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Menopause

Menopause is the stage of life when menses permanently cease, and the reproductive system no longer performs functions related to fertility. A woman is considered to have entered menopause after menses have stopped for 12 months.

Our evidence-based analysis on menopause features 114 unique references to scientific papers.

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Summary of Menopause

Overview

Natural menopause generally occurs between the ages of 40 to 58 and has no obvious pathological or physiological cause, but early menopause can result from surgery, chemotherapy, radiotherapy, or primary ovarian insufficiency. Perimenopause is the transitional phase into menopause and may last between 4 to 8 years. During this phase, menstrual periods become irregular due to fluctuating hormone levels.

For this page, we use the generic term 'woman', but this information can apply to anyone with ovaries and/or who might be undergoing a hormonal shift associated with the symptoms of menopause.

Causes

Menopause is a natural condition that occurs as women age. Over time, a woman’s ovarian follicles and granulosa cells diminish. Given these cells are the main producers of estradiol and inhibin[1](a hormone that tells the pituitary gland to make less follicle stimulating hormone), the body’s hormonal balance shifts toward lower estrogen levels and increased follicle-stimulating hormone and luteinizing hormone levels. This hormonal profile results in irregular menstrual cycles, which ultimately stop altogether. One clinical indicator that a woman is postmenopausal is a follicle-stimulating hormone level greater than 30 mIU/mL and an estradiol level under 30 pg/m.[2]

Hormonal variations across a woman's lifetime

Primary ovarian insufficiency (POI) is a condition often characterized by entering menopause at a young age (i.e. prior to 40 years). There are a variety of causes that underlie POI, but the main one is estrogen deficiency.[3] Other factors that play a role in POI are genetic disorders, autoimmune disease, chemotherapy, radiotherapy, and metabolic disorders. Smoking has also been associated with early menopause.[4]

Symptoms

Hot flashes, night sweats, vaginal dryness, insomnia, trouble focusing, and mood swings are the primary symptoms women experience during the transition into and sometimes throughout menopause. Women can also experience changes in body composition. The majority of these symptoms are a result of hormonal fluctuations accompanying the decline to infertility, with hot flashes among the most commonly reported.

In fact, as many as half of all women report experiencing hot flashes even before they cease menstruating. Hot flashes peak during the later phases of the menopausal transition, tapering off in late menopause. Women tend to experience these symptoms for roughly five years.[5][6]

Changes in vaginal tissue resulting from decreased estrogen account for a number of other commonly reported symptoms, including an increase in urinary tract infections, vaginal atrophy, burning, urinary incontinence, and discomfort during intercourse.[7] Moreover, these changes in hormone levels after menopause affect metabolic processes that can increase the risk of cardiovascular disease, osteoporosis, and stroke.[8]

Regarding changes in body composition, the transition into menopause marks a time when women are particularly prone to gaining fat and losing lean mass. Later onset of menopause seems to temper this increase in weight and body fat.[9] Hormonal changes also tend to shift body fat distribution from a gynoid pattern (body fat around the hips and buttocks) to a more android pattern (body fat around the midsection).[10]

Diagnosis

Menopause is clinically diagnosed after 12 months of amenorrhea without other causes, such as surgical removal of the ovaries, chemotherapy or radiotherapy, or POI. It usually occurs after 45 years of age (median age of 51.4 years) and is considered abnormal if it occurs prior to 40 years of age.[11] The diagnosis does not require hormone testing.

In cases where an alternative diagnosis is suspected, such as in women below the age of 45 or in women with thyroid disorders, the following hormone tests can be performed to predict or diagnose the onset of menopause:
-Anti-Müllerian Hormone
-Estrogen
-Follicle-Stimulating Hormone

Treatments

Hormone replacement therapy

For women under 60 years of age experiencing severe vasomotor symptoms (e.g., hot flashes and night sweats) that affect sleep and quality of life, hormone replacement therapy (HRT) is an effective treatment. HRT can alleviate vasomotor symptoms[5] (e.g. hot flashes and night sweats), improve mood and cognition,[12][13] and prevent osteoporosis.[14][15] Additionally, low-dose vaginal estrogen (applied topically) can restore the integrity of vaginal tissue and relieve dryness, but it may worsen urinary incontinence.[5]

The standard recommendation for HRT is to start in early menopause (not beyond age 60) and use for no more than 4 to 5 years.[16] This recommendation does not apply to women with POI. In this population, HRT is started at a younger age and should be continued until around 50 years of age.

Women with, or at risk for, hormone-related cancers, heart disease, blood clots, stroke, or liver disease are not candidates for HRT and will need to treat their symptoms using non-hormonal interventions.

The types of HRT used during menopause include:
-Estrogen-only
-Progestin-only
-Combined estrogen and progestin
-Estrogen in combination with other medicines

HRT is not recommended for the treatment of chronic conditions, such as osteoporosis. In fact, the U.S. Preventive Services Task Force, an organization made up of primary care physicians who systematically analyze the evidence for various preventative treatments, gave estrogen-only (for women who have undergone a hysterectomy) and combined estrogen-progestin (for postmenopausal women with an intact uterus) a D grade for the treatment of chronic conditions. This means that these therapies may be more harmful than beneficial within this treatment context.

Supplements

There is growing interest in botanical and other nutritional supplements to treat menopausal symptoms. Black cohosh, red clover, omega-3 fatty acids, dehydroepiandrosterone (DHEA), evening primrose oil, Vitex agnus-castus, soy isoflavones and St. John's wort are among the variety of supplements purported to reduce menopausal symptoms.

The effectiveness of these supplements is variable. For example, some women find relief from hot flashes by supplementing soy isoflavones, but some women experience no benefits. This may be because certain gut bacteria metabolize soy isoflavones into equol, a compound that exerts estrogenic effects. Women who don't benefit from supplementing soy isoflavones may be equol nonproducers, and they can take an equol supplement instead to see if this helps reduce their symptoms.[17] The table below displays an analysis of human studies and indicates how supplements may affect the symptoms of menopause.

Certain vitamin and mineral supplementation may also be warranted during perimenopause and menopause. For example, declining reproductive hormones are associated with decreased bone mineral density. In late perimenopause, bone loss accelerates, and menstrual cycles become more irregular. Daily combined doses of 1,000 to 1,200 grams of calcium and 400 to 800 IU of vitamin D have been found to reduce overall fracture risk by 6% and hip fracture risk by 16%.[18]

Psychological therapies

Stress can increase the frequency of hot flashes.[19] Cognitive behavioral therapy (CBT) and mindfulness are effective interventions for mitigating stress. CBT and mindfulness may make hot flashes less bothersome, possibly by increasing coping skills.[20]

Aromatherapy

Some studies find that aromatherapy may reduce menopausal symptoms, such as low libido, depression, and sleep quality[21], when inhaled and/or in combination with massage therapy.[22]

Acupuncture

Acupuncture may alleviate perimenopausal insomnia when given alone or in conjunction with hypnotic drugs, but the quality of evidence supporting this is of low to moderate quality.[23] There is some evidence for acupuncture's ability to reduce the frequency and severity of hot flashes for up to 3 to 6 months post-treatment.[24][25] Conversely, women with menopause induced by breast cancer treatment may not experience relief from hot flashes with acupuncture; but it may improve other menopausal symptoms, such as sleeping disorders, joint pain, and irritability.[26] 

Exercise

Engaging in exercise combats a number of menopausal symptoms, while also improving body composition, reducing blood lipids, preserving bone density, and retaining strength. A wide variety of exercise forms can be used, ranging from yoga to aerobic exercise to strength training. Yoga may be particularly helpful for vasomotor and psychological symptoms.[25][27] Strength and resistance training are especially important for maintaining muscle mass and bone mineral density. For example, bone density can be preserved with weight-bearing exercise, especially when combined with high-impact exercises like jumping, skipping, and jogging.[28][29] 

Lifestyle modifications

There are a few lifestyle changes that can be implemented to manage vasomotor symptoms. Examples include lowering the room temperature, dressing in layers, keeping a fan nearby, and avoiding hot beverages, caffeine, and spicy foods.[30] 

Vaginal laser treatment

Low estrogen levels during menopause can cause genitourinary syndrome of menopause (GSM). GSM is characterized by vaginal dryness and pain, urinary urgency, and frequent urinary tract infections. GSM often occurs more frequently and severely in women with medically induced menopause. First-line treatments for GSM include nonhormonal vaginal and vulvar lubricants. For more severe symptoms, treatments include low-dose topical estrogen, vaginal DHEA, or oral ospemifene (an estrogen agonist/antagonist that thickens vaginal tissue). Vaginal estrogen is contraindicated in women with undiagnosed vaginal or uterine bleeding and in women with breast cancer.[31] 

Recently, vaginal laser therapy was used to treat GSM. Two meta-analyses reported improvements in sexual function, pain, and vaginal dryness with laser treatment. A few adverse events were reported, such as itching, irritation, spotting, and swelling after the treatment.[32][33] The FDA noted these adverse events and, in 2018, issued a press release warning against the use of vaginal laser treatments.

Diet

Postmenopausally, metabolic flexibility (the ability to switch between fat and carbohydrate oxidation) diminishes, and the risk of developing metabolic syndrome, osteoporosis, bone fractures, and vascular events increases. Thus, eating a nutritionally supportive diet is all the more important during this time of life.

The optimal protein intake for normal weight, sedentary adults is 1.2 to 1.8 grams/kg per day. Observational studies find that older women may benefit from consuming protein on the higher end of that scale, as higher protein intakes are associated with greater physical function and muscular strength, as well as the retention of lean mass and bone mineral density.[34][35] 

Hormone changes during menopause can negatively affect lipid and glucose metabolism. Avoiding high glycemic-index carbohydrates and keeping fat intake to no more than 30% of daily calories[36] seems to result in more favorable postprandial glucose control and lipid profiles. The American Heart Association recommends women consume a diet rich in fruits, vegetables, high-fiber whole grains, and oily fish, and that they limit saturated fat, cholesterol, alcohol, sodium, and sugar. Trans-fatty acids should be avoided.

The following are nutrients, foods, and other compounds to help manage abnormal lipid metabolism in postmenopausal women:[37]

NutrientDosage and benefitsFood sources

Vitamin D

The recommended dose of vitamin D is 15 mcg for people aged 19 to 70, and 20 mcg for those 71 and older. Higher doses are likely warranted in cases of insufficiency (optimal is > 20 ng/m). Vitamin D deficiency is linked to unfavorable lipid profiles, reduced bone mineral density, and several inflammatory conditions.



- 3 ounces of sardines: 5.8 mcg
- 3 ounces of salmon: 15.3 mcg
- 3 ounces of canned tuna: 5.7 mcg
- 1 cup of fortified milk: 3.2 mcg

Omega-3 fatty acids

Omega-3 fatty acids have cardioprotective, anti-inflammatory, and insulin-sensitizing effects. Keeping an omega-6/omega-3 ratio under 4/1 is associated with decreased mortality and better overall health outcomes in postmenopausal women.



2, 4-ounce servings of fatty fish per week is recommended by the American Heart Association.

Antioxidants

The drop in estrogen levels at menopause is linked to increased oxidative stress. It is recommended that postmenopausal women increase their antioxidant intake, specifically vitamin A, beta-carotene, vitamin C, and vitamin E, as well as plant flavonoids and soy isoflavones.



High amounts of antioxidants are found in almonds, artichokes, blackberries, blueberries, cherries (sour), chokeberry, chocolate (dark, unsweetened), cloves, cranberry juice, coffee, cranberries, grape juice, pomegranate juice, pecans, raspberries, spinach, strawberries, walnuts, and red wine. Plant flavonoids can be found in a variety of plant foods, including whole grains, vegetables, fruits, nuts, red wine, spices, and dark chocolate.

Calcium

The National Institutes of Health recommends that women over the age of 50 years consume 1,2000 mg of elemental calcium per day, with an upper limit of 2,000 mg per day. The goal of this recommendation is to decrease bone resorption as estrogen levels decline.



These foods provide at least 20% or more of the daily calcium requirement:
- 8 ounces of yogurt
- 1 cup of calcium-fortified orange juice
- 1.5 ounces of mozzarella
- 3 ounces of canned sardines with bones
- 1.5 ounces of cheddar cheese
- 1 cup of milk
- 1 cup of calcium-fortified soy milk
- ½ cup of tofu made with calcium sulfate

Vitamin K2

Vitamin K2 plays a key role in preventing osteoporosis and cardiovascular disease by inhibiting vascular calcification and increasing calcium uptake into the bones. Vitamin K2 also modestly reduces abdominal fat in postmenopausal women.

Vitamin K comes in various forms. Plants contain vitamin K1, or phylloquinone, which plays a role in blood coagulation. Fermented foods and some animal products contain different forms of vitamin K2, or menaquinones, abbreviated as MK-xx. The menaquinones are associated with bone and cardiovascular health.

The minimum effective dose for MK-4 is 1,500 mcg, and doses up to 45 mg (45,000 mcg) have been safely used. For MK-7, the minimum effective dose is between 90 to 360 mcg. A maximum effective dose for MK-7 is yet to be determined.

Warfarin and other blood-thinning drugs interact with vitamin K. If you are taking these prescriptions, it is best to exercise caution, and consult your healthcare provider before increasing your vitamin K intake.



- 100 grams of natto (fermented soybeans): 108 mcg
- 100 grams of eel: 63 mcg
- 50 grams of muenster cheese: 50 mcg
- 50 grams of camembert cheese: 34 mcg
- 50 grams of edam and aged gouda cheese: 32 mcg
- 50 grams of cheddar cheese: 12 mcg
- 100 grams of beef liver: 11 mcg
- 100 grams of chicken: 10 mcg
- 1 tablespoon of butter: 2.1 mcg
- 1 egg yolk: between 67 and 192 mcg (depending on the hen’s diet)

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Human Effect Matrix

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The Human Effect Matrix looks at human studies to tell you what supplements affect Menopause.

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Grade Level of Evidence
Robust research conducted with repeated double-blind clinical trials
Multiple studies where at least two are double-blind and placebo controlled
Single double-blind study or multiple cohort studies
Uncontrolled or observational studies only
Level of Evidence
? The amount of high quality evidence. The more evidence, the more we can trust the results.
Supplement Magnitude of effect
? The direction and size of the supplement's impact on each outcome. Some supplements can have an increasing effect, others have a decreasing effect, and others have no effect.
Consistency of research results
? Scientific research does not always agree. HIGH or VERY HIGH means that most of the scientific research agrees.
Notes
grade-a Minor Very High See all 13 studies
Although there appears to be some benefit over placebo, more recent studies note that the magnitude of benefit is much less than previously though (in the past, a false positive occurred when unblinded studies noted remarkable benefits with black cohosh; the placebo effect appears to be quite potent in regards to menopause)
grade-a - Moderate See all 12 studies
While isolated studies have noted some benefits, the best evidence at this moment in time (Independently conducted and larger, better conducted, studies) tend to note no significant influence on the main climacteric symptoms such as hot flashes with supplementation.
grade-b Minor High See all 3 studies
May decrease some symptoms associated with menopause, mostly related to libido, but this is unreliable.

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Frequently Asked Questions and Articles on Menopause

Put down the apple and have some cheddar
Although both cheese and meat are lumped into the “watch out!” category in heart health recommendations, dairy products often show neutral or positive associations with cardiovascular health. But how do cheese-rich diets fare in randomized trials when compared to other diets? This trial tested three diets against each other in a highly controlled fashion: a cheese diet, meat diet, and high-carb diet.
Is soy good or bad for you?
Moderate consumption of soy foods is unlikely to have adverse effects in adults; it may even benefit cardiovascular health and reduce cancer risk. Eating large amounts of soy foods for 6 months or more, however, may cause problems. Also, the use of soy infant formulas should probably be minimized.
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