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Dr Andrea Robertson is an Osteopath, Naturopath, and Nutritionist. Georgie Beames is a Psychologist and Coach. The information shared in this podcast is for educational purposes only and does not constitute medical advice. Always consult your healthcare provider before making changes to your health regimen.

Show Notes

Episode Transcript

Ep. 18 - What Every Manual Therapist Needs to Know About Treating Women in Perimenopause and Menopause

Andrea: [00:00:00] She's 47. Her shoulder won't settle. Her hip wakes her at night, and she tells her practitioner the same thing every visit. Everything she used to do doesn't work anymore. For years, most of us manual therapists treated each of those complaints as its own separate problem. On the weekend just gone, I stood up in front of osteopaths from right around Australia at the Osteopathy Australia Conference and showed them the bigger picture.

Andrea: Today, I'm bringing that talk to you. I'm Dr. Andrea Robertson, osteopath, naturopath, and nutritionist. Here, we nourish because food is medicine, and what you eat changes everything. We heal because the body has an extraordinary capacity to self-repair when we remove what's blocking it. And we rise because feeling well isn't the destination.

Andrea: It is the foundation for living the life you truly desire. This is Nourish, Heal, and Rise

Our sponsor today is [00:01:00] Mineralite, an Australian electrolytes brand. And I have to tell you how I found them because this is a genuine story. Now, I'm really into paddle tennis, some may say obsessed , and a friend of mine introduced me to Mineralite to use for my hydration support during games. I was a little curious because I'd been recommending clients avoid those terrible sugary sports drinks for years, but I wasn't really sure what other options were available.

I now know that Mineralite is the option I'll recommend. It's unflavored and contains no sugar, no sweeteners, no artificial colors, no nasty additives. Just clean electrolyte support in drops you can add to your water or any hot or cold drink. And my paddle? It was noticeably different. My energy held, my focus held, and I even won some games.

Mineralite is now in my water every single day. Go and check them out at mineralite.com.au or find them in most pharmacies and health food stores throughout Australia and New Zealand

Before we begin, a quick and important note. Everything I share on this podcast is for educational [00:02:00] purposes only. It's not personal medical advice, and it can't be, because in the context of this podcast, I don't know your health history, your medications, and what else is happening in your body. What I want this podcast to do is give you the knowledge to ask better questions, understand your body more deeply, and make more informed decisions in partnerships with the practitioners who do know you.

If something resonates and you wanna take action, please work with a qualified healthcare provider who knows your full picture

Andrea: welcome back. This episode is a little different, and I am so excited to share it with you. On the weekend, as I mentioned, I was speaking at the Osteopathy Australia Conference To osteopaths from all around the country. My talk was called Inflammation, Hormones, and Midlife: The Osteopath's Role in Perimenopause and Menopause Care.

Andrea: And the response in that room [00:03:00] told me how much this seminar was needed. So many practitioners see this woman every week, the one I was talking about, the 47-year-old, and so many of us were trained to treat her one body part at a time. What my talk did was help practitioners look at women in perimenopause and menopause with a much wider lens, and I would love that message to travel further than one conference room.

Andrea: So today's episode is written for practitioners. If you are an osteopath, a physio, a chiropractor, a myotherapist, a massage therapist, a Pilates or yoga teacher, or a personal trainer, this one is for you. But if you are a woman in midlife listening right now, please stay, because this is the conversation I want happening in every treatment room you walk into.

Andrea: You will hear exactly what I think a good practitioner should be asking you, and you can take this episode to your own practitioner and say, "Can we look at [00:04:00] the whole picture here?" So let's just map out what we're covering today so you know what's coming. We're gonna start with the woman on the treatment table, who she is, and why the numbers say she's everywhere.

Andrea: Then we're gonna get clear on what perimenopause and menopause actually are, because the definitions matter clinically. I've talked about them in previous episodes, but we're gonna go through them again here today. Then we're gonna move into the science of why midlife can be an inflammatory transition, and the six drivers that make up what I call the midlife inflammatory load model.

Andrea: Then we'll look at what all of that means for the tendons and capsules and joints us practitioners treat

Andrea: And we're gonna finish with the practical part. For each of those six loads, what I ask, what I do, and when I refer. So every practitioner listening will have something you can take back into clinic tomorrow morning 

Andrea: I opened my talk on the weekend with a patient, and I wanna open this episode with her too, [00:05:00] because I think every practitioner listening will recognize her. She's 47, and suddenly her body feels different. Her shoulder has been sore for months and it just won't settle. She wakes up stiff,

Andrea: her gluteal tendons are grumbling, or maybe it's her Achilles, or her plantar fascia, or her elbow. Her back and neck flare up more easily than they used to, and she doesn't bounce back from a gym session or a weekend in the garden the way she once did. And she's tired. Her body shape is changing even though she hasn't changed what she eats, and she's not sleeping well.

Andrea: Then she says the thing I hear almost every single week, "Everything I used to do doesn't work anymore." In the conference room on the weekend, I planned on asking everyone to put their hand up if they'd had this woman on their treatment table in the last month. With my slight nerves that I had, I forgot that part.

Andrea: But I bet if I did it, [00:06:00] nearly every hand in the room would've gone up. Then I had planned on asking them to keep their hand up if they'd seen her in the last week, And I'm sure most of those hands would've stayed up then too. So this woman is everywhere, and many of us, me included, for a very long time, treated each of those complaints purely as musculoskeletal.

Andrea: The shoulder, the foot, the hip, the neck. We get her feeling better, and a few weeks later she's back with the same concerns. I've seen this woman in my treatment room for 26 years. I trained as an osteopath first, and about 10 years ago I also trained as a naturopath and a nutritionist. So I ran my own clinic in Adelaide for many years, and then five years ago I sold it, and since then I've mostly worked online running health programs for midlife women around the world.

Andrea: And I still treat as an osteopath three half days a week at Parkdale Osteopathy here in Melbourne. That combination of how I work and my [00:07:00] experience and training has changed how I see this woman. When I only had my osteopathic lens, I saw a shoulder, a hip, and a foot.

Andrea: With my naturopathic and nutrition training and experience layered on top, I started seeing the hormones, the blood sugar, the sleep, the stress, and the muscle loss sitting underneath all of this. And that's what I wanna share with you today.

Andrea: This is far from a niche issue. Up to 70% of women report musculoskeletal pain around menopause. The strongest recent data comes from a meta-analysis published this year in JBJS Open Access. It pulled 37 studies from 22 countries with more than 93,000 women. Before perimenopause, about 40% of women reported muscle or joint pain.

Andrea: In perimenopause, that rose to 57%, and after menopause to 59%. That's roughly a 35 to [00:08:00] 40% jump in the number of women living with muscle or joint pain as they move through this menopausal transition. In 2024, a group of clinicians led by orthopedic surgeon Dr. Vonda Wright went a step further and gave this a name, the musculoskeletal syndrome of menopause.

Andrea: It brings together joint pain, loss of muscle, loss of bone, and the progression of osteoarthritis, all linked with falling estrogen. Now, why does that matter so much to manual therapists? Because women very often come to us first. Before she ever mentions hot flushes to her GP, she's on our treatment table telling us about the stiffness, the aches, and the slow recovery.

Andrea: Think of us as the front door, and if we're the front door, we need to understand what's happening in the rest of the house.

Andrea: Before we go any further though, some quick definitions because I find even experienced clinicians use these words [00:09:00] loosely. Menopause is actually one day. It's the date of the final menstrual period, and you can only know that it's happened in hindsight once a woman has gone 12 months without a period.

Andrea: In Australia, the average age of menopause is 51, with a normal range of 45 to 55 years. Menopause before 45 is considered early, and before 40, premature

Andrea: Perimenopause is the lead up to that day. It starts when cycles or symptoms begin to change, and it runs until 12 months after the final period. So those 12 months of waiting still count as perimenopause. On average, it lasts four to six years, but some women notice symptoms five to 10 years before their last period.

Andrea: And then post-menopause is everything after that for the rest of her life. So our 47-year-old still having periods is right in the middle of perimenopause. [00:10:00] She's far from too young for any of this, and that matters because I still hear women being told they are too young to be in perimenopause at 44 or 45. In the talk that I did on the weekend, I showed a lifetime picture graph of estrogen and progesterone adapted from the work of Professor Jerilynn Prior in Canada. I'll paint it for you so you can see the picture of it in your mind's eye. In childhood, estrogen is low. Through the teens, it rises and swings around. Progesterone, which among many other things keeps periods lighter and calms the nervous system, stays low until regular ovulation is established.

Andrea: Then in perimenopause, we see that same pattern again. Higher, erratic estrogen and falling progesterone, which is why perimenopause is sometimes called a second puberty. Hormones are slowly being gained in puberty and slowly lost in perimenopause. Think of it maybe [00:11:00] like a dimmer switch with a faulty connection.

Andrea: Before the light settles at its new low setting, it flickers. Bright one week, dim the next, and suddenly bright again. And that flicker explains something every manual therapist has seen. Symptoms can come and go. A treatment that worked beautifully last month doesn't hold this month. She had a good fortnight, and then everything flares.

Andrea: Eventually, estrogen settles at the stable, lower levels of post-menopause

Andrea: For some women, this transition lasts 10 years or more, but it does end, and there is so much you can do to reduce its impact. These years are also a window for long-term health, bone, muscle, heart, and brain, even for a woman with no symptoms at all. And small changes made now will pay off for decades later.

Andrea: And us, as manual therapists, are in a wonderful position to help women [00:12:00] understand that. Now, an important caveat. Some of you are thinking, "Aren't many of these symptoms simply just aging?" And it's a very fair question, and I asked that of the room on the weekend as well.

Andrea: Aging and the menopausal transition happen at the same time, in the same body, and they overlap. Aging brings muscle loss, connective tissue changes, metabolic change, and slower recovery. The hormonal transition appears to add to that, fluctuating and then falling estrogen, changes in inflammatory signaling, changes in collagen and muscle, bone loss, and a shift in where the fat is stored

Andrea: Separating the two is hard, so I won't tell you that menopause causes every sore shoulder in midlife women. But the overlap still matters clinically. When a woman's hormonal environment changes, her tissues, her metabolism, and her recovery change with it. If we ignore that context, we miss [00:13:00] part of the picture.

Andrea: So what's actually driving this? Menopause doesn't simply flick inflammation on. Not every woman becomes systemically inflamed in perimenopause. Instead, several connected physiological and lifestyle factors influence inflammatory signaling, and many of them change at the same time. One note on language here.

Andrea: The inflammation that I'm talking about has nothing to do with the acute, swollen, hot ankle of a rolled ankle, like an inversion ankle sprain. I mean low-grade, chronic, systemic, or metabolic inflammation, an underlying level of inflammatory signaling that sits a little higher than it used to and makes tissues more sensitive and slower to recover

Andrea: I described six inflammatory drivers in the talk, so I want to go through them today. Driver one is estrogen fluctuation and decline. Estrogen is so much more than a [00:14:00] reproductive hormone. It has receptors throughout the body, in bone, tendon, muscle, the synovium lining our joints, and in immune cells, and it plays a big role in regulating immune function.

Andrea: Think of estrogen as an in-house peacekeeper for the immune system. While it's around in good amounts, it keeps inflammatory response proportionate. Estrogen generally has immune modulating and anti-inflammatory effects, although that does depend on the tissue, the concentration, and the immune pathway involved.

Andrea: As ovarian function declines, we see rises in inflammatory cytokines like interleukin-6 and TNF-alpha. Cytokines are the chemical messenger molecules your immune system uses to call for inflammation. So when the peacekeeper becomes unreliable and then largely leaves, Those messengers get louder.

Andrea: That's one of the biological mechanisms that may help explain why some women start to experience [00:15:00] more joint pain, stiffness, and slower recovery at this stage of life

Andrea: Driver two is visceral fat and metabolic dysfunction. So this second driver is a shift in where the fat is stored. The SWAN study, the Study of Women's Health Across the Nation, has followed women through midlife for decades. A 2029 analysis found that at the start of the menopause transition, the rate of fat gain roughly doubles while lean mass starts to fall, while the number on the scale sometimes barely changes, and those changes can then flatten out around two years after the final period.

Andrea: So when a woman says, "My weight hasn't changed, but my body has," she's kind of right. Fat moves away from the hips and thighs and settles around the abdomen as central or visceral fat. Now, that's not always the case. Women can also put on extra weight around this time too, but they'll find that most of it settles around the stomach as that visceral fat.

Andrea: And visceral fat is far more than just some passive [00:16:00] storage. Think of it as a small factory wrapped around her organs, quietly pumping inflammatory messengers into the bloodstream. The more of it there is, the more pro-inflammatory her metabolic environment becomes

Andrea: That brings us to insulin resistance, driver number three. Think of insulin as the key that opens the cell door so glucose can get in. With insulin resistance, the lock gets a bit sticky. The body has to make more and more insulin to get that same door open. Insulin sensitivity can decline through midlife influenced by aging, body composition, activity or lack of, sleep, and the menopausal transition itself.

Andrea: And insulin resistance and inflammation have a two-way relationship. Inflammation interferes with insulin signaling, and insulin resistance promotes more inflammation. So we get this feedback loop, more metabolic dysfunction, more inflammatory signaling, [00:17:00] poorer insulin sensitivity, and that just goes round and round.

Andrea: This is why I believe metabolic health belongs in the musculoskeletal conversation. We aren't treating insulin resistance directly as manual therapists, but the tissues we're asking to heal and adapt live inside that metabolic environment. Then drivers four, five, and six are sleep, stress, and physical inactivity.

Andrea: The last three drivers will be familiar to every practitioner. So instead of going into them in detail, I'll focus on why they matter so much at this stage of life

Andrea: Now sleep first. Sleep takes a huge hit in perimenopause. Night sweats, 3:00 AM waking, a busy mind that won't let her drift off. Sleep disturbance is linked with higher inflammatory markers like CRP and interleukin 6, and even short periods of poor sleep increase pain sensitivity. Think of sleep as the overnight repair crew.[00:18:00] 

Andrea: If the crew only gets five broken hours, the work doesn't get finished. So picture the woman with stubborn tendon pain who's sleeping five or six broken hours a night. We're asking that tissue and her nervous system to recover in a less than favorable environment.

Andrea: Then we have stress. Stress often peaks in midlife. We've got work, teenagers, and aging parents, and sometimes all three of those at once. Chronic stress affects the HPA axis, the hypothalamus, pituitary, and adrenals. That's our stress system, along with the autonomic nervous system.

Andrea: Think of cortisol as the fire brigade. It's meant to arrive, put the fire out, and go home. Under chronic stress, the fire brigade stays. They stay parked in the driveway, and the body stops listening to it, stops listening to them, so inflammation is harder to switch off.

Andrea: Stress also disrupts sleep and raises pain [00:19:00] sensitivity. Then we have muscle. Skeletal muscle is an endocrine organ. Think of it like a pharmacy. Every time it contracts, it dispenses myokines. These are signaling molecules, some of them anti-inflammatory. Muscle is also one of the body's main places for taking up glucose.

Andrea: But in midlife, pain often starts this downward cycle. Something hurts, so she stops exercising. She then loses strength and tissue capacity. Her metabolic health slips, and movement gets harder. Now, these three, the sleep, the stress, and the muscle, they feed each other, and then they feed everything else. So let's put all six together.

Andrea: This is what I call the midlife inflammatory load model. I was very clear with the room on the weekend that this is a clinical framework I use rather than a validated tool, but it explains so much of what we see in practice. Now, on YouTube, on the YouTube version of this podcast, I'm gonna put an image [00:20:00] up of the midlife inflammatory load model.

Andrea: But if you're listening in on Apple or Spotify, you'll be able to imagine this as I'm talking you through it. So think of a bathtub with six taps running into it. We've got estrogen decline, visceral fat, insulin resistance, poor sleep, chronic stress, inactivity, and muscle loss.

Andrea: Each tap adds to a shared pool of inflammatory load, and that water spills over onto the tissues we treat, tendons, joints, capsules, fascia, and muscle. Manual therapy is excellent at working on the tissues. We reduce pain, improve movement, and help her feel at home in her body again. Think of that as bailing water out of the bath.

Andrea: But while the tap keeps running, the bath keeps filling, and the symptoms keep coming back. That's why these women plateau. Our treatment works, and the environment keeps undoing it. And none [00:21:00] of those taps run independently. Estrogen affects body composition. Visceral fat affects insulin sensitivity. Stress disrupts sleep.

Andrea: Pain reduces activity. So rather than saying menopause causes inflammation, the more useful clinical question is: What is this woman's total inflammatory and recovery load? So what does all of this mean for the tissues we actually put our hands on? Now, this is where the evidence gets really interesting

Andrea: First, tendons are hormone responsive tissues.

Andrea: Estrogen and progesterone receptors have been found in human supraspinatus tendon.

Andrea: That is part of the rotator cuff muscles, and many women in midlife really have problems with their shoulders. I just find it fascinating. It's so cool that we can see estrogen receptors in that muscle. Second, metabolic health shows up in our tissues. Let me paint the picture on how you can see that [00:22:00] come together. A 2016 systematic review in the British Journal of Sports Medicine found people with diabetes have more than three and a half times the odds of tendinopathy. Frozen shoulder is even more striking, around five times the odds of frozen shoulder with diabetes, and roughly 30% of people with frozen shoulder have diabetes.

Andrea: So you can start to see the thread between blood sugar and tissue health

Andrea: And we see the hormone and metabolic story in the shoulder and the hip in particular. Synovitis, inflammation of the joint lining, shows up more often in shoulders of perimenopausal women than in younger women. And in gluteal tendinopathy, Australian research suggests a woman's metabolic picture may change how her tendons respond to treatment.

Andrea: None of this proves that inflammation causes every tendinopathy, but it tells us that hormonal and metabolic status are part [00:23:00] of the tissue story. And this is where a wider lens becomes so valuable. If a 52-year-old woman comes in with plantar heel pain, that's plantar heel pain. I'm not diagnosing systemic inflammation from her foot.

Andrea: But if she's had plantar fasciopathy for nine months, she's developed lateral hip pain, she's had a frozen shoulder last year, she's stopped sleeping properly, she's gained abdominal fat, and she's stopped exercising because everything hurts, that's when I stop looking at each body part as only a musculoskeletal issue

Andrea: so that cluster of symptoms doesn't prove systemic inflammation, but it gives me a reason to ask better questions, and suddenly we're treating more than a shoulder, a hip, and a foot. We're treating a woman whose tissue capacity, metabolic environment, hormones, and recovery may all have changed at the same time.

Andrea: That's the shift I ask the room to [00:24:00] make in their thinking, and it's the shift I'm asking you to make today as well.

Andrea: So now we go into the part I wanted every practitioner to walk out of that room with on the weekend. What do we actually do with this? Let's go back to the midlife inflammatory load model because it gives us a little roadmap.[00:25:00] 

Andrea: For each of the six loads, I'm gonna share three things: what I ask, what I do, and when to refer. You'll notice things overlap, like strength training shows up almost everywhere, and that's the point. When we turn down one tap, we often turn down several.

Andrea: And none of this needs an hour-long menopause consultation. It fits beautifully into a normal case history and treatment plan. And for the women listening, this section is your checklist. If your practitioner isn't asking you these questions, you're allowed to raise them and bring them up yourself.

Andrea: So load one, we have estrogen fluctuation and decline. We can't change a woman's hormones on a manual therapy treatment table, but we can change how she understands them and how we plan around them.

Andrea: So ask, "Are you still having periods? Have they changed in timing, flow, or how you felt beforehand? Any hot flushes or night sweats? Are you using menopause hormone therapy? [00:26:00] And remember, some women won't have periods to guide you because of a hysterectomy, a Mirena, or the pill, so symptoms and age matter more when you're asking these questions.

Andrea: Then do. First, I explain that hormonal wobble, the faulty dimmer switch. When a woman understands why her shoulder was fine last month and is flaring this month, the relief she feels is enormous. Then we plan around it. In a flare week, we adjust the load rather than stop, and we expect the good weeks to come back.

Andrea: If it's within your scope, and that depends on any extra training you've done as a practitioner, supplements can help too. I love magnesium for almost every midlife woman in the bisglycinate or glycinate form. And I ask about gut health and may use a gut powder that includes glutamine. Coenzyme Q10 has some favorable evidence for mitochondrial health, and I see it reduce symptoms in some women.

Andrea: Soy isoflavones, plant estrogens, are well-supported for [00:27:00] easing some perimenopausal and menopause symptoms in some midlife women. And I suggest she gets her vitamin D tested and supplement if it's low

Andrea: Then refer. Patients will ask us about hormone therapy, menopause hormone therapy. The evidence for musculoskeletal pain is mixed. Some trials show benefits, while a 2026 meta-analysis found no overall effect on general musculoskeletal pain. So it's a conversation for her GP or a menopause specialist, and our role is to support her decision whichever way she goes.

Andrea: Load number two is visceral fat and metabolic dysfunction. Ask, "Has your waist or body shape changed even if your weight hasn't?" I'm careful with how I ask this. This is about metabolic health rather than appearance, and most women are relieved to hear that what they've noticed is real. If she knows her waist measurement, a waist over about 89 centimeters [00:28:00] can be a sign of insulin resistance, an indication, it's not a diagnosis

Andrea: And ask about recent blood work. So any known issues with thyroid, gut health, insulin or glucose. Then do. Two things matter the most here. The first is strength training, because muscle is the most metabolically active tissue we can help her build. The second is food.

Andrea: In my nutrition practice, I use a structured elimination trial. I do this inside of my 12-week program. For three to six weeks, women take out gluten, cow's dairy, processed sugars, alcohol, and ultra-processed foods, the five most common pro-inflammatory food groups that I see in practice. Then they add them back in one at a time and watch where the symptoms return.

Andrea: Now, it's different for everyone. Some women finds dairy makes no difference at all. Others notice a change in their joints, their gut or their energy within days. This is [00:29:00] also what I do inside my three-week inflammation detox diet as a starting point, where we walk women through this step by step

Andrea: . Practitioners, you don't need to run an elimination trial yourselves if this is not your department. But suggesting she cuts back alcohol, added sugar, and ultra-processed foods is general advice well within the scope of manual therapists. And watch for the woman who is exercising more and eating less, both at the same time, or one who's gone low carb or keto.

Andrea: In my experience, that usually leaves midlife women exhausted and not recovering well. Then refer to a naturopath, nutritionist, or dietician when she needs individualized care. Load number three is insulin resistance. This is where the link to our tissues is strongest. Remember from previously in this episode, diabetes brings more than three and a half times the odds of tendinopathy and around five times the odds of frozen shoulder. So even [00:30:00] pre-diabetes, the insulin resistance that comes before diabetes, belongs in that musculoskeletal conversation

Andrea: Ask any history of gestational diabetes, pre-diabetes, or diabetes, or a strong family history of type II diabetes. And ask, "When did your GP last check your fasting glucose, fasting insulin, or HbA1c?" Then do.

Andrea: Muscle is one of the body's main sites for taking up glucose, so every bit of muscle she builds helps. Protein matters, too. My recommendation for midlife women is at least 1.2 grams of protein per kilogram of ideal body weight per day, and more if she's active. So a woman with an ideal weight of 65 kilos is aiming for roughly 80 grams of protein a day at minimum.

Andrea: One of the smallest changes with the biggest impacts I see is a protein-rich breakfast no later than 10:00 AM. [00:31:00] 25 to 30 grams of protein at that first meal. For women with insulin resistance or extra visceral fat, I also use time-limited eating. But I'm careful here. That classic 16 and 8 fasting seems to suit men better.

Andrea: For midlife women, I find a 12-hour overnight fast works really well for everyone, stretching that to 14 hours if insulin resistance is present. But still staying with that protein-rich breakfast by 10:00 AM. If it's within your scope, magnesium helps it here again. For women with pre-diabetes or diabetes, chromium has trial evidence for improving glucose control, mostly in type II diabetes.

Andrea: And in my practice, I really love berberine as well, which has been shown in trials to lower HbA1c and improve insulin resistance. However, just a little note, berberine does interact with a number of medications, including diabetes medications. So if this woman is on anything like that, it's really a conversation with her [00:32:00] GP first before you start prescribing

Andrea: Then refer. If you've got a 52-year-old with a frozen shoulder, increasing central fat, fatigue, and a family history of type 2 diabetes, the most valuable sentence you can say is this, "It might be worth having a metabolic health check with your GP." Now, that is good collaborative care. Load four is poor sleep.

Andrea: Ask her, "How are you sleeping?" And go beyond just the number of hours she's getting every night, but ask is she waking with pain or with night sweats. Is she waking at 3:00 AM or struggling to get back to sleep? Then do. Here we have some very practical manual therapy tools. If pain is waking her, we can help her with positioning.

Andrea: For lateral hip pain, that means avoiding lying on the painful side and putting a pillow between the knees. Settling night pain is one of the fastest wins we can give her. And then the basics, a regular wake and sleep time, a cool, dark [00:33:00] bedroom around 16 to 19 degrees, morning light, and a darker house in the evening.

Andrea: And less alcohol at night, too, although my wish list is really none for midlife women because it really does fragment sleep. If within your scope, many women find magnesium helpful. My current favorite is a newer formulation from Give Back Health called MagSleep with magnesium citrate, glycine, L-theanine, and alfalfa.

Andrea: The results that I've seen for sleep in my practice have been wonderful. I'll also consider a gut formula if there are any gut issues, and liver support if she's regularly waking between 1:00 and 3:00 AM.

Andrea: Then refer to her GP if night sweats are driving the waking up, and to a psychologist for cognitive behavioral therapy or other treatment for insomnia if poor sleep has become entrenched. Then load five is chronic stress. Ask, "What's happening at home or at work? Is she caring for teenagers and aging parents while working full-time?

Andrea: Is she [00:34:00] constantly switched on?" Then do. Often the most useful thing is simply recognizing it and naming it out loud. Stress changes pain sensitivity, sleep, and recovery, so addressing stress definitely belongs in the treatment plan

Andrea: Breathwork is a beautiful tool here for shifting the nervous system out of fight or flight into rest and digest. I have three favorite types of breathwork. Box breathing is where you breathe in for four, hold for four, breathe out for four, and then hold for four. Then extended exhale breathing is where the out breath is longer than the in breath.

Andrea: And a double inhale breath is where you breathe in, sip in a little more air at the top, and then a long, slow exhale. Even 90 seconds of these can help someone settle their nervous system. It really doesn't need to be much. And regular movement helps here too. If within scope, magnesium can help again if we look at supplements.

Andrea: [00:35:00] Ashwagandha, also called withania, or B vitamins can support her too. Then refer. When stress is significant, saying, "I think you need some extra support," and referring to her GP or a psychologist is excellent care. She'll often be grateful someone noticed

Andrea: Load six is physical inactivity and muscle loss, and this is one where manual therapists shine. Ask, "What were you doing 12 months ago that you're not doing now?" So often you'll hear, "I stopped exercising because everything started hurting." Then do. Rather than telling her to rest until the pain goes away, we work out what load she can tolerate now.

Andrea: That might be isometrics or a load that doesn't flare her symptoms over the next 24 hours. Then we progress week by week. Then for almost every midlife woman I see, I encourage heavy lifting with progressive overload. Now, most practitioners already know this, but what's new is [00:36:00] how much it matters for this group of women.

Andrea: In the Australian LIFTmore trial, post-menopausal women with low bone mass did supervised heavy resistance training twice a week. Their bone density and function improved, and the training was safe for them. Now, the supplement I recommend most here is creatine monohydrate at five grams a day.

Andrea: The research in post-menopausal women shows it helps build lean mass and strength when it's combined with resistance training. On its own, without the lifting, it doesn't make much difference, so creatine supports the training rather than replacing it. I've also seen great results with creatine for brain fog in midlife women.

Andrea: Then refer to an exercise physiologist or a good strength coach if she needs more supervision than we can give. So here's the whole map again with one action for each load. Estrogen, explain and plan. Visceral fat, strength [00:37:00] training and food quality.

Andrea: Insulin resistance, muscle, protein, and a GP check. Sleep, think about the positionings, the basics, and referral. Stress, recognize it and refer. And muscle, load it and keep progressing. None of this takes manual therapists outside of their scope. It's our case history and treatment plan with a wider lens, asking why it hurts, why it started now, and why it isn't recovering.

Andrea: So let's go back to the forty-seven-year-old woman we started with. She has lateral hip pain and a stiff shoulder. She's put on eight kilos over the last couple of years. She's sleeping badly. Her periods have become irregular. She's stopped strength training because everything hurts, and she's been coming in for treatment, which helps, but only for a week or two.

Andrea: Through the old lens, she has gluteal tendinopathy and shoulder dysfunction. [00:38:00] Both true. We'd treat them, and she'd feel better for a while. Through the wider lens, she still has those same diagnoses, and she's also in the middle of the menopausal transition. She's stopped loading, her sleep is disrupted, her body composition is changing, and her capacity to recover has dropped.

Andrea: So the plan changes. We still treat. We start loading again gradually. We explain what's happening, which on its own is a huge relief for so many women. We talk about sleep and nutrition. Maybe we suggest some supplements, and we refer her to a GP to talk through her symptoms, her bloods, and her options. I shared a real patient of mine with the room on the weekend, I'm gonna call her Michelle for privacy reasons, who was this woman.

Andrea: Twelve weeks later, Michelle was in the gym lifting weights twice a week. She was sleeping through the night. Her hip had settled so well that she'd gone from weekly treatment to a maintenance check [00:39:00] once every two months. And what she said to me was this: "I finally understand what's going on in my body."

Andrea: That sentence is everything. Understanding, understanding our bodies is where the change can start.

Andrea: And none of that sits outside of our scope as manual therapists. For us osteopaths, it's the osteopathic principle every one of us learnt in our very first year, treat the whole person. For the women listening, I want you to know what this can look like when the whole picture is addressed. It rarely happens overnight.

Andrea: Usually, the first thing to shift is understanding, the relief of knowing why. Then sleep often improves, especially once night pain is settled. Then energy comes back, and then strength comes back, and with it, trust in your own body again. Look, flares still happen in perimenopause, but they do get smaller, they pass faster, and they stop [00:40:00] derailing everything.

Andrea: And if you want structured support to turn down those taps that we've been talking about today, the food, the blood sugar, the sleep, the stress, and the strength training, my 12-week Whole Health Solution program is designed exactly to take you through this in a very supported way. So the three things I asked the room on the weekend at the conference to take away is this, and I'd love you to take this away too. One, midlife musculoskeletal pain deserves a hormonal context. Two, treat the painful tissue, but also assess the environment around it. And three, our role extends beyond hands-on treatment to education, movement, lifestyle support, and appropriate referral.

Andrea: So the six loads in summary. One was estrogen fluctuation decline. Two, visceral fat and metabolic dysfunction. Three, insulin resistance. Four, poor sleep. Five, chronic stress. And six, physical inactivity and muscle [00:41:00] loss. We ask, we do, and we refer because sometimes the painful shoulder walking into your treatment room isn't just a painful shoulder.

Andrea: And practitioners, if this episode was useful, please share it with a colleague. That's exactly how this message gets further than one conference room. For the next episode, I'm gonna talk you through what blood tests to ask your doctor for during perimenopause and how to know if when you're told your tests are all normal, if they are actually in optimal ranges or just in the not sick ranges.

Andrea: We really wanna be in optimal ranges, so you don't wanna miss that one. So please hit subscribe or follow the show on whatever platform you're listening on right now, because you do not want to miss a single episode. And if someone in your life needs to hear this, please share it with them too, because the more women who have access to this kind of information, the better.

Andrea: Just a little note, all of my free resources, my three-week Inflammation [00:42:00] Detox, and my 12-week Whole Health Solution programs can be found at andrearobertson.health. Everything you need is right there waiting for you.

Andrea: If you loved today's episode, please take 30 seconds to leave a review on Apple Podcasts, Spotify, or wherever you listen to your podcasts. It genuinely helps more women find the show so they can nourish, heal, and rise too. Until next week, nourish your body, keep healing, and never stop rising. I'm Dr.

Andrea: Andrea Robertson, and this has been Nourish, Heal, and Rise

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