Back to Basics: Rethinking Our Approach to Menopause

by Wendy Warner

Around 6,000 women reach menopause every day — that’s more than two million per year. For many of them, it’s a rocky time filled with mood swings, poor sleep, hot flashes, night sweats and foggy thinking. The really bad news is that at least a third of women in one survey stated they don’t think they’re aware of all the options out there for treatment, or that they are not happy with the options presented to them. Add to this that in conventional gynecologic training, physicians are taught that treatment for symptoms is hormone replacement therapy (HRT)…and then they’re told that HRT isn’t really all that good for women. What’s a doc to do?

The reality is that there are a lot of options out there. HRT is certainly one of them, but jumping into bioidentical hormones right off the bat could mean that the underlying reason for the symptoms and imbalance is never addressed. At some point in the future, when these women decide to stop their hormone therapy, they might start flashing all over again because no one ever helped them fix the cause. Also, hormones can be expensive, so looking for the cheaper alternatives first makes sense.

Get some lab work done. Check a full thyroid panel (TSH, free T4, free T3 plus thyroid antibodies and reverse T3) along with cortisol and DHEA. Check fasting glucose and a hemoglobin A1C, even if the fasting glucose is normal. This information will help establish where to focus attention in treatment.

The first place to look, as usual, is food. How we eat as perimenopausal women really does make a huge impact on how we feel. All the steps in hormone production require nutrient cofactors that are found in vegetables (magnesium and B vitamins, in particular). Eating more veggies and fewer grains and sweets (even excess fruit) can make a huge difference for someone having hot flashes. Also, not everyone needs to be gluten-free, but gluten-containing grains do have a negative impact on the liver’s breakdown of hormones; focusing on gluten-free grains will decrease this. Eating more legumes also helps, as they contain flavonoids, fiber and other chemicals that impact hormone metabolism.

So, although each woman needs to work out details for herself, a good rule to use is the  following: half of what you have eaten by the end of the day should be a vegetable.  This is tough, as most of us don’t eat any at breakfast. Of the remaining half of your food each day, make one-third of it animal protein if you eat animals (this includes eggs and dairy, obviously), one-third should be healthy fats (nuts, seeds, avocados, the oils in salad dressings and what you cook with) and one-third would include grains, fruit and anything else (like chocolate).  Following this rule will result in really small portions of these foods.

Exercise also has a huge impact on menopausal symptoms — the more the better, though it is possible to actually do it “wrong”. Move but don’t get extreme about it.  Focus on strength building and not so much cardio, since most perimenopausal women  lose muscle quickly. That might mean just a more vigorous yoga class or pilates and doesn’t need to include lifting weights in the gym.

Learning more emotional resilience and better stress management has a huge impact as well. Most of us spend a great deal (all?) of our time in the fight-or-flight mode. Too much on our plate, too much bad news, no downtime…this keeps our adrenal hormones  stuck in the “on” position, and when this happens, estrogen and progesterone balance goes out the window. Progesterone gets converted to cortisol to conserve energy for the adrenals, which leads to unbalanced estrogen. Also, the high cortisol is what triggers the temperature-regulating portion of the brain to set off hot flashes. This can be overturned by higher estrogen levels (which is why HRT works), but if it’s still going on when a woman stops her HRT, she’ll simply flash all over again.

When all of these lifestyle issues are being worked on, but sleep and thinking straight are still difficult, interventions like herbs and hormones should be considered. Many plants combat menopausal symptoms, from black cohosh to Siberian rhubarb to night blooming cereus, but all work best when used with herbal adaptogens and nervines. Adaptogens help support adrenal function and include plants like ashwagandha, holy basil and rhodiola. Nervines calm us down; fresh milky oats is a favorite. Different plants  work better for different people, so seeking out a knowledgeable provider is a must.

For some women, hormone replacement therapy may ultimately provide the best results. There are conventional hormones, which one gets at a regular pharmacy. Some  are bioidentical (chemically just like what our bodies make) and some are chemicals that are “new to nature” that have activity similar to estrogen and progesterone, but our bodies have never seen them before. Several major studies agree that among replacement hormones available, bioidentical hormones are safest. The downside to “regular” prescriptions is that they are mostly oral (probably not the best choice) and have limited doses available. Compounded bioidentical hormones, however, are designed to let each woman have the dose that is right for her, and several different forms of delivery are available, including capsules, creams, pellets and bucchal troches.  Compounded forms also allow for inclusion of testosterone and adrenal support, which are not available in “commercial” HRT.

Menopause is not a disease, but it is a transition that will likely require each of us to reevaluate how we’ve been living. We need to look at the big picture and not jump to an easy fix. Our bodies will thank us.

Wendy Warner, MD, ABIHM, is board certified in gynecology and holistic medicine. Her practice, Medicine in Balance, is located in Langhorne. For more information, call 215-741-1600.

May 2016 Issue

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