My last blog, “All About Menopause,” talked about the science behind menopause and hormone testing. In this blog, we’ll go over the treatment options I have up my sleeve in managing menopause to feel more like a peaceful hike than a rollercoaster. Let’s dive in!

Recap: All About Menopause

Before we jump into treating menopause, let’s recap what I discussed in my last blog: what menopause is, what perimenopause is, the symptoms associated with them, and the science behind these processes. I recommend checking out my last blog before reading this one, but in case you haven’t, here’s a quick summary.

As we all know, menopause marks the end of a woman’s reproductive years. This period of time is associated with irritating symptoms that can make the emotional component of menopause even more challenging to manage. These symptoms are caused by the drop in estrogen and progesterone that occurs during menopause. These hormones are known for their roles in fertility and menstruation, but they’re also involved in cognition, memory, skin, bone, and even cardiovascular health. Since estrogen and progesterone influence our reproductive system, bone health, cardiovascular system, and brain, the sudden drop in these hormones can be a difficult transition for these body systems (1-5).

This drop in estrogen and progesterone manifests as pesky symptoms and the eventual cessation of menstruation (1-5). Addressing the hormonal imbalance that occurs with menopause (more specifically, the drop in estrogen and progesterone) can alleviate many of the symptoms associated with the transition. I can accomplish this by testing patients’ hormones and creating a treatment plan that addresses their specific imbalances, symptoms, lifestyle, and preferences.

Now that we’ve got the basics down, let’s talk about treatment options.

 

Managing Menopause with healthy foods

Treatment Strategies #1: Lifestyle Changes

Our first option is to focus on lifestyle changes (13). When done correctly and consistently, lifestyle adjustments can impact menopause symptoms. If a patient decides to go this route, we’ll implement nutrition, exercise, detox, sleep, and stress strategies. My nutritionist Sarah, my medical team at the Spring Center, and I are here to help with these choices.

The diet plan should be very individualized, but let’s take a look at some general guidelines. For diet, we’ll emphasize ideally organic, whole foods, polyphenol diversity (meaning a variety of color in your veggies choices), and hydration.

Whole-food diets, especially those high in plant foods, help with reducing  inflammatory markers (16), though there is a concern about bone health if we lean into it too heavily (17). Eating legumes and nuts, which are high in phytate, can help with bone mineral density in diets that lean toward plant-based (18). On the other hand, some research shows that a dietary pattern that includes meat can help with lipid balance (19). I also recommend higher protein intake to avoid sarcopenia (muscle loss) that often accompanies aging.  Focusing on essential fatty acids to help with metabolic response & lipid metabolism in menopause, as well as antioxidants from fruits (10) – especially blueberries! (21) – are all important.  Food plans may need to be individually tailored as many people have food allergies and sensitivities.  If this pertains to you, be sure to seek out nutrition guidance to ensure you are supporting your body and limiting problematic foods for you.  And since we want to limit exposure to environmental chemicals, choose organic whenever possible!

In addition to choosing the “right” foods, paying attention to food prep is essential. For example, foods cooked in high, dry preparations that are browned contain a lot of advanced glycation end products (AGEs), which can be problematic. Cooking and storage are also important to avoid toxicants.  Avoiding non-stick pans will go a long way to reducing your exposure to “forever chemicals”.  Avoiding plastic for storage and reheating will reduce microplastics and phthalates. It is suggested that avoiding these could help with menopausal symptoms (11).  It is essential to continue to educate yourself on environmental chemical exposure since so many of them have endocrine disrupting effects and can exacerbate menopausal symptoms.

We’ll also work on identifying and eliminating food sensitivities, limiting alcohol, and reducing processed food intake. Clinically, I find that food sensitivities can manifest as insomnia and mood disturbances, and since menopause often presents as sleep difficulties and moodiness, we need to pay close attention to this lifestyle aspect.

Depending on a patient’s gut health and micronutrient levels, we may add in some individualized diet recommendations to ensure that the plan is best suited for them. Keeping blood sugar balanced throughout this process will be important for healthy insulin and cortisol levels too. If this sounds overwhelming, don’t worry – Sarah, our amazing nutritionist, is here to make eating this way feel like a breeze.

Aside from a food plan, we address an exercise plan as well. Surprisingly, not all types of exercise are well suited for balancing menopausal hormone fluctuations. Workouts that induce lots of cortisol – like running for hours, HIIT, or super intense sports like boxing at 5 AM – are not typically recommended. These exercises are often used for weight loss when younger.  At this transition period in life, given that the adrenal system is linked to the production of many other hormones (22), inducing adrenaline spikes with high-intensity exercise will likely have the opposite effect on our goals when trying to address menopause.  It can be too taxing on the body already going through a significant transition.

Instead, I suggest focusing on bone health and muscle strengthening through resistance training (lifting weights) (23). For cardiovascular health, I have my patients do cardio that doesn’t spike cortisol levels, like uphill walking. I also recommend stress reduction practices like meditation and yoga to regulate patients’ adrenal function. Yoga also improves balance and flexibility, which are also critical for healthy aging (24).  I really love yoga as it combines so many positive aspects for health.  It can be strengthening, invigorating, detoxifying and great for maintaining a positive and calm attitude!  I highly encourage you to check out yoga and make it an integral part of your self care plan.

Do your best to avoid endocrine-disrupting chemicals and work to detoxify them from your body. Endocrine disruptors are chemicals that can interfere with hormone functions once they’re in the body (25). These chemicals are found in beloved household items, plastics, cosmetics, and even our food. The EU has banned about 1300 of them, but the US has unfortunately only banned 11 (26).  Check out my Pre-tox and Detox handouts for more details.

Endocrine disruptors can absolutely interfere with our hormone balance, especially as we transition through menopause. Avoiding exposure to them and getting them out of our bodies through detoxification practices like sauna therapy is critical. Check out my blog on environmental toxicants and my free e-book, 10 Daily Detox Tips for Healthy Living to learn more.

 

medicinal herbs

Treatment Strategy #2: Herbal Therapies

Often lifestyle changes are not sufficient to reduce menopausal symptoms. The next step up would be to incorporate herbal supplements, which can be surprisingly powerful. Research shows they can provide relief for hot flashes, mood swings, and sleep disturbances (27). Phytoestrogens, plant-derived compounds structurally similar to human estrogen, found in soy, red clover, and flaxseed, have shown promise in reducing hot flashes and improving cardiovascular health (28). St. John’s Wort has also demonstrated potential for alleviating mood swings (29). Black cohosh is one that has been used for many years for the relief of hot flashes and night sweats. There are also specific combination products that I prefer and have found helpful in patients, including Metagenics Estrovera , whose primary ingredient is rhubarb. Other herbal supplements may be of benefit to the patient’s treatment plan, but my recommendations will really depend on their specific hormonal profile.

As women go through menopause and the ovaries cease making adequate hormones, the source of hormones shifts to the adrenal gland, bringing the adrenal gland to center stage.  We often use a class of herbal supplements called adaptogens that have been shown to enhance the body’s resilience to stress by regulating adrenal function (30). Rhodiola rosea consistently exhibits beneficial effects on physical and mental performance under stress. And ashwagandha, an adaptogenic herb, has shown promise for reducing cortisol (30).

It’s important to note that reducing cortisol isn’t always a good thing. It’s possible to have low cortisol, even if you feel stressed out sometimes. That’s why it’s so important to “test not guess:” to approach these supplements with your test results in mind. Using the help of an experienced healthcare professional who can interpret your test results and prescribe supplements appropriately is of the utmost importance to your emotional and physical health during this time.

 

Managing Menopause with acupuncture

Treatment Strategy #3: Acupuncture

Acupuncture can also be a helpful addition to many patients’ treatment plans. Acupuncture is an ancient Chinese practice that involves the insertion of thin needles into specific points on the body. Recent research indicates that acupuncture can help to alleviate certain menopausal symptoms, like hot flashes, sleep disturbances, mood swings, and vaginal dryness (14, 15).

While its mechanism of action is not fully understood, some studies have suggested that acupuncture may work by stimulating the release of endorphins and regulating neuroendocrine pathways (14, 15). However, individual responses to acupuncture can vary, and it is important to seek treatment from a qualified and licensed acupuncturist. I have found acupuncture and various forms of acupressure to be immensely helpful for most hormone imbalance issues.  And acupuncture can easily be combined with other forms of therapy to have a synergistic effect.

 

medical lab tests

Treatment Strategy #4: HRT

Hormone replacement therapy (HRT) involves supplying the body with hormones it lacks. Think back to our recap of menopause science. Menopause symptoms occur because our ovaries stop producing estrogen and progesterone. So in the case of menopause, HRT treatments administer types of estrogen or progesterone that our body is no longer able to produce.

We often prescribe HRT when a patient’s hormone levels are quite low. The hormone we choose to replace (remember, hormone replacement therapy) depends on the patient’s symptoms and lab test results.

The Women’s Health Initiative, a research program funded by the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the U.S. Department of Health and Human Services has provided a more nuanced understanding of the pros and cons of HRT (7-9). While it’s been shown that HRT can effectively alleviate menopausal symptoms and protect against osteoporosis and cognitive decline, like anything, it’s not without potential risks (7-9).

Increased risks of breast cancer, heart disease, stroke, and blood clots have been associated with certain forms of HRT, particularly in older women or those who start HRT many years after menopause begins (7-9). It’s something I talk to my patients about thoroughly. I weigh its risks in context with patients’ family history, cardiovascular health, and history of cancer if they’ve had any.   And of course, it is important to take into account that epidemiological data is NOT randomized controlled trials and we have to use clinical acumen as well as the literature to support you to make the best choices for yourself.

Sometimes clinicians prescribe synthetic hormones for their HRT patients. Using bioidentical hormones – those that are chemically identical to those the body produces naturally – is an option as well. I personally recommend bioidentical hormones because they seem to carry fewer risks than synthetic versions (8).  It is also important to mention that the Women’s Health Initiative studied synthetic forms of HRT and NOT bioidentical forms.  So when we consider risks and benefits it is a very important distinction to recognize.

Bioidentical HRT can be administered orally with pills; topically with patches, gels, or creams; vaginally with creams, tablets, or rings; injections; or pellets. Oral administration is a popular choice but isn’t ideal for every case. Certain hormones are more problematic when taken orally. For example, oral estradiol  can be problematic due to first-pass liver metabolism, during which the liver metabolizes the hormone before it has a chance to reach the bloodstream in its intended potency (31). The metabolism through the liver means that more toxic estrogens are now in the body.  For that reason, I tend to recommend topical forms of estradiol, either through a compounded cream or patches.

Oral progesterone, on the other hand, doesn’t pose the same metabolism issues as estrogen does. Pellets, which are implanted under the skin and release hormones slowly over time, are also an option. Some women find them particularly convenient since you only need to replace them a few times a year. If smaller doses of hormones are required, I tend to prescribe creams. We can also use targeted therapies to deliver estradiol just to the vaginal tissues or add testosterone for libido, muscle strength and energy once the female hormones have been optimized.

It’s hard to say what the best route is, since prescriptions are so context-dependent. The right dosage depends on various factors, including your symptoms, overall health, and lifestyle. Most importantly, I need to carefully interpret patients’ lab results to determine what needs replacing. As I begin a patient’s HRT, I keep a cautious eye on their hormone levels and symptoms so I can adapt the dose accordingly.  Routine labs are essential for monitoring levels and effects on the body.

You might ask –  do we attempt to replicate a menstrual cycle by administering different levels of estrogen and progesterone throughout the month, or not? We certainly can. Most patients and practitioners use what is called  static dosing, where the same amount of hormone is taken every day. Cyclic dosing, on the other hand, mimics the natural menstrual cycle by taking different amounts of hormones at different times of the month.  Both methods of HRT have their advantages and disadvantages, and the choice between them depends on your symptoms, hormone levels, and preferences.

The Wiley Protocol,  popularized by T.S. Wiley, in her book Sex, Lies and Menopause,  is an approach that uses bioidentical hormones in a rhythmic, cyclic manner to replicate the hormone levels of a healthy young woman (10). However, it remains somewhat controversial, with critics suggesting that such high levels of hormones aren’t necessary for symptom control and could increase risks of cancer.  Proponents counter that fluctuating doses are more in alignment with what our bodies are accustomed to experiencing throughout our lifespan and are therefore more natural and protective.   The option chosen for each person will be the result of a conversation and based on individuality and preferences.

 

healthy man on mountain

The Takeaway: You Can Feel Better

As a woman myself, I’m aware of the tribulations menopause can pose, both emotionally and physically. I’ve seen firsthand how menopause has made my family members, friends, patients, and even myself feel like we’ve hit rock bottom – only to feel like ourselves again once our hormones have been regulated. This blog was written to show you that there are ways to feel better! Whether you’re interested in lifestyle and exercise changes, herbal supplements, or HRT, there’s an option for you. I love helping women feel their best again. Thanks for joining and see you next time!

 

References

  1. NIH. Menopause: Overview. https://www.ncbi.nlm.nih.gov/books/NBK279311/
  2. Santoro, N., Epperson, C. N., & Mathews, S. B. (2015). Menopausal Symptoms and Their Management. Endocrinology and Metabolism Clinics, 44(3), 497-515.
  3. National Institute on Aging. (2020). Menopause symptoms and relief. Retrieved from https://www.nia.nih.gov/health/men
  4. The North American Menopause Society. (2020). Nonhormonal management of menopause-associated vasomotor symptoms. Menopause, 27(6), 607-622.
  5. Faubion, S. S., Sood, R., Kapoor, E., & Genitourinary Syndrome of Menopause Panel of the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice. (2020). Genitourinary syndrome of menopause: Management strategies for the clinician. Mayo Clinic Proceedings, 95(11), 2299-2318.
  6. American College of Obstetricians and Gynecologists. (2019). Hormone Therapy. Retrieved from https://www.acog.org/patient-resources/faqs/menopause/hormone-therapy
  7. Manson, J. E., Aragaki, A. K., Rossouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., … & Howard, B. V. (2017). Menopausal hormone therapy and long-term all-cause and cause-specific mortality: The Women’s Health Initiative randomized trials. JAMA, 318(10), 927-938.
  8. National Institute on Aging. (2018). What Are Bioidentical Hormones? Retrieved from https://www.nia.nih.gov/health/what-are-bioidentical-hormones
  9. Shifren, J. L., & Gass, M. L. (2014). The North American Menopause Society recommendations for clinical care of midlife women. Menopause, 21(10), 1038-1062.
  10. Wiley, T. S., & Schwartz, J. (2011). The Wiley Protocol: Rhythmic, dosed bioidentical hormones. Alternative Therapies in Health and Medicine, 17(6), 36.
  11. Menopause, 2012
  12. https://www.whi.org/
  13. The North American Menopause Society. (2020). Nonhormonal management of menopause-associated vasomotor symptoms. Menopause, 27(6), 607-622.
  14. Dodin, S., Blanchet, C., Marc, I., Ernst, E., & Wu, T. (2013). Acupuncture for menopausal hot flushes. Cochrane Database of Systematic Reviews, (7), CD007410.
  15. Borud, E. K., Alraek, T., White, A., Grimsgaard, S., & Fonnebo, V. (2009). The acupuncture on hot flushes among menopausal women study: Observational follow-up results at 6 and 12 months.
  16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10176721/
  17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10097387/
  18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10097286/
  19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019719/
  20. https://pubmed.ncbi.nlm.nih.gov/36847333/
  21. https://www.maturitas.org/article/S0378-5122(23)00053-1/fulltext
  22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166402/#:~:text=There%20exists%20a%20reciprocal%20relationship,the%20other%20and%20vice%20versa.
  23. https://pubmed.ncbi.nlm.nih.gov/9927006/
  24. https://pubmed.ncbi.nlm.nih.gov/26707903/
  25. https://pubmed.ncbi.nlm.nih.gov/31792807/
  26. https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex%3A32009R1223
  27. Shakeri, A., & Sahebkar, A. (2021). Herbal medicine for hot flashes: A systematic review and meta-analysis of randomized controlled trials. Phytotherapy Research, 35(1), 124-138.
  28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389700/
  29. https://pubmed.ncbi.nlm.nih.gov/10623319/
  30. https://pubmed.ncbi.nlm.nih.gov/19500070/
  31. https://pubmed.ncbi.nlm.nih.gov/22011208/