I could see her struggling to walk along the corridor as I disembarked the plane on the long-haul flight between the United Kingdom and New Zealand recently.
She was a woman in her early to late 50s and noticing her discomfort, and always with menopause and changes to the lymphatic system on my mind, I was I was drawn to look at her ankles. They were swollen and ‘puffy’.
My thoughts turned to whether she understood that her fluid-balance was affected by both oestrogen and progesterone changes during her midlife menopause transition.
The long flight wasn’t helping her either, and memories of my own swollen, aching calves and feet on long flights when I was in my late 40s and early 50s, came flooding back. Â
When we arrive in mid-life, oestrogen and progesterone changes have important effects on body fluid regulation, due to changes associated with the ageing of the cardiovascular and lymphatic systems.Â
Numerous women end up with aching swollen legs and ankles, tightness in their breasts and some may have also experienced a protruding gut during or beyond menopause.
Many don’t understand that these changes are associated with the ageing of their lymphatic system as they move through menopause. Some may find relief if they take progestin in HRT, but oedema or tissue swelling is an issue that needs to be discussed with their Doctor as well.Â
The type of swelling that may arrive during menopause is called Lymphedema and if the swelling occurs in the abdominal cavity, this is called ascites.
Both situations require women to see their Doctor, due to impaired lymphatic drainage and many women may benefit from seeing a Lymphatic Drainage Specialist too, or having massage therapy with a qualified Practitioner who understands the changes to the lymphatic system during menopause. It’s a topic I talk about in the MyMTâą Education Practitioner Course and the MyMTâą Education Menopause Weight Loss Coach Course too.
Whilst the effects of fluid regulation in middle-aged and older women are controlled by the kidneys, very few women realise that oestrogen changes in menopause also cause some sodium retention, which of course, makes them feel a bit swollen and bloated.
However, despite all the attention paid to oestrogen changes in menopause, the role that Progesterone plays in fluid retention and fluid balance is equally important.
Progesterone is the primary steroid involved in blood pressure changes around the time of the menopause and is therefore, important for fluid regulation as well. (Stachenfeld, 2014).
But there is another issue too – our lymphatic system is ageing. As such, the walls of the lymph vessels begin to lose some of their elasticity. In both blood vessels and lymphatic vessels, this is known as âvascular stiffnessâ.Â
Similar to the veins in the cardiovascular system, there are also one-way valves, If these valves also lose some of their elasticity and tensile strength in the walls, then this can cause some leakage of lymph fluid and waste products into nearby tissues. Unlike the cardiovascular circulatory system, lymph doesn’t have a heart to pump it around the body and return the fluid back to the venous system.Â
Hence, when women are sitting or standing a lot or taking a long-haul flight, the return of blood back to the heart from our lower extremities isnât as efficient. We need to help it along otherwise we get swollen ankles or as itâs medically known, oedema.
Vascular stiffness contributes to increased fluid retention and risk of blood clots during menopause for many women.
Leg and ankle oedema is a sign of blood pooling in the veins as well as an inefficient lymphatic system. It is a well-known problem among passengers during and after long-haul flights as well as for women who are on their feet for hours on end.Â
One of the very few studies in understanding fluid retention in long haul flights and the risk of blood clots was done in 2003 by a group of researchers in America.
With more and more people flying for work or recreation, the incidence of a condition called Deep Vein Thrombosis (DVT) had sky-rocketed. In the past few years, interest has focused on a possible causal link between deep venous thrombosis (DVT) and long-haul flights. Â
Earlier studies (prior to 2000) were mainly done under simulated conditions without the high humidity levels on real flights and without the lower oxygen levels that are present on the air craft as it travels at thousands of metres above earth.
Even in these simulated conditions the average fluid accumulation is around 130 mls in the lower leg and ankles after 12 hours of flying.
This is also an important consideration for women who have had treatment for breast cancer, as Sylvie had (below). Following chemotherapy, fluid may not drain away in the normal way, so the area swells. About 1 in 5 people (20%) will have lymphoedema of the arm after breast cancer treatment that includes surgery to remove lymph nodes. (Cancer Research UK, 2024)Â
But back to the study on flying and fluid retention. With the variety of measurements that were conducted in the study, the researchers found considerable retention of fluid in lower extremities and the head.
They measured skin thickness in the forehead, the tibia (front of shin) and just above the ankle. A number of bloods were taken to look for clotting changes and subjects were allowed to drink 1 glass of alcohol. They ate the meals and drank the water offered with meals.
Not one person showed signs of DVT. But what researchers did find was something more interesting to me and I hope you too, even if you donât fly much. Itâs especially important for those of you who are exercisers as well as those of you who are experiencing swollen ankles during your menopause transition.Â
Researchers found that all the subjects retained water in the superficial tissues, thus increasing the thickness of the tissue on average 1.5mm. This calculated to fluid retention in each lower leg of about 190mls. That’s a lot of additional fluid that our lymphatic system has to manage if we fly long-haul!
Over 1/3 of the superficial layer just under the skin consists of water that is continually exchanging in deeper tissues and cells, so this superficial layer was affected the most.Â
What was most important however was this fluid hung around for several days after the flight. And this increased blood viscosity or thickness (measured as haematocrit). It’s this that promotes blood clotting or thrombosis for at least a week after a long-haul flight.
The recommendation by the researchers is that all travelers on long-haul flights should wear individually adjusted support stockings before and after the flight. I would add to that, if you or your clients, are standing all day, and have been experiencing swollen ankles and fluid retention, or if women are on treatment for breast cancer, then yes, get some support stockings.
Especially, with the need to commence exercise again after any cancer treatment or long-haul flying, which is also needed to stimulate lymphatic drainage, especially if weight loss is the goal.Â
This is also the premise of why you now see athletes wearing support socks when training and competing. They are trying to decrease swelling and inflammation in tissues. But thereâs more to this story too.
With researchers finding that fluid retention in lower extremities (and the head), stays around for a few days, and risk for clots and blood pooling remaining high, itâs important to shift that fluid and improve blood flow back to the heart.
Changes to the Lymphatic System with Age
The main changes that occur in our ageing lymphatic vessels are:
- Loss of around 20% of their contraction strength (just like our blood vessels).
- Around a 70% decrease in contraction frequency.
- Increasing loss of lymphatic muscle cells which is linked to oxidative stress (inflammation). Lymphatic muscle cells are linked to contraction of our muscles and propel lymph through valves to the draining lymph nodes.Â
- A reduction in the levels of proteins that regulate muscle contraction.
- A thinning of the lymphatic vessel walls.
As such, we need to better manage and help our lymphatic system as we move through menopause. So, here are 3 things you or your clients can do:Â
- Because the lymphatic vessels donât contract as efficiently as they used to, then having increased plant sources of nitric oxide is important. You can add beetroot (beets) and celery to your diet or juice them instead.
- Learn to breathe better. I talk about breathing in all of the MyMTâą Education Practitioner programmes as this is beneficial to enhance lymphatic drainage.
- The lymphatic system works closely with the nervous system, hence, even a stressful day can affect lymphatic drainage. This is also why improving breathing helps to stimulate the lymph vessels to do their job of removing inflammatory proteins and dangerous toxins that have myriad deleterious effects around the body.Â
- Get moving (preferably in the morning). As part of the cardiovascular network, the lymphatic system doesnât have a pump like the heart. It relies on movement, massage, muscle contraction and improved breathing to function.
I also talk about this in the MyMTâą Education Menopause Weight Loss Coach Course for you and take you on a deep dive into movement for weight loss.
A Poorly Working Lymphatic System Cannot Remove Toxins
All hormones, nutrients and waste products going to and from the cells deep in the tissues, must pass through the interstitial or extracellular matrix (the areas between the tissues and blood vessels). This depends on a reliable, functioning lymphatic system.
If the lymphatic channels cannot remove toxins properly, no hormone medications, no gene, no enzyme, and no molecule is going to work optimally. As such, there will be deposition of waste products into the tissues. This is why many women may feel bloated, experience tissue swelling and/or experience an increase in cellulite during the menopause transition.
When we know that our lymphatic system is so important to our clients’ wellbeing and energy during menopause, then you can support them to drink more water, put their feet up when they can, improve their breathing, wear flight stockings (even at work) and of course, get some massages or do some self-massage.
Then for those women who are regular exercisers, the same rules apply. Exercise (especially, resistance training), may increase blood pressure and cause interstitial tissue swelling.
If women find that their recovery after exercise isn’t as efficient as it used to be, then recovery strategies, including massage therapy may be helpful. Swimming is also another exercise intervention that can be encouraged.Â
It would be my privilege to share my knowledge with you when you join me on any of the Certified MyMTâą Education Programmes. You can meet me in the video below.Â
Dr Wendy Sweet, PhD/ MyMTâą Founder & Coach/ Member: Australasian Society of Lifestyle MedicineÂ
References:Â
Inoue, K., Maruoka, H. (2017). Effects of simplified lymph drainage on the
body: in females with menopausal disorder. J. Phys. Ther. Sci. 29: 115â118.Â
Iwakiri, Y. (2016). The Lymphatic System: a new frontier in hepatology. Hepatology, 64(3), 706-708.
Knight J. & Nigam Y. (2020). The Lymphatic System 1: Structure, Function and Oedema. Nursing Times [online]; 116: 10, 39-43.
Shang T., Liang J., Kapron, C. et al. (2019). Pathophysiology of aged lymphatic vessels. AGING, Vol. 11, No. 16, 1-12.
Stachenfeld N. (2014). Hormonal changes during menopause and the impact on fluid regulation. Reprod Sci. May;21(5), 555-61.
Zolla, I., Nizamutdinova T., Scharf, B. et al. (2015). Aging-related anatomical and biochemical changes in lymphatic collectors impair lymph transport, ïŹuid homeostasis, and pathogen clearance. Aging Cell, 14, 582â594