Introduction
Menopause is a unique event in every woman’s life that marks the end of reproductive years. Menopause results when the ovaries lose sensitivity to gonadotropin (LH, FSH) stimulation, which is directly related to loss of follicle viability. Basically, its when your ovarian follicles become less viable and the number of eggs one has is low. This results in low levels of various hormones; estrogens and progesterone included.
The average age in the US is 51 and the hormonal changes that result predispose women to osteoporosis, increased risk of heart disease and stroke. The incidence of hypothyroidism and metabolic syndrome is greater post menopause as well.
Not only that, but the lack of sex hormones causes a body fat redistribution that many who have already gone through menopause are familiar with – Less storage around the hips and thighs, and more around the belly. It also makes it a bit harder to hit fat loss and muscle gain goals. There are, however, things we can do to combat this.
Why should you, as a coach, care about menopause?
A postmenopausal woman will, on average, be a little bit harder to get results than a premenopausal woman. They’ll also be dealing with symptoms of having a lower sex hormone status. These include hot flashes, night sweats, palpitations, headaches, insomnia, fatigue, bone loss, low libido, vaginal dryness, depression, anxiety, mood shifts, lack of motivation, and difficulty with memory recall.
These changes obviously affect quality of life, which may in turn affect adherence. As I mentioned earlier, it also makes physiological changes towards a better body composition slightly harder. It’s important to understand the changes that occur with menopause so that you can better tailor a plan to your postmenopausal client.
A Note on Hormone Replacement Therapy
Many of these changes can be mitigated through the optimal hormone replacement therapy regimen postmenopause. It’s even advised by many practitioners to begin hormone replacement when one is solidly in the menopause transition and is experiencing symptoms of erratic hormone levels.
Those reading might have concerns about reported risks involved with hormone replacement therapy, such as breast cancer or stroke. All of these concerns came from the large Women’s Health Initiative study in the early 2000’s, which was one of the larger blunders of medical science in the past 50 years.
This article isn’t necessarily about the in’s and out’s of women’s HRT; we have a separate article that dives into that quite in depth, so if you’d like to check that out and learn why the WHI study was less than reliable, and learn more about the optimal HRT regimen, check it out here.
In a nutshell, however, bioidentical, transdermal (cream or patch) estradiol, and bioidentical, oral micronized progesterone is the optimal HRT route and delivery system, and the earlier you start it, the better off you will be from a health perspective.
The Menopause Transition or Perimenopause
Women will typically start to begin the menopause transition or notice progression towards menopause at some point in their 40’s, but can be as early as late 30’s in some women. Anything above 42 is considered normal and before that is “early perimenopause”, which happens to about 1 in 100 women.
Here are a few characterizations of perimenopause:
- Irregular cycle length and missed cycles become more common; early in the transition many women experience shorter cycles (<25 days), however later in the transition cycles may be longer.
- FSH levels become elevated in an attempt to continue follicle stimulation.
- LH levels also rise, but tend to lag behind FSH elevations.
- Estrogen levels can be erratic and variable in the transitionary period, declining towards the end.
- Progesterone levels steadily decline until menopause, and tend to decline first before estradiol.
- Testosterone and DHEA do not change strictly due to the menopause transition, but we do see a general decline due to age.
If you’re looking at the sex hormone panel of your clients labs who are in their mid 40’s, those are the things that might hint they’re heading towards menopause: Higher FSH and LH levels (If just FSH is high, you know its early in the transition; if both are high, it might be indicative that the client is further into the transition). Estrogen levels could be really high or low, and progesterone levels are steadily declining.
During the transition, women can have different sets of symptoms depending on whether it is a period of high estrogen or low estrogen.
These symptoms may indicate periods of high estrogen: Bloating, breast tenderness, and heavy menstrual flow.
These symptoms may indicate periods of low estrogen (and also the main symptoms post-menopause): hot flashes, night sweats, palpitations, headaches, insomnia, fatigue, bone loss, vaginal dryness.
Regardless, the swinging and variable hormones can cause depression, anxiety, and drastic mood swings as well. It is important to note that many women will not have significant discomfort or symptoms during perimenopause, while others may experience a rollercoaster of both emotions and the symptoms previously stated leading up to menopause.
Postmenopause
Menopause is defined as 12 months after the last cycle in context of having gone through perimenopause. Meaning, there are some women who will lose their cycle for that long even if they’re not close to menopause; this will be related to too much stress, under-eating, inflammation, etc, and is much different than menopause.
I’ll go over some of the changes, hormonal and otherwise, that occur in menopause both as a result of menopause but also as a result of general aging. I’ll also talk about the effects this is going to have as far as disease risk as well as the effects on body transformation or recomposition.
- Very low estrogen
- Very low progesterone
- Declining DHEA/Testosterone (not directly as a consequence of menopause, but as a consequence of age)
- Increased cortisol
- Increased insulin
- Decreased melatonin (again as a result of age, not necessarily menopause)
- Decreased energy expenditure – This is largely due to the accelerated muscle mass loss that women experience due to the aforementioned hormonal changes and can be mitigated by building/maintaining muscle.
After menopause, women are at a higher risk of cardiovascular disease, osteoporosis, metabolic syndrome, and hypothyroidism compared to premenopausal women. Here’s the connection:
Estrogen has both significant cardioprotective and bone mineral density benefits, and so the absence of estrogen is the main driver behind increased cardiovascular disease and osteoporosis risk.
Progesterone has beneficial cognitive effects in easing anxiety and also promoting memory, so we can see low progesterone may be contributory to the increased incidence of depression/anxiety and brain fog post menopause.
Fat storage and insulin resistance post-menopause: Estrogen also has effects on fat storage patterns and is one of the reasons that premenopausal women tend to store more of their adipose tissue around the thigh and butt area; this changes after menopause and women begin to store more fat around the abdominal area.
This fact is important: Postmenopausal women also tend to store more fat as visceral fat tissue, or fat around the organs in the abdominal cavity. This visceral fat storage is highly contributory to the increased incidence of insulin resistance and metabolic syndrome postmenopause. .
Summing it up, low estrogen (higher cortisol also has roles in this too) = higher incidence of CVD, osteoporosis, and higher visceral fat storage leading to predisposition to insulin resistance/metabolic syndrome, and low progesterone = negative cognitive effects.
How to Best Serve Postmenopausal Clients
It would be worth being an advocate for their HRT, because the benefits far, far outweigh any risks. The benefits being easier fat loss, easier muscle gain, lower risk of cardiovascular disease, lower risk of metabolic disease and insulin resistance, lower risk of autoimmune disease, and lower risk of cognitive decline. Educate yourself on the real benefits of HRT and be able to debunk myths and concerns. Again, check out this article to do so.
Exercise
One of the most important things a woman approaching menopause should be doing is resistance training. This is one of the only ways to maintain bone mineral density, and is absolutely necessary to get that toned look that most women want.
Ideally, the woman will have been resistance training for years prior to menopause, because its quite hard to rebuild bone density and muscle postmenopause, but that doesn’t mean it can’t happen. During the perimenopause transition, it’s very important to either start or keep maintaining good exercise habits; again, mainly resistance training and as much low grade activity, like walking, as possible.
Postmenopause, it’s even more important that the woman will keep up exercise, specifically resistance training.
Exercise:
- May help with symptoms of perimenopause including mood swings and hot flashes. Several studies have shown reduction in those symptoms with regular exercise.
- Will build or maintain muscle – Muscle mass is going to be a little harder to build postmenopause but much easier to maintain, so the more muscle tissue that a woman has going into menopause, the more protected she will be against metabolic syndrome/insulin resistance.
- Once the woman becomes postmenopausal, resistance training along with proper nutrients that will be discussed in a bit will help maintain or even build bone mineral density, mitigating the risk of osteoporosis.
- Exercise has also been shown to decrease visceral adipose tissue preferentially, so this will also be protective against metabolic syndrome and cardiovascular disease.
As you can see, it’s very important to get your peri- and postmenopausal clients’ resistance training. Endurance or cardiorespiratory exercise is also good, but shouldn’t be the sole methodology as it won’t have any bone mineral or muscle building benefits.
Circadian Rhythms
For those unaware, your circadian rhythm is the 24 hour rhythm of your physiology. Many hormones and physiological processes ebb and flow throughout the day, and circadian rhythm disruption can result in significantly increased disease risk, lower quality of life, and will certainly make it harder to transform the body.
Given the drop in melatonin as we age, it’s even more important that postmenopausal women have good circadian hygiene so they can maintain their sleep/wake rhythm strongly.
Circadian hygiene includes:
- As much sun exposure as possible within 30 minutes to an hour of waking up (15-45 minutes).
- Eating meals during daylight hours and cutting off food intake 2-3 hours before bed. A small, healthy snack is fine if they struggle to sleep.
- Avoiding heavy exercise within a few hours before bed (ideally earlier in the day, but after work is fine if schedule doesn’t permit).
- Sleep hygiene practices like blue blocking glasses at night, a cold, pitch-black sleeping environment, cutting off electronics before bed,
This will have the effect of locking in cortisol and melatonin rhythms; meaning the individual will feel more energized in the morning, and will be easier for them to fall asleep at night.
Nutrition
As always, keeping protein high during both perimenopause and postmenopause will be a boon for satiety, energy expenditure, and building/maintaining lean body mass, which will help keep energy expenditure higher.
Given the hormonal changes that predispose to insulin resistance, the postmenopausal woman specifically may benefit from a slightly lower carbohydrate intake at a foundational level. Of course, you still have to take physical activity into account and the postmenopausal marathon runner, bodybuilder, or avid lifestyle weightlifter is going to need a higher carbohydrate intake than someone who has average activity levels or is just lifting 3x per week.
This can also be a case for clustering most of the starchy carbohydrate intake pre and post exercise for more efficient utilization, and can also be a case for time restricted feeding, if used judiciously and intelligently.
I wouldn’t put a postmenopausal woman on a 16/8 or 20/4 IF regimen every day; significant fasting, if overdone, has been shown to decrease blood sugar control in women (but not men) and may have other negative effects, especially if stress is high. Doing a milder time restricted feeding protocol, like a daily 12/12 or 14/10, or doing 2-3 days a week of 16/8 may be helpful.
It may also be worth experimenting with higher intakes of soy containing foods, ideally less processed ones, like edamame, as the phytoestrogens have been shown to help with symptoms and also may help with disease risk.
As always, high intakes of polyphenol and antioxidant-containing vegetables should be continued for their beneficial effects on cardiovascular disease risk and metabolic syndrome risk.
Specifically, we should be paying attention to food sources of magnesium, calcium for bone mineral density, selenium, zinc, all B vitamins, vitamin K2 (discussed in supplements below as well).
Supplementation
Supplementation specific to symptoms:
- DIM can be used in periods of high estrogen in perimenopause to help with estrogen detoxification, allowing more beneficial estrogen metabolites to be formed.
- St. Johns Wort, black cohosh root, red clover, and royal jelly have been shown to decrease symptomaticity.
- Phytoestrogen supplementation has been shown to decrease symptoms in some women postmenopause, while others may not have an effect. The microbiome plays a role here as it is the bacterial metabolites of the phytoestrogens that actually have the effect.
- Glycine supplementation may help with sleep and blood sugar control
It should be noted that the optimal HRT regimen will take care of the peri/postmenopause-related symptoms.
Supplementation for disease risk, health, or body composition:
- Fish oil (1000mg of BOTH EPA and DHA) for metabolic/CVD health
- Vitamin D + K2 for metabolic health, bone density, and cardiovascular health
- DHEA-S for hormonal support, both through perimenopause and postmenopause
- CoQ10 for cardiovascular health
- Blood sugar control supplements: Berberine HCl, ceylon cinnamon, and/or bitter melon extract. Berberine is probably the most efficacious of these three for this application.
- Curcumin may be helpful for decreasing inflammation.
- NAC can help support antioxidant status
- Ashwagandha if excess stress is present or if cortisol is known to be high.
- If someone isn’t consuming enough of these nutrients from food, it may be pertinent to supplement:
- B vitamin complex
- Magnesium
- Zinc
- Selenium
These are all considerations for your client based on what they’re experiencing from a health perspective, these aren’t blanket recommendations nor should your client be taking ALL of these.
Pretty much all clients should at least be taking fish oil, D3, and K2, but everything else is based on your individual client’s needs.
Conclusion
All that said, while it may be harder for postmenopausal clients to achieve impeccable body composition results, it’s certainly not impossible. With all of the recommendations above, you can get your postmenopausal clients great results.
References
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