The truth about the biology of menopause

The truth about the biology of menopause from a lifestyle medicine perspective

Menopause conversations abound. This natural decline in female hormones that happens around the age of 50 largely known for hot flushes and night sweats is finally recognised for what it is. Insomnia, irritability, mood swings, memory problems, loss of libido and generally a sense of disconnection, “not me”.

Sometimes I wonder what the “Universe” had in mind- was there gender bias right there in the original design? Whilst men’s main hormone testosterone tapers down smoothly and gently over time, women’s estrogen declines hundred-fold in the space of 2-5 years to then become almost undetectable on the standard blood test at menopause. This decline in estrogen doesn’t happen smoothly and neatly but rather in a see-saw pattern- with wide fluctuations during peri-menopause, when estrogen levels can be much higher than normal. Levels in a blood test can be raised in the thousands one month and literally not detected the next month… and so it goes, diminishing returns until they flatline. This may result in periods being regular or sometimes shorter cycles may alternate with longer ones, until they finally stop.

As I think about menopause, I want to acknowledge how much we women have achieved in the last few years, juggling childcare and effortlessly moving from boardrooms to the trading floor, to running homes, we so wanted to have it all! And sometimes I wonder how much we ended up actually doing it all and what impact this had on our health and the transitioning process of menopause.

I appreciate that our bodies are complex and optimising health works best when we really understand the biology of mind and body and the complexity of this interaction.

So, back to biology! Even us doctors, we have long forgotten the biology of sex hormones and even if we didn’t, it seems of little relevance as we look at disease with a ’ name it, shame it and tame it approach’, as we go about fixing things in one part of our bodies by giving a drug that suppresses one symptom as quickly as possible. And although this works in the acute medical model, in the chronic disease model it often gives side effects and risks and benefits have to be carefully considered. Moreover, in our expectation for a quick fix, we are often frustrated when the medical establishment does not deliver it. We approach ageing with fear and dread and usually overlook the process of conscious transformation that life entails, the wisdom and love that we could still be passing on as we age.

Rather than explore menopause treatment options separately, I strive to use a double pronged one, nutrition and hormones where appropriate alongside mapping both physical and emotional needs.

MENOPAUSE AS A TAKE-OVER PROCESS

My brief view of the biology of menopause is that menopause is, in essence, a takeover process. The ovarian function declines and the ovaries produce less estrogen and progesterone. As women, we also make testosterone and dihydroepiandosterone (DHEA) and we continue to produce these from the adrenal glands after menopause. Our bodies have enzymes that transform testosterone into estrogen and this is an important pathway for well-being once menopause sets in. So, after menopause we rely on adrenals for hormones and there is less flexibility in the system without the ovaries. The stress we take on in the preceding years may affect how well the takeover process unfolds.

The steroid pathway

I believe it is really important to understand the steroid pathway, please stay with me on this one.

As you can see, cholesterol is at the top of the tree. This is where diet comes in and why it is important to have healthy fats (avocados, nuts, seeds, quality organic meat) as part of your diet as you age and maybe explains why Japanese women suffer less from symptoms of menopause.

Take a moment to look at the chart and appreciate the little arrows that facilitate the ways our body can adjust hormones levels and balance them depending on what the perceived need is at any time point.

The main steroid hormones are pregnenolone, cortisol, progesterone, di-hydroepiandosterone (DHEA), testosterone and estrogen (and several other metabolites in between).

And if scientific diagrams don’t agree with you, we can look at hormones using a circle dancing analogy. There are many interactions between various hormones and the brain and they all ‘dance’ together. If one is struggling, they all respond and have to adjust. If there is an additional stress on the system, for example a bereavement or a conflict at work, cortisol production may increase. This may put some pressure on the pregnenolone/ progesterone system, which would support the body’s priority to cope with stress. And sustained stress may over time lower your DHEA levels and fatigue sets in. Your body is doing this moment by moment. All. Day. Long. And I did not cover here the role of sex hormones in the brain or how they may interact with our neurotransmitters…

However, each tissue has its limits in adjusting its responses to daily pressures.

At menopause, estrogen and progesterone begin to trip over; it can be a bit harder to keep the show on the road for a period of time. Can you keep dancing in a circle when two dancers are really dragging their feet?

Cortisol is King

Cortisol is the ruler of hormones and can influence how we respond to estrogen and progesterone, high levels of cortisol have been shown to make estrogen and progesterone less effective (when you feel that the hormone therapy you are taking isn’t working for you, this may be a contributor). Cortisol may influence thyroid function and lead to symptoms of low thyroid. It can cause high insulin, insulin resistance and diminished ability to metabolise sugars, which in turn may cause weight gain (that extra weight round our middle).

To address high cortisol it usually requires lifestyle changes. I believe that approaches like CBT, as in the documentary, may also work by addressing cortisol. Dietary changes include avoiding processed foods and refined sugars, having more protein and quality fats at every meal, as well as incorporating mindfulness in our daily routines. Cortisol has been the elephant in the room in our menopause conversations, because we did not understand the biology of it; not until recently. I recommend Dr Rangan Chatterjee’s upcoming book “The stress solution”, I trust him to deliver a down to earth approach that is rooted in the latest science.

Hormone therapy

CONVENTIONAL HRT- Current guidelines define HRT as estrogen replacement therapy. Estrogen however increases the lining of the womb, and giving it on it’s own has an increased risk of endometrial cancer. I have sat in many conferences where esteemed gynaecologists still believe that it is perhaps easiest to have a hysterectomy and then take estrogens alone. Historically, equine estrogens and synthetic progestins have been used and studies showed an increased risk of side effects, such as breast cancer or clotting problems. After those studies there was a move away from HRT. Since 2015, there has been a recognition in NICE guidelines that transdermal estradiol (via gels, patches) alongside natural progesterone has the best outcomes. These hormones have the same structure with the ones we naturally produce and are therefore referred to as Bio-identical or body-identical hormones. There are now body-identical hormone therapies available on the NHS as Estrogel (Estradiol) and Utrogestan (Progesterone). This is still not always available when it is not part of the NHS formulary and many GPs do not have training in menopause management and may be reluctant to offer HRT. The balance between all hormones and the crucial role of progesterone for mood and sleep remains largely unrecognised in conventional menopause management and testosterone is rarely used.

BIO_IDENTICAL HORMONE THERAPY has been used for decades, using the paradigm of hormone balance, replacing like for like and being mindful of the interplay between different hormones. This practice was largely based on a biological hypothesis that if our bodies have optimal physiological levels of hormones they function better. Some clinical trials followed years later confirming the benefit of natural estradiol and progesterone (PEPI trial 2015). Evidence has been catching up and the benefits of bio/body-identical hormones are now universally recognised and more licensed preparations of Estradiol are available, albeit only one fixed dose of Progesterone capsule is available as licensed. Bio-identical therapy practitioners may prescribe adjusted doses to the individual via a compounding pharmacy but controversy remains about the use of compounding pharmacies (regulated by the General Pharmaceutical Council) instead of approved big pharma products.

As a clinician, my medical training has been largely conventional (including menopause training) up until five years ago, when too little of my learning has served to resolve mine or my family’s health issues and I awoke to the power of nutrition, relaxation and meaningful emotional connections with others.

In my consultations I focus on the individual’s needs and I strive to be a doctor and life coach rolled into one. I favour a more holistic paradigm of balancing all hormones, and prioritising lifestyle changes. My prescription will usually include hormones (licensed or unlicensed), a food plan and a self care plan that are all equally important.

I know that, when it comes to menopause, it is not the hot flushes that we fear the most, but rather the changes to our brain and how it can at times feel like depression, dementia and ADHD all at once! And there is nothing more rewarding than to hear a woman saying that ‘I feel more like myself again’.

I admit I loved it when the Dalai Lama said a few years back that ‘… women will save the world’, and I hope that our menopause conversations will bring us closer to ourselves and to each other.