Should Every Woman in Menopause Take Creatine?

Sorting influencer hype from the hard data on bone and muscle health

Ask Dr. Jen

I’ve been hearing that creatine supplements are essential for bone and muscle health as we age. Should every woman in menopause be taking them? Thanks!

-Via The Vajenda

Everywhere you turn, on social media anyway, it seems that there is a meno-influencer recommending creatine as the new magic cure for aging. Unlike many other supplements, creatine has been studied in clinical trials, providing us with more data than is typically available for many other supplements.

So what does the evidence show? Is the hype worth it? Read on, so you can decide for yourself.

What is Creatine?

Creatine is a naturally occurring substance made from amino acids. Humans get about half of the creatine they need from diet, and the rest is made in the liver and kidneys. Most of our creatine is stored in skeletal muscle. Creatine plays a critical role in supplying energy and in metabolism. Most people can easily get the creatine they need from their diet.

Creatine Supplements - The Basics

Creatine supplementation increases creatine levels in muscles and has been shown in numerous studies to improve energy availability, especially during maximal effort, which enhances the ability to perform high-intensity exercise. When combined with resistance training, it increases lean mass. It may also improve training adaptations and post-exercise recovery by stimulating growth factors and activating satellite cells. This is why you may have seen it promoted by athletes, either as an advertisement or simply as part of their regimen. It is particularly useful for activities that involve sprinting or bursts of energy, such as hockey or soccer, or for resistance training to increase muscle mass. Creatine supplementation may also reduce muscle recovery time, which may allow a professional athlete to train harder.

There are several decades of safety data on creatine supplements, and studies with doses of up to 30 g per day for five years have shown that supplementation does not pose a health risk. There has been concern about the effects on kidney function, and for an otherwise healthy person with normal kidney function, there appears to be no cause for concern.

Creatine: Protecting Bone and Muscle Health in Menopause. What Does the Data Show?

Creatine may well help an athlete gain a competitive edge, but what about women in menopause looking to protect bone and muscle health? After all, some data suggest that creatine may provide energy to bone and may stimulate osteoblasts, which are cells that build bone. In addition, when muscle pulls on bone, it also provides a stimulus to build bone. Therefore, if creatine helps someone build more muscle, might it also give an additional boost to the bones? And can creatine help women maintain muscle mass and prevent sarcopenia, which is the gradual loss of muscle mass and strength over time?

What’s truly exciting is that unlike other supplements where I would be trying to make sense of some truly dismal studies, we actually have some quality studies with creatine! Even for women in menopause! I KNOW!!!!

So let’s look at the data.

There are pilot studies and shorter-term studies that suggest a benefit of creatine on bone health. For example, a study of 33 women found that 5 g a day of creatine for women who were also doing a supervised resistance training program had a 3.4% improvement in bone density at the femoral neck (a 5% increase reduces fracture risk by 25%). But we won’t be discussing the preliminary work as we actually have long-term studies to discuss.

(I KNOW!!!)

Creatine Supplementation and Resistance Training

This study (Gualano et al) enrolled women aged 60 years or older with osteopenia or osteoporosis. These women had not been doing regular exercise, and were considered “apparently vulnerable” (which was defined as “people who commonly complain of being 'slowed up' or have disease symptoms.”)

The women were randomized to one of four groups: placebo, creatine, placebo plus resistance training, and creatine plus resistance training. The creatine dose was 20 g a day for 5 days (loading dose), then 5 g a day. The resistance training was twice-a-week for 24-weeks in an intrahospital gym and was supervised by two fitness professionals. The training program included the following exercises: leg press, leg extension, squat, seated row, bench press, lat-pull down, and sit-ups.

After 24 weeks, there was no change in bone density or bone markers for any of the participants, so no benefit or creatine over placebo for bone health with or without resistance training.

Muscle strength was assessed with a 1-RM (the maximum weight for one rep) for the leg press and bench press. After 24 weeks, there were similar gains for the leg press for the creatine plus resistance training and the resistance training alone groups, which were both statistically better than placebo. Regarding the 1-RM bench press, the creatine plus resistance training had a statistically significant improvement versus the other three groups.

Regarding physical function tests, creatine and resistance training groups had superior gains in one of the tests versus the two groups without resistance training, and in one of the tests. In the either test all groups performed the same after 24 weeks.

The groups that took creatinine and did resistance training had the most gain in lean mass compared to the other three groups–in absolute numbers that translated into a 1.31% increase in lean mass or a 0.3 kg increase over 24 weeks. The groups that took creatine by itself or took placebo and did resistance training had a smaller gain in lean mass. The group that faired the worst was the placebo group with no resistance training, who lost an average of 1.2% of their lean mass (an average of 0.2 kg).

The study is small, with only 15 women completing each group, but it is well-designed. I think of it as an excellent exploratory study which provides a useful guide for future studies. One question that arises from this study is with longer use would there be greater gains in lean muscle mass for creatine plus resistance training versus resistance training alone?

Verdict: Creatine plus resistance training and resistance training without creatine can help with building lean mass and strength. Creatine plus resistance training may provide a small additional benefit in some measures. Creatine with or without resistance training did not benefit bone. Admittedly, 24 weeks may not be long enough to see a bone benefit, but there were blood markers for bone turnover, so if there was a small effect at a cellular level that should have been picked up. It’s also possible, of course, the study may not have had enough participants.

Creatine and Bone Health: A 2-Year Study Without Resistance Training

In this randomized double-blind placebo-controlled trial (Sales et al) postmenopausal women with osteopenia who were younger than age 70 received either 3 g of creatine monohydrate daily or a placebo. The women tracked their physical activity, but there was no activity intervention. Bone health was tracked with a bone density scan (DEXA), specialized CT scans, and blood tests for markers of bone health. The women were also evaluated using physical function and muscle strength tests, and their muscle mass was assessed. A total of 170 women completed the two-year study.

What did they find? Two years of creatine had no beneficial effect on bone health or physical function by any of the measures tested. This study also tracked lean mass as well as fractures and falls. The authors concluded that, “these findings suggest that the therapeutic effects attributed to Cr supplementation in conditions characterized by bone and muscle loss are primarily mediated by enhancements in the adaptive effects of exercise training, and cannot be achieved by Cr alone.”

Verdict: A well-designed, randomized, placebo-controlled trial shows that 3 g of creatine per day for 2 years in women not participating in resistance training provides no benefit for bone or muscle health. Many women in the study were getting the recommended amount of aerobic exercise a week, and this did not affect results.

Two-Year Randomized Trial of Creatine and Resistance Training

This study was done by the same group that showed had shown some benefit to bone health with one year of creatine supplementation and resistance training (Cilibeck et al). This new study enrolled 237 postmenopausal women (mean age of 59 years). The women were randomized to receive creatine (0.14 g/kg/day) or placebo (a higher dose than the original study, as a 70 kg woman would be taking 9.8 g/day). All participants engaged in supervised resistance training three days a week, supervised brisk walking three days a week, and unsupervised walking three days a week. Outcomes included bone density, bone measurements by ultrasound, lean mass, strength, and walking speed. A total of 86 women who took creatine and 88 who took the placebo completed the study.

After 2 years, creatine monohydrate supplementation with resistance training did not impact bone density at any of the sites measured when compared with resistance training alone. Creatine supplementation did provide some benefit to the structural properties of bone in some of the imaging measurements, but also in some other measurements, there was no benefit. The authors speculated that the creatine may have stimulated bone remodeling, and in some areas that may have led to bone formation, but in other areas there could also have been more breakdown of bone. While some of these beneficial changes are expected to improve bone resilience, the changes observed were below the threshold for fracture prevention.

Creatine, when combined with resistance training, increased lean mass and also increased walking speed over placebo. While these changes were statistically significant, it’s also important to look at the actual numbers–the creatine plus resistance training group increased lean mass by an average of 2.1 kg over 2 years, and the increase for the placebo plus resistance training group was 1.8 kg over 2 years, a difference of 0.3 kg. With walking speed, the creatine group took 1.5 seconds off their time for walking 80 meters versus only 0.1 second for the placebo. Creatinine did not provide any additional benefits over resistance training alone for measures of strength (hack squat and bench press strength). The authors hypothesized that they didn't see any benefit in strength with creatine supplementation in the current study because of “the large beneficial effect of resistance training alone on muscular strength,” and the “hack squat strength measure is quite variable,” which could obscure a small effect.

The study has some limitations. There was a relatively low compliance with the protocol, and a fair number of people who stopped the study. Also, the authors monitored kidney and liver function closely, and any potential concerns led to a reduction in dose, although the authors attempted to account for that in their analysis and the benefits of creatine and the lack of benefits (depending on the measure studied) remained the same. To me, this likely represents how an average woman might use creatine, because taking something every day is hard and if someone has some changes in liver or kidney function, their doctor will almost certainly ask them to reduce their creatine or even stop it so they can see if there is any link.

Verdict: No benefit of 2 years of creatinine on bone density, but the change in some bone markers should be evaluated in a longer-term study. Creatine increased lean mass over placebo, and while this change was statistically significant, whether a net increase of 0.3 kg of lean mass over resistance training alone is clinically significant (meaning does it prevent sarcopenia or reduce falls) is unknown.

Other Data

Several meta-analyses have looked at creatine and older populations, and the data is pretty consistent with creatine providing an added benefit for muscle mass and strength over resistance training alone. Whether this translates into reduce sarcopenia is not known. However, a more recent meta-analysis that looked at studies that only included older women found only an improvement in strength with creatine plus resistance training, not muscle mass, but this did not include the two-year trial from 2022 which was published later.

The benefits with muscle mass and/or strength haven’t yet translated into studies that have shown a reduction in end points like sarcopenia, fractures, or falls, but it’s also important to add that we may need longer-term studies to see these changes (and of course longer-term studies may also not show benefit, so we shouldn’t speculate).

While changes in muscle strength and/or lean mass in studies may be statistically significant, and may well be important to professional athletes where a 0.1% difference can make a difference, we don’t yet know if the small changes seen in muscle mass and strength with creatine plus resistance training over resistance training alone are clinically meaningful for the general population.

A recent meta-analysis (Burke et al) looked at the amount of muscle that is actually gained and reported a 0.10-0.16 cm change with a combination of creatine supplementation and resistance training “on changes in the upper and lower body muscle thickness.” There is also some data that suggests some people are creatine responders while others are not, so some people may see more gains over others.

Summary

• Every woman in menopause does not need to take creatine for bone or muscle health. However, adding in resistance training will benefit almost every woman.

• If you are not doing resistance training, there seems to be no value to taking a creatine supplement for the specific purposes of bone or muscle health. I would be suspicious of people telling you that it is proven to protect against osteoporosis or sarcopenia as a stand alone therapy. In fact, it could be harmful to tell women that creatine itself can be beneficial as it may lead people to erroneously believe they can just take the supplement without the exercise to get the benefit for muscle health. That’s why I think it’s unethical for meno-influencers to push creatine without first explaining it should be considered an add-on therapy to those committed to a resistance training program. It is not a stand alone therapy. (Basically, you’re wasting your money taking creatine if you aren’t also participating in a resistance training regimen.)

• Women in menopause who are regularly engaging in resistance training may see an additive benefit in strength and/or lean mass from daily use of creatine, but whether those gains are meaningful medically, for example a reduced risk of sarcopenia or falls over resistance training alone isn’t known (remember, resistance training alone is incredibly powerful). An individual can decide whether a 0.3 kg improvement in lean mass over 2 years with creatinine plus resistance training over resistance training alone is of value to them. Some people may wish to take it to see if it improves athletic performance or improves recovery. As some people may see more results than others, that may explain reports of why some find it helps a lot and others not at all.

• Creatine seems very safe, even in doses up to 30 g a day (although side effects may be more common with higher doses). The typical dose for someone wanting to see if creatine gives them an added benefit to resistance training is 3-5 g a day. The idea of needing a loading dose for several days has largely been discarded.

• Creatine does not harm the kidneys. However, creatine supplements can raise the blood level of creatinine, which is a test that we use to monitor the health of the kidneys, and so anyone with kidney disease should first discuss their proposed use of creatine with their doctor. The effects of creatine for people with known kidney disease are less certain as we don’t have long term studies of this population. However, it is reassuring that there were no adverse kidney effects in women in menopause in the two long term studies.

• A creatine supplement should ALWAYS be third-party verified for safety. There are many reports of sports supplements that contain pharmaceuticals and even banned substances. ONLY take a product with a seal from a recognized third-party tester, a claim on the website that says “third party testing” without the name of the testing company is about as good as a statement that says “my mom tested this and she says it’s great!” USP-Verified, NSF, and Informed Sport are three recognized companies for third party testing, but with creatine, because it’s a sports supplement, you will get an extra level of safety if the product says it is NSF certified for sport, or verified by Informed Sport, as this means there has been additional testing or banned substances. The label should be on the packaging and easy to see, if it’s not, give it a pass, regardless of who is promoting it. Here is a good list from Men’s Health of creatine products with price, and the pros and cons of each product, as well as information about the third-party testing. There is definitely a lower cost alternative for someone wanting to give it a try for three months. Another resource to compare creatine supplements is ConsumerLabs.com, and I believe many libraries offer a subscription.

It’s clearly possible to do quality clinical trials with supplements. My guess the reason that researchers have devoted the time and effort into studying creatine is that the basic science suggested a valid hypothesis (important first step), the original preliminary studies were well-done and looked promising, and then each subsequent study showed benefit or a new angle to evaluate. As the quality of the data improved, so did the ability to get funding. And so on. For example, the two-year clinical trial for resistance training with and without creatine received funding from the Canadian Institutes of Health Research and the Canada Foundation for Innovation.

The reason many supplements with bold claims never progress beyond preliminary studies is the hypothesis was never robust, the preliminary studies showed no benefit, or the preliminary studies were low quality. Why would an ethical researcher want to commit precious time, energy, and funding here? Just something to consider the next time you see supplements promoted based on small, short-term studies or even based on animal data.

I know the latest thing is creatine for brain health, and I will tackle that data in another post. Meanwhile, there are actual evidence-based things you can do for brain health, which I covered in this post.

References

Kreider, R.B., Kalman, D.S., Antonio, J. et al. International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. J Int Soc Sports Nutr 14, 18 (2017). https://doi.org/10.1186/s12970-017-0173-z

Devries MC, Phillips SM. Creatine supplementation during resistance training in older adults-a meta-analysis. Med Sci Sports Exerc. 2014 Jun;46(6):1194-203. doi: 10.1249/MSS.0000000000000220. PMID: 24576864.

Gualano B, Macedo AR, Alves CR, Roschel H, Benatti FB, Takayama L, de Sá Pinto AL, Lima FR, Pereira RM. Creatine supplementation and resistance training in vulnerable older women: a randomized double-blind placebo-controlled clinical trial. Exp Gerontol. 2014 May;53:7-15. doi: 10.1016/j.exger.2014.02.003. Epub 2014 Feb 13. PMID: 24530883.

Sales LP, Pinto AJ, Rodrigues SF, Alvarenga JC, Gonçalves N, Sampaio-Barros MM, Benatti FB, Gualano B, Rodrigues Pereira RM. Creatine Supplementation (3 g/d) and Bone Health in Older Women: A 2-Year, Randomized, Placebo-Controlled Trial. J Gerontol A Biol Sci Med Sci. 2020 Apr 17;75(5):931-938. doi: 10.1093/gerona/glz162. PMID: 31257405.

Cilibeck PD, Candow DG, Gordon JJ, Duff WRD, Mason R, Shaw K, Taylor-Gjevre R, Nair B, Zello GA. A 2-yr Randomized Controlled Trial on Creatine Supplementation during Exercise for Postmenopausal Bone Health. Med Sci Sports Exerc. 2023 Oct 1;55(10):1750-1760.

Candow DG, Chilibeck PD, Forbes SC. Creatine supplementation and aging musculoskeletal health. Endocrine. 2014 Apr;45(3):354-61. doi: 10.1007/s12020-013-0070-4. Epub 2013 Nov 5. PMID: 24190049.

Stares A, Bains M. The Additive Effects of Creatine Supplementation and Exercise Training in an Aging Population: A Systematic Review of Randomized Controlled Trials. J Geriatr Phys Ther. 2020 Apr/Jun;43(2):99-112. doi: 10.1519/JPT.0000000000000222. PMID: 30762623.

Burke R, Piñero A, Coleman M, Mohan A, Sapuppo M, Augustin F, Aragon AA, Candow DG, Forbes SC, Swinton P, Schoenfeld BJ. The Effects of Creatine Supplementation Combined with Resistance Training on Regional Measures of Muscle Hypertrophy: A Systematic Review with Meta-Analysis. Nutrients. 2023 Apr 28;15(9):2116. doi: 10.3390/nu15092116. PMID: 37432300; PMCID: PMC10180745.

Dos Santos EEP, de Araújo RC, Candow DG, Forbes SC, Guijo JA, de Almeida Santana CC, Prado WLD, Botero JP. Efficacy of Creatine Supplementation Combined with Resistance Training on Muscle Strength and Muscle Mass in Older Females: A Systematic Review and Meta-Analysis. Nutrients. 2021 Oct 24;13(11):3757. doi: 10.3390/nu13113757. PMID: 34836013; PMCID: PMC8619193.