Could Hormone Therapy Be the Right Solution for Menopausal Masters Runners?

This year has been one for the record books when it comes to female masters runners, or a runner over the age of 40, also sometimes called a veteran runner. In July, four women from The Central Park Track Club set the 4x800m relay world record (for ages 55-59) at the 2023 USATF Masters Outdoor Championships, held in North Carolina. Judy Stobbe (58), Jennifer Harvey (55), Dominique Saint-Louis (57), and Sue Pearsall (58) ran a cumulative time of 10:36.35, beating  the previous record (10:37.07) by nearly a second. At the 2023 Chicago Marathon, Jeannie Rice (75) set the women’s 75-79 age group world record of 3:34:32, while Jenny Hitchings (60) set the women’s 60-64 age group world record of 2:49:43. From January to October, Sue McDonald set a total of nine women’s 60-64 world records in a variety of track and field events, including the 400 meters, the mile, the heptathlon, and the 3000-meter steeplechase.

These stellar performances made many masters runners wonder, is it possible to become faster in our 50s, 60s, and even 70s, even if you’re not an elite athlete? Is there a way to delay slowing down?  How do we train consistently while minimizing the disruption of perimenopausal and menopausal symptoms, including hot flashes, insomnia, mood swing, fatigue, irregular menstruation, and osteoporosis?

Menopause hormone therapy (MHT), or hormone replacement therapy (HRT), has been in the media a lot lately, with celebrities like Oprah and Michelle Obama singing the praises of MHT’s effective relief. The treatment of estrogen alone or in combination with progesterone helps relieve symptoms of menopause. But is it safe? Is it effective? What are the questions you should be asking if you were to talk to your OBGYN about it?

Menopause: Can We Ever Catch a Break?

Menopause is a transitional life stage for women, usually described as puberty in reverse. It occurs “when there are no more follicles in the ovaries capable of ovulating,” according to Jen Gunter in her book The Menopause Manifesto: Own Your Health with Facts and Feminism. A woman’s final menstrual period marks menopause. Perimenopause encompasses the whole transitional years leading to menopause, and is marked by the first year after the final menstruation.

In the U.S., an estimated two million women reach menopause each year. The median age for American women is 51, with racial and ethnic variations. This means women are spending more than one-third of their lives in menopause. The length of menopause transition can vary significantly by individual, but according to the National Institute on Aging, menopause transition usually lasts about seven years to up to 14 years.

Female runners who might have run in college and wish to get back to it again or juggled motherhood with athletic pursuits in their 30s and 40s might find that, just when they get a bit more free time to train in their 50s, menopause hits.

Mary Claire Haver, M.D., an OB/GYN, mom, author and entrepreneur in the Houston area, has been demystifying menopause through her menopause clinic and online platform, The Pause Life. “The advanced athletes in my practice–the committed runners and triathletes–are the ones really struggling with perimenopause and menopause. They seem to enjoy this great level of cardiovascular fitness, but they usually come in because they’ve been gaining weight. It’s frustrating because nothing else has changed in their lives. They’ve never had to deal with this before, and they cannot train more than they already do,” says Haver. “I usually start with the coaching that this is not your fault. This is menopause. This is what the lack of estrogen, progesterone, and testosterone is starting to do to you.”

Christine Yu, an award-winning journalist and author who focuses on the interaction of sports science and female athletics, says that menopause is widely misunderstood and includes a lot more symptoms than people think.

In her book, Up To Speed: The Groundbreaking Science of Women Athletes, she writes, “While menopause is marked by the last menstrual period, it’s so much more than that. Oscillating hormones, and the abrupt withdrawal of those hormones, can induce a long list of symptoms. Vaginal dryness, depression, anxiety, joint pain, heart palpitations, and ‘menopot’ – a term for the potbelly that can take shape in midlife – are all common.”

Is Menopause Hormone Therapy Helpful?

Jessica L. Chan, M.D., associate professor of obstetrics and gynecology and reproductive endocrinologist at Cedars-Sinai in Los Angeles, has been an advocate for a thoughtful discussion on hormone therapy with patients. “A vast majority of my patients experience an immediate relief of their menopausal symptoms once they start their hormone therapies,” she says. “I’m a huge proponent of using hormone therapy to treat menopausal symptoms on the appropriate patients experiencing poor quality of life.”

Menopause hormone therapy (MHT) is a more accurate term than hormone replacement therapy (HRT), argues Gunter. 

In her book The Menopause Manifesto, she writes that HRT “falsely implies that estrogen or other hormones are missing because of a medical problem, and the low levels of estrogen after menopause are biologically abnormal.” Instead, she proposes that Menopausal Hormone Therapy (MHT) is the correct term to describe the medical intervention. “MHT is the use of hormones to manage symptoms and/or prevent certain health complications related to the menopause transition and/or postmenopause.”

As the Central Park Track Club’s team captain and part-time coach, Stobbe says that hormone therapy is commonly-discussed among her masters teammates. “We have over 70 masters runners,” she says. “Hormone therapy is something we talk about quite freely now. My mom’s generation didn’t do that.”

MHT is not a Magic Bullet

Estrogen–the hormone women lose during menopause–not only plays a role in women’s reproductive health, but also impacts bone density, skin, pelvic muscles, and brain function. Aside from the well-known hot flashes and night sweats, major risks of low estrogen also include osteoporosis and heart disease.

“We have a lot of observational studies [on the effect of MHT]. It’s potentially preventative of osteoporosis. There are a lot of women claiming now that it’s helping with brain function and mental clarity,” says Haver.

But getting on MHT doesn’t mean menopausal women snap back to perfect running health. 

Similar to Stobbe’s story, Watkins noticed a difference in her sleep within a couple of months. “After getting on the [estrogen] cream, I no longer woke up in a pool of sweat. Last year I switched to the Estradiol patches, because the cream wears off easily with sweats. And I take an oral progesterone at night.” 

Despite the benefits, Watkins hasn’t bounced back completely. “I don’t think the therapy helped with my tendon issues I’ve been struggling in the past few years. I haven’t put together a solid block of training since the 2018 Berlin Marathon.”

“MHT is not a magic pill,” says Haver. “Menopausal women lose muscle mass quickly. I tell my patients that they have to do the work–the resistance training and taking protein–to hold onto their muscle mass.”

Is MHT Safe?

In 2002, the Women’s Health Initiative caused a stir when it published research that claimed HRT increased the risk of coronary heart disease, invasive breast cancer, stroke, and venous thromboembolism. For decades, women and doctors steered clear of the helpful treatment. The study has since been discredited due to flawed study samples (done primarily among older and post-menopausal women) and misinterpretation of increased risk levels.

According to the Mayo Clinic, hormone therapy started before the age of 60 or within 10 years of menopause confers more benefit than risk. 

There are risk factors associated with combination therapy (a combination of estrogen and progestin) if it lasts longer than five years including an elevated risk of breast cancer even after stopping the therapy. But long-term estrogen alone doesn’t seem to increase the risk of breast cancer or heart attacks.

Jenny Hitchings (60), the 2023 USATF Masters Long Distance Running Athlete of the Year, sought out hormone therapy when she first noticed menopausal changes around age 52. “I had anticipated the hot flashes, but not the edginess of my body,” says Hitchings. “With MHT, I just felt more stable, more like my old self. I came back at age 55 and broke a marathon record.”

Hitchings has been on combination hormone therapy for seven years now, two more years than the recommended five-year period. In order to monitor breast cancer risks, she gets her yearly mammogram. 

“For my healthy and active patients who don’t have underlying cardiovascular diseases, their risks of blood clotting, stroke, and cancer are even lower,” says Chan. “Even among women with a family history of breast cancer, I think they can still make great candidates.” She also recommends routine breast exams, like Hitchings has done.

Hormone Therapy Beyond Treating Menopause

Walters had hormone-dependent (estrogen receptor-positive) breast cancer. Her body produces too much estrogen, which would feed the cancer cells’ growth. To suppress estrogen production and stop the growth of breast cancer, Walters first took Letrozole and later Anastrozole. “I do get hot flashes and night sweats. Running actually helps me get through my hot flashes.”

According to the National Cancer Institute, hormone therapy for breast cancer produces the opposite effect of MHT. “Hormone therapy for breast cancer blocks the growth of HR-positive breast cancer, whereas MHT can stimulate the growth of HR-positive breast cancer,” the institute writes. “For this reason, when a woman taking MHT is diagnosed with HR-positive breast cancer she is usually asked to stop that therapy.”

Laura Osman’s case was different. In 2018, the Cal Coast Track Club runner and mom of three accidentally discovered she was BRCA1 positive through a genetic testing kit at age 37. This meant she had up to 88 percent lifetime risk of developing breast cancer and a 45 percent lifetime risk of ovarian cancer. The All-American former collegiate runner decided to undergo a series of preventative surgeries, including a double mastectomy, putting Osman into menopause a decade early. “At age 40, I had my final ovary removed,” she says. “This put me into an immediate menopause with zero estrogen production. So my hormone replacement therapy began immediately after this surgery, in the recovery room.”

Now at age 42, Osman stays on the estrogen patch to have a minimum dose for bone and heart health. “My estrogen is still lower than someone else with an estrogen patch in regular menopause,” she says. Osman adds that her hormone replacement therapy has been a challenge. “Higher dose of estrogen could bring risks to my health. But as is common with low estrogen, people tend to get insomnia and restlessness. When my body was adjusting to a much lower level of estrogen, I was anxious a lot. My only outlet was running.”

Osman is careful with her training these days because she has been losing bone density faster than her same-age counterparts. She averages 40 miles a week, with two workouts, a couple of strength sessions, and a day off. 

The lower-mileage training has proven successful for Osman, who recently was the masters champion at the California State 10K championship (the Manhattan Beach 10K), running it in 37:34.

“I let my doctors worry about my estrogen numbers and bone density level… I take it one day at a time and keep on plugging away,” says Osman. “I love the feeling of crossing a finish line and going after my goals, despite all the challenges.”

Some Might Not Need MHT

Though many women struggle with menopause, a fair number  also go through it like smooth sailing. 

Sue McDonald (60), USATF Masters Track and Field Athlete of the Year, hardly remembers her menopausal years. “I have always been very lean, and went through a couple of years of not having my period,” she says. “I went on a progesterone treatment to get my cycle started and had my two boys at age 40 and 42. After that, I think my period just gradually went away. I never had hot flashes or night sweats. I was very lucky.”

Rice, who set three other world records this year, besides the one at the Chicago Marathon, also had it easy.“I hardly remember my menopause because I didn’t have many symptoms. In my late 40s, I started skipping periods. Gradually, my menstruation slowed and stopped. I had very minor hot flashes, but they didn’t bother me much. I’m 75 now, and this is my 41st year of running non-stop,” she says.

Ultrarunner Junko Kazukawa also considers herself lucky, despite having two rounds of breast cancer in 2005 and 2009. The 60-year-old Denver resident just completed two 100-mile races, the Bighorn Trail 100 and Leadville Trail 100 Run in the summer, and Tor des Géants, a 200-mile trail race in Italy in September. Kazukawa also had a mastectomy and was on an estrogen blocker for a few years. Now her oncologist has dismissed her after more than five years of remission. “I’m in the clear now. When I was in my late 40s during my cancer period, I had hot flashes once in a while, and was more irritable than usual and sometimes nervous,” Kazukawa says. “But nothing bothered me too much.” Now happily post-menopausal, she is only taking vitamin D supplements for bone health. She is looking forward to her 10th Leadville race next year.

Seeking Alternative Therapy

Leslie Cohen received a prescription of MHT about five years ago, but didn’t take it. The 67-year-old runner who won her age group at the Boston Marathon in 2022 and several age-group wins at the New York City Marathon mentioned that she did not want the hassles of MHT. “I have been seeing an acupuncturist for 10 years now. Every week I get acupuncture. It’s been making a huge difference. I still get hot at night, but it’s not bad. My acupuncturist also gives me this medicine, Eight Flavor Rehmannia Teapills, which are supposed to bring a cooling effect to the body,” says Cohen. Now 10 years post menopause, Cohen still runs five to six marathons a year, and is looking forward to two international marathons in 2024.

Caroline Maruya, a licensed acupuncturist and herbalist based in Pasadena, California, explains how acupuncture might help with menopausal symptoms: “In Traditional Chinese Medicine, we believe in the Yin and Yang balance. When estrogen declines during menopause, it creates a deficiency on one hand, and we also tend to see cortisone in excess on the other hand. With acupuncture, we are able to access the endocrine system and restore hormonal balance. When the needle hits the skin, it causes a micro trauma reaction. It sends a signal to our spinal cord, which has a cascading effect on pain receptors and serotonin production. We’re working on sharpening the connections between the neurotransmitters to the hypothalamus.” Many menopausal patients in her practice feel relief from hot sweats and hot flashes. Some also report a reduction of stress and better recovery.

With nearly two decades of treating a variety of patients, including the Los Angeles Sparks and many recreational athletes, Maruya believes in a collaborative approach with western medicine. “Some patients might still need hormone therapy in addition to acupuncture and herbs.”

Menopause and MHT, There’s Still So Much We Don’t Know

Sarah Lesko, M.D. (54), runner, executive director at Bras for Girls, has found herself searching for menopause and MHT-related information everywhere, even with her background as a family physician and her degree in public health. “I felt great until age 47, 48. I could do fast workouts on the track then and had so much fun in my 40s,” says Lesko. At age 54, she noticed her slower recovery time and on-and-off injuries. “I noticed my sleep quality worsened in my 50s and I also have bad joint pain,” she says. “When I wake up in the morning, I’m very stiff in my wrist, ankles, knees, elbows… It takes a couple of hours to warm up.”

While MHT has been on Lesko’s mind, she wants a thorough understanding of the risks and benefits for herself. 

“My primary doctor retired, and it’s been hard for me to find a doctor with deep expertise in menopause,” says Lesko. “The menopause training I received in medical school in the late 90s was not sufficient.”

A survey published in 2019 in Mayo Clinic Proceedings found that only seven percent of new physicians in family medicine and gynecology felt adequately prepared to deal with patients’ menopause. Twenty percent reported they had not received a single lecture on the topic during residency.

“We don’t have a great education system for menopause right now. The system is built to fail menopausal women,” says Haver. “The OBGYN who delivered your baby and managed your contraceptives might not know enough about menopause.” She recommends The Menopause Society to find a certified provider. 

Chan offers an encouraging message for masters runners: “For highly active athletes, continue doing what you’ve been doing, see your OBGYN or an endocrinologist if you are curious about MHT. Have a conversation.”