Carla Picardo, MD, MPH, an ob-gyn with UPMC Magee-Womens Specialty Services in Erie, specializes in midlife health. When it comes to menopause, she believes there should be a more realistic dialogue about it, along with proper education.
“I truly feel we need to change how we look at menopause and not see it as something we must dread, treat, fix, balance, fight, or change,” she says. “We need to prepare for it and embrace it for what it is, which is another hormonal transition in our lives as women. If we live long enough to get there, we need to approach it like we approach puberty and pregnancy and help support and guide women through it.”
All women facing menopause may benefit from healthy lifestyle adjustments or improvements. Some may benefit from hormonal or non-hormonal prescription interventions to help navigate the transition and improve their quality of life.
Read more as Dr. Picardo answers frequently asked questions about menopause.
Are there any daily vitamins or supplements that can help prepare you for menopause?
If you eat a well-balanced diet of unprocessed foods, most supplements aren’t necessary. Colorful, plant-based foods and whole grains are a good source of vitamins and minerals. However, one of my favorite supplements is magnesium. I feel a lot of women may benefit from it, unless they have a heart condition. Magnesium has a very relaxing effect on the body. It may potentially lower blood pressure and blood glucose, decrease migraine headache frequency, improve sleep, and curb anxiety. When selecting a magnesium supplement, look for magnesium glycinate and magnesium citrate, around 200 to 400 mg a day.
It is typically recommended that women strive for 1,200 milligrams of calcium daily, ideally achieved through diet. If you cannot achieve this intake, calcium supplementation to reach that daily 1,200 milligrams may be important to maximize bone density.
If you are a vegan and only eat plant-based foods, you may need vitamin D and vitamin B12 supplements, because these vitamins are not found in a lot of plant-based foods.
What works best to address sleep issues, specifically having trouble staying asleep?
It depends on what is waking you up. If it’s hot flashes, night sweats, or heart palpitations, we try to address those symptoms through lifestyle, menopausal hormone therapy, or non-hormonal options. If you are getting up in the middle of the night to use the bathroom, medication or pelvic floor physical therapy may help with urinary urgency.
If you are waking up and having trouble getting back to sleep because your mind starts racing, we may need to look at why this is happening. Are you stressed? Do you have anxiety? In those cases, taking a magnesium supplement may help. Exercise, meditation, or mindfulness-based stress reduction may be beneficial. Anxiety may also be managed with counseling or medication.
If waking up in the middle of the night becomes a habit, cognitive behavioral therapy for insomnia may be helpful. Research shows that women in midlife who have sleep disruption show improvement with cognitive behavioral therapy specific for sleep function. UPMC has access to providers who offer this therapy, and there are also programs available online. The goal of this therapy is to reduce the time awake while in bed.
At what point in perimenopause or menopause would someone consider estrogen replacement therapy?
The best time to start estrogen therapy is when symptoms start. Some women have their worst symptoms during perimenopause, and some don’t have any symptoms until they reach menopause. If symptoms like hot flashes, night sweats, and mood disruption are affecting quality of life, estrogen therapy may help. If a woman still has her uterus, she should also include progesterone along with her estrogen therapy.
My depression and anxiety have increased during perimenopause. Do these symptoms level out after menopause transition is complete?
For some women, there is an uptick in depression and anxiety symptoms during perimenopause. Some women say it’s like having PMS almost every day instead of just right before their periods. If you are prone to depression and anxiety, symptoms may be worse during perimenopause. Those symptoms typically respond to low-dose estrogen and progesterone therapy or medications that are more frequently used for anxiety and depression outright. After menopause, estrogen levels drop and stop fluctuating, which may stabilize mood.
I’m post-menopausal and struggling with weight gain, which I have never had a problem with before. What kind of diet do you recommend? Should I reduce calories, carbs, or both? And should I lift weights instead of doing cardio?
The two main reasons women tend to gain weight during midlife is chronological aging, which men also deal with, and the loss of lean body mass that comes with declining estrogen over the menopausal transition.
Multiple studies support the Mediterranean diet as a healthy approach for individuals of all ages. This diet stresses unprocessed, plant-based foods including a variety of fruits, vegetables, whole grains, nuts, seeds, beans, some dairy, and smaller amounts of lean poultry and fish. Research shows this type of diet decreases the risk of cardiovascular disease, dementia, cancer, diabetes, and even the frequency of vasomotor symptoms of menopause, like hot flashes and night sweats. Fiber, which is in unprocessed food from plant sources, helps stabilize estrogen, insulin, and glucose levels.
Women should consider including 40 to 60 minutes of weight training a week. Weight training may include using resistance bands, lifting weights, or doing body weight exercises. Building muscle from weight training may decrease the loss of lean body mass and help with metabolic sluggishness. Weight training can also help reduce bone density loss caused by lower estrogen levels during midlife.
Cardio exercise remains important for heart health. All individuals should strive for 150 to 300 minutes of moderate exercise a week or at least 75 minutes a week of more intense exercise.
How safe is vaginal estrogen for women with a family history of stroke?
Vaginal estrogen is different from systemic estrogen, which includes pills taken by mouth or patches and gels that are applied to the skin. Vaginal estrogen applications found in creams, certain rings, and vaginal tablets are minimally absorbed into the body, with virtually none absorbed into the body after two weeks or so of use.
Although the label does include a warning about stroke and breast cancer risk, this is actually a blanket warning the Food and Drug Administration mandates for any form of estrogen. Unfortunately, many women are afraid to use vaginal estrogen despite multiple studies showing it is safe and poses no increased risk of stroke or breast cancer. There are studies that have shown that women who have already had breast cancer who then use vaginal estrogen were not at higher risk for recurrence of their breast cancer compared to women who were not using the vaginal estrogen.
How long should you take hormone replacements?
There is currently no established time limit for how long one may use menopausal hormone therapy. Local vaginal estrogen may be used indefinitely. However, it is important to start systemic menopausal hormone therapy (pills, gels, or patches) within the first five to 10 years of the onset of menopause, or within six to 11 years of the final menstrual period, to reap the greatest benefit from the therapy. If no significant issues develop over time, one may use systemic menopausal hormone therapy for as long as symptoms are present, bothersome, and affect quality of life.
On the other hand, if a woman has never been on hormone therapy and has been in menopause for 10 or more years, there may be more risks associated with starting hormone therapy, including an increase in cardiovascular events. There are non-hormonal options available for those women.
Is hormone replacement therapy an option for women who have migraines?
While estrogen-containing birth control pills are typically avoided in women who have migraines with auras, the level of estrogen in menopausal hormone therapy is much lower. Therefore, hormone replacement therapy is an option for women who have migraines either with or without auras. It is preferable for women with migraines to use estrogen that is applied to the skin in the form of a patch, mist, or gel.
Are antidepressants effective for controlling hot flashes and improving fatigue and mood?
There are two categories of antidepressant medications that have been studied and shown to work better than placebo for controlling hot flashes of menopause and perimenopause: selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Paroxetine (Paxil), an SSRI, is FDA-approved for managing vasomotor symptoms of menopause. Venlafaxine (Effexor) and desvenlafaxine (Pristiq), both SNRIs, have also been shown in some studies to work better than placebo for controlling vasomotor symptoms of menopause. If you have taken an SSRI or SNRI in the past and had good results, there is often no reason not to consider similar medicine for menopausal and mood symptoms. Because these medicines are antidepressants, they may improve fatigue and mood.
Does hormone replacement therapy help with visceral fat gain?
Menopausal hormone therapy has been shown to slow visceral fat gain but does not prevent it. The body changes that occur during perimenopause and menopause are simply body composition changes. Lifestyle factors including quality sleep, a whole food and plant-based diet, stress management, and an active lifestyle (including cardio and weight training) may have a bigger impact on visceral fat gain than hormone therapy.
Is it normal to have a period that lasts longer than usual and comes more frequently during perimenopause?
We often talk about perimenopause as “second puberty.” Menstrual cycles during puberty usually don’t become regular right away. Cycles may be very long, very short, heavy, or very light. The same is true for perimenopause. We often consider some of the same interventions for perimenopause as we do in puberty to help regulate menstrual cycles if irregularity or bleeding is bothersome.