The Menopause Guide
The perimenopause is typically thought to occur in a woman’s 50’s but it can happen in their 40’s and even 30’s. Perimenopause can last anywhere from 12 months up to 4 years. The perimenopause is separated into 2 phases, an early and late phase. Once a woman has no longer had a menstrual cycle for 12 months she is considered to be in the menopause.
Primary ovarian insufficiency (POI), also known as premature ovarian failure, happens when a woman's ovaries stop working normally before she is 40. This is not the same as premature menopause.
For women with POI, irregular periods and reduced fertility start before the age of 40. With premature menopause, your periods stop before age 40 and you can no longer get pregnant.
There’s no avoiding the menopause unless HRT (hormonal replacement therapy) has begun.
Negative body composition changes: weight gain and muscle loss
With declining hormone levels associated with middle age there is a tendency for a loss of muscle mass and muscle strength, this loss is known as sarcopenia, alongside an increase in fat mass resulting in negative changes in body composition.
With muscle loss this is accompanied with a reduction in metabolic rate. It is the reduction in estrogen, which causes women to experience a redistribution of body fat from around the hips and thighs to around the abdomen. This increases the amount of visceral fat a woman has, an expanding waistline increases the risk of cardiovascular disease and type 2 diabetes.
Resistance training supports muscle growth and muscle mass retention. This type of exercise has a positive effect on metabolic health. The mechanism is that this type of exercise recruits many muscle units which being very metabolically active, increases metabolic rate even after stopping exercise. This supports the regulation of blood glucose control and metabolic health.
Reasons for weight gain:
Aging - taking part in less activity which leads to reduced muscle mass, therefore reducing metabolic rate.
Hormonal shifts - change in body fat distribution - the reduced estrogen and reduced protein absorption from food (you’ll read more on this below) may change the body’s metabolism and the rate at which the body uses circulating fat which can impact fat metabolism, storage and weight gain around the midsection.
Sleep - Leptin (satiety hormone) and ghrelin (hunger hormone) can be negatively impacted on reduced sleep quality and quantity.
Growth hormone
Growth hormone (GH) is an anabolic (building) hormone which continues to play an important role throughout adult life favouring muscle formation and maintenance, as opposed to fat deposition equalling a positive body composition. Growth hormone also promotes fat breakdown and reduction in visceral fat.
GH has this anabolic effect on both men and women throughout their life, with increasing age the production of GH gradually decreases. Reducing levels of GH also has an impact on bone health.
You can support GH production through exercise, quality sleep and vitamin D supplementation.
Bone health and weight training
The reductions in hormones, particularly estrogen, can cause bone loss increasing a woman’s risk of developing osteopenia and later osteoporosis.
As women age there is an increased risk of osteoporosis (bone loss) this is down to the loss of estrogen. (For women after the menopause bone loss can be up to 5% annually).
The risks of osteoporosis are: fracture risk, height loss and respiratory compromise, (this occurs if disks in your spine are compressed enough to reduce your lung capacity, due to stopping over).
Exercise, in particular weight training, has a bone building effect. Bones need a stress placed on them to build and stay strong. Weight training supports bone strength as skeletal muscle attachments pull on the bone to stimulate bone formation. Weight training has been found to limit bone loss or even increase bone density in postmenopausal women. Progressive resistance training can produce substantial increases in strength and muscle size.
Proper nutrition and nutrient intake is needed alongside to maximise this effect. For optimal bone health depends on having healthy levels of vitamin D and estrogen. For women HRT is the most effective treatment for supporting bone formation.
Cardio
All cardio both aerobic (with oxygen) and anaerobic (without oxygen) exercise is beneficial.
Zone 2 cardio, which is working at 60 - 70% of your maximum heart rate, makes our bodies good at burning fuel and it is good to be fit at this level!
‘Fat burning aerobic exercise’ the key hormone driving this is growth hormone and GH reduces visceral fat. As we know, GH is stimulated by exercise and promotes fat breakdown.
We need aerobic exercise to improve mitochondria which are the powerhouses in all of your cells! The mitochondria go to support your metabolism! As well as fat oxidation (The process by which the body breaks down fatty acids to produce energy).
Women as we age have a reduced insulin sensitivity (how well the hormone insulin helps absorb glucose from the bloodstream and deposits the energy into our tissues such as muscle) due to hormonal shifts and reductions in muscle mass.
HITT (High intensity interval training) has its benefits! It Improves glucose regulation (reducing the risk of type two diabetes), insulin sensitivity and makes us more metabolically efficient.
Do both of the above!
Protein - it matters!
Women as they age don’t absorb the aminos acids in protein as well, meaning they need a larger serving of protein per meal to get enough stimuli to preserve or gain lean muscle.
Menopausal women become less reactive to muscle making stimulus from weight training and would need to support this by consuming 30-40g protein after a workout.
They would also benefit from larger servings of protein in one sitting rather than smaller spread out meals. This is due to needing a larger stimulus to hit muscle protein synthesis (MPS - the process of producing new muscle tissue).
The best strategy to support muscle formation over breakdown is to take on board pre-sleep protein. Milk contains casein which is a type of protein that is slow release protein meaning it takes time to break down therefore supporting muscle recovery during the overnight fast.
Food diary example:
Breakfast - 250g of 0% fat greek yogurt with a tablespoon of flaxseed, handful of blueberries and a banana
Lunch - 1 chicken breast with 150g of quinoa and 1/2 an avocado.
Dinner - 1 salmon fillet with chickpeas and Mediterranean vegetables.
Evening snack - 200g of 0% fat greek yogurt with almonds on top or half a tub of cottage cheese.
‘Carbs make you fat’
The loss of estrogen is associated with reduced responsiveness to insulin I.e. you become slightly more insulin resistant. This can lead to visceral fat gain and metabolic syndrome.
As women age they become more sensitive to carbohydrates and have a harder time digesting them. This may just be the answer as to why you’ve been getting the uncomfortable indigestion and GI issues following a high carb meal or snack. BUT it’s not all carbohydrates. Above I’m referring to the high GI (glycemic index) carbohydrates which are digested quicker and cause fluctuations in blood sugar levels, such as white bread, white rice, cakes and sweet treats.When choosing carbohydrates, generally opt for ones with a lower GI level, such as brown rice, wholemeal bread, sweet potatoes, vegetables and whole fruit.
Don’t fear fruit because of its sugar content! Fruit is full of nutrients and fibre! Because of this it takes your body longer to break it down than if you were to eat boiled sweets for example!
Sleep
Sleep quality and quantity has an impact on bone health and muscle health.
Exercise is a powerful stimulus for growth hormone production and so is sleep. Sleep helps increases leptin receptor sensitivity and sharpens up satiety signals as well as keeping ghrelin (hunger hormone) at a normal level.
Tart cherry juice - diluted and consumed within 30 minutes of going to sleep has been shown to help with sleep quantity and quality. Tart cherry juice works by reducing core temperature and increasing melatonin to help aid a restful night sleep.
I also recommend this for menstruating women who are around ovulation and in the luteal phase, core temperature is generally higher so sleep can be impacted.
Menopausal symptoms and hormone replacement therapy
The undesirable body composition changes which worsen in the menopausal transition indicate peri menopause may be the key time for lifestyle interventions to be put in place (exercise, nutrition and sleep) and this goes to all women, HRT or not you will still benefit from making changes in regards to supporting your cardiovascular health, maintaining lean muscle mass and mitigating body fat gain.
With the onset of menopause women lose the protective benefits estrogen provides.
As well as in the female reproductive tract, there are estrogen receptors in the brain, bone, and heart. So when the production of estrogen comes to a halt the effects estrogen has on these organs are affected.
Commonly experienced menopausal symptoms include the following:
Hot flushes/night sweats.
Cognitive symptoms and mood disorders (low mood, anxiety, irritability, loss of confidence, low self-esteem, difficulties with short-term concentration and memory (brain fog), and difficulties in multi-tasking.
Sleep disturbances (insomnia and disturbed sleep), fatigue, tiredness and low energy levels
Loss of sexual desire and libido
Joint and muscle pains
Headaches
Dry and itchy skin throughout the body. This includes vaginal dryness, irritation and discomfort. This may also include urinary symptoms such as urinary frequency urgency and recurrent lower urinary tract infections.
Menopausal women who go on Hormone Replacement Therapy (HRT) show a different physiology than those women who do not
Hormone replacement therapy
HRT Improves the long-term health of women in the terms of reduced overall mortality (death from all causes).
HRT mitigates menopausal symptoms and has long term benefits including a reduced risk of osteoporosis, dementia, type 2 diabetes, depression and cardiovascular disease, all of which are health issues which increase at menopause when the natural levels of ovarian hormones drop.
HRT use is dependent on the individual and options should be discussed with your GP or menopausal specialist.
Your age, lifestyle, medical history and personal preference will be taken into account.
There have been previous concerns for HRT Increasing the risk of breast cancer. However the women who they studied were looked into and the average age of all women in the study was 63 years old. This is more than 10 years post menopause and all participants were overweight. Being overweight is a recognised factor for developing breast cancer so it’s not possible to say it was definitely the HRT alone.
For the majority of women who can take HRT, the pros considerably outweigh the cons.
Breast cancer
For every 1000 women age 50 to 59 years there are 23 cases of breast cancer reported.
Being overweight increases the cases of breast cancer by an extra 24 cases per 1000 women. Conversely there were 7 fewer cases for women taking regular moderate exercise of at least 2.5 hours per week.
HRT accounts for an extra 4 cases per year; this is about the same as taking the combined oral contraceptive pill, drinking two or more units of alcohol per week or smoking.
Being overweight and making less healthy lifestyle choices are far more important risk factors both in clinical and statistical terms for developing breast cancer.
Breast cancer risks are considerably lower in women using the newer hormones used in HRT. These are body identical hormones (they are the same as the hormones we naturally produce) and not the same as synthetic hormones.
Women below the age of 50 using HRT containing transdermal (absorption through the skin via patch or gel) body identical estrogen and micronized progesterone have a lower relative risk of breast cancer in comparison with the older version of HRT.
Women below the age of 50 who have had a hysterectomy and are using transdermal body identical estrogen only, do not have an increased risk of breast cancer.
Please understand that the risk of breast cancer naturally increases as you age whether or not you are on HRT.
When to start
Women in the perimenopause who are experiencing symptoms are best to start taking HRT sooner rather than later to improve quality of life and reduce any negative body composition changes. HRT can be taken indefinitely essentially for the rest of a woman’s life as a woman will be in the menopause for the rest of her life.
HRT does not delay the menopause but simply controls symptoms whilst they are present.
If you still have periods whether monthly or irregularly you would take estrogen HRT ongoing and progesterone HRT for 2 weeks in every 4. If you’re in the menopause and no longer have periods you will take the combined treatment continually.
Estrogen only HRT is suitable if you have had a hysterectomy (the removal of your uterus). People who have had a hysterectomy do not need to include progesterone in the treatment as there is no risk of abnormal changes to the lining of the uterus since it’s been removed.
HRT can be taken as a tablet but is best applied through the skin either on a gel or patch, when HRT is applied this way it bypasses the liver reducing chances of a blood clot.
If you’ve had a hysterectomy as a result of severe endometriosis HRT treatment would differ.This is something which will be discussed with you by your doctor or menopausal specialist. Your doctor may want to include some progesterone in case there is any endometrial cells left in the pelvis.
Weight gain and HRT
HRT does not cause weight gain, in fact it will help you manage your weight. HRT will improve sleep quality therefore affecting your mood and energy levels.
A lower mood on less sleep you’re more likely to eat more as you have a reduced leptin sensitivity (satitety hormone) and increased grelin (hunger hormone). Due to tiredness you will likely move less.
What if HRT is not an option
Some women may choose not to go on HRT for personal choice or if they’ve previously had estrogen driven cancer.
There are alternatives if HRT is not an option:
Vaginal estrogen is for localised symptoms such as vaginal dryness. (This does not increase breast cancer risk).
Lifestyle modifications including regular exercise both cardio and weight training. Alongside a healthy diet, the Mediterranean diet is recommended which includes: fruits, vegetables,whole grains, fish and olive oil.
Stress management techniques include breathing exercises, stretching and practicing self care such as seeing friends, going for walks or having massages.
Sleep - A milk drink at bedtime contains tryptophan to make the sleep hormone melatonin. Tart cherry juice which I’ve mentioned above also helps to increase melatonin and reduce core temperature.
Consuming phytoestrogens - plant sources of estrogen such as soybeans.
Herbal supplement called black cohosh; this may help women to manage symptoms such as hot flashes, night sweats and sleep disturbances, there is some evidence it may support bone health.
Take homes
Aim for 1.6 - 2.0g of protein per kg/bodyweight per day. For example a woman weighing 70 kg will need between 112g and 140g of protein per day.
Consume 30-40g of protein at each meal and focus on workout nutrition I.e. make sure to have a large protein serving (30g+) after your workout to get that muscle protein synthesis response and have casein protein pre sleep to support recovery during the overnight fast.
Include carbohydrates in your diet as they help to lower cortisol. Cortisol is the stress hormone which in excess can lead to increased hunger, this combined with excess calories can lead to abdominal fat storage.
Do your workouts fuelled. There’s so much focus on ‘fasted’ workouts but they come with a downside. For women exercising in a fasted state can negatively impact the female hormone network thus can have subsequent effects on increasing cortisol which can impact metabolic health and body composition in the longer term.
Weight train 2-3 times per week and Include both moderate cardio and higher intensity cardio into your daily routine.
Supplement with vitamin D to support bone health, immunity, cardiovascular health and skeletal muscle. New research indicates that combining supplementation of vitamin D3 and vitamin K2 may be more beneficial for bone and cardiovascular health than just supplementing with vitamin D alone. Vitamin D supports the action of growth hormone. Low levels of vitamin D are well recognised because of muscle weakness, lack of energy and general lack of well being.
Enough sleep, this improves insulin and leptin sensitivity (this hormone influences appetite) and reduces cortisol. You become fitter when you sleep, positive hormonal adaptations actually occur whilst you’re sleeping. Growth hormone is released whilst we sleep, although this hormone reduces as we age we still get the same pattern of secretion.
