April 2019 Issue

Nutrition’s Impact on Menopause Timing
By Jamie Santa Cruz
Today’s Dietitian
Vol. 21, No. 4, P. 40

Can diet influence whether menopause begins early, late, or right on time?

Dietary factors have long been studied for their potential to help manage the uncomfortable symptoms associated with menopause, such as hot flashes and insomnia.1-3 However, new research is shedding light on the potential for nutrition to impact another aspect of menopause—namely, the age at which it starts.

Average age of natural menopause is a public health concern because earlier menopause has been associated with an increased risk of all-cause mortality and shorter life expectancy.4,5 It’s also associated with increased risk of diabetes,6 CVD,5,7-10 stroke,11 atherosclerosis,12 osteoporosis and fracture,13-15 and cognitive decline.16-18 Later menopause, in turn, also has associated health risks—namely, a greater likelihood of hormone-related cancers, including breast, endometrial, and ovarian.19-24 

Given the risks associated with both early and late menopause, the ideal age for natural menopause appears to be between 47 and 53. “If you’re within that age range for menopause timing, typically those women don’t see the increased risk of the outcomes on either side,” says Alexandra Purdue-Smithe, PhD, a postdoctoral fellow in the division of intramural population health research at the National Institute of Child Health & Human Development.

The median age at menopause among white women is 50–52 years, but the average varies by race and ethnicity.25 Approximately 5% of Western women experience early natural menopause (ie, before age 45).26,27

“The thinking behind that variation is that it is potentially due to genetics but also potentially due to modifiable lifestyle factors as well—things like diet, exposure to all sorts of things, physical activity,” Purdue-Smithe says.

Role of Nutrition
Women are born with a fixed number of follicles (immature eggs) in their ovaries, and menopause occurs when the quantity of ovarian follicles falls below a critical threshold.28 Although ovarian reserve (the number of follicles in the ovaries) decreases as a woman ages, the rate of decline varies from woman to woman.29-31 Diet and nutrition status influence factors that promote follicular atrophy, including oxidative stress and inflammation.32,33 Therefore, diet is thought to have a role in influencing ovarian reserve and, by extension, timing of menopause.

However, research on the impact of diet on menopause timing is in the early stages. “There are very few studies regarding the associations between diet and timing of menopause, which makes it difficult to really draw any conclusions,” says Yashvee Dunneram, a PhD student in the School of Food Science and Nutrition at the University of Leeds and the lead author of a 2019 study on diet and menopause timing. Dunneram currently has a narrative review on diet and timing of menopause in press with the Proceedings of the Nutrition Society,34 but she reports having just 14 published papers to draw from in preparing the review.

That said, several large, long-term studies have appeared in the last two years, boosting the case for nutrition’s role in impacting age at menopause. Although these new studies don’t yet provide conclusive evidence of specific dietary factors that impact the timing of menopause, they at least provide strong hints.

Vitamin D and Dairy Foods
Until recently, research on vitamin D and menopause timing has been a paradox. Accumulating research suggests that vitamin D is associated with fertility, with deficiency in this vitamin increasing risk of infertility.35 Some research also suggests that higher vitamin D levels may be linked with increased ovarian reserve.36-38 However, at least two cross-sectional studies failed to find an association between vitamin D and ovarian reserve,39,40 and studies examining vitamin D intake and timing of menopause also have failed to identify a link.41,42 

However, significant new research from Purdue-Smithe and colleagues has shed additional light on the issue of vitamin D and its relation to menopause timing. In a large, well-designed study published in 2017, Purdue-Smithe and her colleagues used data from the Nurses Health Study II (NHS2), which prospectively followed approximately 116,000 female US registered nurses for more than 20 years (1989 to 2011). The study relied on food frequency questionnaires, updated every four years, to estimate calcium and vitamin D intake from both dietary and supplemental sources.

Purdue-Smithe and her colleagues found that those with the highest intake of dietary calcium had a slightly lower risk of early menopause, and those with the highest intake of dietary vitamin D had a significantly (17%) lower risk of early menopause. The association was especially strong with calcium and vitamin D from dairy foods. No benefit was seen from supplemental forms of calcium and vitamin D.43

The fact that the protective benefits appeared especially high with dairy foods raised the question of whether the benefits were coming from calcium and vitamin D, or whether the benefits were coming from some other component of dairy foods (such as the progesterone or estradiol content in dairy). Thus, the same research group published a second prospective study earlier this year examining dairy intake and its association with early menopause. Relying once again on data from NHS2, the researchers found that intake of low-fat (but not high-fat) dairy was associated with a lower risk of early menopause.44

These findings are consistent with another large prospective study of more than 46,000 women published in 2013. This study likewise found that high intake of low-fat dairy—but not total calcium or total vitamin D intake—was associated with later menopause.45

According to Purdue-Smithe, these findings taken together suggest that intakes of calcium and vitamin D are less relevant to menopause timing than consumption of dairy foods. Furthermore, the benefits from dairy consumption probably are due to the nonnutritive components of these foods (namely, the hormone content), rather than the presence of actual nutrients such as vitamins.

Animal vs Vegetable Protein
Various studies have investigated protein intake; few have reported significant associations between total protein intake and age at menopause.32,33,41,42 

Regarding specific sources of protein, results have been mixed. Most research has found no association between soy protein intake and timing of menopause.32,33,42 Findings have been split on meat intake: Some studies have reported no association,33,46 but at least three other studies—one cross-sectional and two prospective—found that higher meat intake was significantly associated with later age at menopause.32,47,48 In a prospective study of 1,130 Japanese women, animal protein intake wasn’t associated with menopause onset, but, surprisingly, moderate vegetable protein intake—though neither low nor high—predicted earlier menopause.42

All of the above research on protein intake included a relatively wide age range and examined dietary factors in relation to timing of menopause overall. By contrast, a 2018 study led by one of Purdue-Smithe’s colleagues examined the association of dietary protein with risk of early menopause (before age 45) in particular. The study, based once again on data from NHS2, found that nurses in the highest quintile of vegetable protein intake had a 16% lower risk of early menopause compared with those in the lowest quintile, whereas intake of animal protein conferred no protective benefits.49 The fact that the study followed participants for 20 years (most prospective studies have followed women for a significantly shorter period) strengthens confidence in the association.

Previous research on fertility supports the hypothesis of a differing impact of animal vs vegetable protein on ovarian function. A separate study using NHS2 data found that high intake of animal protein was associated with greater ovulatory infertility, whereas high intake of vegetable protein was linked with lower infertility. Furthermore, replacing 5% of animal protein in the diet with vegetable protein was associated with a 50% reduction in infertility.50

In addition, findings from animal models provide physiological evidence of a differing role for animal vs vegetable protein in ovarian aging. In a study of macaques, females who were randomized to an animal protein–based diet (casein and lactalbumin) had significantly fewer follicles in their ovaries after 32 months than those who ate a vegetable protein diet (soy with isoflavones). The macaques on the animal protein diet also had significantly worse cholesterol profiles and artery function than those on the vegetable protein diet, leading the study authors to theorize that the reduced follicle pool may have been a result of the animals’ atherosclerosis and reduced blood flow to the ovaries.51

Other Dietary Factors and Menopause Timing
Various research has examined the impact of other dietary factors—including intake of alcohol, fruits and vegetables, fish, fiber, carbohydrates, and fat—on both ovarian reserve and timing of menopause. However, studies on these factors have either failed to find significant associations, or the findings were so inconsistent that it’s difficult to draw any conclusions.52,53

For example, with respect to fish intake, a 2018 study led by Dunneram prospectively followed 35,372 women enrolled in the UK Women’s Cohort Study and found that a high intake of oily fish was associated with a delay of 3.3 years in onset of natural menopause.48 In contrast, however, the EPIC-Heidelberg study, which prospectively followed close to 5,000 premenopausal German women for a median of 5.8 years, found no association of fish intake with age at menopause—although it’s unclear whether oily fish was assessed separately from other fish.32 Furthermore, other research has found that high intake of polyunsaturated fat (the kind of fat found in oily fish) is associated with earlier menopause, not later menopause.53,54

Studies on vegetable consumption have likewise produced conflicting results. In the prospective Shanghai Women’s Health Study, vegetable consumption wasn’t linked to timing of menopause.33 But in a six-year prospective study of 1,130 Japanese women, green and yellow vegetable intake was associated with later menopause.42 Conversely, however, in the EPIC-Heidelberg cohort, women in the third quartile of vegetable intake experienced menopause earlier than those in the first quartile.32

Yet another example of inconsistent findings centers around fruit intake. The EPIC-Heidelberg study found no association between menopause timing and fruit consumption,32 and the Shanghai Women’s Health Study found only a weak correlation regarding fruit intake and later menopause.33 However, an Australian study that prospectively followed participants for 12.5 years found that fruit intake was correlated with a significant delay in natural menopause.55

Making Sense of Contradictory Research
Several factors help to explain why many of the findings relating to diet and timing of menopause have been contradictory. One of these, according to Sunni Mumford, PhD, Stadtman Investigator in the division of intramural population health research at the National Institute of Child Health & Human Development, is that almost all research in this area has relied on food frequency questionnaires to estimate dietary intakes, even though such questionnaires often are prone to error.56,57

“In the Nurses Health Study, for example, [investigators] used food frequency questionnaires, and those are asking women to remember what they ate over the last [four] years,” Mumford says. Even when researchers ask women what they ate just yesterday, “people don’t remember what they eat.”

A second factor that may account for some contradictory findings is that women tend to alter their diets as they near menopause. “In the years leading up to menopause, women go through a lot of hormonal changes,” Purdue-Smithe says. “They are potentially changing their diets to try to lose weight, or they’re dealing with really heavy periods and other issues. So there is a lot of dietary modification in those years.” This means that the dietary intakes women have reported in some of the studies on menopause timing may not reflect the women’s long-term diets. In addition, they may not provide a good indication of dietary factors that actually impacted their menopause timing. “The studies that are done over a longer period of time give a better idea of how diet is related to early menopause,” Purdue-Smithe says.

A third factor that may play a role in the contradictory findings is that many of the available studies included women representing a relatively wide age range and examined associations of dietary factors with overall age of menopause, rather than evaluating the risk specifically for early menopause (before age 45).

According to Purdue-Smithe, factors affecting menopause timing among women who remain premenopausal into their late 40s or beyond are likely different than factors that contribute to menopause before age 45. “We think that dietary factors and lifestyle factors are potentially more strongly related to risk of early menopause (before age 45) than overall menopause timing,” she says. “Dietary factors don’t matter as much once you get beyond about age 45.”

The upshot, according to Dunneram, is that more research—especially in the form of intervention studies—is needed to better establish which dietary factors actually play a role in menopause timing. “Randomized controlled trials are required, and, unfortunately, to date there is only one such trial that has been conducted in this area,” Dunneram says. That trial, published in 2006, evaluated the impact of a low-fat, high-carbohydrate diet on menopause timing, but found that such a diet did not, in fact, influence age at menopause.58

Endocrine Disruptors and Menopause Timing
While the impact of nutrition status on menopause timing is still developing, growing research suggests that exposure to endocrine disruptors—that is, chemicals that either mimic or block the action of human hormones—is an additional factor that influences timing of menopause.

Diet is the major avenue of exposure for a variety of endocrine disruptors, including phthalates, polychlorinated biphenyls (PCBs), bisphenol A (BPA), parabens, and pesticides. Phthalates, for instance, consistently are found in high concentrations in poultry, cooking oils, and dairy products.59 Exposure to PCBs comes primarily through animal foods such as fish, meat, eggs, and dairy.60 Major sources of BPA include canned foods and water from plastic bottles.61,62 In the general population, exposure to pesticides also occurs largely through contaminated food and water.63

All of these endocrine disruptors have been linked to various adverse effects on female fertility,64 and several also have been tied to early menopause. A 2015 analysis of 111 known endocrine-disrupting chemicals found that 15 of them—including nine PCBs, three pesticides, and two phthalates—were significantly associated with earlier menopause. In fact, women with high levels of the 15 endocrine disruptors experienced menopause up to 3.8 years earlier than women with low levels.65

Bottom-Line Counseling Strategies
Given that the field is young and findings regarding many dietary factors are inconsistent thus far, there are few firm indications as to how women should eat to achieve ideal menopause timing. The findings from the large-scale, long-term NHS2 data appear to suggest that low-fat dairy is protective against early menopause, as is higher consumption of vegetable protein. Thus Purdue-Smithe suggests that dietitians can safely encourage consumption of those foods. She adds, however, that the science “is certainly evolving, and it’s really a new frontier, so it’s hard to make any conclusive statements.”

Even if more were known about specific dietary factors that impact menopause timing, making universal dietary recommendations would be difficult, Dunneram cautions. After all, neither delaying nor accelerating menopause is a good idea across the board, since both early and late menopause are linked with negative health outcomes. Thus, as research unfolds, health practitioners and dietitians will need to consider a woman’s family history and specific disease risk factors to provide explicit dietary advice relating to menopause timing.

For now, according to Dunneram, simply encouraging a generally healthful eating pattern is the best course. “As there are no conclusive findings for the timing of menopause in relation to diet, advising premenopausal women or those close to menopause about a balanced diet is key,” Dunneram says.

— Jamie Santa Cruz is a freelance writer of health and medical topics in the greater Denver area.

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