The Impacts of Estrogen Deficiency in Aging Women

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses that the fountain of function is muscle mass and estrogen in the aging female. Christina breaks down these two areas for function, and what we have physical therapist can do to help encourage both muscle mass and estrogen preservation.

Take a listen to learn how to better serve this population of patients & athletes.

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EPISODE TRANSCRIPTION

00:00 - CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the team within our Modern Management of the Older Adult Division. In our division, we have three courses in our geriatric curriculum. We have our eight-week online Essential Foundations course. We have our eight-week online Advanced Concepts course. And we have our two-day live course. We have a couple of courses that are left in the remainder of the year. We have a course coming up in November in Chandler, North Carolina. We have another course coming up in South Carolina. And we have a course coming up in Texas in December. So if you are near those courses or you are looking to get in some content before the end of the year, I encourage you to check those courses out. and you'll be able to get in with some of our faculty before, you know, we ring in 2024. 01:18 - THE FOUNTAIN OF FUNCTION Today I'm going to talk about the fountain of function. And so this is a reframe that I think is really important. And we're going to talk about what those fountains of function are. You'll notice that I did not say fountain of youth. We have this idea in our society that youth is the goal, to not feel like we're getting older in any way, to not show signs of age on our faces. And don't get me wrong, I see my aging face, I was like, oh, my face doesn't look like I am 21 anymore, and I look at the wrinkles on my face, and I have those emotions. But the idea for my life is not to try and get younger. It's to try and optimize my reserve and try and live the way that I want to live with the most amount of function possible into my 30s and 40s and 50s and 60s and hopefully all the way up to 100. Because at MMA and within ice in general, Aging is a privilege. It is something that I am very thankful for because the alternative is not that great. We're not gonna be able to reverse back time, but we can have a really successful aging process, especially when we put in the steps to live the way that we want to live, whatever that filter means for us. So I'm not looking for the fountain of youth. I am looking for the fountain of function. And so the two types, the two areas that are the fountain of function in aging women, so I'm going to talk about female anatomy, is muscle mass and estrogen. And these two things, especially when taken together and optimized to the best of our capacity, is going to allow us to have more function towards the end of our life. So let's talk about muscle mass. You have not been following the Institute of Clinical Excellence in any ways if you don't know that LODE is our love language across all of our division, across all of our faculty, and that is absolutely true in the geriatric curriculum as well. And I love it so much that I did an entire PhD on the influence of resistance training in an aging body. When we look at resistance training, we are accumulating a growth and a continuation, a plethora of education and research that looks at the impact of resistance training on health outcomes. And I just posted a paper that was a narrative review from Stu Phillips, who is one of my committee members on my PhD. 04:18 - THE COMING OF AGE OF RESISTANCE TRAINING And he talked about the coming of age of resistance training and how we are starting to see some accumulation of evidence that is mirroring and is just as strong as literature that we're seeing in aerobic training to prevent stave off different chronic diseases, including some cardiovascular diseases. And so there means that there, as of course, we're going to target the aerobic system. This is not to say to not do cardio in stead, just do resistance training, but it's showing that there is a continual and persistent growth of literature talking about the impact of resistance training on health outcomes. So what we see is that those who have more muscle mass tend to have lower all-cause mortality. They are less likely to develop cardiovascular conditions. They are better able to manage diabetes. They're less likely to get diabetes. We know that muscle mass is protective around things like osteoporosis, right? Tensile strength of the bone is important and we need impact, body weight movements, resistance training across the lifespan in order to optimize that. We see that individuals who are stronger or less likely to have sarcopenia, right? Sarcopenia is clinically relevant amounts of muscular weakness that are preventing a person from completing their day-to-day tasks. It's a totally important output of frailty. Fried's physical phenotype of frailty talks about physical reserve and physical capacity as an output of individuals seeing these constellations and signs and symptoms that lead to vulnerability to external stress. That external stress includes things like hospitalizations and being able to withstand different stressors with respect to immune system insults, including things like COVID-19, pneumonia, and the flu that allows individuals, while they are sick, to have that reserve and resiliency to lean back on in order for individuals to be able to get back to baseline or improve past baseline, post-hospitalization, or acute insult. All this to say, we know that individuals need to be trying optimize their muscle mass in their earlier life and then hold on to it for as long as possible. If you are in a setting where you are not working with individuals who have optimized their muscular mass, we also know that muscular mass can be developed and we can see improvements in physical function with resistance training at any age when we start including in our 90s. The mechanism at which strength develops is a little bit different. We're looking a lot more at neuromuscular efficiency. However, we can absolutely see that it can improve function. And so whether you are 30 or you are 85, muscle mass is a fountain of function and it allows us to withstand stress. 12:24 - ESTROGEN FUNCTION & MENOPAUSE  Now let's kind of talk about this second piece, which is estrogen. I've done several podcasts on menopause, but I want to talk about the influence of estrogen around female physiology, because I think this is really important. So when we are going through the menopausal transition, on average, individuals will start menopause between 50 and 51. Definition of menopause is when you've gone a full calendar year, 12 months without a menstrual period. That is your menopausal transition. But individuals can be experiencing perimenopausal symptoms that are indicators of dwindling or are coming down of estrogen status for up to 10 years prior to the transition into menopause. And so individuals who are in their early 40s can start to see the influences of loss of estrogen on their body. And then that influence is persistent as individuals get older. When we're talking about menopause, we often are putting this into two camps. So we have vasomotor symptoms, which are these symptoms that occur because of an acute withdrawal of estrogen. These are things like night sweats and hot flashes. As individuals transition through menopause and we get into our later life, into our 60s, 70s, 80s, and beyond, those symptoms tend to decline. So those vasomotor symptoms that occur as our body transitions to reductions in estrogen status they tend to go down as our body gets used to this new state of equilibrium that occurs without estrogen. In the opposite direction, the second kind of camp that we speak about when individuals are going through menopause is genitourinary syndrome of menopause or GSM. And that is signs and symptoms across the female physiology that are responding to losses in estrogen. and anywhere where there is an estrogen receptor within our body, they are going to experience changes when individuals transition through menopause. And we oftentimes will, in the pelvic health space, talk about changes to our reproductive anatomy, which are unbelievably relevant, but we have to also extrapolate that out and talk about different areas where estrogen is influencing female physiology and how, if you are working with an aging female, they are experiencing changes because of that change in estrogen status. And so within the reproductive track, we see that there is changes in ligamentous stability around the pelvis. And I hate that word stability, but it's a change in the turnover of the way that our ligaments are restructuring. So we have a little bit more ligamentous breakdown than buildup, right? That turnover rate is different. And so we have this shift between static support in the pelvis to the requirements or dynamic support around the pelvic floor. We see that individuals start to have vaginal atrophy. We see that the vaginal microbiome starts to change. We don't have the same cervical mucus secretion. And so things like chafing and redness can be more prevalent in a person who is postmenopausal. We can see fusing of the labia minora and majora. and this can lead to increased risks for pelvic floor dysfunction. So when we are in estrogen low states, rates for pelvic floor dysfunction go up. This includes anal incontinence, urinary incontinence, pelvic organ prolapse, dyspnea, or painful punitive intercourse, and other aspects of the reproductive tract. We also see, because of this change in the vulvar anatomy, that we have an increased risk for things like urinary tract infections, that increased risk for urinary tract infection also influences individual's physical function. We know that recurrent UTIs can be a cause of changes in cognitive status for our aging females. And so something that is extremely relevant for our aging women. Other things that we see is that as individuals go into an estrogen depleted state, increased risk of cardiovascular disease goes up. Individuals as they transition through menopause, we see that in general, men tend to be more impacted by cardiovascular disease. That is shifting for a lot of different reasons, but that risk profile increases when individuals are in an estrogen depleted state. We see a change in central adiposity where weight starts to increase. Adiposity accumulation can increase, especially visceral fat accumulation, which has a risk profile in and of itself for different chronic diseases. And then we see, for example, in our bone microarchitecture that the influence of estrogen allows for continual bone regeneration and that profile again starts to switch and there's an increased risk for things like osteoporosis in an estrogen deficient state. So there's a lot of things that get impacted, right? Our skin gets impacted, our breast tissue gets impacted, our urinary tract, all of our mucosal membranes, not just in our vulva, but across our entire body, and this has impacts. And so when we are thinking about working with these individuals, one of the things that is starting to become really recommended is topical estrogens. And there's a lot of debate about this because of a study that had been done a little while ago that looked at increased risk for sex-related cancers, breast cancer, endometrial cancer, cervical cancer, et cetera, with systemic estrogen. However, what we are starting to see now and many of our menopausal experts like Dr. Mary Claire and Dr. Rachel Rubin are really trying to have this public health approach to medicine saying that we are not doing our females a service when we are saying that there is a risk profile when subsequent studies have not been able to substantiate or replicate those findings. And so there's been a big shift in the last five years to the need for or the desire for many women who are really suffering with genital urinary syndrome of menopause to be able to take things like topical estrogens in order to really significantly reduce their symptom burden. And I'm not just talking about their pelvic floor, which is an extremely important part of their sexual health, also a vital sign of aging, but also, you know, all of these other physiological signs of estrogen deficiency that are impacting our outcomes, right? We see that individuals with that combination of muscular mass, we are seeing individuals with negative consequences of osteoporotic fracture. if we were able to be preventative in this approach where we are talking about estrogen supplementation when these symptoms start to arise, especially when they hit a threshold of bother, where there's going to be this spectrum, some individuals are very bothered and very impacted by the signs of vasomotor symptoms and genital urinary syndrome of menopause, and then some individuals are not, but for those individuals with bother, is this something that should be taken? Is this something that they can talk to their physician about? Is there this literature to support these topical estrogens? And we are starting to see this mounting of evidence that is starting to come up to help individuals in the aging process. So many of our aging adults are being told that this is just what they should be living with. This is because they're going through menopause. Deal. We saw this in the peripartum space where there's a lot of advocacy still happening with respect to not having this thought process that as soon as you have a baby that pelvic floor dysfunction is just something that you should live with. We're starting to see this rise up in our perimenopausal and postmenopausal population, where they are not accepting that this is what they should be doing. They're not being dismissed anymore for these symptoms, and it's super important. When we take this lifespan approach, this education becomes extremely relevant. Talking about the peripartum space, I truly believe that that is where we start to tell females that they are not resilient, that they are somehow fragile, that they need to be concerned for their organs falling out and all these different pelvic floor dysfunctions. And then they are not encouraged to be as resilient as they could be by taking part in heavy resistance training or impact activities or things at higher intensities. We start bringing that intensity down and the idea of, ooh, be careful or, oh, monitor this or, oh, if you have these symptoms, it's time for you to stop participating in those activities. We are seeing this shift and what this shift is going to do earlier in life is it's going to set up are aging individuals with this mindset that pelvic floor dysfunction one is not inevitable two that reserve is protective when it comes to muscular reserve and three they're going to be advocates for their own health and that includes their hormonal health and that includes not accepting that some of these symptoms of menopause are things that they just need to live with, but things that can be medically managed. Genital urinary syndrome of menopause is a syndrome condition. It is a medical diagnosis, and therefore it is something that we can be treating. As physical therapists, us being educators and conduits of that knowledge translation is extremely important. And then we are going to optimize function for these individuals. Last point that I'm going to make, because I ended up being a lot more long-winded than I thought I was going to be, is that we are now seeing this interaction between menopause, genital urinary syndromes, and long-term health outcomes. We are seeing that individuals with higher physical activity, combination, aerobic resistance, or both, are having a much lower GSM burden than those who are not. And so again, it comes back full circle, whether this health promotion is extremely important, that not only are we gonna optimize a person's muscular reserve, we're gonna make that fountain of function be extremely relevant, but we're also going to make the quality of that function a lot better because their quality of life is better because we are not allowing them to just live with these symptoms and be dismissed by our medical system, us included, that just expects this to be the way that it is. And so this advocacy piece is extremely important and it's something that we are going to be screaming from the rooftops. All right, everyone, I hope you have a wonderful week. I'm going to be diving a lot more onto my page and I'm going to be collaborating it with ICE and MMOA around hormone therapies for individuals with GSM. I am not a medical physician, so I encourage you to reach out to your urogynecologist and urologist in your area. Get that relationship with them so that you can start having these conversations and we can start talking about risk profiles. All right, have a wonderful week. If you are not on our MMOA digest, I encourage you to sign up for those newsletters. Otherwise, have a wonderful week and I will talk to you all again soon.

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