Rebecca Robinson (00:00)

focusing less on the times and the watch. So again, maybe going back to that kind of enjoyment in getting the sessions done, but not saying not comparing because there's that wonderful quote, you know, comparison is the thief of joy. And I think we all do it now. You know, you kind of think, well, that was a good session. Then you look at your garmin or whatever wearable and say, I don't know if it was as

Paul Laursen (00:15)

You

Paul Warloski (00:43)

Hello and welcome to the Athletes Compass podcast where we navigate training, fitness and health for everyday athletes. Today we're talking about something that doesn't get nearly enough attention in endurance sports, women's health across the entire athletic lifespan, especially perimenopause and menopause.

We're thrilled to welcome Dr. Rebecca Robinson, a UK based sports and exercise medicine consultant who works with elite athletes, including Great Britain boxing and British athletics or track and field. She's also a competitive marathoner herself. She finished third at the 2014 Brighton Marathon. Dr. Robinson specializes in female athlete health at every life stage.

including how women can continue thriving in endurance sports throughout menopause, perimenopause and beyond. So Dr. Robinson, as both a sports medicine physician and a competitive marathoner, what drove you to specialize in female athlete health?

Rebecca Robinson (01:45)

I would say it was probably the luck of the timing. So I was doing my probably highest marathon training whilst doing my training, what you'd call residency, which we now also call residency in the UK, and converting that from hospital medicine toward sport exercise medicine, where I do have a couple other things that I like doing, which things like cancer rehab, trying to get people back fit. But around that time, the research and momentum around women's sport has

just seemed to start growing. mean, there is an irony there because obviously half the population and there it should be, but this big evolution in the science, but also the practice and I guess lots of different sports and teams recognizing that there were areas of female health that were just kind of different. So I guess I kind of got lucky in my timing and I feel that the two themes have kind of grown together. I've grown through my practice as these issues have evolved. And what's lovely is quite a of the time when...

patient comes to me, a female patient asking questions, I'm kind of saying, we didn't know this or people weren't empowered to ask this five years ago, even a couple of years ago. So it's, there's a really nice synergy. So I think it was more that kind of maybe cosmic timing than intention.

Marjaana Rakai (03:01)

So what are some of the questions or topics that women that are coming to see you are asking?

Rebecca Robinson (03:09)

I think if we kind of look through the lifespan, sometimes it's younger athletes saying, well, should I have established my menstrual cycle right now? Or some young athletes that seems to be quite a turbulent time for the body and changing, you what should they be doing? How might they focus things better for their training? And kind of looking at that piece where in a similar way, through boys to men sport, there is that period of maturation. And I guess, you know, questions like from female athletes, have I messed up some of my

future in terms of fertility by the hard training I did in my 20s. Sometimes it's kind of myths, sometimes it's just a lack of knowledge. Then moving toward perimenopause, you've got a lot of women now who are performing phenomenally throughout their 30s, 40s and into their 50s, but how to kind of optimize that with an eye on like longevity and how to balance like the science and the medicine. And then what I love is ⁓ the older end of the spectrum, have patients up into their 80s who are still staying active and don't want to just, you know, take to a seat, but

finding ways of staying active and motivated through the lifespan really.

Paul Laursen (04:13)

Can I actually pivot off that, what you just said there, Dr. Robinson? Can a woman do serious damage to her fertility chances if she's training too hard through her 20s and 30s, say for example? Is that a real danger?

Rebecca Robinson (04:28)

I mean, think what we, probably the consensus is it's likely not to be harmful long-term. We don't know enough. This theme will probably come back. There is so little research in female athletes. It's the kind of combination there was fear after some trials of medications where it looked like there might potentially be damage and there's a big, big pullback on the research, but there's also hormones and trying to research a female, hell of a lot harder for researchers. You're men, have testosterone just go up and down predictably.

Paul Warloski (04:53)

you

Rebecca Robinson (04:55)

Whereas if you've got a cohort of women, they're gonna be at all different stages, hormone numbers all over the place sort of thing. So historically that's been tricky. So it's been hard to nail the numbers. There are some signs that if someone is in like a low energy state and over training for a long period of time, then at that time, their fertility will likely be lower because the body just kind of pulls in and doesn't wanna look at what it considers non-essential.

functions and we'll probably come on and chat a little bit more about some other implications for overall health with that. There's no strong evidence that that impacts long-term fertility. However, it's not a great state to be in at the time for lots of other health reasons. And it might just have a little bearing on how regular, kind of how ready the body is, at least somewhat later on, but potentially later on. But we need a lot more research to say that that is the case. So for me, for any athlete in that kind of situation or things they have.

The focus for me is saying, let's optimize your health right now, see what that does, because that's likely to resolve any issues that you're concerned about. But yeah, the more that we can learn from gynaecology, from sports med, or coming together, the better in that domain as well.

Paul Laursen (06:03)

I like how you phrase that though, and you give a lot of women hope that at the end of the day you have a human body that is, if you make it healthy, it's made to reproduce. So even if you have had that situation where you are a lifelong or a high performance athlete in your 20s and your 30s, and there is evidence that potentially absence of a regular cycle, whatever it may be, getting you healthy again is basically a...

going to reset and allow you at least the chance to bear children in the future.

Rebecca Robinson (06:39)

Yeah, I think so. And if that's the priority for that female, you know, either at the time or sometimes I'll see someone that is thinking about that being in their medium term to longer term future. It's just about getting the information for that particular individual, getting that empowerment so that they don't have it as something to worry about, but they can have it something to be thinking about and hopeful about.

Paul Laursen (06:58)

Yeah, amazing.

Paul Warloski (06:59)

You've worked with athletes across all life stages. What gaps did you notice in how the medical community supports female endurance athletes, particularly in midlife?

Rebecca Robinson (07:12)

think what's happened is women are chasing endurance further and further along than we thought. one American that springs to mind is like Sarah Hull, who is still running phenomenally at the marathon. I think she is 40 plus now. ⁓ even I think quite recently, one of our Brits, Eilis McColgan said, you know, when she started training, we thought our careers were done and dusted at 30 and she's now 35 and has like the European

Paul Warloski (07:17)

Hmm

Mm-hmm.

Rebecca Robinson (07:39)

have the European record narrowly taken from her by a whisker by another Scott. But that idea that actually you're going to be performing, well, there have been a few women trailblazers who have shown that and I expect that will grow, but we haven't been prepared for it really. So I think some of these phenomenal women who have had support as well to get to that level are drawing on the next generation. And hopefully it will make it a bit more of a lifelong sport. We won't all be

thinking, my, we have to peak at this time and prioritize. I think you're seeing some younger athletes now finding that the right time for them to, for example, think about family is the right time for them, rather than thinking, I must get this in place in my career now because it's a short career, because it really doesn't have to be. So I think it is surprising and great that we're seeing that longevity in rewriting some of the textbooks, I guess, at some point to say, know, the physiology, the speed drops off a cliff.

because this is not what we're happening on the track and field.

Paul Warloski (08:39)

Hmm.

You've mentioned that after menopause, some women need support to feel fit and healthy until later life. And what does that transition look like physiologically for endurance athletes?

Rebecca Robinson (08:57)

mean, there's a physiological and hormonal level and then there's like the personal level too. So everyone's journey is kind of different. On a physiological level, basically those functions of reproduction are kind of winding down, even though the female has got a lot of healthy years left and when they can perform really well. But we kind of see this slowing down and typically like the hormonal levels drop or the estrogen levels drop. And that is an important one in terms of overall health, which are.

focus on a little bit and we see some of the other markers rising. So we can tell as well, because some women may be over training in their early 40s, for example, and not actually perimenopausal. So really important to figure out where those hormones are going, what is actually happening. But when that does start to happen, it can be a period of a couple of years for some people, some longer, and they may have symptoms at that time. Some women will find they get things like hot flushes typically. Some will get significant pains in their joints as we lose some of that protective estrogen.

Some women will sail through, some already struggle. I think what has been good in terms of shining a light on this in the medical community more recently is that women can come and advocate for themselves and be heard. And if it is someone who is struggling significantly with symptoms, then things like hormone replacements can come into place, which can help steady that change in the body's natural hormones. So some people will benefit from that and need it. Some people won't feel that they need that.

But on a kind of local level, the bone is losing its estrogen support. So we do see a decline in bone density. So if someone doesn't go through treatments and they go through the normal menopause, they will lose that estrogenized bone. you get like your of pre-besantine and then the bone density skyrockets. And that's where I always want to protect those young athletes coming through. And it's because of the estrogen on the bone. And then it kind of rises to a plateau in like the 30s and then 40s until menopause. And then the section that we lose is really that bone that has the estrogen in it.

So it's not necessarily a decline onwards and onwards, but it's that proportion of the bone. So that's where if someone does have a history of low bone density or of family history, we want to maybe monitor what their bone is doing. And kind of similar goes to the tendons and muscles. They just lose that big overall environment of estrogen, but you still get local hormones from the joints and muscles when we activate them. And also women do have testosterone. So that's relevant as well. You know, we lose...

some of that systemic support. And in terms of wider health, women have the upper hand in terms of lower cardiovascular disease through the lifespan. If there's someone who's had a regular cycle or at least those normal levels of estrogen. And then they actually lose that support. So without other good things like physical activity, our risk reverts kind of to that of the men as well. So we kind of lose that protective effect. So there's a whole system change.

There are some cognitive changes. Again, we haven't got quite the amount of research, but some people will find it harder to focus, concentrate, and that might be important in skill-based sport as well, especially during that perimenopause. it does, the good news is it does even off afterwards. So it's not, ⁓ you know, an unmitigated disastrous period, but for some people it's more turbulent.

Paul Laursen (12:11)

MJ, I see you're nodding your head and go, you know, it sounds kind of familiar.

Marjaana Rakai (12:18)

Yeah, there's a lot to unpack there, Dr. Robinson. I am someone who was overtraining in my early 40s and some of the symptoms kind of, you know, are similar to what I'm experiencing now, like sleep disruptions, brain fog, a little edgy mood. ⁓

Paul Warloski (12:21)

There.

you

Paul Laursen (12:44)

Yeah.

Marjaana Rakai (12:46)

⁓ and just like joint pains and lots of fatigue. ⁓ So, yeah, so essentially a bit of a handful to deal with. But something that I kind of want to dig a little bit deeper into is the cardiac health and potentially arrhythmias that

Rebecca Robinson (12:59)

Yeah.

Paul Warloski (13:09)

you

Marjaana Rakai (13:12)

can be caused by that declining estrogen. Can you tell us a little bit more about that?

Rebecca Robinson (13:19)

I mean, estrogen has a cardioprotective effect and on its own without it, people won't necessarily have a cardiac arrhythmia. However, sometimes if we couple that with endurance athletes who tend to run a low heart rate and we see in men and women that there can be some groups who appear to have a slightly more raised likelihood of conditions like atrial fibrillation, which is where there's an arrhythmia in the top chambers of the heart. It doesn't usually have consequences. It doesn't conduct to the lower chambers. We talk about ventricular arrhythmias then.

all of us medics get very nervous, that's something that is very severe and life threatening. The atrial arrhythmias do have risk, they do have an impact on an endurance athlete because people would feel unwell and it can impact their training. But it might be that for some people the trigger could be when they go through like the perimenopausal menopause. So that one more thing that changed in a situation where they may have been a bit predisposed with the athletic heart and with a slower heart rate.

So that can be the timing that we sometimes see those symptoms first happen. If that sounds good.

Marjaana Rakai (14:21)

Yeah.

So in a case where there's been a longer term

palpitations that athletes has been cleared by a doctor to train, but they feel like a little bit discomfort. And it is kind of alarming to you when you actually, when your heart hasn't had any, you know, problems before. And then suddenly you start having palpitations and it kind of throws you in this loop. Should I train? How should I train? Like what, what, what are, what are your advice for?

someone who is experiencing palpitations that is cleared ⁓ by a doctor.

Rebecca Robinson (15:04)

Yeah,

think the important thing is like you said has been cleared. So always check out what's happening because there are different types of palpitations and changes in heart rhythm. Some people get what's called a supraventricular tachycardia where the heart can sometimes go into this rhythm. Some have seen quite commonly the swimmers sometimes ⁓ certain maneuvers can help that. Certain medications can also help that with their maneuvers. There's something like the valsalva when you're kind of doing a sort of braced breathing position that medical.

Teams will teach how to do that and they can be medications too, something like atrial fibrillation, something to be cautious of and in terms of a diagnosis and sometimes medical treatment, that's something to be established so that ideally the heart's not continuing in that rhythm long-term. But I think any new change, still go get checked out, still go see a medic because even if it's something that is totally benign, it puts you back in control. And any new change as a doctor, we kind of tend to see it with fresh eyes and go, hang on, this is different. And if you're having...

chest discomfort especially, because we know and we have underplayed women getting different symptoms for cardiovascular disease. We present differently that kind of left central crushing chest pain radiating to the drawer and arm is a very male pattern. Doesn't mean it can't happen in women, but I recall and I don't think I was taught medicine too badly, but it was just in the time we were told that a woman around or below menopause age couldn't be having heart attack because they'd be protected. We know that was so wrong. So

I think just presenting, saying this is not an athlete's no, we know our own bodies. So I think this is not what's quite right for me. And going back to get it checked out before continuing is what I advise.

Marjaana Rakai (16:38)

Yeah.

Great. Great advice.

Paul Warloski (16:42)

So how do you know you've talked about the estrogen changing and lowering how do those hormonal changes during menopause typically affect training adaptation recovery and performance those kind of things for everyday athletes?

Rebecca Robinson (17:00)

it can slow things down. can be a bit of a beginning of a change where things do slow down. And one of the reasons when I skip back on the spectrum to athletes in energy deficiency, I kind of say, you know, without being placing them in a different bracket of life where they are, but so saying, you know, that you won't adapt to training as well. And we know this off some really small studies, but we know that the women who've gone through a healthy lifespan and reached the perimenopause or menopause stage can often have other things in their armory, other...

Paul Warloski (17:02)

Okay.

Rebecca Robinson (17:27)

aspects of their training background. So the muscle mass they have, the muscle memory, the neuromuscular patterns that they have, that can sometimes attenuate that overall loss, if that makes sense. So it can be a phase where, yeah, as we go through menopause, at some stage, inevitably, some of the times will start changing. But guess what? Actually, that happens to guys as well, around the kind of 50 brackets. So some of those changes occur. And also some of the training that we do, we can adapt a little bit more slowly, which means, and I think this is where

Paul Warloski (17:36)

Mm-hmm.

Mm-hmm.

Rebecca Robinson (17:55)

possibly MJ sometimes that tendency toward pushing the trainings, we're thinking we're getting a bit older, we need to do more. But actually, it means that sometimes the body does well off of a different type of adaptation. So there is a school of thought that looking at higher load, ⁓ higher sort of load in the reps, but less reps can suit some women really well. ⁓ Just changing things up a little bit to adapt, but not necessarily doing more, sometimes doing less, but getting that quality there. So we're not pushing the body.

quite as much if we know there's a finite amount of turnover in the muscles and tendons and bones relative to what there is always a finite turnover, but it's less than what it was. So kind of getting that quality in, but maybe supplementing more with other modalities such as cross training and yoga so that we're getting that stimulus, but we're not pushing the body physiologically quite at the same rate that we might do in our twenties.

Paul Laursen (18:45)

why is sleep affected in the peri and menopausal condition? What's going on there? Any idea?

Rebecca Robinson (18:55)

It's usually the hormonal changes that occur kind of can be quite, quite wide sweeping in terms of what happens to the body. I think for some people it can be things like night sweats that occur, but in terms of perimenopause and sleep, then it can be a combination of those factors. There can be some mood changes, but that overall change in the hormones just disrupts.

We are just hormonally regulated and driven. So some of those factors can just disrupt those circadian rhythms. And some people really struggle with that.

Paul Laursen (19:34)

Do you know why the cold sweats actually occur? Do you know the mechanism of that? I'm just curious. It's just of fascinating to me. Why is that occurring? What's going on there?

Rebecca Robinson (19:48)

So it tends to be like, it's almost like the brain's thermostat ⁓ as the estrogen can kind of control our temperature. ⁓ basically the system's pretty stable and as our estrogen, yeah, it fluctuates through the month, but that's why some people will get changes, some people more than others, but around the time that they ovulate have their periods, but it becomes kind of like lower than the estrogen. doesn't just drop, it gets a bit erratic, so up and down a little bit.

but also the part of the brain that ⁓ is responsive to that also is quite sensitive. So it's like waiting for that signal that doesn't come. So there's a little bit of a mismatch between the systems, if that makes sense. And so normally like that tolerance is quite stable, but it can get to a point where just little changes like the night's a bit colder or the duvet is a bit warmer. And it basically, the brain kind of overreacts and then tries to drench with the sweat to cool us down when actually the real change in the world was.

bigger deal, but it does a lot. And often that's quite disruptive at night because the heart rate will go up and the blood vessels dilate and things like that. So it's quite a sudden reflex from the brain. And for some people, say, some people will get that worse because they've got quite a lot of sensitivity in the brain there. How quickly those changes happen, how quickly they will go through perimenopause. There's a little bit to say that the athletic population may, in general, and some will still find it very hard, but some may find it less

dramatic because we wonder whether body composition and general fitness can sometimes impact that positively. But yeah, those are some of the reasons. So it's basically that sensor in our brain is waiting for the estrogen and the supply chain has changed a bit.

Paul Laursen (21:22)

Hmm.

Yeah, for sure. The temperature regulation center and the hypothalamus, that makes sense. So what's, from a, put my coach hat on, I'm coaching a perimenopausal or menopausal woman. What, sort of advice do you think I should give them from a, you know, rest? You've got a symptom sort of situation. Should you rest or should you push through? Like, how do you draw that line in terms of giving a recommendation

to a certain symptom on any sort of given day.

Rebecca Robinson (21:58)

Yeah, I think it's like any good coaching in this world won't influence too much, it's listening. Cause if you've got an athlete who's, if someone's been athletic the whole lifetime, it might be quite easy to lean into, it can be hard to lean into the change because we don't want things to change and we like things how they were. But obviously having that awareness of the body and that kind of respect of if it's telling you something that it doesn't want to push through, then that can be something to listen to for sure.

On the other hand, you probably get more women actually taking up sport later in life and maybe they only started it in their early 40s or later 30s. So sometimes maybe knowing that a bit of discomfort and some fatigue is actually okay and they're not going to come to harm by going through it. So I think as athletes, if we've been athletes for long time, sometimes you can grade that we're kind of a bit tired today, but actually the session is still going to be okay versus when you're really fatigued and you probably shouldn't have done that session. So I think maybe in the earlier phases taking each day, week, period of time,

Paul Warloski (22:36)

and

Rebecca Robinson (22:52)

as it comes and if you're having a good spell going for a session but maybe not pushing it so you're really overkill because you can get an idea of what maybe new thresholds are. I think using heart rate can be, I think intuition is always key and I prefer that to some of the heart rate measures personally but I think those can be quite useful to listen into.

Paul Laursen (23:11)

Yeah, nice.

Same question to you, MJ. ⁓ What percentage of sessions that you know you want to kind of do on paper, and then you might not be feeling up to it, how often do you think you're happy that you've started and you're feeling better? Or versus, no way, I got to pull the plug. Can you put a percentage on it or not really?

Marjaana Rakai (23:36)

Not really right now because I'm not really following a plan because of my heart issues, but...

Paul Laursen (23:42)

No,

but even before the heart issue.

Marjaana Rakai (23:44)

Bye!

Like I've been so lucky. Like I hit Paramount of Oz like super late. Like I think I just hit it last year and boy, did it hit me like a wall. ⁓ Like suddenly I just started to notice like my running pace. It just started to drop, drop, drop, drop. Like it, like.

really the symptoms like training related symptoms really mimic the overtraining that I experienced a few years earlier, which is kind of funny, but makes sense, you know, after that. But my question to you is like, how long, how long

someone who has been an endurance athlete all their lives, how long should they be expecting to go through this change and possibly like the initial big and you mentioned earlier that

everybody experiences perimenopause and menopause a little bit different, some with lots of symptoms and very strong symptoms and some people just cruise through. Those are the lucky ones. ⁓ But can you tell like, how long should we expect to experience this? And how do we get to the other side? Is it hormonal therapy or is it just to

Paul Warloski (25:07)

Thank

Paul Laursen (25:07)

going to

put up with this.

Rebecca Robinson (25:10)

⁓ Yeah.

Marjaana Rakai (25:13)

Do know, like mentally just say, okay, this is a phase that I'm going through and whatever, however long it takes, it will take and hope to be better on the other side.

Rebecca Robinson (25:22)

Yeah.

Yeah, I think it depends on people kind of phrase it because if people talk about like, the point at which some people just talk about symptoms when they have totally regular periods, and I think increasingly, women are identifying that they feel like they're in perimenopause, like at a point where they're still getting regular cycles. I think that's where sometimes hormone testing can be useful. It's not to say that we can't black and white say that isn't a hormonal change, even if we don't have the figures and the blood test. So some people will actually need or want treatment, like

up to three years before the menopause. but technically perimenopause is scientifically, I guess, that point where the periods start to become erratic. And for some people it's around about two years. Some people it can be longer. It can be like longer than sort of five years. But I think if people are getting symptoms for over a year, a couple of years where they are impacting on how they feel, I guess that is a point to consider where the hormone replacement is something that smooths that transition for that person. Cause if they have it for a few years, it might be the time they come off it. Actually they've gone through that.

Marjaana Rakai (26:15)

Mm-hmm.

Rebecca Robinson (26:22)

point where the periods have actually stopped, is menopause almost happens on one day. Paramodern menopause is a lot longer, but menopause is just that one day when the period stops. But yeah, it's quite individual. But I think if it feels like it's been going on forever sort of thing, know, age has some relevance on it, a ovarian reserve, like how slowly that declines, some other things. Like, actually, what was quite interesting, one thing I should have probably ⁓ said to Paul is we need to fuel like it was

any other time, like there is a high demand and there's this kind of myth around getting older that we don't need as much fuel, but we absolutely do and hydration and great amounts of carbohydrate and protecting sleep like it was a training session can all be factors that help that through. So it's almost like having to double up on the stuff that we already do as athletes to get a good return.

Paul Laursen (27:11)

Yeah,

Marjaana Rakai (27:11)

Mm-hmm.

Paul Laursen (27:12)

perfect segue. That was exactly my question. So maybe just to be clear, what are the consensus nutrition recommendations ⁓ for women going through this? What do we try to emphasize?

Paul Warloski (27:14)

Thank

Rebecca Robinson (27:25)

Yeah, I mean, I don't know how much there is really a ⁓ huge consensus. But I think there's quite a lot going on with the thermal stress and the kind of cortisol spikes of hormones that we can get, where the body therefore needs to have good amounts of carbohydrates to kind of soothe that through. so, especially during like longer or harder sessions, making sure there's good fueling before and after. I think, as I say to quite a lot of there are people that find faster training for them. ⁓

effective, but I think for women, it's one of the things that I don't hesitate to say, it's not usually great for us. That happens at an earlier age, because we're trying to get everything kicking off and staying regular, but the body can quite quickly perceive faster training, even skipping breakfast, because it's easier to get the workout in, it can perceive that as a stress. So anything else that adds stress to the system is something to avoid. I think one of the other ones is

making sure you're well hydrated before a session. For some people, again, when we come into like perimonopause and age and things, we have to think a little bit more about our blood pressure than we do at 20, but making sure there are good amounts of electrolytes. And for some people that might be like adding an amount of salt, a more than they normally would so that it's kind of not just water going in. ⁓ But yeah, because you're going to be losing fluids if there's kind of more sweat going on and that will directly impact how you feel and how the performance goes. And I think the other side of it is protein too, because we're trying to now maintain this muscle.

that will still have, as I said before, like local hormones supporting the system. It's not all gonna fall apart, but in order to maintain that muscle mass, because annoyingly, it's a phase where that good body composition that a lot of athletes have, the body will just switch to wanting to hold onto a little bit more fat and not always the kind of healthy type and losing some muscle. But, know, the lifestyle that you've built around it, you know, that is, that's one of the major medical sides. I think it is important that the people that need it

have hormone replacement, but I do think because exercise and physical activity and lifestyle is not a pill packaged, we would have far greater impact with it. I it's a bit of, I don't want to go too far from topic, but there are some drugs like the weight loss drugs, the GLP antagonists that have a really useful place right now for some people with some conditions. But what we know about those drugs is people lose muscle and they may well lose bone mass too. So we really need to couple it with a strengthening program. So like with physical activity, we know it gives...

Paul Warloski (29:47)

Mmm.

Rebecca Robinson (29:50)

something that so far no drug can actually give us. So you're doing all the right things, might just be bolstering that recovery.

Paul Laursen (29:55)

Mm-mm.

Marjaana Rakai (30:00)

You know.

Paul Laursen (30:00)

Yeah,

so ⁓ I guess, you know, strength ⁓ training becomes ⁓ non-negotiable almost at this phase of life for women. Is that your thinking just to preserve bone and muscle mass?

Rebecca Robinson (30:13)

Yeah,

absolutely. And I think what's really nice to integrate some kind of strength training that can go from like Pilates and yoga to kind of muscular multi system training that targets muscles in a multi, lots of multi directions, which I guess we should be doing lifelong, but that can mean we kind of get a global approach and we're targeting all of the muscle because we look at bone density when we scan it at the lumbar spine and at the hip, whereas

the bones, if someone's got really poor bone density, yeah, that hip is what we're really worried about. But the typical more frail older person will fall on an outstretched arm and fracture a wrist or something like that. So if we can be doing multi-directional training and the other bonus that we get off that pull is that we start to lose, it sounds like a losing game, it's so much is able to maintain, but we naturally start to lose like neuromuscular control and balance way earlier than perimenopause. But again, some of those changes augment the older we get, but if we can,

have that balance training in. Again, it just appears to get maintained and they've done, there's been some lovely studies and I can't quite quote the author, but I can maybe get it so you can put it in the footnotes. But there've been some lovely studies of like masters athletes and looking at how like they can't, there's not such a big systemic effect, but there's such a local effect on the hormones on the muscles and bones. It's really positive. And also some of the neuromuscular junctions that can't like keep on growing and growing fibers, but they sprout new ones like a little shrub.

And we actually see that in athletes into their 80s and 90s. And so it's wonderful in a way sports medicine, having studied that older veteran athletes, has seen that. So we know that those changes can come and we know we can actually assure somebody who's in that older age group and wanting to be active that they can keep striving for physical and physiological changes.

Marjaana Rakai (32:02)

Yep.

Paul Warloski (32:03)

Can we go back a quick step though, because I want to ask more about the hormone replacement therapy. You've talked about that a couple of times. Is that something you'd recommend for, I mean, is that something that most women should be taking who are athletes with menopausal symptoms, or is that something that you recommend on a case-by-case basis? How do you go with that?

Rebecca Robinson (32:25)

personally would still go case by case. I was speaking to an athlete earlier today actually, and we were saying how there's been like a revolution in terms of access and that's great. I think sometimes that can make us all feel like we all need it. Now as an athlete, coming towards like that age when you think about like forties and performance, you think, well, you know, there are some performance boosting impacts of supplements like testosterone. We need to acknowledge that as you know, it's a banned substance in sports. So depending what level people are training at, they're gonna have to

make sure that if that's allowed, and I don't know quite the rules from WADA for example, on exemptions, but it would probably have to be, it would definitely have to be written on the medical record what someone was taking and declared if they're performing at that level. However, ⁓ for most athletes, most people being active might not be in that position. They just want to train and compete. So I think it is very case by case because say some people won't need it and I'm very much an advocate of not medicating when we don't need to.

HRT, everything from like the pill to hormone replacement later in life, we seem to think it's pretty safe. It's been used for quite a long period of time. However, there is a significant shift, I think in the US as well as the UK, away from using some of the hormonal birth controls, basically on preference. It doesn't suit everybody. And in the same way, I think having a blanket approach that if someone, I guess I wouldn't want people to think that I've hit this point in life, I have to now take a medication because it's a normal part of our life. we, you know, I've got

Paul Warloski (33:48)

Right.

Rebecca Robinson (33:50)

plenty of people who are very fit in their 70s and 80s, women who are doing all the things and competing at whatever they want to and feeling very fit and strong who haven't needed it. So I think trying to find out what's right for that female. But on the other side, the good news is that now healthcare practitioners know to listen. And if they don't, if your practitioner is not listening, just go find someone who will do because for some people, the struggle is a lot bigger than for others. So, you you might have a training partner and they might be breezing through and you might be really struggling.

So I think acknowledging that you have the right to feel as well as they do is probably the important point. So yeah, the short answer is individual, I would say.

Paul Warloski (34:29)

And then, and then to go back again, you talked about some supplements, you know, nutrition, and you talked about protein. there other supplements that you might recommend for women endurance athletes over 40 or in men in perimenopause?

Rebecca Robinson (34:44)

Yeah, I think there are kind of some general ones which I would probably recommend for like all athletes at different life spans, which is maybe having an idea of what your vitamin D is and making sure that it's optimal. Because that's really good for bone health in general, but it's more of a critical phase when someone's in the perimenopause that that doesn't decline. And it's good for muscle health and immunity as well. So, if you live in a very sunny part of the States, for example, then that might be something that you don't have to think about too much.

But if it's somewhere where the winters are quite long and dark, then checking out your vitamin D, aiming for a level above 70 is generally, I'd say that's blanket for all athletes from what we know. Things like Omega oils, which is fish oils, or you can get vegetarian sources too. They promote the good fats. So that can help like a bit anti-inflammatory and can help with like joint pain and recovery as well. Another one that's quite good, magnesium is pretty good for sleep. And you don't have to take that as a pill.

can actually be in an Epsom salt if that's the same, if that name translates across the Atlantic, but like in a bath where you can absorb the salts too. So those would be some. And I think, you know, for some people, ⁓ like having whey protein will help. Some people will get enough from their diet if they're getting about, you know, the aim is kind of looking at about two grams per kilogram of weight. But

There are some adaptogens that I know, I learn these more from my patients than any textbooks, but some people will find adaptogens. So there are a few like ashwagandha or rhodiola that some people report will help, but it varies and the evidence isn't enormous because they're kind of supplements, if that makes sense. I guess the other one to keep an eye on is iron. Iron shouldn't naturally decline. In fact, it can often stabilize. That can be one of the benefits for not bleeding.

every month if someone has a monthly bleed, so we're not losing iron as much, but it's always worth checking because there could be other factors in that fatigue that actually isn't all perimenopause and checking that iron levels are good can be one of the ways to make sure that that's not the case.

Marjaana Rakai (36:48)

⁓

You mentioned, strength training. was recently in Norway, visiting my old, ⁓ university, Norwegian school of sports sciences. And there was a webinar about, ⁓ women and strength training. And it was really good because they took the female athletes from, ⁓ puberty through pregnancy, after pregnancy, perimenopause and postmenopause. And they, they just talked about how important strength training is for women in

all ages ⁓ and how coaches can support strength training during all those phases. So ⁓ keep it up, Pauls.

Rebecca Robinson (37:34)

Yeah.

Paul Warloski (37:35)

you

Paul Laursen (37:37)

Yeah, It's just so apparent now in the literature and throughout. We need to lift throughout the lifespan. My mom had Peter Reburn on my other podcast. Again, he was talking all about the good things my mom at 81 is doing with her support group, and they're all doing their resistance training. Yeah, and she loves it.

Rebecca Robinson (37:47)

Yeah, I think.

Paul Laursen (38:04)

It's great.

Rebecca Robinson (38:06)

think, you know, has like women even in the gym is something that's just increasing now. It's a place that we feel we can be. I know these things go in fits and start with kind of other forms of social media and, but the right to be strong and to be strong through life. So that even if we're before that time feeling like we're training for our strong bodies in our midlife and beyond is kind of a, I think it's a great feel and a great look. also, yeah, as you say, like if you've got older people doing that, it can be a really good social environment as well.

Marjaana Rakai (38:33)

Definitely.

Paul Warloski (38:35)

you

Paul Laursen (38:35)

Yeah.

So I don't want to take us too far off the, you know, the current thought train around the perimenopause and menopause, but I'm really curious, Dr. Robinson, if you could kind of, you know, you reached a very high standard with, you know, a bronze medal at the Brighton Marathon. Could you go back there and reflect on the key factors that allowed you to build up to that level of performance? ⁓ I'm just, and, you know, maybe with your female

health hat on or not, but I'm just curious if you could reflect on how you reach such a high level.

Rebecca Robinson (39:12)

think probably it was probably stubbornness, a great coach. And, and like, yeah, that was probably the combination at the time. And for some reason, doing odd hours in, in residency, but I think I'd probably go back to my former self and teach them about strength training. used to have a very good coach who always believed that I could do things. So I'd run for GB on the mountains before that, he said, you could go and on the mountains. I like running up hills. I've come from the Lake District in England. So you could go and do that. And just that belief. Okay.

Paul Warloski (39:15)

you

Rebecca Robinson (39:40)

And then I went and did the marathons and eventually represented GB in the marathons. And yeah, Brighton was was a lovely fun day. remember that. And I think it's having fun as well. I did not push the mileage. I didn't push the mileage. And then I had done a few marathons. I I should do more mileage. So that was definitely a mistake and something I'm still trying to unlearn. Everyone is different. You know, I have friends who've gone to Olympic level who've done kind of 100 miles a week and friends have gone to Olympic level that have done 50 miles a week and

everything in between. ⁓ But I think it is, it's the enjoyment, the feeling that they were privileged to do it. But I say even then 2014, we didn't know as much, I I should be doing a bit of strength, but I felt it was kind of busy. was doing my like residencies, I was doing the running and it just didn't quite fit. But I think, yeah, that I had to learn that later in order to keep running now, which luckily I can still do. ⁓ But yeah, I think that and I think having the right people around you that don't push too hard and I

Paul Warloski (40:19)

Yeah.

Paul Laursen (40:21)

Thanks.

Yeah.

Rebecca Robinson (40:36)

I see a lot of brilliant, talented young athletes and there's always some new phenomena that's coming on the scene. I think, especially now that we know that the career can go so long, not having that pressure, having the right people that support and make it fun for you, but not having a pressure that's negative, if that makes sense.

Paul Laursen (40:54)

Yeah, that's such stage advice and I'm so glad I asked the question. That's a brilliant answer. Thank you.

Rebecca Robinson (40:58)

⁓

Paul Warloski (41:01)

Yeah, I was curious how you did that with being in residency at the same time and running that kind of volume. It's like, that's, that's a lot.

Paul Laursen (41:04)

You

Rebecca Robinson (41:05)

There were

some fun balances and there were some funny hours where I didn't know which day to put the training run in. You if you kind of went out before midnight and did you call that? But yeah, I wouldn't say that was always good, great practice, but there were some fun things. that, you know, that said that wasn't a case of running all the hours every day. think always, I think I figured out quite early whenever I had to work some night shifts, sleep was a non-negotiable. Fueling before that session was a non-negotiable. You kind of mess it up one time and you go, no.

Paul Warloski (41:18)

Yeah.

Rebecca Robinson (41:32)

that's not a great feeling. So I think feeling good when we do our sessions, because I know there's a lot of talk about the grind and like it being hard work, but I think if we can get a good positive feedback of any given training session, to me, that's more powerful. And actually, probably the best times I've run came without a garment. So I was quite good at like tuning into my body felt good on that session. It must have been a good session. And I think I preferred that personally.

Paul Laursen (41:58)

Yeah, that's awesome. did you get from your coach? were the key, you said you had a great coach, so what were the characteristics of that coach that made you reflect on that?

Marjaana Rakai (41:58)

Mm-hmm.

Rebecca Robinson (42:10)

I think that belief, that absolute belief, but without pushing. unfortunately we have a wonderful sport with some absolutely wonderful coaches. And I've been lucky to have a couple of coaches in my training lifespan who have been wonderful. But sometimes that pressure can, there's a fine line between what you can do and should do and just believing that you can do it. And actually my coach wouldn't write me a very strict program because he said, well, you'll go and do that session if I write it down when you're tired and you've just been on night. So I'm gonna...

give you a suggestion and then you come back to me and say what you've done. He wanted to make himself redundant from coaching relationship by me getting to grips with it. Now, I'm not sure that he did that. I was very lucky little personal anecdotes that I went to the European Marathon Championship and he was very poorly. He'd driven me to the trials with oxygen on his back and come to watch and he passed away very shortly after and our girls team got on the podium that year. So that was kind of magic.

Paul Warloski (42:43)

Hmm.

Paul Laursen (42:45)

Yeah.

Rebecca Robinson (43:07)

Yeah, after that, I must say for a couple of years, I struggled with injury and getting the balance. I couldn't get it right for myself, think. So I think for some people, it's fun to have that relationship that someone just believes in you, but doesn't push you, just brings it out. Something that you didn't know was inside you.

Paul Laursen (43:26)

Brilliant. Good news. It's awesome.

Marjaana Rakai (43:26)

⁓

What's your take on misconception that as you age as a female athlete the decline is inevitable?

Rebecca Robinson (43:39)

think we're showing that, know, with these athletes going well into their 40s now. I think it was at last year's World Champs or the last version of the World Champs Marathon, there were like seven women who were 45. And I'm thinking that can't be a coincidence. also, I think traditionally, you know, I thought, oh, we're done by 30 because everyone is. And I think that's the last, I think that is probably looking at men's running as well.

It looked like you're running with something you did and then you settled down, had a family and moved on from it. And now it's much more of a, I think I can say obsession, right? Like, because we all love it and it's something lifelong. So I think everyone's different and some people will have like, will feel that they slow down or they want to like not put that impetus and have that as a big, as big a focus in their life. Cause some, for some pro runners that is, it's a big chunk of life and actually stepping away to have other things come into life can be really, really healthy and, and enriching.

But I think, yeah, we will all inevitably slow down at some point, but I think, you know, we'd do well not to put too fine a point on it. I had a ⁓ good running kind of rival who's a friend, Emma Steptoe from the UK. And I just remember running my half marathon PB, I think it was the year after Brighton. I was delighted with my time, but she came zooming past me at like 12 miles and clocked, know, slightly faster time. And she was...

in her mid-40s at that point and that was her actual peak. So I think we've to be careful. think when like selectors are probably getting wise to it now that we have to pick someone when they're at that peak and not say, well, they're older so they won't be as good if that makes sense. So everyone has their moments and some people are lucky enough to peak several times over a career. So I think, yeah, letting the body do the talking and not putting labels on ages quite so much would be really healthy.

Paul Warloski (45:20)

Hmm.

Marjaana Rakai (45:20)

What would

Paul Laursen (45:20)

Yeah.

Marjaana Rakai (45:20)

you be your advice to someone who is starting to feel that perimenopausal challenge? ⁓ What are three steps that they can take to keep training and keep having fun and staying positive about their own athletic journey?

Rebecca Robinson (45:44)

Yeah, I think maybe focusing less on the times and the watch. So again, maybe going back to that kind of enjoyment in getting the sessions done, but not saying not comparing because there's that wonderful quote, you know, comparison is the thief of joy. And I think we all do it now. You know, you kind of think, well, that was a good session. Then you look at your garmin or whatever wearable and say, I don't know if it was as good. So I think like what also I love about running is my running friends range from the teens to the 80s and always have done.

Paul Laursen (46:01)

You

Rebecca Robinson (46:11)

So I think if you're in a running group where the ages are diverse, age doesn't actually matter, but that, you know, I had a friend who's now 60, who, when I trained with her was 40 and, I was 20 at the time and she could run rings around me on a 400, never could touch her. And I got my own back when it came to longer reps, cause she was really classically a middle distance runner, but had not discovered that, sprints are kind of eight, four to 800, hadn't discovered that until she hit 40. So had that period then. So I think surrounding yourself in a group that will bring you on.

Paul Warloski (46:38)

Hmm.

Rebecca Robinson (46:41)

regardless of age. And I think that kind of keeps us young. And I think that's where running has this wonderful sociable aspect too. So maybe those things. And then focusing on recovery. Like I think the other thing around perimenopause, it's often a busy time. It's often like the same women will, if they have parents or older people they need to care for, if they have children or some sort of dependents, and then in terms of career, it's also a busy point. So how much of it is attributable to those stresses? Now we can't go through all those out the park and say, you know, we're just focused on recovery.

But I think sometimes listening into that a little bit and saying, this is a different phase when our body needs to be heard and nurtured a bit and kind of drawing in whatever the things that refill you. And it might be partner support, family support. It might be the little like treats that you can get to kind of refill your cup and like relax and bring things like yoga or a spa day and that kind of thing of self care, I'd say, making sure that that is on the menu as well and happens.

Marjaana Rakai (47:39)

So how can Paul's who are both coaches to female athletes, how can they support and maybe understand what the female athletes are going through?

Rebecca Robinson (47:53)

I've to answer that for them. You know what, like I think from the questions I've had and the conversations, it's like, think you guys are probably doing it already. Do you know? I think, you know, the fact that you're so engaged and listening, that's, that's what's going to bring out the questions. Cause sometimes, you know, I think at all stages, I know I have an athlete this week who should like to talk to me about something and doesn't want the coaches to know yet. And it'll be about female athlete health. Cause it's a personal area. you know there are areas about our bodies and our journeys that feel person.

Marjaana Rakai (47:54)

I'm just throwing it out there.

Paul Laursen (48:03)

you

Rebecca Robinson (48:22)

I think between men and women, yeah, okay, guys won't have a lot of the issues that we've talked about, but we still have different life phases. We still have lots of synergies. We still have families and partners and parents and kids that we know about. So I think just having that open conversation and listening and like that's the fact I already know. I it just meant to that you must be good coaches because having that space to listen and learn as we all keep learning.

about the changes and each athlete, that's the magic, I guess, of coaching. Sometimes I get a little insight, sometimes I'll get an athlete as a patient that I have over the long term. It's like seeing that journey and where it evolves to.

Paul Laursen (49:02)

Yeah, that's nice. I remember from my days in high performance sport in New Zealand, we had a, it was a bit of a motto for coaches. What's the definition of a good coach? It's, ⁓ or what's the best monitoring system for a coach? And it's a coach that listens. So ⁓ yeah, that's really, that's aligned with what you just said there, Dr. Robinson.

Paul Warloski (49:22)

Dr. Robinson, you've worked in healthcare your whole career. What are you working on now and what's in your future?

Rebecca Robinson (49:28)

So I've just started doing my PhD, which is the kind of curve to that. It's that's looking at cancer and exercise. Some people who are maybe not fit enough for their surgeries and then they can't have the surgeries. Can we alter that? Can we modify that if we get some physical activity in there and it doesn't have to be, you know, a whole like a marathon program. We're talking about small movements, getting someone fitter and meaningfully stronger. So that's going to take up a fair chunk of my time that I'm really

looking forward to. And then I guess on the other sides of it, working with athletes and continuing to see how this journey progresses in my own personal life. I'm pregnant, I'm seven months pregnant now. So I'm going to have some my own challenges in, know, expediting that learning in terms of, well, what does that bring? What, does that change things for me? And, you know, not just how do I get back running? like, you know, I think

Paul Warloski (50:13)

⁓ wow! Congratulations!

Rebecca Robinson (50:25)

having that evolution of what that looks like for someone who's quite used to being in control of what I can do and actually changing that up a bit, I think will probably be a good thing, but that is another project for sure. So yeah.

Paul Laursen (50:35)

It's a big project.

Paul Warloski (50:36)

Wow.

Marjaana Rakai (50:36)

What an exciting project.

Paul Warloski (50:38)

Yeah.

Paul Laursen (50:40)

Congrats, that's awesome.

Rebecca Robinson (50:41)

Thank you.

Paul Warloski (50:43)

Well, Dr. Robinson, where can people reach you if they want to follow you or learn more about your journey?

Rebecca Robinson (50:49)

well, I have a couple of places that I practice being from like the north of England. We're very small compared to the States, but ⁓ I practice up in the north of England, a little bit in London. So I can give you some links. I can give you send you an email link type thing to for like asking questions. do I use ⁓ I use things like Instagram. I don't tend to. I tend to put pictures of our pretty mountains and hills on it rather than put lots of educational content. But sometimes it's kind of if it feels easier for someone to reach out with a connection on that, then I can happily like.

into a more clinical space and answer that sort of thing. But yeah, I can give you a couple of links and things to get in touch with people if it helps anybody.

Paul Warloski (51:28)

Well, thank you.

Paul Laursen (51:30)

Yeah, just thank you. Thank you, Dr. Robinson. Just a fantastic chat. I so enjoyed it learning from you and I hope I know our listeners did as well.

Rebecca Robinson (51:39)

Thank you very much. It's really great to meet you. You some brilliant questions got me really thinking. So that's always stimulating and fun.

Paul Warloski (51:46)

good. Thanks for listening today to the Athletes Compass podcast. Take a moment now, subscribe, share, and let's keep navigating this endurance adventure together. Improve your training with the science-based training platform, Athletica, and join the conversation at the Athletica Forum. For Dr. Rebecca Robinson, Marjaana Rakai , and Dr. Paul Laursen I'm Paul Warloski and this has been the Athletes Compass podcast. Thank you so much for listening.