A dialogue between two Peri-menopausal Triathletes

This blog is a bit different it’s a transcript of a dialogue between two perimenopausal triathletes who share their experiences and nuggets of wisdom to get through the Perimenopause as a triathlete and ultra-distance cyclist.

Kate – Is an Ironman AgeGrouper (AG) Triathlete and accomplished Ultra distance AG time trialist/ cyclist and like me, is very keen to support other women athletes going through the early stages of the menopause. Her knowledge and journey through the Perimenopause to date is exceptionally informative for all athletes.

PMT: This is me, the Peri-menopausal AgeGrouper Triathlete.

Below I have pieced together an emailed conversation where Kate shares very openly and honestly her journey as an athlete through the early stages of the peri-menopause. Like me, you will learn a lot of useful stuff and hopefully come to feel that you are not alone going through this transformative and what can be difficult stage in a woman’s life.

For purposes of readability, Kate’s dialogue is in Black Bold and italic, I respond in usual font Kate: Just wanted to thank you for your blog on all things menopausal and its impact on sporting performance.  Bearing in mind the menopause will affect all women (i.e. more than half of the population!) it seems utterly crazy that there isn't more information out there about the impact it has on women's sporting performance. I have searched high and low over the last few years for good detailed information on the subject and only really come across the wonderful 'Roar' book (which I have recommended to or given, to pretty much every woman I know!). It's probably only by sharing our own stories that we can start to piece a way through and come out the 'other side' smiling! So thank you for starting the conversation.  

Yes I know so little information out there, I’m desperate for other women to share thank you!

I'm 50 and have been going through peri-menopause for probably about 5 years or so although it took me a long time to realise that the strange nausea, dizziness, extreme brain fog and performance anxiety I was experiencing with increasing frequency, was due to the peri-menopause and not some recurring weird virus or psychological weakness.  I felt like this too, experiencing the same symptoms so went to the doctor! I started off doing triathlon (Ironman) but following some injuries a few years ago (which were quite possibly exacerbated by menopausal symptoms I ditched the running and concentrated on ultra-distance cycling instead - 12-hour time trials and mountain events such as the Marmotte & Haute Route in particular. 

WOW! did you do well?

Not too badly - I won the 1st 12hr I did (actually, it was my first proper time trial that wasn't part of a triathlon - nice not having to run afterwards!) and the 2nd one in 2017, I did 259miles which at that time, put me at the 7th fastest woman of all time. (I was on a road bike with clip on aero bars).

OMG! AMAZING

I did the Haute Route Alps (Geneva to Nice) last year and entered it as a mixed duo with my husband - we won each of the 7 stages and overall, and by time, I was 5th fastest woman overall too (3rd on the mountain time trial). I would point out that as I'm retired, I have a lot of time to train, so this really helps! 

Even so.... bloody amazing!! And very inspiring for other age groupers out there!

Over the last 3 years, the peri-menopausal symptoms started to have a bigger and bigger impact on my training until last summer - once I had worked out what the problem was - I sought out the help of an HRT specialist. Since then I have been 'on a journey' to find an HRT combination that works for me and lets me be 'me again'. I haven't yet reached the final destination on that yet but there have been some improvements along the way.

Brilliant! Did your doctor refer you? Where did you go? Is it free/ cheap? I'm going to include this in my next blog which is about HRT/ what it is, what Bioidenticals are and what we can do so I'm a bit nervous because I won’t have all the right information but I'm going to give it a go until someone tells me/us it's different? I've just been to see my doctor she was a bit frustrated with me, she was late & I was unsure what I wanted, 10 mins later I came away with HRT pills (still in their box and more brain fog about what I should do, and a “come and see me in 3 months time”. I don't feel right about being fobbed off with this prescription because I’ve still got concerns).

I really feel for you in the treatment you had with the GP - I don't think it's uncommon but it's very lamentable. Might you be able to see a different doctor instead? I found reading the menopause matters website very helpful in learning about the different prescription options etc and risks/benefits involved in each. The GPs at my NHS practice didn't seem to know very much about menopause apart from prescribing the standard 'option' (novofem & then femoston) and they certainly didn't seem to know about progesterone intolerance. It was by reading the menopause matters website and finding that I had a very strong adverse reaction to the progesterone portion of the HRT they had given me, that I then sought out the help of a specialist. It was only because of my wonderful physio that I knew that these specialists existed when she told me that some of her clients had seen specialists and found much better HRT solutions that way, I found the specialist online and she diagnosed me as progesterone intolerant. Unfortunately the specialists are quite pricey but I was pretty desperate and felt if I wanted to have any quality of life over the coming years, I had no other option. The specialist prescribed me Oestrogel (17beta Oestradiol) a gel which is applied to the skin - initially 2 pumps per day - and 100mg utrogestan (progesterone) to be taken vaginally on days 15 to 26 of one’s cycle. These are both bio-identical hormones. From what I can tell, this prescription is what a lot of specialists prescribe (maybe different dosages though) but far fewer GPs - possibly due to cost to the NHS? - although they are both available on the NHS. This approach worked pretty well from last Sept until about March of this year when I noticed side effects of the progesterone creeping back in - feeling sick and dizzy in particular but also more anxious socially etc. Kate, I'm hearing a lot of similarities here, did you have very heavy periods? I did and still do although the merino coil (https://www.menopausematters.co.uk/contra4.php) helped reduced the volume slightly unfortunately, I became very uncomfortable with it. I became sore during my period as though bits of endometrium were getting stuck causing a burning/ itching sensation, most unpleasant!  Also, I have endometriosis and thinking about it since the coil was fitted, I have experienced more dizzy spells, so perhaps I have a progesterone intolerance too? I'm very sorry to hear about the endometriosis - it sounds really awful. ​It could well be worth looking into progesterone intolerance just in case. ​I had very light, irregular periods with few adverse symptoms ​ (I now know how lucky I was!)​ but I had pretty bad depressive episodes to coincide with high hormone times - puberty & pregnancy - for example.​ It was taking the progesterone portion of the HRT that gave me a very bad reaction; ​suicidal thoughts, crying a lot, feeling sick and dizzy and truly awful - and this prompted me to research why.​ Both specialists then confirmed my suspicions that I'm progesterone intolerant.​ ​You can have uterine scans on the NHS - I did have one done like this but it took a while before I got an appointment. ​But subsequent ones have been done privately and cost around a few hundred pounds. ​ They're not very pleasant(!) although not painful. ​ ​Unfortunately the first specialist I found online was quite unhelpful when I went back to her about how we could correct this. (In terms of the specialists, the first one I had was a specialist endocrinologist and this was OK but I've felt the ​second one (Dr Saidman) who is a GP and menopause specialist, seems to give better all-round care.​ I hadn't really realised that there would be much difference between the two. Obviously, I could just have been unlucky first time round!​) The new specialist (Dr Suzanne Saideman), again found online, seemed a whole lot better & with whom I could actually ask and get answers to my questions. I'm now on 4 pumps of Oestrogel per day and 100mg utrogestan (progesterone) and the progesterone side effects seem to have disappeared. Fingers crossed they stay away!  If I start getting symptoms again, I can take the utrogestan every other day from day 15 to 26 - the minimum dose is 7 days. There is the possibility of an increased risk of uterine cancer in the absence of progesterone, so I will have a scan every 3 months or so to check on the thickness of the uterus lining.  A couple of points that she mentioned that could well be relevant to other female athletes are:

• As estrogen is produced by the body's fat tissues as well as the ovaries, if you're a woman with low body fat, you will have fewer estrogen 'supplies' to draw on when the estrogen being produced by your ovaries is reducing, so this may makes you more even sensitive to estrogen fluctuations than someone with higher levels of fat.  

• If you were athletic as a teenager, started your periods late (15yrs or more), perhaps had relatively low levels of body fat then too and irregular periods, this may have impacted on the number of years your body had to build up bone density and this could then put you at a higher risk of osteoporosis as you approach menopause. My understanding is that it doesn't need to have been as extreme as complete loss of periods and a very low BMI, for this to be an issue. Add to this the fact that cycling and swimming don't seem that helpful for bone health, then perhaps it's worth talking to a GP about this and maybe getting a DEXA scan to see if you are at risk. It's also worth checking vitamin D levels as these impact on calcium absorption (amongst other things).  

• In addition to estrogen and progesterone, testosterone levels also drop through menopause. In many instances, this dropping of testosterone is talked about as a problem only in terms of loss of libido. Whilst loss of libido might be an issue(!), from an athletic point of view, maybe the far more important impact of loss of testosterone relates to the fact that as an anabolic hormone, it stimulates muscle growth and repairs injured tissue but also helps produce new blood cells, build bone, maintain muscle mass and help with an overall sense of well-being and energy - all things that are pretty important in endurance sport! Total testosterone levels for a woman are in the range: 0.3 and 2.4 nmol/L (by comparison, in men it is 10.4-41.6 nmol/L), with a woman's testosterone level peaking around age 18 or so and decreasing slowly after that until peri-menopause when the rate of decrease speeds up. Currently, testosterone is an 'off-licence' prescription - there is no standard treatment dose so it needs to be prescribed by a specialist.  My current specialist has mentioned about testosterone treatment for me and although it's not something I had considered before, looking at how my testosterone levels have been plummeting over the last year and are now below that lowest level of 0.3nmol/L, maybe it would be a good idea! 

I agree but would this negate the need for a TUE if racing? My guess is surely the dose will be so small that it would be in line with ‘normal’ for women but are you worried about the debate of 'not normal for our age' hence 'affordable’ cheating? Have you noticed a power drop on the bike?

Good point about the TUE for testosterone supplementation. I don't know that you would be able to get a TUE as testosterone is a banned substance. ​ Obviously, this is only an issue if you compete. ​I do think however, that it's an issue that needs to be reviewed when the testosterone is being given for medical reasons.​  To put it in context, my testosterone levels were 0.8nmol/L last Sept and fell to 0.087nmol/L which puts me at the level of 'very low for my age' and​ has definitely been affecting my energy and concentration levels. ​If I took a supplement that put me in the 'normal for my age' category would that be unfair? Good question.   I haven't really noticed a reduction in strength in terms of reducing power figures on the bike - but I have noticed it's taking a bit longer to recover from injury and get back to the level of fitness I had before plus an increase in soft tissue injuries, and I do wonder whether low testosterone levels are playing a part in this? I think it must be related. I’ve tried to look into this but can’t seem to find any ‘scientific’ research that’s age related just this: https://www.biobalancehealth.com/testosterone-role-injury-recovery/  and given that men also develop more injuries as they age it’s surely linked to decreasing testosterone levels (the Andropause? Late-onset hypogonadism https://www.nhs.uk/conditions/male-menopause/)? As an aside, did you see the Martina Navratilova ​BBC documentary about trans athletes competing as women as this had a few interesting snippets ​about testosterone levels in women and effects on sporting performance)​ ​ Yes fantastic documentary. I found this research article around this subject which makes you think too: https://www.inverse.com/article/60149-testosterone-women-s-sports-study I have been looking into the rules surrounding testosterone taking and TUEs following your comments - it seems it's all a bit more complicated than I had previously thought! So, maybe not an option after all. Have you thought about protein and collagen supplements for your injuries? I read an interesting article re my achillies:  https://www.mdpi.com/2072-6643/11/1/76/htm So, what happens with your treatment now regarding doses and hormone levels? I have been having a blood test done every 3 months or so (through ForthEdge.co.uk - there are many other suppliers too) originally, mainly to keep a check on my iron levels which have a tendency to be low even though I take an iron supplement every day. These blood results are quite helpful to have so I have been able to see the large reduction in testosterone levels this past year. I'm also going to have a female hormone check (through Medicheck.com) which covers, amongst others, testosterone, oestradiol (estrogen) and sex hormone binding globulin (SHBG) as this gives info about levels of 'free' hormones which are available for use by one’s cells.  Thanks for the link on protein and collagen supplements, I've currently been off the bike​ completely for the last 2 weeks with suspected high hamstring tendinopathy and bad sciatica, it is​ especially good timing! I’ve had several hypnosis sessions to help reduce the stress I was feeling around being in chronic pain etc from my high hamstring tendon tears & tendinopathies and I was surprised to find that it really helped me a lot. I now also use self hypnosis combined with meditation to help reduce stress generally.  To my training log, I've also been adding in daily details of any menopausal symptoms, waking heart rate, heart rate variability, any blood flow info (sounds grim but is useful info to have!), what dosage of the HRT I took. This has then been really helpful in trying to uncover patterns and to figure out what's going on. 

Absolutely not grim Kate, its science!  Maybe I need to do this now? I've sort of started on the Garmin app but maybe more diary information could be useful for a future 'study', I was thinking about contacting universities to see if anyone was interested in this?

I'm more than happy to share information that I have learned over the last few years if you think it could be useful to anyone else?  

Yes please, what else?

• That agonising burning pain on the balls of your feet when cycling long distances might not be your shoes or cleat set up but be Morton's Neuromas which become much more common in peri-menopause.

:/ Owww I get this running wonder if it’s the same thing?

• That burning undercarriage pain on long rides might not just be down to saddle and chamois choice but due to vaginal dryness caused by lowering estrogen levels and for which you can get a cream to help alleviate symptoms.

Tell me about it I feel like my lady bits are permanently bruised, so sore after every TT and bike session now, never used to be but of late bloody Nora! When I remember to chamois up I'm sort of ok.

• Undercarriage issues in the time trial position.... obviously this is all very individual because it will depend upon one's anatomy in addition to the hormonal impact but here's what worked for me:  I use a saddle with a large cut out  - Koobi.com 

I use ISM Tri saddle on my TT bike, maybe I need to change the saddle on my road bike now?

I've heard good things about the specialized 'Mimic' saddle & I'm hoping to give one of these a try soon. Selle SMP also do lots of saddles with cut outs and these used to work well for me. I customise my bike shorts so that they have a channel through the chamois to reduce chafing in the most sensitive bits.

Good idea!

I buy Assos shorts which are well padded elsewhere, turn them inside out so that I can then cut away a channel from the middle of the chamois. I use a combination of creams - sudocrem, conotrane (designed for people suffering from bed sores! You can buy it on Amazon) and Vagisil which contains lidocaine and therefore acts as a bit of an analgesic. On long or very hot rides, I re-apply the Vagisil if things are starting to hurt! I use Estriol cream twice a week to help with the overall effects of lowered estrogen levels 'down there'.  I wouldn't say these things completely remove any pain on long rides but they definitely help quite a lot - and maybe you're never going to be pain free doing something stupid like a 12hour time trial! 

well .... I guess you've had a good bike fit so maybe it's to be expected a bit? have you chatted to other female ultra-cyclists do they suffer like this too?

Good advice about chatting to other ultra-distance female cyclists and under-carriage pain as I haven't tried this​ yet.

• - I also know that your heart rate variability readings might be lower and all over the place not because of over training but because of your hormone fluctuations

Yes, I'm just starting to realise this but didn't make the connection to the perimenopause!!

Your waking heart rate might be really high because of an increase in progesterone and not because you are about to be very ill.

Interesting!! Although so tired from lack of sleep I never remember to take my heart rate!

Sorry to hear about your sleep problems - they can leave you feeling dreadful - have you managed to find anything that helps you?   I hope you manage to sort it out soon and maybe the HRT will help. ​I did notice that it helped me a bit and they do say that because progesterone has some sedative​ effects it will help (only if you take it before bed, otherwise, not very helpful!) ​

I've tried tart cherry juice, meditation, lavender, cool room, etc. but no, not really helpful during the 'hot flush phase' but so far, it’s sporadic and only happens for stretches of about 14 weeks at a time, then I seem to sleep better for a while. I'm guessing whilst my hormone levels are changing each time there's a drop in eostrogen my body responds with hot flush etc? Until it gets use to it then it settles down for a while. If I do take the HRT maybe at night might be a better time to take it, I’ll see, I’m still very unsure about this.

• A reduction in your ability to 'suffer' through intense intervals might also be affected by your hormones and not because you've lost strength or fitness at all. (I have managed to get a range of power PBs over the last few years)

Now I totally get this! I can’t ‘suffer as much these days on the intense intervals!

• Being reduced to a quivering wreck before races (or even group rides) with performance anxiety is not necessarily due to any deep psychological problem but again could be due to hormone fluctuations.

Yes, happened to me on Wednesday at a local TT no pressure just a hard training ride but I got major nerves beforehand.  I'm usually quite chatty too but last week experienced proper social anxiety and immense pressure previous even though I went to train, and knew that I wasn’t going to be fast due to my training data. Turns out I held my own on this occasion but I did suffer with recovery it took me 2 days for legs to get back to normal!!

It was really interesting to read about your 2 day TT recovery. As well as the physiological recovery your body needs there's also an element of psychological recovery and I think that this becomes more important when going through the menopause. If you've had a large stress response before an event e.g. all that abnormally high race and social anxiety, your body has to recover from that as well as the physical recovery. It's all just stress on the system no matter where it's coming from. Sometimes my pre-event anxiety has been so bad it's almost as though my brain & body think I'm about to be eaten by a lion at any moment! I found this psychological recovery especially a problem in the multi day events I've done like the Haute Route Alps & Tour of Wessex. My body wasn't feeling too bad at all but being able to recover from all of the race stress & anxiety each day was by far the hardest aspect.

Yes, I get this I'm totally stoked after any race now a days and vividly involved in the evaluation/ re thinking it for hours after!

As the hormone imbalances increase these anxiety levels, I feel that I need to work even harder on recovery and not just the usual sleep (miraculous tool that may be), massage, foam rolling, contrast bathing, compression & nutrition etc but on calming my mind down too and helping my body come out of a flight or fight stress response mode - so doing things that activate the parasympathetic nervous system. The things that work well for me are:  - being in nature & mindful nature walks - forest bathing(!) and being near the sea or in mountains is especially good too (not necessarily so easy in the UK!) ​- hypnosis has helped me reduce stress and manage pain  - meditation - although it has taken quite a long time to get the hang of this but once I did, I found it wonderful. It's also something that's much harder to do when I'm stressed and need it most, which is why regular practice is important so you can do it even in these tricky times. I've found the Headspace app quite helpful in learning how to meditate etc - having a laugh and hugs with my family - massage - of the gentle kind rather than full on sports massage (which I find great for physical recovery) Apparently, yoga and Tai Chi are very good and so too is breathing from your diaphragm. Partly because of this additional anxiety but also because of other hormonal symptoms that seem to appear randomly, I've found that I have to train much more 'intuitively' than ever before by really listening to my body and matching the workouts I do with what my body tells me it needs on any particular day. Sometimes this means I can handle hard workouts on back to back days and feel absolutely great, other times, low intensity rides are the order of the day! Although I do take into account my heart rate variability scores that morning and power and heart rate during the warm up, I pay most attention to how my legs actually feel and base what I do on that. All of this obviously makes it really difficult to follow any kind of written training plan - or even using a coach to give daily workouts - but I find it's my only option. I also find turbo workouts much, much harder to do - not because of the power output but I think that being outside offers more of a distraction from some of the hormonal symptoms (e.g. nausea & dizziness). I had to use this very intuitive approach last year in training for the Haute Route and whilst the awful hormonal symptoms made the whole thing a lot harder, it didn't work too badly. I did keep saying to my husband that I was under-going reverse doping which was hardly fair! 

! :) hardly fair!

Anyway, thanks again for your blog! 

No, Thank You Kate x

By the way, hope it goes well with the HRT and that your symptoms subside as your body gets more used to it all.  Otherwise, the Estrogel and Utrogestan approach seems to be tolerable option for a lot of people with progesterone intolerance - & even those without. I've been on 4 pumps Estrogel and Utrogestan vaginally for 9 days per month for about 3 months now and it seems to be working pretty well. I can go down to a minimum of 7 days of Utrogestan but so far haven't needed to. I don't know that this is an option a 'normal' GP would know about so it's worth bearing that in mind if you need to tweak your regimen. Take care and all the best and I'll put something together about the osteoporosis relatively soon, Kate.

You’re a legend thanks Kate.

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If you have a perimenopausal journey that you’d be willing to share or chat to me about, please do get in touch and share your story. Email me:   tpmtriathlete@gmail.com

As always, thanks for reading,

The Peri-Menopausal Triathlete