Today, it is estimated that more than 40 million American women are in the life-changing phase known as perimenopause. All of these women are likely to experience some symptoms associated with this shift (Saunders 2002).
Perimenopause—from the Greek words peri (“near”), men (“month”) and pauein (“to cease”)—describes the natural hormonal transition that occurs during the years leading up to menopause and ending 12 months after a woman’s final period (Mayo Clinic 2008). Many women notice the first signs of change in their 40s, but others experience symptoms as early as their mid-30s (Mayo Clinic 2008). In the United States, the average age of menopause is 51 (Mayo Clinic 2009).
During perimenopause, progesterone levels normally undergo a gradual decline while estrogen levels fluctuate. These hormones primarily control and regulate the menstrual cycles and help keep a woman’s mind, mood and heartbeat normal. During peak reproductive years, the amount of estrogen in circulation rises and falls fairly predictably throughout the menstrual cycle. However, the estrogen “roller coaster” that is set in motion during perimenopause can easily disrupt the normal feedback between the pituitary gland and the hypothalamus, which helps regulate the menstrual cycle and estrogen production. The hypothalamus plays a crucial role in regulating blood pressure, body temperature, sleep and appetite. This interaction encourages a condition referred to as estrogen dominance, meaning there is too much estrogen relative to progesterone (Northrup 2006). This condition is extremely typical of perimenopause and can produce a variety of new changes.
Over the course of the transitional years, progesterone production severely slows down or stops, resulting in a lack of regular ovulation, even though the menstrual cycle driven by estrogen still continues. This ever-changing journey is unique to each individual. Unfortunately, the body can go a “bit berserk” as it attempts to make a multitude of adjustments to balance its own hormones and natural healing abilities. The physical changes of perimenopause are rooted in these hormonal alterations, particularly the variations in levels of circulating estrogen.
Estrogen levels are largely controlled by two hormones, known as follicle-stimulating hormone (FSH), a small protein produced in the brain to spur follicle growth and communicate ovualtion, and luteinizing hormone (LH), produced by the pituitary gland to help regulate the menstrual cycle and egg production (ovulation).
During each cycle, FSH stimulates the growth of a number of ovarian follicles, which contain eggs. As follicles grow, estrogen levels increase. When estrogen reaches a certain level, the brain signals the pituitary to turn off the follicle hormone and produce a surge of LH. This stimulates the ovary to release an egg from its follicle (ovulation). The leftover follicle cells produce progesterone, in addition to estrogen, for pregnancy preparation.
As these hormone levels rise, FSH and LH levels drop. If pregnancy does not occur, the progesterone level falls, menstruation takes place and the cycle begins again. As a woman nears perimenopause, the number of follicles recruited in each cycle diminishes. When follicles mature, they secrete significant amounts of estradiol. This increase in serum estradiol levels causes a decrease in FSH production in the hypothalamus.
The conventional medical mindset is that estrogen deficiency results from ovarian failure. While estrogen levels certainly decrease during perimenopause, they do not fall appreciably until after a woman’s final period. During the transition, women are more likely to suffer from the effects of estrogen dominance than from those of estrogen deficiency.
In most cases, symptoms of estrogen dominance last for 10–15 years, usually beginning around age 35. It is extremely important for women to listen to their bodies, as symptoms often arise when estrogen overstimulates the body and the brain. Stress can exacerbate the symptoms (see the sidebar “Symptoms of Estrogen Dominance”). Estrogen dominance has been linked to allergies, autoimmune disorders, breast cancer, uterine cancer, infertility, ovarian cysts and increased blood clotting (Northrup 2006).
Most of these conditions are caused by fluid retention from increased levels of the fat-storing hormone cortisol (Northrup 2006). High cortisol levels support a catabolic environment in which complex substances are broken down into simpler ones. Daily stress can increase the release of cortisol and change hormone levels, creating an increase in appetite and thus allowing a woman’s body to become more efficient at storing fat, especially in the abdomen, thighs and waistline.
Estrogen dominance can contribute to hot flashes, mood swings, urinary symptoms, irritability and decreased sex drive, in conjunction with additional fat storage. Depending on an individual’s symptoms and diagnosis, a complete blood test to check follicle and other hormone levels can be very beneficial.
A few simple changes in diet can help balance out the numerous changes that occur during perimenopause and restore relief for your female clients.
Cut Back on Highly Refined Carbohydrates. High-calorie, nutrient-poor foods are usually loaded with fats that promote estrogen dominance, making it difficult to balance hormones naturally. Diets excessively high in carbohydrates and too low in calories and fats can lead to nutritional deficiencies.
Women might want to consider following the glycemic index (GI), which measures the speed at which foods enter the blood steam. Carbohydrates are essential in any diet, but it is wise to look for those with a lower GI rating and attempt to eat carbohydrates in conjunction with proteins and fats in order to slow down the blood glucose response. This can protect against the ups and downs of sharply varying blood sugar levels. A carbohydrate intake of about 5 grams per kilogram of body weight per day (g/kg BW/d) can easily support moderate bouts of exercise of about 1 hour per day; however, a carbohydrate intake of 7–12 g/kg BW/d should be used to restore glycogen stores after intense workouts (Coyle 2004). This recommendation targets endurance exercise and is appropriate for prolonged, high-intensity resistance workouts as well. Some experts suggest that eating carbohydrates 30 minutes before and within 2 hours after resistance exercise allows insulin to regulate catabolic hormones (Coggan & Coyle 1991). Adding phytochemicals can help as well. These nonnutritive plant chemicals have an antioxidant property that helps protect against diseases. Phytochemicals are found in fruits, vegetables and grains, and include lycopene in tomatoes, isoflavones in soy and flavonoids in fruits.
Fuel Up With Foods High in Potassium, Including Most Fruits. These foods are full of antioxidants, vitamins and minerals. Potassium-rich foods also promote healthy water flushing to reduce cramps and bloating and keep muscles and bones lubricated. Getting enough fiber—approximately 20–25 g/d—is important as well (Harvard School of Public Health 2010). Estrogen is excreted by the bowel; if stool remains in the bowel, estrogen is reabsorbed.
Ingest Oils, Especially Omega-3 and Omega-6 Fatty Acids. These help regulate ovarian hormones by impacting prostaglandins, hormone-like substances that control virtually every bodily function. Some oily fish (i.e., salmon & tuna) and vegetable oils are also useful in keeping muscles supple, while helping the digestive system. Oils such as primrose and flaxseed are outstanding in combating irritability, mood changes, headaches, anxiety and premenstrual syndrome.
Include Vitamins and Minerals—Calcium, Magnesium, B6, Zinc and Vitamin E. Try to include zinc, vitamin B6, calcium, magnesium, iron, vitamin C and vitamin A or beta carotene in the daily diet. Consult a physician or nutrition professional for the amounts needed, based on individual blood work. Potentially, discuss adding lipoic acid, an antioxidant that can assist in ridding the body of toxins.
Maintain a Diet Rich in Protein. Protein, such as eggs, turkey, fish and cottage cheese, will help sustain hormone and brain chemistry balance. Women who consistently engage in moderate to high levels of exercise should consider a protein intake that exceeds the U.S. Dietary Reference Intake (DRI) of 0.8 g/kg BW/d (Block & Kravitz 2006).
In most cases, ingesting about 1 gram of high biological protein (protein efficiently used by the body; i.e., animal proteins) per kg BW/d seems to be the ideal protocol for active females, but intake can be higher based on caloric consumption and exercise intensity (Block & Kravitz 2006). In addition, ingesting amino acids (protein’s building blocks of protein, glutamine or alanine) prior to resistance exercise can minimize catabolism and increase protein synthesis.
This information is crucial for perimenopausal females, as the ideal situation is hormonal regulation, not fluctuation. It is important to note that excess protein may affect calcium absorption, which is a major anatomical component of bone density, and that estrogen acts as an osteoclast (cell that breaks down bone). Also worth noting is that insulin (secreted by the pancreas) does not increase protein synthesis, but it does reduce protein breakdown after resistance training.
By far the richest sources of phytoestrogens (sometimes called “isoflavones”) are soybeans and foods made from soy extracts. Studies confirm that soy can help manage perimenopause symptoms, including hot flashes, fatigue, reduced libido, decreased blood cholesterol and bone loss (Beck 2001). The isoflavones in soy may bind to the body’s estrogen receptors and stimulate the glands to produce natural hormones more efficiently. Soy can be consumed in the form of tofu, cheese, meat substitutes, burgers, drinks, low-fat breads and muffins made with soy flour. Soy powders and supplements contain much higher levels of phytoestrogens than soy foods and may have a significant effect in alleviating symptoms. If you have too much estrogen relative to progesterone, soy will act as an estrogen blocker at the tissue level.
Be aware that traditional Western medicine and naturopathic schools of thought can differ on using soy for perimenopausal symptom relief. Consulting a medical or nutrition professional for further guidance is advised.
Helping Clients Meet the Challenge
The various symptoms of perimenopause can make this transitional time a challenging one for your female clients. However, a sound nutrition (and exercise) strategy can go a long way toward making the journey more balanced. Provide clients with information that is evidence-based, and always refer to a nutrition professional when you reach the boundaries of your scope of practice.
It’s normal for women in their 30s and early 40s to experience moderate to severe symptoms of estrogen dominance during perimenopause. Although every woman can respond differently to symptoms, it’s not uncommon to encounter many of the following:
- decreased sex drive
- irregular or abnormal menstrual periods
- bloating (water retention)
- fibrocystic breasts
- mood swings
- irritability or depression
- weight and/or fat gain (particularly around the abdomen and hips)
- cold hands and feet (a symptom of thyroid dysfunction)
- hair loss
- sluggish metabolism
- premenstrual syndrome (hormonal changes that trigger disruptive symptoms in women)
Block, P., & Kravitz, L. 2006. Tailoring nutrient intake to exercise goals. IDEA Fitness Journal, 3 (8), 48–55.
Coggan, C., & Coyle, E.F. 1991. Carbohydrate ingestion during prolonged exercise: Effects on metabolism and performance. Exercise and Sports Sciences Reviews, 19, 1–40.
Coyle, E.F. 2004. The highs and lows of carbohydrate diets. Sports Science Exchange 93, 17 (2). Gatorade Sports Science Institute.
Harvard School of Public Health. 2010. Fiber: The bottom line. www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fiber/; retrieved Dec. 2, 2010.
Kleiner, S.M., & Greenwood-Robinson, M. 2001. Power Eating (2nd ed.). Champaign, IL: Human Kinetics.
Mayo Clinic. 2008. Periomenopause. www.mayoclinic.com/health/periomenopause/DS00554; retrieved Dec. 2, 2010.
Mayo Clinic. 2009. Menopause: Symptoms. www.mayoclinic.com/health/menopause/DS00119/DSECTION=symptoms; retrieved Dec. 2, 2010.
Northrup, C. 2006. The Wisdom of Menopause: Creating Physical and Emotional Health and Healing During the Change. New York: Bantam.
Saunders, M. 2002. The puzzles of perimenopause, part 1. ACSM’s Health & Fitness Journal, 6 (6), 27–29.
Saunders, M. 2003. The puzzles of perimenopause, part 2. ACSM’s Health & Fitness Journal, 7 (2), 25–28.