The signs and symptoms associated with menopause occur over a period of time, called perimenopause, which literally means 'around menopause.' For many women, the first sign of perimenopause is an erratic menstrual cycle -- either skipped, lighter or shorter periods. The hallmark of this countdown to menopause is a fluctuating level of the female sex hormones, estrogen and progesterone. Estrogen highs can bring on PMS-like symptoms, including mood swings, fluid retention and headaches, whereas estrogen lows promise hot flashes, vaginal dryness and forgetfulness.
A woman is considered to have reached menopause when a year has passed since her last period. Although it can vary, the average age a Canadian woman hits menopause is 51. It's at this time that women enter post menopause, the phase of life in which the risks for heart disease, osteoporosis and breast cancer increase.
Symptoms of Perimenopause
The tissues of the vagina and urethra (opening to the bladder) become thinner, less elastic and drier with declining estrogen levels. This can result in decreased lubrication, burning, itching, urinary tract infections and uncomfortable sexual intercourse.
Hot Flashes and Night Sweats
Hot flashes occur in up to 85 percent of North American women. It's estimated that 10 to 15 percent of women have them severely enough to interfere with their daily life. On average, hot flashes persist for three to five years, but in 50 percent of women, they last up to five years.
A warning signal or aura often precedes a hot flash. A hot flash may begin as a pressure in the head, a headache or a wave of nausea. A sensation of heat then starts in the head and neck and spreads to the torso, arms and entire body. Sweating follows and is most intense in the upper body. Clothing may become soaked, particularly if hot flashes occur during sleep. (Night sweats are another term for hot flashes that occur during sleep.) Chills or shakes may follow as a result of a drop in body temperature. The entire event can last a few seconds to several minutes, and it may take an hour for chills to subside.
Night sweats often cause disrupted sleep. While many women have no difficulty falling back to sleep, some simply cannot. Fatigue caused by lack of sleep can lead to irritability, depression and forgetfulness. Many experts believe that there is something else going on to interrupt sleep, something that's not related to hot flashes during sleep.
Most women describe the mood swings of perimenopause like those of premenstrual syndrome (PMS). Feelings of depression, anxiety and irritability can be disruptive to personal and work life.
During perimenopause there are a few things happening to your body that may cause forgetfulness. For one, there's an aging process going on. The older we get, the more short-term memory we lose. Menopausal symptoms such as insomnia and fatigue can also cause memory problems. Evidence suggests that estrogen affects the brain chemistry and structure that's involved in memory, and that the loss of estrogen associated with menopause may be largely responsible for memory decline.
Most women will experience some change to their monthly cycle. The first sign of perimenopause is irregular menstruation. Your periods may stop suddenly or may become lighter and closer together, and then stop. Some women, on the other hand, experience heavy bleeding during their periods. In some cases, heavy bleeding can be the sign of another health disorder: polyps, a fibroid or, less commonly, cancer. Alert your gynecologist if your periods last more than seven days, if you bleed between your periods, or if your menstrual flow becomes much heavier than usual.
Who's at Risk?
While perimenopause can start in the late 30s, most women begin noticing symptoms in their 40s. But not all women experience uncomfortable symptoms associated with perimenopause. Although research is lacking in this area, there are a few factors that may increase your risk for suffering one or more of the symptoms of perimenopause. Ask yourself the following:
- Are you in your mid to late 40s?
- Did your mother experience any perimenopausal symptoms?
- Do you suffer from premenstrual symptoms, especially mood swings?
- Do you eat a diet that's high in animal fat and lacking fruits, vegetables and fibre?
- Do you drink too much alcohol and coffee?
- Is your life full of stress and tension?
- Do you lack adequate sleep on a regular basis?
- Do you lack regular exercise?
Hormone Replacement Therapy (HRT). A combination of estrogen and progestin may be used to relieve hot flashes, mood swings and vaginal dryness. Women who have had a hysterectomy use estrogen alone. Hormone Replacement Therapy (HRT) prevents bone loss and may prevent bone fracture in women with osteoporosis. HRT may also reduce the risk of heart disease by lowering bad LDL cholesterol and raising good HDL cholesterol.
The protective effects of HRT last only as long as you take the medication. Surveys show that adherence to HRT is low. Side effects such as bloating, fluid retention, weight gain, irregular bleeding and nausea are frequently cited reasons for stopping the medication. Taking hormone replacement by pill, cream or patch can influence the potential for side effects. If you are taking HRT and finding it difficult to tolerate the side effects, or the medication is not relieving your symptoms, ask your doctor about your options.
HRT is not without risks. When taken for more than five or ten years, HRT may increase the risk of breast cancer. And HRT may actually increase the risk of heart disease in women who have the disease. The long-term benefits of HRT on breast and heart health are under investigation.
Biphosphonates. These non-hormonal drugs are used to prevent osteoporosis and reduce the risk of bone fractures. Types of biphosphonates include Didrocal (etidronate and calcium carbonate) and Fosomax (aldendronate). Fosomax may cause gastrointestinal upset and irritation of the esophagus.
Selective Estrogen Receptor Modulators (SERMs). Often called 'designer estrogen' drugs, these medications offer some of the beneficial effects of estrogen (bone protection, cholesterol lowering) without any of its negative effects (increased breast cancer risk, endometrial bleeding). Evista (raloxifene) is one SERM. These medications may increase the risk of blood clots and gallstones.
Dietary Strategies for Managing Perimenopause
Today, more and more Canadian women are seeking alternative approaches to HRT. While the list below is not all-encompassing, it highlights a few important strategies that can help ease perimenopausal symptoms. If you're looking for a more comprehensive guide to managing perimenopausal symptoms, pick up a copy of my book Managing Menopause with Diet, Vitamins and Herbs (Prentice Hall Canada, 2000).
Trigger Foods. Eliminate foods in the diet that can worsen hot flashes, insomnia or mood swings. Caffeine-containing foods and beverages like coffee, tea, dark chocolate, colas, certain orange sodas and root beers trigger hot flashes and can affect the quality of your sleep. Start by avoiding caffeine in the afternoon. Replace these beverages with caffeine-free or decaffeinated beverages like herbal tea, mineral water, fruit and vegetable juice or decaf coffee. Medications such as Midol, Excedrin and Anacin also provide a fair amount of caffeine.
Reduce alcohol intake to no more than one drink a day, preferably none if you are experiencing hot flashes or you are under stress. Drinking alcoholic beverages can bring on a hot flash, interrupt sleep and affect mood. To lessen the effect of alcohol, drink alcohol only with a meal. One drink is equivalent to 5 ounces of wine, 12 ounces of beer, 10 ounces of wine cooler or 1.5 ounces of liquor.
If you are experiencing hot flashes, avoid spicy foods. Many women complain that certain spices can trigger a hot flash.
Soy Foods and Isoflavones. Diets rich in soy may explain why women living in China and Japan have a 20 percent incidence of hot flashes compared with women in Western countries who have an 85 percent incidence. Well-controlled studies have found that soy foods can modestly ease hot flashes.
Soybeans contain naturally occurring compounds called isoflavones, a type of phyto (plant) estrogen. Genistein and daidzein are the most active soy isoflavones and have been the focus of much research. Isoflavones have a similar structure to the hormone estrogen and, as a result, they have a weak estrogenic effect in the body. Even though isoflavones in soy are about 50 times less potent than estrogen, they are able to offer women a source of estrogen. When a woman's estrogen levels are low during perimenopause, a regular intake of foods like roasted soy nuts, soy beverages and tofu can help reduce hot flashes.
Experts believe that a daily intake of 40 to 80 milligrams of phytoestrogens is required to help alleviate hot flashes and reduce other health risks.
||Serving Size||Isoflavone Content (milligrams)|
|Roasted soy nuts||1/4 cup (60 ml)||40-50 mg|
|Green soybeans, uncooked
||1/2 cup (125 ml)||70 mg|
|Tempeh, uncooked||3 oz (90 g)||38 mg|
|Soy flour||1/4 cup (60 ml)||37 mg|
|Tofu, firm||1/2 cup (125 ml)||27 mg|
|TVP, dry||1/2 cup (125 ml)||30-120mg
|Soy milk||1 cup (250 ml)||24 mg|
|Soy protein powder||1 oz (28 g)||28 mg|
|Yves Veggie Dog||1 (52 g)||12-19 mg|
USDA: Iowa State University Database on the Isoflavone Content of Foods, 1999.
See page 72, Chapter 5, for ways to incorporate soy into your diet.
L.B.'s Note - If you are a women with a history of estrogen positive breast cancer you might be wondering about soy. Can plant estrogens in soy increase your risk for breast cancer? The truth is, we don't know. Soy isoflavones may have different effects depending on the dose and the time in a woman's life when she consumes them. For example, in a premenopausal women with estrogen, soy isoflavones may act like ant-0estrogens and prevent the binding of estrogen to breast cells. On the other had, in a postmenopausal woman who is deficient in estrogen, soy isoflavones may have an estrogenic effect.
This role of soy foods in breast cancer risk is currently under investigation by scientists in Canada and the United States. In the meantime, most experts agree that eating soy foods three times per week does not pose a risk for women at high risk for breast cancer. However, some experts do recommend that plant estrogens from any source can pose a risk and therefore advise patients to avoid soy all together. In the end, it becomes a personal decision until we have more research to guide us. But one recommendation is universal - women at high risk for breast cancer should avoid large doses of isoflavones in powders or pills.
Carbohydrates. If you are experiencing sleep problems, try eating a small serving of a carbohydrate-rich food before bed. Carbohydrate-containing foods, such as milk, cereal or a slice of toast, provide the brain with an amino acid called tryptophan. The brain uses tryptophan as a building block to manufacture serotonin, a brain chemical that has been shown to facilitate sleep, improve mood, diminish pain and even reduce appetite.
If you're suffering from fuzzy thinking, include carbohydrates in your breakfast. Studies in children and adults have shown that compared with breakfast skippers, individuals who eat the morning meal score higher on tests of mental performance that same morning. The speed of information retrieval (a component of memory) seems to be affected the most by breakfast skipping.
Vitamins and Minerals
Vitamin B12. Many studies have found that vitamin B12 promotes sleep, especially in people with sleep disorders. B12 is thought to restore sleep by working with melatonin, a hormone that's involved in maintaining the body's internal clock. A deficiency of vitamin B12 may cause disturbances in melatonin release.
The recommended dietary intake for vitamin B12 for healthy women is 2.4 micrograms. Vitamin B12 is found in all animal foods: meat, poultry, fish, eggs and dairy products. If you're eating these foods every day, chances are you are meeting your B12 needs. Foods fortified with the vitamin include soy beverages, rice beverages and breakfast cereals (but check labels to be sure).
Strict vegetarians, women who take acid-blocking medication and women over the age of 50 must get B12 from foods fortified with the vitamin or by taking a supplement. Vitamin B12 supplements come in 500 or 1000 microgram strengths. B complex supplements provide 25 to 100 micrograms of B12 along with the family of B vitamins.
Iron. If you're experiencing heavy menstrual flow, it's extremely important to eat an iron-rich diet. Iron is used by red blood cells to form hemoglobin, the molecule that transports oxygen from your lungs to your cells. If your diet falls short of iron, or if your body loses iron faster than your diet can replace it, red blood cell levels drop and less oxygen is delivered to your tissues. Symptoms of iron deficiency include weakness, lethargy and fatigue on exertion. Iron deficiency is a progressive condition. Even if your iron stores aren't low enough to diagnose anemia, symptoms of iron deficiency can still be felt.
Women who are menstruating require 18 milligrams of iron per day. Postmenopausal women need 8 milligrams.
The best iron sources are lean beef, tofu, legumes, enriched breakfast cereals, whole-grain breads, raisins, dried apricots, prune juice, spinach and peas. Iron in food comes in two forms: heme iron in animal foods and nonheme iron in plant foods. Heme iron is the most efficiently absorbed and is found in red meat, chicken, eggs and fish. Nonheme iron is less efficiently absorbed. Refer to page 56, Chapter 4, for tips on how to enhance iron absorption.
A multivitamin and mineral supplement is recommended for women with higher iron requirements. Most formulas provide 10 milligrams, but you can find some that provide up to 18 milligrams. If you're experiencing persistent heavy bleeding, the recommended daily intake might not be enough to meet your needs. Sometimes supplemental iron is recommended to rebuild your iron stores. Single iron supplements are toxic in large doses and should be taken only under supervision by your doctor.
Black Cohosh for Hot Flashes. Based on clinical experience and findings from controlled scientific studies, black cohosh is the most promising herbal remedy for treating hot flashes. A number of randomized controlled trials have found black cohosh to be as effective as estrogen therapy at relieving flashes. Black cohosh does not cause the uncomfortable side effects associated with hormone therapy. And unlike estrogen, laboratory research has found that black cohosh inhibits the growth of breast cancer cells.
The recommended dose is 40 milligrams twice daily. Buy a product standardized to contain 2.5 percent triterpene glycosides. The specific black cohosh evaluated in much of the scientific research is sold under the name Remifemin. This product is sold as a 20 milligram tablet, since a recent study showing that a lower dose of the herb is equally effective. Once you start black cohosh, it may take up to four weeks to notice an effect. Mild stomach upset and headache may occur.
Herbal Combination Formulas. These products combine black cohosh with a number of herbs known to ease a variety of perimenopausal symptoms. These may be used instead of taking black cohosh alone. Estro-Logic (Quest Vitamins) contains standardized black cohosh, soy isoflavones and a number of other herbs supportive to menopause. It was developed by American gynecologist Dr. Kathleen Fry and medical herbalist Claudia Wingo. The product is currently being studied in a trial of 100 menopausal women. Preliminary findings show the product to be effective at easing a number of common menopausal complaints. Other products include Menopause Formula (Natural Factors), Meno+ (ehn) and Life Menopause Formula (Shoppers Drug Mart).
Valerian for Insomnia. A number of European studies have shown that valerian makes getting to sleep easier and that it increases deep sleep. Unlike popular prescribed sleeping pills, valerian does not lead to dependence or addiction. Nor does it cause a morning drug hangover. Scientists have learned that valerian promotes sleep by binding weakly to two brain receptors, GABA receptors and benzodiazepine receptors.
The recommended dose is 400 to 900 milligrams, taken 30 minutes to one hour before bedtime. Buy a product that is standardized to contain at least 0.5 percent essential oils or 0.8 percent valerenic acid. If you wake up feeling groggy, reduce the dose. The herb is most effective when used over a period. Do not take valerian with alcohol or sedative medications. The herb is not recommended for use during pregnancy and breastfeeding.
For more detailed information, pick up a copy of my book
'Managing Menopause with Diet, Vitamins and Herbs' (Penguin Canada, 2002).
Recommended Web Resources
National Women's Health Resource Center
The North American Menopause Society
The above excerpt is from "Leslie Beck's Nutrition Encyclopedia" (Penguin Canada, 2001/2003), available at bookstores across the country. The following is copyrighted and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or means - electronic, mechanical, photocopying, or likewise.
All research on this web site is the property of Leslie Beck Nutrition Consulting Inc. and is protected by copyright. Keep in mind that research on these matters continues daily and is subject to change. The information presented is not intended as a substitute for medical treatment. It is intended to provide ongoing support of your healthy lifestyle practices.