Menopause

Menopause is the cessation of menstrual cycles, occurring for most women between the ages of 47 and 55 years. During perimenopause, as estrogen levels decrease, women often experience hot flashes, night sweats, vaginal dryness, and mood swings. While some women experience debilitating symptoms, others transition through this time with few complaints. Unless precipitated by surgery or illness, menopause is part of the natural aging process. As such, women should be reminded to consider this time as an opportunity to celebrate their beauty, strength, and vitality by recommitting to a healthy lifestyle.

Diagnosis

Menopause is a retrospective, clinical diagnosis made after 12 months of amenorrhea, resulting from the cessation of ovarian follicle production. At this time, follicle-stimulating hormone (FSH) levels rise significantly in an attempt to stimulate follicle production. Although an elevated FSH level is diagnostic of menopause, FSH levels are not routinely checked, as the level varies greatly in the months leading up to menopause due to irregular and missed menstruation. Clinicians should consider checking FSH and estradiol levels for symptomatic women less than 40 years old with missed periods, in whom premature ovarian failure is suspected.[1][2][3]

Controversy exists regarding the practice of measuring hormone levels for the diagnosis, treatment, and monitoring of menopause and its symptoms. Testing may not be reliable depending on the source (serum, saliva, or urine) and the method of hormone replacement administration. Because of the lack of research, routine testing is likely unnecessary for most women.[4]  The diagnosis of menopause should be made based on clinical findings; treatment is based on symptoms.

A Healthy, Comprehensive Approach to Menopause

Before addressing specific symptoms, clinicians should review the importance of a comprehensive approach to wellness during the menopausal transition. Cardiac and bone health should be addressed because of the increased risk of coronary artery disease and osteoporosis.

Diet

A healthy diet is always important, especially during menopause.

  • Review a healthy diet to maintain an optimal body weight. For many, this diet incorporates whole, unprocessed foods consisting of primarily fruits and vegetables; whole grains, and low-fat protein. For more information, refer to “Food and Drink,” a Whole Health overview.
  • Encourage foods high in calcium, with the goal of 1,000-1,200 mg daily as recommended by the Institute of Medicine.[5] If possible, encourage calcium intake from dietary sources. Refer to Table 1.
  • Consider adding sources of phytoestrogens, including soy and flax, for their health benefits and possible improvement in menopausal symptoms. For more information, refer to “Phytoestrogens” Whole Health tool.

Table 1. Foods High in Calcium

wdt_ID Food Amount of calcium (milligrams/serving)
1 Yogurt, low-fat, 8 ounces 315-415
2 Mozzarella, 1.5 ounces 330
3 Sardines, canned 3 ounces 325
4 Cheddar cheese, 1.5 ounces 300
5 Cow’s milk, 8 ounces 250-300
6 Orange juice, calcium fortified, 6 ounces 250
7 Tofu, with calcium sulfate, ½ cup 140-250
8 Salmon, canned, 3 ounces 180
9 Cottage cheese, 1 cup 140
10 Kale, 1 cup 100

Supplements

Note: Please refer to the Passport to Whole Health, Chapter 15 on Biologically-Based Approaches: Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer.

Although many supplements can be beneficial during menopause, assessing for adequate vitamin D supplementation and omega-3 fatty acid intake is especially important during this time.

Vitamin D.  The Institute of Medicine recommends 600 IU daily for women <70 years and 800 IU daily for women >70 years.[5] Consider checking a 25-hydroxy vitamin D level or supplementing with higher doses of 1,000-2,000 IU daily for women at higher risk of deficiency (northern/southern climates, darker skin, elderly) to support bone health.

Omega-3 fatty acids.  The American Heart Association (AHA) recommends eating two, 3.5-ounce servings of fatty fish a week because of the health benefits of the omega-3 fatty acids DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid). In those with documented coronary heart disease, the AHA recommends consuming 1 gm of combined EPA and DHA daily, either through fish or in supplement form. Assess dietary intake of fish and omega-3 fatty acids, considering supplementation for those with difficulty obtaining omega-3s through their diet. Other great sources include walnuts, ground flaxseed, and leafy green vegetables.

Movement

Prescribe moderate exercise for at least 30 minutes on most days of the week. Exercise should include muscle strengthening, weight-bearing activities, and yoga or tai chi to strengthen the mind-body connection. A 2011 Cochrane review found that non-weight-bearing, high-force activities such as progressive resistance strength training was most effective in increasing femur neck bone density,[6] whereas combinations of aerobic activity and weight-bearing and resistance exercises improved bone density of the spine.

Lifestyle

Everyday behaviors, patterns, and choices influence how we feel.

  • Assess for substance use or misuse, including tobacco, drugs, and excessive alcohol intake.
  • Support a healthy sleep-wake cycle. For more information, refer to the Whole Health overview “Recharge.”
  • Encourage use of light, loose-fitting clothing in layers to adjust to changing body temperatures.
  • Evaluate for healthy stress management. The body’s stress hormone, cortisol, is made from precursors that include progesterone. With an increasing need for cortisol production because of high stress, progesterone levels may decrease, disrupting the balance of estrogen and progesterone in the body. Review approaches for decreasing stress, in addition to coping techniques, relaxation exercises, and mind-body practices.

Power of the Mind

Encourage exploration of the mind-body connection to bring awareness to menopause as a life transition.

  • Explore helpful tools including breathing exercises, mindfulness meditation, yoga, tai chi, or Guided Imagery. For more information, refer to the Whole Heath tools “Breathing,” “Meditation,” “Yoga: Looking Beyond ‘The Mat,’” and “Guided Imagery.”
  • “Mastering Menopause,” a CD by Belleruth Naparstek, includes Guided Imagery practices to help with sleep, reinforce self-esteem, and redefine beauty and aging.

Spirituality

Encourage a connection in life that gives a greater sense of meaning and purpose.

  • Explore helpful tools including journaling, meditation, or connecting with religious or spiritual communities.
  • Suggest connecting with wise, older women who have transitioned into and through menopause.

Approaches to Treating Menopausal Symptoms

Although hormone replacement therapy (HRT) is an effective treatment for many menopausal symptoms, it is also associated with potential risks. Many therapies, including botanicals and lifestyle changes, offer alternative approaches that may improve symptoms with less risk. For a more thorough discussion on hormone replacement, refer to “Hormone Replacement Therapy” Whole Health tool.

Hot Flashes

Many women experience hot flashes during perimenopause and menopause. For some, they can be debilitating, and for others, they are better tolerated when viewed as a surge of heat or power. In some cultures, no word even exists for hot flash.[7] Experiences may vary based on diet, lifestyle, or cultural perception.

Black cohosh (Cimicifuga racemose) is an herb with estrogenlike properties. Results are inconsistent for the effects of black cohosh on menopausal symptoms, with significant variation among the herbal preparations studied. A Cochrane review in 2012 concluded that the evidence for use of black cohosh for menopausal symptoms was insufficient; however, “there is adequate justification for conducting further studies in this area.”[8]  The most conclusive evidence is for a commercial product Remifemin, containing 1 mg of triterpenes per 20 mg tablet.  Studies show it significantly reduces menopausal symptoms and hot flash frequency when compared to placebo.[9]  The standard dose is 40 mg once or twice daily.  Side effects are rare; the most common is mild gastrointestinal discomfort.

Because a small number of women have experienced liver problems while taking black cohosh, consider monitoring liver function tests with prolonged use and avoid use in women with liver disease.  The use of black cohosh for longer than 6 months has not been well-studied.  More information is available in the Whole Health tool “Top Supplements for Every Clinician to Know.”

Phytoestrogens are plant compounds with structures similar to estrogen, resulting in the ability to cause estrogenlike effects on the body.  The North American Menopause Society’s Isoflavones Report from 2011 concluded, “there are mixed results of the effects on midlife women. Soy-based isoflavones are modestly effective in relieving menopausal symptoms.”[10].  The variation in therapeutic effects of phytoestrogens in the treatment of menopause may be influenced by a woman’s intestinal bacteria and its ability to metabolize phytoestrogens into therapeutic substances in the body (i.e. converting daldzein into equol).[11]

Multiple meta-analyses have documented improved frequency of hot flashes with use of isoflavones in doses ranging from 50-100 mg daily.[11][12][13][14][15]  Refer to the “Phytoestrogens” Whole Health tool for increasing dietary intake. For more information on the use of soy, a particular type of phytoestrogen and its use in breast cancer, refer to the Whole Health overview “Cancer Care.”

Red clover (Trifolium pratense) contains isoflavones, a type of phytoestrogen. A systematic review of 10 trials concluded that red clover supplementation of 80 mg daily improved frequency of hot flashes and improved vaginal dryness, with more significant effects in women with severe hot flashes (>5/day).[16]  Side effects are rare.

Regular exercise has significant benefits for overall health and well-being. However, a Cochrane review in 2007 concluded the evidence was insufficient to determine the effectiveness of exercise on hot flashes.[17]  In a recent study, regular exercise did not alleviate hot flashes, but did result in improved sleep and mood.[18]

Acupuncture has been shown to reduce the frequency and severity of vasomotor symptoms in perimenopause and menopause, both individually and as adjunctive treatment.[19]  Research also supports its use in reducing sleep disturbances caused by menopause-related symptoms.[20]

Yoga studies suggest that it is effective in reducing menopausal symptoms.  Yoga was superior to other exercise for treatment of vasomotor symptoms.[21][22]

Other therapies some women find significant benefit from include alternative therapies and approaches such as energy work, traditional Chinese medicine, or Ayurveda for treatment of their menopausal symptoms, although extensive research has not yet been done. Use of mindfulness, meditation, and hypnosis have not shown improvement of menopausal symptoms.[23]  Tai chi has been shown to improve overall general health, vitality, and bodily pain.[24]  One must consider potential side effects and risks when considering these therapies.

Prescription medications have been shown to help with menopausal symptoms, particularly hot flashes. Consider a trial of clonidine, gabapentin, a selective serotonin reuptake inhibitor, SSRI), or a serotonin norephinephrine reuptake inhibitor (SNRI).  Evidence specific to medications will not be reviewed here.

Mood Swings and Irritability

Menopause is often a time of transition for most women, and life stressors in combination with changing hormone levels can result in some women feeling more sad and irritable. Healthy eating, regular exercise, and self-care are important to maintaining a stable mood. There are supplements that may also help

St. John’s wort (Hypericum perforatum) is commonly used for depression, and has been shown to improve mood and climacteric complaints in menopausal women. In one particular study, women using the combination of St. John’s wort and black cohosh reported improved scores for general menopausal symptoms and depression when compared to placebo.[25] The suggested dose is 300 mg three times daily (standardized to 0.3% hypericin or 4%-5% hyperforin). St. John’s wort is generally well-tolerated, but should be used with caution in combination with other medications metabolized through the P450 system.

Vaginal Dryness

As estrogen levels decrease in menopause, some women may experience vaginal dryness, leading to irritation and painful intercourse. Intravaginal estrogen will significantly improve dryness, but there are many other products and interventions that can help.

Vaginal moisturizers.  Women with vaginal dryness should use a vaginal moisturizer daily to maintain moisture and flexibility. Women should massage the product in small, circular strokes into the inner vagina and outer vulvar region once a day for five minutes, using a vibrator for internal placement and massage. Waiting two to four weeks after starting a vaginal moisturizing regimen may be necessary before resuming sexual intercourse.

When having intercourse, women should also be counseled to use a lubricant to reduce discomfort from friction. Lubricants with glycerin should be avoided if prone to yeast infections. Avoid petroleum jelly and oil-based lubricants because the vagina cannot clear oils and these substances can dissolve the latex in condoms.

Herbs and supplements.  A systematic review of 17 trials suggested that soy isoflavones may decrease vaginal symptoms in menopausal women when compared to control.[26]  Refer to the “Phytoestrogens” Whole Health tool for more information.

Sex and menopause.  Despite hormonal changes, a healthy sex life is possible during and after menopause.  Encourage women to actively treat vaginal dryness, to touch and be touched, and to have sex regularly. Weekly orgasms help maintain healthy blood flow and sensation.[27] For more information about sex and menopause, check out the book Better Than I Ever Expected by Joan Price.

Resources

  • Women’s Bodies, Women’s Wisdom: Creating Physical and Emotional Health and Healing, by Christiane Northrup, MD. Bantam Books; 2010.
  • Our Bodies, Ourselves: Menopause, by Boston Women’s Health Book Collective. Touchstone; 2010.
  • Better than I Ever Expected: Straight Talk About Sex after 60, by Joan Price. Seal Press; 2006.
  • A Woman’s Touch – Retail and information

Author(s)

“Menopause” was written by Anne Kolan, MD (2014, updated 2020). Sections were adapted from “Supplements for Hot Flashes During Menopause” by Caitlin D’Agata, MD, and David Rakel, MD, and edited by Charlene Luchterhand, MSSW.

This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

References

  1. Vo B, Kolahi A, Craemer E, Wilkinson J. Menopause. Essential Evidence Plus. 2019; https://www-essentialevidenceplus-com.ezproxy.library.wisc.edu/content/eee/241#accept. Updated May 31, 2019. Accessed April 28, 2020.
  2. Family Practice Notebook. Serum estradiol. 2014; http://www.fpnotebook.com/Gyn/Lab/SrmEstrdl.htm.
  3. Family Practice Notebook. Follicle stimulating hormone. 2014. http://www.fpnotebook.com/Endo/Lab/FlclStmltngHrmn.htm.
  4. Hudson T. Menopause. In: Maizes V, Dog TL, eds. Integrative Women’s Health. New York: Oxford University Press; 2010:366-384.
  5. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. In. Washington, DC: Institute of Medicine of the National Academies; 2010.
  6. Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2011(7):Cd000333
  7. Low Dog T, Riley D, Carter T. An integrative approach to menopause. Altern Ther Health Med. 2001;7(4):45-57.
  8. Leach M, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. Cochrane Database Syst Rev. 2012;9.
  9. Natural Medicines Comprehensive Database. Black Cohosh. 2020; Natural Medicines Comprehensive Database website. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=857. Updated March 9, 2020. Accessed April 28, 2020.
  10. The North American Menopause Society. The role of soy isoflavones in menopausal health: report of The North American Menopause Society. Menopause. 2011;18(11):732-753.
  11. Daily JW, Ko BS, Ryuk J, Liu M, Zhang W, Park S. Equol decreases hot flashes in postmenopausal women: a systematic review and meta-analysis of randomized clinical trials. J Med Food. 2019;22(2):127-139.
  12. Chen MN, Lin CC, Liu CF. Efficacy of phytoestrogens for menopausal symptoms: a meta-analysis and systematic review. Climacteric. 2015;18(2):260-269
  13. Franco OH, Chowdhury R, Troup J, et al. Use of plant-based therapies and menopausal symptoms: a systematic review and meta-analysis. JAMA. 2016;315(23):2554-2563.
  14. Perna S, Peroni G, Miccono A, et al. Multidimensional effects of soy isoflavone by food or supplements in menopause women: a systematic review and bibliometric analysis. Nat Prod Commun. 2016;11(11):1733-1740.
  15. Myers SP, Vigar V. Effects of a standardised extract of Trifolium pratense (Promensil) at a dosage of 80mg in the treatment of menopausal hot flushes: A systematic review and meta-analysis. Phytomedicine. 2017;24:141-147.
  16. Ghazanfarpour M, Sadeghi R, Roudsari RL, Khorsand I, Khadivzadeh T, Muoio B. Red clover for treatment of hot flashes and menopausal symptoms: a systematic review and meta-analysis. J Obstet Gynaecol. 2016;36(3):301-311.
  17. Daley A, Stokes-Lampard H, Macarthur C. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev. 2011(5):Cd006108.
  18. Sternfeld B, Guthrie KA, Ensrud KE, et al. Efficacy of exercise for menopausal symptoms: a randomized controlled trial. Menopause. 2014;21(4):330-338.
  19. Befus D, Coeytaux RR, Goldstein KM, et al. Management of menopause symptoms with acupuncture: an umbrella systematic review and meta-analysis. J Altern Complement Med. 2018;24(4):314-323.
  20. Chiu HY, Hsieh YJ, Tsai PS. Acupuncture to reduce sleep disturbances in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Obstet Gynecol. 2016;127(3):507-515.
  21. Cramer H, Peng W, Lauche R. Yoga for menopausal symptoms-a systematic review and meta-analysis. Maturitas. 2018;109:13-25.
  22. Shepherd-Banigan M, Goldstein KM, Coeytaux RR, et al. Improving vasomotor symptoms; psychological symptoms; and health-related quality of life in peri- or post-menopausal women through yoga: an umbrella systematic review and meta-analysis. Complement Ther Med. 2017;34:156-164.
  23. Goldstein KM, Shepherd-Banigan M, Coeytaux RR, et al. Use of mindfulness, meditation and relaxation to treat vasomotor symptoms. Climacteric. 2017;20(2):178-182.
  24. Wang Y, Shan W, Li Q, Yang N, Shan W. Tai Chi exercise for the quality of life in a perimenopausal women organization: a systematic review. Worldviews Evid Based Nurs. 2017;14(4):294-305.
  25. Uebelhack R, Blohmer J-U, Graubaum H-J, Busch R, Gruenwald J, Wernecke K-D. Black cohosh and St. John’s wort for climacteric complaints: a randomized trial. Obstet Gynecol. 2006;107(2):247-255.
  26. Ghazanfarpour M, Sadeghi R, Roudsari RL. The application of soy isoflavones for subjective symptoms and objective signs of vaginal atrophy in menopause: a systematic review of randomised controlled trials. J Obstet Gynaecol. 2016;36(2):160-171.
  27. Leiblum S, Bachmann G, Kemmann E, Colburn D, Swartzman L. Vaginal atrophy in the postmenopausal woman. The importance of sexual activity and hormones. JAMA. 1983;249(16):2195-2198.

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