Integrative approach to Menopause
An estimated 6000 US women reach menopause every day; by 2020, the number of US women older than 51 is expected to exceed 50 million.
The natural process of menopause results from the progressive loss of ovarian follicle function. Natural menopause, defined as 1 year after cessation of menstruation, occurs on average at age 51, with most women falling between age 45 to 55. Certain factors are associated with an earlier age of menopause, including smoking, high-fiber or vegetarian diet, low body mass index, type 1 diabetes mellitus, and nulligravida. Menopause also may be induced from surgery or medications, such as chemotherapy.
The perimenopause transition time may begin when a woman is in her late 30s to early 40s, with episodic symptoms, such as night sweats and changes in cycle length.
In general, laboratory testing is not required to establish menopause, although some measurements may be beneficial in staging during the perimenopausal years. Your primary care provider or Ob/GYN instead can focus on taking a thorough history to elucidate any symptoms related to hormone changes, review preventive strategies to maintain health, and partner with the patient to help her define and achieve her goals. Laboratory markers of menopause, when used, include an increase in serum follicle stimulating hormone (FSH) and decreases in estrogen. In perimenopause, due to the lack of ovulation, progesterone decline often precedes changes in estrogen, leading to a relative estrogen dominance, with associated increasing premenstrual syndrome and breast tenderness. When hormones such as testosterone are being considered for use alongside estrogens and progestogen for hyposexual sexual disorder, levels of androgens and baseline chemistries and blood counts can be obtained.
Up to 80% of perimenopausal and postmenopausal women report having vasomotor symptoms (VMS), including hot flashes and night sweats, with up to half reporting moderate or severe symptoms. Vasomotor symptoms peak during the menopausal transition, but up to 25% of women in their 60s and 70s report VMS. Given the broad spectrum of symptoms a woman may experience during the menopausal transition.
Dietary factors commonly reported by women as triggers for vasomotor symptoms include caffeine, alcohol, and spicy and hot foods and beverages. Studies on specific dietary factors are limited, with the primary interventions studied being weight loss and phytoestrogens.
Weight – It has been seen that those who lost weight via reduced fat and increased fruit, vegetable, and fiber intake reported a reduction or elimination of VMS over 1 year.The diet appeared to impact symptoms over and above the effect of weight change.
Dietary phytoestrogens – Many plants produce chemicals that mimic or interact with hormone signals. Soy isoflavones genistein and daidzein can bind estrogen receptors, resulting in both estrogen agonist and antagonist actions. Soya isoflavones are found in chickpeas, fava beans, pistachios, peanuts, and other fruits and nuts. Both composite phytoestrogen supplementation and individual phytoestrogen interventions, such as dietary and supplemental soy isoflavones, can be associated with modest reductions in the frequency of hot flashes and vaginal dryness but not night sweats. Soy protein is generally safe when used in moderation, although some patients note gastrointestinal side effects, such as bloating and loose stool.
Acupuncture: Acupuncture once to twice a week significantly reduces the frequency and severity of hot flashes, with effects lasting up to 3 months. Referral to a provider trained in acupuncture, with appropriate licensure and credentials, should be considered for menopausal women seeking a holistic strategy.
Movement and meditation-based practices: Yoga, meditation, tai chi, muscle relaxation, breath-based techniques are mind-body practices that play a prominent role in a menopause management strategy. Many studies on yoga, tai chi, and meditation-based programs reported improvement in overall menopausal and vasomotor symptoms.
Mindfulness based stress reduction, in particular, is found to improve sleep, mood symptoms, and hot flashes.
Although good quality data are lacking in general for dietary supplements, the following show the greatest promise in menopause.
Sage – Sage (Salvia officinalis) has been used in traditional herbal medicine for excessive sweating and hot flashes, and may have some estrogenic activity.
Black cohosh – Black cohosh (Cimicifuga racemosa) is frequently used for menopause in the United States and Europe. The mechanism for its effect is unclear. Black cohosh does not directly bind estrogen receptors or stimulate the growth of estrogen dependent tumors. The studies however have not consistently shown to decrease menopausal symptoms.
Other herbals – Chaste berry, kudzu, alfalfa, hops, licorice, evening primrose oil, Panax ginseng, maca, wild yam, and vitamin E have all been promoted for menopausal symptom relief, but studies are limited.
Pharmaceuticals – Antidepressants like Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors, as well as gabapentin and pregabalin, are the most common medications prescribed for VMS based on studies showing mild to moderate improvements. These medications have the potential for significant side effects, and the antidepressants carry black box warnings regarding the risk of suicidal thoughts and behaviors.
Menopausal hormone therapy – A full guide to the available menopausal hormone therapy (MHT) is beyond the scope of this blog. Please consult with your provider for the treatment options.
Natural: implies that hormones are derived from a naturally occurring source but tells nothing about the actual content. This term should be avoided.
Synthetic: hormone formulations with a chemical structure not produced by the human body.
Bioidentical: the molecular structure of the hormones is identical to the natural hormones. Bioidentical hormones are available both through compounding pharmacies and in pharmaceutical versions.
Vaginal Laser Treatment: diVa Laser Vaginal therapy is a quick – 3-5 minutes (after topical anesthesia has taken effect), in-office procedure. diVa has a unique hybrid (2 different laser wavelengths) fractional laser technology. Its use results in new tissue formation, thicker mucosa, increased vascularity, and enhanced lubricating powers for women with vaginal dryness in menopause. diVa laser vaginal therapy has also been shown to improve stress urinary incontinence (peeing after coughing, sneezing, or jumping), problems with vaginal dryness, and painful sex – all associated with genitourinary symptoms of menopause.
Platelet Rich Plasma: The vaginal Platelet Rich Plasma (PRP) rejuvenation is part of an integrative approach designed to treat loss of desire and deceased orgasm. It involves injection of the PRP into the upper wall of the vagina and clitoris, triggering stem cells’ multiplication and “younger” tissue growth. Growth Factors released from the activated PRP, promote collagen and elastin production inside the vagina and around the clitoris, causing its expansion due to tissue thickening, leading to easier stimulation, sexual enhancement and improved vaginal hydration.