Having just entered my forties, my radar’s perked for solid information coming out of the research community on the perimenopausal transition. What can I do to make this 10 or so years of transition useful and even helpful to the future postmenopausal me? As women, we’re no strangers to functioning in some level of consistent discomfort – whether cycle-related, birth control related, pregnancy or post-partum related, or multiple-role related. We just manage through it one way or another with the idea that the pain is for a purpose. That said, perimenopause may be different: for instance, we now know that a highly symptomatic perimenopause may be directly associated with cardiovascular risk, suddenly turning that “pain for a purpose” attitude we’ve had for decades into something different. And with coronary heart disease being the leading cause of death for humans on this planet, perhaps our perimenopausal experience should prompt more than just a symptoms management approach. Perhaps a lot more.

What is Perimenopause?

Before we stop having periods for good, hormones like estrogen and progesterone fall out of their expected rhythms because the perimenopausal time directly links with our declining ovarian reserve. As we run low on viable follicles or eggs, the signals from the brain to the ovary – that’s LH and FSH – begin to amplify little by little (to a lot). The less follicular estrogen and inhibin the ovary produces, the louder FSH gets. Similarly, the fewer successful ovulations, the higher that LH signal becomes in its effort to make ovulation happen. Ovulation is where we get most of our progesterone, so when we’re not ovulating we have basically no progesterone and thus end up fluctuating between estrogen dominant and estrogen deficient states, which leads to irregular bleeding. For some women, this phase is rather short, going from regular cycles to no longer cycling seemingly overnight and with few to no attributable symptoms. Other women take the scenic route through perimenopause over many, many years of bleeding changes, hot flashes, mood swings, and shifts in body composition.

With my personal family history being full of typical postmenopausal afflictions like osteopenia, cardiovascular disease, uterine prolapse, autoimmune disease, and thyroid problems, I really have to look at this perimenopausal time period as a runway to takeoff. It’s a silly metaphor but I’ve got to gas up because I want to fly for a long, long time! Perimenopause may be the most important time to squirrel away resources and get the hormonal (sex, adrenal, and thyroid especially), body composition, and nutritional statuses in order to prepare for the coming famine because I don’t trust the ground work I laid in my teens and twenties to carry me through.

So, I’ve devised a plan. A perimenopausal game plan.

Step One: Replace

The decision to replace estrogen and progesterone in menopause is truly such an individual one. Some in the naturopathic community may feel we should embrace the natural senescence on the other side of menopause. Some in the anti-aging community probably feel like folks should be knee deep in injectable peptides and hormone replacement by their mid-30s for max benefit. I’m somewhere in the middle, I suppose, and my rationale is this: as we live in a world in which cardiovascular disease will usher more folks to the morgue than breast cancer, I’m pretty locked on to the idea of using hormone replacement therapy as early on in menopause as possible for the biggest benefit to my heart, brain, and bones (the things that, without estrogen, are most likely to rob me of my health or kill me). And without knowing what the future holds from a hormone research standpoint or for my own future health at this point, I do plan to remain on HRT for decades in an effort to increase my health span [1,2]. I don’t see myself slathering on 10 or 20 mg of topical estradiol every day or anything, I’m more of the mind of using a low to mid-dosed transdermal or topical. As for progesterone; none of that progestin business, especially medroxyprogesterone acetate that links up with cardiovascular events and breast cancer, but good old bioidentical progesterone for breast, bone, brain, and endometrium [3]. Maybe I’ll cycle it using rhythmic dosing for the potential cardiovascular benefit if that ends up fleshing out in the research – I haven’t decided yet. It’s early. That’s for tomorrow.

Today, I’m zeroed in on Step 2 and 3: BUILD and FAST, also known as exercise and diet – admittedly the two greatest medical treatment clichés of American culture. I can do that starting right now, even before that first perimenopausal symptom sets in. I’m really inspired by the research coming out on the circadian rhythms of the body and how dependent our cardiovascular and metabolic health is on the proper diurnal excursions of our hormones, peptides, and inflammatory cytokines. After all, in women, the menstrual cycle both governs (with estradiol) and is governed by (with light/dark) the circadian rhythm ultimately set by the suprachiasmatic nucleus (SCN) – so yes, hormone replacement is a part of keeping the clocks synchronized. But that’s not the end of the story. We also have peripheral clocks that have to stay coordinated with that master central clock for our brain hormone signals to stay in sync with the tissues. Cortisol is that coordinator between peripheral and central. Its diurnal rhythm is constantly adjusted by the master (central) clock primarily through the HPA axis and by direct splanchnic innervation from the SCN. But secondarily, cortisol rhythms are heavily regulated by the times of day in which our bodies are moving and eating. I’m sufficiently convinced that if I can actively synchronize and reinforce these diurnal rhythms through my lifestyle choices, that groundwork will define my perimenopausal experience. So let’s look closer at steps 2 and 3.

Step Two: Build

Through Movement: Walking + Resistance Training

To build a resource cache in my bones and muscles, I have to move them enough to make it a habit. Blue Zone research says walking 6 hours a week will decrease the risk of dying from cardiovascular disease [4]. Check plus. This, I can do and enjoy. Of course, while aerobic exercise like walking carries the cardiovascular benefit, with my family history I’m also interested in bone health. I tend to put most stock into research looking at increased femoral neck, hip, and lumbar bone mineral densities. And from perusing studies linking greater bone density with exercise, the take home message for me has been this: incorporate resistance training [5,6]. Use my own body weight like squats (easy while I’m brushing my teeth) push-ups and planks (while watching a show), but also incorporate weights like bench press, bicep curls, and – seriously I want to do this – dead lifts. So, get stronger. This is not a weight loss thing; rather it’s a way to build resources within my own body. I’m certain I will not be a 90-year old body builder, but the idea is I’ll be less likely to suffer spinal compression fractures or – goodness forbid – a broken hip on my way to an early cardiovascular-related grave. 

Benefit to perimenopausal symptoms

Outside of the cardiovascular and bone benefits, several studies have identified resistance training as an effective strategy for reducing the frequency and severity of perimenopausal hot flashes. Additional research on aerobic exercise – that’s your walking, dancing, and shaking – found that it decreased night sweats, urinary problems, headaches, irritability, mood swings, and increased overall quality of life in postmenopausal women even at just 2.5 hours a week [7,8,9].

Step Three: Fast (and then Break-fast)

The irony of titling the diet section Fast is not lost on me. But the research on calorie restriction, time restricted feeding (TRF) schedules, and fasting mimicking diets (FMDs) just keeps getting more interesting, yielding a growing list of compelling health implications.

I’ve always proselytized the idea of eating breakfast everyday regardless of level of hunger in the early hours, based on a preponderance of research relating breakfast-skipping to metabolic syndrome in adolescents and adults alike. But now we know that the fasting portion of the daily schedule, the times in which we’re not eating, matters just as much as the eating part for other parameters of health.

Time restricted feeding (sometimes referred to as intermittent fasting or IF, but is just one of many types of IF) essentially means eating for a 6-8 hour block of the day and then fasting for the rest of it. Early time restricted feeding (eTRF) concentrates the eating hours into the hours of the day just following morning waking. An eTRF schedule can strengthen and synchronize those circadian rhythms by advancing the sleep phase, influencing our gut microbiome, adjusting our hormonal rhythms that signal hunger/satiety/adipose functions, honing hormone receptor sensitivities, and reducing inflammatory markers like TNFα, IL-6, and IL-1β [10]. 

FMDs work on the same underlying mechanism and have gained notoriety for influencing many of the same health parameters as the TRF diets, as well as lowering systolic blood pressure, CRP, IGF-1, and potentially engaging some of the same anti-aging/anti-cancer benefits of autophagy/apoptosis/cell regeneration, including neuro-regeneration [11]. Instead of compressing the eating period on a diurnal feeding/fasting schedule on a daily basis, FMDs usually entail an intense caloric restriction phase (500-800 calories a day) for some period of time – these protocols may vary from 2-7 days a month to 2 consecutive days a week (aka the 5:2 plan) to every other day.

For me, I’ll probably start out with one of the expensive pre-packaged FMD plans until I get comfortable with it (I really don’t even know how to wrap my mind around 600 calories a day yet) and see how my body feels on it. I’m not big on repressive regimens and happen to believe in the health benefits of social eating, so there will have to be a lifestyle balance for it to work for me. 

 Benefit to perimenopausal symptoms

No real direct studies have looked at menopausal symptoms and intermittent fasting exactly, but it’s not hard to extrapolate the effects of the diet by its known effects on different blood markers also known to be attributed to perimenopausal symptoms and imagine there could be a benefit. For instance, because higher levels of inflammatory cytokines like TNFα, IL-8, and IL-6 are associated with hot flashes in menopause [12], an eating schedule that includes a fasting component may reduce those cytokines, alleviating those hot flashes [13]. You could say the same thing about cognitive changes and BDNF, or night sweats and systolic blood pressure, or body composition and adiponectin:leptin ratio.

Ladies, perimenopause serves a purpose. It’s our time to take our health into our own hands and plan for the next phase, not just weather through drenched sheets and “brain fog”. If perimenopause turns your life upside down, it may be worth taking a hard look at your cardiovascular system – that means teaming up with your health care providers to perhaps get some baselines for coronary artery calcium (CAC) score and look at modifiable markers like homocysteine and BDNF, sex hormones, and diurnal cortisol patterns. I can’t help but think that if we started thinking of perimenopause as 10+ years of heavy cardiovascular prevention work, there would have to be a huge benefit to our health care system, not to mention to ourselves and our families. That’s my perimenopausal plan, what’s yours? 

Related Resources

• Webinar: Hormone Replacement Therapy Dosing for Optimal Clinical Response
• Blog: Mood and Menopause – Going Through "The Change"
• Blog: Heat Waves & Hot Flashes in Perimenopause

References

[1] Palacios, S, et al. Hormone therapy for first-line management of menopausal symptoms: Practical recommendations. Womens Health (Lond). 2019;15:1745506519864009.

[2] Velarde, MC. Mitochondrial and sex steroid hormone crosstalk during aging. Longev Healthspan. 2014;3:2.

[3] Lobo, RA, et al. Prevention of diseases after menopause. Climacteric. 2014;17:540-56.

[4] https://www.bluezones.com/2018/07/research-says-walking-this-much-per-week-extends-your-life/

[5] Berin, E, et al. Resistance training for hot flushes in postmenopausal women: A randomised controlled trial. Maturitas. 2019;126:55-60.

[6] Bailey, TG, et al. Exercise training reduces the frequency of menopausal hot flushes by improving thermoregulatory control. Menopause. 2016;23:708-18.

[7] Moilanen, JM, et al. Effect of aerobic training on menopausal symptoms--a randomized controlled trial. Menopause. 2012;19:691-6.

[8] Mansikkamäki K, et al. Sleep quality and aerobic training among menopausal women--a randomized controlled trial. Maturitas. 2012;72:339-45.

[9] Courneya KS, et al. Dose-Response Effects of Aerobic Exercise on Quality of Life in Postmenopausal Women: Results from the Breast Cancer and Exercise Trial in Alberta (BETA). Ann Behav Med. 2017;51:356-364.

[10] Jamshed, H, et al. Early Time-Restricted Feeding Improves 24-Hour Glucose Levels and Affects Markers of the Circadian Clock, Aging, and Autophagy in Humans. Nutrients. 2019;11:1234.

[11] Paoli, A., et al. The influence of meal frequency and timing on health in humans: the role of fasting. Nutrients. 2019;11:E719.

[12] Huang, WY, et al. Circulating interleukin-8 and tumor necrosis factor-α are associated with hot flashes in healthy postmenopausal women. PLoS One. 2017;12:e0184011

[13] Franco, OH, et al. Vasomotor symptoms in women and cardiovascular risk markers: Systematic review and meta-analysis. Maturitas. 2015;81:353-61.