Drug-free treatments for perimenopausal symptoms
Part 3 of The Menopause Files
In Part 2 of the Menopause Files, I discussed the pros and cons of menopausal hormone therapy (MHT), summarising the conditions for which it provides effective relief, the conditions that are not helped by it, and the diseases for which it increases risk.
Many women’s medical histories rule out MHT, and others may choose not to take it after weighing its benefits and risks. What can these women do instead of (or even in addition to) MHT, to ease their transition into the post-reproductive phase of their lives?
Prevention is better than cure
There’s an old saying – dubiously described as a Chinese proverb – that ‘The best time to plant a tree was twenty years ago; the second-best time is now’. Likewise, preparing for perimenopause and for a healthy postmenopause life would ideally begin well before women start noticing telltale signs such as menstrual irregularity, vasomotor symptoms (hot flushes/flashes and night sweats) and changes in weight distribution.
That’s because multiple studies that have tracked a cohort of women from their forties, through the menopausal transition and into postmenopause, have found that women who are overweight, sedentary, have poor eating and sleeping habits, and inadequate coping skills and social support before they enter perimenopause, have the most troubling symptoms during their transition and the steepest rise in risk of bone fractures, cardiovascular disease and dementia.
That said, it’s never too late to switch to a healthier eating pattern, and to develop a regular physical activity program. As we’ll soon see, research has demonstrated that even women who are plagued with terrible hot flushes, or are struggling to lose weight on the other side of menopause, can gain great results when they adopt the right practices.
Let’s take a closer look at those studies, and what they uncovered.
Cohort studies investigating the menopausal transition
The 1990s saw an explosion of research into the unique health challenges faced by women. But these researchers took a very different approach to menopause than the disease-centric mid-twentieth century model, exemplified by Dr Robert Young’s 1966 book Feminine Forever which characterised the ‘change of life’ as a serious disease state that signified the end of women’s useful lives, and thus required urgent medical intervention to save women (and, perhaps more importantly, their husbands) from becoming unattractive, sexless old crones. Instead, the new crop of researchers positioned menopause as a normal and natural phase of women’s lives that should be understood through the eyes of women, not chauvinistic men like Dr Young.
The Seattle Midlife Women’s Health Study, launched in 1990, recruited 508 women aged 35–55 living in Seattle, Washington, and followed them up until 2013. Its aims were to explore women’s experiences of symptoms during the menopausal transition and early postmenopause, and to identify biological and psychosocial factors that influenced the frequency and severity of these symptoms.
The Melbourne Women’s Midlife Health Project – subsequently renamed the Women’s Healthy Ageing Project – was also initiated in 1990, with the recruitment of 438 Australian-born women aged between 45 and 55 years old, who were not taking any form of hormonal therapy. Regular follow-up visits with this cohort have been conducted ever since, to measure biomarkers, conduct brain imaging and body composition scanning, carry out genetic and neuropsychological testing, and gather data on sociological, relationship, demographic, diet and lifestyle, and life course factors that could influence women’s experience of perimenopause and postmenopause.
The Study of Women’s Health Across the Nation (SWAN) began in 1994, and over the next few years, it recruited 3302 42-52 year old premenopausal women from five racial/ethnic groups, through seven designated research centres located throughout the US. This still-ongoing cohort study has examined the relationship between physical, biological, psychological and social changes in women’s lives, and their experience of menopause and the post-fertile phase of their lives. SWAN has investigated the factors that impact changes in bone density and body composition, cardiovascular disease risk, vaginal and sexual health, physical function, sleep and cognitive function, among many other concerns and conditions of midlife and older women. The findings are summarised in a series of fact sheets which are essential reading for women who are going through the menopausal transition, as well as their health care providers.
The Penn Ovarian Aging Study enrolled 436 premenopausal, non-hormonally-medicated women who were aged 35–47 in 1996–1997, with equal numbers of black and white participants. The chief aim of the study was to track changes in reproductive hormones, and their association with race, menopausal symptoms, mental health, and cardiovascular risk factors. Subsequently, researchers have used this cohort to explore the impact of adverse childhood experiences on inflammation and major depression during the menopause transition.
And finally, the Midlife Women’s Health Study recruited 780 women aged 45 to 54, who were living in the Baltimore, Maryland area, and who were either late premenopausal or perimenopausal. Participants were followed up from 2006 to 2015. The research was focused on identifying associations between the severity of vasomotor symptoms and participants’ demographic characteristics, health behaviours (smoking, alcohol intake, BMI, weight change), exposure to pthalates (endocrine-disrupting chemicals found in many personal care products), and hormone levels.
Findings from these studies
Vasomotor symptoms
The Penn Ovarian Aging Study found that obesity increased the risk of experiencing moderate to severe hot flushes in white women, but not in black women:
Anxiety also increased the risk of experiencing hot flushes; the Penn Ovarian Aging Study found that for every one-point increase in the Zung anxiety score, the risk of suffering hot flushes increased by five per cent. Subsequent analysis pinpointed somatic anxiety – the physical manifestation of anxiety in the form of symptoms such as muscle tension, trembling, gut disturbance, headaches and shortness of breath – as being a strong predictor of experiencing hot flushes, whereas affective anxiety – the emotional experience of anxiety, in the form of feelings like nervousness, fear, or worry – was not.
The Midlife Women’s Health Study reported that current and former cigarette smoking put women at higher risk of hot flushes, and smokers also had a longer total duration of hot flushes. Smoking for at least ten pack-years was also reported to be a risk factor for hot flushes in the Melbourne Women’s Midlife Health Project. Other studies have found no association between smoking and duration of hot flushes.
Another finding from the Midlife Women’s Health Study was that women with higher concentrations of pthalate metabolites in their urine were more likely to suffer hot flushes.
On the other hand, in the Penn Ovarian Aging Study, higher education levels were found to be protective; women with education beyond high school had a 34 per cent lower risk of hot flushes. Diet and lifestyle factors were not assessed in this study, but education levels are generally a proxy measure for health behaviours – that is, people with more years of education tend to have healthier eating habits and to be more physically active. The Midlife Women’s Health Study found that women with a higher education level experienced hot flushes for a shorter time period.
Depression and well-being:
Depression is frequently claimed to be a symptom of perimenopause, but the Seattle Midlife Women’s Health Study researchers found that menopausal changes in and of themselves had minimal effect on depressive symptoms. Instead, perceived life stress and poor health status were the most influential factors. Likewise, the Melbourne Women’s Midlife Health Project concluded that “no significant increase in depression or negative moods was directly associated with menopause.”
The Seattle study also analysed the correlates of general well-being, and found that women who indicated that they had a) adequate social support and b) a sense of mastery – defined as “the mental and emotional capacity to perform skills and behaviors needed to manage new situations or environments” reported the highest level of well-being, while a decrease in well-being was associated with negative life events. No correlation was found between well-being and factors related to the menopausal transition itself.
Bone health
The Study of Women’s Health Across the Nation (SWAN) found that women who were more physically active – whether through vigorous work and household activity, regular exercise or participation in sports – entered the perimenopausal transition with higher bone mineral density and bone strength at the femoral neck (the site of so-called ‘hip fractures’). And the more active the women were, the denser and stronger their bones.
Given that previous research has shown a dose-dependent relationship between femoral neck strength and the risk of fracture, the SWAN researchers estimated that every step up in activity level (from sedentary to low to moderate to high) would decrease the risk of any fragility fracture during menopause by 10 per cent, and the 10-year postmenopausal hip fracture rate by 17 per cent. Put simply, the more physically active you are, every day, the lower your chance of breaking a bone, and especially, of suffering a devastating hip fracture.
If you’ve watched my interview with orthopaedic surgeon Dr Nick Birch, you’ll know that bone density and bone strength have a complex relationship; denser bones are not always tougher and more fracture-resistant. SWAN confirmed this, finding that although obese premenopausal and early perimenopausal women had higher bone density than healthy-weight women, when compared to non-obese women with similar bone density, the obese women suffered significantly more fractures.
Cardiovascular disease
While premenopausal women rarely develop heart and blood vessel disease, the risk of angina, heart attacks and other manifestations of cardiovascular disease (CVD) rises steeply after menopause. In the Melbourne Women’s Midlife Health Project cohort, women who were already overweight/obese, or who gained weight during perimenopause had the greatest increase in CVD risk. An increased free testosterone index and a decrease in estradiol also boosted CVD risk.
Participants in the Women’s Healthy Ageing Project cohort who ate more red meat, and particularly processed meat, upped their risk of CVD compared to those who ate less meaty diets.
Urinary incontinence
Urinary incontinence and leakage are not symptoms of menopause per se. Weight gain and diabetes both increase the risk of developing urinary incontinence, and of the incontinence worsening over time.
Action steps for pre-, peri- and postmenopausal women:
1. Pull out all stops to attain a healthy weight and body composition
If you’re overweight or obese in your forties, you can not only expect a rougher time with vasomotor symptoms as you’re going through the menopausal transition, and a higher likelihood of developing urinary incontinence, and a greater risk of bone fracture and cardiovascular disease as you get further into your sixth decade and beyond… no, as if that wasn’t enough, it’s also going to become ever more difficult to attain a healthy weight as you transition through menopause and into the post-fertile phase of your life because of the body composition changes (less lean tissue, more body fat) that are driven by perimenopausal changes in hormone levels.
1a. What dietary pattern is best for midlife women?
The best way for midlife women to lose weight is to adopt a high-fibre, high-antioxidant diet, rich in plant protein and relatively low in fat – that is, a plant-centred diet that prioritises fruits, vegetables, legumes, nuts, seeds and whole grains. Not only does such a diet help you reduce your energy (calorie/kilojoule) intake without feeling hungry, it also helps to mitigate perimenopause symptoms:
In the Women’s Health Initiative Dietary Modification trial, women who lost weight by increasing their intake of fruit, vegetables, and whole grains, and reducing fat intake, were more likely to eliminate their vasomotor symptoms than the control group. Those who lost more than ten per cent of their starting weight on the plant-rich diet had a 90 per cent likelihood of getting rid of their hot flushes and night sweats. And reducing dietary fat intake to 20 per cent or less of daily calories, was associated with more body fat loss, and a slower rise in body fat levels as women aged up.
A cross-sectional study of women in Tehran found that those eating the most fruits and vegetables were the least likely to experience either physical or mental symptoms of menopause.
Furthermore, the Tehran women’s dietary total antioxidant capacity was inversely related to the likelihood of them experiencing any menopausal symptoms – that is, the more antioxidants in the diet, the less the hot flushes and night sweats, sleeping difficulties, anxiety, exhaustion and difficulty concentrating.
Women with worse menopausal symptoms ate more fat and less carbohydrate and protein, while those with the fewest menopausal symptoms ate diets higher in protein, carbohydrate and vitamin C.In a survey of 45–80 year old women on vegan, vegetarian and omnivorous diets, those of perimenopausal age who ate a vegan diet reported the least bothersome vasomotor and physical symptoms (including muscle and joint aches, fatigue, sleep difficulties, neck, head and back aches, reduced strength/stamina, lethargy, skin changes, weight gain, facial hair, bloating, frequent or involuntary urination and flatulence). Vegetables, soy foods, omega 3-rich plant foods and berries were the foods most associated with protection against perimenopausal symptoms, while meat and dairy food intake were associated with more severe symptoms.
These findings from individual studies were confirmed in a systematic review of studies investigating nutrient and food intake and eating patterns associated with the intensity of menopausal symptoms, which concluded that women with higher consumption of vegetables, whole grains, and unprocessed foods had a lower intensity of psychological symptoms, sleep disorders, and vasomotor, urogenital, and somatic symptoms; on the other hand, women who ate more highly processed foods, saturated fats, and sugars suffered more intense symptoms.
In postmenopausal women with bothersome vasomotor symptoms (two or more hot flushes per day), a small randomised controlled trial of a 12 week low-fat, all-plant diet which included half a cup (86 g) of cooked soybeans daily, reduced total hot flushes by 79 per cent in the intervention group (vs 49 per cent in the control group who made no dietary changes), while moderate-to-severe hot flushes decreased by 84 per cent (vs 42 per cent in controls). By the end of the 12 week intervention, 59 per cent of women who made the dietary changes were free of moderate and severe hot flushes, while no women in the control group achieved this outcome. Psychosocial, physical and sexual symptoms also declined more in the women on the vegan plus soy diet. Repetition of the study with a larger participant group replicated these impressive findings.
A narrative review of evidence on the association between dietary patterns and clinical endpoints in postmenopausal women concluded that low fat plant-based diets have beneficial effects on body composition, while the Mediterranean dietary pattern helps to preserve bone strength and reduces the risk of metabolic and cardiovascular diseases in the postmenopausal period.
Conversely, high fat, low carbohydrate diets are associated with worse menopausal symptoms across the board. And as mentioned above, a meat-heavy ketogenic or carnivore-style diet will increase your risk of heart disease. (It will also elevate your risk of developing dementia.)
Contrary to the social media hype, jacking up your protein intake does not help you gain more muscle mass after menopause; intervention studies have found that women who undertake a resistance training program will gain lean body mass whether they eat the recommended dietary allowance/intake for protein (0.8-1 g of protein per kg of body weight per day), or a high protein diet:
You’ll (hopefully) remember from the Melbourne Women’s Midlife Health Project cohort study, that an elevated free testosterone index is associated with an increased risk of cardiovascular disease. How might one lower one’s free testosterone index? By increasing sex hormone-binding globulin (SHBG), which preferentially binds to testosterone, effectively reducing the amount that’s available for cells to take up. Both pre- and postmenopausal women on vegetarian diets have higher levels of SHBG (and hence, lower free testosterone), largely driven by higher fibre intake. The same study found that women on vegetarian diets had higher apolipoprotein A levels, along with lower apolipoprotein B and body mass index – all three being known protective factors against cardiovascular disease.
The Penn Ovarian Aging Study found that regular physical activity also reduces circulating testosterone levels in women in the late transition stage; the most physically active women had a whopping 47 per cent lower testosterone level than the least active.
Putting all this into real-world terms, the best way for midlife women to eat, in order to reduce excess weight and body fat and maintain lean mass, while reducing the risk of perimenopause symptoms, cardiovascular disease and bone fractures, is to centre their diet on fresh produce (fruits and vegetables), plant protein-rich foods such as legumes (including soy), and whole grains, with some omega 3-rich nuts and seeds (flaxseed, chia seed, hemp seed and walnuts), while minimising or avoiding highly processed foods, and choosing unprocessed animal products that are lower in fat.
1b The vital role of exercise
Muscle-strengthening exercise is critical for maintaining lean mass (muscle and bone) as you move through perimenopause and into the post-fertile phase of life. As shown in the figure above, women can gain significant amounts of muscle mass when they undertake resistance training.
It’s well worth the effort, as women who maintain higher levels of lean body mass (muscle and bone, noting that increasing muscle mass generally increases bone mass as well) during the menopausal transition are less likely to develop vasomotor symptoms. The figure below plots the probability of developing hot flushes and night sweats as a function of time since recruitment into the study, and skeletal mass index (SMI), which expresses the relationship between skeletal muscle mass and height. Each line on the graph represents the probability of participants reporting vasomotor symptoms at each visit, as a function of their SMI.
The striking relationship between skeletal muscle index and the likelihood of developing hot flushes and night sweats is clearly evident. Almost 70 per cent of women who had the lowest skeletal muscle index (i.e. the least muscle mass for their body size) were experiencing some vasomotor symptoms by Visit 10, compared to less than 10 per cent of women with the highest SMI.
In other words, women who maintained or built muscle mass as the study progressed, were able to keep hot flushes and night sweats at bay
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In addition, even women who are genetically predisposed to weight gain can effectively neutralise their fat genes by increasing their physical activity level, and this anti-fat gene effect becomes more pronounced with age, such that women 70 or older reap the most benefit from physical activity if they have been ‘cursed’ with genes that predispose to weight gain.
2. Build up your psychological resilience to stress
Some life stressors are unavoidable, and the risk of some of the greatest sources of life stress inevitably increases with age – for example, the death of, or diagnosis of devastating disease in, a partner, parent or close friend. But we do have significant leverage over other sources of stress. Your own health status – a major contributor to stress – can almost always be improved with diet and lifestyle changes; you can cultivate a broader social network in order to buffer yourself against inevitable losses of loved ones; and you can consult a reputable financial adviser to help you plan for a more economically comfortable post-work life (another major source of later-life stress).
You can also engage in practices such as meditation, prayer and journalling that help to cultivate resilience in the face of unavoidable stress, and you can commit to life-long learning which provides not only mental stimulation – vital for staving off cognitive decline – but also exposes you to new ways to look at, and potentially solve, your problems.
A word on psychological treatments for vasomotor symptoms
Both clinical hypnosis/hypnotherapy and cognitive behaviour therapy are highly effective for relief of hot flushes and night sweats, and mindfulness-based therapy may be effective. For example:
In a randomised controlled trial of five weekly sessions of either clinical hypnosis or structured-attention control (discussion of symptoms, attentive listening, interpersonal exchange, avoidance of negative suggestions, monitoring, measurement and encouragement), clinical hypnosis reduced the frequency of hot flushes by 74 per cent (vs 13 per cent in controls), and the severity of hot flushes by 80 per cent (vs 15 per cent in controls). At 12 week follow-up, the women who received the clinical hypnosis intervention still had 57 per cent fewer hot flushes while controls only had 10 per cent fewer. Clinical hypnosis also significantly improved hot flush-related interference in daily activities and sleep quality, and more women felt satisfied with this treatment than with the structured-attention control.
In a randomised controlled trial of cognitive behaviour therapy (CBT) vs waitlist control (i.e. no active intervention), CBT significantly reduced vasomotor symptom bothersomeness and interference with daily life. CBT also reduced depressive symptoms, sleep difficulties, and sexual concerns.
In a randomised controlled trial of a six-week program of group cognitive behavioral therapy (CBT) or guided self-help CBT for vasomotor symptoms, both group and self-help CBT produced clinically significant reductions in hot flushes and night sweats compared to the no-treatment control condition, and these improvements largely persisted through to the final follow-up visit at 26 weeks:
Finally, a meta-analysis of mindfulness-based interventions for menopausal symptoms concluded that they may improve quality of life, but there is insufficient evidence to analyse whether they can reduce vasomotor symptoms.
If you’re unable to locate a professional trained in CBT and/or clinical hypnosis for vasomotor symptoms, near you, there’s an app for that! The Evia app provides a convenient and affordable way to access clinical hypnotherapy for vasomotor symptoms. Caria delivers app-based CBT focused on vasomotor and other symptoms of menopause.
And finally, I’d love to hear from my readers about their perimenopause and postmenopause experience. Did you suffer from vasomotor symptoms and if so, what did you find effective for relieving them? Was ‘the change of life’ a terrible time in your life, or a terrific time, or something in between? What do you wish someone had told you, that would have helped you navigate midlife with more ease and grace? Leave a comment below!
And finally, this post has taken approximately 20 hours to research and write. If you feel you’ve benefited from reading it, please consider a paid subscription to help me continue this work: