Perimenopause brought minor changes in my periods. Why should menopause be different? After all, weren’t hot flashes just another form of heat training? I was an ultrarunner, conditioned to push through uncomfortable physical sensations. But the associated sleep disruption and anxiety impaired my physical and mental performance. I also experienced less common (but equally disruptive) symptoms, including joint pain and sensory overload. It showed in my training logs, my relationships and at work—once I chose to analyze the data.
I knew I wasn’t alone. More than 75% of females experience menopausal symptoms, and the symptoms typically last 4–8 years. That’s a lot of wet sheets, disrupted sleep and years of not feeling like a runner. But could I do anything to reduce my symptoms?
The answer was a resounding “Yes!” but understanding the pros and cons of various interventions took some research. I found it helpful to group the interventions into buckets,1 progressing from lifestyle changes to non-hormonal therapies and finally, hormonal therapy.
Let’s start with a quick review of the menopause transition, then introduce the interventions.
From puberty until menopause, ovarian follicles produce estradiol and progesterone. Estradiol is the major contributor to muscle growth and strength, bone density, body metabolism and skin health. Progesterone balances estradiol’s effects and triggers the monthly shedding of the uterine lining.
By your early 40s, the supply of follicles is running low. As fewer oocytes mature, progesterone levels decrease and estrogen levels fluctuate. Periods become erratic and irregular. This is perimenopause or the beginning of the menopause transition.
Menopause starts when you have gone 12 full months without a period. The ovaries are no longer releasing eggs, so pregnancy is no longer possible and menopausal symptoms typically increase.
As an ultrarunner, I’d already checked off this box: I was physically active, didn’t smoke and managed stress through exercise. I also tracked my training data digitally and in a written log, so it was easy to identify performance changes. During perimenopause, I tracked period frequency and duration. Later, I added a section about sleep, with quantity (number of hours) and quality (disruptions).
I discovered I was experiencing symptoms more days than not. That suggested my menopause symptoms were disrupting my athletic and life performance. With my training log, I was able to provide symptom dates and duration to my primary care provider. Together, we decided it was time to dip into non-hormonal therapy.
This includes herbs, acupuncture and massage, among other therapies. Many females find these helpful, though studies find no therapeutic benefit. The difference likely comes from the placebo effect; females believed the therapies would help, and that belief creates a beneficial effect. Placebo effect is powerful; as a recent study on menopause therapy concluded, “Beneficial effects of placebos are high in double-blind hot flash trials and….and suggest that honestly prescribed placebos may elicit symptom improvement.”2
Cognitive-behavior therapy is proven to reduce hot flashes and improve moods.4 It is also time-intensive and may not be covered by insurance. Meditation, yoga or mindfulness-based stress reduction may be equally effective.1
Become Hormone Curious
Like many of you, I’d heard about the Women’s Health Initiative and that menopause hormone therapy (MHT) increases risk of blood clots and breast cancer. As an athlete, I’m careful about what goes into my body and certainly don’t want to take medication that might jeopardize my athletic performance or health. Being curious about MHT felt like a failure, that I was giving in and not doing enough to control my symptoms.
Clearly, it was time to re-evaluate this monster-in-my-closet. After a lot of reading, I discovered two very important things. First, sleep disruption has a number of health consequences.3 Second, I had greatly overblown the risks of MHT.
The challenge, if I wanted to do a hormone trial, was determining what formulation to take. Estrogen provides the therapy, so I started by evaluating the formulations. Topical estrogen formulations (patches, gels and vaginal rings) are applied directly to the skin and absorb directly into the blood stream. The advantages—steady state hormone levels and no increase in the risk of blood clots—were appealing, but the logistics felt daunting.
Oral estrogens, on the other hand, are available in six formulations and a variety of doses allowing lots of room for adjustment. Unlike topical estrogen, oral formulations are associated with a low but increased risk of stroke and blood clots over time.
After reviewing my risks and history with my primary care provider, I elected to start with oral estrogen. It took me less than 48 hours to feel like a runner again. This was a bit atypical, as most females feel symptom improvement in 1–8 weeks.
Once I had the estrogen route and dose, it was time to add a progesterone. Progesterone offsets the effect of estrogen on the uterus by preventing uterine thickening that can develop into uterine cancer. Progesterone is also the hormone associated with PMS.
I would love to tell you that the first estrogen/progesterone combinations didn’t give me terrible PMS-like symptoms. They did. But after a few months of adjustments, I found a combination that resolved my menopause symptoms and left me feeling like a runner again.
I keep my primary care provider updated with how the MHT is working and have regular appointments to evaluate my current therapy, health and symptoms. As new drugs and new studies are available, I have no doubt we will make additional changes.
I also want to note that menopause hormone therapy is a personal decision, between the patient and provider. We know from ultrarunning how differently each body responds to training and racing. While I’ve found MHT helpful, many others do not need (or may not want) hormone therapy. This article just touches the surface of available therapies. The references and resources listed below provide additional information.
- Yaeger, Selene (Host). (2022, August 31). Do you Need Hormone Therapy? (No. 95) [Audio podcast episode]. In Hit Play Not Pause. Feisty Media.
- Pan, Y., et al. (2019). “Non-concealed placebo treatment for menopausal hot flushes: Study protocol of a randomized-controlled trial.” Trials 20(1): 508.
- Institute of Medicine (US) Committee on Sleep Medicine and Research. Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 3, Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK19961/
- The North American Menopause Society. (2020). The Menopause Guidebook, 9th Available from: https://www.menopause.org/publications/consumer-publications/-em-menopause-guidebook-em-9th-edition
- Gunter, J (2021). The Menopause Manifesto: own your health with facts and feminism. Toronto: Random House.
- Sims, ST and Yeager S (2022). Next Level: Your Guide to Kicking Ass, Feeling Great, and Crushing Goals Through Menopause and Beyond. New York: Random House.