When women seek help for menopause, unpleasant symptoms such as hot flashes, sleep disturbances, and vaginal dryness are often on their list of concerns, along with mood swings, weight gain and more. In our work with women and physicians throughout the US, Canada, and abroad, we find it useful to consider three categories of symptom management options:
- Lifestyle measures (diet, exercise, stress reduction)
- Nutritional supplements and over-the-counter treatments (vitamins, minerals, herbs, other)
- Prescription medications (hormones, other)
These categories help women evaluate their options and raise their awareness of the important distinctions in the way exercise, food, herbs, and medications work in the body. They also eliminate the expectation that medications, herbs, and vitamins, used interchangeably, will produce the same results.
Whether a woman chooses prescription therapy or not, self-care, including stress reduction, exercise and a healthy diet, is an important foundation for hormone balance. Things you can do yourself include changing to or maintaining a healthy diet, starting or continuing an exercise program suitable for your fitness level, and finding a support group with whom you can share what you’re going through.
As menopause arrives, many women find it difficult to manage a plethora of disruptive symptoms that may be new or increasing in frequency. What many women don’t know is that diet plays an important role in keeping menopausal symptoms in check by optimizing your hormonal health along with your physical and emotional wellbeing.
During menopause, it’s more important than ever to eat a balanced diet that includes protein at each meal along with a variety of fruits and vegetables. Eat grains in moderation and choose whole grains wherever possible. Limit saturated fats, oils and sugars. Eat at least 3 meals a day and keep portion size in mind, rather than focusing on calories. Drink water, avoid caffeine, which can make it hard to get to sleep, and avoid drinking too much alcohol, which can interrupt sleep.
Christine Northrup, author of The Wisdom of Menopause recommends the following to help maintain hormonal balance and a healthy weight:
- Herbal supplements such as dong quai, chaste berry, black cohosh, licorice root
- Omega-3 fats found in fatty fish and flaxseed
- Bioflavonoids found in cherries, cranberries, blueberries, whole grains and grapes
- Green tea
- Calcium-rich foods
- Smoking (if you’re still smoking, consider quitting altogether)
- MSG and aspartame
- Refined, high glycemic foods such as white bread, white rice and sweets
- Grain products (grains can be a problem if you’re carbohydrate-sensitive)
When you consider the average lifestyle of perimenopausal women, it is not hard to understand why insulin, estrogen and eicosanoids become imbalanced, setting the stage for increased risk of heart disease, high blood pressure, arthritis and breast cancer. Here are my suggestions for keeping your blood sugar, eicosanoids and hormones in balance.
As we enter the menopausal phase, we begin to face more health issues specific to aging women. Exercise plays a key role in maintaining good health as we age. In fact, some studies show that active women are not only healthier, but they report fewer menopausal symptoms than sedentary women. Experts recommend at least 2.5 hours of exercise each week including weight-bearing exercise to help:
- Speed up your metabolism, burn fat and help you maintain a healthy mid-life weight
- Balance your hormones, reduce your stress levels and improve your mood
- Increase bone mass to help prevent osteoporosis
- Reduce your cardiovascular risks by increasing your heart and respiratory rates
- Keep your joints limber to prevent arthritis
- Reduce low back pain
- Possibly reduce hot flashes
- Maintain optimal bowel function to help relieve constipation and/or diarrhea.
Exercise and Urinary Health
Women entering menopause should also consider incorporating pelvic floor exercises into their routine to help maintain urinary health. After menopause, as estrogen decreases, the pelvic floor muscles (which control urination) begin to atrophy. This is the time that women often report more urinary stress incontinence. Incorporating pelvic floor (Kegel) exercises into your routine may help alleviate pelvic floor dysfunction and symptoms of incontinence. If urinary incontinence is a concern, ask your health provider for a referral to a physical therapist who can develop an exercise routine that’s right for you and ensure you’re performing exercises properly.
Deep Breathing For Stress Relief
Along with exercise, stress-relieving techniques such as deep breathing, paced breathing, yoga and meditation increase progesterone (the calming hormone) and can help relieve menopausal symptoms such as insomnia and mood swings.
At jeanhailes.org, Professor Robert Freedman of Wayne State University in Detroit discusses the use of paced breathing for hot flashes.
Take a Break At Your Desk
Choose a 2 (or more) minute Guided Calm at www.calm.com
Vitamins, Supplements & OTC Treatments
At womenshealth.com, we always recommend a good quality multi-vitamin mineral supplement as the nutritional foundation for healthy hormone balance. Beyond the multi-vitamin, there are also a number of specific vitamins and alternative supplements that may help menopause symptoms and support your transition.
When choosing nutritional supplements purported to reduce menopause symptoms (especially “formulas” for women), we suggest considering the value of the treatment in relation to the price. Many supplements are expensive, even cost prohibitive for women on a budget. By calculating the annual cost of a particular product if you were to take it for a year, you can help shed light on whether it contains enough essential nutrients to make it worthwhile. For example, some pricey “menopause formulas” contain only very small amounts of isoflavones. The occasional glass of soy milk can deliver as much of the nutrient, for a fraction of the price.
Vitamins and Herbs For Health & Symptom Management
Calcium, Magnesium and Vitamin D
Bone strength is a major consideration for women reaching menopause, and multiple clinical trials document calcium’s bone building properties. Magnesium helps with the absorption of calcium, and vitamin D is as important for bone health. Calcium also helps promote restful sleep and may help with menopause related insomnia.
Some women report that vitamin E can help reduce mild hot flashes and night sweats, though scientific studies to prove these claims are lacking. If you’re considering supplementing with this vitamin, consult your doctor for an appropriate dosage, as doses above 400 IU may be associated with cardiovascular risk.
Some women try soy as a first line of defense when menopause symptoms first begin. A type of plant estrogen, rich in isoflavones, soy has certain estrogenic effects in the body. Supplementing with soy many help provide relief from hot flashes and more. Learn more.
Although the plant is native to North America, its extract is more widely used in Europe to treat a variety of conditions, from menopause symptoms to arthritis. The Remifemin® brand of black cohosh extract is the most widely used and studied. Studies on black cohosh have demonstrated that it can provide relief from hot flashes, joint pain, and vaginal dryness. In animal studies, the plant extract appears to work like estrogen. It also appears to lower levels of luteinizing hormone (LH), the hormone that prompts the ripened follicle to be released at ovulation.
The recommended dosage of black cohosh is 20 mg, twice a day, which should not be exceeded. Too much black cohosh can cause dizziness, nausea, and headache. Some women report breast tenderness when taking black cohosh. Because the data on long-term effects of black cohosh are limited, women are advised to take this supplement for no more than six months. Some experts recommend taking it for only three months, and under the guidance of a knowledgeable health care practitioner with experience in using black cohosh for women in menopause.
The flower of the red clover is used to make a dietary supplement containing isoflavones. In two small Australian studies, 80 mg of red clover daily reduced hot flashes better than placebo. This plant also contains anticoagulant chemicals called coumarins, which thin the blood. Check with your doctor or pharmacist to be sure none of your other prescription medications or supplements interact with the blood thinning agent in red clover.
OTC Vaginal Lubricants & Moisturizers For Sexual Health
Vaginal dryness and pain during intercourse is often one of the first concerns of post-menopausal women. Fortunately, there are over the counter treatments that can help.
Non-prescription options include vaginal moisturizing creams that promote comfort and health for sensitive vaginal tissues. Water-based lubricants such as Astroglide are also options to consider. They provide light lubrication for enhancing the comfort and ease of intimate activity. Avoid petroleum jelly products, which can clog delicate tissues.
Hormone Replacement Therapy (HRT) Or Hormone Therapy (HT)
Hormone therapy is often prescribed for managing symptoms that stem from hormone imbalance. Replacing or supplementing a single hormone or multiple hormones that the body is no longer producing (or is producing in lower amounts) can offer relief from symptoms that often accompany PMS, perimenopause, and menopause in women, (and andropause in men) and can also help promote bone and vaginal health.
Low-dose natural hormone therapy prescription options include a wide variety of customized dosage strengths and forms:
- Even-Release tablets
- Sublingual tablets
- Micronized oil capsules
- Transdermal creams, gels and patches
- Suppositories and rectal suspensions
Conventional-strength dosage forms are also available by prescription.
Other RX Treatments
Prescription therapy is also available with options beyond traditional hormone therapy. Low dose vaginal creams, tablets, and suppositories are suggested for their localized effect. These treatments can help alleviate vaginal dryness, itching and discomfort, and slight incontinence when OTC treatments are not enough.
Hormone Therapy (HT), commonly called Hormone Replacement Therapy (HRT), is a leading therapy for women whose hormone levels have dropped, whether through the aging process or for some other reason, such as ovarian hysterectomy. As more and more women live longer, hormone therapy has become a way to extend a healthy vibrant life with strong healthy bones.
Natural or Biodentical Vs Synthetic Hormones
The terms natural or bioidentical are confusing when used in connection with hormones. When we say a hormone is natural or bioidentical, we are referring to the molecules that make up the structure of the hormone. A bioidentical hormone has a chemical structure that is identical to the hormone naturally produced by the body. A bioidentical hormone does not mean that it is an organic product purchased in a health food store. In fact, many bioidentical hormones are synthesized in laboratories using pharmaceutical-grade products. The important thing to remember is that for a hormone to be considered bioidentical its structure must replicate exactly the structure of hormones your body produces.
Natural or bioidentical and synthetic hormones should not be considered the same or used interchangeably.
A synthetic hormone is made in a laboratory, en masse and may have a structure similar to, but not exactly the same as, a hormone produced by your body. These chemical differences can mean that the synthetic hormone acts differently in your body and produces substantially different effects. Because they are not identical, synthetic hormones cannot be counted on to act in the same way human hormones do. They may or may not produce the PMS, perimenopause, and menopause symptom control you desire. Studies show, they may also produce potentially dangerous side effects such as an increased risk of heart attack, blood clots, stroke, and breast cancer. Furthermore, synthetic hormones are prescribed in a one-size-fits-all standard dose, not a low dose individualized for each woman. This “one-size-fits-all” approach increases the chance that the prescribed drug will produce unwanted and potentially dangerous side effects.
Womenshealth.com, researchers, and healthcare providers use the terms natural and bioidentical to mean molecularly identical to the hormones produced in your body. Individualized, low-dose bioidentical hormone therapy is an alternative approach to synthetic hormone therapy. It uses what are called bioidentical (natural) hormones like estradiol, estriol, progesterone, cortisol, testosterone, and DHEA. The chemical structure of these hormones is exactly the same as the hormones produced naturally by a woman’s body.
A low-dose bioidentical hormone therapy prescription can be easily customized for each woman’s unique needs by qualified compounding pharmacies that make customized medications.
Individualization includes testing a woman’s current hormone levels with a highly sensitive saliva test, determining the specific combination of hormones she requires, and prescribing at the lowest effective dose, thereby minimizing unwanted side-effects. These prescriptions can be administered in a variety of forms including tablets, capsules, patches, and creams. The ability to customize the strength as well as the dosage form is unique to compounding pharmacies and an option many women find appealing as it enables them to have their medication tailored to their individual needs and preferences.
Bioidentical hormone therapy has been enhancing the quality of life for countless women, protecting many from chronic and debilitating disease for nearly thirty years. Talk to your healthcare provider about whether it’s right for you.
What Hormone Levels Should I Test?
If You’re Not Currently On Hormone Therapy
Most women should, at a minimum, consider testing their Estradiol (the strongest form of estrogen) and Progesterone levels. Estradiol not only relieves symptoms of menopause, it also protects against osteoporosis, protects the tissues in your pelvis (which helps prevent bladder leaking and vaginal thinning), enhances your memory and mental focus, and even supports your skin tone. Even if you have had a hysterectomy, Progesterone does more than just protect your uterus; it helps to improve mood, regulate fluid balance in your body, and relieves symptoms of PMS, perimenopause and menopause, among other benefits.
If you are having problems with fatigue, lack of energy, lack of libido (sex drive), problems with maintaining your muscular strength, and/or with bone loss than you may want to test your Testosterone level. Testosterone can increase your energy and libido, helps build muscles, and aids in strengthening your bones.
If you are concerned about how your body is responding to physical and/or mental stress than you should consider testing your DHEA and Cortisol levels. DHEA and Cortisol work in tandem to help you respond to and cope with stress – whether it is emotional or physical.
To assess your current rate of bone breakdown, you may wish to have an NTx test. NTx testing measures your current rate of bone break-down by measuring a metabolite of bone loss that is found in your urine. An NTx test can allow you to assess your rate of bone breakdown and act to correct your bone loss before you have actually lost enough bone for it to be found on an x-ray (Dexa scan). If you have been diagnosed with osteoporosis or osteopenia, have a family history of osteoporosis, and/or are concerned about your bone health, consider testing your NTx level. NTx testing can determine the effectiveness of a hormone therapy, vitamin/mineral supplement and or diet and exercise regimen in preserving bone health in as few as three months after therapy is initiated.
For Women Who Are Already On Hormone Therapy
You would definitely want to consider testing each hormone you are having replaced/supplemented. This includes over-the-counter hormone products that contain Progesterone or DHEA.
What Else Should You Test?
Ask your healthcare provider about checking your thyroid function. Thyroid testing to measure Thyroid Stimulating Hormone (TSH) is one of the principle laboratory tests recommended by the American Thyroid Association for detecting either overactive or underactive thyroid conditions.
TSH is a hormone produced by the pituitary gland that signals the thyroid gland to produce additional hormones that control body metabolism and organ function. Thyroid and other hormone function are interactive and interdependent; optimal thyroid function is necessary not only to achieve hormonal balance, but also to feel the best symptom control.
Hormone Testing Methods
Salivary Hormone Testing
Saliva testing is the most accurate method for assaying hormone levels. Hormones exist in the body in two forms: free and protein-bound. Only the free hormones are available for use by the body. Blood tests measure both free and bound hormones, while saliva tests measure only free hormones. Thus saliva tests measure the level of bioavailable hormones, and provide a more useful metric.
The use of saliva for biomarker testing has enormous advantages. Collecting saliva samples is simple, painless, non-invasive, and requires no specialized training or equipment. If required, subjects can be given kits to take home and can perform the collection procedures themselves.
Validity of Salivary Hormone Tests
Although salivary assay methodology has been used successfully for decades, some controversy still exists about its validity and the extent to which it reflects serum (blood) concentrations of hormones. In fact, many studies confirm the reliability and utility of testing salivary hormone levels. A few are listed below.
Dabbs, J.M. (1990). Salivary testosterone measurements: Reliability across hours, days, and weeks. Physiology & Behavior, 48(1), 83-86.
Voss, H.F. (1999). Saliva as a fluid for measurement of estriol levels. American Journal of Obstetrics and Gynecology. 180(1), S226-S231.
Kirschbaum, C., & Hellhamme, D.H. (1994). Salivary cortisol in psychoneuroendocrine research: Recent developments and applications. Psychoneuroendocrinology. 19(4), 313-333.
Woolston, J.L., Gianfredi, S., Gertner, J.M., Paugus, J.A., Mason, J.W. (1983). Salivary Cortisol: A Nontraumatic Sampling Technique for Assaying Cortisol Dynamics. Journal of the American Academy of Child & Adolescent Psychiatry. 22(5). 474-476.
Blood and Urine Testing
An elevated FSH level, measured with a blood or urine test, is one piece of information that may indicate if you are menopausal. It’s important to understand that FSH levels may fluctuate from month to month in the years before menopause, so one test showing high FSH levels doesn’t necessarily mean you are menopausal. Many physicians rely on an FSH test and the fact that a woman has not menstruated for 12 months as confirmation of menopause.
Most biomarkers can be measured by testing urine. A standard medical urinalysis, for example, tests for specific gravity, pH, proteins, ketone bodies, nitrites, bilirubin, glucose, hemoglobin, red blood cells, white blood cells, and hCG. Hormones and other biomarkers may also be assayed in urine.
Urine may be tested via microscopic examination, or by combining the sample with a reactant in which the resulting change indicates the presence or level of the biomarker.
Urine sample collection may be done in several ways, depending on the biomarker being assayed.
Some biomarkers, generally those associated with oncology studies, can only be assayed with blood samples.
As with all of the major hormones, baseline and follow-up testing of testosterone levels is critical for determining if treatment is needed to keep hormone levels in the normal therapeutic range.
When Menopause Is Early
When menopause arrives prematurely (before the age of 40) a woman may experience a host of emotional symptoms above and beyond the physical symptoms of menopause. Jean Hailes for Women’s Health outlines the emotional aspects of premature menopause:
- Feelings of grief, sadness and depression
- Loss of self esteem and control and a sense of helplessness
- Concern about how her partner will see her in terms of appearance, femininity, sexuality and sensuality
- Potential issues concerning fertility, adjustment to childlessness, reduced family size and loss of reproductive capacity
- Feeling old before her time and out of harmony with her own age group
For women who want children, losing fertility at an early age can cause deep feelings of anger, frustration and sadness. If this is you, there is help available. A psychologist or therapist can help you work through your feelings and a primary care doctor or OBGYN can explain other options such as adoption or donor egg programs.
If you think you’re in menopause early, it’s important to see your doctor to confirm the diagnosis and discuss your options. If it is premature menopause, treatments such as hormone therapy may help your menopausal symptoms as well as protect you from health risks such as osteoporosis and heart disease.