From nutrition and reproduction to menopause, the most important patient topics at every stage of the female life cycle
Given that more than half of chiropractic patients are female, it is especially important to take into consideration the unique experiences women face in their physiological journeys during treatment. From puberty through the reproductive age to menopause and beyond, women undergo many biochemical, hormonal and biomechanical changes during the female life cycle.
Educating the next generation of chiropractors on how to differentiate women’s health from the health of the general population can have a positive impact on female patients’ overall wellness.
Puberty and spinal manipulation
As females age into the pubescent years, it’s important to know that girls who play sports or live active lifestyles have a greater chance of injuring themselves at certain points in their menstrual cycles.
Just before a female starts her period, her body experiences peaks of the protein hormone relaxin. This activates matrix metalloproteinases (MMPs), which degrade collagen and gelatin in specific areas of the body where receptors are present, including the ACL, acetabular labral cells and hip capsule or synovial cell. So, increased amounts of relaxin correlate with more musculoskeletal injuries.
In recent years, more research has been done about the relationship between menstrual cycles and ACL tears in women. One study1 found that female athletes with relaxin levels greater than 6.0 pg/mL were four times more likely to sustain an ACL tear. In addition, studies suggest that “oral contraceptives may offer up to a 20% reduction in risk of injury.”
Another menstrual cycle-related issue that females experience is dysmenorrhea, or severe cramps and pelvic pain that accompany menstruation. Although a common complaint among menstruating women, dysmenorrhea can cause disruption in a woman’s daily life by preventing them from going to work or school.
A 2016 study2 investigated the relationship between pelvic alignment and dysmenorrhea in women. While it has been found that kinesiology taping can alleviate the intensity of painful menstruation, this study specifically examined trunk imbalance, pelvic tilt, pelvic torsion, surface rotation, lateral deviation, kyphosis angle and lordosis angle. The results showed that participants who had menstrual pain displayed greater pelvic torsion. With dysmenorrhea, the value of pelvic torsion was 2.4 ± 1.8 degrees, while it was 1.7 ± 1.1 degree in those without. The good news is that spinal manipulation chiropractic manipulative reflex techniques (CMRT), and soft tissue therapy can often correct or minimize this condition.
Reproductive age and nutrition
As women reach reproductive age and consider having children, nutrition is extremely important.
It has been found that a mother’s prenatal diet and the child’s nutrition in the first two years of life play an immensely important role in the child’s neurodevelopment and lifelong mental health. Health risks like obesity, hypertension and diabetes during childhood and adulthood may be determined by nutritional status during this critical period.
According to a recent study3, “Calories are essential for growth of both fetus and child but are not sufficient for normal brain development. Although all nutrients are necessary for brain growth, key nutrients that support neurodevelopment include protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. Failure to provide key nutrients during this critical period of brain development may result in lifelong deficits in brain function despite subsequent nutrient repletion.”
Additionally, many essential vitamins and minerals are depleted during pregnancy, which is why it is suggested that pregnant women take a prenatal supplement. In addition to benefiting their child’s development, the vital nutrients in prenatals can help prevent postpartum depression (PPD). Studies4 have shown connections between PPD and deficiencies of n-3 fatty acids, folate, iron and zinc. Providing PPD screening and nutritional counseling to pregnant patients can largely benefit them, as they may not receive this type of support from their other health care providers.
During each trimester of pregnancy, a woman’s body undergoes significant stress and change. Besides some of the most common musculoskeletal complaints of low back pain, hip pain and round ligament pain, it’s important to know how a woman’s body is affected biomechanically at this stage of her life.
Specifically, during the second trimester, research has shown women are at a greater risk of falling. At this time, a mother’s belly grows rapidly, and she hasn’t had a chance to neurologically adapt. Her center of gravity has shifted, and this can affect balance and overall body stability. As she enters her third trimester, the risk of falling decreases since her body has had time to adjust. When performing a chiropractic adjustment on a pregnant woman in her second trimester, be especially aware and careful as she is lying down on and getting up from the adjustment table.
With adjusting a pregnant woman in the side-posture position, care should be taken with positioning. It is essential to keep the spine in a neutral position with adjusting the pelvis and lumbar spine. Torsion of the fascial planes of the pelvis and diaphragm places undue stress into the joints as well as the fascial leading to constraint within the uterus.
Just as greater levels of relaxin are present in the body at certain points in a woman’s menstrual cycle, relaxin levels also increase during pregnancy, causing pubic symphysis disorder (PSD). Here, relaxin loosens the grip of the ligaments in the joint between the left and right pelvic bones. This allows for extra movement, making it possible for a baby to be born. However, the weight of a fetus can put pressure on this joint, causing pain. The softening of the sacroiliac joints and the pubis symphysis may lead to hypermobility. While chiropractic adjustments can ease general pain and symptoms from pregnancy, additional support may be needed. In some cases, the use of a trochanteric or sacroiliac belt will provide support and diminish symptoms. The pain should subside within a few months after giving birth as the mother’s body stops producing relaxin and the ligaments tighten again.
Another common issue which arises during pregnancy is diastasis recti, the partial or complete separation of the abdominal muscles that meet in the middle of the stomach. Diastasis recti affects about 60% of women during pregnancy or postpartum. Chiropractors can evaluate a patient for diastasis recti by:
- Having the patient lie on her back with knees bent.
- Placing your finger at the umbilicus and pressing down gently.
- Instructing patient to lift their head about an inch while keeping shoulders on table. Note the engagement of the abdominal muscles.
- Repeat 2-2.5 inches above and below umbilicus, assessing for the following:
- Gap between muscles wider than 1 inch
- Depth of separation (how loose the tissue feels)
- Length of separation (where it starts and ends)
Further evaluation and imaging can be done with an abdominal ultrasonogram or abdominal CT scan. If a patient does have diastasis recti, there are exercises that can help strengthen the abdominal muscles and improve this condition. There are many programs designed to include modifications for diastasis recti. The following is one example
- Sit on the floor cross-legged with hands on belly. Take a big breath and let the belly fully expand.
- Exhale, suck in the belly muscles as far back as they’ll go toward the spine. Hold this position.
- Take tiny breaths. With each exhale, push stomach back further and tighter toward the spine.
- Do this exercise in several positions, making sure to keep the back flat: sitting cross-legged, sitting on knees, standing with knees slightly bent, on all fours or lying on your side in fetal position.
- Complete this exercise for 10 minutes each day, changing positions about every two minutes.
The female life cycle: menopause and post-menopause
As women age into menopause and post-menopause late in the female life cycle, one of the most common issues they face is pelvic floor dysfunction (PFD), which can cause urinary and fecal incontinence, and prolapse of the uterus or bladder, contributing to constipation or difficulties with urination.
While this topic can be embarrassing for patients to discuss with their doctors, it is our role as health care providers to make them feel comfortable while asking these important questions. This type of information can significantly impact a patient’s treatment plan and improve their quality of life.
There are some fantastic online resources for women’s health, including the American Chiropractic Association Council on Women’s Health, the U.S. Department of Health & Human Services Office on Women’s Health and healthywomen.org.
It’s important to consider where a woman is in the female life cycle and the specific issues and challenges she could be experiencing during that time. Informed doctors create more robust care plans that lead to better patient care, which is the ultimate goal.
MARY UNGER-BOYD, DC, DICS, CACCP, graduated from Logan College of Chiropractic in 1997. In addition to owning a private practice in the St. Louis area, she is an associate professor at Logan University and has taught Sacro Occipital Technic (SOT®), Logan Basic Methods, Pediatrics, and myofascial techniques for more than 20 years. Most recently, in 2021 she was named International Chiropractor of the Year by the International Craniopathic Society and the Sacro Occipital Research Society International (SORSI). Learn more at logan.edu/faculty/mary-unger-boyd-dc-dics-caccp.