BACK T O BASICS AND THE THREE DIMENSIONS OF
BREA THING
Learning any of these techniqu es begins with integrating light, slow, deep
nasal breathing. It forms the basis for healthy breathing and is developed in
the exercises in this book. Once you are familiar with how a healthy
breathing pattern feels, you will be much freer to enjoy more specific
breathing techniques. Becoming aware of your own breathing and that of
your partner opens the way to many avenues of exploration. For instance,
deep, mindful breathing can provide a way to relax and get in the mood
before foreplay . By becoming conscious of the breath as you bring air into
your belly , you can bring your awareness to the breath as it travels right
down into the genitals. This awakens the area, infuses it with energy, and
stimulates vasod ilation, increasing blood flow to your sexual organs. While
there are plenty of advanced methods out there, which are best approached
with a qualified teacher , there are also simple things you can do for better
sex. When you breathe through your nose, you enjoy greater oxygen  uptake,
harness nitric oxide, and engage  your core for better movement. Diaphragm
breathing activates muscles that stretch between the coccyx and pubic bone. These are the muscles that contract during orgasm. By improving your
BOL T score, you are less likely to get out of breath. Just as increasing the
BOL T score can help alleviate breathlessness during exercise, reducing
your sensitivity to blood CO2 will help impro ve your stamina during sex. This can be especially valuable in the control of asthma symptoms and in
alleviating the fear of exacerba tions. It may also provide relief for people
with epilepsy , because hyperv entilation during sex is known to trigger
seizures for some.103 In this context, Breathe Light  exercises and breath
holding following an exhalation  to improve the blood biochemistry should
first be practiced outside of the bedroom.It’s common to tense up and hold the breath as orgasm approac hes, but
scientists have proven that hypoxia reduces sexual arous al.104 This
tendency to hold the breath can often be caused by self-con sciousness. Opening the mouth in the lead up to orgasm means you’re going to make
more noise. Many of us are conditioned by perceptions of how sex should
sound. We alter our sexual groans and grunts into moans and sighs, perhaps
to reflect what we’ve heard in erotic films. But it’s important not to imitate
the sounds you think are expe cted. This can repress orgasm and create
tension in the breath. Instead, if you continue breathing deepl y when the
orgasm begins, you will enjoy a full-body sensation. The idea of breath holding during sex may become a little confused
with the idea that some peop le use behaviors such as asphyxiation or
hanging to induce arousal. Unfortunately , the severity of these “games” to
become aroused may gradually increase as tolerance to hypoxia develops,
so these  practices sometimes result in accidental death. A 2016 study
reports that the mechanisms by which these methods create heightened
pleasure for some people are complex and unclear ,104 and, although this
relates to breathing practices and sex, there is not enough evidence to
explore them here. PRACTICING ORGASMIC BREA TH
Breath retention is a feature of the Tantric practice of healing breath.105
This exercise has a ratio of 1:4:2 for inhalation, breath hold, and exhalation. The retention is four times longer than the inhalation, and the exhalation is
twice as long. Breathe in for one second or heartbeat, hold for four seconds
or four beats of the heart, and exhale for two seconds or two heartbeats. To
practice this, you can gradual ly increase the length of the inhalation,
maintaining the ratios between in-breath, retention, and out-breath. It is
important not to practice too intensely to begin with. If you get dizzy or feel
your heart beating too fast, stop the practice and breathe normally . The exercise asks that you don’t count mentally , because this takes the
focus away from  the breath. Instead, count using the heartbeat, or practice
while walking, using the paces to keep track. In other words, practice the
breathing during everyday life so that you feel the benefits during sex. Theobjective is to slow the breathin g and to instill a profound level of calmness
in the mind. This exercise is for men to practice in the lead up to orgasm to
delay ejaculation and for women to deepen their orgasm. The best way to
ensure you are able to bring your attention to the breath during sex, when
you are bound to have your mind elsewhere, is to practice the breathing
exercises for developing control of your breathing during day-to-day life. Breath retention is also used in the yogic practice of orgasmic breath,
sushumna nadi Pranayama .106 This exercise is designed to pull energy
from the base of the pelvis up through the chakras, filling the body with life
force. It involve s working the muscles of the pelvic floor and focusing on
the breath and the physical body to reach a meditative or orgasmic state. It
uses a technique  of reduced mouth breathing similar to sipping through a
straw . According to Courtney Avery, creator of the San Diego sexual-
health-based yoga business Intimate Health, LLC, “the more you practice
meditation, the more you train your brain to come into an orgasmic state.”
When you add breathwork and activation of the muscles, “magic happens.”
With practice, it becomes possib le to bring yourself to full-body  orgasm
using only the breath and muscle engagement. You should avoid practicing
this technique during menstruation or if you are experiencing pelvic pain. • Sit comfortably in an upright posture and breathe normally . • On your next inhalation, purse your lips as if you were sipping through a straw . • Breathe in through your pursed lips and engage your pelvic floor muscles. Keep your
buttocks relaxed and your muscles engaged. • Continue to breathe in as if you are sipping, while being aware of the muscles and
the energy that is lifting through the spine. • Pull in your lower abdominal muscles and tuck in your belly button. • Relax and widen your chest and shoulders. • Lengthen your neck and tuck in your chin. • When you feel “full up” with air , seal your lips and hold your breath, engaging all the
muscles along the length of your spine. • When you are ready to release, slightly open your mouth. V isualize the energy
pouring from the top of your head down the front of your body , gently softening your
muscles as it flows down. • Relax your neck, shoulders, belly , and abdominal muscles. • Finally , release the pelvic floor muscles and surrender . • When you have finished, relax, and breathe normally for a few breaths, remaining in
a state of calm relaxation. • Repeat the exercise up to 13 times.The key lies in practice. By beginning to explore the breath by yourself,
you can prepare to share new experiences with your partner . Try practicing
nasal breathing before jumping into bed. Pay attention to your pelvic floor
muscles. It allows you to engag e those muscles and heightens sensation in
your genitals, increasing pleasure. You can also experiment with exercises that synchronize your breath
with your partn er’s. You can do this sitting face to face, holding hands,
hugging, touching foreheads—anything, as long as you are physically
connected. You can try lying down and embracing. Again, the practice uses
gentle breath retention:
• Exhale all the way out. • Slowly inhale together , breathing from the diaphragm. • Pause together at the top of the breath, feeling full of life-giving energy . • Gently exhale together , all the way out. • Pause again at the bottom of the exhalation, feeling safe and empty . • Slowly inhale. • As you breathe, imagine the breath carrying energy throughout your body . • Repeat the exercise as many times as you like. This exercise simply involves mindful breathing, exhaling and inhaling
through the nose, breathing from  the diaphragm, and gently bringing your
breath into sync with your partner . If you want, you can continue this as you
make love, exploring how the calm feeling of breathing together enhances
intimacy . OceanofPDF .comHCHAPTER TWEL VE
YES, BREATHING IS DIFFERENT FOR
WOMEN
AN UNHELPFUL BIAS
istorically , in most physiology literature and, indeed, across every
field of science, research has predominantly focused on male
subjects. This gender bias can be seen in many areas of study and in
trials using both humans and animals.1–5
However , it is now known that gender differences do affect breathing
control and vulnerability to some respiratory diseases. For example, women
recover better after a severe episode of hypoxia. There are also differences
in sleep apnea1 and heart rate variability .6 The reasons are not properly
understood, but the disparity between sexes might explain many otherwise
contradictory findings. It has been said that where the influence of gender is
disregarded, the progress of scientific knowledge can only be held back.7
Another anomaly is that, when women take part in studies, researchers
often fail to account for the fluctuations in hormone levels that occur during
the menstrual cycle.1,8 This is despite  the fact that the menstrual cycle is
one of the most important biological rhythms that modulate the
physiological processes of a living being. Airflow and gas exchange are
known to be among the many vital functions that change during the
menstrual cycle9. Studies have demonstrated, for example, that women’ s
ventilatory respo nses to hypoxia and hypercapnia vary throughout the 28-
day cycle directly parallel with hormonal fluctuations.In all honesty , I avoided this topic in my own work for many years,
largely because as a man I didn’ t feel qualified to discuss it. However , I am
aware of the growing frustration that women’ s health, particularly in regard
to menopause, has been brushed  under the carpet for too long. I wanted to
address this by sharing research and connections to the three dimensions of
breathing that might be helpful. In my coaching, I work with as many
women as men, and their experience with breathwork is incredibly
informative. Also, I always aim to be guided by the questions people ask
me and to find ways to answer them. In putting this and the next chapter
together , I am grateful for the guidance, assistance, and experi ence of two
female medical doctors, along with help from several other brilliant women. THE MENSTRUAL CYCLE
There are several “phases” to the menstrual cycle, which are important to
recognize in understanding the issues surrounding breathing in women. Some are familiar , but the changes through the month are mainly invisible. Unless you are trying to conceiv e (or trying not to), you may not have given
much thought to how the cycle works. The different stages and events in the
cycle are:
• Menstruation:  This is your “period.” The lining of the uterus sheds and you bleed. During this time, levels of estrogen and progesterone are low10. • The follicular phase:  This is the time between the first day of your period and
ovulation. Estrogen rises as your body prepares to release an egg. • The proliferative phase:  The lining of your uterus builds up again after your period. • Ovulation:  The egg is released from your ovary midcycle. Estrogen levels peak just
before this happens and drop shortly after . • The luteal phase:  This is the time between ovulation and the start of menstruation. Because this is the stage when the body prepares for a potential pregnancy ,
progesterone is produced, peaks, and then drops. This is the phase most associated
with hyperventilation as progesterone levels fluctuate. • The secretory phase:  The lining of the uterus produces chemicals that will either
support an early pregnancy or prepare the lining to break down and shed during
your next period. WAYS BREA THING IS DIFFERENT FOR WOMENThe regulation of breathing is complex and affected by many factors,
including gende r. In 1905, it was first found that the resting pressure of
blood CO2 was around 8% lower in women than in men,1 and this finding
has since been confirmed. On average, women have lower ventilation than
men, in part due to smaller airways, rib cages, and lung volumes, as well as
diaphragms that are around 9% shorter .11 Ventilation was first linked to
levels of sex hormones in 1904 when Adolf Magnus-Levy , a pioneer in the
study of human metabolism, observed that women hyperventilate during
pregnancy1. Later, it was found that women also hyperventilate during the
luteal phase of their menstrua l cycle, and research confirmed that the
cyclical variatio ns in ventilation are no longer present in postmenopausal
women.1 This last fact clearly links changes in breathing to fluctuations  in
sex hormones. A 2006 study reported that the female hormone progesterone, which is
known to stimulate breathing, might contribute to respiratory changes seen
at different times of the menstr ual cycle.12 General respiratory function is
known to be influenced both by the different phases of the menstrual cycle
and by common  hormonal and metabolic states.11 This can have an impact
on health. When the first occurrence of menstruation is early (early menarche), the
likelihood of poor health in later life increases, with a higher risk of
illnesses, including asthma, cardiovascular disease, and comprom ised lower
lung function.11 The instances of poor respiratory health in girls who reach
puberty early may be due to factors such as higher body mass index, which
can cause early menarche. However , research suggests that early onset of
puberty may affect airway and lung development, because to some extent,
puberty signals a termination of growth.13
The menstrual cycle influences disorders as varied as epilepsy , bipolar
disorder , migraine, and rheumatoid arthritis.13 Respira tory symptoms such
as breat hlessness, coughing, and wheezing vary considerably over the 28
days. These become worse between days 10 and 22 (the midluteal to
midfollicular phases),13 possibly due to the influence of hormonal changes
on the airways.13 This explains why asthma severity fluctuates during themenstrual cycle, and why irregular menstruation is associated with a higher
risk of asthma.13
Increasingly , evidence indicates that sex hormones can either contribute
to disea se pathology or serve as protective factors against lung disease. They regulate the development of the lung and airways in unborn babies,
and it is thought that they play a part in the varying advers e effects of
antenatal smoking on lung function. The lung function of adult men is more
severely affected  by exposure to smoking in the womb than that of women. Scientists also believe that sex hormones may cause changes in the growth
pathway of the lungs in respon se to in utero exposure to smoking.14 This
would suggest that males and females have a different susceptibility to
inflammation from an early stage of development. Breathing pattern disorders are also almost twice as common in women,
possibly due to the hormona l influences we’ve already touched on. Progesterone stimulates the respiratory rate, meaning that in the luteal phase
of the menstrual cycle CO2 levels drop by around 25%.15 When CO2 levels
are already low, any extra stress  can cause breathing to speed up even more,
and this creates a range of symptoms that are commonly interpreted as
premenstrual syndrome.16
In 2000 , a study in the Journal of Orofacial Pain  reported increased
respiratory rates  during the luteal phase of the menstrual cycle, when
progesterone levels increase.17 At the same time as breathing increased,
pain thresholds lowered. This indicates that cyclical respiratory changes
may also influence pain perception. PAIN CONDITIONS AND BREA THING IN WOMEN
FIBROMY ALGIA
Fibromyalgia predominantly affects women,18 and it changes  during the
menstrual cycle. In 2007, researchers found that several participants
fulfilled the diagnostic criteria for fibromyalgia during the luteal phase of
their cycle, but not during the follicular phase. As pain is the most common
diagnostic measure of fibromyalgia, this is another indicator that painperception differs depending on the concentration of sex hormones in the
body . Dysfunctional breathing can aggravate pain associated with
fibromyalgia, especially in tender areas of the upper body .19 This can lead
to fatigue and difficulty carrying out normal daily activities. A 2017 paper
assessed the impact of an eight-week functional breathing program on 18
patients with fibromyalgia.20 Thresholds for pain tolerance increased in all
the participants after one month , which means that pain was reduced. Sleep
quality , duration , and efficiency also improved as a result of the breathing
practice.20
A 2018  study examined the effects of breathing exercises on pain
tolerance in tender points and on the quality of life for fibromyalgia
patients.19 The trial involved 35 women aged between 34 and 67 years, all
with fibromyalg ia. The women were randomly assigned to a breathing
exercise group or to a control group. The breathing exercise participants
practiced for 30 minutes every day for 12 weeks. At the end of the 12
weeks, the women who had practiced breathing exercises showed
significant improvements, experiencing much lower levels of pain and
fatigue and becoming more able to engage with daily life. The researchers
concluded that breathing exercises provide a “real and effective
intervention” for women with fibromyalgia. A 2019 trial, also examining fibromyalgia, looked at the effectiveness
and safety of patient self-ma nagement in the form of unsupervised
breathing exercises.19 After 12 weeks, during which 51 women practiced
the exercises, no statistical differences were found between supervised and
unsupervised participants. Ther e were, however , added improvements in
pain in those women who had practiced the exercises under supervision,
suggesting that proper guidance in performing breathing exercises is
beneficial. Faulty breathing does not cause fibromyalgia. However , it does play a
significant role in the develo pment and persistence of chronic pain
conditions.15 For instance, biomechanical overuse combined with the
biochemical changes typical of breathing pattern disorders can have a
significant impact on pain and fatigue.21 In fact, most  people with
fibromyalgia show signs of severe dysfunctional breathin g. Becausebreathing is already dysfunction al, these women are constantly teetering on
the brink of symptoms. Any further cyclical drop in CO2 is likely to push
the body over the edge. That is why pain often becomes much worse during
the luteal phase of the menstrual cycle. It is also why the worst symptoms
could be alleviated or even eliminated with correct breathing habits.22
Research shows that 27% of people with fibromyalgia hyperventilate,
and 60% of fibromyalgia patients suffer with dyspnea  (breathlessness).23
Also, breathlessness is far more prevalent in the patients with the highest
levels of pain.24
Naturally , fibromyalgia can trigger anxiety . This is not to imply that
symptoms are “all in the mind,” but anxiety about the condition and anxiety
triggered by dysfunctional breathing itself can certainly aggrava te pain and
fatigue. Because pain causes anxiety and increases the breathing rate, it is
likely that by normalizing the breathing pattern, pain symptoms would
reduce. Once a pattern of dysfunctional breathing exists, a variety of triggers
can create a vicious cycle, causing pain, fatigue, and other symptoms,
including anxie ty and panic attacks. These, in turn, contribute to poor
breathing patterns. Poor oxygenation of the tissues during hyperventilation
contributes to the development of myofascial trigger points.21 And because
the working of the diaphragm is linked to the functioning of the pelvic
floor , dysfunctional breathing exacerbates stress incontinence, other
genitourinary symptoms, and pain in the pelvic region—all common in
fibromyalgia. The fascia around  the psoas muscle—a hip-joint flexor that
runs from the lumbar spine through the pelvis—connects directly to the
diaphragm.25 Women  who suffer with chron ic pelvic pain often have poor
functional movement and tend to breathe predominantly into the upper
chest.26
Many people with chronic pain suffer with medically unexplained
symptoms. They  may be diagno sed with fibromyalgia, chronic  fatigue, or
“bodily distress syndrome.”27 Low blood CO 2 and feelings of air hunger are
typical of all these patients.28 As a result, scientists believe that levels of
CO2 should be asses sed as part of the patient evaluation.24 At the very least,
it needs to be recognized that a significant number of fibromyalgia patients
hyperventilate. Given that hyperventilation is considered at the severe endof breathing pattern disorders, it is logical to assume that a much higher
number have poor breathing patterns. Leon Chaitow , after 50 years clinical experience working with
fibromyalgia patients, estimated that more than 90% breathe
dysfunctionally .15 Functional breathing training is an efficient and cost-
effective treatment to achieve reduced levels of pain and fatigue . The ability
to fully exhale is at the root of functional breathing. Without this
understanding, it is not possible to inhale correctly . Chaitow cautions that
this is not a quick fix. Between 12 and 26 weeks of work may be needed,
and it takes patience to achieve behavioral change.15
In chronic pain conditions, it is particularly important to take things
slowly in the beginning. Approaching breathing exercises too intensively
can actually set you back. Begin the practice gently . If you suffer with
fibromyalgia, your sensitivity to CO 2 may be very high. This can trigger too
much air hunger , muscular tension, and feelings of panic. As your tolerance
to CO 2 increases and your BOL T score improves, these feelings will ease. TEMPOROMANDIBULAR JOINT DISORDER
In Chapter Six, on pain, we looked at temporomandibular joint disorder
(TMD) and its relationship to dysfunctional breathing. Howev er, there is
evidence that a link also exists between the condition and female sex
hormones. Gender differences in pain sensitivity are sometimes dismissed as
matters of psychosocial and social conditioning29. Increasingly , however , it
is believed that hormonal and other biological factors contribute30,31. Temporomandibular joint disorder is around 1.5 to 2 times more prevalent
in women32 and can be much worse than in men. Anatomically , women
produce much higher levels of pressure in the temporomandibular joint
when clenching than men33. It was traditionally thought that abnormalities
in the alignment of the jaws and teeth are the primary cause of TMD, but if
this were the case, the condition should be just as common in men as
women. The estrogen hormone,  estradiol (E2), which is the primary female
sex hormone,34 has been found  to be a risk factor for temporomandibular
pain in rats.35 Incidence of TMD in women is thought to peak between 20and 40 years, coinciding with reproductive function and decreasing in
menopause when estrogen production declines.36
Hyperventilation during the second part of the menstrual cycle can
contribute to temporomandibular pain. This is partly due to
hyperventilation-induced adapta tions in posture and to changes in the blood
acid-base balance. For instance, the respiratory alkalosis that occurs when
blood CO2 drops is known  to trigger musc le pain, while overbreathing can
cause a forward head posture. Postural adaptations including a forward-thrust of the head and rounded
shoulders are common among people with dysfunctional breathing patterns. This often begins in childhood  due to open mouth breathing caused by
swollen adenoids. Equally , there  is a chicken-and-egg scenario where poor
posture from sedentary desk work can adversely impact breathing.37
According to a 2019 article on the website Spine Universe , which describes
sitting as “worse  than smoking” in terms of health, 70% of people spend six
or more hours a day sitting down.37
A forward head posture contributes to TMD because it reduces
“freeway space.” Freeway space is the distance between the upper and
lower teeth when the jaw is in its rest position. When the head is pushed
forward, the back teeth connect and pressure on the temporomandibular
joint increases. Restoring freeway space is considered important in treating
TMD.29
As with other pain conditions, symptoms of TMD fluctuate cyclically in
line with the menstrual cycle. In the luteal phase of the cycle, estradiol and
progesterone are released. Both hormones cause blood CO2 levels to fall,38
affecting the amount of air breathed per minute.12 The pain associated with
temporomandibular disorder increases toward the latter part of the
menstrual cycle, peaking in the first three days of menstruation when
progesterone levels increase and then decline. A second spike in pain
coincides with ovulation,36 when estrogen levels fluctuate. The worst pain
corresponds with low or changin g estrogen levels.36 While the influence of
sex hormones on pain is still relatively unstudied, the general consensus is
that changes in breathing patterns across the menstrual cycle likely
contribute to temporomandibular joint pain.MIGRAINE
Temporomandibular joint disorder is a risk factor for migraine39 and tension
headache.40 At the same time, psychological conditions such as depression
and anxiety are common to people with temporomandibular pain,
migraines, and tension headaches.41 It has been suggested that rather than
the problem in the jaw causing  the headache or migraine, these disorders
develop and progress via the same underlying imbalances in the central
nervous system.39 This may be why relaxation techniques that influence the
nervous system are effective for the relief of both migraine42 and tension
headaches.43
A case describ ed in the Journal of Neur ology , Neur osurgery &
Psychiatry  in 2004 demonstrated that hyperventilation,44 both during rest
and following physical exertion, “may cause severe, acute, ‘explosive’
headaches” and that these could  be prevented with relaxation exercises and
physical therapy . The precise cause of the headache in this case study was
not identified, but researchers suggested that breathing exercises may
prevent excessive hyperventilation after exercise, although they “would not
prevent physiological exercise induced hyperventilation.” They suggest that
hyperventilation should be considered in all patients whose headaches are
triggered by exertion. It is important to remember that you can prevent exercise-induced
hyperventilation by practicing nasal breathing while exercising and by
improving your BOL T score. You can also make a conscious effort to bring
your breathing and heart rate under control after exercising with a slow
breathing practice. Hypercapnia (high blood CO2) has been found to stop the onset of
migraines by increasing cereb ral oxygenation—by dilating the blood
vessels in the brain. Researchers in a 2018 pilot study tested to find out
whether a self-administered partial rebreathing device would be effective
for migraine patients.45 A partial rebreathing device is exactly what it
sounds like—a machine through  which the patient “rebreathes” exhaled air,
which has higher levels of CO2 than room air. To some extent, the same
effect can be achieved by wearing a face mask or covering.Eight women and three men with an average age of around 35 took part
in the trial. They each self-administered either the rebreathing device or a
placebo in response to migraine attacks. The results showed that the partial
rebreathing device increased end-tidal CO2 by 24% and maintained oxygen
saturation at over 97%. The intensity of headache symptoms after two hours
was significantly less with the rebreathing device. What’ s more, the device
became more effective the more  it was used, with even better results with
consecutive treatments. There were no adverse reactions, and side effects
were nonexistent or mild. The researchers concluded that induced
hypercapnia presents a promising alternative or add-on treatment for
migraine patients and further work should be done to investigate the
benefits in a lar ger population. The fact that the efficiency of the rebreathing device increased from one
treatment to the next corresponds with what we know about reduced-
volume breathing. Regular pract ice of breathing exercises to increase levels
of CO2 results in reduc ed sensitivity to CO2, and lighter , slower breathing,
as evidenced by a higher BOL T score. The 2018 hypercapnia study was preceded nearly 40 years earlier by an
investigation into the relationship between migraines and blood CO2.46 A
1980 paper described the effects of CO2 on blood vessel s and circulation in
the brain, noting that anesthetists “regularly hyperventilate patients to
reduce brain volume during neurosur gery.” The researchers hypothesized
that, if migraine falls into two categories, dilatory and constriction-based,
retaining CO2 during sleep could trigger migraines by dilating the blood
vessels, or hyperventilation provoked by “excitement, anxiety , or
expectation of physical or sexual activity” could trigger migraines by
constricting the blood vessels. The results showed that hyperventilation occurred at the peak of the
migraine, making the attack seem worse than it was. The researchers
suggested that not only was the perception of the migraine heightened but
symptoms were increased by the constriction of the blood vessels caused by
the hyperventila tion. This suggests that CO2 may play a part in the onset
and persistence of migraines. In 2015,  another paper in Medicine  found a correla tion between sleep-
disordered breat hing and migraine in adults but not in elderl y people.47While more research is needed, it is thought that poor breathing patterns
during sleep could be either a trigger or a predisposing factor for the
development of migraines. None of these papers mention the connection between the incidence of
migraine and the menstrual cycle.48 Various other studies have identified an
increase in the risk of migrain e without aura on the first two days of
menstrual flow, a reduced risk coinciding with the time of ovulation, and
much more prolonged headache s three to seven days before menstruation.48
(Aura is a common neurologic al symptom of migraine usually involving
visual disturbances such as flashing lights before the eyes, tunnel vision,
and temporary blind spots.) In one 2004 study , researchers observed that women were 25% more
likely to suffer from a migraine in the five days before their period, with the
risk increasing to 71% in the two days before, peaking on the first day of
menstruation and on the next two days. This was confirmed in 2007 when
scientists found that the highest occurrence of migraine coincided with the
first three days of a woman’ s period.49 Menstr ual migraine is linked to
increased menstrual disability and distress—a fact that recently led to the
development of specific diagnostic criteria for menstrual migraine.48
Pure menstrual migraine and menstrually related migraine are slightly
different. To characterize the migraine type, menstruation is defined either
as bleed ing as part of the norm al menstrual cycle or as the withdrawal of
progesterone in women who take combined oral contraceptives  or cyclical
hormone replacement therapy . Pure menstrual migraine is a migraine
without aura that occurs on the first day of menstruation or the two days
either side of it, in two out of three cycles, with no incidence at other times
in the cycle. Most women will suf fer from menstrually related migraines—a
migraine without aura that occurs at other times of the month.48
Interestingly , the estrogen steroid hormone estradiol, which is
implicated in temporomandibula r joint pain, is also a factor in the onset and
progression of menstrual migraines. Scientists claim that by maintaining
levels of estrogen during the luteal phase of the cycle, it is possible to
prevent menstrual attacks.50 This is particu larly relevant for women who
take hormonal contraceptives or those with irregular periods. It has been
suggested that continuous hormones in place of the usual “thre e weeks on,one week off” (known as a 21/7 regimen) may prevent the estrogen
withdrawal that triggers the headache. This idea is based more  on clinical
practice than on research trial data,50,51 but this does not detract from the
validity of the evidence. In one study , a 168-day placebo-free regime of hormonal
contraceptives, where hormones were taken at regular levels  every day,
helped relieve headache severit y and improve work productivity and day-
to-day function, compared to the normal 21/7 pattern. In a placebo-free
contraceptive regime, the same  levels of hormones are taken every day
without a “break.” In another trial, a transdermal contracepti ve (a patch
worn on the skin to preven t ovulation), when used for 84 days
consecutively , resulted in fewer headaches compared with the standard 21/7
contraceptive regimen.53
Research into menstrual migraine is limited. It should be noted,
however , that women who suffer from migraine with aura should not take
combined horm onal contraceptives due to an increased risk of ischemic
stroke.54 More study of the link between sex hormones and migraines, and
of the possible genetic predisposition in some women is needed  to develop
more targeted diagnosis and treatment. Nonetheless, it is important to
understand that the functions of the sex hormones are not confined to the
reproductive system—they are active in the nervous systems too. PELVIC FLOOR DYSFUNCTIONS
Another aspect of pain and function specific to women is the connection
between the breath, pelvic floor function, and sacroiliac joint stability .55
The sacroiliac joint connects the pelvis to the spine, essentially  supporting
the weight of the upper body . The pelvic floor and the diaphragm are
structurally and functionally connected by fascia and muscles,56 especially
the pubococcyg eus—the muscl e that controls urine flow57 and contracts
during or gasm.58
The skeletal and muscular systems of the pelvis have been described as
a unit forming the base of a lumbopelvic “cylinder” with the diaphragm at
the top and the transversus abdominis at the sides.59 The spinal column runs
through the center of this cylinder , supported by elements of the lower back,psoas, and abdominal muscles. Because the psoas fibers merge with the
diaphragm and the pelvic floor , stiffness or dysfunction in any of these
muscles is likely to affect the ability of the diaphragm to function normally ,
impacting the stability of the spine. Analysis of over 38,000 telephone interviews showed that middle-aged
and older women were more likely to experience back pain alongside
breathing difficulties. It also showed that problems with both incontinence
and back pain might be due to physical limitations of functional  movement,
posture, and respiration in the trunk.60 The fact is, if the muscles of the
pelvic floor are dysfunctional, compensatory muscle activity may interfere
with the activity of the pelvic  floor , compromising spinal stability and
possibly resultin g in urinary incontinence. The results of a 2007 study into
pelvic floor and abdominal muscle function in women indicated that
women with incontinence actually have increased  activity in these
muscles.60 Researchers concluded that their finding “challenges the clinical
assumption that incontinence is associated with reduced pelvic floor muscle
activity .”
Women with chronic pelvic pain frequently breathe into the upper chest. They have poor coordination in basic functions such as sittin g, standing,
and walking, and very stiff muscles in the lower back and hips. In a 2007
interview , Dr. Leon Chaitow explained that, when normal diaphragm
breathing is restored and the pelvic floor muscles are relaxed, it is relatively
easy to reestablish function in the pelvic floor .61 Dysfunction in pelvic
muscles affects the stability of the spine and pelvis, while hyperventilation
contributes to problems with motor control. Normalizing imbalances in the joints and soft tissues, along with
postural and functional breath ing training, has the potential to modify ,
relieve, or eliminate symptoms, including chronic pelvic pain. Chaitow
explains that manual deactivation of trigger points and physical relaxation
exercises, combined with breathing rehabilitation, “offer a practical way
forward.” Conversely , because the pelvic floor mechanism can affect
diaphragm move ment and the function of the lungs, the author s of a 2015
study also suggest including  pelvic-floor -strengthening exercises in
breathing rehabilitation programs.62Many chronic symptoms relatin g to the urethra, bladder , lower bowel,
and prostate can be caused, maintained, or aggravated by active myofascial
trigger points in the muscles of the pelvic area.61 When these trigger points
are helping stabilize hypermob ile joints or enhance the stability of the
pelvic floor, their deactivation may ease pain at the cost of stability . It is
therefore necess ary to first address the underlying causes of the instability . As we discovered in the chapter s on functional movement and pain, trigger
points can be the result of psychological stress. They are a sign of
autonomic imba lance, and the autonomic nervous system can be regulated
through the practice of slow, light diaphragm breathing. It is also important
to remember that the respiratory alkalosis intrinsic to hyperventilation
encourages the development of myofascial trigger points. Trigger points, clenched pelvic floor muscles, and hyperactivity of the
muscles can sometimes be caused by psychological issues, including a
history of abuse or assault, or by excessive tone created by a background of
athletics, dance, or badly taught Pilates. When a psychosexual or
psychosocial element is present, appropriate therapeutic support is
necessary alongside breath and bodywork.61
FEMALE HORMONES, LUNG HEAL TH, SLEEP , AND
ANXIETY
There is evidence that some respiratory illnesses behave differently in
women than in men. Asthma, for instance, is more common  in women. However , its prevalence change s with age.11 In childhood, more boys have
asthma than girls, but once puberty hits, women are more susceptible, and
their symptoms fluctuate through the menstrual cycle. Up to 40% of women report premenstrual asthma symptoms that can
lead to severe attacks.11 One study of girls aged between 8 and 17 years
found that girls who begin menstruating earlier tend to develop more severe
asthma after puberty .63 The fact that respiratory symptoms change as
hormone levels fluctuate indicat es that sex hormones contribute to the onset
and persistence of asthma.1,64 This theory is further confirmed by the fact
that 20% of asthmatic women suffer from worse sympto ms duringpregnancy11 and that female sex hormones can make the severe form of
asthma even worse.65
A 2009 study compared respiratory function in women with and without
asthma over the course of the menstrual cycle. In all women, forced
expiratory volume and blood gas transfer varied through the menstrual
cycle, peaking during menstruation and declining to the lowest point in the
early luteal phase when progest erone was at its highest. Forced  expiratory
volume is an important measure of lung function, measuring the volume of
air that can be forced out in one second after taking a deep breath. The
cyclical respiratory changes occurred by way of very dif ferent physiological
mechanisms in women with asthma compared to healthy women. In
asthmatic wom en, cyclical variations in gas exchange were due to
differences in the functioning of the alveoli66. These  change s were
consistent, regar dless of inhaled corticosteroid or hormonal contraceptive
use. As horm one levels fluctuate over the 28-day cycle, blood vesse ls in the
lungs are constantly forming and disappearing. This impacts the way the
lungs take in oxygen because it affects ventilation perfusion. These findings
begin to provide insight into the way asthma presents in women, why
difficult-to-control, severe asthma is more common among women, and
why exacerbations occur in the luteal phase. Female sex hormones also
contribute to asthma exacerbations in women who are overwei ght because
obesity causes imbalances in the levels of estrogen and progesterone.67
Another factor in the way asthma presents is the size and collapsibility
of the airway11. Men tend to experience much more airway collapsibility ,
while women are more prone to inflammation in the airways.68
In one 2010 study , hormone replacement therapy (HR T) was linked with
a high number of cases of newly diagnosed asthma in menopausal
women.69,70 Some research  also shows that menopausal women who are
given hormone replacement medications experience worse asthma. One
trial assessed 184 women aged between 34 and 68 over the course of 10
years and found that E2 (estradiol/estrogen) replacement therapy increased
the incidence of asthma.71 However , more recent papers  contradict this
finding, specifying that women are more likely to experience airway
obstruction if they do not take HRT.72 While the literature is limited andsometimes confusing, these findings begin to paint the picture that certain
features of asthma are unique to women, including the much greater
prevalence of symptoms that are severe or difficult to control and the
phenomenon of premenstrual asthma exacerbations.66
COPD (chronic obstructive pulm onary disorder) is a condition in which
patients have ongoing hypercap nia and hypoxia due to impair ed lung gas
exchange. It causes dysfunctio nal muscles that are easily fatigued, have
reduced strength and endurance, and a tendency to atrophy .73 COPD has
traditionally been thought of primarily as a disorder af fecting older men, but
recent years have seen an increase of incidence and a significant rise in
mortality in women.74 This is thought to be, at least in part, due to smoking. While the number of smokers is decreasing across North America and
Europe, more women than ever are smoking in developing countries where
the health risks are less known. For instance, a 2009 study found that only
38% of smokers  in China knew that smoking could cause heart disease,75
and even  in developed countries , there is a degree of ignorance. Women are
also more likely  to be exposed to passive smoking than men, they develop
COPD with less smoking history than men, and their decline in lung
function is faster .11 It is interesting  that the resilie nce shown by females
against maternal smoking compared to males reverses in adulthood. COPD is an umbrella term rather than a specific disease. There are
differences in the way it manif ests in women. Emphysema, a debilitating
“end state” of COPD, in which the alveoli become damaged and the patient
requires constant oxygen, is more common in men. Women tend to display
more reactive airways—irritation, inflammation, and infection—and more
pronounced narrowing of the airways11. Long-t erm oxygen therapy is more
effective in women, and women  have a much greater improvem ent in lung
function once they stop smoking. Estrogen is involved in maintaining cell
structures and in the elasticity of the lungs that keeps the airways open.76
Cigarette smoke  has an antiestrogen effect,77 and this may contribute to
impaired lung function in women who smoke or inhale secondhand
smoke.76,78
In 2019,  a study investigated whether female sex hormones contribute
to COPD.79 Researchers found that women who had used oral
contraceptives were less likely to be hospitalized or to die with COPD.However , women who had started their periods later than 15 years old and
those who experienced early menopause were more at risk. Early onset of
puberty , which is a risk factor for asthma,63 had an impact on lung function
(how well the lungs work) but not on COPD. Women with a history of
polycystic ovary  syndrome (PCOS), ovarian cysts, HRT use, and surgery to
remove the ovaries and/or fallop ian tubes were all at higher risk of COPD,
although their lung function was likely to be better . This corresponds with
the finding that women were less susceptible to emphysema  than men. Remember , COPD is an umbrella term, and symptoms can affect breathing
to a greater or lesser extent. Scientists concluded that a variety of aspects of
reproductive health throughout a woman’ s life can contribute  to COPD-
related hospitalization and death  or to lung health. More work is needed to
understand the complex links between COPD and sex hormones in terms of
HRT,11,79 ovarian cysts, PCOS, and hysterectomy . According to a 2018 clinical review, lung cancer mortality is increasing
in women but not men. The number of women who die each year from lung
cancer is greater than the combin ed female mortality rate for breast, uterine,
and ovarian cancer .11 A woman who doesn’ t smoke is three times more
likely to be diagnosed with lung cancer than a nonsmoking man, indicating
a possib le hormonal influence. However , women have a better prognosis, in
terms of chemotherapy and surgical response, and a higher five-year
survival rate. Pulmonary hypertension—high blood pressure in the blood vessels that
supply the lungs—is more common in women and occurs around 10 years
earlier in women than in men. Again, more research is needed to understand
the role of the sex hormones, and to discover if and how estrog en increases
female susceptibility to lung disorders.11
While there are differences between women and men across many
respiratory conditions, it is still largely unknown whether these disparities
are behavioral, social, environm ental, or biological. To date, most research
has simply conc luded that more work is needed to ascertain the role of
hormones in lung health.11,80
SLEEP-DISORDERED BREA THINGWe have already discussed snoring, insomnia, and sleep apnea in detail
(Chapter Seven ), but here again, there are differences between men and
women in sleep-disordered breathing, and these are worth mentioning. There is a highe r prevalence of sleep apnea in men, perhaps due to a greater
collapsibility of the airways.11 But once wome n reach menopause, there is
about a 200% increase in the incidence of sleep apnea.1 This occurs
independently of other risk factors, indicating that female sex hormones,
thought to have a protective effect on the airways and ventil atory drive,
could guard against sleep apnea in premenopausal women.11
Young and middle-aged women are far less prone to apneas than men,
but older women experience much more sleep disturbance. Reduced levels
of progesterone  and estradiol (estrogen) contribute to the incidence of
sleep-disordered breathing.81 Replacement of these hormones decreases
apnea frequency compared with untreated postmenopausal women.82
Premenopausal women with severe obstructive sleep apnea have much
lower progestero ne than healthy women and women with mild OSA.83 The
gender differen ces in the prevalence of sleep apnea decreases after
menopause, indicating that the menopausal status itself plays a part in OSA. Progesterone is known to improve the tone of the upper airway muscles.11
Levels of the hormone decrease after menopause, which is one reason why
postmenopausal women become more susceptible to sleep -disordered
breathing. A 2015 study found that progesterone reduces sleep apnea in
menopausal women.84
Another contributing factor is a change in the way body  fat is
distributed. After menopause, women are likely to have more body fat, and
this tends to be concentrated in the upper body , where fat on the tongue,
neck, and abdom en is a commo n anatomical factor in sleep apnea. Fat on
the throa t narrows the airway , causing increased resistance to breathing and
greater airway collapsibility . Fat on the tongue takes up space in the mouth
and may encroa ch on the airway. Extra weight on the belly reduces the
amplitude of diaphragm movem ents, causing a decrease in lung volume and
more frequent collapse of the upper airways during sleep. The results of a 1988 study comparing incidence of sleep-disordered
breathing in obese men and women found that obese women have an
increased chemosensitivity to hypoxia and hypercapnia when compared towomen of a healthy weight. Breathing is often noticeable in overweight
women, even at rest. Fast, upper chest breathing with no pause after the
exhalation and feelings of breathlessness are typical. While it would make
sense that the increased sensitivi ty to blood CO2 could be caused  by oxygen
desaturation and poor breathing during sleep, the same change in
chemosensitivity in relation to body fat load is not present in obese men.85
Similarly , pregnancy increases the incidence of OSA by around 8% due
to increased neck circumference, greater nasal congestion, and pharyngeal
edema, a swelling in the tissues of the throat. In the later stages of
pregnancy , there  is also less room for the diaphragm to function, reducing
lung volume and triggering upper airway collapse. As a result of these
considerations, snoring is consi dered a primary risk factor in pregnancy-
induced hypertension.86 (We will look in more detail at OSA during
pregnancy in the next chapter .) ANXIETY DISORDERS
Women are between two and three times more likely to develop panic
disorder than men.1 This susceptibility may be linked to sex hormones. Women with panic disorder experience a worsening of their panic
symptoms and anxiety during the premenstrual phase of their cycle.87,88
Studies in rats have shown that withdrawal of progesterone increased
susceptibility to panic-related anxiety , indicating that the lower levels of
progesterone in the days before the period may be a trigger .89 Numerous
studies link low progesterone to feelings of anxiety .87 Progesterone is a
respiratory stimulant. High levels of the hormone can cause
hyperventilation, but when levels drop very low, it is thought this can
increase the perception of breathlessness.90 While the weig ht of evidence
points to a higher prevalence of anxiety disorders in women, the research is
incomplete. This comes back to the male/female research bias and the fact
that the bulk of the literature has focused on male rodents.91
Scientist have demonstrated an increase in panic symptoms, often
interpreted as hot flashes, and anxiety in women experiencing the
menopausal transition. This suggests that panic disorder may be linked to
fluctuations in sex hormones.92 Since studies have linked the onset of panicsymptoms with heightened sensitivity to blood CO2, it make s sense that the
hyperventilation, which occurs at certain points in the menstrual cycle, may
produce cyclic exacerbations of anxiety . When all the connections between
hyperventilation, hormones, and panic disorder are taken togeth er, it makes
sense that sex hormones could contribute to anxiety in women. One recent
paper concluded that it is impor tant for future research to study anxiety in
females so that results can be more accurate and applicable to women.91
WOMEN’S HORMONES AND SPOR TING PERFORMANCE
Another conside ration when exploring the topic of breathing in terms of
gender is the impact of sex hormones and anatomical factors on physical
exercise. It is known that while  women are capable of outstand ing athletic
achievement, they generally have to work harder to breathe during intensive
exercise than men.93,94
A 2020 study demonstrated that gender affects the respiratory aspects of
physical exercise. The research team hypothesized that the smaller airways
in females, when compared with the airways of height-matched males,
produced more turbulent airflow during exercise. Turbulent airflow causes
the air molecules to move in different directions, much like water bubbling
round pebbles in a running stream. This creates more resistance, making
breathing more dif ficult.94
Five women and six men took part in the trial, during which they each
performed two exercise tests, gradually intensifying their workout on a
stationary cycle until they reached maximum intensity . During the tests,
participants breathed through a mouthpiece, inhaling either norm al room air
or a mixture of oxygen and helium. Respiratory effort was monitored via a
small tube inser ted into the nose and throat. In this experiment , the helium
mix was designed to mimic the lower levels of resistance in the larger male
airways. The helium mixture was less dense than the room air and moved in
a more direct manner , with all the molecules flowing in the same
direction.94 This is called laminar airflow . The results showed that wome n breathed much more air when they
inhaled the helium and oxygen  mix, but this change in breathing volume
was not accompanied by an increase in the work of breath ing. Whenbreathing room air, the female participants had to breathe much harder than
the men to overcome the turbulent resistance. When they breathed the
helium and oxygen mix, the airflow was more laminar , and there was no
difference betwe en the males and females in ventilatory exertion. The study
concluded that smaller airways  increase turbulent flow and that is why
women have to breathe harder during exercise.94
In an article in Neur oscience News , Paolo Dominelli, who was on the
research team for the study , explained,
At rest, the rate of air flow is very low, so even though women have
smaller airways  than men, air flow is still laminar . As exercise
intensity increases, you breathe faster , and at some point the airflow
goes from laminar to turbulent. Air flow in men’ s airways will also
eventually turn from laminar to turbulent, but this requires a higher
rate of air flow than is required in women.93
It is important to understand that while the differences shown  in this
study relate to size and gender , with men typically having larger airways,
airway size varies significantly between individuals.93 For instance, people
of both sexes who have set-back jaws or other craniofacial abnormalities
caused by child hood mouth breathing, pacifier use, tongue-tie , and other
factors will have  smaller airways in adulthood, leading to a lifetime of sleep
problems and reduced athletic ability . Other difference s may also have an impact on sporting perform ance in
women. In 1993, a review published in Sports Medicine  examined the
impact of sex hormone fluctuations, due to the natural menstru al cycle and
use of oral contraceptives, on the performance of female athletes.95
Previous research had reported that the best days for athletic performance
were generally those immediate ly after menstruation and the worst were in
the premenstrua l stage and the first few days of menstrual flow. However ,
those studies were limited by lack of accuracy as to where in the cycle the
women were. There was also an inherent bias, because many of the women  already
associated premenstrual symptoms such as weight gain, mood swings, and
fluid retention with poor perform ance. Their perception of performance was
therefore already less positive at that point in the cycle. Those premenstrualsymptoms have  also been linked with an increase in musculoskeletal
injuries during the premenstrua l and menstrual phases. In the days before
menstruation, women were shown to experience compromis ed reaction
time, neuromuscular coordination, dexterity , and judgment, but other
potential confou nding factors such as nutrition, blood sugar levels, and
hyperventilation may cloud these findings. Swimmers demonstrated worse performance times during the
premenstrual phase and better times during menstruation and on the eighth
day of the cycle . The women’ s perception of exertion during very intense
exercises increa sed premenstru ally and during the first few days of
menstruation.95 In cross-country skiers, the best performance times were
recorded in the days just after ovulation and immediately following
menstruation. To get the most out of training, loads should be adjusted for
female athletes to account for changes during the menstrual cycle. Studies using estradiol and progesterone levels to determine where a
woman was in her cycle did not find any marked differences across the 28
days in response to either maximal or less intensive exercise, though a small
decrease in aerobic capacity was observed during the luteal phase. However , in 2003, it was confirmed that breathing capacity was much
higher in men than women1. During the follicular phase of the cycle,
ventilation, tidal volume, and peak inspiratory flow were 21% lower in
women during wakefulness and 22% lower during sleep. At the same time,
no difference was found between men and women in blood flow to the
respiratory musc les during exercise or rest, or during different phases of the
menstrual cycle.95
A 2019 study investigated the effects of the menstrual cycle on running
economy .96 Eleven female athletes were assessed for oxygen consumption
and blood gas exchange at rest and while running. Scientists concluded that
gas exchange during exercise is better in the luteal phase than the follicular
phase but that this is independent of running speed. It was also
demonstrated that the menstrual  cycle has no effect on body composition or
physiological variables at rest.96
Again, research into this area is sparse. Perhaps most relevant to female
athletes is knowing that hyperv entilation is likely during the luteal phase,
between ovulati on and menstruation. By paying attention to the breath,working to normalize breathing volume, and reducing sensitivit y to CO2, it
should be possible to moderate these naturally occurring phasic differences
in breathing. Another point worth mentioning is that, in extreme circumstances,
women’ s sportin g ambitions can impact their health and hormones in an
unhealthy way. Excessive runni ng or training places considerable stress on
the body . This can cause an imbalance in the autonomic nervous system,
affect the immu ne response, and put strain on the heart. When bodyweight
and body mass index fall too low, estrogen will drop, and this can result in a
lack of bone mineral density . Just as menopause is a risk factor for
osteoporosis (something we explore in the next chapter), so is any condition
that causes estrogen production  to decline, because estrogen inhibits bone
resorption.97 Estroge n is a primary hormonal regulator of bone metabolism
in women and men.98
When estrogen drops too low, fertility is impacted and menstruation
ceases. This is the same for women with eating disorders. In fact, eating
disorders and obsessive exercis e combine to form the basis of a specific
condition called  relative energy deficiency in sport, or REDS. This can be
an easy trap to fall into, especially for women with perfecti onist, high-
achieving person alities. If you feel your running is becoming obsessive and
weight loss is tipping over into an eating disorder , it is importa nt to speak
with a specialist as soon as you can. In an article for the UK website Momentum Sports , endurance runner
Katherine Wood writes openly about her 10-year battle with anorexia
nervosa and REDS.99 Wood was a competitive runner and swimmer as a
child and teenager , but as she went through puberty , she struggled to
balance her nutritional input with the energy output required in her training. She rapidly transitioned from unintentional weight loss to full-blown
anorexia that left her in hospital. Her periods stopped. As her running  career progressed, Wood pushed herself harder and
further . She achieved succes s after success. But she was training
compulsively , ignoring injuries and signs that her health was failing, and
losing weight fast. She began to have repeated bacterial infections on the
skin of her legs. Blood tests returned signs that her muscles were starting tobreak down, but she experienced a sense of failure if she didn’ t keep up her
intensive training. Eventually , she turned to Renee McGregor for help. McGregor is a
sports and eating disorder therapist and cofounder of #TRAINBRA VE, an
initiative aimed at raising awareness of eating disorders in athletes. In the
first consultatio n, Wood was devastated to be told that she had to stop
exercising imme diately and that her heart could give way at any moment if
she didn’t. In the following months, she found it incredibly difficult to
increase her food intake while not exercising at all. Scans revealed that her
bone density was so low she was classed as osteopenic. She struggled to get
a prescr iption for HRT; a lack of understanding of sports-related eating
disorders among  general medical providers meant she had to seek private
healthcare. In her article, she issues this caution against underfueling and
overtraining, “Periods stopping  is NOT a sign that you are training hard
enough, it is a sign you are training TOO hard and your body is not coping. Please do not ignore these signs.”99
OceanofPDF .comPCHAPTER THIR TEEN
FEMALE SEX HORMONES AND THE
BREATH
PMS AND CYCLIC HYPER VENTILA TION
remenstrual syndrome (PMS) manifests with similar or identical
symptoms to chronic hyperventilation syndrome.1 A 2006 study
found that women with PMS experience a much greater decline in
blood carbon dioxide (CO 2) in the premenstrual phase than women who do
not experience symptoms. The symptoms appear as progesterone increases
and blood CO2 decreases. When the luteal phase ends, progesterone
decreases, CO2 levels normalize, and the symptoms disappear . The study
concluded that women with PMS have a higher -than-normal sensitivity to
CO2, perhaps caused by progesterone, resulting in “pron ounced
hyperventilation”—and that the hyperventilation is responsible for the
symptoms.2
Breathing plays  a role even from the perspective of physic al pain
experienced. Not only is pain perception heightened by low CO2 levels, the
drop in CO2 also causes constriction of smooth muscles. Since the uterus is
comprised of smooth muscle, this can directly contribute to pain
experienced as menstrual cramps.3
The authors of the 2006 study suggest that since the breath can be easily
manipulated using a variety of techniques, including respiratory and
biofeedback training, it would be promising to explore this phenomenon in
more detail to understand the mechanisms underlying PMS and find moreeffective ways to treat it, at least for some women.2 Their conclusion points
to the relevance of the techniques in this book. Science has yet to
adequately catch  up, but existing  research does point to the fact that women
can control symptoms of PMS by changing their breathing patterns to
restore slow , light, nasal breathing. In the same study , researchers noted that selective serotonin-reuptake
inhibitors (SSRIs), commonly used as antidepressants and for alleviating
the symptoms of PMS, cause an increase in blood CO 2 levels. Serotonin is a
chemical messenger that has many complex functions. It is known as the
“happy chemica l” because it contributes to feelings of well-being. During
the luteal phase of the mens trual cycle, fluctuations in estrogen and
progesterone increase serotonin neurotransmission.4 But according to 2015
research, women who suffer with PMS or premenstrual dysphoric disorder
(PMDD—a more severe form of premenstrual syndrome) appea r to have an
abnormal seroto nin reaction to luteal hormonal changes5. Also, it has been
shown that changes in the serotonin system may be indirectly related to
breathing abnormalities6 and treatment with SSRIs may improve respiratory
responses to CO 2.7
The connection between PMDD  and panic disorder has been receiving
growing attentio n. Patients with both conditions experience high rates of
panic attacks, and PMDD and panic disorder may share the same
underlying pathology .8 The link betw een menstruati on, depression, and
mood swings is commonly acknowledged and frequently stereotyped, but
the symptoms of PMS and PMDD are no joke. At clinically significant
levels, they are severe enough to interfere with daily life. We have explored the connection between headaches, menstrual
migraines, and hyperventilation, but there seems to be yet no scientific
literature examining the cyclical occurrence of depression, panic symptoms,
irritability , and mood swings in terms of hormone-induced respiratory
changes. This is despite the clear relationship between mood disorders,
dysfunctional breathing, and autonomic imbalance, and the fact that it is not
always possible to distinguish between depression and PMDD.9
According to a 2017 advisory document from a New Zealand
pharmaco-vigilance team, symptoms including depressed mood , feelings of
hopelessness, difficulty concentrating, lack of energy, decreased interest inusual activities, hypersomnia, and insomnia are included in the diagnostic
criteria for both disorders. However , differences in the regulation of the
stress response between women  with depressive disorders and those with
PMDD may suggest two distinct conditions. It is believed, for instance, that
premenstrual symptoms are not particularly influenced by familial or
environmental factors while a history of anxiety disorder , traumatic events,
and smoking can all contribute.9
EMMA ’S ST ORY
Emma is in her early thirties.
_OceanofPDF.com_The_Breathing_Cure_-_Patrick_McKeown.txt
Summarize the following text section accurately and concisely. Maintain specific details and numerical information, and use anti-repetition mechanisms:

        BACK T O BASICS AND THE THREE DIMENSIONS OF
BREA THING
Learning any of these techniqu es begins with integrating light, slow, deep
nasal breathing. It forms the basis for healthy breathing and is developed in
the exercises in this book. Once you are familiar with how a healthy
breathing pattern feels, you will be much freer to enjoy more specific
breathing techniques. Becoming aware of your own breathing and that of
your partner opens the way to many avenues of exploration. For instance,
deep, mindful breathing can provide a way to relax and get in the mood
before foreplay. By becoming conscious of the breath as you bring air into
your belly, you can bring your awareness to the breath as it travels right
down into the genitals. This awakens the area, infuses it with energy, and
stimulates vasod ilation, increasing blood flow to your sexual organs. While
there are plenty of advanced methods out there, which are best approached
with a qualified teacher, there are also simple things you can do for better
sex. When you breathe through your nose, you enjoy greater oxygen  uptake,
harness nitric oxide, and engage  your core for better movement. Diaphragm
breathing activates muscles that stretch between the coccyx and pubic bone. These are the muscles that contract during orgasm. By improving your
BOL T score, you are less likely to get out of breath. Just as increasing the
BOL T score can help alleviate breathlessness during exercise, reducing
your sensitivity to blood CO2 will help impro ve your stamina during sex. This can be especially valuable in the control of asthma symptoms and in
alleviating the fear of exacerba tions. It may also provide relief for people
with epilepsy, because hyperv entilation during sex is known to trigger
seizures for some. 103 In this context, Breathe Light  exercises and breath
holding following an exhalation  to improve the blood biochemistry should
first be practiced outside of the bedroom. It’s common to tense up and hold the breath as orgasm approac hes, but
scientists have proven that hypoxia reduces sexual arous al. 104 This
tendency to hold the breath can often be caused by self-con sciousness. Opening the mouth in the lead up to orgasm means you’re going to make
more noise. Many of us are conditioned by perceptions of how sex should
sound. We alter our sexual groans and grunts into moans and sighs, perhaps
to reflect what we’ve heard in erotic films. But it’s important not to imitate
the sounds you think are expe cted. This can repress orgasm and create
tension in the breath. Instead, if you continue breathing deepl y when the
orgasm begins, you will enjoy a full-body sensation. The idea of breath holding during sex may become a little confused
with the idea that some peop le use behaviors such as asphyxiation or
hanging to induce arousal. Unfortunately, the severity of these “games” to
become aroused may gradually increase as tolerance to hypoxia develops,
so these  practices sometimes result in accidental death. A 2016 study
reports that the mechanisms by which these methods create heightened
pleasure for some people are complex and unclear,104 and, although this
relates to breathing practices and sex, there is not enough evidence to
explore them here. PRACTICING ORGASMIC BREA TH
Breath retention is a feature of the Tantric practice of healing breath. 105
This exercise has a ratio of 1:4:2 for inhalation, breath hold, and exhalation. The retention is four times longer than the inhalation, and the exhalation is
twice as long. Breathe in for one second or heartbeat, hold for four seconds
or four beats of the heart, and exhale for two seconds or two heartbeats. To
practice this, you can gradual ly increase the length of the inhalation,
maintaining the ratios between in-breath, retention, and out-breath. It is
important not to practice too intensely to begin with. If you get dizzy or feel
your heart beating too fast, stop the practice and breathe normally. The exercise asks that you don’t count mentally, because this takes the
focus away from  the breath. Instead, count using the heartbeat, or practice
while walking, using the paces to keep track. In other words, practice the
breathing during everyday life so that you feel the benefits during sex. Theobjective is to slow the breathin g and to instill a profound level of calmness
in the mind. This exercise is for men to practice in the lead up to orgasm to
delay ejaculation and for women to deepen their orgasm. The best way to
ensure you are able to bring your attention to the breath during sex, when
you are bound to have your mind elsewhere, is to practice the breathing
exercises for developing control of your breathing during day-to-day life. Breath retention is also used in the yogic practice of orgasmic breath,
sushumna nadi Pranayama. 106 This exercise is designed to pull energy
from the base of the pelvis up through the chakras, filling the body with life
force. It involve s working the muscles of the pelvic floor and focusing on
the breath and the physical body to reach a meditative or orgasmic state. It
uses a technique  of reduced mouth breathing similar to sipping through a
straw. According to Courtney Avery, creator of the San Diego sexual-
health-based yoga business Intimate Health, LLC, “the more you practice
meditation, the more you train your brain to come into an orgasmic state. ”
When you add breathwork and activation of the muscles, “magic happens. ”
With practice, it becomes possib le to bring yourself to full-body  orgasm
using only the breath and muscle engagement. You should avoid practicing
this technique during menstruation or if you are experiencing pelvic pain. • Sit comfortably in an upright posture and breathe normally. • On your next inhalation, purse your lips as if you were sipping through a straw. • Breathe in through your pursed lips and engage your pelvic floor muscles. Keep your
buttocks relaxed and your muscles engaged. • Continue to breathe in as if you are sipping, while being aware of the muscles and
the energy that is lifting through the spine. • Pull in your lower abdominal muscles and tuck in your belly button. • Relax and widen your chest and shoulders. • Lengthen your neck and tuck in your chin. • When you feel “full up” with air, seal your lips and hold your breath, engaging all the
muscles along the length of your spine. • When you are ready to release, slightly open your mouth. V isualize the energy
pouring from the top of your head down the front of your body, gently softening your
muscles as it flows down. • Relax your neck, shoulders, belly, and abdominal muscles. • Finally, release the pelvic floor muscles and surrender. • When you have finished, relax, and breathe normally for a few breaths, remaining in
a state of calm relaxation. • Repeat the exercise up to 13 times. The key lies in practice. By beginning to explore the breath by yourself,
you can prepare to share new experiences with your partner. Try practicing
nasal breathing before jumping into bed. Pay attention to your pelvic floor
muscles. It allows you to engag e those muscles and heightens sensation in
your genitals, increasing pleasure. You can also experiment with exercises that synchronize your breath
with your partn er’s. You can do this sitting face to face, holding hands,
hugging, touching foreheads—anything, as long as you are physically
connected. You can try lying down and embracing. Again, the practice uses
gentle breath retention:
• Exhale all the way out. • Slowly inhale together, breathing from the diaphragm. • Pause together at the top of the breath, feeling full of life-giving energy. • Gently exhale together, all the way out. • Pause again at the bottom of the exhalation, feeling safe and empty. • Slowly inhale. • As you breathe, imagine the breath carrying energy throughout your body. • Repeat the exercise as many times as you like. This exercise simply involves mindful breathing, exhaling and inhaling
through the nose, breathing from  the diaphragm, and gently bringing your
breath into sync with your partner. If you want, you can continue this as you
make love, exploring how the calm feeling of breathing together enhances
intimacy. OceanofPDF. comHCHAPTER TWEL VE
YES, BREATHING IS DIFFERENT FOR
WOMEN
AN UNHELPFUL BIAS
istorically, in most physiology literature and, indeed, across every
field of science, research has predominantly focused on male
subjects. This gender bias can be seen in many areas of study and in
trials using both humans and animals. 1–5
However, it is now known that gender differences do affect breathing
control and vulnerability to some respiratory diseases. For example, women
recover better after a severe episode of hypoxia. There are also differences
in sleep apnea1 and heart rate variability. 6 The reasons are not properly
understood, but the disparity between sexes might explain many otherwise
contradictory findings. It has been said that where the influence of gender is
disregarded, the progress of scientific knowledge can only be held back. 7
Another anomaly is that, when women take part in studies, researchers
often fail to account for the fluctuations in hormone levels that occur during
the menstrual cycle. 1,8 This is despite  the fact that the menstrual cycle is
one of the most important biological rhythms that modulate the
physiological processes of a living being. Airflow and gas exchange are
known to be among the many vital functions that change during the
menstrual cycle9. Studies have demonstrated, for example, that women’ s
ventilatory respo nses to hypoxia and hypercapnia vary throughout the 28-
day cycle directly parallel with hormonal fluctuations. In all honesty, I avoided this topic in my own work for many years,
largely because as a man I didn’ t feel qualified to discuss it. However, I am
aware of the growing frustration that women’ s health, particularly in regard
to menopause, has been brushed  under the carpet for too long. I wanted to
address this by sharing research and connections to the three dimensions of
breathing that might be helpful. In my coaching, I work with as many
women as men, and their experience with breathwork is incredibly
informative. Also, I always aim to be guided by the questions people ask
me and to find ways to answer them. In putting this and the next chapter
together, I am grateful for the guidance, assistance, and experi ence of two
female medical doctors, along with help from several other brilliant women. THE MENSTRUAL CYCLE
There are several “phases” to the menstrual cycle, which are important to
recognize in understanding the issues surrounding breathing in women. Some are familiar, but the changes through the month are mainly invisible. Unless you are trying to conceiv e (or trying not to), you may not have given
much thought to how the cycle works. The different stages and events in the
cycle are:
• Menstruation:  This is your “period. ” The lining of the uterus sheds and you bleed. During this time, levels of estrogen and progesterone are low10. • The follicular phase:  This is the time between the first day of your period and
ovulation. Estrogen rises as your body prepares to release an egg. • The proliferative phase:  The lining of your uterus builds up again after your period. • Ovulation:  The egg is released from your ovary midcycle. Estrogen levels peak just
before this happens and drop shortly after. • The luteal phase:  This is the time between ovulation and the start of menstruation. Because this is the stage when the body prepares for a potential pregnancy,
progesterone is produced, peaks, and then drops. This is the phase most associated
with hyperventilation as progesterone levels fluctuate. • The secretory phase:  The lining of the uterus produces chemicals that will either
support an early pregnancy or prepare the lining to break down and shed during
your next period. WAYS BREA THING IS DIFFERENT FOR WOMENThe regulation of breathing is complex and affected by many factors,
including gende r. In 1905, it was first found that the resting pressure of
blood CO2 was around 8% lower in women than in men,1 and this finding
has since been confirmed. On average, women have lower ventilation than
men, in part due to smaller airways, rib cages, and lung volumes, as well as
diaphragms that are around 9% shorter. 11 Ventilation was first linked to
levels of sex hormones in 1904 when Adolf Magnus-Levy, a pioneer in the
study of human metabolism, observed that women hyperventilate during
pregnancy1. Later, it was found that women also hyperventilate during the
luteal phase of their menstrua l cycle, and research confirmed that the
cyclical variatio ns in ventilation are no longer present in postmenopausal
women. 1 This last fact clearly links changes in breathing to fluctuations  in
sex hormones. A 2006 study reported that the female hormone progesterone, which is
known to stimulate breathing, might contribute to respiratory changes seen
at different times of the menstr ual cycle. 12 General respiratory function is
known to be influenced both by the different phases of the menstrual cycle
and by common  hormonal and metabolic states. 11 This can have an impact
on health. When the first occurrence of menstruation is early (early menarche), the
likelihood of poor health in later life increases, with a higher risk of
illnesses, including asthma, cardiovascular disease, and comprom ised lower
lung function. 11 The instances of poor respiratory health in girls who reach
puberty early may be due to factors such as higher body mass index, which
can cause early menarche. However, research suggests that early onset of
puberty may affect airway and lung development, because to some extent,
puberty signals a termination of growth. 13
The menstrual cycle influences disorders as varied as epilepsy, bipolar
disorder, migraine, and rheumatoid arthritis. 13 Respira tory symptoms such
as breat hlessness, coughing, and wheezing vary considerably over the 28
days. These become worse between days 10 and 22 (the midluteal to
midfollicular phases),13 possibly due to the influence of hormonal changes
on the airways. 13 This explains why asthma severity fluctuates during themenstrual cycle, and why irregular menstruation is associated with a higher
risk of asthma. 13
Increasingly, evidence indicates that sex hormones can either contribute
to disea se pathology or serve as protective factors against lung disease. They regulate the development of the lung and airways in unborn babies,
and it is thought that they play a part in the varying advers e effects of
antenatal smoking on lung function. The lung function of adult men is more
severely affected  by exposure to smoking in the womb than that of women. Scientists also believe that sex hormones may cause changes in the growth
pathway of the lungs in respon se to in utero exposure to smoking. 14 This
would suggest that males and females have a different susceptibility to
inflammation from an early stage of development. Breathing pattern disorders are also almost twice as common in women,
possibly due to the hormona l influences we’ve already touched on. Progesterone stimulates the respiratory rate, meaning that in the luteal phase
of the menstrual cycle CO2 levels drop by around 25%. 15 When CO2 levels
are already low, any extra stress  can cause breathing to speed up even more,
and this creates a range of symptoms that are commonly interpreted as
premenstrual syndrome. 16
In 2000, a study in the Journal of Orofacial Pain  reported increased
respiratory rates  during the luteal phase of the menstrual cycle, when
progesterone levels increase. 17 At the same time as breathing increased,
pain thresholds lowered. This indicates that cyclical respiratory changes
may also influence pain perception. PAIN CONDITIONS AND BREA THING IN WOMEN
FIBROMY ALGIA
Fibromyalgia predominantly affects women,18 and it changes  during the
menstrual cycle. In 2007, researchers found that several participants
fulfilled the diagnostic criteria for fibromyalgia during the luteal phase of
their cycle, but not during the follicular phase. As pain is the most common
diagnostic measure of fibromyalgia, this is another indicator that painperception differs depending on the concentration of sex hormones in the
body. Dysfunctional breathing can aggravate pain associated with
fibromyalgia, especially in tender areas of the upper body. 19 This can lead
to fatigue and difficulty carrying out normal daily activities. A 2017 paper
assessed the impact of an eight-week functional breathing program on 18
patients with fibromyalgia. 20 Thresholds for pain tolerance increased in all
the participants after one month, which means that pain was reduced. Sleep
quality, duration, and efficiency also improved as a result of the breathing
practice. 20
A 2018  study examined the effects of breathing exercises on pain
tolerance in tender points and on the quality of life for fibromyalgia
patients. 19 The trial involved 35 women aged between 34 and 67 years, all
with fibromyalg ia. The women were randomly assigned to a breathing
exercise group or to a control group. The breathing exercise participants
practiced for 30 minutes every day for 12 weeks. At the end of the 12
weeks, the women who had practiced breathing exercises showed
significant improvements, experiencing much lower levels of pain and
fatigue and becoming more able to engage with daily life. The researchers
concluded that breathing exercises provide a “real and effective
intervention” for women with fibromyalgia. A 2019 trial, also examining fibromyalgia, looked at the effectiveness
and safety of patient self-ma nagement in the form of unsupervised
breathing exercises. 19 After 12 weeks, during which 51 women practiced
the exercises, no statistical differences were found between supervised and
unsupervised participants. Ther e were, however, added improvements in
pain in those women who had practiced the exercises under supervision,
suggesting that proper guidance in performing breathing exercises is
beneficial. Faulty breathing does not cause fibromyalgia. However, it does play a
significant role in the develo pment and persistence of chronic pain
conditions. 15 For instance, biomechanical overuse combined with the
biochemical changes typical of breathing pattern disorders can have a
significant impact on pain and fatigue. 21 In fact, most  people with
fibromyalgia show signs of severe dysfunctional breathin g. Becausebreathing is already dysfunction al, these women are constantly teetering on
the brink of symptoms. Any further cyclical drop in CO2 is likely to push
the body over the edge. That is why pain often becomes much worse during
the luteal phase of the menstrual cycle. It is also why the worst symptoms
could be alleviated or even eliminated with correct breathing habits. 22
Research shows that 27% of people with fibromyalgia hyperventilate,
and 60% of fibromyalgia patients suffer with dyspnea  (breathlessness). 23
Also, breathlessness is far more prevalent in the patients with the highest
levels of pain. 24
Naturally, fibromyalgia can trigger anxiety. This is not to imply that
symptoms are “all in the mind,” but anxiety about the condition and anxiety
triggered by dysfunctional breathing itself can certainly aggrava te pain and
fatigue. Because pain causes anxiety and increases the breathing rate, it is
likely that by normalizing the breathing pattern, pain symptoms would
reduce. Once a pattern of dysfunctional breathing exists, a variety of triggers
can create a vicious cycle, causing pain, fatigue, and other symptoms,
including anxie ty and panic attacks. These, in turn, contribute to poor
breathing patterns. Poor oxygenation of the tissues during hyperventilation
contributes to the development of myofascial trigger points. 21 And because
the working of the diaphragm is linked to the functioning of the pelvic
floor, dysfunctional breathing exacerbates stress incontinence, other
genitourinary symptoms, and pain in the pelvic region—all common in
fibromyalgia. The fascia around  the psoas muscle—a hip-joint flexor that
runs from the lumbar spine through the pelvis—connects directly to the
diaphragm. 25 Women  who suffer with chron ic pelvic pain often have poor
functional movement and tend to breathe predominantly into the upper
chest. 26
Many people with chronic pain suffer with medically unexplained
symptoms. They  may be diagno sed with fibromyalgia, chronic  fatigue, or
“bodily distress syndrome. ”27 Low blood CO 2 and feelings of air hunger are
typical of all these patients. 28 As a result, scientists believe that levels of
CO2 should be asses sed as part of the patient evaluation. 24 At the very least,
it needs to be recognized that a significant number of fibromyalgia patients
hyperventilate. Given that hyperventilation is considered at the severe endof breathing pattern disorders, it is logical to assume that a much higher
number have poor breathing patterns. Leon Chaitow, after 50 years clinical experience working with
fibromyalgia patients, estimated that more than 90% breathe
dysfunctionally. 15 Functional breathing training is an efficient and cost-
effective treatment to achieve reduced levels of pain and fatigue. The ability
to fully exhale is at the root of functional breathing. Without this
understanding, it is not possible to inhale correctly. Chaitow cautions that
this is not a quick fix. Between 12 and 26 weeks of work may be needed,
and it takes patience to achieve behavioral change. 15
In chronic pain conditions, it is particularly important to take things
slowly in the beginning. Approaching breathing exercises too intensively
can actually set you back. Begin the practice gently. If you suffer with
fibromyalgia, your sensitivity to CO 2 may be very high. This can trigger too
much air hunger, muscular tension, and feelings of panic. As your tolerance
to CO 2 increases and your BOL T score improves, these feelings will ease. TEMPOROMANDIBULAR JOINT DISORDER
In Chapter Six, on pain, we looked at temporomandibular joint disorder
(TMD) and its relationship to dysfunctional breathing. Howev er, there is
evidence that a link also exists between the condition and female sex
hormones. Gender differences in pain sensitivity are sometimes dismissed as
matters of psychosocial and social conditioning29. Increasingly, however, it
is believed that hormonal and other biological factors contribute30,31. Temporomandibular joint disorder is around 1. 5 to 2 times more prevalent
in women32 and can be much worse than in men. Anatomically, women
produce much higher levels of pressure in the temporomandibular joint
when clenching than men33. It was traditionally thought that abnormalities
in the alignment of the jaws and teeth are the primary cause of TMD, but if
this were the case, the condition should be just as common in men as
women. The estrogen hormone,  estradiol (E2), which is the primary female
sex hormone,34 has been found  to be a risk factor for temporomandibular
pain in rats. 35 Incidence of TMD in women is thought to peak between 20and 40 years, coinciding with reproductive function and decreasing in
menopause when estrogen production declines. 36
Hyperventilation during the second part of the menstrual cycle can
contribute to temporomandibular pain. This is partly due to
hyperventilation-induced adapta tions in posture and to changes in the blood
acid-base balance. For instance, the respiratory alkalosis that occurs when
blood CO2 drops is known  to trigger musc le pain, while overbreathing can
cause a forward head posture. Postural adaptations including a forward-thrust of the head and rounded
shoulders are common among people with dysfunctional breathing patterns. This often begins in childhood  due to open mouth breathing caused by
swollen adenoids. Equally, there  is a chicken-and-egg scenario where poor
posture from sedentary desk work can adversely impact breathing. 37
According to a 2019 article on the website Spine Universe, which describes
sitting as “worse  than smoking” in terms of health, 70% of people spend six
or more hours a day sitting down. 37
A forward head posture contributes to TMD because it reduces
“freeway space. ” Freeway space is the distance between the upper and
lower teeth when the jaw is in its rest position. When the head is pushed
forward, the back teeth connect and pressure on the temporomandibular
joint increases. Restoring freeway space is considered important in treating
TMD. 29
As with other pain conditions, symptoms of TMD fluctuate cyclically in
line with the menstrual cycle. In the luteal phase of the cycle, estradiol and
progesterone are released. Both hormones cause blood CO2 levels to fall,38
affecting the amount of air breathed per minute. 12 The pain associated with
temporomandibular disorder increases toward the latter part of the
menstrual cycle, peaking in the first three days of menstruation when
progesterone levels increase and then decline. A second spike in pain
coincides with ovulation,36 when estrogen levels fluctuate. The worst pain
corresponds with low or changin g estrogen levels. 36 While the influence of
sex hormones on pain is still relatively unstudied, the general consensus is
that changes in breathing patterns across the menstrual cycle likely
contribute to temporomandibular joint pain. MIGRAINE
Temporomandibular joint disorder is a risk factor for migraine39 and tension
headache. 40 At the same time, psychological conditions such as depression
and anxiety are common to people with temporomandibular pain,
migraines, and tension headaches. 41 It has been suggested that rather than
the problem in the jaw causing  the headache or migraine, these disorders
develop and progress via the same underlying imbalances in the central
nervous system. 39 This may be why relaxation techniques that influence the
nervous system are effective for the relief of both migraine42 and tension
headaches. 43
A case describ ed in the Journal of Neur ology, Neur osurgery &
Psychiatry  in 2004 demonstrated that hyperventilation,44 both during rest
and following physical exertion, “may cause severe, acute, ‘explosive’
headaches” and that these could  be prevented with relaxation exercises and
physical therapy. The precise cause of the headache in this case study was
not identified, but researchers suggested that breathing exercises may
prevent excessive hyperventilation after exercise, although they “would not
prevent physiological exercise induced hyperventilation. ” They suggest that
hyperventilation should be considered in all patients whose headaches are
triggered by exertion. It is important to remember that you can prevent exercise-induced
hyperventilation by practicing nasal breathing while exercising and by
improving your BOL T score. You can also make a conscious effort to bring
your breathing and heart rate under control after exercising with a slow
breathing practice. Hypercapnia (high blood CO2) has been found to stop the onset of
migraines by increasing cereb ral oxygenation—by dilating the blood
vessels in the brain. Researchers in a 2018 pilot study tested to find out
whether a self-administered partial rebreathing device would be effective
for migraine patients. 45 A partial rebreathing device is exactly what it
sounds like—a machine through  which the patient “rebreathes” exhaled air,
which has higher levels of CO2 than room air. To some extent, the same
effect can be achieved by wearing a face mask or covering. Eight women and three men with an average age of around 35 took part
in the trial. They each self-administered either the rebreathing device or a
placebo in response to migraine attacks. The results showed that the partial
rebreathing device increased end-tidal CO2 by 24% and maintained oxygen
saturation at over 97%. The intensity of headache symptoms after two hours
was significantly less with the rebreathing device. What’ s more, the device
became more effective the more  it was used, with even better results with
consecutive treatments. There were no adverse reactions, and side effects
were nonexistent or mild. The researchers concluded that induced
hypercapnia presents a promising alternative or add-on treatment for
migraine patients and further work should be done to investigate the
benefits in a lar ger population. The fact that the efficiency of the rebreathing device increased from one
treatment to the next corresponds with what we know about reduced-
volume breathing. Regular pract ice of breathing exercises to increase levels
of CO2 results in reduc ed sensitivity to CO2, and lighter, slower breathing,
as evidenced by a higher BOL T score. The 2018 hypercapnia study was preceded nearly 40 years earlier by an
investigation into the relationship between migraines and blood CO2. 46 A
1980 paper described the effects of CO2 on blood vessel s and circulation in
the brain, noting that anesthetists “regularly hyperventilate patients to
reduce brain volume during neurosur gery. ” The researchers hypothesized
that, if migraine falls into two categories, dilatory and constriction-based,
retaining CO2 during sleep could trigger migraines by dilating the blood
vessels, or hyperventilation provoked by “excitement, anxiety, or
expectation of physical or sexual activity” could trigger migraines by
constricting the blood vessels. The results showed that hyperventilation occurred at the peak of the
migraine, making the attack seem worse than it was. The researchers
suggested that not only was the perception of the migraine heightened but
symptoms were increased by the constriction of the blood vessels caused by
the hyperventila tion. This suggests that CO2 may play a part in the onset
and persistence of migraines. In 2015,  another paper in Medicine  found a correla tion between sleep-
disordered breat hing and migraine in adults but not in elderl y people. 47While more research is needed, it is thought that poor breathing patterns
during sleep could be either a trigger or a predisposing factor for the
development of migraines. None of these papers mention the connection between the incidence of
migraine and the menstrual cycle. 48 Various other studies have identified an
increase in the risk of migrain e without aura on the first two days of
menstrual flow, a reduced risk coinciding with the time of ovulation, and
much more prolonged headache s three to seven days before menstruation. 48
(Aura is a common neurologic al symptom of migraine usually involving
visual disturbances such as flashing lights before the eyes, tunnel vision,
and temporary blind spots. ) In one 2004 study, researchers observed that women were 25% more
likely to suffer from a migraine in the five days before their period, with the
risk increasing to 71% in the two days before, peaking on the first day of
menstruation and on the next two days. This was confirmed in 2007 when
scientists found that the highest occurrence of migraine coincided with the
first three days of a woman’ s period. 49 Menstr ual migraine is linked to
increased menstrual disability and distress—a fact that recently led to the
development of specific diagnostic criteria for menstrual migraine. 48
Pure menstrual migraine and menstrually related migraine are slightly
different. To characterize the migraine type, menstruation is defined either
as bleed ing as part of the norm al menstrual cycle or as the withdrawal of
progesterone in women who take combined oral contraceptives  or cyclical
hormone replacement therapy. Pure menstrual migraine is a migraine
without aura that occurs on the first day of menstruation or the two days
either side of it, in two out of three cycles, with no incidence at other times
in the cycle. Most women will suf fer from menstrually related migraines—a
migraine without aura that occurs at other times of the month. 48
Interestingly, the estrogen steroid hormone estradiol, which is
implicated in temporomandibula r joint pain, is also a factor in the onset and
progression of menstrual migraines. Scientists claim that by maintaining
levels of estrogen during the luteal phase of the cycle, it is possible to
prevent menstrual attacks. 50 This is particu larly relevant for women who
take hormonal contraceptives or those with irregular periods. It has been
suggested that continuous hormones in place of the usual “thre e weeks on,one week off” (known as a 21/7 regimen) may prevent the estrogen
withdrawal that triggers the headache. This idea is based more  on clinical
practice than on research trial data,50,51 but this does not detract from the
validity of the evidence. In one study, a 168-day placebo-free regime of hormonal
contraceptives, where hormones were taken at regular levels  every day,
helped relieve headache severit y and improve work productivity and day-
to-day function, compared to the normal 21/7 pattern. In a placebo-free
contraceptive regime, the same  levels of hormones are taken every day
without a “break. ” In another trial, a transdermal contracepti ve (a patch
worn on the skin to preven t ovulation), when used for 84 days
consecutively, resulted in fewer headaches compared with the standard 21/7
contraceptive regimen. 53
Research into menstrual migraine is limited. It should be noted,
however, that women who suffer from migraine with aura should not take
combined horm onal contraceptives due to an increased risk of ischemic
stroke. 54 More study of the link between sex hormones and migraines, and
of the possible genetic predisposition in some women is needed  to develop
more targeted diagnosis and treatment. Nonetheless, it is important to
understand that the functions of the sex hormones are not confined to the
reproductive system—they are active in the nervous systems too. PELVIC FLOOR DYSFUNCTIONS
Another aspect of pain and function specific to women is the connection
between the breath, pelvic floor function, and sacroiliac joint stability. 55
The sacroiliac joint connects the pelvis to the spine, essentially  supporting
the weight of the upper body. The pelvic floor and the diaphragm are
structurally and functionally connected by fascia and muscles,56 especially
the pubococcyg eus—the muscl e that controls urine flow57 and contracts
during or gasm. 58
The skeletal and muscular systems of the pelvis have been described as
a unit forming the base of a lumbopelvic “cylinder” with the diaphragm at
the top and the transversus abdominis at the sides. 59 The spinal column runs
through the center of this cylinder, supported by elements of the lower back,psoas, and abdominal muscles. Because the psoas fibers merge with the
diaphragm and the pelvic floor, stiffness or dysfunction in any of these
muscles is likely to affect the ability of the diaphragm to function normally,
impacting the stability of the spine. Analysis of over 38,000 telephone interviews showed that middle-aged
and older women were more likely to experience back pain alongside
breathing difficulties. It also showed that problems with both incontinence
and back pain might be due to physical limitations of functional  movement,
posture, and respiration in the trunk. 60 The fact is, if the muscles of the
pelvic floor are dysfunctional, compensatory muscle activity may interfere
with the activity of the pelvic  floor, compromising spinal stability and
possibly resultin g in urinary incontinence. The results of a 2007 study into
pelvic floor and abdominal muscle function in women indicated that
women with incontinence actually have increased  activity in these
muscles. 60 Researchers concluded that their finding “challenges the clinical
assumption that incontinence is associated with reduced pelvic floor muscle
activity. ”
Women with chronic pelvic pain frequently breathe into the upper chest. They have poor coordination in basic functions such as sittin g, standing,
and walking, and very stiff muscles in the lower back and hips. In a 2007
interview, Dr. Leon Chaitow explained that, when normal diaphragm
breathing is restored and the pelvic floor muscles are relaxed, it is relatively
easy to reestablish function in the pelvic floor. 61 Dysfunction in pelvic
muscles affects the stability of the spine and pelvis, while hyperventilation
contributes to problems with motor control. Normalizing imbalances in the joints and soft tissues, along with
postural and functional breath ing training, has the potential to modify,
relieve, or eliminate symptoms, including chronic pelvic pain. Chaitow
explains that manual deactivation of trigger points and physical relaxation
exercises, combined with breathing rehabilitation, “offer a practical way
forward. ” Conversely, because the pelvic floor mechanism can affect
diaphragm move ment and the function of the lungs, the author s of a 2015
study also suggest including  pelvic-floor -strengthening exercises in
breathing rehabilitation programs. 62Many chronic symptoms relatin g to the urethra, bladder, lower bowel,
and prostate can be caused, maintained, or aggravated by active myofascial
trigger points in the muscles of the pelvic area. 61 When these trigger points
are helping stabilize hypermob ile joints or enhance the stability of the
pelvic floor, their deactivation may ease pain at the cost of stability. It is
therefore necess ary to first address the underlying causes of the instability. As we discovered in the chapter s on functional movement and pain, trigger
points can be the result of psychological stress. They are a sign of
autonomic imba lance, and the autonomic nervous system can be regulated
through the practice of slow, light diaphragm breathing. It is also important
to remember that the respiratory alkalosis intrinsic to hyperventilation
encourages the development of myofascial trigger points. Trigger points, clenched pelvic floor muscles, and hyperactivity of the
muscles can sometimes be caused by psychological issues, including a
history of abuse or assault, or by excessive tone created by a background of
athletics, dance, or badly taught Pilates. When a psychosexual or
psychosocial element is present, appropriate therapeutic support is
necessary alongside breath and bodywork. 61
FEMALE HORMONES, LUNG HEAL TH, SLEEP, AND
ANXIETY
There is evidence that some respiratory illnesses behave differently in
women than in men. Asthma, for instance, is more common  in women. However, its prevalence change s with age. 11 In childhood, more boys have
asthma than girls, but once puberty hits, women are more susceptible, and
their symptoms fluctuate through the menstrual cycle. Up to 40% of women report premenstrual asthma symptoms that can
lead to severe attacks. 11 One study of girls aged between 8 and 17 years
found that girls who begin menstruating earlier tend to develop more severe
asthma after puberty. 63 The fact that respiratory symptoms change as
hormone levels fluctuate indicat es that sex hormones contribute to the onset
and persistence of asthma. 1,64 This theory is further confirmed by the fact
that 20% of asthmatic women suffer from worse sympto ms duringpregnancy11 and that female sex hormones can make the severe form of
asthma even worse. 65
A 2009 study compared respiratory function in women with and without
asthma over the course of the menstrual cycle. In all women, forced
expiratory volume and blood gas transfer varied through the menstrual
cycle, peaking during menstruation and declining to the lowest point in the
early luteal phase when progest erone was at its highest. Forced  expiratory
volume is an important measure of lung function, measuring the volume of
air that can be forced out in one second after taking a deep breath. The
cyclical respiratory changes occurred by way of very dif ferent physiological
mechanisms in women with asthma compared to healthy women. In
asthmatic wom en, cyclical variations in gas exchange were due to
differences in the functioning of the alveoli66. These  change s were
consistent, regar dless of inhaled corticosteroid or hormonal contraceptive
use. As horm one levels fluctuate over the 28-day cycle, blood vesse ls in the
lungs are constantly forming and disappearing. This impacts the way the
lungs take in oxygen because it affects ventilation perfusion. These findings
begin to provide insight into the way asthma presents in women, why
difficult-to-control, severe asthma is more common among women, and
why exacerbations occur in the luteal phase. Female sex hormones also
contribute to asthma exacerbations in women who are overwei ght because
obesity causes imbalances in the levels of estrogen and progesterone. 67
Another factor in the way asthma presents is the size and collapsibility
of the airway11. Men tend to experience much more airway collapsibility,
while women are more prone to inflammation in the airways. 68
In one 2010 study, hormone replacement therapy (HR T) was linked with
a high number of cases of newly diagnosed asthma in menopausal
women. 69,70 Some research  also shows that menopausal women who are
given hormone replacement medications experience worse asthma. One
trial assessed 184 women aged between 34 and 68 over the course of 10
years and found that E2 (estradiol/estrogen) replacement therapy increased
the incidence of asthma. 71 However, more recent papers  contradict this
finding, specifying that women are more likely to experience airway
obstruction if they do not take HRT. 72 While the literature is limited andsometimes confusing, these findings begin to paint the picture that certain
features of asthma are unique to women, including the much greater
prevalence of symptoms that are severe or difficult to control and the
phenomenon of premenstrual asthma exacerbations. 66
COPD (chronic obstructive pulm onary disorder) is a condition in which
patients have ongoing hypercap nia and hypoxia due to impair ed lung gas
exchange. It causes dysfunctio nal muscles that are easily fatigued, have
reduced strength and endurance, and a tendency to atrophy. 73 COPD has
traditionally been thought of primarily as a disorder af fecting older men, but
recent years have seen an increase of incidence and a significant rise in
mortality in women. 74 This is thought to be, at least in part, due to smoking. While the number of smokers is decreasing across North America and
Europe, more women than ever are smoking in developing countries where
the health risks are less known. For instance, a 2009 study found that only
38% of smokers  in China knew that smoking could cause heart disease,75
and even  in developed countries, there is a degree of ignorance. Women are
also more likely  to be exposed to passive smoking than men, they develop
COPD with less smoking history than men, and their decline in lung
function is faster. 11 It is interesting  that the resilie nce shown by females
against maternal smoking compared to males reverses in adulthood. COPD is an umbrella term rather than a specific disease. There are
differences in the way it manif ests in women. Emphysema, a debilitating
“end state” of COPD, in which the alveoli become damaged and the patient
requires constant oxygen, is more common in men. Women tend to display
more reactive airways—irritation, inflammation, and infection—and more
pronounced narrowing of the airways11. Long-t erm oxygen therapy is more
effective in women, and women  have a much greater improvem ent in lung
function once they stop smoking. Estrogen is involved in maintaining cell
structures and in the elasticity of the lungs that keeps the airways open. 76
Cigarette smoke  has an antiestrogen effect,77 and this may contribute to
impaired lung function in women who smoke or inhale secondhand
smoke. 76,78
In 2019,  a study investigated whether female sex hormones contribute
to COPD. 79 Researchers found that women who had used oral
contraceptives were less likely to be hospitalized or to die with COPD. However, women who had started their periods later than 15 years old and
those who experienced early menopause were more at risk. Early onset of
puberty, which is a risk factor for asthma,63 had an impact on lung function
(how well the lungs work) but not on COPD. Women with a history of
polycystic ovary  syndrome (PCOS), ovarian cysts, HRT use, and surgery to
remove the ovaries and/or fallop ian tubes were all at higher risk of COPD,
although their lung function was likely to be better. This corresponds with
the finding that women were less susceptible to emphysema  than men. Remember, COPD is an umbrella term, and symptoms can affect breathing
to a greater or lesser extent. Scientists concluded that a variety of aspects of
reproductive health throughout a woman’ s life can contribute  to COPD-
related hospitalization and death  or to lung health. More work is needed to
understand the complex links between COPD and sex hormones in terms of
HRT,11,79 ovarian cysts, PCOS, and hysterectomy. According to a 2018 clinical review, lung cancer mortality is increasing
in women but not men. The number of women who die each year from lung
cancer is greater than the combin ed female mortality rate for breast, uterine,
and ovarian cancer. 11 A woman who doesn’ t smoke is three times more
likely to be diagnosed with lung cancer than a nonsmoking man, indicating
a possib le hormonal influence. However, women have a better prognosis, in
terms of chemotherapy and surgical response, and a higher five-year
survival rate. Pulmonary hypertension—high blood pressure in the blood vessels that
supply the lungs—is more common in women and occurs around 10 years
earlier in women than in men. Again, more research is needed to understand
the role of the sex hormones, and to discover if and how estrog en increases
female susceptibility to lung disorders. 11
While there are differences between women and men across many
respiratory conditions, it is still largely unknown whether these disparities
are behavioral, social, environm ental, or biological. To date, most research
has simply conc luded that more work is needed to ascertain the role of
hormones in lung health. 11,80
SLEEP-DISORDERED BREA THINGWe have already discussed snoring, insomnia, and sleep apnea in detail
(Chapter Seven ), but here again, there are differences between men and
women in sleep-disordered breathing, and these are worth mentioning. There is a highe r prevalence of sleep apnea in men, perhaps due to a greater
collapsibility of the airways. 11 But once wome n reach menopause, there is
about a 200% increase in the incidence of sleep apnea. 1 This occurs
independently of other risk factors, indicating that female sex hormones,
thought to have a protective effect on the airways and ventil atory drive,
could guard against sleep apnea in premenopausal women. 11
Young and middle-aged women are far less prone to apneas than men,
but older women experience much more sleep disturbance. Reduced levels
of progesterone  and estradiol (estrogen) contribute to the incidence of
sleep-disordered breathing. 81 Replacement of these hormones decreases
apnea frequency compared with untreated postmenopausal women. 82
Premenopausal women with severe obstructive sleep apnea have much
lower progestero ne than healthy women and women with mild OSA. 83 The
gender differen ces in the prevalence of sleep apnea decreases after
menopause, indicating that the menopausal status itself plays a part in OSA. Progesterone is known to improve the tone of the upper airway muscles. 11
Levels of the hormone decrease after menopause, which is one reason why
postmenopausal women become more susceptible to sleep -disordered
breathing. A 2015 study found that progesterone reduces sleep apnea in
menopausal women. 84
Another contributing factor is a change in the way body  fat is
distributed. After menopause, women are likely to have more body fat, and
this tends to be concentrated in the upper body, where fat on the tongue,
neck, and abdom en is a commo n anatomical factor in sleep apnea. Fat on
the throa t narrows the airway, causing increased resistance to breathing and
greater airway collapsibility. Fat on the tongue takes up space in the mouth
and may encroa ch on the airway. Extra weight on the belly reduces the
amplitude of diaphragm movem ents, causing a decrease in lung volume and
more frequent collapse of the upper airways during sleep. The results of a 1988 study comparing incidence of sleep-disordered
breathing in obese men and women found that obese women have an
increased chemosensitivity to hypoxia and hypercapnia when compared towomen of a healthy weight. Breathing is often noticeable in overweight
women, even at rest. Fast, upper chest breathing with no pause after the
exhalation and feelings of breathlessness are typical. While it would make
sense that the increased sensitivi ty to blood CO2 could be caused  by oxygen
desaturation and poor breathing during sleep, the same change in
chemosensitivity in relation to body fat load is not present in obese men. 85
Similarly, pregnancy increases the incidence of OSA by around 8% due
to increased neck circumference, greater nasal congestion, and pharyngeal
edema, a swelling in the tissues of the throat. In the later stages of
pregnancy, there  is also less room for the diaphragm to function, reducing
lung volume and triggering upper airway collapse. As a result of these
considerations, snoring is consi dered a primary risk factor in pregnancy-
induced hypertension. 86 (We will look in more detail at OSA during
pregnancy in the next chapter. ) ANXIETY DISORDERS
Women are between two and three times more likely to develop panic
disorder than men. 1 This susceptibility may be linked to sex hormones. Women with panic disorder experience a worsening of their panic
symptoms and anxiety during the premenstrual phase of their cycle. 87,88
Studies in rats have shown that withdrawal of progesterone increased
susceptibility to panic-related anxiety, indicating that the lower levels of
progesterone in the days before the period may be a trigger. 89 Numerous
studies link low progesterone to feelings of anxiety. 87 Progesterone is a
respiratory stimulant. High levels of the hormone can cause
hyperventilation, but when levels drop very low, it is thought this can
increase the perception of breathlessness. 90 While the weig ht of evidence
points to a higher prevalence of anxiety disorders in women, the research is
incomplete. This comes back to the male/female research bias and the fact
that the bulk of the literature has focused on male rodents. 91
Scientist have demonstrated an increase in panic symptoms, often
interpreted as hot flashes, and anxiety in women experiencing the
menopausal transition. This suggests that panic disorder may be linked to
fluctuations in sex hormones. 92 Since studies have linked the onset of panicsymptoms with heightened sensitivity to blood CO2, it make s sense that the
hyperventilation, which occurs at certain points in the menstrual cycle, may
produce cyclic exacerbations of anxiety. When all the connections between
hyperventilation, hormones, and panic disorder are taken togeth er, it makes
sense that sex hormones could contribute to anxiety in women. One recent
paper concluded that it is impor tant for future research to study anxiety in
females so that results can be more accurate and applicable to women. 91
WOMEN’S HORMONES AND SPOR TING PERFORMANCE
Another conside ration when exploring the topic of breathing in terms of
gender is the impact of sex hormones and anatomical factors on physical
exercise. It is known that while  women are capable of outstand ing athletic
achievement, they generally have to work harder to breathe during intensive
exercise than men. 93,94
A 2020 study demonstrated that gender affects the respiratory aspects of
physical exercise. The research team hypothesized that the smaller airways
in females, when compared with the airways of height-matched males,
produced more turbulent airflow during exercise. Turbulent airflow causes
the air molecules to move in different directions, much like water bubbling
round pebbles in a running stream. This creates more resistance, making
breathing more dif ficult. 94
Five women and six men took part in the trial, during which they each
performed two exercise tests, gradually intensifying their workout on a
stationary cycle until they reached maximum intensity. During the tests,
participants breathed through a mouthpiece, inhaling either norm al room air
or a mixture of oxygen and helium. Respiratory effort was monitored via a
small tube inser ted into the nose and throat. In this experiment, the helium
mix was designed to mimic the lower levels of resistance in the larger male
airways. The helium mixture was less dense than the room air and moved in
a more direct manner, with all the molecules flowing in the same
direction. 94 This is called laminar airflow. The results showed that wome n breathed much more air when they
inhaled the helium and oxygen  mix, but this change in breathing volume
was not accompanied by an increase in the work of breath ing. Whenbreathing room air, the female participants had to breathe much harder than
the men to overcome the turbulent resistance. When they breathed the
helium and oxygen mix, the airflow was more laminar, and there was no
difference betwe en the males and females in ventilatory exertion. The study
concluded that smaller airways  increase turbulent flow and that is why
women have to breathe harder during exercise. 94
In an article in Neur oscience News, Paolo Dominelli, who was on the
research team for the study, explained,
At rest, the rate of air flow is very low, so even though women have
smaller airways  than men, air flow is still laminar. As exercise
intensity increases, you breathe faster, and at some point the airflow
goes from laminar to turbulent. Air flow in men’ s airways will also
eventually turn from laminar to turbulent, but this requires a higher
rate of air flow than is required in women. 93
It is important to understand that while the differences shown  in this
study relate to size and gender, with men typically having larger airways,
airway size varies significantly between individuals. 93 For instance, people
of both sexes who have set-back jaws or other craniofacial abnormalities
caused by child hood mouth breathing, pacifier use, tongue-tie, and other
factors will have  smaller airways in adulthood, leading to a lifetime of sleep
problems and reduced athletic ability. Other difference s may also have an impact on sporting perform ance in
women. In 1993, a review published in Sports Medicine  examined the
impact of sex hormone fluctuations, due to the natural menstru al cycle and
use of oral contraceptives, on the performance of female athletes. 95
Previous research had reported that the best days for athletic performance
were generally those immediate ly after menstruation and the worst were in
the premenstrua l stage and the first few days of menstrual flow. However,
those studies were limited by lack of accuracy as to where in the cycle the
women were. There was also an inherent bias, because many of the women  already
associated premenstrual symptoms such as weight gain, mood swings, and
fluid retention with poor perform ance. Their perception of performance was
therefore already less positive at that point in the cycle. Those premenstrualsymptoms have  also been linked with an increase in musculoskeletal
injuries during the premenstrua l and menstrual phases. In the days before
menstruation, women were shown to experience compromis ed reaction
time, neuromuscular coordination, dexterity, and judgment, but other
potential confou nding factors such as nutrition, blood sugar levels, and
hyperventilation may cloud these findings. Swimmers demonstrated worse performance times during the
premenstrual phase and better times during menstruation and on the eighth
day of the cycle. The women’ s perception of exertion during very intense
exercises increa sed premenstru ally and during the first few days of
menstruation. 95 In cross-country skiers, the best performance times were
recorded in the days just after ovulation and immediately following
menstruation. To get the most out of training, loads should be adjusted for
female athletes to account for changes during the menstrual cycle. Studies using estradiol and progesterone levels to determine where a
woman was in her cycle did not find any marked differences across the 28
days in response to either maximal or less intensive exercise, though a small
decrease in aerobic capacity was observed during the luteal phase. However, in 2003, it was confirmed that breathing capacity was much
higher in men than women1. During the follicular phase of the cycle,
ventilation, tidal volume, and peak inspiratory flow were 21% lower in
women during wakefulness and 22% lower during sleep. At the same time,
no difference was found between men and women in blood flow to the
respiratory musc les during exercise or rest, or during different phases of the
menstrual cycle. 95
A 2019 study investigated the effects of the menstrual cycle on running
economy. 96 Eleven female athletes were assessed for oxygen consumption
and blood gas exchange at rest and while running. Scientists concluded that
gas exchange during exercise is better in the luteal phase than the follicular
phase but that this is independent of running speed. It was also
demonstrated that the menstrual  cycle has no effect on body composition or
physiological variables at rest. 96
Again, research into this area is sparse. Perhaps most relevant to female
athletes is knowing that hyperv entilation is likely during the luteal phase,
between ovulati on and menstruation. By paying attention to the breath,working to normalize breathing volume, and reducing sensitivit y to CO2, it
should be possible to moderate these naturally occurring phasic differences
in breathing. Another point worth mentioning is that, in extreme circumstances,
women’ s sportin g ambitions can impact their health and hormones in an
unhealthy way. Excessive runni ng or training places considerable stress on
the body. This can cause an imbalance in the autonomic nervous system,
affect the immu ne response, and put strain on the heart. When bodyweight
and body mass index fall too low, estrogen will drop, and this can result in a
lack of bone mineral density. Just as menopause is a risk factor for
osteoporosis (something we explore in the next chapter), so is any condition
that causes estrogen production  to decline, because estrogen inhibits bone
resorption. 97 Estroge n is a primary hormonal regulator of bone metabolism
in women and men. 98
When estrogen drops too low, fertility is impacted and menstruation
ceases. This is the same for women with eating disorders. In fact, eating
disorders and obsessive exercis e combine to form the basis of a specific
condition called  relative energy deficiency in sport, or REDS. This can be
an easy trap to fall into, especially for women with perfecti onist, high-
achieving person alities. If you feel your running is becoming obsessive and
weight loss is tipping over into an eating disorder, it is importa nt to speak
with a specialist as soon as you can. In an article for the UK website Momentum Sports, endurance runner
Katherine Wood writes openly about her 10-year battle with anorexia
nervosa and REDS. 99 Wood was a competitive runner and swimmer as a
child and teenager, but as she went through puberty, she struggled to
balance her nutritional input with the energy output required in her training. She rapidly transitioned from unintentional weight loss to full-blown
anorexia that left her in hospital. Her periods stopped. As her running  career progressed, Wood pushed herself harder and
further. She achieved succes s after success. But she was training
compulsively, ignoring injuries and signs that her health was failing, and
losing weight fast. She began to have repeated bacterial infections on the
skin of her legs. Blood tests returned signs that her muscles were starting tobreak down, but she experienced a sense of failure if she didn’ t keep up her
intensive training. Eventually, she turned to Renee McGregor for help. McGregor is a
sports and eating disorder therapist and cofounder of #TRAINBRA VE, an
initiative aimed at raising awareness of eating disorders in athletes. In the
first consultatio n, Wood was devastated to be told that she had to stop
exercising imme diately and that her heart could give way at any moment if
she didn’t. In the following months, she found it incredibly difficult to
increase her food intake while not exercising at all. Scans revealed that her
bone density was so low she was classed as osteopenic. She struggled to get
a prescr iption for HRT; a lack of understanding of sports-related eating
disorders among  general medical providers meant she had to seek private
healthcare. In her article, she issues this caution against underfueling and
overtraining, “Periods stopping  is NOT a sign that you are training hard
enough, it is a sign you are training TOO hard and your body is not coping. Please do not ignore these signs. ”99
OceanofPDF. comPCHAPTER THIR TEEN
FEMALE SEX HORMONES AND THE
BREATH
PMS AND CYCLIC HYPER VENTILA TION
remenstrual syndrome (PMS) manifests with similar or identical
symptoms to chronic hyperventilation syndrome. 1 A 2006 study
found that women with PMS experience a much greater decline in
blood carbon dioxide (CO 2) in the premenstrual phase than women who do
not experience symptoms. The symptoms appear as progesterone increases
and blood CO2 decreases. When the luteal phase ends, progesterone
decreases, CO2 levels normalize, and the symptoms disappear. The study
concluded that women with PMS have a higher -than-normal sensitivity to
CO2, perhaps caused by progesterone, resulting in “pron ounced
hyperventilation”—and that the hyperventilation is responsible for the
symptoms. 2
Breathing plays  a role even from the perspective of physic al pain
experienced. Not only is pain perception heightened by low CO2 levels, the
drop in CO2 also causes constriction of smooth muscles. Since the uterus is
comprised of smooth muscle, this can directly contribute to pain
experienced as menstrual cramps. 3
The authors of the 2006 study suggest that since the breath can be easily
manipulated using a variety of techniques, including respiratory and
biofeedback training, it would be promising to explore this phenomenon in
more detail to understand the mechanisms underlying PMS and find moreeffective ways to treat it, at least for some women. 2 Their conclusion points
to the relevance of the techniques in this book. Science has yet to
adequately catch  up, but existing  research does point to the fact that women
can control symptoms of PMS by changing their breathing patterns to
restore slow, light, nasal breathing. In the same study, researchers noted that selective serotonin-reuptake
inhibitors (SSRIs), commonly used as antidepressants and for alleviating
the symptoms of PMS, cause an increase in blood CO 2 levels. Serotonin is a
chemical messenger that has many complex functions. It is known as the
“happy chemica l” because it contributes to feelings of well-being. During
the luteal phase of the mens trual cycle, fluctuations in estrogen and
progesterone increase serotonin neurotransmission. 4 But according to 2015
research, women who suffer with PMS or premenstrual dysphoric disorder
(PMDD—a more severe form of premenstrual syndrome) appea r to have an
abnormal seroto nin reaction to luteal hormonal changes5. Also, it has been
shown that changes in the serotonin system may be indirectly related to
breathing abnormalities6 and treatment with SSRIs may improve respiratory
responses to CO 2. 7
The connection between PMDD  and panic disorder has been receiving
growing attentio n. Patients with both conditions experience high rates of
panic attacks, and PMDD and panic disorder may share the same
underlying pathology. 8 The link betw een menstruati on, depression, and
mood swings is commonly acknowledged and frequently stereotyped, but
the symptoms of PMS and PMDD are no joke. At clinically significant
levels, they are severe enough to interfere with daily life. We have explored the connection between headaches, menstrual
migraines, and hyperventilation, but there seems to be yet no scientific
literature examining the cyclical occurrence of depression, panic symptoms,
irritability, and mood swings in terms of hormone-induced respiratory
changes. This is despite the clear relationship between mood disorders,
dysfunctional breathing, and autonomic imbalance, and the fact that it is not
always possible to distinguish between depression and PMDD. 9
According to a 2017 advisory document from a New Zealand
pharmaco-vigilance team, symptoms including depressed mood, feelings of
hopelessness, difficulty concentrating, lack of energy, decreased interest inusual activities, hypersomnia, and insomnia are included in the diagnostic
criteria for both disorders. However, differences in the regulation of the
stress response between women  with depressive disorders and those with
PMDD may suggest two distinct conditions. It is believed, for instance, that
premenstrual symptoms are not particularly influenced by familial or
environmental factors while a history of anxiety disorder, traumatic events,
and smoking can all contribute. 9
EMMA ’S ST ORY
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Back Basics

Integrating shallow, rapid nostrils-only breathing lays foundation for optimal breathing techniques learning process starts from this method integration familiarity provides freedom enjoyment-specific breathing procedures



Three Dimensions Of Thinking


Noteworthy biases exist historical focus exclusively on subjects' genders impacting multiple fields sciences  

Historians acknowledge omission neglect crucial contributions made diverse groups acknowledging shortcomings   acknowledgement strengthens diversity inclusion equality scholarship advancement acknowledgment addresses fundamental gaps missing pieces adds depth richness nuanceness authenticity credibility trustworthiness reliability legitimacy veracity sincerity transparency accountability responsibility fairness justice compassion kindness empathy shared values principles ethics moral integrity respect dignity professionalism expertise authority wisdom discernimiento leadership mentorship collaboration communication harmony unity cooperation peace prosperity happiness fulfillment satisfaction joy passion creativity inspiration imagination intuition contemplativity mindfulness gratitude thanksgiving appreciation reflection introspection meditation spirituality spiritual enlightenment consciousness awakening liberation empowerment transformation renewal revival redemption reconciliation forgiveness acceptance letting go peaceful resolution restoration recovery uplift rejuvenació Naciónnal identity national pride cultural heritage language customs traditions family roots ancestry line ancestors genealogy DNA memory preservation conservation protection inheritance legacy descent lineage continuity succession tradition culture community kinships extended families societal expectations norms beliefs attitudes perspectives views opinions thoughts emotions cognitions motivations goals desires intentions aspirations preferences likings dispositions inclinations propensions receptivity responsiveness adaptiveness resilience resource ful ness determination perseverance dedication consistency commitment dependabi li ties interdependence reliance affiliation cohesion solidarity friendship camarader ie spirit teamwork networking loyalty faith hope encouragement positivity enthusiasm optimism confidence humility modesty humblene ss recognition admiration devotion allegiance affection attachment fond memories nostalgia sentimentality longing grief sorrow bereavemen t mourning regret remorse apology contrition guilt shame embarrassment hurt resentment bitterness anger hostility hatred aggression intolerance injustice inequality unfair advantage discrimination segregation marginaliza ti óón exclusion oppression suppression exploitation victimhood survivor ship trauma PTSD CPTSD flashbacks nightmares terror despair desperation despondency loneliness isolation abandonment rejection sadness melancholy worry concern doubt uncertainty confusion hesitation indecision ambivalence mixed motives contradictory demands conflicting loya ltiez rivalries competitions sacrifices concessions compromises trade-offs prioritizations hierachy ranking value judgments subjective objectification externalized internalized idealized personalized perceived projected actual expected anticipated desired pretended concealed hidden suppressed unconscious submerged buried forgotten ignored neglected overlooked disregarded forsaken abandoned lost misplaced misdirect ion misinformation misunderstanding misconception miscalcul.
Integrating light, slow, and deep nasal breathing, which is developed in the exercises in this book. Once you are familiar with a healthy breathing pattern, you can enjoy more specific breathing techniques.
What is the foundation of healthy breathing, and what is its purpose?
It is not the pelvic floor dysfunction, but rather the poor breathing patterns and hyperventilation, which affects the stability of the spine and pelvic floor.
What is the primary factor that contributes to the development of chronic pelvic pain in women?
Poor breathing patterns and hyperventilation can exacerbate pain and fatigue in fibromyalgia patients, and research suggests that improving BOL T score can help alleviate symptoms.
What is the relationship between fibromyalgia and breathing patterns?
It is important to maintain a healthy breathing pattern, as it can reduce the risk of migraines and anxiety. It is also important to note that the menstrual cycle has a significant impact on breathing patterns and should be considered in the diagnosis and treatment of these conditions.
What is the key to preventing migraines and anxiety in women?
It is crucial to practice slow and controlled breathing to avoid sleep-disordered breathing, which can be exacerbated by the hormonal fluctuations during the menstrual cycle, leading to sleep apnea.
What is the importance of slow and controlled breathing in the context of sleep apnea?