Managing Menopause Dr Nitu BajekalMD ObGyn LondonDNB MD FRCOG Dip IBLM

Consultant GynecologistWomen’s Health Expert

Lifestyle Medicine PhysicianRoyal Free NHS Hospitals, London

Founder, Women for Women’s Health

Educate, Energize, Empowerwww.nitubajekal.com

@drnitubajekal

Menopause and Beyond

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Understanding Menopause

Nutrition and Lifestyle Considerations

Soy Facts:Myth busting

Hormone Replacement Therapy

Common Problems faced in the Menopause

Perimenopause (Menopausal Transition)

• Average age : 47 years• Gradual change• Lasts 4 years (2-8) • Ovaries start to fail• Hormonal fluctuations • Menstrual irregularities

Menopause

• The absence of periods for >12 months• Ovaries stop producing eggs• Estrogen levels fall• Rising FSH (Follicular Stimulating Hormone)

• Average age: 51.4• Predictors of age at natural menopause (Dunneram et al. 2018)

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Menopause Diagnosis• After the age of 45, clinical

diagnosis only, unless other problems coexist

• 40-45 years: Clinical diagnosis and blood tests

• Under 40 years: Premature Menopause. Needs specialist input

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Menopausal Symptoms8 out of 10 women suffer, only 3/10 seek help

• Hot flashes – Most Common• Night Sweats• Lack of Concentration• Reduced sex drive • Painful sex/Vaginal dryness• Sleep disturbance/ Mood changes/ Tiredness• Stress/ Depression/Memory loss• Urinary symptoms• Weight management issues

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What are Hot Flashes?

Commonest symptom of menopause• Exact cause unknown• Warm sensation, most intense over face,

neck and chest • Sweating, palpitations, chilled feeling• Few a week to several an hour• May last several years, (4-10 years), 20 years)• Rarely, caused by other conditions or

medications

Hot Flashes: Geographical Variations

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15% women in SE Asia vs 80% suffer in the US

Low fibre, high fat animal based diet implicated

RISK FACTORS

African American women > Caucasian women

Smoking

Lower SE status

Body weight – Increasing BMI was worse

Positive impact of vegetable and fruit intake on menopausal symptoms

• Cross-sectional study (Soleymani et al. 2019)

• Three major dietary patterns: Vegetables and Fruits (VF)

• Mayonnaise, Liquid oils, Sweets and Desserts (MLSD)

• Solid fats and Snacks (SFS)• VF dietary pattern was associated

with < menopausal symptoms • MLSD and SFS dietary patterns

correlated to a > risk

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Weight loss and hot flashes Kroenke et al. 2012

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17,000 women with baseline vasomotor symptoms

Women who lost ≥10% of their baseline weight were significantly more likely to experience elimination of these symptoms vs women with no weight loss

Reductions in serum cholesterol, estrogenlevels and mammographic densities were also noted

Cross sectional study: Vasomotor Symptoms Beezhold et al 2018

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Vegans reported less bothersome vasomotor and physical menopausal symptoms than omnivores

Among perimenopausal women, vegans reported less vasomotor (p < 0.01) and physical symptoms (p < 0.01) than omnivores

For both symptom types, more vegetables and fewer animal products were associated with less bothersome symptoms (p values < 0.05)

CONCLUSION: Eating a plant-based diet may be helpful for women in the perimenopause who prefer natural ways to manage symptoms

Managing MenopauseLifestyle measures onlyLifestyle Measures +HRT

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Estrogen is the most effective treatment available for relief of menopausal symptoms

Hormone Replacement Therapy (HRT) is however, not for everyone

Small but real increased risks of stroke, breast cancer and thrombotic episodes

Women may prefer to avoid HRT

Contraindication for HRT (cancer, heart disease etc)

Doctors should encourage lifestyle measures alongside/instead of HRT

Keeping Hot Flashes At Bay• Turn heating down • Layer clothes/thin sheets• Keeping hydrated• Cooler showers/baths• Regular exercise – Walking, swimming• Avoid High Impact Exercise unless used to it• Avoid Alcohol/Smoking• Meditation/Yoga• Hypnosis• Whole Food Plant Based diet• Phytoestrogens

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Restorative Sleep• Short nap in the day• Exercise• Early evening meal• Chamomile tea• Book/music/podcast • Black out curtainsAvoid • caffeine/alcohol/TV• fluids close to bedtime• screen time 30-60 min before

Whole Food Plant Based (WFPB) diet

Eat Foods rich in FIBERüFruitüVegetablesüWhole grainsüBeans, Lentils, Peas üHerbs, spicesüSeeds, nutsüAvoid SOS: salt, oil,

sugar: use as flavourings

Avoid Foods WITHOUT FIBER• Sweetened drinks• Fruit Juices• Oils • Refined Grains• Junk food• Ultra Processed food• Animal derived foods

Phytoestrogens : Plant substances with weak but similar effects to estrogens in some tissues and blocking effects in others (SERM effect)

Isoflavones: genistein & daidzein • soybeans• chickpeas• beans

Lignans: enterolactone & enterodiol• Flaxseed• whole cereals• Fruit• Cereal bran

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Soy

Soy is a complete plant protein, with all nine essential amino acids, similar profile to animal protein and is rich in üfiber,üvitamins, üminerals, ühigh in PUFAs ülow in saturated fat üIsoflavones (daidzein and genistein)

Soy Isoflavones: mechanism of action

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Isoflavones is not the same as the hormone estrogenand soy foods are not just isoflavones

Isoflavones do not stimulate the vaginal maturation index or increase C-reactive protein whereas estrogendoes

Isoflavones have a chemical structure similar to the hormone estrogen which allows them to bind to both receptors (ER)—ERα and Erβ

Estrogen binds to and transactivates ERα and ERβ equally, isoflavones preferentially bind to and transactivate ERβ

This preference for ERβ is the reason for the tissue-selective effects (SERMs) of soy

Difference betweenEstrogen vs isoflavones

EstrogenHormone

ERα ERβ

Soy Isoflavones

ERβ

Soy Controversy

• Isoflavones mimic estrogen in some tissues and blocking its effect in others (SERM effect)

Effect of soy dependent on

• How much estrogen is present to start with

• Timing and duration of exposure to soy

• Gut bacteria may be a reason for varied results

• EQUOL producers: Intestinal bacteria that convert daidzein into the isoflavonoid equol (> estrogenic activity)

Action of Soy isoflavones on tissues• Reduces menopausal hot flashes, a pro-

estrogenic effect• Promotes bone strength, a pro-estrogenic effect• Breast: Anti-estrogenic effect (SERM), blocking

the growth promoting effects of estrogen• Likely cause of reduction of breast cancer risk

shown • One portion of Soy/day intake in childhood can

reduce future risk of breast cancer• Reduction in colon, lung, prostate and ovarian

cancer (soy inhibits neoangiogenesis)

Effect of Soy on Menopausal Symptoms

• Increased soy consumption is likely the reason for reduced hot flashes in SE Asians• Phytoestrogens reduces the frequency of hot

flashes in menopausal women, without serious side-effects

(Recent systematic review and meta-analysis using either high or low genistein isoflavone supplement (Kurzer MS, Messina M)

Non Hormonal Effects of Soy• Soy products are cardio protective • Significant reductions in body

weight, fasting glucose and insulin (meta-analysis of controlled clinical trials)• Whole or minimally processed soy

foods should be recommended over isolated soy isoflavones where possible

Soy intake recommendation

• Consuming soy products regularly is safe, unless allergic

• Choose minimally processed products (edamame beans (16), tofu (20 mg of isoflavones in 3 oz) over processed soy foods

• Fermented forms of soy such as tempeh (30mg), miso (37) and natto (70 mg) are excellent

• Aim for two portions a day (a cup of soy milk (6mg) , 80g tofu)

• Avoid isoflavone supplements and soy protein isolates, the latter may increase IGF1 similar to animal protein

• Iodine intake and thyroid medication is not a contraindication

• Avoid taking thyroid meds at the same time as soy intake• No recommendation can be made with regards to cognition

Keeping Hot Flashes at bayAim for 2 portions of soy/day in a WFPB dietMeal Ideas from nitubajekal.com

Breakfast• A cup of soy milk (250 ml) with porridge oats (lignans)• Or 80-100g plain soy yoghurt with berries• Add 1-2 tbsp of flaxseed powder (lignans) and a teaspoon of

chia seeds/6 walnut halves for Omega 3 Mid morning snack – handful of mixed nuts/fruit/green smoothie/ edamame beansLunch • 100g of Soy Yoghurt/Soy latte/Salad with

beans/chickpeas/hummus• 80g Tofu scramble on seeded bread• 250 ml of miso soupDinner • Tofu or Tempeh vegetable stir fry• Brown Rice with a bean curry/bean burrito

Menopausal Hormonal Therapy (MHT, HRT)• Use only if symptoms affect quality of life• Start with lowest dose• Both estrogen + progesterone if uterus intact• Should be assessed yearly• Breast cancer risk depends upon duration and

type of HRT• Increased risk of stroke, thrombosis, CHD• Good practice is to encourage lifestyle and

dietary advice alongside

Hormone Replacement Therapy (HRT, MHT)

• Replacing Estrogen and Progesterone• Does what it says on the pack!

• Useful for relief of menopausal symptoms• Hot flashes• Night sweats• Vaginal dryness• ? Improve Mood/ libido

• Will not change your life circumstances• Stress maybe due to other factors- HRT

not the answer to everything

Alternatives to HRT?

Relaxation techniques• Acupuncture• Aromatherapy• Meditation and

mindfulness• Yoga• Hypnosis

Medical treatments• Antidepressants, Clonidine-

poor side effect profile• NK3 antagonistsHerbal medicine (Reductionist approach, billion-dollar industry)• Soy isoflavones• Red clover• Black cohosh• St. John’s wort

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Bioidentical Hormones• Custom-compounded, multihormone

regimens • Dose adjusted with serial hormone

monitoring• From soy and plant extracts and modified to

be identical to endogenous hormones• Same approach is also used for most

approved commercial HRT preparations• Not recommended by any expert group• No evidence for their safety or efficacy when

compared with standardised HRT• Not regulated and dose is not standardised

Problems faced during Menopause

OBESITY POST MENOPAUSAL

BLEEDING

FEMALE CANCERS BREAST, UTERINE

VAGINAL DRYNESS PAINFUL SEX

URINARY INCONTINENCE

OSTEOPOROSIS DEMENTIA RISK

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Vaginal Dryness (Atrophic Vaginitis)• Sex can be painful • Reduced sex drive• Be aware of your body and changes with

age• Less inhibition/no fear of pregnancy• Regular sex• Vaginal Dilators• Local Lubricants • Water based vaginal moisturisers• Natural oils external application• Laser treatment to improve collagen• Local vaginal estrogen is safe

Urinary Problems Stress and Urge Incontinence• Weight loss• Uterine prolapse makes it worse• Yoga/tai-chi/Pilates improves pelvic

floor• Avoid tea/caffeine/smoking• Avoid fluids before bedtime• Bladder training• (Medications/Surgery)Cystitis is often helped by local estrogenProven urinary infections will need antibiotics (E coli)Blood in the urine needs urgent tests

Unwanted Pregnancy:Contraceptive methods • Use contraception for 1 year after

menopause if > 50• Use contraception for 2 years after

menopause if < 50 years• The COC Pill can be used in younger

menopausal patients• The Pill can be used safely until

menopause (51 years), if no other risk factors and other options not acceptable

Weight Management Issues and Obesity• USA: 39.8% of adult pop obese

41.0% > 60 • Diet + Sedentary Lifestyle• Severe Menopausal symptoms• Urinary problems• Vaginal prolapse• Vascular Dementia• Lifestyle Cancers

Breast Cancer in postmenopausal womenØPostmenopausal women with breast cancer

were found to have higher estrogen levels (body weight)

ØWomen on a plant based diet had the lowest levels of estrogen

Ø Soy products may reduce the risk of breast cancer and breast cancer recurrence (SERM tissue blocking effect)

ØPost-menopausal breast cancer survivors on Tamoxifen who ate the most soy had the lowest rates of breast cancer recurrence

Ø This was also true of lignan intake (high levels in flax seeds)

ØMushrooms can help in disruption of breast cancer cells (which can produce their own estrogen)

Post Menopausal Bleeding• Any bleeding after one year of stopping

periods • 10-20% of bleeding is a gynae cancer• Rule out Cancer with detailed history,

exam and appropriate testsCommon Causes of PMB• Atrophic tissues • Endometrial or cervical polyps• Endometrial (womb) cancer

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Endometrial Cancer• Most common cancer of the female reproductive

organs in the US• 55-65 years peakRisk Factors: Estrogen dependent Cancer• Obesity, diabetes and hypertension >Cancer • Early onset of periods, late menopause,

infertility • Tamoxifen therapy for breast cancer• Conditions like HNPCC (Lynch syndrome) and

Endometrial hyperplasia (PCOS)• Family or personal history of ovarian/breast

CancersMost womb cancers are detected at an early stage with hysterectomy treatment of choice

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Age and changes in overall bone massHarvard Nurses’ Health study12 year prospective study of 77,761 women• Fracture risk assessed looking at

calcium intake and milk consumption

• ≥3 glasses of dairy milk per day had no reduction in the risk of hip or arm fractures compared to those who drank little or no milk, even after adjustment for weight, menopausal status, smoking, and alcohol use

• Fracture rates were slightly, but significantly, higher for those who consumed this much milk, compared to those who drank little or no milk

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Osteoporosis(1 in 2 women and 1 in 5 men lifetime risk)

• Loss of bone strength due to slowed repair process

• Asymptomatic until fragility fractures (wrist, hip, spine)

• Calcium / Vit D protein/vitamins C, E, K Minerals Boron Magnesium

• Per day 2 servings of soy may protect against osteoporosis (Sathyapalan et al, 2015)

Avoid • Smoking• Alcohol• Salt/sugar/caffeine• Sedentary lifestyle

Prevention of osteoporosis and sarcopenia• Weight training is helpful to reduce risk• Twice a week at least, working out all groups of

muscles• All ages, under supervision if needed• Earlier children start, the better• 150min moderate intensity exercise/week for cardio

and balance exercises to prevent fallswww.nitubajekal.com

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Sunlight and vitamin D

• UV A deep penetration into skin but rarely burns. Implicated in cancer caused by tanning beds

• UV B is the Vitamin D producer but also the ‘burner’

• UV C most damaging but rare due to ozone layer protection

• ‘Holloways’ rule- identifies best time of day for UV B

• Vit D3 is a hormone: 15-45 min sunlight • Testing and supplementation? but still

recommended

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• Whole food plant based diet• Physical activity – yoga, tai chi, walking• Group activities: Book Club• Encourage new hobbies • Social interaction• Looking after your heart• Type 2 Diabetes

Reducing the risk of Dementia

Menopause Summary

• Hot Flashes are the commonest symptom • A SAD diet makes symptoms worse

while a WFPB diet helps manage symptoms• Isoflavones (soy) and lignans (flaxseeds)

are the main groups of phytoestrogens• Eat two portions of soy daily• Soy reduces hot flashes, protects the

heart and bones• Soy is safe in women with breast cancer,

thyroid issues, and reduces incidence of breast and prostate cancer

Ways to reduce cancer risk

üAvoid alcohol and smokingüEat a WFPB diet (+ soy)üRegular exercise üMaintain normal weight

My vegan journey into aWhole Foods Plant Based lifestyle

What I eat in a day!

Whole Plant foods

Anti hot flashesAnti cancerAnti PCOSAnti heart diseaseAnti endometriosis Anti aging diet

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Whole Food Plant Based Lifestyle

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HEALTH

One Diet Fits All

• A diet that prevents so many health conditions and reverses some

• A diet where you do not have to count calories

• A diet that addresses some of the world’s biggest problems…

• Climate change• Reduces animal suffering

Ikigai (A reason for being)

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Women for Women’s HealthEDUCATE ENERGIZE EMPOWERwww.nitubajekal.comwww.rohinibajekal.com@drnitubajekal