how you can help your mid-life clients
Menopause can be a game-changer when it comes to health and fitness. By understanding how it affects women in their mid-life years, you can make a difference to how your clients feel, how they look and how they stay healthy.
I call menopause the ‘game-changer’. Not only because, for some women, their quality of life is severely impacted by the symptoms of menopause (more about this soon), but also because, for some, this is the time when it doesn’t matter how active or ‘healthy’ they have been in the past: menopause navigates its own path, causing all sorts of havoc on hormones and metabolism.
For many women used to good health in their past, the transition into and through menopause can be fraught with challenges, not only internally but also externally, in the form of fat depositing in places that it hasn’t previously done.
For fitness professionals, especially personal trainers, training menopausal women can be challenging, not only in terms of understanding the support that some female clients need at this time, but also in terms of what works and what doesn’t when it comes to exercise and nutrition prescription.
Here, we explore why and how menopause and post-menopause are critical events for the health of women and why, now that hormone replacement therapy (HRT) is no longer in vogue, finding new ways to manage menopause matters.
Understanding the menopause transition
While menopause is a natural process that occurs in women’s lives as part of normal ageing, for some women this transition can be quite disabling. Defined by the World Health Organisation (WHO) as the permanent cessation of menstrual periods that occurs naturally or is induced by surgery, the Greek derivative is men (month) and pausis (cessation).
The years preceding menopause that encompass the transition from normal menstruation to cessation are termed the peri-menopausal years and are generally characterised by irregular periods. On average, in non-surgical menopause, peri-menopause begins around the late forties and may last up to four years, but it is well known that smokers begin to transition into menopause about three to four years earlier than non-smokers. The Massachusetts Women’s Health Study of over 2,500 women found the mean age of menopause to be 51.3 years, and this hasn’t changed since ancient times.
Post-menopause begins at the time of the final menstrual period, although it is often not recognised until after 12 months of a woman’s periods ceasing. This cessation of menses is known medically as the climacteric, the end of a woman’s reproductive potential. With the huge decrease in oestrogen levels that occurs at this time, it is no wonder that, for some women, havoc is wreaked on the endocrine (hormonal), psychological and somatic (bodily) systems. This is the time when thousands of women may spiral into negative health changes, which may affect how healthy they will continue to be as they age.
Let’s examine these changes and take a look at why it can be a time of physical and psychological chaos.
It’s all about the hormonal cascade
In the peri-menopausal transition, women experience an accelerated loss of ovarian follicles. This can take from two to eight years. With the human endocrine system working as a negative feedback loop (i.e. when a single hormone production is decreased or increased it influences other hormone production in the body), this subsequently has an effect on the amount of follicle-stimulating hormone (FSH) released from the pituitary gland. FSH simply tells the ovary to recruit eggs, and oestrogen is made by the developing eggs. In normal ovulation another hormone, luteinising hormone (LH), works in tandem with FSH in oestrogen-producing ovulation. This cycle forms the normal menstrual cycle in younger women.
As peri-menopause approaches, however, the ageing ovaries become less responsive to FSH. As such, the amount of FSH rises 10 to 20-fold as more and more FSH is released by the pituitary gland to ‘bribe’ the ovaries into responding. LH is cleared from the blood faster, so the real culprit in peri-menopause – causing havoc on menopausal symptoms during this time – is FSH, and for some it can go on for years.
As a woman hits her fifties, fewer and fewer follicles respond. The overwhelming effect of this is that the amount of oestrogen made begins to decrease significantly. This drop in oestrogen (which is quite dramatic in some women, especially those who are already overweight) can often be the start of the chaos that some women experience at this time, both physically and psychologically.
Another hormone, progesterone, is also implicated in all of this turmoil. In the younger menstruating female, progesterone is made by the cells of the uterus to ready it for receiving a fertilised egg. Progesterone is the hormone of pregnancy and in peri-menopause progesterone levels also fluctuate. Although this uneven rising and falling of various hormones can impact hugely on how your client may be feeling at this time of peri-menopause, it is post-menopause that the real health impacts might occur.
Hormone production after menopause
Once menstruation stops completely for 60 days or more (amenorrhea) there are few remaining ovarian follicles. This doesn’t mean that the ovaries cease functioning, however. Post-menopause, the ovaries continue to secrete hormones, although not oestrogen. These hormones are androstenedione (derived mainly from the adrenal glands, but these do decline with ageing) and testosterone.
Androstenedione is the precursor to testosterone production, as well as oestrones and oestradiol which make up oestrogen. The adrenal glands and ovaries each produce about 3mg a day of androstenedione in pre-menopausal women. After menopause, however, the production of androstenedione in the adrenal glands generally halves. The impact of this in a post-menopausal body is that a range of symptoms begin to be experienced. It is these symptoms that, for many women, define how menopause is experienced. For women who are particularly sensitive to these changes in hormones, it’s not only irritability and depression that set in, but also weight gain around the mid-riff and poor sleep patterns, as well as exhausting hot flushes and night sweats.
Hot flushes and night sweats
Sometimes known as ‘hot flashes’ these are clinically defined as an instability of the vaso-motor system. This is the system that is driven by the adrenal glands through the sympathetic nervous system and controls blood pressure, including the dilation and constriction of blood vessels.
Hot flushes and night sweats are the hallmark of menopause for many women. Reddening of the face, a sensation of heat and, in some women, profuse sweating, drive many women to despair and, because they commonly occur at night, hot flushes can be a major cause of insomnia.
While very little is known about the causes of hot flushes (apart from decreased oestrogen production), they may be bought on by stress (the adrenal glands control your stress levels) and even hyperglycaemia (high levels of blood glucose). This makes sense when we think about the adrenal system and the influences of all the endocrine glands as a negative feedback system.
As a fitness professional, it is important to understand that clients who are having moderate to severe and frequent hot flushes are also experiencing general inflammation in the body. Add this inflammation to a poor diet and little or no (or, sometimes, too much) exercise, and you have the accumulation of inflammation in other parts of the body, such as the joints.
With diaphragmatic weight gain, poor sleep patterns and low energy, what ensues is a jigsaw of metabolic changes that are difficult to isolate. Although hormone replacement therapy (HRT, which was developed to mitigate the symptoms of hot flushes and night sweats) may help, recent evidence from the Women’s Health Initiative Study linking long-term use to breast cancer has resulted in the use of HRT becoming somewhat curtailed.
The metabolic chaos that menopause can cause negatively impacts women’s health. Two of the main health concerns are to do with the higher risk of cardiovascular disease in post-menopause women, as well as insulin sensitivity and insulin resistance.
With regard to cardiovascular disease, the main culprit is, again, oestrogen. Low oestrogen has an effect on the sympathetic nervous system, specifically the blood pressure-lowering receptors that control vaso-dilation and calcium channel opening in smooth muscle cells. Low oestrogen causes this mechanism to be lost. Put this alongside diaphragmatic weight gain, and blood pressure starts to rise in post-menopausal women, increasing their risk of heart disease in older age.
Insulin sensitivity is another concern for post-menopausal women. It is known to worsen with advancing age and increasing central obesity (diaphragmatic obesity in menopausal women), thereby making it difficult for some women who are already overweight or obese to tease out the effects of menopause.
Some studies show that an increase in body fat, low exercise, loss of muscle and poor sleep (which drives up another hormone, cortisol) sends many menopausal women spiralling into ‘metabolic syndrome’. This is the name given to the cocktail of clinical disorders, including obesity, insulin resistance (the inability of muscle cells to allow insulin to move glucose into them), high blood lipids (hypertriglyceridemia) and high levels of low-density lipoprotein. These symptoms seem to be exacerbated in women who are already overweight or obese as they head into menopause and who have what naturopaths often refer to as a ‘fatty liver’. The change in levels of circulating FSH has been positively correlated with the change in central fat mass.
As fitness professionals, it is important therefore to understand that some women who have exercised regularly in the past and maintained a healthy weight could gain weight as they transition through and into menopause. Not only does this diaphragmatic weight gain increase their risk of cardiovascular disease three-fold, but low oestrogen also causes the loss of bone-building calcium, thus increasing their risk of developing osteoporosis.
Managing menopause in your training clients
When it comes to managing menopause in your clients, it is a case of ‘different strokes for different folks’. For some of your menopausal clients, you might not have to change a thing. For them, menopause is a breeze and they are asymptomatic. For others who are having a hard time of it, however, the following strategies may be useful. By no means are these definitive, but they can allow you to empathise with and support your menopausal clients in ways that may make a difference to how they feel, how they look and how they stay healthy.
1. Put sleep strategies in place
If your client says she is tired, she is. You can’t train a tired client effectively. It’s that simple. While your client may not tell you that she is having difficulty sleeping due to hot flushes and night sweats, it’s your job to at least ask. Try to set in place some sleep strategies. Advise her to use a fan by the bed at night; to avoid caffeine before bed; to keep the room dark; to go to bed earlier and get up earlier to re-adjust her natural diurnal rhythm (melatonin supplements may also help); and demonstrate some pre-bedtime deep breathing strategies to alleviate sympathetic nervous system activity (especially palpitations).
2. Focus on food
There is a host of information about dietary choices available, but without going into too much depth, your symptomatic menopausal client needs to focus on nutrition. Specifically, a Mediterranean-style diet, which is known to be anti-inflammatory, is beneficial. This means no refined foods, high protein (up to 30 per cent of daily intake) and low-glycaemic foods (e.g. low sugar and white-starch). This type of diet supports the maintenance of normal blood glucose levels, keeping insulin secretion by the pancreas low. By adhering to this way of eating, and drinking sufficient water (at least two litres a day), some women are able to control insulin production, and thereby partially alleviate the severity of hot flushes and night sweats.
3. Increase isoflavones and other phytoestrogens in the diet
A substantial number of studies of phytoestrogens and isoflavones have been conducted, motivated by epidemiologic data showing differences in menopausal symptoms in countries with different levels of these nutrients in their diets. Several studies of soy extracts suggested that they may have some mitigating effect on hot flushes.
4. Adapt your client’s training to match how she feels
Adjust your programming to moderate aerobic exercise, which is proven to reduce blood pressure. Prescribe appropriate resistance training exercises. If your client has poor sleep patterns, then back off the HIIT (High Intensity Interval Training) until she has greater daily energy. While HIIT is well evidenced in assisting in weight management, your menopausal client may have low iron levels, low calcium and magnesium levels and poor thyroid function, as well as high cortisol through lack of sleep. A blood profile such as this doesn’t bode well for recovering from HIIT sufficiently.
5. Explore the use of botanicals
The Women’s Health Study has investigated a number of botanicals on the market in relation to their potential to affect menopausal symptoms. The ones most popular, but not always evidenced as effective in mitigating hot flushes, seem to be Black Cohosh (Actacea racemosa), Kava (Piper methysticum) for anxiety reduction, Red Clover Leaf (Trifolium pretense) and Ginseng root (Panax ginseng). However, you should never suggest botanicals to a client without telling her to check with her doctor, as some medications contraindicate botanicals.
While this article has focused on the physiology of menopause, including strategies for managing it, there also exists a host of qualitative studies that explore the subjective dimension of menopause and what it means to women. In addition to exploring the practical strategies outlined above, as their fitness professional you might also reflect on how your female clients feel about their transition through menopause, and talk to them about the support they may require from you at this time of their life.
Wendy Sweet, MSpLS is a fitness industry educator, consultant and resource developer. In 2014 she was named Australian Fitness Network’s Author of the Year in recognition of her contribution to the ongoing education and upskilling of fitness professionals.