Lifestyle tips for perimenopause and beyond

Written by Dr Marissa Kelaher, graphics by Dr Taisia Cech

Are you a woman in your late 30s, 40s or 50s, and wondering why life and health suddenly seem so much harder?

It could be your hormones!

Perimenopause and menopause are times of massive changes in a woman’s life, but often are not talked about much (if at all!) - meaning many women may suffer in silence for years before seeking help.

They refer to the transition that occurs when a woman’s ovaries naturally slow down.

This initially causes levels of oestrogen, progesterone (and to a lesser extent testosterone) to fluctuate, before eventually dropping to low levels, when periods and fertility disappear. This process can vary hugely from woman to woman in regards to how long it takes, and what symptoms are experienced - even though it's an entirely natural process!

Most women spend up to 1/3 of their lives in menopause, and interestingly humans are one of the few species that experience menopause (many others die off as soon as they stop being fertile). This has led many experts to believe that women surviving after menopause is essential for human societies to function.

In traditional societies postmenopausal women are treasured as vital members of the community, and play a key role in the survival of our species - research shows that families who had postmenopausal women in them, historically tended to have better nutrition and higher child survival rates than those who didn't!

Yet with modern life, women are often juggling family life, careers, and other responsibilities during the time of perimenopause and menopause, meaning it can be a challenging time.

And many studies show that menopause can have a significant effect on work productivity, absences, and satisfaction, so it's not just a personal issue, but one that also impacts wider society....

But on the flip side, educating and empowering women about menopause can have huge benefits, in both the short term, as well as in future health - so let's get the conversation rolling!

WHAT ARE PERIMENOPAUSE AND MENOPAUSE?

✔️Perimenopause refers to the transitional time when hormone levels start to fluctuate (often significantly) each month, and gradually decline.

Ovulation and menstruation still occur during this time. Periods may get heavier, lighter, or irregular, and other symptoms can also occur due to hormonal changes. Perimenopause is highly variable and can continue for years before menopause occurs.

✔️Menopause is when hormone production from the ovaries has stopped completely - usually defined as the menstrual cycle stopping for 12 months or more (ie no periods for a year).

If a woman doesn't have periods due to medication or a hysterectomy, menopause can be diagnosed by checking FSH and oestradiol levels on a blood test.

Many people think women only get symptoms during menopause, and that these are limited to hot flushes, night sweats, and genitourinary changes (vaginal and bladder symptoms).

Sadly this belief can occasionally still be present in health care providers too, meaning women may feel dismissed or unheard when they seek help.

Yet perimenopause can actually be just as difficult as menopause, and symptoms of both of these can be incredibly varied - including mood changes, anxiety, migraines, palpitations, joint pains, brain fog, poor sleep, weight gain, hair loss, dry skin, and even raised cholesterol and blood sugar.

Which sounds odd, but makes perfect sense when you think that oestrogen receptors are present in almost every cell of a womans body!!!

Perimenopause can also cause significant mood swings, sleep changes, and even new onset anxiety or depression.

These can labelled as stress related, mental illness, or even chronic pain or fatigue if the possibility of hormonal causes aren't considered.

While all of these issues can also be more common in perimenopause for various reasons, for some women their symptoms are primarily related to hormonal fluctuations - so addressing these tends to be far more helpful.

Menopause can also cause a variety of symptoms, ranging from typical hot flushes and night sweats, to less obvious ones such as muscle pain and weakness, palpitations, and even migraines or brain fog.

Menopause also increases the risk of various health issues, such as heart disease, dementia, type 2 diabetes, high blood pressure, osteoporosis, and depression, due to the loss of the protective effect of oestrogen.

So taking steps to prevent these health issues as much as possible via lifestyle is also an important part of any menopausal health plan!

Interestingly some oestrogen is still produced by a woman’s fat cells after the ovaries have stopped producing it (which may be part of why weight gain often occurs during menopause - ie women need some fat to protect the body - some additional around the thighs and buttocks is normal and healthy).

Excess weight gain (especially around the tummy, this is also known as 'visceral fat') may worsen metabolic health however and increase the risk of heart disease and diabetes - so like everything its about balance!

Fortunately, there are many ways to help women thrive through menopause and beyond.

DIET

This is key, both to help current symptoms, and to reduce the risk of future health issues. An anti-inflammatory whole food plant rich diet is widely recommended.

It provides all the essential nutrients needed for health; protects the heart, brain and bones; reduces inflammation (which can increase with menopause); optimises immune health and metabolism; and boosts our gut microbiome (gut health)

An anti-inflammatory diet generally involves :

✔️Swapping refined carbohydrates ('white' foods) for whole grains (think 'right carbs', not 'low carbs')

✔️Avoiding ultraprocessed (junk) foods, and limiting added sugar as much as possible

✔️Swapping saturated (animal) fat such as fatty meat and full fat dairy for unprocessed or minimally processed unsaturated (plant) fats such as seeds, nuts, avocado, and olive oil

✔️Limiting fat to 30% of your calorie intake (there is evidence from some studies that lower fat diets improve hot flushes and night sweats)

✔️Aiming to eat legumes, seeds and nuts daily (these contain fibre for gut health and phytoestrogens for hormone health, and may even help protect the ovaries)

✔️Including 5+ servings of colourful veges/day (with most of these being above ground non starchy veges, and 2+ servings of fruit - 'eat a rainbow'

✔️Include leafy greens in your diet daily, these contain powerful anti-inflammatory compounds; may reduce hot flushes; are high in calcium and Vit K for bone health; contain B vitamins and magnesium for sleep and mood; and also help protect the heart and brain

✔️Eat cruciferous veges regularly, such as brocolli, kale, cauliflower, brussel sprouts and cabbage.

Cruciferous veges are rich in fibre, and contain compounds such as glucosinolates, sulforaphanes, DIM, indole-3-carbinol and isothiocyanates, which help promote liver and hormone health (by promoting detoxification pathways and gut metabolism of oestrogen), as well as reducing inflammation and protecting against cancer such as breast cancer (brocolli in particular promotes oestrogens that help reduce breast cancer risk).

They are also rich in calcium and vit K, may improve blood sugar levels, and are powerful antioxidants.

✔️Having adequate omega 3, which is essential for brain, heart, and immune health, and can be found in oily fish, flaxseed, walnuts, chia seeds and hemp hearts - try to include plant sources daily, and fish 2-3 days/week if you choose to eat this.

We cover anti-inflammatory diets in depth in our Reboot and Nutrition courses if you'd like to learn more about these.

Other nutrition tips include :

✔️Eat healthy protein at each meal to help balance blood sugars, and optimise muscle and bone health, aiming for 1/4 of each meal to be protein-rich foods

This should ideally be mostly plant-based protein (legumes, whole grains, nuts and seeds) as this helps improve overall health and longevity.

A woman’s protein needs increase during perimenopause and menopause to around 1g/kg/day, and this increases further after age 65 to 1.2g/kg/day to help prevent age-related muscle loss

You can also include animal-based protein sources 2-3 days/week if desired, including fish, chicken and eggs; red meat should be limited to a maximum of 300g/week in line with general health recommendations

✔️Ensure you are getting micronutrients such as B12, iron, folate and iodine in your diet (B12, folate and iron are important for energy and mental health, and iodine plays a key role in thyroid and hormone health)

You can get b12, iron, folate and iron levels checked on a blood test through your GP if you're unsure if you're getting enough, iodine testing is not routinely done

Gut health is also thought to play a key role in hormonal (and general!) health, as it impacts metabolic health, brain health, heart mood, inflammation, and hormonal health, as well as potentially cancer risk (among other things).

Central to gut health is FIBRE, as this is what feeds our ‘good ‘ gut bacteria.

Increased fibre intake has been shown to decrease post-menopausal symptoms, including hot flashes and mood disturbances.

This is partly due to the beneficial compounds (postbiotics) produced by our gut bacteria when they feed on this fibre.

These postbiotics make their way into our bloodstream, and can even cross over into the brain, where they can help mood and sleep.

This is similar to why a healthy gut microbiome also helps with depression and anxiety (see our article on food and mood here)

It‘s also believed that complex interactions between our hormones and gut micro-organisms could explain the benefits of a high fibre diet. New studies are coming out on this all the time, it's an exciting rapidly evolving area of research!

Aim to feed your gut bugs with a diversity of fibre (aim for 30 different plant foods per week, and at least 30g fibre /day) as well as probiotic (fermented foods), to keep your gut bugs and tummy happy. For more details check out our blog post here.

Fortunately, this is also exactly what's recommended for an anti-inflammatory diet so you get the best of both worlds 😊😍

If you'd like to take a deep dive into gut health, or find out how to eat a balanced plant focused diet, please check out our Reboot or Nutrition courses!

Phytoestrogens are worth a mention, these are plant compounds that have oestrogen-mimicking properties, and have beneficial effects on hormonal health. They're found in high levels in soy, flaxseed, sesame seeds, legumes (especially chickpeas), whole grains, peanuts, berries, barley, and tea.

Phytoestrogens are an estrogen-like molecule, called an SERM (selective estrogen receptor modulators). They are pretty amazing compounds, as they have the ability to be pro-estrogenic effects on tissues that need it (ie helping with symptoms of low estrogen such as in menopause), and anti-estrogenic effects on tissues that don’t (protecting from the negative effects of ‘estrogen dominance’ such as fibroids, breast cancer, and endometrial cancer) .

Studies have shown that populations with the highest soy consumption for example, have the lowest rates of estrogen-dependent cancers such as breast and endometrial cancers.

Some research also indicates that phytoestrogens can help improve menopause symptoms (especially hot flushes, cognitive changes, and poor sleep), improve bone health, and reduce the risk of heart disease.

Soy intake in particular is associated with a lower risk of breast cancer, as well as a lower risk of recurrence in breast cancer patients. There is also evidence it can significantly reduce hot flushes.

High soy intake does NOT increase breast cancer risk (contrary to popular belief), so it's a great hormone healthy food to include in your diet. Aim for whole or minimally processed soy products ideally, such as Edamame beans, tofu, tempeh, soy milk.

Calcium is important for bone health, as women need the highest levels in their life (1200mg/day) after menopause. Dairy alone is not particularly protective for bones (contrary to popular belief!) for various reasons, so it’s best to get calcium from a variety of sources as well as dairy, such as tofu, green leafy veggies, seeds, and legumes.

Vitamin K is also needed for bone health, and dark green leafy veggies are rich in this (they also help brain and heart health and reduce inflammation!).

And lastly vit D is crucial for bone health (among others), this is from sunlight, so taking a supplement if you cannot maintain levels with sun exposure is recommended (especially over winter). Levels can be checked on a blood test, but a cost usually applies.

Time-restricted eating is gaining increasing attention for its role in helping weight loss, blood pressure, cholesterol and blood sugar. Extended fasts are still controversial for women, however, aiming to eat your meals within a 10-12 hour window (circadian eating) can be helpful for many women. It's not generally recommended if you suffer from malnutrition, or have a history of eating disorders.

So in summary - aim to eat a variety of colours, whole grains, quality protein at every meal, unsaturated fats, whole plant-based foods, items rich in calcium and optimise your gut health. Your body will thank you for it!!

ALCOHOL, CAFFEINE AND SMOKING :

Alcohol is not always a popular topic, but it’s particularly important during perimenopause and menopause, as it increases the risk of many cancers (especially breast cancer), and can negatively impact heart and brain health as well as sleep and mood. It can also worsen osteoporosis, and is a common hidden cause of weight gain! Advice is to drink as little as possible, and if you do choose to drink, limit to no more than 10 units per week.

Caffeine in itself is fine, but it may worsen hot flushes and poor sleep, so it can be worth considering cutting it out or switching to decaffeinated coffee if you have these symptoms.

Smoking should be avoided completely if possible, as it tends to worsen menopause symptoms (especially hot flushes), as well as increasing the risk of heart disease, dementia, and osteoporosis.

If you do smoke, quitting (or cutting down as much as possible if quitting is not an option) it's strongly recommended, and menopause is a great reason to do so! If you struggle with this there are lots of great options to help you quit - talk to your doctor or a quit smoking provider for more details.

We cover alcohol, smoking, and caffeine in more detail in our Reboot course.

Exercise

Exercise is important during perimenopause and menopause, to help keep muscles and bones strong, as well as boosting mood, heart health, brain health, and immunity, as well as reducing the risk of menopause related health issues.

It’s also proven to improve overall quality of life during menopause due to a variety of reasons.

Oestrogen stimulates bone and muscle growth, and the drop in levels of this means bones and muscles can get weaker quickly if steps aren't actively taken to prevent it

Strength training helps to build muscle mass as the exercise that moves muscle against resistance, stimulating the muscle to grow stronger.

This includes bodyweight exercises (ie pushups, squats, situps etc as well as weights). It’s particularly vital in perimenopause and beyond, as women progressively lose muscle mass from age 40, and can lose up to 10% of muscle mass in the perimenopausal transition!

Preserving muscle is key for immune health, metabolic health, and bone health, as the process of muscle loss (sarcopenia, which also occurs in men) is linked with poorer long-term health in many areas as well as reduced life expectancy.

Aim to do strength training working all muscle groups 3-4 days/week, alongside cardio, flexibility, and balance exercises.

You don't need to bulk up or join a gym either - just aim to work all muscles in your body again resistance, and do it regularly! Using body weight or small hand weights is great, and there are loads of short easy workouts online - one of my favourites is the seven-minute workout.

Bone health is another important topic during perimenopause and menopause, as women can lose up to 20% of bone mass during the time between perimenopause and menopause, and this process continues at a slower rate after menopause.

Weight-bearing exercise is the best way to protect bones (alongside adequate nutrition, limiting alcohol, and not smoking), as the gravitational forces stimulate bone to grow and get stronger, as well as improving blood flow to bone and muscle. This includes brisk walking, running, jumping, skipping, dancing, and high intensity sports.

Aim to do this most days of the week, for at least 30min/day if possible.

The drop in oestrogen during menopause means women also become more insulin resistant (the risk of diabetes gets higher, as oestrogen in increases insulin sensitivity).

Strength training is particularly helpful to counteract this (alongside cardio), as muscle burns glucose at rest - so building strength is great to regulate blood sugar levels.

Building muscle is also helpful to increase metabolism, and counteract the weight gain that is so common from perimenopause onwards!

We take a detailed look at physical movement and how it affects our health, as well as how to make sure you're doing the right exercise - plus online resistance training, balance, and flexibility workouts to help you get moving - in our Reboot and Boost your Activity courses!

Sleep and Stress management

And lastly, sleep and stress management play a vital role in feeling better, as hot flushes are worsened with higher stress levels, and sleep deprivation tends to aggravate most menopausal symptoms (as well as increasing the risk of future health issues).

Ironically though these are also things that tend to get worse during menopause, as oestrogen and progesterone affect the brain, improving mood, reducing stress, and helping sleep - so when levels drop it can become a vicious cycle!

SLEEP

Many people think night sweats are the only symptom that affects sleep, but in reality, sleep disturbance can occur well before night sweats start, due to the effect of fluctuating hormone levels on the brain and circadian cycle.

Cortisol (stress hormone) levels often rise during the perimenopause transition due to a drop in oestrogen (see below), causing disrupted sleep, 3am waking, and feeling 'tired but wired'. Plus night sweats are extremely common as perimenopause progresses, also due to lower oestrogen levels.

Progesterone also acts as a natural sedative, helping sleep - so as levels of this drop too it adds to the problem!

Yet ensuring you get adequate sleep (7-8 hours a night) is super important, as sleep deprivation worsens blood sugar levels, mood swings, brain fog, stress levels, and weight gain, and can also increase the risk of heart disease, diabetes, and dementia 😳

Some tips for sleep include:

✔️Make sure your bedroom is well-ventilated, consider investing in a fan if you feel too hot

✔️Wear light natural clothing e.g. cotton pyjamas to bed, and use natural fabrics for bedding as these help reduce body temperature fluctuations .

✔️Switch off electronic devices at least one hour before bed and ideally leave your phone out of the bedroom

✔️Aim to get up at approximately the same time each day, as this sets your 'sleep clock' (the time you feel sleepy) at night

✔️Get outside in the morning daylight (whatever the weather) for at least 20 minutes to help set your body clock, if this isn't possible, try to have your breakfast/morning drink close to a window/in a naturally lit area, or use a bright light device.

✔️Avoid alcohol and food within 3-4 hours of bedtime, and caffeine after midday

✔️Some women find magnesium or melatonin helpful for sleep, although evidence for these limited - melatonin is prescription only in New Zealand, so talk to your doctor if you'd like to consider this

Learn about how sleep works, it's effects on health, and how to improve it in depth in our Reboot and Restore your Sleep courses. Or for some simple tips check out our blog post here

STRESS

Stress can be a particularly tricky topic in perimenopause, as oestrogen helps to regulate cortisol (stress hormone) production, meaning the drop in oestrogen can end up in women operating in a 'higher cortisol' state, where the nervous system is activated.

Progesterone also has a calming effect on the nervous system, so a lack of this adds to stress and anxiety levels.

This can lead to feelings of irritability, being 'on edge' and anxious, and having a shorter fuse than normal, which can come out of the blue for some women! It can even worsen symptoms of inflammation, as well as palpitations, pain, and hot flushes.

Add to this poor sleep, hot flushes, night sweats, and the general pressures of daily life, and women can end up feeling like they're going mad 😬

Recognising what is happening, taking steps to reduce stressors where possible, building stress resilience, and being kind to yourself are all strategies that can help significantly!

Some of our top tips are:

✔️Identify triggers and situations that cause stress, and minimise these wherever possible

This may mean saying 'no' more often, cutting back on work responsibilities if this is an option, delegating more and sharing the load, and getting rid of unnecessary commitments (as well as not trying to do too much!)

Even practical things like meal delivery boxes and hiring a cleaner (if this is financially an option), or sharing transport/after-school care of your children with other parents can make a big difference. Getting your spouse on board to share the load is also a great idea if possible (feel free to share this blog post with them if they need an explanation why 😉)

✔️Try to eat to keep blood sugar levels and energy balanced and even, aiming for regular wholegrain carbs/lower sugar meals, adequate protein, and lots of fibre (as covered earlier in this post). These all help to reduce the effects of stress on the body and mind, as blood sugar ‘spikes and crashes’ from high sugar/refined carb/low protein meals will often worsen food cravings and fatigue. It's extremely common to crave sugar and ‘white’carbs when stressed or tired, as this is the bodies way of trying to get a quick energy fix, yet it actually tends to make symptoms worse overall - understanding why cravings are occurring can be helpful (rather than wondering what is going on!).

✔️Aim to prioritise sleep and exercise in your day over other commitments, as these both help improve stress resilience (ability to cope with stress)

✔️Practices such as controlled slow breathing (such as box breathing), meditation, yoga, and exercises can all also help to 'turn down' the stress response and improve sleep and menopause symptoms. Even 5-10min a day can help!

✔️And be kind to yourself and allow yourself at least 30 minutes a day to do something just for you e.g. reading a novel, or listening to your favourite music/podcast.

Recognise your body and mind are going through a large period of change, that although natural, may require you to slow things down and listen to your body more. This can often have a silver lining, as you become more aware of looking after yourself and investing in your health - which pays off massively in the long term!

We take a deep dive into how stress works, how the mind and body are connected, and practical evidence based ways to reduce stress (and improve your ability to manage it) in our Reboot and Take control of your Stress courses.

And if you're still really struggling despite lifestyle changes, or your symptoms are so severe you find it too hard to try lifestyle strategies first, consider talking to your doctor about whether HRT is an option for you.

The new body identical forms of HRT (oestrogen patches and utrogestran) are extremely safe and effective and can make a huge difference to the quality of life and health.

We prescribe them regularly alongside lifestyle strategies, and like many other medicines, can be a useful tool to have in your toolbox - lifestyle and medication can go hand in hand if needed!

The key to a healthy menopause is identifying what's happening in your body, understanding why and how changes are occurring, and feeling empowered to be able to do something about them ❤️

The Japanese word for menopause is konenki, which means renewal years or energy - we love this phrase, as it changes our perception of menopause from a time of loss or negativity, to a time of new beginnings!!!

And if you'd like more help with perimenopause or menopause, and want a comprehensive look at your health, with a structured approach to creating better health both now and in future, we also offer 1:1 consults New Zealand-wide.

In these, we look at your health history, current health issues, and goals for well-being, and create a personalised evidence-based wellbeing plan that centres around what is important to YOU.

We are both highly experienced in menopause management from both a lifestyle and medical perspective, and would love to help you feel your best self!

Details on our booking page here

Or if you'd like to take a deeper dive into any of the areas we've talked about on this post, we have courses in whole food nutrition, stress reduction, restorative sleep, and exercise in our focus modules.

Plus we also run a comprehensive Reboot course, covering these topics and more, as well as the resources you need to get started, more details here!

If you've enjoyed this post, please share it with others who might find it helpful, and follow us on social media for lots more tips and articles, we'd love to help you on your journey to better well-being ❤️

REFERENCES :

Safabakhsh M, Siassi F, Koohdani F, Qorbani M, Khosravi S, Abshirini M, Aslani Z, Khajehnasiri F, Sotoudeh G. Higher intakes of fruits and vegetables are related to fewer menopausal symptoms: a cross-sectional study. Menopause. 2020 May;27(5):593-604. doi: 10.1097/GME.0000000000001511. PMID: 32068682.

Shifren JL, Gass ML, NAMS Recommendations for Clinical Care of Midlife Women Working Group. The North American Menopause Society recommendations for clinical care of midlife women. Menopause. 2014;21(10):1038-62. [PMID:25225714]

Bolland MJ, Leung W, Tai V, et al. Calcium intake and risk of fracture: systematic review. BMJ . 2015;351-365.

Tai V, Leung W, Grey A, Reid IR, Bolland MJ. Calcium intake and bone mineral density: systematic review and meta-analysis. BMJ . 2015;351-365.

Pludowski P, Holick MF, Pilz S, et al. Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality-a review of recent evidence. Autoimmun Rev. 2013;12(10):976-89. [PMID:23542507]

Kim JK, Park SU. Current potential health benefits of sulforaphane. EXCLI J. 2016. 15:5. 571-577.

Ruan, X., Seeger, H., Wallwiener, D. et al.. The ratio of the estradiol metabolites 2-hydroxyestrone (2-OHE1) and 16α-hydroxyestrone (16-OHE1) may predict breast cancer risk in postmenopausal but not in premenopausal women: two case–control studies. Arch Gynecol Obstet. 2015. 291. 1141-1146.

Bahadoran Z, Tohidi M, Nazeri P, Mehran M, Azizi F, Mirmiran P.. Effect of broccoli sprouts on insulin resistance in type 2 diabetic patients: a randomized double-blind clinical trial.. Int J Food Sci Nutr. 2012. 63(7). 767-771.

Axelsson AS, Tubbs E, Mecham B, Chacko S, Nenonen HA, Tang Y, Fahey JW, Derry JM, Wollheim CB, Wierup N, Haymond MW, Friend SH, Mulder H, Rosengren AH. Sulforaphane reduces hepatic glucose production and improves glucose control in patients with type 2 diabetes. Science: Translational Medicine. 2017. 9.

Connolly EL, Sim M, Travica N, Marx W, Beasy G, Lynch GS, Bondonno CP, Lewis JR, Hodgson JM and Blekkenhorst LC (2021). Glucosinolates From Cruciferous Vegetables and Their Potential Role in Chronic Disease: Investigating the Preclinical and Clinical Evidence. Front. Pharmacol. 2021. 12. 767975.

Tortorella SM, Royce SG, Licciardi PV, Karagiannis TC. Dietary Sulforaphane in Cancer Chemoprevention: The Role of Epigenetic Regulation and HDAC Inhibition. Antioxid Redox Signal.. 2015. 22(16). 1382-1424.

Palliyaguru DL, Yang L, Chartoumpekis DV, et al. Sulforaphane Diminishes the Formation of Mammary Tumors in Rats Exposed to 17β-Estradiol. Nutrients. 2020. 12(8). 2282.

Mayra ST, Johnston CS, Sweazea KL. High-nitrate salad increased plasma nitrates/nitrites and brachial artery flow-mediated dilation in postmenopausal women: A pilot study. Nutr Res. 2019 May;65:99-104. doi: 10.1016/j.nutres.2019.02.001. Epub 2019 Feb 22. PMID: 30954341.

https://aacrjournals.org/cebp/article/9/8/773/179852/Brassica-Vegetable-Consumption-Shifts-Estrogen

Liu ZM, Ho SC, Xie YJ, et al. Whole plant foods intake is associated with fewer menopausal symptoms in Chinese postmenopausal women with prehypertension or untreated hypertension. Menopause. 2015;22(5):496-504. [PMID:25387345]

Beezhold B, Radnitz C, McGrath RE, et al. Vegans report less bothersome vasomotor and physical menopausal symptoms than omnivores. Maturitas. 2018;112:12-17. [PMID:29704911]

Kroenke CH, Caan BJ, Stefanick ML, et al. Effects of a dietary intervention and weight change on vasomotor symptoms in the Women's Health Initiative. Menopause. 2012;19(9):980-8. [PMID:22781782]

Yim G, Ahn Y, Chang Y, et al. Prevalence and severity of menopause symptoms and associated factors across menopause status in Korean women. Menopause. 2015;22(10):1108-16. [PMID:25783469]

Murkies AL, Lombard C, Strauss BJ, et al. Dietary flour supplementation decreases post-menopausal hot flushes: effect of soy and wheat. Maturitas. 2008;61(1-2):27-33. [PMID:19434877]

Lewis JE, Nickell LA, Thompson LU, et al. A randomized controlled trial of the effect of dietary soy and flaxseed muffins on quality of life and hot flashes during menopause. Menopause. 2006;13(4):631-42. [PMID:16837885]

Lethaby A, Marjoribanks J, Kronenberg F, et al. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database Syst Rev. 2013. [PMID:24323914]

Franco OH, Chowdhury R, Troup J, et al. Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis. JAMA. 2016;315(23):2554-63. [PMID:27327802]

Chen MN, Lin CC, Liu CF. Efficacy of phytoestrogens for menopausal symptoms: a meta-analysis and systematic review. Climacteric. 2015;18(2):260-9. [PMID:25263312]

Barnard ND, Kahleova H, Holtz DN, Del Aguila F, Neola M, Crosby LM, Holubkov R. The Women's Study for the Alleviation of Vasomotor Symptoms (WAVS): a randomized, controlled trial of a plant-based diet and whole soybeans for postmenopausal women. Menopause. 2021 Jul 12. doi: 10.1097/GME.0000000000001812. Epub ahead of print. PMID: 34260478.

Messina M. Soy foods, isoflavones, and the health of postmenopausal women. Am J Clin Nutr. 2014 Jul;100 Suppl 1:423S-30S. doi: 10.3945/ajcn.113.071464. Epub 2014 Jun 4. PMID: 24898224.

Jull J, Stacey D, Beach S, Dumas A, Strychar I, Ufholz LA, Prince S, Abdulnour J, Prud’homme D. Lifestyle interventions targeting body weight changes during the menopause transition: a systematic review. J Obes. 2014; 824310.

Kapoor E, Collazo-Clavell ML, Faubion SS. Weight Gain in Women at Midlife: A Concise Review of the Pathophysiology and Strategies for Management. Mayo Clin Proc. 2017 Oct;92(10):1552-1558.

Lonnie M, Hooker E, Brunstrom JM, Corfe BM, Green MA, Watson AW, Williams EA, Stevenson EJ, Penson S, Johnstone AM. Protein for Life: Review of Optimal Protein Intake, Sustainable Dietary Sources and the Effect on Appetite in Ageing Adults. Nutrients. 2018 Mar 16;10(3):360. doi: 10.3390/nu10030360..

Simpson SJ, Raubenheimer D, Black KI, Conigrave AD. Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage. BJOG. 2023 Jan;130(1):4-10.

Nie, X., Xie, R. & Tuo, B. (2018). Effects of Estrogen on the Gastrointestinal Tract. Dig Dis Sci 63, 583–596.

Siddiqui, R.; Makhlouf, Z.; Alharbi, A.M.; Alfahemi, H.; Khan, N.A. The Gut Microbiome and Female Health. Biology 2022, 11, 1683. https://doi.org/10.3390/biology11111683

Veira, A., Castelo, P. et al, (2017). Influence of oral and gut microbiota in the health of menopausal women. Front. Microbiol. 8: 1884

Baylis, D., Bartlett, D.B., Patel, H.P. et al. (2013). Understanding how we age: insights into inflammaging. Longev Healthspan 2, 8. https://doi.org/10.1186/2046-2395-2-8

Ferrucci L. & Fabbri, E. (2018). Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol. 15(9):505-522. doi: 10.1038/s41569-018-0064-2. PMID: 30065258; PMCID: PMC6146930.

Franceschi, C. et al. (2018) Inflammaging: a new immune-metabolic viewpoint for age-related diseases. Nat. Rev Endocrinology, 14(10):576-590.

McCarthy M, Raval AP. The peri-menopause in a woman’s life: a systemic inflammatory phase that enables later neurodegenerative disease. J Neuroinflammation. 2020 Oct 23;17(1):317.

Neves J., & Sousa-Victor, P. (2020). Regulation of inflammation as an anti-aging intervention. FEBS J. 287(1):43-52. doi: 10.1111/febs.15061 31529582.

McCarthy, M., Raval, A.P. The peri-menopause in a woman’s life: a systemic inflammatory phase that enables later neurodegenerative disease. J Neuroinflammation 17, 317 (2020). https://doi.org/10.1186/s12974-020-01998-9

Aslani Z, Abshirini M, Heidari-Beni M, Siassi F, Qorbani M, Shivappa N, Hébert JR, Soleymani M, Sotoudeh G. Dietary inflammatory index and dietary energy density are associated with menopausal symptoms in postmenopausal women: a cross-sectional study. Menopause. 2020 May;27(5):568-578. doi: 10.1097/GME.0000000000001502. PMID: 32068687.

Davis, S., Castelo-Branco, C. et.al. (2012). Understanding weight gain at menopause. Climacteric, 15: 419–429.

Reinke H. & Asher G. (2017). Circadian clock control of liver metabolic functions. Gastroenterology, 150: 574–580.

North American Menopause Society (12th Oct. 2022). Hot flashes are not just uncomfortable but also could be hard on the heart

Kodoth V, Scaccia S, Aggarwal B. Adverse Changes in Body Composition During the Menopausal Transition and Relation to Cardiovascular Risk: A Contemporary Review. Womens Health Rep (New Rochelle). 2022 Jun 13;3(1):573-581.

Biglia N, Cagnacci A, Gambacciani M, et al. Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases? Climacteric. 2017;20(4):306-312. [PMID:28453310]

Franco OH, Muka T, Colpani V, et al. Vasomotor symptoms in women and cardiovascular risk markers: Systematic review and meta-analysis. Maturitas. 2015;81(3):353-61. [PMID:26022385]

Lee, E., Anselmo, M, Tahsin, T. et al. Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease. 2022, Am. J. of Physiology

Stachowiak G, Pertyński T, Pertyńska-Marczewska M. Metabolic disorders in menopause. Prz Menopauzalny. 2015 Mar;14(1):59-64. doi: 10.5114/pm.2015.50000. Epub 2015 Mar 25.

Daley A, Stokes-Lampard H, Thomas A, et al. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev. 2014. [PMID:25431132]

Daley A, Macarthur C, Stokes-Lampard H, et al. Exercise participation, body mass index, and health-related quality of life in women of menopausal age. Br J Gen Pract. 2007;57(535):130-5. [PMID:17266830]

Ayers B, Smith M, Hellier J, et al. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012;19(7):749-59. [PMID:22336748]

Daley A, Stokes-Lampard H, Macarthur C. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev 2011 5:CD006108.

Carpenter JS, Burns DS, Wu J, Otte JL, Schneider B, Ryker K, Tallman E, Yu M. Paced respiration for vasomotor and other menopausal symptoms: a randomised controlled trial. J Gen Intern Med 2013 28:193–200.

Woods, N. et al. (2009). Cortisol Levels during the Menopausal Transition and Early Postmenopause: Observations from the Seattle Midlife Women’s Health Study. Menopause, 16(4): 708–718

Saensak S, Vutyavanich T, Somboonporn W, et al. Relaxation for perimenopausal and postmenopausal symptoms. Cochrane Database Syst Rev. 2014. [PMID:25039019]