Navigating menopause with smart nutrition

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Every woman going through the perimenopause and menopause will experience fluctuations in the production of female hormones, while the relationship between diet and hormonal status is a two-way street. Hormones can influence dietary intake and what a woman chooses to eat can influence her hormones.

Sex hormones have an influence on appetite, energy metabolism and eating behaviour. Women may notice that their appetite changes during perimenopause and menopause, and weight gain affects at least 50 per cent of women.

Progesterone and testosterone can stimulate appetite, whereas oestrogen reduces food intake. When hormone levels decrease, the appetite suppression role of oestrogen can diminish. Some women find their appetite increases as their oestrogen levels drop. 

Gut microbes regulate oestrogens via secretion of beta-glucuronidase, an enzyme that deconjugates oestrogens into their active forms. When this process is impaired because of gut microbiota dysbiosis (i.e. lower microbial diversity), the decrease in deconjugation results in a reduction of circulating oestrogens.

What a woman chooses to eat can influence her nutritional status and oestrogen levels during this time of change and this, in turn, can influence the symptoms she experiences.

Protein-rich foods such as meat, fish, seafood, eggs and dairy products increase satiety, which may help to avoid overeating. Additionally, diet influences the microbes living in the gastrointestinal tract. A diet containing a varied mixture of foods, including lots of vegetables, fruits and other plants, such as nuts, pulses and beans, influences the quantity and variety of microbes in the gut.

It is therefore important to maintain a varied diet to navigate menopause with a broad range of whole foods from different food groups. 

Menorrhagia and iron deficiency

Menorrhagia can be a severe problem for some women. It increases with age and peaks during the perimenopause. The condition is defined as blood loss of more than 80ml and/or a duration of more than seven days, but is difficult to categorise as blood loss is rarely measured in clinical settings. It can be subjective and what one woman considers heavy bleeding may be considered normal by someone else.

A more practical definition from NICE describes it as “excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life, and can occur alone or … with other symptoms.”

When blood loss has been measured in research settings, it has been found that women may lose up to 800ml of blood or more per month.

Iron deficiency anaemia affects 12 per cent of premenopausal women in the UK and can be caused by heavy blood loss. Symptoms include tiredness and lack of energy, shortness of breath, heart palpitations, headaches and an impaired ability to regulate body temperature. Iron supplements may be recommended.

The richest and most bioavailable dietary source of iron is red meat such as beef and lamb, and offal such as liver or kidney. Other foods containing iron include seafood, fish, meats such as pork and poultry, dark green leafy vegetables, pulses, and dried fruit such as prunes, apricots and raisins.

As well as restoring iron levels, other nutrients may also need to be replenished in women experiencing frequent and heavy blood loss. Therefore a woman with iron deficiency anaemia should be encouraged to eat a range of whole, nutrient-dense foods to improve their overall nutritional status.        

A potential cause of heavy menstrual bleeding is uterine fibroids, common in perimenopausal women – 70 per cent of white women and 80 per cent of black women are affected by 50 years of age.

Observational studies have shown lower fibroid prevalence in women with higher vitamin D levels, and some intervention studies have shown reduced fibroid growth when participants are treated with vitamin D. Studies have been small so far and further research is needed.

Bone and muscle health

Bone density peaks in women at about age 30 and then there is a slow decline. This decline accelerates after menopause and the prevalence of osteoporosis increases from 2 per cent in women at 50 years of age to almost 50 per cent of postmenopausal women at 80 years of age.

Diet and exercise influence bone and muscle health. Examples of micronutrients needed to support bone mineral density include vitamin D, calcium, vitamin K2 and magnesium (see Table 1).

Adequate protein intake is also essential for preserving bone and muscle mass during ageing.

Vitamin D

Despite its name, vitamin D is not actually a vitamin – it is a hormone. Humans can synthesise vitamin D from the action of sunlight (UVB) on the skin. It is increasingly acknowledged that people have different vitamin D requirements. Just as thyroid hormone or insulin doses need to be titrated for the individual, the vitamin D dose may have to be tailored. In other words, there is no ‘one size fits all’ recommended dose that is guaranteed to result in optimal levels.

A range of factors influence vitamin D status. The risk of deficiency increases with age as the skin’s ability to synthesise it from the sun reduces during the ageing process. Other risk factors include limited sun exposure and darker skin tones, which reduce the skin’s ability to produce vitamin D from sunlight.

In obesity, more vitamin D is stored in greater amounts of subcutaneous fat, resulting in lower serum levels. This means that menopausal weight gain may reduce the body’s ability to access and use vitamin D. Furthermore, local environmental factors influence access to UVB sunlight, including latitude and regular cloudy or rainy weather.

The further north a person lives, the more likely they are to experience low vitamin D levels. In the UK, the sun is not sufficiently high in the sky between October and March to synthesise vitamin D from sunlight. Supplements are often needed to optimise vitamin D levels in winter.

The minimum dose to maintain normal vitamin D levels is 400iu, but the required dose to correct a deficiency will likely need to be much higher to restore levels to the optimal range (i.e. serum 25(OH)D greater than 75nmol/L (or 30ng/ml). Local prescribing guidelines will give an indication of dose to correct a deficiency; the daily dose may need to be 4000iu or more.

When vitamin D deficiency has been corrected, an individual’s supplement dose may need to be titrated to maintain optimal levels. Studies have shown that daily dosing is better than weekly dosing.

Vitamin D is found in a limited selection of foods. Vitamin D3 – the most bioavailable form – is found in fish (especially oily fish), seafood, meat, offal, eggs and dairy products. There are small amounts of vitamin D2 in mushrooms.

Calcium

Absorption of calcium is optimal when vitamin D levels are in the ideal range, so any vitamin D deficiency should be corrected. In recent years, some studies have shown that calcium supplements can increase the risk of cardiovascular disease, including heart attacks and stroke.

It is recommended that, ideally, calcium should come from dietary sources, such as milk and dairy products or green leafy vegetables. Calcium supplements may need to be considered if it is not possible to obtain sufficient calcium from the diet.

Vitamin K2

Vitamin K is the name given to a series of compounds that are naturally present in some foods. Phylloquinone, also known as vitamin K1, is predominantly found in green leafy vegetables, while compounds called the menaquinones are known as vitamin K2.

Vitamin K is involved in bone mineralisation and turnover. Vitamin K2 is associated with the inhibition of arterial calcification and arterial stiffening, and adequate intake reduces the risk of vascular damage. Put simply, the role of vitamin K2 is to place calcium in bone and not in soft tissue such as arteries.

The menaquinones predominantly come from bacteria and can be found in a range of animal-based and fermented foods such as meat (e.g. chicken, beef, liver), eggs, fish, seafood and fermented dairy products such as cheese.