian/Accredited Practising Dietitian). During our discussion it was highlighted that there is limited literature guiding nutrition standards for the mature female athlete and nutrition is also highly individual. The quality and quantity of foods consumed during menopause becomes key, and oftentimes requires expert consultation to guide practice.

Navigating what to eat can be overwhelming and we do not want people counting calories and obsessing over their daily intake. If you want a starting point, think about protein intake. The application of external training stressors (discussed above) to improve lean muscle mass is only one piece of the puzzle. Protein dosing around exercise enhances the body’s response to building lean muscle. This is what we want. It is important to not only consume protein throughout the day but prioritise the consumption of protein (and carbohydrates) immediately post-exercise.

External exercise stress + protein dosing after exercise → extends the window where the body will build lean muscle

Most endurance athletes are aware that training the gut and practising race nutrition is important. There is so much individual variation, so nutrition needs to be tried and tested. As female athletes age, it is important to consider that what may have worked in the past may no longer have the same impact. Becoming aware of energy intake and the body’s response to what is ingested during training is important. Remain flexible and adapt as required.
Some female athletes may struggle with body composition. Where once they were lean from running, they now have less muscle and carry more weight. To lose weight they may find themselves consuming insufficient energy to meet their daily metabolic and training needs. This is referred to as low energy availability (LEA). There are long-term impacts associated with LEA, many of which mimic menopausal symptoms, further compounding the impacts of menopause. If you struggle with LEA or find circumnavigating the world of nutrition challenging, contact a sports dietitian to take the guesswork out of what you eat.

Is there anything else we can do

Sleep
There is a lot of science behind why sleep becomes challenging during the hormonal shifting years. We know sleep is restorative, allowing for recovery and repair from what we throw at our bodies (and as endurance athletes, that is a lot). So how do we get a better sleep? Given there are multiple reasons for sleep disruption, the solutions are varied. They range from having a sleep friendly bedtime routine (no caffeine, alcohol or screen time prior to bed, having a cool room and regular sleep time) to targeting menopausal symptoms (once I managed my hot flushes I slept better) and supporting medicinal therapies. Yep, another example of when to consult with a health professional.

What am I doing differently
I have become more aware of my protein intake (it was way too low) and when I consume protein in relation to training.
I have prioritised sleep (where I can) over early morning training sessions.
I have become more consistent with strength training.
I am still in the process of finding a menopause-informed health professional. This has been surprisingly challenging and therefore why I recommend starting early.

Acknowledgements
Much of the information presented was from learnings from the following course:
Dr Stacy Sims Menopause 2 0 Course
I also reviewed the chapter on menopause in Dr Stacy Sims’ book ‘Roar’.
Thank you to Sylvia Pfeffer an Accredited Sports and Practising Dietitian for her review of the nutrition component of this article. If you require her expertise in all things nutrition, you can find her here:
Sylvia Pfeffer – Apple to Zucchini