New Approach to Musculoskeletal Pain in Menopause with Dr. Jessica Drummond

Dr. Jessica Drummond 00:00:03 Hi and welcome to the Integrative Women’s Health Podcast. I’m your host, Doctor Jessica Drummond, and I am so thrilled to have you here. As we dive into today’s episode, as always innovating and integrating in the world of women’s health. And just as a reminder, the content in this podcast episode is no substitute for medical advice, diagnosis, or treatment from your medical or licensed health care team. While myself and many of my guests are licensed healthcare professionals, we are not your licensed healthcare professionals, so you want to get advice on your unique circumstances. Diagnostic recommendations treatment recommendations from your home medical team. Enjoy the episode. Let’s innovate and integrate together.

Dr. Jessica Drummond 00:01:02 Hi, and welcome back.

Dr. Jessica Drummond 00:01:03 To the Integrative Women’s Health Podcast. I’m your host, Doctor Jessica Drummond. Today I have a very special solo episode for you. We’re going to dive into a case study looking at our brand new maps framework and keeping it integrated with our seven step system. If you’re unfamiliar with these, these are some of the frameworks and systems that we use in the Perimenopause and Menopause Certificate program.

Dr. Jessica Drummond 00:01:34 We have fully updated that program, optimized it, expanded it exponentially to integrate the perspective of confidence in complexity. We’re opening enrollment for that program October 1st of this year. If you want to learn more about it, please email our team support Integrative Women’s Health Institute. Com that support at Integrative Women’s Health Institute. Com. So I want you every single listener to be certified as a perimenopause menopause expert through this confidence and complexity perspective. Because here’s the reality. All women coming to you in midlife, no matter what your health care or wellness background perspective, are likely struggling with complex issues that overlap far beyond only the hormone shifts. And we cannot ignore the hormone shifts in this time frame. So I want to talk to you about how this would work in a really common case study, in fact, one that I saw in my practice just this week where women are coming to us with musculoskeletal syndrome of menopause. So if you’re a physical or occupational therapist, acupuncturist, chiropractor, primary care physician, nurse, nurse practitioner, PA fitness professional, this is for you.

Dr. Jessica Drummond 00:03:11 Yoga teacher. You are in exactly the right place because very often when we see someone with chronic musculoskeletal painter pain that’s starting to be labeled as chronic musculoskeletal pain or musculoskeletal pain, that seems to progress in a way that doesn’t feel maybe consistent with a common knee injury, let’s say like a ligament irritation that is resolved within 4 to 6 weeks or less with compression, with stabilization exercises, anti-inflammatory strategies, and just is maintained in one joint. So let’s think about a case where your client is 51 and she has had a most recent knee injury that she thinks is related to hiking. But you dig a bit further and you find that over the last year or so she’s had back pain that hasn’t really resolved. She’s had right shoulder pain, right elbow pain, then a little bit of left elbow pain. By the way, she doesn’t play tennis. She’s a hiker and a swimmer. So maybe from the swimming now she’s got right knee pain. So what’s going on? It’s all more on one side. But actually that back pain originated actually in both hips.

Dr. Jessica Drummond 00:04:38 So you start to wonder what’s going on. Why is this starting to be so systemic? So she has been referred to you from her primary care physician, and she is here to see you. Whether it’s for nutrition, physical therapy, fitness, strength training, acupuncture. She’s coming to you with this increasingly widespread pain that has now been labeled fibromyalgia by her primary care physician, because it is in four distinct locations of the nine locations. So it is diagnostic for fibromyalgia. But remember, she’s 51 and she is still cycling. She’s perimenopausal. She has not stopped cycling, but she’s cycling irregularly. Her cycle is lighter, it’s more inconsistent, and she’s noticing she’s really having trouble sleeping now, which she tracks back to because of the pain. Every day the pain is a little bit inconsistent. Some days it’s a lot worse. So I want you to take a step back for a moment and familiarize yourself or familiarize yourself. If you’re not already, I want to introduce you to our seven step system. Step one aligns with nervous system regulation.

Dr. Jessica Drummond 00:06:01 So is your client starting to become increasingly stressed by this scenario? What is her stress look like? Does she feel stressed? Does she feel fine? The client in this case has a lot of stress related recent history related to a move and a divorce. But she says, you know, I don’t really feel stressed. Okay, fine. So we put a pin in that. She feels pretty relaxed. One of the things we often do is now start tracking stress using a heart rate variability tracker using wearables. So obviously we teach a lot about that in our perimenopause and menopause course. Now I want to introduce you to our Maps framework and we have 14 different maps. One of them that I would pull in for this case is known as our pain fatigue post Exertional Malaise map. Now, this also is a really valuable map for people who have chronic fatigue conditions Me, CFS, chronic inflammatory conditions. And there are other maps related to this kind of patient. But in every map you are going to learn the common symptom clusters and overlaps.

Dr. Jessica Drummond 00:07:19 You are going to learn likely mechanisms, physiology, environmental and other risk factors, genetic risk factors, how this overlaps with perimenopause. So let’s circle back to that. How this overlaps Mary. Menopause right. We know some of our symptoms. There is a pain fatigue component. She’s not sleeping well. She thinks it’s related to the pain. She’s not really sure pain is waking her up. It’s different, you know. Now she’s starting to have pain in about six different joints. So can’t sleep on one side, can’t sleep on the other side. It wasn’t so bad when most of the pain was on the right side. Now it’s starting to be on the left side more too. But in the perimenopause and menopause overlap, I think it’s very important for us to integrate in the musculoskeletal syndrome of menopause. Now you’re going to learn in this course a lot more about the G-protein coupled estrogen receptor, because estrogen receptors, estrogen receptor A, estrogen receptor B are all over the body. And one of the things that I think is most interesting about the estrogen receptor when it comes to the musculoskeletal syndrome of menopause, and we’re going to go much deeper into this in the course.

Dr. Jessica Drummond 00:08:41 But Estrogen is related to satellite cell proliferation. Satellite cells are the cells that come in and help with myofascial muscle, and also tendon and ligament healing. When there is an injury or a stressor, such as related to exercise, and estradiol stimulates the activation and proliferation of the satellite cells through estrogen receptors, part of the force generated by skeletal muscle is also likely, at least in mouse models, related to how well estrogen binds to estrogen receptor A, so it’s going to make it harder if your client’s estrogen is low for them to even do the strength and stability training exercise that they need to do to recover if it was a mild injury or if we’re just starting to see more instability. Now, another note on this client is that she has a negative two Dexa score on both hips and her spine. Another key important aspect of how the estrogen receptors function, and one of the reasons we need adequate levels of estrogen in perimenopause and for decades beyond, is that estrogen stimulates osteoblasts. So she has been diagnosed with osteopenia in both hips and her spine.

Dr. Jessica Drummond 00:10:14 As I said, negative two Dexa score. And so if she’s low on estrogen, she is not going to be able to rebuild and maintain that bone, at least keep from losing it. Ideally build it a bit. We can actually stimulate osteoblasts even in perimenopause and menopause, especially with appropriate estrogen support. So this client is not on hormone therapies. This is something we want to have a really important conversation about between her, her gynecologist, her primary care providers, any of the prescribers on her team, and helping her to really understand the mechanism of why she might want to add estrogen to this equation. And we we talk a lot more about that in our prescriber module, because I think every practitioner needs to understand how estrogen and progesterone, which is really important in this case since she is having trouble sleeping low. Progesterone is really important when it comes to sleep. In fact, oral progesterone supplementation or medication, if you will. The metabolites of oral progesterone actually help to stimulate Gaba receptors, which help with deep restorative recovery.

Dr. Jessica Drummond 00:11:30 Sleep. So, so many areas in which menopause is truly impacting this person’s ability to heal her musculoskeletal and myofascial related pain. And yet the other thing we talk a lot about in our pain map when it comes to environmental factors, is the fact that these women are often labeled as complainer or sort of gaslit, not necessarily drug seeking, but sometimes because the doctor is just like, oh, you know, you’re getting old chronic pain, you know, go exercise. But they can’t exercise adequately and effectively to start rebuilding and remodeling the muscle for stability in this low estrogen environment. So these risk factors that are psychosocial and related to the systemic dismissal of women with chronic pain will impact how well this situation is managed. And what can often happen is that now we’re in this downward spiral of chronic pain, of less movement trauma related to the medical experiences of having this pain. People can start to have a lot of fear, as this patient did. She was a big hiker. Now she was doing a little bit of water aerobics, but that’s not going to rebuild her bone.

Dr. Jessica Drummond 00:12:55 Right. We have to get out of this cycle of now. You’re super delicate now. You’re old now. Your bones are fragile because it’s the exact opposite strategy we need to implement. All right, so moving on in our seven steps. Next we need to define what is going on here. And it looks like given our walk through the pain and fatigue map, that her fatigue may be related to the pain waking her up, but she’s also deep in perimenopause. Maybe, you know, months away from complete menopause. And it’s very likely that her progesterone levels are low now. Actually menopause therapies hormone therapies are not prescribed related to a particular level of hormones. It can be valuable to take a look at that. And we often use tools such as the mirror or the Dutch test. And you’ll learn all about how to use those. But they’re actually prescribed related to symptoms because there isn’t a clear level globally that is sort of the perfect level we want to hit with that hormone replacement. Still, it can be valuable to see patterns.

Dr. Jessica Drummond 00:14:09 It can be valuable to see the hormone shifts related to particular symptoms. It can just be an interesting piece of the puzzle. Is it required? Absolutely not. But I think learning these tools helps to refine more how we communicate what is going on for this client. So let’s assume her progesterone levels are low, at least during part of the cycle. And this is where it gets very messy in perimenopause. She might sleep wonderfully, some days terribly. Other days it’s not aligning as well as it used to with her menstrual cycle, because now her menstrual cycle is a bit all over the place as well. So we likely have low progesterone. We almost certainly have low estrogen, or at least low estrogen part of the time. She’s likely having at least some and ovulatory cycles. The other key factor that estrogen is going to play in this situation is that estrogen is very important as an anti-inflammatory hormone and as an insulin sensitivity hormone. So we’re going to also talk in our maps about metabolic health and inflammatory health.

Dr. Jessica Drummond 00:15:24 We’ll dig deeper in that in the course. But just your aware. So step two is we want to define what is going on here, and that’s where the maps can be really helpful. But even more importantly, what are her goals? So this particular client really wanted to get back to hiking with friends. She had a community group around that and it was really disrupting her sleep. She was feeling so exhausted and swimming was important to her, but not as important to her. And she wanted the more functional capacity. She just felt like she was kind of like slogging through every day with this low grade, constant moving around some joints, other joints, chronic pain and fatigue day in and day out. So step three is we’re going to empower this situation, this conversation with data. So that’s where I was talking about tracking heart rate variability possibly doing some hormone testing getting some inflammatory markers tested, you know, looking at a more complete picture. And if there are any areas of data that we can fill in.

Dr. Jessica Drummond 00:16:39 In this case, the stress scores were very valuable. This client was living in a constant state of very low HRV overnight, like in the high teens, and stress scores of elevated most of the day, even when she wasn’t quote unquote like feeling stressed. So this is where we have to help distinguish for our, our clients, many of whom are very driven, accomplished women that are used to getting so much done. And they’re like, I’m fine. I can power through it. They’re really good at powering through discomfort. So tracking stress scores and overnight heart rate variability we want to see is she recovering? We have a whole module in this new course about the importance of deep. Daily, at least weekly or monthly. But as often as possible, balancing recovery. That, I would say, is the number one challenge I see in my practice for women in perimenopause and menopause. They are excellent at ignoring symptoms exhaustion. They don’t know what stress feels like in their body until we start bringing that to the surface, like tracking it.

Dr. Jessica Drummond 00:18:03 And they’re just excellent at showing up and powering through until they absolutely crash. They’re shocked. Why did they crash? They have no idea because they have never been taught exactly how to deeply and fully recover. All right. So there’s a whole module in that. But let’s move on to step four is where we start advising. So if we go back to our pain fatigue map we are going to use I have recommendations for you on each map around questionnaires, validated tools that you can use to track symptoms. So in this case we can use symptom severity score. We can track a daily diary of fatigue and look for any patterns sleep questionnaires that I’ve included for you. And as we talked about using wearable tracking, I also would be really interested in thyroid function with chronic fatigue. I’m also interested in iron deficiency, particularly in those perimenopausal and menopausal women who have very heavy bleeding. This client did not share. Her cycles were becoming quite light and irregular, but often before people hit menopause in that late perimenopause phase.

Dr. Jessica Drummond 00:19:24 There are experiences of significantly heavy bleeding. B12 deficiency is also quite common, especially depending on what their nutrition is looking like. And now we are going to start with an entire suite of recommendations around inflammation, optimizing estrogen levels, strength and stability and mobility, and keeping these always connected to her goals. So for this client in particular, we talked a lot about and collaborated with her prescribing provider on utilizing 100mg nightly of oral progesterone and transdermal Astra ideal starting at 0.05. There are other areas we could start, but again, you’ll learn a lot more about that in the prescriber module. So for my pharmacists, Pas, nurse practitioners, physicians, and all of us in allied health as well. Nutrition. Dietetics. Physical and occupational therapy. Acupuncture. You want to understand how these medications are utilized, because we need to be able to have those conversations and be valuable resources as educators and connectors to prescribing resources for our clients. A lot of these tools are available, but they’re often available in sort of direct consumer checklists.

Dr. Jessica Drummond 00:20:50 Like everyone gets the same recommended protocol. We need to help our clients understand how to put these tools into context. All right. So this client was not at all on an anti-inflammatory diet. She was eating a high sugar diet. She was still drinking alcohol not a lot, but about four times a week, 1 to 2 glasses of wine. She was eating a lot of processed grains, a lot of breads and pastas and things like that because she was just so busy and overwhelmed by her life and her pain that it felt very difficult to cook. If your shoulder hurts, if your elbow hurts, if your knee hurts, you don’t want to stand and chop vegetables for hours. So we had to come up with some shortcut solutions. Getting her teens involved in meal prep to make sure she was starting to add more anti-inflammatory foods to her diet. Sleep hygiene is still very important. Even if we get those progesterone levels optimized, we have to make sure we’re helping our clients have good sleep habits, good circadian rhythm habits.

Dr. Jessica Drummond 00:21:53 She was so exhausted every morning. She was like getting up, grabbing her phone, grabbing her coffee, just trying to, like, slog to get herself to the cart to get to work. Five minutes sitting outside in the sunlight, drinking a full glass of water, breathing slowly, not touching her phone until she got to work. That very simple shift in her our morning routine made a dramatic change to her pain and her inflammatory levels. So there are all these little tiny tweaks we can do, even for people who are overwhelmed, busy, exhausted, and in chronic pain. That’s why we have to look at such a holistic picture that menopause prescription of 0.05 transdermal estrogen and 100mg of oral progesterone is going to help, but that is not going to solve this entire problem. In the same way that just doing physical therapy is not going to solve this entire problem. Acupuncture is not going to solve this entire problem. We have to look at all levels sleep, nutrition. And so that brings us to our what I call the foundations foundational lifestyle and nutrition recommendations.

Dr. Jessica Drummond 00:23:10 You’re going to talk to her about hydration Nutrition, circadian rhythm, sleep hygiene, stress, nervous system regulation strategies. This client loved yoga, but again, it had fallen by the wayside. Yoga is not the only way to yoga. Nervous system regulation. Some people love hands on cranial sacral therapy, some people love self myofascial. And actually it’s more of a myofascial cranial sacral self technique that you’ll learn about ear pulling and kind of stimulating gently the vagus nerve and the lymph system around the neck. Some prefer nature exposure, some prefer mindfulness or other forms of meditation. Some prefer laughter. There are so many tools we have at our disposal for nervous system regulation, and you’re going to learn a lot about that. We talk about supplementation, particularly in this case anti-inflammatory supplementation and mitochondrial Real support. This woman is living a high performance life without high performance scaffolding, without high performance support. And often nutrition is not enough when someone is trying to both heal and recover from decades of pushing through and overdoing it and running too fast.

Dr. Jessica Drummond 00:24:39 You know, we’ve all heard of the rushing woman syndrome. We have to also slow down and look at the mitochondria. We can measure the mitochondrial function, and we can do that in a couple of different ways, such as urinary organic acids testing, also using things like miter swab testing. But often it’s just empiric and intuitive. When people have physiologic stress related to too much oxidative stress for their mitochondria to function optimally, and this shows up as high inflammatory markers as things like elevated cholesterol, as creeping up blood sugar as creeping up blood pressure. These are all clues as to the cellular energy system being stressed, and often mitochondrial supplements help women feel better much more quickly. And we talk about in our map system, red flags for referral, how to build our teams. And then we’re going to look at 12 week milestones. How should this client be progressing. So I expected and saw with this client that as we had her begin to do some joint stability exercises, that morning routine was a huge game changer.

Dr. Jessica Drummond 00:26:01 She got on hormone therapy. She started sleeping much better. Her heart rate variability by week three was up into the 20s. So these are going to be subtle, consistent slow shifts and changes. We’re going to implement a little bit at a time because we don’t want to overwhelm our client. And we have to talk to them about what pacing is right for them. Some of them are like, you know what, my last kid just left for college, and, you know, I quit my job or I’m retired. And it’s like, starting today, I’m going to implement absolutely everything. I’m ready to make big changes. That’s one of the things that’s actually really fun about working with this population. Oftentimes they have cleared the decks a little bit before they’ve even come to see you, and they’ve created space to make some big changes. But now it’s like implementing those, making them habits, letting go of some of the habits that haven’t served them for a long time. That can be hard. A lot of emotions can come up.

Dr. Jessica Drummond 00:27:01 We can hit some walls, we can go slower or faster than we expected we were going to go. So that can be great. And on the other hand, a lot of these clients are often super busy. They have teenagers, they have full time jobs. They are caring for aging parents. So the pacing of how we make these changes is what you’re going to learn all about in our coaching modules for this course, because health coaching communication skills are the secret sauce to getting your clients better for the long term, where this is a whole new skill set that is implemented into their lives, that’s so important, they begin to own the capacity to make these changes and make these changes stick, not just for six weeks. This isn’t a quick fix program, but for months, years, decades and beyond. And they understand what’s beneath these new skills because you’ve put on your educator hat and you’ve helped them really understand what’s going on in their body so that when they get off track, inevitably we can help them get back on track with a lot more ease because they understand what happened and you’re there as a resource over the long term.

Dr. Jessica Drummond 00:28:19 These patients are great to work with as clients in a group coaching model, because they really positively feed off each other’s energy. All right. So we’ve made some recommendations. We’ve done them over time. We’ve tracked them through the maps in terms of what goals where we expect them to get to week by week. So we’re seeing how well their pace is compared to kind of an average expectation. Some of these women that I’m working with are more and more being diagnosed with neurodivergent conditions, such as autism and ADHD, much later in life. So we have some tools and recommendations for you to help support implementation, Even with neurologic differences. So in step five, we create that as a daily schedule with all the supports they need. Sometimes it’s human support. Increasingly I think it’s going to be AI support. Sometimes it’s things like supplement pill organizers, sometimes it’s color coded post-its or things on their calendar. Sometimes it’s really about the pace one thing at a time and what we expect from making that shift. Doing too much too quickly sometimes overwhelms people and can often be unnecessary because now we don’t know.

Dr. Jessica Drummond 00:29:42 What were the biggest needle movers? So there’s pros and cons to making big changes quickly or smaller changes over time. And that’s something we’ll work through on all of the live calls that we do in this program, helping you actually navigate this in real time with your clients. And then in step Three. We talk about integrating all of this long term in life. Even when you know they’re traveling for Thanksgiving, they’re eating at someone else’s house, their exercise program falls off the wayside. Or they do a big trip that requires a lot of exercise. Even when emotional shifts happen, a lot of emotional shifts that can be either wonderful and just big emotions or hard and big emotions or traumatic, often do pull up some of the trauma that people have felt much, much earlier in their lives, whether it was in childhood or during pregnancies or postpartum. These traumas, these big emotional shifts, can live physiologically. And so we have to learn to hold space for that. The coaching skills are so valuable there. And again, just helping women understand what’s going on, that it’s perfectly normal to feel these emotional waves and to support them in a way that is strongly trauma informed.

Dr. Jessica Drummond 00:31:04 And then finally, this is a lifelong process, and our seven step model is designed in a circular way. I actually see it as an upward spiral because there are new goals every few months. Every year there are new opportunities to expand. The goals might change. This is a time when women are like, oh, maybe I want to learn how to play tennis, or maybe I want to stop doing, you know, these five other things. I think it’s a really wonderful time of continuously reassessing our goals, and that is going to change how we’re going to prepare. So this woman in particular, while physiologically, of course, she needs to get healthy enough to start being able to do heavy strength training for her metabolic health, for her bone health, for her myofascial health. The number one cause of death for women over 75 is fracture. So she needs to get her bones healthy. She’s already on a downward spiral there, and she lost her estrogen. And she’s lost her ability to rebuild her muscle.

Dr. Jessica Drummond 00:32:13 And she’s not even strength training because of all this pain and poor sleep. So this is physiologically really important for her, but it’s also really important for her life. Now that her kids are older, she wants to start traveling. You know, she wants to carry her suitcase, put it in the overhead. She wants to go on long walking tours. She wants to hike in hot conditions, you know, and she needs strength and functional ability to be able to do that. So continuously connecting this to our goals. So this is the kind of client that I work with over months, two years. And she’s making really big gains already. And the reason I love to work with these women over the years is because their goals get so much more expansive, and they really learn how to take care of themselves through the really wild changes that happen in their lives and their families, in their caregiving statuses. More caregiving, less caregiving, in their work opportunities, in their recreational opportunities. So that is how we will utilize the combination of the maps frameworks and our seven step system for implementing these Maps frameworks.

Dr. Jessica Drummond 00:33:31 And in the maps frameworks, I also talk about what’s the next one we might consider. What are a couple of concurrent maps frameworks we may want to use? I like to start with 1 or 2 at a time. We have hormone maps and chronic conditions maps. Right now there are 14. I can see these expanding, but I can’t wait to teach you all about this, so I will see you in our course starting October 1st. Think about this client as you go back to your practice this week. And the other thing I forgot to mention was this client being labeled by her primary care physician as having fibromyalgia was now starting down a path of antidepressants. Gabapentin. She was taking a lot of Advil. Her doctor recommended kind of 2 to 4 Advil as needed. It was a lot that can impact her gut microbiome. And without slowing down and thinking about how this fits into what is most commonly presenting in perimenopause, you’re going to miss big things, and you’re often going to send clients down sort of a traumatic chronic pain rabbit hole.

Dr. Jessica Drummond 00:34:45 And that’s where we don’t want them to go. We want them to be on this continuous upward spiral of support. There are bumps in the road. She’s going to have more pain. Sometimes her stress is going to flare. She may have a more intense injury as she starts doing new functional activities. A lot of things can happen that can make this path more rocky, but once we start a downward spiral of just kind of supported polypharmacy without a real plan, especially around musculoskeletal syndromes and pain, around chronic fatigue, we really start to cause other secondary issues like worsening osteopenia and osteoporosis, deeper chronic fatigue issues, more chronic inflammation, more oxidative stress, which is going to put more pressure on mitochondrial function. So your first goal when working with patients that have this sort of complexity of presentation is your own nervous system regulation and your own slowing down and really thinking about all the pieces that could go into this puzzle, making changes, watching closely for response. And that comes from having confidence with complexity. Most programs teach you how to work with textbook cases.

Dr. Jessica Drummond 00:36:14 We teach you how to help solve the real ones. They’re all complex. That’s the secret. And I want you to have confidence so that no matter who walks through your door, you have these tools, you have these systems, you have these frameworks to lean on as you build skill, as you build experience, and as you build confidence. So keep an eye out on your inbox over the next couple of weeks, and I look forward to inviting you into our brand new perimenopause and menopause certification. Confidence in complexity. I’ll see you next week. Think about this case in the context of your practice. Make one little change with the next client who resembles this client and see how it works. One mindset shift, one different perspective can make a whole lot of difference. See you next week.

Dr. Jessica Drummond 00:37:14 Thank you so much for joining me today for this episode of the Integrative Women’s Health Podcast. Please share this episode with a colleague and if you loved it, hit that subscribe or follow button on your favorite podcast streaming service so that we can do even more to make this podcast better for you and your clients.

Dr. Jessica Drummond 00:37:38 Let’s innovate and integrate in the world of women’s health.