Understanding Menopause: A Guide

menopauseAuthor: Lily Mazzarella
 If it's been a year since your last period, then congratulations—you've officially hit menopause. Tomorrow, you’ll technically be postmenopausal. If you're not menstruating for other reasons, like after uterus removal or uterine ablation, and your hormone tests show high levels of FSH (follicle stimulating hormone) and low levels of estrogen and progesterone, you're likely in menopause.

The Mixed Bag of Menopause

For some, true menopause brings about the first real signs of estrogen withdrawal (aka, low estrogen).  You might start experiencing hot flashes, joint or connective tissue pain, memory lapses, vaginal dryness, and changes in your skin and hair, with major impacts on your daily functioning and self-perception. For those who had a tough time with the erratic hormone levels of perimenopause (which is basically puberty in reverse), you might actually be finding more ease in your day-to-day life.  Perhaps both were a breeze; perhaps, both hellish.  

Either way, you’re in a new normal with globally lower sex hormone levels, which, as it turns out, is very impactful for systemic health. You might be surprised to find after a routine checkup that your cholesterol, blood pressure or weight is creeping up, or that you're suddenly getting injured during your usual exercise routine. Sex might be painful, if you ever feel like having it.  

My time in practice (and my personal experience) tells me that the unifying theme for this varied time is the importance of being proactive.  The things that easily righted themselves in the past with minimal intervention can become stuck, and can snowball, if we don’t take action. Menopause isn't just a hormonal adjustment—it affects various aspects of health that require attention and care. Here are 7 key areas where support is often needed.

Key Health Considerations During Menopause

  1.  Bone Health: Estrogen plays a critical role in maintaining bone density by promoting the activity of osteoblasts (cells that create new bone) and inhibiting osteoclasts (cells that break down bone). These cells are active our whole lives, and are responsible for renewing our bones as we carry on with life. As estrogen levels drop during perimenopause, and continue to fall in the first 5 years of post-menopause, the balance shifts towards osteoclast activity, which results in bone loss and an increased risk of osteoporosis and fractures. It’s worth noting that stress and inflammation also stimulate osteoclast activity.   
  2.  Cardiovascular HealthEstrogen has a beneficial effect on the inner layer of artery walls, helping to keep blood vessels flexible and promoting good blood flow. It also influences lipid profiles, usually resulting in higher HDL (good cholesterol) and lower LDL (bad cholesterol). With the decline in estrogen during menopause, the risk of developing cardiovascular diseases increases. Rising levels of follicle stimulating hormones, aka FSH (which is essentially shouting at the ovaries in perimenopause, trying to get them to ovulate), is associated with higher levels of LDL cholesterol, especially in the early stages of menopause.  There may be great alarm at high readings, and move towards medications to manage cholesterol.   
  3. Cognitive Health: The brain benefits from estrogen's protective effects, which support the health and survival of neurons and influence neurotransmitter systems related to mood, memory and learning. Menopause-associated declines in estrogen can increase brain inflammation, and cause changes in memory and overall cognitive performance.  Newer understandings of menopause rightly focus on this aspect. I’ve encountered many menopausal people with cognitive impacts so great they feel for certain that they are experiencing early dementia.  This worry is extremely stressful in its own right.   
  4. Connective Tissue, Skin, Eye and Joint Health: Estrogen influences the production of collagen and elastin, proteins that provide structure and strength to connective tissues and joints. With lower estrogen levels, there's a decrease in collagen production, which can result in weaker connective tissues and joints, leading to increased joint pain and a decrease in skin elasticity.  This contributes to the formation of wrinkles, as well as changes to face and body shape.  The barrier function of the skin and the functioning of glands that moisturize the skin and eyes are maintained by estrogen. Reduced levels of estrogen leads to drier skin and eyes due to decreased moisture production and retention in these tissues.  This can lead to diminished wound healing capacity, and more easily irritated eyes.  
  5.  Mobility: Estrogen affects muscle function and mass. It helps to maintain muscle strength and repair, and its decrease can lead to a reduction in muscle mass and strength. Tendinopathies, or inflammation, pain & dysfunction of tendons are unfortunately very common at this time, in part due to estrogen withdrawal, and can present real barriers to exercise and mobility.  Sudden hip pain?  Hard to get comfortable at night?  You may have gluteal tendinopathy–one of the main causes of hip pain in menopause!   And “frozen shoulder” (adhesive capsulitis) is so common in menopause that I feel it should be listed as one of its symptoms.   
  6. Genitourinary Health:  Menopause brings about significant changes in the genitourinary system: vaginal dryness, an increased incidence of urinary tract infections, alterations in vaginal flora, frequent urination and urinary incontinence. Vaginal dryness occurs due to the decreased production of estrogen, leading to thinner, less elastic, and more fragile vaginal tissues. This hormonal change also disrupts the balance of vaginal flora, increasing the vulnerability to infections as protective lactobacilli decrease.. Changes in the strength and function of the pelvic floor muscles contribute to urinary incontinence.
  7. Metabolism: Estrogen is one of the hormones that regulates body fat distribution and metabolism, and its reduction during menopause typically results in more fat being stored around the abdomen, as opposed to the hips, thighs and breasts.  Declining estrogen levels lead to reduced lean muscle mass, which further decreases the basal metabolic rate (BMR) – the rate at which calories are burned at rest. This situation is compounded by changes in insulin and leptin sensitivity, which affect hunger and metabolism. These changes can contribute to weight gain, even as people maintain their physical activity and ordinary diet.  We have to do more to effect change.  

     So how do we put out this dumpster fire?  

    Enhance Calcium Utilization with Vitamins K2 and D3: Ensure you're getting enough calcium through your diet or supplements and pair it with fat-soluble vitamins and minerals (boron, magnesium, and phosphorus) that support bone health. Vitamin K2, in particular, works synergistically with Vitamin D3 to enhance calcium absorption and distribution, helping to deposit calcium in the bone, not the blood vessels.


    Consider Bioidentical Hormone Replacement Therapy (HRT): The pendulum has swung!  As HRT gains popularity once more, we are learning more about its benefits for the brain, bones, and cardiovascular system, and newer studies are pointing to limited risk that needs to be taken in the context of quality of life. Estrogen is particularly protective but it's not a panacea.  And for those who can't use HRT due to health risks, exploring natural alternatives like maca, black Cohosh, and adaptogenic herbs (e.g., schisandra, American ginseng, eleuthero, shatavari and ashwagandha) can be beneficial in managing menopausal symptoms.

    Support Collagen Production: Intake of collagen precursors such as Vitamin C, flavonoids, sulfur, zinc and amino acids AND maintaining an anti-inflammatory diet can boost your body's natural collagen production.  This is totally essential for skin, joint, and bone health.  You can also add collagen peptides to your coffee, smoothie or soup to help support your skin, cartilage and other connective tissues.  

    Adapt Your Diet to Your Changing Metabolism: Reducing simple carbohydrates like white rice, crackers, chips, pasta, scones, bread, etc, and focusing on anti-inflammatory foods can help lower LDL and triglyceride levels, and improve overall cardiovascular health. Increasing quality protein can support your metabolism by stabilizing blood sugar and contributing to lean muscle formation.  Supplements like Berberine, Bergamot, Resveratrol, and Curcumin may also be beneficial for cardiovascular health and metabolism.  

    Prioritize Mobility and Strength Over General Exercise: Mobility is crucial for aging well. Activities that enhance your ability to move freely, maintain balance, and preserve muscle mass are key to long-term health and independence. This excellent article gives a detailed review of the science on exercise, bone density and fracture prevention. It is summarized here on our website, but the upshot is:  as important as they are, walking, yoga and pilates alone don’t hit the mark for bone building.  

    Nurture Your Adrenal Glands: The adrenal glands play a pivotal role in sex hormone production post-menopause, as do our fat cells. Often we arrive at menopause exhausted and stressed, especially if you’re in the demanding "sandwich generation,”  balancing care for children and elderly parents–not to mention work and a suddenly unfamiliar body.  Supporting the adrenals with proper nutrition (especially Vitamin C, Pantothenic Acid, Zinc and Magnesium) and adaptogens really helps to smooth out the effects of long term stress.  In practice I’ve seen regular adaptogen use (6-12 weeks minimum) improve sleep, libido, energy, mood and exercise recovery, in addition to making people feel simple “better” and “more like themselves.”  

    Incorporate Beneficial Fats: Omega-3 fatty acids from sources like fish, algae, seeds, grass-fed beef, leafy greens and high-quality supplements support brain, skin, and eye health. Omega-7 from sea buckthorn is excellent for combating dryness in the eyes, mouth, and other areas, while the lesser-known C:15 fatty acid is emerging as a supporter of cellular communication, insulin sensitivity and resilient skin.

    Menopause Action List:

  1. Sort out your bone health: 
      • Ask your doctor to run a vitamin D level, and find out what the actual number is (“normal” isn’t enough information).  Based on my clinical experience, ideal numbers are 55-65 (with some people requiring more or less for their specific health picture).  This range gives you room to move up and to move down.  Supplement accordingly; don’t just shoot in the dark.  
      • Enter all your food into an app like Cronometer or MyFitnessPal to get a rough calcium count for your diet.  If you eat abundant dairy, green leafy vegetables, tofu and almonds, you may be hitting your mark for total calcium intake (1200 mg/day).  If not, consider supplementation with an easy-to-absorb form of calcium (NOT calcium carbonate, which is hard for the body to absorb).  And since calcium is only part of healthy bone formation, it is best to include magnesium, boron, and other bone-supporting minerals.
      • Make sure your Vitamin D supplement contains vitamin K2 as well.
    • Make an appointment with your ND, NP or MD to discuss bioidentical HRT.  “Bioidentical” just means hormones that are structurally identical to the hormones found in your own body, not altered as they are for oral contraceptives or earlier forms of estrogen replacement like Premarin, which is made by tinkering with mare’s urine in a lab.  The idea is that our bodies can process these “identical” (and yes, originally plant-based) hormones better than synthetic forms.  There is some evidence to support this. There is also significant evidence to support protective effects from estrogen replacement therapy, especially in the arenas of cardiovascular, bone and cognitive health.  All hormonal therapies have some risk, and usually it is recommended to take progesterone alongside estrogen therapy to reduce risk of endometrial cancer if you have a uterus.  Yes, it is likely that one day you will have to get off your HRT, and you will likely experience some symptoms then.  That said, one can taper HRT very slowly to allow the body to adjust, avoiding the worst symptoms.  
    • Reduce simple carbs to help lower LDL, triglycerides and insulin levels.  
    • Increase protein throughout your day to help stabilize your nervous system and blood sugar, and maintain lean muscle mass.
    • Add collagen to your coffee or morning smoothie to support connective tissue and bone health.
    • Consider this helpful trifecta for boosting metabolism:  
      • Intermittent fasting (going at least 14 hours between dinner and the next day’s meal, except for clear liquids or plain tea or black coffee); 
      • Berberine 1500 mg/day
      • Eating 3 meals per day, 2 more substantial and 1 larger, and not snacking between meals.  
    • Explore functional fitness and strength training.  The book “Born to Move” gives a great introduction and many helpful exercises for healthy aging.  
    • Eat anti-inflammatory nutrients and fats for brain and cardiovascular health.  See the Farmacopia Summer Inflammation Soother guide for a comprehensive food plan! 
    • Try a course of adaptogens–6-12 weeks of stabilizing and nourishing tonic herbs–to see what they can do for your sleep, energy and stress resilience.  

    The Basics:

    Shop our Menopause Collection. 

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