What are the options for a Healthy Menopause?

Menopause is a natural process and cannot be avoided. Research shows that race in Canada and the US may be a factor in having a healthy menopausal transition. Because race is linked to chronic stress levels and social- economic factors, it is hard to separate these complex factors from what is happening during menopause transition.[6][7]

Regardless of race, menopause is a universal human female experience and awareness of the changes occurring in your body gives you options on if or how you manage your menopause symptoms. 

It is really helpful to keep a health journal and track your periods and menopausal symptoms throughout your menopausal transition. 

Track any changes in:

  • Periods: length, regularity, flow, and pain or weirdness (colour, consistency, etc.) 

Symptoms:  When did they start? When do they happen? How intense are they? Can you connect them to life events like stress? Learn more about the different symptoms by selecting the link below.

The Science

Much of the science underlying menopausal transition is not well known. However, we do know that some reproductive hormones, such as estrogen and progesterone, decline and that follicle stimulating hormone (FSH) increases, as shown in the graph and described in the text below. [9][10][11][12] Note that the cause- and effect- interaction of declining E2 and FSH in a woman’s body are not understood at this time.

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Estrogen is a steroid hormone (estradiol or E2) secreted by the ovaries and adipose tissue and it’s secretion becomes irregular as early as the Late Reproductive Stage (LRS) of life. [13] Estrogen may make very dramatic oscillations during the early perimenopausal stage and through to the late perimenopause stage, finally steeply declining to close to zero in the last year before menopause. How these E2 “waves” affect short -term symptoms like mood and hot flashes, or chronic conditions like bone thinning, is not known.  [14]

Estrogen is important because it is a master regulator of metabolism, brain health, cell division, bone strength, and many other functions in addition to reproduction.[15][16]

Progesterone is a steroid hormone, secreted by ovaries with more specialized and fewer known functions than estrogen.

Progesterone mainly functions in fertility and pregnancy. It is secreted by the corpus luteum body of the ovary, triggering changes in the uterus that make it ready to support an implanted fertilized egg. The human placenta also secretes progesterone in support of pregnancy. As well, progesterone is involved in regulating breast tissue growth and differentiation, along with estrogen. [17]

Progesterone may reduce the stiffness of blood vessels, reduce water retention in the body, and modulate the sleep regulating hormone melatonin. [18] Consequently, the gradual loss of progesterone during menopausal transition may increase water retention and affect sleep quality.

Progesterone declines during perimenopause and is at very low levels post- menopause.  [19][20]

During the late reproductive stage (LRS), follicle stimulating hormone (FSH), a biochemical signal from the brain’s hypothalamus to the ovary, oscillates in sync with your other reproductive hormones. then it is possible you are in the LRS.FSH triggers oocyte (egg cell) maturation and release. FSH also stimulates the secretion of estrogen and inhibin B from the ovary. Inhibin B and estrogen levels rise during the menstrual cycle and feedback to the hypothalamus, which then suppresses estrogen release. [21]

During early perimenopause, FSH rises steeply to high levels, likely due to the decline of feedback from estrogen, and possibly the decline of inhibin B. The steep perimenopausal rise in FSH indicates oncoming menopause. FSH plateaus near the end of late perimenopause and persists at this level post- menopause. [22][23][24] High levels of FSH, along with declining estrogen, may cause bone resorption and increase the likelihood of obesity. [25]

Blood glucose levels may become dys-regulated and variable during perimenopause, possibly due to irregular and declining estrogen and rising FSH. Brain glucose dysregulation may contribute to memory and concentration challenges seen during the menopause transition. [26]

Quality of Life During Your Menopause Transition

Healthy menopause and a high quality of life (QOL) are both rooted in a woman’s personal health and in her environment as shown in the figure below. Genetics play a large role in menopause, so the age your mother reached menopause is a good predictor of when you may reach it. You can’t control your genetic heritage, or some aspects of your environment, but there are many choices you can control such as getting adequate exercise and good nutrition, and increasing your resilience to stress.

Myths and Mysteries of a Healthy Menopause

MYTH

This myth is rooted in ageist and sexist attitudes. Most women in menopausal transition are healthy, happy and productive. Women cope with their symptoms like they cope with most other challenges in life – adequately at worst and successfully at best.

MYSTERY

There is little data about the individual women’s reproductive hormone levels on a day-to-day, and month-to month basis during menopausal transition. Other important hormones and neurotransmitter levels are not known either. [27]

MYSTERY

Since hormone levels can’t be accurately tracked day-to-day/ month-to-month for individual women, the impact of hormones on symptoms is speculative for most symptoms. Technological tracking of symptoms and biomarkers over time is lacking. The result is that current research can only correlate changing hormones with symptoms for averaged populations of women, and with only a rough idea of timing of these events.

MYSTERY

  1. “Why do women outlive their fertility?”

Twenty-first century women (and people in general) are living 40- 50 years longer than women did before 1900. At that time, most women died around age 40 (across different cultures), before even reaching the menopausal transition. Living through the menopausal transition and beyond is relatively recent. 

There may be no evolutionary “purpose”, or survival advantage, to either individual women or to their descendents. The length of the reproductive life span in human females is comparable to other great apes, however great apes die soon after their reproductive systems age and stop functioning. The hypothesis is that menopause might not be the key trait. Perhaps the ability to extend life post-menopause is the critical trait that needs more attention. [28] 

  1. “The Grandmother Hypothesis”

Overwhelmingly, women of past generations had children at a younger age than now, typically starting in their teens and early 20’s. After children are born to a young woman and her family, her genetic contribution to future generations is complete. Since childhood disease and trauma impact human mortality so strongly, children’s survival becomes evolutionarily paramount. When women have children that survive long enough to bear them grandchildren, the continuation of the woman’s genes becomes more probable. As well, grandmothers may improve the likelihood of her grandchildren’s survival by sharing her resources, help and knowledge, creating more insurance for the survival of her genes. This hypothesis is called “Kin Selection” and it proposes that there are strong natural selection factors supporting longer lifespans (for both women and men). [29][30]

Compiled References

[1] Int.World Health Organization. (2007) Women, ageing and health : a framework for action : focus on gender. II. United Nations Population Fund. ISBN 978 92 4 156352 9
[2] Allshouse A, Pavlovic J, Santoro N. (2018) Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstet Gynecol Clin North Am. 2018 Dec;45(4):613-628. doi: 10.1016/j.ogc.2018.07.004. Epub 2018 Oct 25. PMID: 30401546; PMCID: PMC6226272
[3] Minkin, M.J. (2019) Menopause: Hormones, Lifestyle and Optimizing Aging. Obstet Gynecol Clin N Am 46 501–514 https://doi.org/10.1016/j.ogc.2019.04.008
[4] Jaspers L, Daan NM, van Dijk GM, Gazibara T, Muka T, Wen KX, Meun C, Zillikens MC, Roeters van Lennep JE, Roos-Hesselink JW, Laan E, Rees M, Laven JS, Franco OH, Kavousi M. (2015) Health in middle-aged and elderly women: A conceptual framework for healthy menopause. Maturitas. 2015 May;81(1):93-8. doi: 10.1016/j.maturitas.2015.02.010.
[5] Minkin, M.J. (2019) Menopause: Hormones, Lifestyle and Optimizing Aging. Obstet Gynecol Clin N Am 46 501–514 https://doi.org/10.1016/j.ogc.2019.04.008
[6] Santoro N, Lasley B, McConnell D, Allsworth J, Crawford S, Gold EB, Finkelstein JS, Greendale GA, Kelsey J, Korenman S, Luborsky JL, Matthews K, Midgley R, Powell L, Sabatine J, Schocken M, Sowers MF, Weiss G. (2004) Body size and ethnicity are associated with menstrual cycle alterations in women in the early menopausal transition: The Study of Women’s Health across the Nation (SWAN) Daily Hormone Study. J Clin Endocrinol Metab. 2004 Jun;89(6):2622-31. doi: 10.1210/jc.2003-031578. PMID: 15181033.
[7] Assari S, Wisseh C, Bazargan M. (2019). Obesity and Polypharmacy among African American Older Adults: Gender as the Moderator and Multimorbidity as the Mediator. Int J Environ Res Public Health. 2019 Jun 20;16(12):2181. doi: 10.3390/ijerph16122181.
[8] Murray, A., Bennett, C. E., Perry, J. R., Weedon, M. N., Jacobs, P. A., Morris, D. H., Orr, N., Schoemaker, M. J., Jones, M., Ashworth, A., Swerdlow, A. J., & ReproGen Consortium (2011). Common genetic variants are significant risk factors for early menopause: results from the Breakthrough Generations Study. Human molecular genetics, 20(1), 186–192. https://doi.org/10.1093/hmg/ddq417
[9] Allshouse A, Pavlovic J, Santoro N. (2018) Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstet Gynecol Clin North Am. 2018 Dec;45(4):613-628. doi: 10.1016/j.ogc.2018.07.004. Epub 2018 Oct 25. PMID: 30401546; PMCID: PMC6226272.
[10] Brinton, R.D., Yao, J., Yin, F., Mack, W.J. and Cadenas, E. (2015). Perimenopause as a neurological transition state. Nat. Rev. Endocrinol. 11, 393–405 (2015); published online 26 May 2015; corrected online 8 June 2015 doi:10.1038/nrendo.2015.82
[11] Santoro, N. (2016) Perimenopause: From Research to Practice. Journal of women’s health. Volume 25, Number 4, 2016
[12] El Khoudary SR, Greendale G, Crawford SL, Avis NE, Brooks MM, Thurston RC, Karvonen-Gutierrez C, Waetjen LE, Matthews K. (2019) The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause. 2019 Oct;26(10):1213-1227. doi: 10.1097/GME.0000000000001424.
[13] Bulun, S.E. Physiology and Pathology of the Female Reproductive Axis (2019). William’s textbook of endocrinology, fourteenth edition. Melmed, Koenig, Rosen, Auchus, Goldfine eds. eBook ISBN: 9780323711548 Hardcover ISBN: 9780323555968 Imprint: Elsevier Published Date: 14th November 2019
[14] Allshouse A, Pavlovic J, Santoro N. (2018) Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstet Gynecol Clin North Am. 2018 Dec;45(4):613-628. doi: 10.1016/j.ogc.2018.07.004. Epub 2018 Oct 25. PMID: 30401546; PMCID: PMC6226272.
[15] El Khoudary SR, Greendale G, Crawford SL, Avis NE, Brooks MM, Thurston RC, Karvonen-Gutierrez C, Waetjen LE, Matthews K. (2019) The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause. 2019 Oct;26(10):1213-1227. doi: 10.1097/GME.0000000000001424.
[16] Brinton, R.D., Yao, J., Yin, F., Mack, W.J. and Cadenas, E. (2015). Perimenopause as a neurological transition state. Nat. Rev. Endocrinol. 11, 393–405 (2015); published online 26 May 2015; corrected online 8 June 2015 doi:10.1038/nrendo.2015.82
[17] Bulun, S.E. Physiology and Pathology of the Female Reproductive Axis (2019). William’s textbook of endocrinology, fourteenth edition. Melmed, Koenig, Rosen, Auchus, Goldfine eds. eBook ISBN: 9780323711548 Hardcover ISBN: 9780323555968 Imprint: Elsevier Published Date: 14th November 2019
[18] Greendale G.A., Witt-Enderby, P. Arun S. Karlamangla, A.S., Munmun, F. Crawford,S., MeiHua Huang,MH, and Nanette Santoro, N. (2020) Melatonin Patterns and Levels During the Human Menstrual Cycle and After Menopause. Journal of the Endocrine Society, 2020, Vol. 4, No. 11, 1–10. doi:10.1210/jendso/bvaa115
[19] Santoro N, El Khoudary SR, Nasr A, Gold EB, Greendale G, McConnell D, Neal-Perry G, Pavlovic J, Derby C, Crawford S. (2020) Daily luteal serum and urinary hormone profiles in the menopause transition: Study of Women’s Health Across the Nation. Menopause. 2020 Feb;27(2):127-133. doi: 10.1097/GME.0000000.000001453. PMID: 31794501; PMCID: PMC7050767.
[20] Greendale G.A., Witt-Enderby, P. Arun S. Karlamangla, A.S., Munmun, F. Crawford,S., MeiHua Huang,MH, and Nanette Santoro, N. (2020) Melatonin Patterns and Levels During the Human Menstrual Cycle and After Menopause. Journal of the Endocrine Society, 2020, Vol. 4, No. 11, 1–10. doi:10.1210/jendso/bvaa115

[21] Bulun, S.E. Physiology and Pathology of the Female Reproductive Axis (2019). William’s textbook of endocrinology, fourteenth edition. Melmed, Koenig, Rosen, Auchus, Goldfine eds. eBook ISBN: 9780323711548 Hardcover ISBN: 9780323555968 Imprint: Elsevier Published Date: 14th November 2019
[22] Ibid.
[23] Santoro, N. (2016) Perimenopause: From Research to Practice. Journal of women’s health. Volume 25, Number 4, 2016
[24] El Khoudary SR, Greendale G, Crawford SL, Avis NE, Brooks MM, Thurston RC, Karvonen-Gutierrez C, Waetjen LE, Matthews K. (2019) The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause. 2019 Oct;26(10):1213-1227. doi: 10.1097/GME.0000000000001424.
[25] Zaidi M, Lizneva D, Kim SM, Sun L, Iqbal J, New MI, Rosen CJ, Yuen T. (2018) FSH, Bone Mass, Body Fat, and Biological Aging. Endocrinology. 2018 Oct 1;159(10):3503-3514. doi: 10.1210/en.2018-00601.
[26] Brinton, R.D., Yao, J., Yin, F., Mack, W.J. and Cadenas, E. (2015). Perimenopause as a neurological transition state. Nat. Rev. Endocrinol. 11, 393–405 (2015); published online 26 May 2015; corrected online 8 June 2015 doi:10.1038/nrendo.2015.82
[27] Allshouse A, Pavlovic J, Santoro N. (2018) Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstet Gynecol Clin North Am. 2018 Dec;45(4):613-628. doi: 10.1016/j.ogc.2018.07.004. Epub 2018 Oct 25. PMID: 30401546; PMCID: PMC6226272.
[28] Powledge, T.M. (2008) The Origin of Menopause: Why Do Women Outlive Fertility? Scientific American.
[29] Ibid.
[30] Blell, M. (2018) Grandmother Hypothesis, Grandmother Effect, and Residence Patterns. The international encyclopedia of anthropology. 2018 John Wiley and Sons. DOI:10.1002/9781118924396.wbiea2162