An estimated 1.3 million women enter menopause annually in the United States. These hormonal shifts, often equated to a "second puberty," manifest physically, mentally, and emotionally. An integrative approach to hormonal support may help ease this hormonal transition.
This article will discuss what menopause is, lab tests that can help individualize options for managing symptoms, and a sample protocol that can be applied to clinical practice to support women seeking menopausal care.
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What Is Menopause?
Menopause is the normal and permanent cessation of menses for one year that results from estrogen deficiency as ovarian function diminishes. Menopause is one point in a continuum of life stages for women that marks the end of their fertile years.
After menopause, a woman cannot become pregnant naturally. The menopausal transition typically occurs gradually over many years, beginning with perimenopause, when menstrual cycle irregularities and other hormonal symptoms are first observed. (9, 31, 35)
Natural menopause occurs in three stages: perimenopause, menopause, and postmenopause.
- During perimenopause, the body begins to make less estrogen and progesterone. This hormonal decline occurs rapidly during the last one or two years of perimenopause. Perimenopause can last from months to ten years, although the average duration is four years.
- Menopause is the point in time 12 months after a woman's last menstrual period.
- Postmenopause is the time after having gone without a menstrual period for 12 months.
For most women, perimenopause begins in their mid-40s, typically 8-10 years before they reach menopause. The average American woman will reach menopause at 51. However, about 5% of women experience early menopause, between ages 40-45, and 1% of women experience premature menopause before age 40 due to premature ovarian insufficiency. (32)
Menopause Signs & Symptoms
In the months to years leading up to menopause, you may notice the appearance of menopausal-related symptoms, which most commonly include:
- Irregular and missed periods
- Temperature fluctuations: hot flashes, chills, and night sweats
- Vaginal dryness and discomfort during sexual intercourse
- Low libido
- Sleep disturbances
- Changes in mood: irritability, mood swings, anxiety, depression
- Weight gain
- Thinning hair
- Dry skin, eyes, and mouth
- Breast changes: loss of fullness, tenderness
- Urinary urgency and frequency (9, 35)
How to Identify Menopause
Diagnostic labs are not required to identify menopause. However, they can help understand menopausal symptoms and to individualize management plans.
Step 1: Clinical Identification
Menopause is identified clinically, meaning that it can be recognized based on the patient's age and history. Perimenopause is suspected in women in their 40s who are experiencing longer menstrual cycles or amenorrhea (the absence of menstruation). Natural menopause is identified in women who are not on hormonal forms of birth control after 12 consecutive months of amenorrhea.
Step 2: Hormonal Evaluation
Laboratory evaluation of hormones is not necessary for identification but can help understand the stage of the menopausal transition and confirm that a woman has reached menopause. This can be particularly helpful for women who do not have a uterus.
Follicle-stimulating hormone (FSH) is the preferred marker for confirming menopause. It is often tested in conjunction with estradiol. FSH levels consistently elevated above 30 mIU/mL with estradiol levels less than 20 pg/mL support the identification of menopause. These labs are a good starting point for a basic laboratory evaluation of menopausal status:
- Follicle-Stimulating Hormone (FSH) and Estradiol (E2) by Access Med Labs
- Female Hormone Panel by BostonHeart Diagnostics
During perimenopause, serum FSH and estradiol levels can be misleading due to their inherent variability. A single measurement is an unreliable indicator of menopausal status. Comprehensive salivary and urine hormone tests may provide more beneficial insights into menopausal symptoms. These tests allow for multiple samples to be collected throughout the day and/or month to better capture hormonal variations and more accurately assess hormone levels over time.
These testing panels offer a more nuanced and dynamic understanding of a patient's hormonal status and symptomology:
- Menopause Plus + CAR by Genova Diagnostics
- DUTCH Plus by Precision Analytical (DUTCH)
Step 3: Comprehensive Health Screening
Perimenopausal and postmenopausal women may have an increased risk for heart disease, osteoporosis, and thyroid disease due to declining hormone levels. This needs to be considered as part of holistic healthcare management to support overall health and maintain a good quality of life.
In addition to regular cancer screenings with pap smear, mammogram, and colonoscopy, the following labs can be ordered on an annual basis to assess cardiometabolic and thyroid function:
- Comprehensive Metabolic Panel by Access Med Labs
- Hemoglobin A1c by Access Med Labs
- Lipid Panel Comprehensive by BostonHeart Diagnostics
- Comprehensive Thyroid Panel w/ Antibodies by Precision Point
Additionally, bone mineral density testing should be performed in all women older than 65 years, or sooner in those with additional risk factors for osteoporosis (38).
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Approaches to Menopause Management
The fundamental goals of a comprehensive approach to menopause are to provide relief from common menopausal symptoms and support overall health.
Step 1: Support Hormone Balance
Here's Why This Is Important:
Managing menopausal symptoms involves understanding the hormones involved.
How Do You Do This?
Creating hormonal balance requires addressing the amount of hormones in circulation and how those hormones are metabolized and eliminated from the body. Both sides of these equations are equally important in creating hormonal harmony.
Support Hormone Metabolism and Elimination
Supporting liver detoxification pathways, increasing sweating, and improving daily bowel movements may help the body break down hormones into their respective metabolites and efficiently eliminate them from the body (41). To do so, consider including foods rich in the following nutrients:
- Indole-3-Carbinol (I3C): cruciferous vegetables, such as cabbage, kale, broccoli, brussels sprouts
- Resveratrol: red grapes, berries, peanuts
- Folate: green leafy vegetables, asparagus, brussels sprouts, liver
- Riboflavin: eggs, meat, and milk
- Vitamin B6: fish, beef, turkey, beans, and nuts
- Vitamin B12: meat, fish, eggs, dairy
- Choline: eggs, liver, soybeans
- Magnesium: green leafy vegetables, legumes, nuts, seeds, whole grains
- Calcium-D-Glucarate: broccoli, brussels sprouts, cabbage, oranges
- Fiber: whole fruits and vegetables, whole grains, nuts, seeds
Consider Hormone Receptor Modulation
Phytoestrogens are plant-derived compounds that mimic the effects of estrogen in the body. There are two major classes of phytoestrogens:
- Isoflavones, found in soybeans
- Lignans, found in flaxseed, whole grains, legumes, fruits, and vegetables
Phytoestrogens may help alleviate menopausal symptoms, such as hot flashes, and they may support bone and cardiovascular health due to their mild estrogenic effects.
Herbal medicines can also be considered for their phytoestrogenic effects. Popular examples include:
- Red clover extract standardized to contain 40-80 mg total isoflavones daily may help reduce hot flashes
- Black cohosh standardized extract of 40-160 mg daily may help reduce the frequency and severity of hot flashes and night sweats
According to the North American Menopause Society (NAMS), hormone replacement therapy (HRT) remains a common approach for managing menopausal vasomotor symptoms (hot flashes, night sweats) and genitourinary syndrome (vaginal and urinary symptoms). It may also help support bone health. Hormone therapies should be used at the lowest dose and for the shortest duration needed to meet patient goals. For women under 60 or within ten years of menopause onset without contraindications, the benefit-risk ratio may favor managing menopausal symptoms with HRT.
Systemic HRT uses estrogen, progesterone, and/or testosterone in various forms, such as pills, patches, rings, gels, creams, or sprays, to manage systemic symptoms of menopause. Vaginal products provide local estrogen to the vagina in a cream, tablet, or ring form to manage vaginal and urinary menopausal symptoms. (10)
Step 2: Provide Additional Symptom Support
Why Is This Important?
Patients may begin to experience a reduction in menopausal symptoms as they start to implement the natural and hormonal therapies discussed above. However, healthcare providers may also recommend additional supportive solutions to address specific bothersome symptoms that interfere with daily activities of living and overall quality of life.
How Do You Do This?
Nonhormonal pharmaceutical options are available to manage physical and emotional menopausal symptoms, including low-dose serotonin reuptake inhibitor (SSRI) antidepressants, gabapentin, pregabalin, and vaginal moisturizers. (24)
Natural supplements may also help manage menopausal symptoms. Evidence-based examples include:
- Maca is an adaptogenic herb that may act on the hypothalamus to modulate hormone levels. Research suggests that taking 1,000 mg twice daily may help reduce hot flashes, improve sleep, increase libido, and boost mood (30, 36).
- Kava 100-200 mg daily may help reduce depression, irritability, mood swings, and sleep disturbances (2, 5).
- Vitamin E 100 IU inserted vaginally may help with vaginal dryness and pain.
- Omega-3 fatty acids (350 mg EPA/50 mg DHA three times daily) may help reduce hot flash frequency.
Step 3: Support Foundations of Health for Overall Well-being
Why Is This Important?
Not only can our lifestyle choices significantly influence the severity of menopausal symptoms, but they also hold immense sway over our risk of chronic diseases. Therefore, a holistic menopause approach should include exercise and nutritional strategies that can improve overall health, enhance quality of life, and promote longevity.
How Do You Do This?
Weight-bearing exercises like walking, jogging, and resistance training may help maintain bone density, reducing the risk of osteoporosis and fractures. Aerobic exercises may improve cardiovascular health by enhancing heart function, lowering blood pressure, improving lipid profiles, and maintaining a healthy weight. Staying active regularly may also assist in alleviating menopausal symptoms, including mood swings, sleep disturbances, and hot flashes.
The Mediterranean diet is backed by a strong level and quantity of evidence for reducing the risk of many age-related diseases. This anti-inflammatory diet emphasizes consuming foods rich in key nutrients required for maintaining hormonal homeostasis and healthy aging.
Menopause Case Study
You can read about a real case study here:
How To Address Low Libido Caused By Menopause
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Key Takeaways:
- Menopause is a natural part of a woman's life. For many women, this transition to their post-fertile years can be rocky, accompanied by many uncomfortable symptoms that present new health challenges. However, it doesn't need to be this way.
- The hormonal changes and increased disease risks associated with menopause necessitate a proactive, age-based approach to healthcare. Many options are available to support menopausal symptoms, making the transition manageable – and even enjoyable.
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