October
2006 Today’s CPE: Perimenopause:
Nutritional Management
By Carol Ann Brannon, MS, RD, LD
Today’s Dietitian
Vol. 8 No. 10 P. 10
For many women, midlife is both the best and
worst of times. Children are less dependent, allowing women
more energy to be creative, productive, and adventurous. The
middle years can be a time of freedom, prosperity, self-confidence,
and self-expression—a true prime of life. The term prime
time women has been coined to describe Baby Boomer women born
between 1946 and l964.1
But prime time can also be the worst of times
because physical and social factors place maximum stress on
women. The middle years have also been characterized as the
“sandwich years,” with child care duties butting
into, and sometimes overlapping, parent care obligations. This
is compounded by delayed childbearing, the increasing life span
of elders, the fragmenting of community support in a mobile
society, and a tendency toward smaller families, leaving fewer
adults to share elder care duties. The late humorist Erma Bombeck
once commented: “I’m trying very hard to understand
this generation. They have adjusted the timetable for childbearing
so that menopause and teaching a 16-year-old how to drive a
car will occur in the same week.”
Female Baby Boomers represent nearly 38% of
the U.S. population, which means an estimated 50 million women
are in the prime time phase of life or are about to be. The
daily stress level can be tremendous and unrelenting, and it
is compounded by a series of developing physical and emotional
maladies related to menopause.2
The “M”
Word
Menopause is a single event: the last menstrual flow of a woman’s
life. Perimenopause, a relatively new term, describes the transitional
period (usually three to 10 years) before menopause, when the
ovaries begin decreasing hormone production.2,3 An estimated
30 million women are menopausal and 20 million are on the brink
of menopause.4
Today, women are seeking ways to approach and
manage perimenopausal symptoms “naturally,” without
prescription hormones or medications. Herbs, supplements, yoga,
bodywork, stress management, and exercise all have their place.
But increasingly, women look to foods and beverages that promote
health, wellness, and longevity as part of their regime.1
Overview of Perimenopause
Perimenopause generally begins in the mid-40s to early 50s,
but some women may begin to experience subtle changes as early
as their 30s or as late as their mid- to late-50s. Smokers experience
menopause one to two years earlier than nonsmokers.4
The signs and symptoms of perimenopause differ
slightly from menopause symptoms, as shown in Table
1. Women may experience a few or all of these symptoms.2,3
By far, the most significant physiological change
is fluctuating levels of hormones, especially estrogen and progesterone.
Estrogen is the female sex hormone responsible
for monthly ovulation. During perimenopause, estrogen levels
decline, preventing ovulation. Estrogen also promotes cell division
in the hormone-sensitive tissues (breast, uterus, bone, liver,
heart, brain), protects against cardiovascular disease by increasing
high-density lipoprotein levels and decreasing low-density lipoprotein
(LDL) levels and lipid oxidation, and assists with bone mineralization
and maintenance of bone mass. Estrogen also plays a major role
in midlife weight gain. As the ovarian estrogen production declines,
fat cells migrate to the abdominal area and begin estrogen production.
Women who are obese have higher levels of estrogen.2,3,4
Progesterone levels, like estrogen levels, decrease
during perimenopause. Water retention and bloating are attributed
to low progesterone levels. Although water retention does not
result in actual weight gain, women complain that their clothes
feel tighter and they feel heavier. Water retention and bloating
usually disappear within a few months.3
When these two hormones are in balance, women
feel vital, alert, optimistic, and have a healthy sex drive.
Hormone balance promotes healthy, soft, firm skin and offers
protection against heart disease, stroke, and osteoporosis.
Estrogen levels drop approximately 40% to 60% in perimenopause,
while progesterone levels can drop to zero. Estrogen and progesterone
have opposing and complementary roles (see Table
2).3,4
Androgens are steroid hormones such as testosterone
and dehydroepiandrosterone that play important roles in maintaining
sexual desire, muscle mass, bone density, fat distribution,
mood, energy, and feelings of well-being. During perimenopause,
androgen levels decline.3
Testosterone helps the body create lean muscle
mass. The greater the percentage of lean body mass (LBM), the
higher a woman’s basal metabolic rate (BMR). Declining
levels during perimenopause result in loss of LBM, thereby lowering
basal metabolism.3
Weight Gain
Especially troublesome for many women is a tendency toward weight
gain and increased body fat percentage—midlife spread.
Many factors influence midlife weight gain, including genetics,
activity and fitness level, diet history, use of birth control
pills or hormone replacement therapy (HRT), and stress.5 There
is a definite gender bias: Females have an estimated 30 billion
fat cells, and female fat cells are larger and contain more
fat mass than male fat cells. They can store fat quickly and
are resistant to dieting. At midlife, there is an increase in
fat-storing enzymes and a decrease in fat-releasing enzymes.5
Accordingly, the sandwich years often become
the “no sandwich” years. Chronic dieting, the restriction
of calories in the absence of increased activity or exercise,
results in an increased level of fat-storing enzymes, a decrease
in LBM, lowered BMR, and an increase in percentage of body fat.5
Chronic dieting may intensify and lengthen the
duration of perimenopause symptoms and is associated with developing
insulin resistance during the prime time years. A low-fat, high-carbohydrate
diet, including processed and refined foods, contributes to
insulin resistance as well as midlife weight gain.5
Since hormones are the culprits, it is logical
to prescribe low-dose birth control pills to alleviate hot flashes,
vaginal dryness, and premenstrual syndrome (PMS).6 However,
this extra estrogen can increase body fat by 1% to 2%.5 HRT—particularly
combined estrogen and progesterone—is no longer routinely
prescribed, as it may actually be harmful.7 Some studies conclude
that women on HRT gain more weight and body fat, while other
studies report no significant difference in the amount of weight
gain but a difference in where fat was gained. Women on HRT
gained more fat in the lower body. Although any weight gain
is undesirable, an increase in abdominal fat is more hazardous
to health as it increases the risk of diabetes and heart disease.5
Stress contributes to weight gain by increasing
the release of adrenaline, cortisol, and other “fight
or flight” hormones. The body stores fat to ensure that
energy is available when needed. Unremitting stress results
in chronic elevation of stress hormones. Long-term stress can
cause adrenal fatigue, a metabolic disorder, and/or a state
of chronic inflammation.3 In addition to fat storage, stress
can contribute to compulsive behavior: overeating, drastically
restricting calories, purging, and/or exercising excessively.
Midlife weight gain is not all bad. The estrogen
produced by fat cells protects against osteoporosis and loss
of skin elasticity, enhances sleep, and may help ameliorate
hot flashes.5 Women should be encouraged to focus on their total
well-being rather than just their weight. Part of that focus
should be on functional foods.
Functional Foods
The role of functional foods is three-fold: to manage perimenopause
symptoms, control weight gain, and reduce the risk of postmenopause
diseases (heart disease, osteoporosis, breast and colon cancers,
metabolic syndrome, and diabetes). The optimal diet includes
various functional foods, such as the following:
Whole Grains. Most experts agree that women,
especially those in midlife, should replace refined, processed
sugars and carbohydrates with whole grains and seeds. Whole
grains contain B vitamins, antioxidants, vitamin E, selenium,
zinc, calcium, copper, iron, manganese, magnesium, phytochemicals
such as rutin (a flavonoid found in buckwheat that may reduce
heart disease risk), and lignans, a type of phytoestrogen. Whole
grains appear to play a role in alleviating perimenopausal symptoms
and are important for weight control.8
Some experts advise avoidance of wheat since
wheat foods can worsen perimenopause-related endometriosis and
PMS symptoms, especially in women sensitive to gluten. Brown
rice, quinoa, corn, or soy-based breads, crackers, pasta, and
other whole grains can be enjoyed as a replacement to wheat.9,10
Eating whole grains is linked to a lower risk
of heart disease and stroke due to the cholesterol-lowering
properties of soluble fiber. Oats, barley, and rye are particularly
rich in soluble fiber. Whole grains and cereals appear to improve
insulin sensitivity.11 Whole grains promote regularity and may
reduce the risk of colon cancer and possibly other cancers.8
Phytoestrogens are naturally occurring plant
compounds or phytochemicals found in various fruits, vegetables,
legumes, nuts, and seeds. There are two classes of phytoestrogens:
lignans and isoflavonoids. Lignans are found in whole grains,
certain seeds, fruits, vegetables, and flaxseed. Isoflavonoids
are divided into two subgroups: isoflavones and coumestans.
Legumes, particularly soybeans, are the richest source of isoflavones.
Coumestans are found in bean sprouts.8,12,13
Because they chemically resemble estrogen, phytoestrogens
can mimic estrogen’s actions by acting as selective estrogen
receptor modulators by binding to receptors for estrogen metabolites.
Their estrogenic activity is approximately 1,000 times weaker
than true estrogen. The perimenopause health benefits of phytoestrogens
include the following8,12-14:
• reduce severity of hot flashes;
• reduce LDL cholesterol/heart disease
risk;
• favor bone density; and
• reduce breast cancer risk.
Isoflavones are found almost exclusively in
legumes, including soybeans, chickpeas, lentils, beans, and
peanuts. Soy isoflavones are converted to the active metabolites
genistein, daidzein, and equol by colonic bacteria. Isoflavones
appear to stabilize hormones, lower cholesterol, and protect
against cancer, strokes, osteoporosis, and cognitive decline.8,13,14
The message that soy phytoestrogens act as surrogate
estrogens has been widely promulgated, leading women to believe
that soy foods or supplements can naturally and effectively
relieve perimenopausal symptoms, particularly hot flashes. Research
is inconclusive. However, many women believe soy/isoflavone
supplements are helpful, despite a lack of substantial scientific
evidence to support their use.8,13-15
Soy phytoestrogens, due to their estrogenic
effect, stimulate the growth of breast cancer cells in vitro.
Several studies suggest that soy protein isolates stimulate
the growth of normal breast cells, similar to the action of
natural estrogens, thereby increasing breast cancer risk in
the absence of progesterone. There is controversy over whether
soy foods may be contraindicated for women with existing estrogen-sensitive
breast cancer. Women with breast cancer should discuss soy consumption
with their oncologist. Yet, there is scientific evidence suggesting
that soy consumption during adolescence may help protect against
breast cancer later in a woman’s life.8
The potential effect of soy on thyroid function
is a controversial topic. Some researchers believe soy depresses
thyroid function in menopausal women while others claim that
human trial studies do not demonstrate that soy or isoflavones
adversely affect thyroid function in healthy women. Soy intake
may increase the thyroid medication dose needed by women with
hypothyroidism, but this is not unusual; even fiber supplements
have a similar effect. More studies are needed to clarify the
relationship between dietary soy and thyroid function.16
In general, experts advise that healthy adults
can safely consume two to three servings of soy foods daily,
providing 100 to 160 milligrams of isoflavones.
The following are the recommendations for healthy
adults:
• Eat soy foods daily
• Soy isoflavones: 100 to 160 milligrams
(Caution: Consult your doctor before taking isoflavone supplements.)
• Each 1/2-cup serving of the following
has 35 to 50 milligrams of soy isoflavones:
- Soy milk
- Tofu
- Tempeh
- Edamame
The availability of isoflavones is highest in
fermented soy foods (natto, miso, tempeh, and fermented tofu
and soy milk). Processed and unfermented soy foods are relatively
poor sources of isoflavones.8,12
The FDA has concluded that there is adequate
scientific evidence to warrant a health claim regarding soy
protein and reduced risk of heart disease. To qualify for this
health claim, a food must be low in fat and cholesterol and
contain at least 6.25 grams of soy protein per serving.8
Lignans are found in a wide selection of plant
foods (cereals, seeds, flaxseed, fennel, parsley, nuts, vegetables,
apples, and other fruits). Linseed (flaxseed) is the richest
source of phytoestrogens while rye is a moderately rich source.13,15
Flaxseed has been called “the most powerful
plant on the planet” because it contains phytoestrogens,
antioxidants, omega-3 fatty acids, and anticancer agents (see
Table 3). It is rich in
fiber, which facilitates the excretion of excess, harmful estrogen
metabolites. This may reduce the risk of colon and breast cancers.
Unlike soy isoflavones, lignans inhibit the proliferation of
estrogen-sensitive breast cancer cells. In addition, flaxseed
stabilizes cholesterol levels. Consumption of flaxseed lengthens
menstrual cycles. Longer cycles reduce a woman’s exposure
to potentially harmful estrogen metabolites, increase progesterone-estrogen
ratios, decrease anovulatory cycles, and alleviate hot flashes.13,14
The recommended daily dietary intake is 2 to
4 tablespoons of ground flaxseed or 1 tablespoon of flax oil.
It’s important to grind flaxseeds in a coffee or spice
grinder before eating because whole seeds pass through the digestive
system intact. For optimal freshness, store in the freezer..8,13
Cruciferous vegetables, such as cabbage, Brussels
sprouts, cauliflower, and broccoli, contain the phytochemical
indole, the precursor of diindolylmethane. In animal studies,
supplemental diindolylmethane favors the production of 2-hydroxyestrogen—the
“good” estrogen metabolite that can stimulate progesterone
production. So, by promoting 2-hydroxy production, diindolylmethane
supplementation indirectly supports progesterone production.
Since progesterone levels decline during perimenopause, such
supplementation may be beneficial. In addition to favoring the
metabolism of good estrogen metabolites, indole reduces the
proliferation or reproduction of estrogen-receptive cancer cells,
thereby decreasing breast cancer risk.
It is premature to recommend dietary supplementation
with diindolylmethane, available in nutrition stores or online
as indole-3 carbinol. However, dietitians can and should encourage
perimenopausal women to consume cruciferous vegetables frequently
for various reasons.14,17
Omega-3 fatty acids: It is important for perimenopausal
women to maintain a healthy balance of omega-6 and omega-3 fatty
acids. The typical American diet consists of a 10-to-1 ratio
of omega-6–to–omega-3 fatty acids; a healthy ratio
is 5-to-1 or less. Diets deficient in omega-3s have been associated
with low production of good estrogen metabolites. Omega-3 fatty
acids protect against inflammation, prevent postmenopausal heart
disease and bone loss, enhance cognitive ability, and aid in
depression treatment.8,14 (See Table
4 for dietary sources and recommendations.)
Probiotics are beneficial bacteria that live
in the colon. The most common probiotics are lactobacillus acidophilus,
lactobacillus bulgaricus, and bifidobacterium bifidum. Probiotics
are beneficial in food digestion, synthesis of B vitamins, promoting
urinary/genital health, lowering cholesterol levels, enhancing
immune function, and decreasing cancer risk. Probiotics can
be especially beneficial during perimenopause in protecting
against yeast infections and urinary tract infections, aiding
in hormone balance, and lowering cholesterol levels. Probiotics
are involved in the synthesis of B vitamins (B6, B12, folate),
which function as cofactors for enzymes involved in estrogen
metabolism.8,14
Probiotics are found in fermented foods, particularly
dairy foods, and in various supplemental forms, including freeze-dried
powders, capsules, wafers, and liquids. Homeostatic soil organisms
(HSO), the newest addition to the list of probiotic supplements,
are cultured in labs in a substrate containing approximately
70 trace minerals, micronutrients, proteins, and enzymes. The
recommended daily dosage of HSO is three capsules or 1 teaspoon
of powder.18,19 To ensure viability and potency, probiotic supplements
should be refrigerated and packaged in airtight glass rather
than plastic containers.20 Capsules are preferred over powders
and liquids because they are more convenient and have better
viability.20
A daily dose of at least 1 billion colonizing-forming
units (CFUs) is needed for health improvement. Yogurt products,
depending on the brand, provide a range of 15 to 155 billion
CFUs per serving. On average, probiotic supplements provide
approximately 20 million to 70 billion CFUs per daily dose.20
Probiotic supplements should be taken in the morning or between
meals when stomach acid levels are low.20 A person should always
consult a physician before taking any dietary supplement and
be aware of any potential food-drug interactions.
Prebiotics are nondigestible carbohydrates that
selectively stimulate the growth of probiotics. Inulin and fructo-oligosaccharides,
the most popular prebiotics, are found in various plant foods
and fat or sugar replacers. Prebiotics yield a host of health
benefits, including inhibiting pathogenic bacteria growth; maintaining
regularity; preventing colon carcinogenesis; enhancing mineral,
especially calcium, absorption; decreasing serum triglycerides;
and decreasing postprandial glucose and insulin levels (reported
in animal studies).8,21
Synbiotics. To improve the viability and vitality
of probiotics, a prebiotic should be included with probiotics.1,8
Foods and supplements containing both probiotics and prebiotics
are called synbiotics. Fermented milks, yogurt and kefir, and
some cheeses are the most popular synbiotic foods. However,
not all fermented milks contain prebiotics.1,8
Green tea’s popularity as a health beverage
continues to increase. Green tea contains antioxidants and phytochemicals—including
flavonoids and polyphenols, known for their ability to enhance
immunity, and epigallocatechin gallate (ECGC), a phytochemical
found to positively affect BMR. ECGC is included as an active
ingredient in many over-the-counter weight-loss supplements.
Many other health benefits, including weight loss, are attributed
to the consumption of 3 to 6 cups of green tea daily.22
Micronutrient-rich foods. Selected micronutrients
have been identified as beneficial in managing perimenopausal
symptoms and offering disease protection. Vitamins C and D and
magnesium help preserve bone mass. Boron helps maintain magnesium
levels, which decrease as estrogen levels decline. Vitamin E
helps alleviate hot flashes. Chromium improves glucose control.
The phytochemical hesperiden exerts a weak estrogenic effect.2,3,14,23
Supplemental intake may be warranted, but it is better to increase
dietary intake of micronutrients (see Table
5).
Variety is key. Women should consume 20 to 30
different foods daily. Sound impossible? Not if you include
whole multigrain breads and cereals and lots of colorful plant
foods.9,10 Women may find it helpful to keep a food diary to
heighten awareness of their hot flash triggers and alleviators.
The most common hot flash triggers are caffeine, alcohol, and
hot or spicy foods.9 When women eat may be as important as what
they eat. Large meals can raise body temperature.
Perimenopause is a good time for women to take
a lifestyle inventory and take steps to improve their health.
Dietitians must understand that each woman’s experiences
are unique and be respectful and sensitive to each client’s
worldview. Often, women start pondering the “big”
questions: “What is life?” “Why am I here?”
“How much Healthy Choice ice cream can I eat before it’s
no longer a healthy choice?” Did I mention the importance
of maintaining a sense of humor?
— Carol Ann Brannon, MS, RD, LD, is
a consulting dietitian at Fowler YMCA and in private practice
in Georgia.
Examination
1. Perimenopause:
a. occurs three to 10 years prior to menopause.
b. is characterized by decreasing progesterone levels.
c. occurs earlier in life for smokers.
d. is characterized by symptoms similar to menopause.
e. all of the above
2. Today’s prime time women are:
a. seeking foods that will enhance longevity and wellness.
b. losing interest in nutritional remedies.
c. not impacted by stress.
d. not concerned about the safety of hormone replacement therapy.
e. all of the above
3. All of the following are functions of estrogen,
except:
a. stimulates growth.
b. increases body fat.
c. acts as a natural diuretic.
d. elevates mood.
e. protects bone mass.
4. Female midlife fat cells:
a. are smaller but more dense than male fat cells.
b. are larger and more dense than male fat cells.
c. can help restore hormone balance by producing progesterone.
d. are sensitive to insulin.
e. none of the above
5. ___________ is/are found in whole grains
and is/are components of coenzymes involved in estrogen metabolism.
a. B vitamins
b. Vitamin C
c. Omega-3 fatty acids
d. Isoflavones
e. Selenium
6. The phytochemical rutin is found in:
a. oats.
b. buckwheat.
c. rye.
d. cruciferous vegetables.
e. soybeans.
7. The scientific evidence conclusively supports
soy as being:
a. safe for all women.
b. effective in alleviating hot flashes.
c. effective in lowering cholesterol levels.
d. beneficial for women with hypothyroidism.
e. all of the above
8. Low levels of ____________ are implicated
in causing bloating and water retention is.
a. estrogen
b. cortisol
c. testosterone
d. progesterone
e. epinephrine
9. ____________ is/are considered the “most
powerful plant food(s).”
a. Soybeans
b. Whole grains
c. Flaxseed
d. Cruciferous vegetables
e. Red and purple berries
10. ___________ contains antioxidants and a
phytochemical that may increase basal metabolic rate.
a. Tempeh
b. Yogurt
c. Cruciferous vegetables
d. Green tea
e. Fermented milk
References
1. “Tools for Innovation: Dairy Foods for Today’s
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2. Northrup C. The Wisdom of Menopause: Creating
Physical and Emotional Health and Healing During the Change.
New York: Bantam Books, 2001.
3. Lee JR, Hopkins V. What Your Doctor May Not
Tell You About Menopause: The Breakthrough Book on Natural Progesterone.
New York: Warner Books, 1996.
4. Menopause.
Integrative Medicine. AJC Health. Accessed September 26, 2005.
5. Waterhouse D. Outsmarting the Midlife Fat
Cell: Winning Weight Control Strategies for Women Over Age 35
to Stay Fit Through Menopause. New York: MFJ Books, 1998.
6. Perimenopause.
Mayo Clinic. Accessed July 16, 2006.
7. Rossouw JE, Anderson GL, Prentice RL, et
al. Risks and benefits of estrogen plus progestin in healthy
postmenopausal women: Principal results from the Women’s
Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.
8. Brannon CA. Functional Foods: Vol 1 &
2. Nutrition Dimension, Inc. Available at: http://www.nutritiondimension.com.
Ashland, Ore., 2005, 2006.
9. Magee E. The Change of Life Diet & Cookbook.
New York: Avery, 2004.
10. Gittleman AL. Hot Times: How to Eat Well,
Live Healthy, and Feel Sexy During the Change. New York: Avery,
2005.
11. Weickert MO, Mohlig M, Schofl C, et al.
Cereal fiber improves whole-body insulin sensitivity in overweight
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12. Lyons P. A nutritional perspective on soy
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