Menopause is a natural process that affects every woman in the world when she reaches middle age. Even so, the “change of life” catches many women by surprise. After decades of living in a predictable body, things start to change — physically and sometimes emotionally as well.
It helps to understand a bit about what’s going on in the body during menopause. Menopause results from the fairly abrupt decline in estrogen levels associated with the natural cessation of ovarian function. Put more simply: when the ovaries run out of eggs, estrogen stops.
A woman’s ovaries typically contain a supply of eggs that last until midlife. Estrogen production is tied to ovulation (the monthly release of an egg from the ovaries). When the ovaries run out of eggs, estrogen levels decline sharply, along with reproductive function. When ovulation ceases, menstrual periods also stop.
Menopause, signaled by loss of menstrual periods, typically occurs between ages 45 and 55 (average age of menopause is 51 in the U.S.). Sometimes periods can come and go with increasing irregularity for years before they stop completely. The interval of irregular periods leading up to menopause is known as perimenopause. Hormonal fluctuations during perimenopause can also cause breast tenderness, bloating, and pelvic discomfort. Classic symptoms of menopause include hot flashes, night sweats, vaginal dryness, sleep disturbance, and mood imbalances. These symptoms can also occur during perimenopause and for years after the last menstrual period occurs.
Although menopause isn’t a disease, sometimes it feels like a disease. That’s because menopause can be the proverbial last straw. Stress that’s been adding up for years — poor eating habits, the mental stress of navigating the complexities of modern life, not getting enough sleep, and not staying physically active — often go unnoticed until menopause comes along and tips the balance. Then, everything seems like it’s falling apart.
However, there are a few significant health concerns that come along with menopause. One is cardiovascular disease. The cyclic production of estrogen associated with normal menstrual cycles has been linked to lower risk of cardiovascular events, as compared to men. After menopause, however, that protection is erased; postmenopausal women have about the same cardiovascular disease risk as men of the same age.
Postmenopausal women also need to be aware of their newly elevated risk of osteoporosis. Accelerated bone loss (up to 20% of total bone mass) occurs in the first seven years after menopause and then levels off as the body adapts to having minimal estrogen.
Tips for a Comfortable Transition
Health habits matter. Over many years of following women making the transition, it’s been impossible to overlook the fact that women with poor health habits have more pronounced symptoms, and the symptoms go on longer. Smoking, poor dietary habits, chronic stress, poor sleep, and inactivity translate into greater menopausal symptoms. Better health habits reduce symptoms.
Get your diet squeaky clean!
Walk right past those tempting processed foods, and pack your shopping cart with fruits and vegetables. Fill half of your plate with vegetables at every meal. Packed with fiber and phytonutrients, vegetables can help you maintain a healthy weight, especially during menopause and postmenopause, when weight gain is common. A diet high in veggies also helps to maintain a healthy cardiovascular system and good bones and brain health (for women and men of all ages!).
Prioritize self-care and relaxation.
Menopause is a period of change, which can often feel stressful. That’s why it’s so important to manage your stress and make time for relaxing activities. Yoga, qigong, and other mind-body modalities are good for balancing stress, but choose any activity that brings you joy.
Exercise can help you balance stress, maintain a healthy body weight, and keep your heart and lungs strong as you age. In response to such activity, your body generates endorphins, the “feel good” molecules that naturally help to elevate mood and sense of wellbeing while reducing pain. Aim for at least 30 minutes of moderate intensity activity at least 5 days a week. The decline of estrogen after menopause tends to lead to an increase in visceral fat and a loss of muscle mass and bone density. But resistance training — including yoga and other weight-bearing activities — can help you maintain and build muscle and bone.
Establish a relationship with a health care provider.
A health care provider, such as a gynecologist, can administer medical therapy when indicated and order or perform health screens such as PAP smears and mammograms.
Herbal Support for Menopause
In regard to menopause, you will often see the phrase “HPA axis” because reproductive function is closely tied to the hypothalamic-pituitaryadrenal axis (known as the HPA axis). As discussed in Chapter 13, the hypothalamus is a walnut-size gland at the base of the brain that controls sleep and wake cycles, body temperature, stress tolerance, energy and metabolism, body weight, and reproductive functions. It does so by regulating the pituitary gland, which in turn regulates the thyroid gland (metabolism), the adrenal glands (stress glands), and the ovaries (reproduction). Fluctuating estrogen levels disrupt the delicate balance of the HPA axis, resulting in many of the menopause symptoms.
Fortunately, Mother Nature has provided some very functional answers for balancing the HPA axis and reducing menopausal symptoms. Herbal options include both herbs that have estrogenic activity and others that act by non-estrogenic mechanisms. One of the best options is ashwagandha, already previously mentioned because, as an adaptogen, it has many applications.
Ashwagandha balances the HPA axis, thus reducing menopausal symptoms, but without having any estrogenic effects. Ashwagandha has been used in India for thousands of years to treat symptoms that are indicative of hypothalamic imbalance, including menopausal symptoms.
Over years of practicing gynecology and helping many women through menopause, I’ve found that ashwagandha pairs especially well with L-theanine (a natural substance that improves focus and concentration), along with some calming herbs such as extracts of the magnolia and phellodendron species from traditional Chinese medicine (known for supporting adrenal function and stress tolerance). This combination reduces all HPA axis–related symptoms, including hot flashes and anxiety, without being sedating. Because none of these herbs have estrogenic activity, they can be safely used along with estrogen replacement therapy when it is indicated. With use of the herbs, symptoms can typically be controlled with lower doses of estrogen.
(See Chapter 13 for complete profiles and dosing for ashwagandha and L-theanine.)
For irregular periods associated with perimenopausal women, the herb, vitex, also known as chaste tree berry is excellent for regulating periods and reducing PMS symptoms.
Vitex (Vitex agnus-castus)
Vitex acts as a tonic (hormonal modulator) specific for the female reproductive system. It is thought to work by normalizing ovarian function by affecting the pituitary gland. Vitex is effective for symptom management and regulation of periods during perimenopause and management of PMS symptoms. Note that it takes several months of taking vitex to see full benefit.
Suggested dosing: 500 mg of standardized vitex extract twice daily. It can be combined with cyclic administration of natural progesterone cream (for 2 weeks before expected time of the period) for optimal benefit.
Potential side effects and precautions: Vitex is generally well tolerated. Side effects are rare and include mild stomach upset, itching, rash, fatigue, and hair loss. Caution is advised if used with drugs that affect dopamine, but no other drug interactions are known.
Black cohosh is another herb commonly used to curb hot flashes without having estrogenic activity. My clinical experience is that ashwagandha is superior and covers a wider range of symptoms, but there’s nothing wrong with taking black cohosh along with the herbs previously mentioned.
Black cohosh (Actaea racemosa)
This herb is derived from the roots of a shrub-like plant native to the Appalachian forests of North America. Though well known for treating hot flashes, black cohosh was traditionally used to treat rheumatism. Having well-documented anti-inflammatory properties, black cohosh is an effective remedy for joint aches exacerbated by menopause. The clinical response for treating hot flashes is variable among individuals. Response appears to be dose dependent and also dependent on the quality of the product.
Suggested dosing: 20-80 mg per day of black cohosh standardized extract.
Potential side effects and precautions: Black cohosh appears to be quite safe and is well tolerated at normal doses. Black cohosh has not been found to have significant estrogenic activity. There is a slight risk of adverse effects on liver function with use of black cohosh at very high doses.
Some herbal supplements used for menopause do have estrogenic activity. This shouldn’t be a surprise because plants use many chemical messengers that are similar to ours. Phytochemicals with estrogenic activity (often called “phytoestrogens”) come from a class of chemicals called isoflavones, which are very abundant in certain plants. Soy and red clover are common sources of isoflavones found in herbal supplements.
It’s important to note that the estrogenic activity of phytoestrogens (isoflavones) is very weak. It’s only about 1% of the activity of estrogens produced by the ovaries. Although it’s common knowledge that estrogenic activity is equated with increased breast cancer risk, it doesn’t work that way with phytoestrogens. Phytoestrogens compete with stronger estrogens in the body for the same receptors, so phytoestrogens actually reduce estrogenic stimulation of breast tissue.
Here’s a fact worth considering: women in Japan consume large amounts of soy, which is very rich in isoflavones. Yet, women in Japan have a lower-than-average risk of breast cancer, which suggests that isoflavone consumption doesn’t promote breast cancer. That being said, women with a high genetic risk of breast cancer or women who have had an estrogen-sensitive cancer (breast or uterine) would be wise to avoid supplements containing isoflavones or having any estrogenic activity.
Phytoestrogens are best obtained from dietary sources, and 40-80 mg of isoflavones are recommended daily. One cup of soymilk contains about 6 mg; ½ cup edamame, 16 mg; 3 oz of tofu, 20 mg; 3 oz of tempeh, 30 mg; 1 oz of dry-roasted soybeans, 40 mg.
Women with symptomatic menopause will be confronted with whether or not to consider hormone replacement therapy (HRT). Symptoms of vaginal dryness and decreased libido are not benefited by herbal therapy. Properly administered HRT can help with those issues and protect against accelerated loss of bone mass and increased risk of cardiovascular disease.
Remember that the key to reducing symptoms of menopause is restoring balance in the HPA axis. One way to do that is by taking estrogen. When the ovaries stop working and estrogen secretion becomes erratic and eventually stops, abnormal feedback signals to the hypothalamus disrupt the entire HPA axis, including metabolic functions and management of the stress response. Administering estrogen restores balance to the HPA axis. For women who have a uterus, progesterone must be administered along with estrogen to prevent uterine bleeding.
Though HRT can dramatically reduce all symptoms of menopause and lower risk of osteoporosis, the type of HRT is important to consider. Pharmaceutical preparations of conjugated equine estrogen and medroxyprogesterone have been linked to increased risk of breast cancer, uterine cancer, and cardiovascular incidents (heart attack and stroke). This may be less true with low doses of transdermal (patches or cream) preparations of bioidentical estrogen and progesterone (identical to the natural hormones produced by the body). The greatest benefit of HRT appears to be within the first 7 years after menopause. The decision of whether or not to do HRT must be carefully weighed between the patient and a qualified health care provider.
You may choose to combine HRT with carefully selected herbal supplements. In almost all women, the hormonal imbalances of menopause gradually equilibrate over time. However, in the interim, nutritional and herbal therapies and/or properly dosed bioidentical hormone therapy can be safe, effective, and sometimes almost lifesaving.
As with any medical therapies, it’s important to open the lines of communication with your health care provider, discuss the risks and benefits of all possible therapies, and then be ready to adjust those therapies as needed to confidently transition through this phase of life.
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