Joe Jackson's 1979 single release, It's Different for Girls, put a spotlight on the female experience of relationships, and attracted plenty of attention by doing so. It felt to me back then that a taboo was being aired openly and, notably, by a man. It is different for girls / women, and ‘it’ can refer to various aspects of female life, some of which really matter.
I've written previously about the impacts on women of a world created, in no small part, to correspond to men and, in particular, the male body. In the world of research and medicine, frequently bypassing the biology of women is at best unhelpful (how can we be sure a medicine or intervention will be effective if it's not tested on representatives of the group to whom it will be applied?) and at worst dangerous, even fatal. Women need and deserve to know more about their own physiology, both individually and collectively.
It came as a surprise when feedback from a student I'd been working with to improve her day-to-day breathing began with something neither of us had been focused on throughout the duration of her course: "Since working on my breathing with Annette, my period pain is gone.” She was amazed, I hadn't made any reference to this possibility in the course of her training so it was an unexpected bonus. I was delighted, but less surprised. Nevertheless, my knowledge had come too late to be of similar benefit to me. The younger me had absolutely no idea of a link between breathing and any menstrual cycle symptoms. Why would I? Despite the various hormone-related challenges I experienced, leading to doctors’ visits and even hospitalisation (for endometriosis), there was never a mention of the bi-directional effects of hormones on breathing and breathing affecting symptoms. That is undoubtedly still the case today. Whilst this information is not absent from the scientific literature, it is absent from medical training. A cynical person might conclude that the apparent lack of interest may well relate to the fact that adjusting one's breathing doesn't require a profitable medicine or other medical intervention.
PMS and Hyperventilation
If I suggest to you that anyone hyperventilating is almost certainly in a state of hyper-arousal, maybe even panic, you probably won't be unduly challenged by that notion. This is when hyperventilation is at the extreme end and is obvious to anyone close by at the time. But hyperventilation can just be over-breathing, breathing in excess of one's metabolic needs. It's less apparent to onlookers and the associated symptoms, although present, are much less likely to include panic and will rarely be assumed to be correlated with one's breathing. These symptoms are, for example, anxiety, brain fog, mood swings and heightened pain perception. This means that anyone can experience such effects anytime they're breathing too fast, or too hard, or through an open mouth or a combination of two or three of them. But a woman in the luteal phase of her menstrual cycle (the phase between ovulation and the period) has an increased likelihood of these symptoms. In the luteal phase, progesterone increases. This hormone is a respiratory stimulant, in other words, it promotes faster breathing. This may or may not immediately lead to / contribute to symptoms as it's likely to depend on whether or not over-breathing is already present, but since over-breathing is far more common in the whole population than we might imagine, there’s a good chance that it might. And what if a stressful event occurs simultaneously? You can probably see how easily the balance can shift and anxious feelings get triggered, possibly even panic. So yes, some symptoms of PMS can indeed be caused by hyperventilation!¹ Did you know this? I didn’t, so I assumed there was nothing I could do.
And there's another consideration for women especially if they already have respiratory challenges. The symptoms of their condition may worsen:
"Respiratory symptoms (i.e. wheeze, shortness of breath and cough) vary significantly with the menstrual cycle-induced hormonal changes. They tend to get worse during the mid-luteal to mid-follicular phases of the menstrual cycle (between days 10 and 22 of the cycle). Fluctuations in asthmatic symptoms are also reported during the menstrual period, possibly due to hormonal influence on airways.”²
As for my student's experience of period pain, the rise in progesterone is accompanied by a drop in CO² which intensifies pain perception and causes constriction of smooth muscles which, in turn, can directly contribute to menstrual cramps. By changing how she was breathing, she was able to balance her blood gases better and her pain was gone.
This is wonderful news because we can do something about it, and the sooner the better because natural, healthy breathing patterns, which can be re-established, will support us in all phases of life, not least during perimenopause and menopause.
How Breathing relates to Menopause
When it comes to heading towards, going through, and being in menopause, I may well be my own best case study; it's a long, drawn-out process and I've been there throughout! I knew nothing about breathing in the context of menopause until I was well and truly through to the ‘other side’. I was reliant, primarily, on what I'd learnt about diet and I suspected that the dietary measures I'd introduced almost two decades earlier to manage a recurrence of endometriosis, a hormone mediated condition, would be of benefit as I headed towards ‘the change’ as it used to be euphemistically called. All indications are that my nutrition did indeed help; I wasn't inundated with hot flushes, night sweats and some of the other common symptoms. But my sleep went from (long-term) bad to worse, and I was at a loss to know what to do about it and, in fact, assumed there was little or nothing I could do.
If you've concluded from my previous references to progesterone that this hormone doesn't have our best interests at heart, think again. Yes, it's a respiratory stimulant, but it also has a protective effect on the airway, it helps to keep the airway open and functioning well. The decline in sex hormones associated with menopause brings about a big statistical shift, namely a 200% increase in sleep apnea in females.³ The airway is now more susceptible to collapse at night and the genioglossus muscle at the base of the tongue is less active after menopause which can also impact on the airway. It's not surprising that sleep apnea is primarily associated with men, the incidence in men is higher across all the age groups. But this one-gender focus is problematic for women. First of all, being measured as men are measured means many women are told their score on the AHI (Apnea Hypopnea Index) is lower than a score that, for men, does indicate sleep apnea.³ The problem here is that the absence of a diagnosis of sleep apnea doesn’t remove the symptoms that these women experience as a result of their sleep disturbances. They’re left combating symptoms with no understanding of why they're experiencing them. The symptoms they and their doctors then work to manage include headaches, anxiety and depression, but the sleep problem which may be worsening or even causing those symptoms is overlooked. This can have further knock-on effects. The link between Obstructive Sleep Apnea and cardiovascular risk is well-established… in men. The cardiovascular impact of OSA in women isn't known because most studies have only involved men.³ Women with untreated Obstructive Sleep Apnea who were followed for 6 - 8 years had a greater incidence of stroke and chronic heart disease than women without OSA. Before I continue, bear in mind that Obstructive Sleep Apnea involves full or partial collapse of the airway. Not all apneas involve airway obstruction, some women have disturbed sleep due to what is known as low arousal threshold, ie they wake up easily and often frequently. Each of these phenotypes of sleep apnea relate to breathing which is good news because we do have some control over our breathing.
Upper Airway Resistance - pre-menopause
Sleep Disordered Breathing in females doesn't begin with menopause. The drop in hormones starts before menopause and women are more likely than men to experience Upper Airway Resistance Syndrome. The first sign of UARS may be that breathing has become audible indicating some resistance even if there's as yet no turbulence, no snoring and no apneas. UARS in women typically goes unnoticed because the women who experience it may well be younger, the average age is 38, and a preponderance of those affected are of East Asian origin.⁴ And they may not be obese. (There is an assumption that apneas and upper airway resistance occur primarily in obese individuals but 50% of those who have it, women AND men, are not obese). Maybe this is the most ideal stage of life to focus on breathing, and other supportive measures, to stop any downward spiral that may ensue as hormones decline further. However, this doesn’t mean that later interventions are not useful, far from it, as I’m seeing for myself.
It seems to be a travesty that women are so far away from getting appropriate medical recognition for their experiences and it's every bit as tragic that retraining breathing to help to alleviate the various phenotypes⁵ of sleep apnea is never considered. Of course, breathing exercises as interventions along with breathing retraining for better everyday (and every night!) breathing are most definitely not the only useful response to the challenges that accompany hormone fluctuations and changes, but it's one of the simplest to address, so why let disordered breathing persist when it doesn't need to? I made reference earlier to my own transition which seemed to benefit from the nutritional route I'd taken. I made particular reference to hot flushes, not knowing then that I might also have benefitted from slow, deep breathing as demonstrated in a study which also looked at a music-listening intervention.⁶ The success of slow deep breathing for reducing hot flushes which was certainly demonstrated in this study was superseded by a music-listening intervention. Great! This means there's another available strategy. Why not do both? It makes no sense to overlook the positive effects of good breathing because, unlike the music-listening intervention, breathing is with us 24/7 and its effects go way beyond the symptoms referred to here.
A few breathing-related recommendations
Nasal breathing is a must. Mouthbreathing will exacerbate the symptoms referred to here. Unless there is a physiological impediment to using the nose, retraining and practical nasal support will lead to better breathing. (If it is physically impossible to use the nose, do consult your doctor as surgery may be needed).
Practise light breathing; most of us over-breathe and, surprisingly perhaps, it perpetuates poor oxygenation (a cause of brain fog) by virtue of an imbalance of blood gases.
Practice slow breathing. Ideally make your exhale a little longer than your inhale. Studies often refer to a breathing rate of 4 seconds inhale, 6 seconds exhale as being an optimal breathing rate. If this seems in any way challenging at first, reduce it to eg 2 in 3 out. You'll be able to extend it comfortably (which is important) with practice. This practice also stimulates your Vagus Nerve which has a wealth of positive effects on multiple aspects of our health.
Use your diaphragm, the big breathing muscle at the base of your ribs (front, sides and back). Using this muscle along with nasal breathing helps to keep the airway taut. By breathing slowly and lightly through your nose, you are more likely to engage your diaphragm and again, practice will help you to get there.
If you know or suspect your airway is prone to collapse / partial collapse or resistance don’t let gravity give it a helping hand when you sleep! In other words, avoid sleeping on your back.
Thank you for reading this far. It's been nagging at me for a while to raise awareness of these issues and offer encouragement to those for whom it may be relevant.
I wish you the best health possible in an era when much of life works against it. ‘Better’ or even ‘much better’ is possible. I’m pleased to say that my long-term case study, me, is proving that to me.
~ Annette Henry
PS I am delighted to report that the student quoted above was so taken by what she learnt, she has since trained to become a breathing instructor herself.
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