Last week, we talked about the genitourinary syndrome of menopause (GSM), a chronic, progressive condition of the vulva, vagina, and lower urinary tract that begins during menopause and continues throughout a woman's life. GSM can impact negatively multiple aspects of a woman's life but today, we will talk about how GSM and other genital concerns of menopausal women can complicate exercise, particularly cycling.
To review, GSM affects virtually every woman to a lesser or greater degree. It starts during menopause, and symptoms become progressively worse throughout a woman's life unless she takes steps to treat the resultant condition(s). Dryness and thinning of the vulvovaginal area is caused by reduced estrogen levels during menopause. Common symptoms include vaginal itching, dryness, burning, and pain (particularly with intercourse). Urinary symptoms caused by the low level of estrogen include painful urination, incontinence, urgency, and increased frequency of UTIs. With all that happening, it's not so surprising that GSM symptoms might have an impact on our cycling where we sit on a hard, small saddle for hours at a time.
Menopausal women experience significantly more issues and discomfort due to the thinning and drying of the vulvovaginal tissues, which makes them more susceptible to tearing and chafing. Often, discomfort for premenopausal women on the bike is caused primarily by sweating and friction from clothing and the bike saddle. Heat, moisture, and friction are the perfect recipe for vaginal itching, redness, irritation, chafing, and odor. Menopausal women are different in that their the vulvovaginal tissues are not as thick, pliable, or healthy as they used to be.
Severe GSM can result in a vulvovaginal surface that is easily torn, as well as urethral issues, including incontinence. The result is a higher incidence of saddle sores where the skin in the region makes regular contact with the saddle. Severe chafing can result in open wounds. Other sores may be caused by an infected hair follicle. Sores that look more like boils also are common - they are usually larger and can be more painful. All of these sores and wounds increase a woman's risk of infection and cause quite a bit of discomfort. Menopausal women also experience a more irritating vaginal discharge, often as a result of irritation in the vagina due to GSM and/or sexual intercourse, which can further aggravate sensitive tissues. And for women who experience incontinence, the small amounts of urine leakage can add to the irritation of the vulvovaginal area. In addition, lichen sclerosis and other genital issues are more commonly seen in menopausal women and also can cause pain in the vulvovaginal area. In some severe cases, the pain is so severe that women have a difficult time with daily living activities, much less sitting on a bike saddle.
Just because you've been cycling regularly since you were young, things might not be the same as you age. There are quite a few variables involved in making cycling more comfortable for menopausal women. I advise changing one thing at a time to find what works for you. Note that this advice also applies to those who only cycle indoors, including on a Peleton or in group classes. In fact, indoor cyclists arguably need to pay even closer attention since indoor cycling typically involves more pressure, friction, and moisture than riding outdoors where you change position more often and there is evaporative cooling to reduce moisture.
Get your vulvovaginal health on track
The 2020 Menopause Society consensus position on GSM identifies that there are a number of over-
the-counter and prescription therapies for GSM that have been shown to be safe and effective, including vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA) - in creams, rings and inserts, systemic menopause hormone therapy (MHT), and an oral medication called ospemifene. Nonhormone therapies provide sufficient relief for many women with mild symptoms. I typically recommend Bezwecken Hydration Ovals as a starting option for mild symptom relief. In addition to the the hormonal and nonhormonal options, evidence supports the use of vaginal dilators and vibrators for vulvovaginal health. Pelvic floor physical therapy also can be an important addition to every menopausal woman's pelvic health. Finally, there are some data supporting the use of laser therapy for GSM and lichen sclerosis. Attention by your doctor to other vulvovaginal conditions common during menopause, like cancers and vulvodynia, as well as conditions common to all women like yeast infections and bacterial vaginosis.
Be patient. Symptom reduction may take 1-3 months, and continued therapy is generally required because symptoms are likely to recur if you stop treatment. Best results are observed when a women starts treatment as soon as mild symptoms appear and continues treatment throughout the rest of her life. It's worth repeating that GSM is a progressive, chronic condition so the treatment that works for you today, might not be sufficient in the future. Make sure you talk with your doctor regularly about your symptoms so that your treatments can be modified, as appropriate.
Get a good chamois
The importance of quality bike shorts cannot be overstated since this is where you have direct contact with your vulvovaginal tissues. Some may be asking...what is a chamois? A chamois is a pad that’s sewn into your bike shorts or a liner that goes under your shorts. If you don't already know, do NOT wear underwear while cycling because it has too many seams and is often made from a material that isn't ideal for exercising. You should look for a chamois with flat seams to minimize chafing. Use your fingers to feel along the sew line to make sure there aren't raised areas that might cause problems. Don't skimp on cheap bike shorts...look for ones made for women by cycling clothing companies that include a quality chamois. Chamois pads typically come in different thickness. But more is not necessarily better since wearing a bulky chamois can feel like wearing a diaper and actually cause skin issues instead of preventing them. You'll need to try a few different sizes with your riding style and distance to decide what works best for you. The rest of the short is typically made from tight, stretchy material so that it won't move while you cycle (or get caught in your drivetrain) and provides some support for your legs and midsection. Bike shorts should feel quite tight but not uncomfortable. Don't buy cycling shorts that are too big for you - they will get caught on your saddle and cause chafing because they move around on your body. Look for leg bands that have anti-slip materials on them to prevent them from riding up your leg as you pedal. Note that bike shorts can come in bibs that have no waist band to dig into your midsection but make it harder to manage nature calls, shorts, and/or liners, which are intended to be worn under other clothing, like mountain bike shorts, commuting pants, or skirts.
Cycling shorts are personal, but I've included some of my favorites since some of my patients have asked:
Pearl Izumi PRO Bib Shorts ($168) - some colors are on sale
Specialized RBX Shorts ($42) - on sale.
Velocio Women's LUXE Bib Shorts ($279) - more compression than some others, which is nice on a long day
Sugoi RS Pro 2 Shorts ($150) - on sale
Club Ride Chamois Liner ($50) - some colors are $40 on sale
Shredly Mountain Bike Chamois Liner ($98) - Currently not many sizes available (runs small)
Use some chamois cream
In addition to a good chamois, you may need to use chamois cream to further reduce chafing. Chamois cream is spreadable and designed to reduce friction between your skin and the saddle. Apply liberally to all areas where you experience redness, chafing, and soreness. Do not apply chamois cream inside your vagina - it's for external use only. Also, avoid double dipping into the container with your hands while applying to avoid contamination.
Personally, I find that application to my leg creases and sit bones works well, but direct application to my vulvar region increases my discomfort since it causes my vulvar region to slide around more on the saddle. Test out different options of chamois cream and application sites on your rides and go with what works best for you. Skip chamois creams with perfumes or dyes, as well as those that contain menthol since they will be more irritating to your less healthy vulvar skin. Some creams marketed to women have a lower pH level, which they claim reduces the risk of vaginal irritation and infection. A good place to start in choosing a chamois cream is Chamois Butt’r Originals, the original anti-chafe cycling cream. This cream contains mineral oil, lanolin, and aloe. The same company also makes a women's version and a new Coconut Anti-Chafe product that they market as being more gentle for sensitive skin. Another brand to try is Assos Women’s Chamois Creme.
Wash your cycling clothes the right way
Take off your bike shorts as soon as you finish you ride, and make sure to wash your cycling shorts as soon as possible after every use. Most cycling apparel companies recommend that you wash your cycling clothing separately from your other clothing. Turn all of your shorts (and shirts) inside out. Wash in cold water with a mild detergent (do not use bleach or softener.) Pair the detergent with something like OxiClean Odor Blasters Odor & Stain Remover Laundry Booster to kill odor-causing bacteria without damaging the integrity of the fabrics. Line dry. You will need to have several pairs of cycling shorts to avoid having to do laundry too often.
Get the right saddle and make sure your bike fits
We've talked about ways to improve the health of your vulvovaginal tissues, how to reduce friction with clean bike shorts that have a good chamois and chamois cream. The final piece of the puzzle deals with the saddle itself. There is no one perfect saddle that fits everyone. There are, however, a few tips to help you find the one that works best for you. 1) More padding doesn't equate with the best saddle. In fact, more cushy saddles often cause more friction due to greater surface area touching. 2) Saddles come in different sizes. Make sure you know the width between your sit bones (ischial tuberosities) before you pick a saddle. Just like picking bras, it's hard to know where to start if you don't know what size you are. Most bike shops can measure you. Or you can do it at home - lightly spray water on the top of a stool, place a paper towel on it, then add a sheet of white paper, sit for a couple of minutes on the paper in the closest approximation as you can to a riding position (do this while naked or only in your underwear), stand up, measure the distance (in mm) between the middle of the two wet spots. Add 40mm for a saddle for road biking and 20mm for mountain biking. If you are cycling indoors, approximate your riding position to determine how much you should add - if you are more upright, use the mountain bike numbers. There also are a number of sizing tools online, but, anecdotally at least, they are often more accurate for men than women. Finally, don't assume your sit bone width corresponds to your overall size - some small women have wide sit bones and vice versa. Measure it. 3) Get a professional bike fit. Your body geometry on the bike has a huge effect on where your pressure points are. Bike shops can do the fit or recommend someone who can. Make sure they check your height on the bike since having the saddle too high can cause intense pressure on your vulvovaginal area and sit bones. Also have your bike fitter check your reach since having to reach too far forward for the handlebars (or having the handlebars too low) can pull your vulvovaginal region onto the saddle.
Some bike shops have loaner saddles so you don't end up buying a bunch of saddles to find the best one for you. You also can ask your riding partners to permit you to try their saddles before you buy.
Some saddles you could try include:
WTB Deva ($48)
Ergon SMC Core Women ($160)
Get your body optimized for cycling
Make sure that you are using correct body mechanics when pedaling. In addition to having a professional bike fit, check a couple of things related to your biomechanics on your next ride. Enlist your riding partner to give you feedback since it can be hard to accurately assess yourself.
What is the position of your back when you ride? You should be keeping your core tightened and ride with a neutral spine. Basically, this means that if you find yourself in the yoga positions referred to as seated cat or cow, you're not in the most efficient position and increase your risk of pain in many areas of your body. Letting your pelvis rock forward (cat position) will put additional pressure on your vulvar tissues, including your clitoris. Ouch!
Are your hands falling asleep? Pay attention to the amount of pressure you are putting on your hands. Your hands should be relaxed and inline with your lower arm. A strong core should support you without requiring much pressure through your hands. If your core is weak and/or your position on the bike is too aggressive (hands too far forward or handlebars too low), you may experience numbness in your hands and/or pain in your elbows.
Are your hips rocking? When transitioning from sitting to standing, your torso should remain in the same plane as the bicycle. If your hips move from side-to-side during this movement, you need more strength work on your obliques and gluteal muscles.
What are your doing with your shoulders? Your shoulders should be relaxed, not up near your ears. Ideally, your shoulders should remain square to the handlebars when pedaling in a seated position. Don't allow your shoulders to rock left and right or tilt, particularly during seated climbing. If this happens, likely you need to strengthen your scapular stabilizers, which provide stability and mobility .
Where are your knees during your pedal stroke? You should ride with your knees inline with your feet. If your knees are angling out (or in), your riding will be inefficient, and you may experience knee pain. Make sure your bike fit was done well. Knees angling out can happen if your saddle is too low, for example. If the bike fit is good, consult a physical therapist to help you identify the issue.
Are you looking straight ahead? Be sure you keep your neck inline with your spine and relaxed. Riding with your head drooped or tilted back will increase your neck pain.
What about your elbows? Keep your arms bent and relaxed to act as suspension. You can't steer as well if your shoulders and arms are tense.
You can improve your bike stability and strength with some simple exercises. Remember that you may need to do more strength and flexibility work off the bike in-season and out of season than you did when you were premenopausal. Additionally, you should consult a physical therapist if you are having pain that does not resolve within a couple of weeks.
Front Walk-outs - Strengthen and stabilize your core. Place your hands on the floor and your feet on a Swiss ball. Walk out on your hands until you are in plank position and return.
Crunches and back extensions - More work on your core. Start doing these exercises on the floor, then move to a Bosu ball or a Swiss ball once you become proficient. Put your feet on a Bosu ball to make it even harder.
Side planks - Don't forget to work your obliques. Start doing these exercises on the floor, then move to a Bosu ball or a Swiss ball once you become proficient. Put your feet on a Bosu ball to make it harder.
Russian Twist - Another good oblique exercise. Do them with a medicine ball or barbell to make it harder.
Glute Bridges - Tight hip flexors can result in lower back pain. This exercise strengths your gluteal (butt) muscles, hamstrings, and transverse abdominis, which is the deepest muscle layer of your torso. Add a band around your knees to make it harder, straighten one leg at the top of the movement, extend one leg above you into the air at the start of the movement and hold it there throughout. Put your feet on a bench, chair, or box, put your feet and shoulders on a bench, chair, or box once you become proficient.
Push-ups - Do this compound body weight exercises to hit your chest, arms, and core. Start doing these exercises on the floor, then move to a Bosu ball or inverted Bosu ball once you become proficient. Put your feet on a Swiss ball to make it even more challenging.
Seated (Standing) Rowing (using bands or cable machine) - Hit those scapular stabilizers. Start while sitting on a Bosu ball. Move to standing on a Bosu ball or standing on 2 Bosu balls once you are familiar with the exercise.
Beware of the impact of hair removal (waxing or shaving) in your vulvar region. Stubble can increase friction and make in-grown hairs more likely. Additionally, GSM often makes the process of shaving or waxing more difficult since the tissues are thinner and more irritated. If you do shave or wax, pay attention to the timing of it compared with your riding plans to minimize irritation.
Take short breaks during your ride. If you don't want to stop, at least make sure you stand up and move into different positions regularly to relieve pressure.
Sitting on the saddle when riding over rougher terrain can cause more pressure on the vulvovaginal area and sit bones. Standing up in rougher areas can help. Many of my patients actually find mountain biking less chafing since there is much more movement off, on, and around the saddle compared with road biking.
Saddle Sore Treatment
The best treatment for saddle sores is prevention. But once a saddle sore has developed, you should wash the area well with a soap intended for sensitive skin (try Cetaphil or Cerave). Dry the area well by blotting (don't rub which could aggravate the sore.) Some people recommend covering the sore with a thin layer of petroleum jelly or diaper rash cream, but I find that most heal better when the sore is clean but uncovered. Avoid anti-bacterial soaps and ointments, like Neosporin, since they can alter the vaginal bacterial environment and cause vaginitis. Warm compresses, sitz baths, and loose clothing can make you more comfortable. Don't pick at the sore or try to "pop" it. You'll just irritate it and increase your risk for infection. Take a few days off the bike to let the wound heal - cross-training is good for you!
See your doctor if you’ve had the same sore for 7-10 days and it isn't healing, you keep getting recurring sores in the same area, your sore is excruciatingly painful, and/or the sore is infected (warm and red, contains yellow pus, and/or you have a fever or chills).
Now that you're comfortable on the bike, we'll talk next week about other changes in menopause that can negatively affect your ability to keep you cycling, running, etc. well during menopause.