When the symptoms started, I had no idea what was wrong. I was experiencing heart palpitations, my joints and muscles ached. Even easy runs felt laborious, as if I was carrying an unseen weight. I felt low, too. Where had my mojo gone?
Unsurprisingly, these symptoms wreaked havoc on my running performance, so I began to race less often, and then not at all. I saw my GP, hoping to identify this mystery run-wrecking disease and was sent for tests: thyroid function, iron levels, etc. Nothing appeared to be wrong with me. I’m just past it, I thought.
Now I know different. I wasn’t ill, or old; I was menopausal. Of course, the ageing process does impact performance, but the menopause years are particularly ravaging, mentally and physically. In a Runner’s World poll, 83% of female runners said menopause had affected their running. So it’s important both we and our loved ones understand what we’re up against.
Menopause has only recently begun to get the attention it deserves, after decades of being disregarded by the medical establishment and belittled with terms like ‘women’s problems’ and ‘the change.’ In a 2022 survey by the Fawcett Society, 44% of working women reported that their ability to do their job had been affected by the menopause and its symptoms, yet 41% had witnessed it being treated as a joke in the workplace. The upsurge in interest is thanks, in part, to public figures like Davina McCall, Michelle Obama and Mariella Frostrup talking openly about their experiences. A TV documentary McCall made in 2021, Sex, Myths and the Menopause, had such an impact on British women – including a 30% increase in demand for HRT – that it was dubbed the ‘Davina effect’.
‘It’s great that there’s finally a conversation about menopause so women are educated and informed and can make the right choices about how to navigate it,’ says Dr Sam Brown, a menopause specialist and co-director of the Bronte Clinic in London.
Kate Muir, producer of the McCall documentary, went on to write Everything You Need To Know About The Menopause (But Were Afraid To Ask), a book that taught me many things I wish I’d known sooner – what was happening to me? Was it normal? How long would it go on? How could I mitigate the symptoms? It wasn’t so much a matter of being too afraid to ask as simply not knowing I needed to.
Once I started to discuss what Muir calls the ‘sledgehammer’ of symptoms with other runners, I realised there was an army of us struggling with joint pain, extreme fatigue, the sudden onset of soft tissue injuries, sleeplessness, heart palpitations, weight gain, loss of motivation and more. ‘Longer runs have become a real struggle,’ said one. ‘I’ve had to pull out of races because I found the training so tiring.’ Another, who had previously run marathons and ultras, said she sometimes found it difficult to shuffle around the block due to extreme tiredness, dizziness, nausea, hot flushes and excessive sweating.
The official definition of menopause is when a woman has gone twelve months without a menstrual bleed, signifying that her ovaries are no long producing oestrogen or progesterone. The average age of menopause in the UK is 51, with the normal range considered to be 45-55. The extended period that leads up that point (known as perimenopause or menopause transition) averages four to seven years, and is a time when fluctuating hormone levels can knock you for six mentally, physiologically and in terms of musculoskeletal health.
The overwhelming majority of women (estimates range from 75%-90%) experience menopausal symptoms. According to the British Menopause Society, around one third suffer symptoms lasting seven years or more, while the Fawcett Society survey found 77% of women had at least one symptom they found ‘very difficult’, and 44% described three or more this way. Any common menopausal symptoms – bloating, hot flushes, heavy or erratic periods, brain fog or sleepless nights – can affect your running, but some are likely to have a more direct impact.
Perimenopausal
Back in my perimenopausal days, I pulled out of a 10K convinced there was something wrong with my heart. The beating was fluttery and irregular, and I felt weak. The St John’s Ambulance team monitored me briefly but saw no cause for concern. It was only recently I learned that 41% of women experience heart palpitations during menopause transition. ‘Declining oestrogen can increase heart activity and lead to erratic beats,’ says Brown. ‘It can also raise levels of the stress hormone cortisol, leading to palpitations.’
Aching joints and sore muscles – sensations you might associate with DOMS – are also common (again, thanks declining oestrogen), with the Fawcett survey showing 67% of menopausal women experience them. ‘Too often, this kind of pain isn’t identified as being menopause-related,’ says Brown. ‘Partly because it’s one of the earliest symptoms, so there aren’t other tell-tale signs.’ This is even more likely if you’re a fit, healthy runner, as you may not be experiencing weight gain, hot flushes or sleeplessness, leading you to dismiss menopause as a cause. If you’re in the ballpark of perimenopause or menopause and start experiencing what Dr Brown describes as ‘feeling old in the mornings’, it’s worth addressing.
Then there’s that overwhelming fatigue. A staggering 84% of menopausal women experience exhaustion and/or sleeplessness. ‘Constant sleep problems can lead to a vicious circle of fatigue and subsequent inactivity,’ says Muir, a lifelong runner. You’re too tired to run, your fitness slides and when you try getting back out there, perhaps having gained weight, it’s even harder. It’s enough to dent the most committed runner’s dedication, but when accompanied by depression or anxiety (69% of menopausal women) or brain fog (73%), it’s no surprise that motivation goes AWOL. ‘I’ve gone from running five times a week to once,’ one woman told me. Another said: ‘On a good day, only one thing hurts.’
Weight gain is a fact of ageing irrespective of menopausal status, but research published in the journal JCI Insight revealed that while women were gaining weight at 0.25kg per year before perimenopause, this almost doubled to 0.45kg during perimenopause. Their loss of lean muscle mass also accelerated.
These bodily changes and their effect on our physical prowess can have significant psychological impact, especially on those who’ve always invested in being fit. ‘We’ve got the physiological changes, musculoskeletal changes, neurological changes – but we also need to talk about the emotional side,’ says Amanda Thebe, a personal trainer and affiliated member of the North American Menopause Society. ‘Women can lose belief in themselves when a 10K race suddenly takes four days to recover from [plummeting oestrogen levels affect muscle recovery and repair] or running at the same effort produces a slower pace. The effect can be huge.’
Light at the end of the tunnel
It’s worth pointing out – and bear with me here – that there’s a certain comfort in knowing just how debilitating and widespread menopausal symptoms can be. You’re not going mad. You’re not becoming decrepit. You’re not all washed up. You are menopausal.
What’s more, it won’t last forever. Polish research shows that while risk of depression is two to five times greater during menopause transition, this is no longer the case post-menopause. As for cognition, a large long-term US study found disturbances to memory, information-processing speed and attentional focus (aka brain fog) during perimenopause resolved post-menopause. Hot flushes and night sweats, collectively known as ‘vasomotor symptoms’, typically last around seven years in total, persisting for an average of 4.5 years post-menopause. And while weight gain and muscle loss accelerate during menopausal transition, the JCI Insight study mentioned above found this slowed post-menopause. ‘The menopause isn’t a cave, it’s a tunnel – with light at the end of it,’ says Thebe, author of Menopocalypse: How I learned to Thrive During Menopause and How You Can Too. Thebe admits to eight ‘shitty’ years , with depression, migraines and a nagging Achilles injury. But four years post-menopause, she’s now symptom-free. ‘I’m back,’ she says. ‘It’s different, but I’m running again, I’m stronger than ever.’
Many women – both with and without Hormone Replacement Therapy (HRT) – talk of having come out the other side of menopause, feeling better and rediscovering their running mojo.
The fact that you’re already a runner means you enter menopause in a positive state of health and fitness, which not only seems to have a mitigating effect on symptoms but is also crucial for long-term wellbeing. A study published in the journal Menopause found that sedentary women experienced more severe menopausal symptoms than active women, while other research suggests exercisers suffer less sleeplessness and sleep disturbance, less mood disruption and less weight gain during menopause transition. Research also shows that regular exercise not only combats midlife weight gain, but attenuates the characteristic shift from gynoid (hips, thighs and buttocks) fat storage to visceral fat storage, which is associated with increased incidence of metabolic, cardiovascular and other chronic diseases. The evidence is equivocal regarding hot flushes and night sweats – with some studies reporting that regular exercisers suffer fewer of these, but others finding no difference. (My night sweats were horrendous, but I’ve never experienced a hot flush to this day.)
Of course, the health benefits of exercise extend beyond menopause: in a 2020 study post-menopausal women with high levels of physical activity reported better mood, greater life satisfaction and fewer depressive symptoms than their low physical activity counterparts. So you definitely want to keep your running habit as you transition through menopause. But how?
Listen to your body
‘Learning to work with your menopausal body is key,’ says Thebe. ‘Runners love structure, but there’s a tendency to stick doggedly to a programme, regardless of how you’re feeling. Your plan might say three 10km runs a week, but your body’s screaming “will you listen to me please!”’
The most problematic time for symptoms is perimenopause, when oestrogen and progesterone levels are erratic. ‘You never know what each day will bring,’ says Thebe. This is what prompted her to introduce ‘structured flexibility’ into her training. Her Structured Flexibility chart (see pXX) prompts you to grade your energy level from 1-10, and adjust your workout accordingly. ‘It might mean a walk instead of your planned 5K after a sleepless night, or running drills on days when you’re too exhausted to run,’ says Thebe. ‘When we work with the body, rather than fighting against it, we start to see improvements. We no longer feel like we’re failing.’
It’s not just with exercise that we need to work with our bodies, it’s also nutrition. ‘In the past, you might have got away with a scattergun approach, but now, appropriate nutrition and rest to support your workouts are non-negotiable,’ says Thebe. ‘That means not being fearful of carbs – the body’s preferred fuel source for long-distance runs – and ensuring you get adequate protein in your overall diet, and especially post-exercise, for repair and recovery.’
The body becomes less efficient at muscle protein synthesis during menopause, which is why European guidelines recommend women over 50 consume slightly more – 1-1.2g protein per kg body weight per day. They note that optimal protein intake combined with exercise 3-5 times a week produces a greater degree of muscle protein synthesis than either one alone. For post-menopausal musculoskeletal health, the guidelines also recommend 1000mg calcium and 800 iu vitamin D.
Women who experience heavier or more frequent bleeds as their hormones fluctuate in perimenopause can become low on iron, adding to fatigue. ‘Women should look out for symptoms of iron deficiency, which include chronic low energy, irritability and trouble thinking, which may be put down to brain fog,’ says Elizabeth Ward, a registered dietitian and co-author of The Menopause Diet Plan: A Natural Guide to Managing Hormones, Health and Happiness. But don’t take iron supplements ‘just in case.’ ‘Iron status is most accurately measured through a blood test,’ says Ward. And post-menopause, research suggests that iron levels tend to increase, since there’s no longer any blood loss through menstrual bleeds. ‘Experts advise postmenopausal women to avoid taking supplemental iron because iron needs decrease after menopause,’ adds Ward.
Resistance and strength training during menopause
While aerobic exercise, like running, plays an important role in menopausal health (and midlife sanity), there’s compelling evidence that strength/resistance training is also vital. ‘Strength training enables us to hold on to, or even increase, muscle mass,’ says Thebe, ‘which helps maintain healthy body composition, reduces injury risk and aids recovery.’ A recent study published in Climateric (the journal of the International Menopause Society) also found that regular resistance training reduced hot flushes and improved quality of life in menopausal women.
Strength training is also key for bone health – vital, as researchers describe the three-year period spanning the final menstrual period as the ‘phase of rapid bone loss’. Though not as beneficial as strength work, running also has a positive effect on bone density, and it’s recently been shown that high-intensity work is far more beneficially impactful (pun intended) on bone health than long steady runs.
Dr Brown is another keen advocate of strength training, along with activities to maintain flexibility and balance, such as yoga and Pilates. Rather than seeing these as yet more things on your to-do list, consider them tools in your armoury. When long runs don’t feel doable, focus on short sprints or strength training – which stimulate muscle growth – rather than endurance work, which depletes energy and requires extended recovery. When you’re too exhausted to run, build core strength with a Pilates session.
Injury risk during menopause
It was as a running coach that I first noticed women of menopausal age seemed to be getting more than their fair share of injuries. My own menopausal transition was accompanied by nagging high-hamstring pain and intermittent plantar fasciitis; and a third of the women I spoke to said they’d experienced unaccustomed injuries, most commonly tendinous ones, such as the hamstring, gluteal and Achilles tendons.
Until recently, evidence of a correlation between menopause and more frequent injuries was mostly anecdotal; something I’d heard physios and runners talking about but not seen supported by science. That’s beginning to change. ‘There is a growing body of evidence linking reduced levels of circulating oestrogen levels in postmenopausal women with increased risk of tendinopathy,’ says Dr Rachael Mary McMillan, Lecturer in Physiotherapy at La Trobe University, Melbourne, Australia. ‘Research has linked reduced oestrogen levels in postmenopausal women with declines in collagen synthesis and tensile strength.’ The prevalence of Greater Trochanteric Pain Syndrome (pain at the side of the hip or buttock, often relating to one of the gluteal tendons) has also been shown to be higher in postmenopausal women.
Dealing with menopause symptoms
We’ve covered the importance of exercise, good nutrition and of listening and responding to your changing energy levels, body and mood. But what if you’re doing all of that and still suffering some, or God forbid, all the 32 menopausal symptoms listed on the Menopause Support Symptom Checker? (menopausesupport.co.uk)
‘Don’t suffer in silence,’ says Dr Brown. ‘I always recommend looking at lifestyle first – nutrition, exercise, sleep, self-care – but women should definitely consider whether HRT might be a good additional option.’
The Fawcett Society survey found that of women who go to their GP and are confirmed as being menopausal, only 39% are offered HRT, even though current National Institute for Care and Health Excellence (NICE) guidelines recommend offering it for some specific menopausal symptoms. The guidelines, however, do emphasise the importance of an individualised approach – something Brown fully agrees with. ‘It’s a very individual decision whether to take HRT and if so, for how long,’ she says. ‘Women need at least an annual review to check on dose, symptom relief and to optimise their lifestyle. We need to review any changes to their medical or family history and ensure we are practising according to the most up-to-date research, which is likely to change in the years to come.’
It's worth taking the NICE guidelines with you to a doctor’s appointment about menopause treatment. A list of your symptoms is also useful. Apps, such as Balance (balance-menopause.com/balance-app/), allow you to log and track your symptoms and download a report. Ask if the practice has a menopause specialist, or check the British Menopause Society website, which lists accredited professionals working within the NHS and privately (thebms.org.uk).
It was sleeplessness (accompanied by crushing night-time anxiety) and perpetual exhaustion that compelled me to bring up HRT with my GP. I was prescribed oestrogen as a patch and progesterone as a pill and my symptoms are now all either much reduced or gone completely. My experience is mirrored by many runners I spoke to. One said that when perimenopause hit, aching joints and weight gain stopped her running altogether. ‘Now I’m on the right dose of HRT, running again and feeling better.’
To HRT or not to HRT?
There’s still a lot of confusion and negativity surrounding HRT, much of which stemmed from the results of the 2002 Women’s Health Initiative Study, which found breast cancer risk was doubled among HRT users, causing widespread panic and abandonment. However, critics have argued that the synthetic hormones used in the study are different from those now prescribed and that the average age of subjects was 63 – long past menopause and, due to advancing age, more susceptible to breast cancer. In addition, many were overweight, which also raises breast cancer risk.
Most modern HRT is ‘body identical’, not synthetic. Derived from yams and with the same molecular structure as hormones produced by the ovaries, it’s considered safer. ‘Body identical HRT uses transdermal oestrogen – in other words, it’s applied to the skin, either in the form of a patch, gel or spray,’ explains Brown. If you still have a uterus, transdermal oestrogen is accompanied by micronised progesterone (Utrogestan), also derived from yams, taken orally.
HRT patches that contain both hormones – body identical oestrogen plus synthetic progesterone – are also still prescribed, but, says Brown, this doesn’t suit all women and won’t allow the individual hormone levels to be manipulated separately to tailor to each woman’s needs.
Dr Brown says that HRT has been a gamechanger for her own menopausal symptoms and among her patients, she has seen improvements in brain fog, sleep, joint pain, hot flushes, libido, training capacity and motivation. ‘The benefits outweigh the risks for most women,’ she says.
Not all women want or are able to take HRT, however. Thebe found it made her symptoms worse. There are many non-hormone prescription medicines available for vasomotor and psychological symptoms, as well as herbal remedies, (though you should discuss using these with your doctor). A high dietary intake of phytoestrogens, which occur naturally in soya products, has also been shown to be effective in reducing vasomotor systems, but the evidence isn’t strong enough for it to be recommended in the NICE guidelines.
Post-menopause and running
The rocky road of menopause doesn’t go on forever, but post-menopausal absence of the associated hormones does, with an unequivocal impact on cardiovascular and bone health. Increasingly, there’s discussion about the potential role of HRT in mitigating these risks in the long term. For example, 9 out of 10 studies reviewed by NICE showed a lower risk of fracture, or increased bone mineral density with HRT use; while a study published in the Journal of Women’s Health looking specifically at the effect of transdermal oestrogen found some evidence of a possible protective cardiovascular effect.
‘Most of us will live for more than 30 years post-menopause,’ says Muir. ‘We need to be much better informed about hormones and safe hormone replacement, and not let the medley of symptoms or the long-term health effects of the menopause bring us down.’
Thebe, however, rejects the portrayal of menopause as a ‘long-term hormone deficiency,’ framing it instead as a natural life transition. This is echoed by the recent Joint Position Statement from the British Menopause Society, Royal College of Obstetricians and Gynaecologists and Society for Endocrinology on optimising the menopause transition which states: ‘For most women, initiating HRT has a favourable benefit/risk profile. However, HRT should not be used without a clear indication and should not be used for the sole purpose of disease prevention. Menopause is a life stage and does not represent a deficiency state.’
‘It’s so important to stress that women can live long, healthy, vibrant lives with or without HRT,’ says Thebe. ‘There are amazing athletes out there in their 50s and 60s nailing it in marathons and ultramarathons.’
While the debate continues about how best to deal with the symptoms of menopause and its effects on long-term health, one thing is clear: physical activity is one of the most important tools we have in weathering the storm, playing a pivotal role in maintaining health and preventing disease after menopause, including reduction in cardiovascular disease, breast cancer and diabetes, increasing muscle and bone mass and improving mood, cognitive functioning and overall quality of life.
That doesn’t mean you should – or will be able to – keep running in the same way as you transition through menopause and beyond. One friend of mine says she can no longer run in the mornings because her energy levels are too low – she’s had to adapt to running later in the day, while another has switched her focus from racing to simply ‘getting out there’ and has, at last, regained her enjoyment of running.
While I’m back in my racing shoes now, I have a less rigid attitude to running than before: I work with my body, rather than seeing it as an enemy or a let-down. If I’m having a bad day, I’m more accepting of it. I find that knowing what’s behind it really helps reduce the angst and self-flagellation. In fact, that’s one of the best things about post-menopause life. A more reflective and balanced attitude, following a period of turmoil and change. I’ll run if I feel like it, I’ll race when I feel like it and if I don’t, then I’ll savour whatever I do instead, be it have a lie-in, cake and coffee, Pilates or a dog walk – with equal relish.
How to approach training
Use Amanda Thebe’s chart to rate your energy levels from 1 (bone tired, depressed) to 10 (firing on all cylinders) and adjust your workout accordingly.
- 1-2 Go for a walk, even if you don’t feel like you can. Just ten minutes typically improves mood.
- 3-4 Light activity: easy swim, bike ride, jog, mobility session. Some type of activity that feels good but isn’t a ‘workout’.
- 5-6 Reduced version of planned workout – concentrating on form.
- 7-8 Attempt planned workout. Sometimes it’ll go to plan, other times you might have to reduce the volume.
- 9-10 Best winter running gear!
To cope with hot flushes during a run, dress in layers so you can adjust body temperature. Drinking cold water or splashing it on your face also helps.
Allow longer to warm-up. It might take 15-20+ minutes of light running to ease stiff joints and sore muscles.
Drink more water. Night sweats and hot flushes, –together with reduced fluid intake owing to fears about urinary incontinence – can leave you dehydrated. This can increase the incidence of heart palpitations.
To help an HRT patch stay on through sweaty workouts, warm it for a few seconds with a hair dryer before applying and hold firmly against your skin for at least 10 seconds.
'Go for a walk, even if you dont feel like you can. Just ten minutes typically improves mood’
Running helped me through menopause without HRT
‘I started running at 41. I’ve never been fast, but I enjoy the social aspect and the fresh air. After my first marathon, which I loved, I embarked on a challenge to run 50 marathons and ultras before my 50th birthday. I did it – then perimenopause hit. Hot flushes, tiredness, weight gain, fatigue, brain fog... Sleep became a problem as I would wake with night sweats, my mind racing. And I developed bilateral knee pain, which made running uncomfortable. I struggled to keep up with my younger friends and worried about holding them back, losing confidence and motivation. Running became an occasional activity, limited to 5kms where I would simply try to run without walk breaks.
I started HRT in early 2022, with a 50mcg oestrogen patch. This was gradually increased to 100mcg. My mood improved, my sleep was better and I wasn’t so achy, but I still had to have a nap every day and even reduced my hours at work. Now I'm doing much better. I’m no longer exhausted and Go for a walk, even if you dont feel like you can. Just ten minutes typically improves mood, which is a great feeling to have again. The combination of HRT, gaining knowledge and respecting my body’s changing ability have helped me navigate my menopausal transition.’
'Resting heart rate,'
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‘I started running in my mid-forties, aware of menopause looming and wanting to give myself the best chance of getting through it well and into heathy old age. My menopause started when I was 51, and apart from my periods stopping my only other symptom was hot flushes, which were minor compared to those some non-running friends, and my mother, experienced. I’ve avoided menopausal weight gain, which I definitely attribute to running. A few years ago, my energy levels dropped, and I assumed it was menopause-related, but I was diagnosed with an underactive thyroid, so I would recommend anyone struggling with energy to get that checked.
Running gives me energy and joy, and helps me work off the day’s stresses, whether it’s a chatty run with friends or some me time. It also gives me confidence, which I know can decrease around the menopause. After my first marathon in 2018, I felt I could achieve anything (although stairs were a challenge for a day or two). I’ve gone on to do more marathons and ultras. I’m not the fastest, but I love running and I’m 100% convinced that it helped me through the menopause without HRT.’
