Menopause and Perimenopause: A Holistic Approach

Natural and holistic support for menopause and perimenopause
 
 

Menopause & Perimenopause:

Menopause is a natural phase in a woman’s life that marks the end of her menstrual cycles. It’s officially confirmed when 12 consecutive months have passed without a period. It usually occurs between the ages of 48 years and 55 years. Rarely does a woman develop menopause before the age of 40 years but hormonal fluctuations can start in the mid 30’s and progress through menopause. At menopause, your ovaries stop producing the female hormones estrogen and progesterone. 

Definitions:

Perimenopause: Symptoms can begin several years before menopause with symptoms typically increasing in the 1-2 years prior to menopause. Hormone levels fluctuate significantly during this time and can cause significant symptoms. Note that many women notice changes to their menstrual cycles and other hormonal changes well before they stop ovulating - this is very common in the early 40’s but can start in your mid 30’s. 

Menopause: begins 1 year after your last menstrual bleed. Symptoms will continue at varying degrees and slowly taper off. Some symptoms will resolve and some symptoms may progress.

HRT or BHRT: hormone replacement therapy or bioidentical hormone replacement therapy. This is the use of synthetic or bioidentical hormones for the replacement of your natural hormones as levels drop in perimenopause and menopause. For some women this can be a safe and very effective treatment protocol for perimenopausal and menopausal symptoms. See the section on hormonal therapy options to see if it is a good fit for you.

Hormones:

FSH - Follicle stimulating hormone. This level increases when you are supposed to release an egg during your cycle. If the ovary releases an egg, this number will stay low. If the ovary does not release an egg then the number remains high. This number will fluctuate during perimenopause and will stay elevated in menopause. This is one of the best tests to determine if you are in perimenopause or menopause, especially if you have medical or physical reasons you are not having a period (endometrial ablation, use of IUD, history of a hysterectomy, etc).

E2 - Estradiol - your most active female sex hormone. Primarily produced in the ovaries during reproductive years. It is also produced in smaller amounts in fat tissue of the breast, osteoblasts and chondrocytes of bone, in blood vessels and smooth muscle cells of the heart, and numerous sites in the brain - these sites become more important after menopause. Actions of estradiol:

  • Helps mature and signal release of an egg at ovulation

  • Helps thicken the uterine lining to help with proper implantation

  • Keeps vaginal tissue healthy and promotes healthy vaginal fluids

  • Important role in mental health - to much or too little is associated with depression and anxiety

  • Too little estrogen (typically seen in menopause and perimenopause): vaginal dryness, recurrent UTIs, hot flashes, mood swings, depression, fatigue, and mental fog.

Progesterone:  progesterone is primarily produced in the ovary by the corpus luteum (follicle remnant) after ovulation. Drop in progesterone levels signal the shedding of the uterine lining and initiates your period. Actions of progesterone:

  • Reduces the risk of endometrial cancer by preventing endometrial hyperplasia.

  • Has vasodilating effects that may improve circulation and cardiovascular health.

  • Promotes relaxation and reduces feelings of anxiety. 

  • As progesterone levels drop in menopause, some women may feel more anxiety and insomnia. Sometimes a prescription for progesterone is used alone for these reasons or along with estrogens to help prevent endometrial cancer.

  • Of note, the synthetic form of progesterone (progestogens) do not offer the same protective effects as natural or bioidentical progesterone.

Testosterone -  In women, testosterone is produced in the ovaries and adrenal glands. Testosterone levels also tend to drop in menopause so it is sometimes considered as an option for HRT. 

While it is produced in much smaller levels when compared to men, testosterone is still an import hormone for: 

  • Bone health and muscle growth

  • Promotes healthy reproductive tissue

  • Cognitive function and mood

  • Promotes libido

Signs of elevated testosterone:

  • Acne

  • Abnormal hair growth such as facial hair

  • Irregular menses

  • Deepened voice

Signs of low testosterone:

  • Thinning hair or hair loss

  • Decreased libido

  • Fatigue

  • Sleep disturbances

Non-Hormonal Treatment Options:

It is recommended to only try a selection of supplements at a time so that you can determine what is actually improving your symptoms. Some supplements may take 1-3 months to start being effective so be patient and kind with yourself during this process. Start with the recommendations given in our office visit as we will try to pick the most effective treatments for your symptoms. Note that some supplements may work well for one person and have little to no effect for another person.

Important note: some supplements can interact with medications you are taking or may not be recommended for you based on your medical history. Please speak to a medical provider prior to starting any supplement and to discuss appropriate dosing.

Lifestyle:

  • Multivitamin/mineral

  • Reduce dietary saturated fats and avoid trans fats

  • Get plenty of heart healthy fats and oils from oil oil, salmon, or avocado oil.

  • Reduce refined carbohydrates, sugar and salt.

  • Assess for food sensitivities or allergies that may contribute to “brain fog,” fatigue, swelling, or bloating.

  • Increase fruits, vegetables, legumes, whole grains, nuts, seeds, healthy fats and cold water fish. 

  • Increase intake of soy, chia and flax.

  • Eat calcium rich foods

  • Aim for 150 minutes of aerobic exercise weekly.

  • Aim for three, 20 minute strength training exercises weekly.

 

Stress/mood support: 

  • Sleep hygiene - handout provided upon request

  • Self care- aim for 20 minutes of self care daily.  Examples: read a book, take a bath, have alone time or people time (depending on which makes you happier).

  • Mindfulness based exercises and meditations.

  • Cognitive behavioral therapy

  • Saint John’s Wort - supports depression (this supplement interacts with many medications - please consult a health care provider prior to considering regular use of this herb)

  • Lavender oil caps - supports anxiety

  • Rhodiola - supports mood, energy, and focus

  • Kava supports reduces stress, can improve sleep (limit to short term or as needed use)

  • Non-hormonal medications options: SSRIs, SNRIs, or bupropion

 

Hot flashes/night sweats: 

  • Bioflavonoids: combined Vitamin C – for hot flashes.

  • B6 for mood support, sleep support.  It is a cofactor for serotonin production. 

  • Evening primrose oil:  for breast tenderness and alleviating vasomotor symptoms (night sweats, hot flashes, flushes).

  • Red Clover:  dried herb for hot flashes.

  • Black cohosh for hot flashes

  • Lachesis 30C homeopathic

  • Non-hormonal rx option: Venlafaxine extended release (SNRI, also helps with anxiety and depression)

For vaginal dryness: 

  • Vitamin E vaginal suppositories

  • Use of water based lubrication during sex.

  • Bezwecken Hydration cube

  • See hormonal treatment options as well because topical HRT for vaginal health poses fewer health risks than systemic HRT for most women and can be very effective for both vaginal and urinary symptoms related to menopause.

 

For cognition support:  

  • Bacopa

  • Ginkgo biloba

  • Rhodiola

  • Panax Ginseng:  

  • Combined formulas:

    • Pure encapsulations Memory Pro

    • Vitanica mind blend

    • Bacopa Plus:    


Bone support:

  • Check your risks for Osteoporosis

  • DEXA screening recommended for women 65 and older or postmenopausal under 65 who have additional risk factors (click on the FRAX link to look at your risk factors)

  • Fracture risk assessment (FRAX) tool -  https://www.sheffield.ac.uk/FRAX/tool.aspx?country=23 

  • Calcium rich foods.

  • Smoking cessation.

  • Core strengthening exercises.

  • Weight bearing exercises

  • Vitamin D3

  • Calcium supplements

  • Bone support supplement: 

    • Jarrow Bone Up

    • OR - Integrated therapeutics OsteoPrime Ultra

 

Multiple component supplements for menopausal symptoms:

  • BioFem Transitions by Biogenesis

  • Vitanica Women’s Phase II


Hormonal treatment options:

HRT or BHRT may be very helpful at resolving symptoms in perimenopause and menopause. Timing of treatment: Treatment often begins in perimenopause as symptoms from hormone fluctuations rise - this is about 1-2 years prior to Menopause. Some people start treatment after menopause as symptoms they thought would resolve  have remained persistent and affect their quality of life. The length of the hormone therapy depends on the individual's personal risk factors, symptoms, and personal goal of treatment but typically used for 5-10 years.


Benefits and Risks of HRT:

The balance of benefit to harm always needs to be assessed for each patient but appears to have shifted favorably for HRT for most individuals.

If women start HRT around the time of menopause the risk is very small and there appear to be cardiovascular and bone protective benefits. It is not usually appropriate for women over 60 to be starting HRT but as the WHI study shows, women initiating it over 60 years do not seem to be at increased risk of cardiovascular events or mortality.

Women who are good candidates for HRT/BHRT:

Most women with menopausal symptoms can benefit from HRT if they do not have significant risk factors for adverse events.

Risk factors to consider:

  • Not recommended if a person is at high cardiovascular risk (using the ASCVD risk score calculator)

  • Not recommended for those with a personal history of breast cancer, coronary heart disease, a previous venous thromboembolic (VTE) event or stroke, active liver disease, current unexplained vaginal bleeding, or if she is at high-risk of endometrial cancer.

Additional info:

Bio-identical hormones are hormone preparations which are identical molecules to those produced by the body. Products labeled as a “bio-identical” hormone will carry the same benefits and risks as the HRT products produced by pharmaceutical companies and properly licensed for use, and there is absolutely no evidence that the bio-identical hormones are any safer than those used in traditional HRT with the exception of synthetic progesterone (progestin) vs bioidentical progesterone. Some progestins (such as medroxyprogesterone acetate (MPA)) may increase the risk of cardiovascular events and breast cancer.

The dose and duration of HRT use should be made on an individual basis after discussing the risks and benefits. No arbitrary limit should be set on duration of use.

HRT users are assessed by their health care provider 2-3 times in the first year then at least once a year for continued monitoring. 

Route of administration: 

Oral route - for estrogen and progesterone, no testosterone

Sublingual - similar to oral but is done with liquid that is placed under the tongue or a troche that is held in the side of the mouth.

Transdermal - cream, gel, or patch. This is typically a good route for most people as the dose stays more level in the body and does not enter “first pass metabolism” (oral routes have to go through the liver first before getting to the rest of the system. 

Injection - not typically the first route of option but may be considered

Vaginal route - cream or estring: this can be a great option for women that are having primarily vaginal symptoms in menopause or for those that systemic HRT poses greater risk than benefit.

Treatment Goals:

The goal of hormonal therapy is to reduce your symptoms with the lowest effective dose. This means we will start on the low end of the dosing options and may increase based on symptoms improvement and estrogen levels in your blood.

What to expect from your appointments:

  1. Initial labs - these may include one or more of the following depending on your personal history or your symptoms: Estradiol, progesterone, FSH, testosterone, lipid panel, metabolic panel, complete blood count, TSH.

  2. Assessment your overall health risks and benefits for use of HRT

  3. Choose the best hormonal options for you and choose the route of delivery 

  4. Repeat labs: we will repeat hormone labs we are treating and follow up on any other necessary labs in 3 months

  5. We will have a follow up appointment in 3 months to review your labs and assess if symptoms are well managed. 

    1. If well managed we will recheck levels again in 6 months and follow up with a visit.

    2. If symptoms are not fully managed we can consider increasing the dose or adding additional support. We will then repeat labs and follow up in 3-6 months depending on what treatments changed.