Menopause can drastically affect a woman’s quality of life and can cause significant work impairment. Women spend about a third of their life in postmenopause, with little to no ovarian hormone production, therefore it is really important to know what your options are as you enter this phase of your life.
How long does menopause last?
Let’s define some terminology first! The perimenopause or premenopause phase is split up into early and late transitions. The early menopause transition is defined as 7 or more days of persistent difference in cycle lengths from your previous normal cycle. On the other hand, the late menopause transition is defined as 60 or more days of amenorrhea (no period). The length of the menopause transition can vary from woman to woman and we see differences in different cultures as well. For example, African American women tend to have a longer menopause transition. Menopause is the official cessation of menses, therefore we can only really know what date that is retrospective. The average age of menopause is 52. The time before menopause (perimenopause) can last anywhere from 4-8 years. You can experience perimenopause anytime after the age of 40.
Here are some common symptoms and signs of menopause
Irregular menstrual cycles
Worsening in PMS
Sleep disturbances
Hot flashes
Mood changes (low mood/anxiety)
Weight gain
Hair Loss (and growth)
Hot flashes / Night sweats (night sweats are hot flashes that occur at night)
Decreased libido
Joint pain
Vaginal dryness/irritation
Pain with intercourse
Cardio-metabolic dysfunction
Osteopenia / Osteoporosis
While I am a North American Certified Menopause Practitioner, and I do prescribe hormones, I think it’s important to discuss what non-hormonal options we have for women who maybe are still hesitant to start hormone therapy, or are not good candidates for hormone therapy (such as a history of a hormone receptor-positive malignancy.)
So let’s dive into some of the evidence-based therapies!
Exercise
Moderate exercise in menopausal women has been linked to a better quality of life, improved cognitive and physical function, and a significant reduction in all-cause mortality. Yoga has been shown to reduce total menopausal symptoms compared to not doing any exercise. Resistance training 3 times per week for 15 weeks in non-exercising women has been shown to decrease hot flashes significantly.
Some women will report that they get an increase in their hot flashes during exercise, and in this case, I would explore other potential reasons like low blood sugar that could be contributing to this. I always include exercise as part of my patient’s treatment plan, especially because of the many beneficial effects it will have on bone health, cardiovascular health, as well as cognitive health.
Cognitive Behavioural Therapy
I find cognitive behavioural therapy (CBT) to be really effective for women experiencing insomnia (CBT-I). The strong evidence for the efficacy of CBT-I led to its recognition as a first-line treatment by the National Institutes of Health Consensus Statement as well as by the American College of Physicians. The core components of CBT-I are delivered across four to six sessions and consist of psychoeducation, sleep restriction, stimulus control, cognitive restructuring, and sleep hygiene education.
Resources
If you are interested in looking for a practitioner who practices CBT-I, The Society of Behavioral Sleep Medicine provides a list of board-certified sleep medicine provider members on their website.
Sleepio is an online resource developed by sleep scientist Colin Espie and ex-insomnia sufferer Peter Hames. Sleepio is a fully automated digital sleep improvement program based on CBT. Over the course of six sessions, a virtual sleep expert will teach you evidence-based cognitive and behavioral skills to start to support your sleep problems. You can look into the details on their website here.
Nutrition
Timing of Food Intake
Dietary intake has been shown to affect the timing of hot flushes. Studies have shown that in the 30-minute period immediately preceding the meal or snack, the hot flush frequency was greater than in the 30-minute period immediately following dietary intake. Therefore, hot flush frequency has been shown to increase as the length of time between meals increases (Dormire 2007). This is often why intermittent fasting may not be the best option for women during this transition as the blood sugar drops between meals may be a trigger for hot flashes in some women.
Omega-3
In a 16-week intervention trial, women were randomized to an Omega-3 group or an extra-virgin olive oil group. Both groups ate a lacto-ovo-vegetarian diet. While this study has a low number of participants, it demonstrated that the Omega-3 group showed a significant improvement in hot flashes compared to the extra-virgin olive oil group, and a marginally significant improvement in nervousness (Rotolo 2019). In another 8-week trial of an enriched EPA supplement containing 350mg of EPA and 50mg of DHA given 3 times daily vs. placebo among 91 emotionally distressed women with vasomotor symptoms, hot flashes frequency, and intensity significantly improved in the active treatment group compared to the placebo group (Lucas 2009). However, there have been studies that have shown no effect as well (Cohen 2014). There was a lack of adverse effects in all studies and good compliance with treatment. This can be a great non-hormonal alternative option for patients where hormonal therapy may not be indicated.
Fiber
Women need at least 25g of fiber a day. When we look at the standard North American diet, women are well under this amount. There are many different reasons fiber is beneficial. For one, we know that postmenopausal women are more at risk of cardiovascular disease. Fiber is associated with a reduction in total cholesterol and LDL cholesterol. Fiber is found in legumes, fruits, vegetables and whole grains. In the Study of Women's Health Across the Nation (SWAN) study, there has been no conclusive evidence to suggest that phytoestrogens or fiber can independently reduce VMS. However, it is important to note that for at least half of the duration of follow-up in this study, most of the participants were not postmenopausal, and the participants did not have vasomotor symptoms at baseline (Gold 2013). Fiber is something that should be discussed with every patient, whether or not they are suffering from menopausal symptoms because it benefits overall health and a high-fiber diet is associated with lower rates of cardiovascular disease, type 2 diabetes, and colon cancer (Lichtenstein 2021).
What about supplements?
Black Cohosh
I would say that one of the very common supplement treatments for menopause that I see my patients self-prescribe is black cohosh. The evidence of black cohosh for vasomotor symptoms is actually not very strong. There's a little bit of research in improving things like quality of life in women who are perimenopausal and menopausal. However, the evidence is not particularly strong for vasomotor symptoms, which I was surprised about when I looked at the research since it is found in so many menopause supplements.
Salvia officinalis (Sage)
Sage does have evidence for reducing hot flashes, sleep disturbance, and night sweats. It often takes 4-12 weeks to see benefits and it needs to be taken as a supplement, not as a tea. About 30% of patients will see a benefit at the two-week mark and more than 50% will see an improvement at four weeks. Talk to your healthcare practitioner about an appropriate dosing strategy.
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