There are numerous health concerns during menopause, including increased risk of certain conditions and changes in body composition, muscle mass and bone mass. Interventions include diet, exercise, supplements and hormonal replacement therapy.
What is menopause?
Menopause is defined as the final menstrual period. In practice it can difficult to identify menopause as periods start changing (e.g. they can become irregular) years before that last one. The last menstrual period is considered “the last” if there are no other periods in the 12 months that follow. The time before menopause is called perimenopause, and the time after that last menstrual period is called postmenopause (1).
Menopause normally happens around 50 years old (51-52 years on average in Australia, 1) and is characterised by a decrease in oestrogen and an increase in progesterone (2).
Health concerns during menopause
Besides physical and emotional symptoms, menopause is associated with increased risk of conditions such as obesity, metabolic syndrome, osteoporosis (3), high blood pressure and cardiovascular disease (CVD, 3, 4).
The downsides of menopause seem to be dependent on the age at which it happens. Women who get to menopause earlier in life are at risk of bone density loss, osteoporosis, depression, premature death and CVD. On the other hand, women who get to menopause later in life are at higher risk of some cancers (breast, ovarian and endometrial) (2).
Menopause is associated with a shift in body composition (lower muscle mass and greater fat mass). This is potentially a result of impaired metabolic flexibility, or the ability to switch between carbohydrate and fat utilisation for production of energy (3).
Ageing is associated with a decline in muscle mass and strength. This decline starts in women in their 30s and accelerates in their 50s. Significant muscle mass loss (technically, 2 standard deviations below the mean in the reference population) is known as sarcopenia and leads to serious loss of function and disability (5).
There are a number of changes in the muscle composition of older women:
- Greater proportion of non-contractile muscle tissue. If you think about performing an exercise, such as a bicep curl, you need your muscles to contract. Therefore, a larger proportion of non-contractile muscle tissue means that the individual is less able to generate contraction, which translates to reduced muscle strength (5).
- Lower proportion of type II (a.k.a. fast twitch) muscle fibres, impacting the ability to generate power and speed. These loses can negative affect the ability of an individual to execute common activities and prevent falls (5).
- Greater deposition of fat in muscles (a.k.a. intramuscular fat), which negatively affects muscle strength and function (5).
The factors that lead to loss of muscle mass in women include the lack of physical activity, low protein intake (5) especially considering that protein requirements increase with age due to anabolic resistance (3), oxidative stress and hormonal status (5). In addition, vitamin D deficiency can lead to reduced bone mineral density and impaired muscle function. When talking about hormones, it is important to note that oestrogen is not the only one that changes in menopause. In fact, there is no convincing evidence that oestrogen levels are correlated with muscle strength. On the other hand, other hormones such as Dehydroepiandrosterone (DHEA), growth hormone (GH) and insulin-like growth factor 1 (IGF-1) decrease with age and have negative impacts in muscle maintenance. Similarly, many postmenopausal women have insulin resistance, further preventing muscle mass maintenance (5).
A significant proportion (15-30%) of postmenopausal women in developed countries have osteoporosis or low bone mass (35-50%). These women are at an increased risk of fractures which can lead to significant morbidity and even mortality (4, 6).
Interventions for menopause
Mediterranean-style diets have been associated with better body composition, a mitigation in bone mineral density loss and a reduction in blood pressure and CVD risk in postmenopausal women. These effects are thought to be related to the variety of nutrients and other components present in Mediterranean dietary patterns (3).
Similarly, eating a low glycaemic index diet is associated with better body composition (3).
Individuals who eat higher amounts of fruit and vegetables, as opposed to processed foods, tend to have lower mortality rates (3) and risk of CVD (3, 4), atherosclerosis (3) and cancer (4).
Low-fat diets can help reduce LDL-cholesterol levels and low-carbohydrate diets may reduce triglycerides and HDL-cholesterol levels (3), reducing the risk of CVD.
The recommended daily intake of calcium is increased in women of menopausal age due to its importance in bone health. In Australia, this increase is from 1000 to 1300 mg per day, which translates to an increase from 2.5 to 4 serves of dairy foods and alternatives (7). Individuals taking supplements should adjust their intake from dietary sources.
Likewise, older women should consume more protein to compensate for the aforementioned anabolic resistance in order to preserve muscle mass, improve bone health and increase the absorption of calcium.
Dietary choices seem to influence the age at which women hit menopause. Larger portion sizes of refined pasta and rice and increased intake of savoury snacks are associated with an earlier menopause. Increased intake of oily fish is associated with a later age of menopause as well as increased intake of fresh legumes, although to a lesser extent. Other foods that seem to be associated to a later onset of menopause are grapes and poultry, although this only applies to women who have never had children. Looking at individual nutrients, higher intakes of vitamin B6 and zinc are associated with a slight delay of menopause age. A non-vegetarian diet is associated with a later age of menopause, however these benefits don’t apply to non-vegetarian women who consume higher amounts of savoury snacks and soft drinks (2).
Individuals with high blood pressure can benefit from restricting energy, fat (in general but also saturated and cholesterol), sodium and alcohol intake and increasing potassium, low GI carbohydrate and fibre intake (4).
Exercise can reduce the degree of bone loss that happens with age. However, not all exercise is created equal. Resistance exercise is necessary to maintain bone mineral density and strength (4, 6). Moreover, it is important that the exercises are moderate to high intensity by utilising adequate sets/reps and challenging weights which should be increased according to progress (6).
High impact exercises that involve jumping and/or moving in multiple directions can improve bone mineral density in certain areas of the skeleton (6).
Walking and other non-weight bearing exercises such as cycling and swimming don’t seem to be very effective at maintaining bone health, however they can have a beneficial effect on cardiovascular health, metabolic health (4, 6), mood and mental health (4). These benefits are likely proportional to the frequency, duration and intensity of exercise (4).
In addition, older individuals should also perform exercise modalities that improve power and balance in order to prevent falls (6).
Phytoestrogen supplements (e.g. isoflavone) can alleviate some menopausal symptoms (e.g. hot flashes, 4), help increase muscle mass, especially when combined with resistance exercise (5) and reduce the risk of subclinical and premature CVD (3, 4).
Supplementation with both vitamin D and calcium may help prevent osteoporosis and its related risks (3, 4). This is due to the fact that calcium absorption declines dramatically with ageing and is associated with vitamin D deficiency (4).
Omega-3 supplementation may be used to reduce the risk of CVD (4).
Hormonal replacement therapy
Low dose hormonal replacement therapy (HRT) can relieve some menopausal symptoms but does not impact muscle mass (5). Oestrogen and combined oestrogen-progesterone therapy may reduce the risk of fractures in osteoporotic postmenopausal women (4). However, some types of HRT may increase the risk of conditions such as stroke and deep vein thrombosis (4).
- Jean Hailes for Women’s Health. Understanding menopause [Internet]. 2019. Available from: https://assets.jeanhailes.org.au/Fact_sheets/Perimenopause.pdf?_ga=2.213491988.1861125893.1663152918-2084582265.1662286990
- Dunneram Y, Greenwood DC, Burley VJ, Cade JE. Dietary intake and age at natural menopause: results from the UK Women’s Cohort Study. J Epidemiol Community Health. 2018 Aug;72(8):733–40.
- Silva TR, Oppermann K, Reis FM, Spritzer PM. Nutrition in Menopausal Women: A Narrative Review. Nutrients. 2021 Jun;13(7).
- Hagey AR, Warren MP. Role of exercise and nutrition in menopause. Clin Obstet Gynecol [Internet]. 2008;51(3):627–41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18677156
- Maltais ML, Desroches J, Dionne IJ. Changes in muscle mass and strength after menopause. J Musculoskelet Neuronal Interact. 2009;9(4):186–97.
- Daly RM, Dalla Via J, Duckham RL, Fraser SF, Helge EW. Exercise for the prevention of osteoporosis in postmenopausal women: an evidence-based guide to the optimal prescription. Brazilian J Phys Ther [Internet]. 2018/11/22. 2019;23(2):170–80. Available from: https://pubmed.ncbi.nlm.nih.gov/30503353
- National Health and Medical Research Council. Australian Dietary Guidelines. 2013. Canberra: National Health and Medical Research Council.
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