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All humans experience milestone biological development stages throughout their lifecycle. Perimenopause, also known as the menopausal transition, is a significant female life stage when reproductive hormone levels fluctuate and ultimately decrease until menstrual periods stop permanently at menopause. While the span and experience of the transition to menopause is very individual, the average time spent in perimenopause is reportedly around four years,1 and common symptoms include irregular or heavy menstruation, hot flashes, disrupted sleep, musculoskeletal pain,2 and mood changes. Women in perimenopause may also experience other health impacts such as cardiometabolic changes, less favorable fat distribution, increased systemic inflammation, and cognitive health issues.3-6
Lifestyle-based approaches such as nutrition, exercise or movement routines, and stress transformation practices may help support a woman’s optimal health during perimenopause. How can personalized lifestyle interventions also help to alleviate a patient’s problematic perimenopausal symptoms?
In the following video, IFM educator Wendy Warner, MD, IFMCP, discusses vasomotor symptoms that individuals may experience during their menopausal transition and how the functional medicine approach may benefit patients experiencing such symptoms. At IFM’s Hormone Advanced Practice Module (APM), Dr. Warner expands this discussion to more fully explore the topic of navigating perimenopause.
Maintaining Optimal Health During Perimenopause
The potential health problems and increased chronic disease risks due to reduced estrogen levels in the years following menopause are well documented.7 However, research studies have often combined peri- and postmenopausal populations when investigating this female life stage, even though these populations are unique and have different clinical needs. More recent studies have progressed to differentiate between populations and to specifically explore health outcomes associated with perimenopause and beneficial lifestyle-based approaches for symptoms experienced during the menopausal transition.
CARDIOMETABOLIC HEALTH & body composition
Changes in body composition and cardiometabolic risks have been noted for women in perimenopause. A 2020 US-based cohort study assessed these changes and risks among white women (n=69; average BMI 26.3) and Black women (n=25; average BMI 28.8) during the menopausal transition.8 Investigators found that during perimenopause, white participants gained significant weight, total body adiposity, and abdominal adipose tissue, including a 15% increase of visceral fat. In addition, they showed significant increases in total cholesterol and LDL-c.8 Conversely, investigators found that Black participants who initially had BMIs indicating borderline obesity had more abdominal adiposity prior to perimenopause and maintained their body composition and levels of abdominal adiposity during the menopausal transition.8 In addition, during perimenopause, they did not show significant changes in cardiometabolic risk factors.8 A 2020 retrospective observational study (n=275 women from Spain) investigated changes in the metabolic profile during the menopausal transition by evaluating lipid profiles.3 Investigators in this study found that for this population, significant changes in LDL-c levels occurred during perimenopause, with levels highest after the menopausal transition was complete.3
Recent observational studies have found that women in perimenopause who reduced their sedentary time, increased their fruit and vegetable consumption, and improved their cardiorespiratory fitness, upper-body flexibility, and lower-body muscular strength were more likely to prevent central obesity development and optimize their cardiovascular health.9,10 A small 2021 randomized controlled trial (n=78 Chinese women in perimenopause) found the number of patients with abnormal cardiometabolic measurements decreased significantly if they either received a three-month personalized nutrition intervention (similar to the DASH diet) or if they received a three-month comprehensive intervention consisting of detailed nutrition/exercise education, a personalized dietary intervention similar to the DASH diet, and an exercise program (resistance exercises 2x/week, aerobic exercise 2x/week, and 6,000-10,000 steps/day).11
Sleep, Mood, AND DEPRESSION
Sleep disorders and disturbances are common concerns during the menopausal transition, and studies indicate that the fluctuation of estrogen and progesterone levels during this time contributes to the disruption of sleep.12 A 2022 randomized controlled trial of 187 women (60 participants in perimenopause) studied the effect of a 20-week yoga intervention (three 75-minute sessions/week) on menopausal symptoms and sleep quality compared to controls.13 In addition to improvements in overall menopausal symptoms, significant improvements in sleep quality were noted for the perimenopausal yoga group as well as the postmenopausal yoga group who completed the yoga intervention compared to their pre-treatment scores.13
Many women in perimenopause experience mood changes and may develop depressive symptoms or major depressive episodes, especially if they have experienced a prior episode of depression.14,15 A 2020 meta-analysis of 23 RCTs (n=1,812 total participants) evaluated the efficacy of mind-body therapies (MBTs) and exercise-based interventions on perimenopausal symptoms and depression.16 Seven of the included studies investigated depression specifically, and the resulting meta-analysis found that among women in perimenopause, a large, statistically significant improvement of depressive symptoms (SMD -1.10; 95% CI: -1.73 to -0.47) was associated with exercise and MBT interventions with durations greater than 12 weeks (i.e., walking, dance, stretching, massage, relaxation) compared to controls.16
A small randomized controlled trial (n=78 Chinese women in perimenopause) found that following a personalized DASH diet–type nutrition plan for three months was associated with significant reductions in moderate to severe perimenopausal symptoms including depression as well as hot flashes compared to pre-treatment.17 Also of interesting note, those participants who followed a personalized DASH diet–type nutrition plan while also engaging in resistance and aerobic exercise regimes several times a week for three months also reported a significant reduction of hot flashes compared to pre-treatment.17
Studies suggest that isoflavones may help reduce hot flashes, attenuate lumbar spine bone mineral density, benefit systolic blood pressure during early menopause, and improve glycemic control.18,19 Soy-derived isoflavones may also impact depressive symptoms experienced during perimenopause. A 2022 questionnaire-based prospective observational study (n=39 women in perimenopause, 61 women in post-menopause) investigated the impact of taking 40 mg soy isoflavone supplements twice per day for 12 weeks on menopausal symptoms.20 While this study was not randomized or placebo-controlled, the before and after questionnaire responses indicated a 37.5% reduction in symptoms of depression for those participants in perimenopause after the treatment.20
Perimenopause Through a Functional Medicine Lens
During perimenopause, the production of estrogen and progesterone begins to decrease overall, but daily hormone levels are less predictable, with major hormone fluctuations potentially leading to adverse symptoms. Within this complex hormonal environment, understanding an individual patient’s complete health story is a vital step for optimizing wellness during perimenopause. For example, a woman in the menopausal transition who has a history of depression may benefit from practicing a mind-body therapy, or a woman in perimenopause who does not have a current regular exercise routine may find that practicing yoga a few times a week or simply reducing sedentary time improves health and wellness. A personalized approach is essential to effectively assess and treat dysfunctional perimenopausal hormone patterns such as estrogen dominance, suboptimal hormone metabolism, and hormonal insufficiency. Lifestyle habits, gut health issues, chronic stress experiences, environmental toxicant exposures, and blood sugar sensitivities are all important components to consider.
IFM’s “PTSD” mnemonic is a foundational principle for the assessment and treatment of all hormonal imbalances. This functional medicine approach identifies points of leverage where personalized interventions help restore hormonal balance through the improvement of production, transport, sensitivity, and detoxification of hormones. One of IFM’s tools specific to menopause is the Menopause Decision Tree, which is available when attending the Hormone APM. This resource provides an additional guide for assessing an individual patient’s menopausal symptoms and health goals. Identifying menopausal patterns and wellness concerns helps inform an appropriate intervention, and modifiable lifestyle factors, nutrient supplementation, botanicals, and hormone therapies may all be beneficial treatment avenues. Lifestyle-based therapies for optimal health are at the core of the functional medicine approach, and as detailed previously, interventions such as nutrition, exercise, and mind-body therapies have been associated with significant improvements in perimenopausal symptoms, including hot flashes, sleep quality, and reports of depression compared to controls and pre-treatment measurements.
Learn more at IFM’s Hormone APM as functional medicine experts share their clinical pearls for navigating perimenopause while also exploring the multiple factors that affect hormonal balance and function.
Hormone Therapies at MenopauseMenopause, Chronic Illnesses, and the Role of Nutrition
Chronic Stress and Hormone DisruptionSex Hormones and the Gut MicrobiomeSex Hormones and the Female Brain: A Focus on Mood DisordersHormones and Bone Health
- Office on Women’s Health. Menopause basics. US Department of Health & Human Services. Updated January 6, 2023. Accessed May 23, 2023. https://www.womenshealth.gov/menopause/menopause-basics#1
- Lu CB, Liu PF, Zhou YS, et al. Musculoskeletal pain during the menopausal transition: a systematic review and meta-analysis. Neural Plast. 2020;2020:8842110. doi:1155/2020/8842110
- Inaraja V, Thuissard I, Andreu-Vazquez C, Jodar E. Lipid profile changes during the menopausal transition. Menopause. 2020;27(7):780-787. doi:1097/GME.0000000000001532
- Gottfried S. Women: diet, cardiometabolic health, and functional medicine. Phys Med Rehabil Clin N Am. 2022;33(3):621-645. doi:1016/j.pmr.2022.04.005
- McCarthy M, Raval AP. The peri-menopause in a woman’s life: a systemic inflammatory phase that enables later neurodegenerative disease. J Neuroinflammation. 2020;17(1):317. doi:1186/s12974-020-01998-9
- Zhu C, Thomas N, Arunogiri S, Gurvich C. Systematic review and narrative synthesis of cognition in perimenopause: the role of risk factors and menopausal symptoms. Maturitas. 2022;164:76-86. doi:1016/j.maturitas.2022.06.010
- Office on Women’s Health. Menopause and your health. US Department of Health & Human Services. Updated December 15, 2022. Accessed May 23, 2023. https://www.womenshealth.gov/menopause/menopause-and-your-health
- Marlatt KL, Redman LM, Beyl RA, et al. Racial differences in body composition and cardiometabolic risk during the menopause transition: a prospective, observational cohort study. Am J Obstet Gynecol. 2020;222(4):365.e1-365.e18. doi:1016/j.ajog.2019.09.051
- Acosta-Manzano P, Segura-Jiménez V, Coll-Risco I, et al. Association of sedentary time and physical fitness with ideal cardiovascular health in perimenopausal women: the FLAMENCO project. Maturitas. 2019;120:53-60. doi:1016/j.maturitas.2018.11.015
- Su J, Li Q, Mao P, et al. Does the association of sedentary time or fruit/vegetable intake with central obesity depend on menopausal status among women? Int J Environ Res Public Health. 2022;19(16):10083. doi:3390/ijerph191610083
- Hao S, Tan S, Li J, et al. Dietary and exercise interventions for metabolic health in perimenopausal women in Beijing. Asia Pac J Clin Nutr. 2021;30(4):624-631. doi:6133/apjcn.202112_30(4).0009
- Haufe A, Baker FC, Leeners B. The role of ovarian hormones in the pathophysiology of perimenopausal sleep disturbances: a systematic review. Sleep Med Rev. 2022;66:101710. doi:1016/j.smrv.2022.101710
- Susanti HD, Sonko I, Chang PC, Chuang YH, Chung MH. Effects of yoga on menopausal symptoms and sleep quality across menopause statuses: a randomized controlled trial. Nurs Health Sci. 2022;24(2):368-379. doi:1111/nhs.12931
- Maki PM, Kornstein SG, Joffe H, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. J Womens Health (Larchmt). 2019;28(2):117-134. doi:1089/jwh.2018.27099.mensocrec
- Hernández-Muñoz AE, Méndez-Magaña A, Fletes-Rayas AL, Rangel MA, García LT, de Jesús López-Jiménez J. Subjective well-being’s alterations as risk factors for major depressive disorder during the perimenopause onset: an analytical cross-sectional study amongst Mexican women residing in Guadalajara, Jalisco. BMC Womens Health. 2022;22(1):275. doi:1186/s12905-022-01848-1
- Shorey S, Ang L, Lau Y. Efficacy of mind-body therapies and exercise-based interventions on menopausal-related outcomes among Asian perimenopause women: a systematic review, meta-analysis, and synthesis without a meta-analysis. J Adv Nurs. 2020;76(5):1098-1110. doi:1111/jan.14304
- Hao S, Tan S, Li J, et al. The effect of diet and exercise on climacteric symptomatology.Asia Pac J Clin Nutr. 2022;31(3):362-370. doi:6133/apjcn.202209_31(3).0004
- Chen LR, Ko NY, Chen KH. Isoflavone supplements for menopausal women: a systematic review. Nutrients. 2019;11(11):2649. doi:3390/nu11112649
- Li N, Wu X, Zhuang W, et al. Soy and isoflavone consumption and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomized trials in humans. Mol Nutr Food Res. 2020;64(4):e1900751. doi:1002/mnfr.201900751
- Khapre S, Deshmukh U, Jain S. The impact of soy isoflavone supplementation on the menopausal symptoms in perimenopausal and postmenopausal women. J Midlife Health. 2022;13(2):175-184. doi:4103/jmh.jmh_190_21