Menopause

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Alternative Names

Lifestyle Changes

Everyone should maintain a healthy diet rich in fresh fruits, vegetables, whole grains, and low in saturated fats (found in dairy and animal products) and trans-fatty acids (found in shortening, commercial baked goods, and hard margarines). Reducing salt intake is also important as people age.

Whole Grains, Fresh Fruits, and Vegetables

Vegetables, fruits, whole grains, nuts, and legumes (beans and peas) contain fiber and many nutrients that are important for the heart and overall health. Of note, vitamin supplements are not recommended in place of healthy foods. Research is increasingly suggesting the high supplement doses, even of vitamins E and C, may have harmful effects.

Mineral-Rich Fruits and Vegetables. Studies specifically suggest that diets rich in fresh fruits and vegetables are high in potassium and magnesium and can help preserve bones. Many of these foods also help protect against heart disease and cancers. Potassium-rich fruits include bananas, oranges, prunes, and cantaloupes, and vegetables that contain potassium include carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados and broccoli. Foods rich in magnesium include dairy products, spinach, potatoes, beets, nuts, sole, and halibut.

Avoid Fast Foods and Limiting Salts. Reducing salt is important for protecting both the heart and the bones. High sodium intake interferes with calcium retention. Limiting table salt is not sufficient, since most salt in the Western diet comes from fast foods and commercial food products. Such foods are often also high in dangerous fats called trans-fatty acids and are harmful to the heart.

Effects of Fiber. Fiber is important for the heart. Of some concern are reports of estrogen loss with high amounts of wheat bran (but not oat or corn) and calcium loss with any high-fiber diet. Calcium supplements can help offset this effect.

Protein from Soy and Animals

Some studies report a lower risk for diseases associated with estrogen and a high intake of so-called plant estrogens (phytoestrogens), which are generally categorized as isoflavones (found in soy and red clover) and lignans (found in whole wheat and flaxseed). At this time there is insufficient evidence on the benefits and risks of phytoestrogens to recommend them as an approach menopausal health. Nevertheless, foods containing them may be healthful.

Soy is of particular interest, however. It is rich in both soluble and insoluble fiber, healthy fatty acids, and provides all essential proteins. Soy products, many of which contain calcium, are widely available. The following are some forms and the amount of soy they contain:

• Four ounces of tofu equals about eight to 13 grams of soy.
• A soy burger contains about 18 grams of soy.
• Soy powders, soluble in juice or milk, that list amounts of isoflavones per serving are now available in health food stores. Be sure the soy powder is taken from the complete soy protein.

Soy appears to have numerous effects on the body, many positive but some potentially negative ones as well. For example, supplements containing specific isoflavones found in soy--typically the estrogen-like compounds genistein and daidzein--do not appear to provide any benefits compared to the whole soy protein. Taking them separately may, in fact, cause harm, including a possible increase in estrogen-related cancers or a drop in white blood cells in infants. (Studies suggesting this have used animals or laboratory evidence. To date, there is no evidence of harm for humans who eat soy products.) More research is needed.

Effect on Menopausal Symptoms. Studies have been mixed on whether soy relieves menopausal symptoms. One report suggested that if it did have any benefits, they were short lived.

Effects on the Heart. A number of studies have indicated that subjects who consume at least 25 grams of soy protein improve cholesterol levels. Not all studies are consistent about particular effects, but the majority shows improvements in at least one of the cholesterol components. (Soy diets may also reduce high blood pressure in men, although not in women.) Powdered whole soy protein that contains at least 60 mg of isoflavones may provide similar benefits.

Effect on Bone. The role of protein in osteoporosis is not entirely clear. An important 2000 study confirmed earlier reports that adequate protein is important for bone health. Other studies have also reported thinner bones in people who were deficient in protein. Investigators are trying to determine benefits, if any, from either animal or vegetable protein.

• Animal protein has been associated with bone loss in some studies, but a 2002 study reports a protective role from animal protein. Of note, oily fish (salmon, mackerel, fresh tuna, herring) are high in vitamin D, which is bone protective. (Note: American brands of tuna generally contain no significant amounts of vitamin D.)

Omega-3 fatty acids, found plentifully in oily fish and flaxseed and canola oils, are beneficial to people afflicted with IBD (inflammatory bowel disease).

• The same 2002 study that reported bone protection with animal protein, found a greater risk for bone loss with higher intake of vegetable protein. However, studies on soy, perhaps the most important vegetable protein, have suggested some protection against bone loss. Soy is high in estrogen-like plant chemicals called isoflavones, which may actually improve bone health in older women. (A 2002 study suggested it had no effect on bone density in healthy premenopausal women.) Soy food products, such as tofu, that also contain calcium may be particularly beneficial. In such cases 3 ounces of tofu supply 60% of daily calcium requirements. Some experts recommend 25 to 45 milligrams of isoflavones a day. There is still no strong evidence supporting soy's protection, however. It is not yet clear, for example, if the benefits reported are simply because women who eat soy tend to have a healthier lifestyles in general. Also to date, evidence suggests that supplements containing only isoflavones do not provide benefits. If protection exists it is likely to be from whole soy protein products.

The effect of protein on bone is complicated, however, and laboratory studies suggest that high protein intake may increase calcium loss. And indeed some studies have reported higher bone loss associated with a high intake of protein, particularly when calcium or potassium intake was low. Of particular, note, there is some evidence that popular high-protein low-carbohydrate diets, such as the Atkins diet, may cause osteoporosis. The bottom line may be that in order for protein to be protective, or even not harmful, individuals should also eat plenty of mineral-rich foods. In any case, the best sources of protein for bone protection are oily fish and soy.

Effects on Cancer. The effects of phytoestrogens on cancer are less clear. In general, Asian women have a lower incidence of reproductive and breast cancers as well as a higher intake of soy. A 2000 study of 120 Asian women reported an association between high levels of soy compounds in the urine and a lower risk for breast cancer, as much as 50% lower. And a 2001 study in China reported that high soy intake during adolescence was associated with a lower risk for breast cancer later on. The effects of phytoestrogens, however, in all cases are far from settled. Of concern are studies that report breast cell proliferation with low levels of genistein (one of the important isoflavones compounds in soy). In one study, the compound actually reversed the protective properties in tamoxifen, which is used to prevent breast cancer in high-risk women. In general, women at risk for breast cancer should avoid consuming large amounts of plant products with high levels of phytoestrogens until more is known about their effects. A 2002 study reported no indication of a higher risk for uterine cancer in women consuming soy isoflavones daily. More research is needed on the effects of soy on breast and reproductive cancers.

Effects on the Brain. A 2001 animal study reported that soy appeared to protect against changes in the brain associated with Alzheimer's disease. Of concern, however, was a study of older men that found an association between a high intake of tofu in middle age with later mental decline and brain atrophy, a finding that researchers were at a loss to explain. In general, any evidence on the effects of soy on menopause symptoms is weak, with some studies reporting no benefits. In general, more clinical trials on soy are necessary before conclusions about its myriad effects can be drawn, and experts say it is too early to recommend soy as a replacement for estrogen.

Fats

Benefits of Fats and Oils. Although no one wants to be overweight, even a slight excess of fat helps protect bones. In fact, in one 2000 study, women who ate more fat in their diet were, on average, better able to absorb calcium than were women who had been put on a low-fat, high-fiber diet. Fats that contain fish oil or oils, such as olive or canola, may also be healthy for the heart.

Dangers of Fats and Oils. Everyone should avoid saturated fats (found in animal products) and trans-fatty acids (found in hydrogenated fats, fast foods and commercial products). And of course, women should be aware that all fats, regardless of the type, are high in calories. No one should over-eat any fat or oil.

Click the icon to see an image of saturated fats.

Click the icon to see an image of trans-fatty acids.

Calcium and Vitamin D

Calcium. Women should be sure they have sufficient calcium and vitamin D in their diet by consuming low-fat dairy products or calcium-enriched orange juice. The standard recommended dose for older people is between 1000 and 1500 mg per day, depending on risk factors. Even doses of 1000 mg may help preserve bone in many postmenopausal women without osteoporosis, especially during winter months (when bone loss is greatest). In women who have already experienced osteoporosis-related fractures, however, 1000 mg daily may not add any protective benefits without bone-building medication. Calcium citrate (Citracal) is better absorbed than many other calcium compounds and was the first reported calcium supplement to preserve bone density after menopause.

Click the icon to see an image of the benefits of calcium.

High doses (over 2,500 mg per day) of calcium supplements may increase the risk for kidney stones. (Because many commercial foods are now fortified with calcium, this upper limit may be easier to reach than people think.)

Click the icon to see an image of calcium sources.

Vitamin D. Vitamin D is necessary for the absorption of calcium in the stomach and gastrointestinal tract and is the essential companion to calcium in maintaining strong bones.

Vitamin D is manufactured in the skin using energy from the ultraviolet rays in sunlight. It can also be obtained from dietary supplements. As a person ages, vitamin D levels decline. They also fall during winters months and when people have inadequate sunlight. Pollution may also contribute to less sunlight and declining vitamin D levels.

Click the icon to see an image of vitamin D sources.

Current adult guidelines recommend the following:

• 400 IU (10 mcg) for people between ages 50 and 60.
• 600 IU (15 mcg) for those over 70 who do not have sufficient exposure to sunlight.

Drinking milk fortified with vitamin D and sunlight exposure supply most peoples need for vitamin D. (One cup of whole milk provides about 100 IU of vitamin D.) Oily fish (sardines especially, also salmon, fresh tuna, mackerel) are also important dietary sources of vitamin D. Of concern, however, is the increasing use of sunscreen to prevent skin cancers and the intake of milk products (such as yogurt and skim milk) that may have little vitamin D. People who need to avoid sunlight and whose diet is low in foods that contain vitamin D should take supplements. People with darker skin are at higher risk for deficiencies than those with whiter skin. (Note: vitamin D is toxic in high doses, and no one should exceed the recommended daily intake of vitamin D except under the direction of a physician.) It should be noted that some studies suggest that vitamin D agents can protect against osteoporosis only in combination with calcium and that they do not appear to be protective in isolation.

Caffeinated Beverages

Tea. Tea may have a very positive effect on the heart. Although it contains caffeine, it also is rich in flavonoids and other substances that offer protection against damaging forms of LDL. A 2002 study also suggested that drinking tea regularly may help protect bones. Green tea is often cited for its health benefits, but black tea may also be beneficial. In one study, higher intake of black tea, particularly by women, was associated with a reduced risk for severe coronary artery disease. Tea also contains folic acid, which reduces homocysteine levels, a possible factor in coronary artery disease.

Coffee. Some evidence suggests that, coffee, like red wine, contains phenol, which helps prevent oxidation of LDL cholesterol. One study also suggests that it may boost estrogen levels. One 10-year study, in fact, reported the highest rates of fatal heart disease in non-coffee drinkers, and women who increased their coffee intake reduced mortality rates. Regular intake of coffee does have a harmful effect on blood pressure in people with existing hypertension. (Caffeine causes a temporary increase in blood pressure in everyone, an effect thought to be harmless in people with normal blood pressure.) Of note: Unfiltered coffee (Turkish coffee, Scandinavian boiled or French pressed coffee, and espresso) contains an alcohol called cafestol, which may raise cholesterol levels. Filtered coffee does not contain this residue.

Studies have been conflicting about the association between caffeine and low bone mass. In one trial, consumption of lots of coffee, nine or more cups per day, was associated with an increased risk of hip fractures in women, but not in men. Nevertheless, a 2001 animal study reported that coffee consumption did not cause bone loss. And other studies suggest that when calcium intake is sufficient, coffee does not harm bones.

Note: The enhancing effects of coffee on estrogen may be harmful for women with risk factors for breast or ovarian cancer or premenopausal women with estrogen-related disorders, such as endometriosis.

Alcohol

Effect on the Heart. One drink a day in women who are not at risk for alcohol abuse may be beneficial for the heart. Red wine in particular contains a substance called resveratrol, which is classified as a phytoestrogen and has estrogen-like effects.

Effect on Bones. Alcohol has different effects on bones depending on how much is consumed. One 2000 study found that women older than 65 who drank one to two drinks (one to two ounces) of alcohol weekly had higher bone density than non-drinkers. Alcohol, in moderate amounts, may increase estrogen levels. Excessive drinking, however, has been associated with brittle bones.

Effect on Breast Cancer. Women who drink more than two or more alcoholic drinks a day face an increased risk for breast cancer.

Controlling Weight Gain

Many women need to increase physical activity and reduce caloric intake before and after menopause. Weight gain is common during these years, and it can be sudden and distressing, particularly when habitual exercise and eating patterns are no longer effective in controlling weight. Gaining weight around the abdomen (the so-called apple shape) is a specific risk factor for heart disease and diabetes and many other health problems.

Click the icon to see an image of different types of weight gain.

Exercise

For protection against all aging diseases, women, whether or not they are taking hormone replacement therapy, should pursue a lifestyle that includes a balanced aerobic and weight resistance exercise program appropriate to their age and medical conditions. Brisk walking, stair climbing, hiking, dancing, and tai chi are all helpful. One study reported that exercise alleviated hot flashes. In another study, a healthy diet plus regular, consistent exercise helped ward off the weight gain associated with the menopause. Weight-bearing exercises are specifically helpful for protecting against bone less. A recently designed successful program for older women employs weighted vests instead of traditional weights. In a 2001 study, after more than five years women on the program lost less than 1% of hip bone mass compared to 3.8% in women not on the program.

Quit Smoking

If a woman smokes, she should quit. Smoking is linked to a decline in estrogen levels. Women who smoke experience menopause about two years earlier than nonsmokers. Smoking also accounts for 41% of heart-related deaths in women and is a major risk factor for osteoporosis.