By Karen Miller-Lane, ND, L.Ac
“ The fact is, everyone--both men and women-- naturally lose muscle and strength with age. If you do nothing to stem that loss, you can expect to lose up to 8 percent of your strength each decade after your thirtieth birthday, and that decline accelerates after age 60. So by the time you’re 55, you might be 20 percent weaker. The years around menopause can make this worse, as estrogen is essential for muscle stem cell function and maintenance and is also the main driver of muscle mass and strength.”
STACY T. SIMS, MSC, PhD. is a forward-thinking international exercise physiologist and nutrition scientist who aims to revolutionize exercise nutrition and performance for women.
“Older muscle still responds to resistance training, proving again that it’s never too early or too late to start reaping the benefits of this crucial strategy for preventing muscle losses with age. Show me a 90-year-old who says, “Gee, I wish I had less muscle mass” and I’ll show you a leprechaun at the end of a double rainbow riding a unicorn kissing a mermaid.”
Peter Attia, MD. a Stanford/Johns Hopkins/NIH-trained physician focusing on the applied science of longevity, the extension of human life, and well-being
In the following article, I hope to do four things to explain the importance of strength training for peri and postmenopausal women:
Provide a definition of who we are speaking about when we use the term “peri” and postmenopausal women.”
Clarify the mixed messages women have received regarding the importance of strength and, in particular, muscle mass, as we age.
Explain how strength training, along with other forms of exercise, can support the effects of normal declining sex hormones.
Lastly, I will offer some practical recommendations regarding how to include strength/resistance training in our lives now, and for the rest of our lives. I want to make explicit how we can meet our expected life transitions and how mindful attention, action, and commitment to strength training (and of course, good nutrition, and sleep) is essential throughout our lives, but, specifically, in the second half of our lives.
I want to empower you through education, tools and embodied awareness to meet the next half of your life with strong and open arms.
1. What is Perimenopause and Menopause?
Menopause is defined as the moment when women have not had a menstrual cycle for one year or 12 months. If you do not have a cycle for seven months, and have one in month eight, you start counting anew. Menopause is defined as 12 consecutive months without a menstrual cycle.
Perimenopause refers to the time before menopause which can be anywhere from five to 10 years prior to menopause. During this time, hormones are in flux. We can feel like we’re in different bodies every 6 months and in a sense, hormonally, we are. These are moments in time similar to when a girl gets her first menstrual cycle. A girl's first menstrual cycle and a woman's last menstrual cycle mark the beginning and end of a particular hormonal dance. This hormonal dance impacts our heart health, bone health, muscle strength, metabolic health and so on. Female bodies dance with estrogen and progesterone (along with numerous others) from our first menstrual cycle to declining levels of these two hormones after our last menstrual cycle. These terms - menstrual cycle, PMS, perimenopause and menopause - are ways in which medicine delineates and measures, but in no way do these terms reflect the nuanced, dynamic, whole and varied experience of each woman as she journeys through the moments and transitions of a life. We are continually learning and understanding our hormonal dance.
“It’s never too late to begin incorporating some form of resistance training into one’s fitness routine, and evidence shows that even adults in their eighth and ninth decades of life gain muscle mass when they engage in resistance training. Although the hypertrophic gains are modest in older adults, the relative strength gains can be enormous -- and may even be lifesaving, reducing the risk of falls and other aspects of frailty. Of course, one will gain the greatest benefits from resistance exercises when they’re part of a lifelong program of fitness.”
Brad Shoenfeld, Ph.D. He is a full professor in the Health Sciences Department at Lehman College in the Bronx, NY, and serves as the Graduate Director of the Human Performance and Fitness program.
2. The historical exclusion of women in medical studies and the impact this exclusion has had on our understanding of the importance of strength training for peri and menopausal women.
Before 1993 women were rarely included in formal medical studies in the United States.1 The majority of studies on exercise, let alone strength or muscle mass were done only on men. As a result, conclusions from these male only studies regarding what might be “normal” were simply applied and ‘translated’ to female bodies. The assumptions on which the medical establishment has determined how to address cardiovascular health, how we build strength, and so on, have been historically based on male only data. This is starting to change, albeit slowly. Research that includes female bodies is starting to decipher how to support and enhance aging well in female bodies. We are beginning to understand that what supports peri and postmenopausal women may be different from a lot of the information regarding strength and fitness that is currently considered mainstream but was, in fact, built on male only studies.
Myths surrounding muscle building for women: Socio-culturally in the U.S., being fit for men has meant building muscle and for women losing weight. Women have been steered toward cardio to lose weight. We've had to contend with myths such as, “strength training causes women to ‘bulk up’” or “women shouldn’t get too muscular”. This emphasis on weight loss over strength training is misguided and wrong because strength and muscle mass are crucial to healthy aging.
Strength training, including lifting heavy weights with fewer repetitions translates to strength and power; strength and physical power can help provide overall body stability that can help prevent falls and not breaking a bone if we do fall. Furthermore, strength training does not have to mean “bulking up.”
Fortunately, we are now seeing spaces and places where a range of women's bodies are celebrated. The 2024 Paris Olympics, for example, provided an opportunity to witness strong, powerful, amazing women in many shapes and sizes from gymnast Simone Biles to rugby player Ilona Mayer. The message I want to reinforce is that strength training is about getting healthy and strong. Strong means the ability to carry groceries, lift luggage, play with our grandchildren, catch ourselves when we fall–in other words, staying active and engaged. Female bodies are different from male bodies. We do not have the same hormones and females have different mass and a different ability to put on muscle than male bodies, especially in peri and postmenopause. Let’s stop the not so old messages of being only one particular size or shape. Let’s think strong and allow ‘strong’ to show up in as many different shapes and forms as there are women in the world.
“Overall, [we are] breaking the stigma that women need to prioritize long, endurance exercises and exclusively body weight work because they offer little benefits for body composition or lean mass during this time. Instead, lifting heavy (whatever that means to you) will help most during this transitional period.”
Dr. Stacy Sims
3. Female hormones, the dynamic experience of menopause and the need for strength exercises
The subject of female hormones is a beautiful and complex field (how could it be anything else?!). In this section, I will offer a brief overview of how our hormones play a role in muscle strength, flexibility, injury and recovery.
Your hormones are signaling molecules that regulate your physiology and communicate with nearly every cell in the body. Hormones guide your cells to do various things such as build or break down bone. Some hormones are altered due to changes in body composition, poor insulin sensitivity, and disrupted sleep. Other hormones, such as estrogen and progesterone decline with age. This decline is normal although women have varied experiences.
Throughout peri and postmenopause there is a decline in estrogen and progesterone. This decline is not linear but dynamic. Estrogen and progesterone are always in relationship with one another; levels of one can significantly influence the other. Estrogen and progesterone levels also fluctuate, and they can be irregular.
Estrogen is important for strong muscle contractions and for generating power and force. As a result, it helps drive the development of lean mass. Estrogen also promotes insulin sensitivity, helps manage body temperature through control mechanisms like blood flow to the skin and sweating, helps regulate nitric oxide, a compound in your body that works to expand your blood vessels for better flow, and is critical for maintaining both bone density and the strength of our bones. Estrogen helps to protect against heart disease and helps to keep your blood vessels healthy, limit inflammation, and control cholesterol levels. 2
Progesterone dances with estrogen in that it can stabilize connective tissue and support increased tension on tendons and ligaments. Progesterone also produces a calming, anti-anxiety effect in the brain and may enhance memory function. When progesterone levels are high we also have a greater pain tolerance. Finally, as with estrogen, progesterone decreases the rate of bone resorption and also reduces the loss of calcium in our urine thereby supporting bone health. As you can see from just this very short overview, hormones are involved in numerous pathways to support women's health.
How strength training supports declining sex hormones. Certain types of exercise, such as strength training (a type of exercise that uses resistance to build muscle strength, endurance, and size), provide the neural stimulation you need to get your muscles contracting strongly to reproduce estrogen's positive effects. Building true strength is a matter of increasing the maximum force your muscle can produce in a single contraction--how much you can lift or move in one action. Exercises that challenge us stimulate satellite cells which regenerate muscle stem cells and replace the muscle and strength-building stimulus that we are losing as estrogen declines in the peri and menopausal years. Estrogen affects how your brain structures are connected, the way your brain cells communicate, and even the shape of your brain.3 Hence, we want to approach exercise as not only good for muscle building but also as crucial to our overall brain health and function.
When we engage in strength training, we are using the central nervous system to create new neural pathways. High intensity work, such as lifting heavier weights over time, produces more brain derived neurotrophic factor (BDNF) thereby supporting and benefiting brain health. 4
Strength training stimulates a hormonal response to build lean mass, maintain and build our bones, and support other hormones such as serotonin and norepinephrine to support vasomotor symptoms such as hot flashes. Strength training is also good for our hearts. It increases our vascular compliance (our blood vessels dilating and constricting more readily) giving us better blood pressure control and flow to skin and muscles. Women who did strength training saw an even greater reduced risk of cardiovascular-related deaths – a 30% reduced risk, compared to 11% for men.5
Strength training increases metabolic rate which means you burn more fat while you exercise. Researchers have noted that “lean body mass seems to be the most important contributor to the observed changes in metabolism in women in the early stages after menopause”.6 After six weeks of strength training and eventually lifting heavier weights, you begin to create changes to how the muscle utilizes carbohydrates for energy so we need less insulin, therefore better blood sugar control. Building resistance (ie. strength) involves lifting heavier weights over time, which stimulates lean mass development and sends a signal to our body to decrease central and total body fat. Heavy resistance training is much more effective for changing body composition than endurance-based lifting or your typical cardiovascular exercise, especially in the years leading up to menopause and the years that follow. 67
Lifting heavy weights (properly!) stimulates your tendons and ligaments to increase their tension and give you overall stability and support your joints–such strength training is important for bone health. It improves bone mineral density which means stronger bones. The bones need a compressive force on them to grow, and the compressive force comes typically when the muscles around them are contracting. When the bone is put under load with strength training it sends a chemical signal to the osteoblasts and osteoclasts, which are the bone building and bone decaying cells respectively. I refer you to this study by Belinda Beck at Griffith University in Australia called the LIFTMOR trial. Here is a you tube video of her talking about the study.
In summary, strength training, a certain type of high intensity interval training called sprint interval training, plyometrics, balance and mobility exercises support the outcomes that sex hormones once did in our early years, for the second half of our lives. Just adding back hormones will not prevent muscle loss. Engaging in these types of exercises - along with a good diet, and sleep - support building healthy bones, heart health, mood and cognition, and muscle strength. My goal here is to provide accurate information that will enable you to make informed choices to meet this next life transition actively. Now, let’s review how to begin.
4. How to begin–some practical recommendations
Begin where you are. Seriously. If you have never lifted a weight before, strength training will initially mean supporting your own body weight. Start with a beginner’s yoga, pilates, or bone builder’s class. If you have been lifting weights for some time, using the same amount of weight, with the same number of repetitions and the same movements, you are putting in work without any significant gains. Our body adapts and needs regular stimulus to get stronger and mobile. At least every 6 to 12 weeks we want to try new workouts or increase weight for example. In addition, correct form is crucial.
Take a class from a trusted and respected instructor, work with a trainer, or watch a YouTube video of someone who can educate you on proper form. Otherwise, we risk injuring ourselves and stopping the process before we have a chance to make progress. Slow and steady is the rule here. Building muscle is a lifetime endeavor. We also need to work with the body we have - past injuries and health concerns need to be thought through and discussed with your doctor, perhaps a trainer or physical therapist. We need to listen to our body, which means there will be weeks when we may need to tone things down or ramp things up. We want to be aware of changes to our schedule and how we can accommodate workouts in the face of these changes. For example, on vacation, we can do some body weight exercises in our hotel room or family guest room and go for long walks if we don’t have access to equipment of the same routine. My mantra is to stay mindful and consistent. We are consistent when we are able to dance with change and meet it in innovative ways.
How do we sustain a healthy routine? Try to establish the habit of doing something active every day. This does not mean you need to do strength training daily. Strength training 3 times a week builds and maintains muscle strength and power. The rest of the week can include things like walking, cycling, yoga, stretching, zumba, swimming, dancing, yoga, pilates, tai chi, sprint interval training, and plyometrics to name a few.
If you have never lifted a weight before or been very active - start walking most days for 15 to 30 minutes. Then, start including hill work. Then, consider working with a trainer. Take a strength training class, bone builders, yoga, or pilates. You can graduate to adding other bodyweight exercises. I’ve included examples below. Then begin lifting weights!
Over 60 - 5 exercises - scapular retractions; glute bridges; squats; heel lifts; grapevine
For seniors - wall push up; pull up; farmers carry; hip hinge; squat
When will I see the results? Be aware that the data on muscle protein turnover does not show increases in hypertrophy (building muscle) during the first six weeks of strength training (with weights). During this time, muscle tissue is remodeled to become stronger, more resilient, and it starts protecting itself against damage. The first six weeks is a time and cycle where muscle tissue is simply turned over. After approximately 6 weeks, you will start seeing increases in building muscle and lean mass. Keep going. After 8 to 12 weeks we start to notice differences in our strength, energy and power. We can sometimes begin to measure the increased muscle mass in inches.
Things to keep in mind when strength training
Correct Form. Using correct form is extremely important to prevent injuries in any activity but, particularly, when we are engaged in strength training. We need to learn how to use our hips, knees, track our legs with our feet, and how to balance and create stability. As we are building our practice - we need to consider increasing the frequency, then duration, and lastly intensity. If we build intensity first, we are likely to injure ourselves. Try to be mindful and consistent.
Neuromuscular control. In weight training, proper form not only ensures that we are building strength safely, but proper form means we are learning to control the weights we are using. Our hand-eye coordination, coverall coordination, and balance increases with our strength. A lack of neuromuscular control means that we are moving a weight we cannot control which inevitably leads to injury. (8 min video on the basic concepts behind neuromuscular control)
Progressive overload. This is a type of strength training that gradually increases the intensity of workouts to avoid a plateau in muscle mass and strength. If we are not continuing to challenge ourselves whether in the amount of weight we are moving, the duration, or intensity, then, we are no longer building muscle or strength. In other words, if you have been doing the same strength training regimen for the past year without any changes you are not building strength or muscle. Again, this matters because as we get older, if we aren’t consistently training, we can lose 10–15% of our muscle mass and strength per decade.
And we need to realize that as we age our bodies have gotten into various patterns and certain muscles are overused and others are underused. As we continue to build strength, mobility, and balance we may need to account for these imbalances with further support from a personal trainer or physical therapist to ensure that we do not injure ourselves.
Recovery. Recovery is another important element of any workout. Conscious and healthy recovery is correlated with muscle growth and strength (if we are sore all the time we are probably training incorrectly or overtraining). We need to give our bodies time to recover from a hard workout. If we did a full body strength training workout then we need to give our body a day or two to recover, repair, and build muscle. If we overtrain, doing too much too soon, we will injure ourselves and not gain many of the benefits.
If you have been lifting weights, here are some examples of at home you tube videos.
Other recommendations to support strength training
The following are included to provide a full picture of other aspects of strength and balance that are critical to aging well. Experiment with the various options below and begin to sprinkle these in throughout the week.
CORE EXERCISES
Complete Core Strengthening 10 minute follow along
PLYOMETRICS
Whether you jump, hop, or bound, plyometrics gives your bones and muscles the extra stimulus that comes when you push off against gravity and land back down. It is those impacts—big or small—that generate important physiological changes. For one, they help build bone, which we lose during the menopause transition. Plyometrics also trigger epigenetic changes, or changes in your genes. When you do plyometrics, you wake up some otherwise very quiet genes inside your muscle cells that stimulate those cells to improve power and even the composition of the muscle itself in a way that improves the integrity of the muscle, its contractile strength, and its response and reaction time. They also improve your mitochondria function and insulin sensitivity—both of which are important for menopausal women. If you are not used to doing these exercises, start slowly and if you are hesitant, working with a guide or organized group can help.
SPRINT INTERVAL TRAINING (SIT)
Sprint Interval Training is a form of HIIT (High intensity interval training). If you want to maintain your top end, you need to train your top end. That’s especially true during the menopause transition. The best type of high-intensity interval training for menopausal women is super short, sharp sprint-style intervals lasting about 30 seconds or less.
When you extend intervals past 60 seconds, you can get greater increases in the stress hormone cortisol and cortisol is good for a surge of energy. However, you don’t want those stress-hormone levels to stay elevated longer than necessary to get the job done, especially in menopause when cortisol can already be elevated. With 30 second sprint intervals, you still get the benefits–improved insulin sensitivity, stronger mitochondria, improved fat burning (especially visceral fat), and an ever-important boost of growth hormone after you finish! “Tabatas” are a simple way to add intensity to any exercise: After a warm-up, push as hard as possible for 20 seconds. Recover for 10 seconds. Repeat 6 to 8 times. Rest 5 minutes, and work up to repeating 2 to 3 more rounds.” 8
Here is another example of a sprint training interval that would be performed after a really good warm up or after your strength training workout: Do a dynamic warm up moving all joints in all directions. Then jog or fast walk for five to ten minutes. Wear a stopwatch and time your sprints. Do your warm-up, sprint for 20 to 30 seconds and stop completely or walk. Rest (or walk ) for a duration twice as long as your sprint. For example, your rest would be 40 to 60 seconds. Sprint again after your rest and repeat for two to five intervals. If you don’t want to sprint you could do this on a bike, rowing machine or on the road. If you can’t do more than 2 or 3, you are on the right track! This should be hard. You can always add it at the end of your strength training workout.
There have been several studies on postmenopausal women showing the muscle-making powers of sprint interval training (SIT). In a 2019 study published in the journal Medicine & Science in Sports & Exercise, researchers had a group of postmenopausal women ages 47 to 59 perform 20 minute bouts of SIT—alternating 8 seconds of sprinting on a stationary bike with 12 seconds of easy pedaling—three times a week for eight weeks. By the study’s end, the women lost fat, regained muscle mass, and also improved their aerobic fitness by 12 percent.9
TOES/FEET/CALVES
“ Toe strength is the biggest predictor of falling in people 65 years old and older.”
Courtney Conley an internationally renowned foot and gait specialist
An often overlooked part of the body involved in building strength involves our toes and feet. We want to include exercises to build toe/foot strength and calf strength. Courtney Conley, DC, is an internationally renowned foot and gait specialist. As Courtney’s good friend Jay Dicharry always says, “You can’t build a jet engine on a paper airplane.” She emphasizes how we’re building all of our strength and focus on everything above the knee when in reality gait is shock absorption, it’s stance ability, it’s propulsion, and all of those things enable us to become efficient with movement.10 Below are some exercise examples that include our feet and calves, a whole body approach to strength training.
Big toe banded exercises: 40 reps in each direction, if you can’t do the little toe, just focus on the big toe and then the 4 toes
Training for the Anterior Fall Envelope: 20 reps. 3-5 second holds
Any type of calf raise: double leg standing, double leg seated
To specifically target the soleus, seated is better since the knee needs to be bent >60 degrees
Do a single-leg calf raise using something as simple as a container of laundry detergent on your knee at home (a full detergent container weighs about 17 lbsThe aim is to feel fatigued after about 3 sets of 6-8 rep
For a challenge, you can slow down the tempo and really squeeze at the top
For general balance this works on activating the extensions of the toes and works on toe splay
Do 20 reps then try to balance; ideally start with 10 seconds on each side, working up to 30 seconds.
Closing thoughts
Hopefully you have gotten a flavor of why strength training is part of a practice of aging well during perimenopause, menopause, and beyond. My focus is on our quality of life. Growing older requires thinking about and experiencing ourselves as dynamic beings who are always changing and evolving. We need to loosen the grip on the question, “How do I get back to where I was?” and, instead ask:
What patterns will support how I want to live the rest of my life?
In order to step into the years that will follow with courage, grace and strength (literally!), we need to honor and welcome honoring where we are now and who we are now and build from this beautiful, dynamic place. This approach will require different kinds of work and attention. Just because we didn’t need to work out very much in our 20’s and 30’s doesn’t mean that there is something wrong if we have to in our 50’s, 60’s, and beyond. If we are already active, we may be noticing more aches, pains and injuries that have sidelined our ability to do the things we love with the same intensity that we once did. Healthy aging requires different choices, and different kinds of work to stay strong, flexible, and mobile. There is a lot of good life to live and,if we look around, we see numerous examples of people stepping up, embracing the work with humor, humility and grace, and aging well.
I know that I have included a lot of information in this post, but don’t let it overwhelm you. Start simply. Whatever that looks like for you. Schedule it in. Just begin. Strength training doesn’t solve all our problems. There is never one magic thing that changes our health outcomes. Our health includes a constellation of practices that we engage with and stay consistent with over time. This is not a short term solution. This is for life. The choice to eat in a manner that will support a healthy body composition is not about the latest fad diet but what we are willing to do, consistently over time, along with other healthful practices that have lasting effects. [See my article on protein.]
Our consumer culture would have us believe that the right fix takes just one, perfect purchase. But, by the time we are in our 50’s and beyond we have accrued enough life experience to recognize this is wrong and harmful. We also start to recognize that we have to put more time and effort into our food choices, our sleep, exercise, and other lifestyle choices in order to stay healthy, fit, and have the quality of life we want for the next decades of our life. Science is confirming what we know deep inside–we can get better with age with the conscious, mindful incorporation of consistent, life-affirming habits, in community.
“Faith is in taking the first step even when you don’t see the whole staircase”
Martin Luther King, Jr.
1. National Institutes of Health, NIH Inclusion Outreach Toolkit: How to Engage, Recruit, and Retain Women in Clinical Research
2. Centers for Disease Control and Prevention. Leading Causes of Death - Females - All races and origins - United States, 2018.
3. Barth C, Villringer A, Sacher J. Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods. Front Neurosci. 2015;9:37. doi:10.3389/fnins.2015.00037
4. Sarita Khemani, MD, https://longevity.stanford.edu/lifestyle/lifestyle-team/khemani-bio/
6. Stacy T. Sims, Roar, New York: Rodale, 2024.
7. Ibid., pg. 90.
9. Boutcher YN, Boutcher SH, Yoo HY, Meerkin JD. The Effect of Sprint Interval Training on Body Composition of Postmenopausal Women. Med Sci Sports Exerc. 2019 Jul;51(7):1413-1419. doi: 10.1249/MSS.0000000000001919. PMID: 31210647.
10. https://peterattiamd.com/courtneyconley/ Peter Attia Podcast #296 - Foot health: preventing and treating common injuries, enhancing strength and mobility, picking footwear, and more | Courtney Conley, D.C., April 1, 2024.
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