Perimenopause

Brain fog, fatigue, mood swings: Defining ‘not feeling like myself’ in perimenopause

Posted by

0


Key takeaways:

  • Survey data show 63% of midlife women reported “not feeling like myself” half the time or more over 3 months.
  • Symptoms most correlated with “not feeling like myself” included fatigue, overwhelm and low feelings.

The menopausal transition can be associated with a variety of bothersome symptoms, including hot flashes and mood swings, but some women might experience more subtle symptoms that can begin years before the final menstrual period.

“Not feeling like myself” is a phrase often used by women on the path to menopause — when symptoms related to mood or cognition arise that impact their daily lives, according to Nina Coslov, MBA, founder of Women Living Better, an organization focused on understanding and improving the perimenopausal years through education and research.

Nina Coslov, MBA, quote

In a recent survey of more than 1,300 women aged 35 to 55 years who met criteria for the late-reproductive stage or menopausal transition, 63.3% of women reported “not feeling like myself” at least 50% of the time during the past 3 months. Researchers then correlated 61 individual symptoms and symptom-bother scale scores with the phrase “not feeling like myself.”

After accounting for education level and overall stress ratings, “not feeling like myself” was most strongly predicted by the symptom groups of anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms and volatile mood symptoms.

“Because these symptom groups have not been typically associated with the menopausal transition, they may represent inexplicable and unfamiliar feelings and responses for which women lack an explanatory model and thus use the phrase, ‘I’m not feeling like myself,’” the researchers wrote.

The latest survey data build on earlier work conducted by Coslov and colleagues that found women in the late reproductive stage experience symptoms strikingly similar to those often associated with the menopausal transition.

Healio spoke with Coslov about the use of the phrase “not feeling like myself,” the symptoms women report while still having regular menstrual cycles, and the importance of educating clinicians and patients about the late reproductive phase. The latest data from the Women Living Better survey were recently published in Menopause.

Healio: Why center a survey question on the phrase “not feeling like myself”?

Coslov: “Not feeling like myself” was one element in a much bigger survey that we conducted in 2020. This is the seventh paper coming from that survey. “Not feeling like myself” is a phrase I had heard through talking to many people. Women Living Better, which launched in 2018, serves as a repository of people’s experiences through submissions to the website, and that is where a lot of the questions that comprised this survey came from. We tried to use women’s words to describe their symptoms.

I had used the phrase myself early in perimenopause. I remember going for a walk with a friend and saying, “I just don’t feel like myself and I don’t’ know what is going on.”

When we were designing the survey, co-author Marcie K. Richardson, MD, said, “I hear that all the time. It is vague and it is difficult to know what it means.” We discussed how it is much easier during a time-pressed appointment to focus on more straightforward symptoms typically associated with menopause, such as, “Do you have hot flashes? Do you have vaginal dryness?” “Not feeling like myself” is nonspecific. So, we decided to put the question out there.

In this piece of research, we used, in two different statistical approaches to determine what bothersome symptoms were associated with this phrase. The way we asked the question was, “What percent of the time over the last 3 months have you not felt like yourself?” Approximately 63.3% of women reported not feeling like themselves 50% of the time or more. That is a lot.

Healio: Did the number of women who reported not feeling like themselves surprise you?

Coslov: It did a little bit. With this work, we are trying to normalize and validate experiences for women. The hope is that when many women understand that most of these symptoms are part of the perimenopausal period of fluctuating hormones and that it is not a permanent state, they will feel less worried or scared That is not to say that anyone should suffer — when symptoms are disrupting daily activities, seeking medical care can help. But for most women, knowing that these experiences of mood and sleep changes or just feeling “off” are normal can go a long way. That plays into not feeling like myself: Not having an explanatory model for what is happening.

Our research was cross-sectional, it was one point in time, but we had a lot of participants. They were a convenience sample, recruited through email and on social media, who were willing to take a survey about their midlife experience. When we set out to establish what symptoms were correlated, I did not know what would come up. Mood is strikingly associated. So are fatigue and brain fog symptoms. I would have felt so much better if someone had been able to tell me that that these things are commonly associated with perimenopause.

Healio: What does Women Living Better hope to do with these data?

Coslov: We want to normalize and validate what people are experiencing. We had a poster at The Menopause Society Annual Meeting in September about these data, and so many providers came up and said, “I hear this all the time.” Now, they can reference this study. They can follow up with specifics when they hear, “I’m just not feeling like myself.” We hope it will allow patients and providers to feel more connected and help start conversations about mood changes or brain fog. Ultimately, I hope it leads to more successful and satisfying health care interactions for both parties.

Healio: What are your plans going forward, beyond this latest survey data?

Coslov: To me, mood is the most under-researched and most misunderstood area on the path to menopause. Just like in our early work, we would focus on to what degree experiences with mood changes are happening before noticeable, significant menstrual cycles changes vs. after.

Once you say, “Oh, I’ve skipped a period” or, “I’ve had 60 days between periods,” most providers will recognize perimenopause. But for many women, these subtle [hormonal] changes begin before significant menstrual cycle changes. That is when it is most surprising, concerning — unexpected. That is when most health care providers do not identify and validate, and cannot validate, that this is the beginning of the path to menopause.

According to STRAW+10 criteria, the beginning of the menopausal transition is defined as two times where consecutive cycle length differ by 7 days or more. The problem is thatmany people experience the impact of fluctuating hormones before that. That is why I use this broader phrase: the path to menopause. A focus on the late reproductive stage, the official term of what comes before perimenopause as defined by STRAW, has been a major focus of Women Living Better’s effort and research.

We also hope to reach out to more women aged 38 to 42 years. In terms of timing, that age range is the holy grail. Those women need to know what might be coming and that it is generally normal.

Menopause Brain Is Real—Experts Explain What to Know About the Brain Fog Phenomenon

Posted by

0


Plus, what you can do to boost your memory.


A new book, The Menopause Brain, breaks down what happens in the brain during perimenopause and menopause.

  • Many women experience brain fog during this time, leading to the term “menopause brain.”
  • Doctors say there are a few things you can do to help with symptoms.

Menopause is a natural life transition, but there’s a lot that’s still unknown about how it impacts various areas of the body. Now, a new book called The Menopause Brain details the impact this change has on women’s brains, and why. Delving into the “menopause brain” phenomenon and brain fog.

In the book, author and neuroscientist Lisa Mosconi, Ph.D., director of the Weill Cornell Women’s Brain Initiative, notes that more than 60% of women have brain fog at some point during perimenopause (the period before menopause) or menopause. This brain fog—which some may mistake for early signs of dementia—is due to changes happening in the brain during the menopausal transition, she explains.

Meet the experts: Lauren Streicher, M.D., a clinical professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine; Jessica Shepherd, M.D., an ob/gyn in Texas and author of the upcoming book on menopause, Generation M; Mary Jane Minkin, M.D., a clinical professor of obstetrics and gynecology and reproductive sciences at Yale School of Medicine and founder of Madame Ovary; Michael Krychman, M.D., medical director of Women’s Health Services at MemorialCare Saddleback Medical Center in Laguna Hills, CA

Mosconi’s new book has raised a lot of questions about so-called “menopause brain” as well as what can be done about it. Mosconi and other doctors break it down.

What happens to the brain during menopause?

During menopause, the body has decreasing levels of estrogen, explains Lauren Streicher, M.D., a clinical professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine. “There are estrogen receptors throughout the brain and the body,” she says. When estrogen drops in the body during perimenopause and menopause, it has an impact on the brain.

The brain “controls everything, including body temperature and libido,” Dr. Streicher says. When the brain has lessening levels of estrogen, it can create a feeling of brain fog, she notes.

“Estrogen plays a crucial role in maintaining brain health, influencing neurotransmitter levels, promoting neuroplasticity, and protecting against oxidative stress and inflammation,” Mosconi says. “As estrogen declines, women may experience changes in body temperature—a.k.a. hot flashes—sleep, mood, libido, and cognition, which are all brain-regulated functions.”

But it’s “very hard to differentiate what is the cause of this fog—it certainly could be related to the sleep disruptions that many women experience or some of the mood changes they undergo,” says Mary Jane Minkin, M.D., a clinical professor of obstetrics and gynecology and reproductive sciences at Yale School of Medicine and founder of Madame Ovary. It also could be related to changes in the hypothalamus—the part of the brain that produces hormones that control body temperature, heart rate, and hunger, among other things—“which we know occur from the decreasing levels of estrogen,” Dr. Minkin says.

Most women in their 40s and 50s have many other stressors they’re dealing with, and all of that can impact the brain, she says.

In fact, Mosconi says that the brain is actually rewiring itself during the menopausal transition. “We’ve made significant progress in demonstrating that menopause changes the brain’s structure, functionality, and even its connectivity in fairly unique ways,” she says. “Overall, menopause is a neurologically active period, which comes with both resilience and vulnerability.”

How does menopause affect memory?

There are a few ways menopause can impact the brain. “Estrogen declines may lead to alterations in brain structure and function, as well as changes in neurotransmitter production, affecting memory processes such as encoding, retrieval, and consolidation,” Mosconi says. Menopausal symptoms like hot flashes, sleep disturbances, and mood changes can also impact memory function, she says.

You may feel like you can’t focus as well as usual, have trouble concentrating as well as you did in the past, struggle with multi-tasking, and have a shorter attention span, says women’s health expert Jessica Shepherd, M.D., an ob/gyn in Texas and author of the upcoming book on menopause, Generation M. “The main thing is having body awareness—a lot of people are unaware that a lot of these things that occur could be menopause,” Dr. Shepherd says.

“Many women report brain fog during the menopausal transition,” Dr. Minkin says. “The good news is that it tends to get better as women get through the perimenopausal transition and go onto the post menopausal state.”

Michael Krychman, M.D., medical director of Women’s Health Services at MemorialCare Saddleback Medical Center in Laguna Hills, CA, agrees. “This is very, very common,” he says. “People think they’re losing their minds. They’re really having a lot of difficulty remembering numbers and words. Brain fog is not uncommon as a woman transitions into menopause.”

How to deal with menopause brain

The reason “menopause brain” happens is because the brain is deprived of estrogen, “so give the brain estrogen,” Dr. Streicher says. Hormone replacement therapy (HRT), which replaces the estrogen that the body no longer makes, can help with symptoms of menopause brain, she says.

Many women benefit from taking estrogen therapy “which is quite safe for most women,” Dr. Minkin says. “It will usually help hot flashes, sleep, and mood,” Dr. Minkin says. “If women don’t want to take hormonal therapy, there are some herbal products that can help.”

Remifemin good night, which is a mix of black cohosh and other herbs, and Relizen, which is derived from Swedish pollen extracts, can help with sleep and hot flashes, Dr. Minkin says. Dr. Minkin also points to research from Neill Epperson, M.D., chairman of psychiatry at the University of Colorado, which has found that medications like lisdexamfetamine, which is commonly used to treat ADHD, can also be helpful for menopause brain.

Mosconi also says the following can help if you’re dealing with menopause brain:

  • Exercise regularly, “which has been shown to improve cognitive function and mood, and alleviate hot flashes,” she says.
  • Prioritize your sleep hygiene.
  • Incorporate stress management techniques like mindfulness meditation or deep breathing exercises.
  • Have a balanced diet rich in nutrients essential for brain health, including omega-3 fatty acids, antioxidants, fibers, and vitamins.
  • Try to avoid or minimize environmental toxins, especially endocrine disruptors.
  • Stay mentally active by participating in things that challenge the brain, like puzzles, reading, or learning new skills.

Can you prevent menopause brain?

It’s not clear. “While it may not be possible to completely prevent menopause-related symptoms, the strategies listed above may help mitigate their impact,” Mosconi says. She also points out that the menopause experience “varies greatly” in women.

“While approximately 10% of women report no brain symptoms, many experience some symptoms, and some may have multiple and more severe symptoms,” she says. “The reasons behind these differences are still under investigation.”

But Mosconi says that evidence suggests that having a healthier lifestyle and prioritizing your self-care may lead to milder symptoms in menopause. “There’s power in our everyday choices,” she says.

Just don’t be afraid to talk to your doctor about what you’re going through. “If you are experiencing disconcerting brain fog with perimenopause or menopause, do check in with your gynecological practitioner for some advice,” Dr. Minkin says.

Navigating Menopause and Perimenopause with Diabetes

Posted by

0


Menopause causes many hormonal changes in women, which can make managing blood glucose levels even more complicated

Maybe you’ve noticed your blood glucose levels fluctuate when your period is coming, or that you crave chocolate or other carb-heavy foods when it’s that time of the month. But what happens when your menstrual cycle seems to be going haywire, with a heavier, lighter, or more irregular flow, and you’re approaching midlife?

You could be experiencing perimenopause, the time when a woman’s body decreases hormone production and when egg production slows down. Perimenopause is the body’s transition to menopause, when the reproductive process permanently ends. During this shift, diabetes and menopause can complicate one another.

What are perimenopause and menopause?

Menopause happens when a woman has missed a period for 12 months in a row; perimenopause is the transition into menopause, but it’s not always a straight path. Some women can be in perimenopause for years, experiencing periods here and there, with changes in flow or frequency.

Perimenopause can last for eight to ten years before menopause. It typically occurs for women between the ages of 45 and 55, though some women begin experiencing perimenopause in their 30s.

The symptoms of perimenopause can include sore breasts, sex issues (such as vaginal dryness or little to no interest in intercourse), peeing problems (such as frequent urination or urinating while coughing or sneezing), disrupted sleep, moodiness, and hot flashes. Hot flashes can cause you, in an instant, to go from feeling serene and comfortable to scorching and sweaty.

How does menopause affect diabetes?

Weight gain is common with menopause, but what is more common and worrisome is an increase in abdominal (belly) fat, says Ekta Kapoor, an endocrinologist, menopause specialist, and associate professor of medicine at the Mayo Clinic. Additional abdominal fat makes the body more insulin resistant. Women may find they need additional insulin or medications to keep their blood glucose levels in range.

  • Tip: If your blood glucose levels are changing in ways you haven’t experienced since before perimenopause or menopause, talk to your healthcare professional about whether you need to adjust or change your diabetes medications, particularly if you’ve gained weight or aren’t as active as you were previously.

The hormone changes during menopause can cause hot flashes and sweating that may be disruptive to sleep. Sleeplessness is very common during menopause, and can negatively affect many critical aspects of diabetes and overall health. To learn more about sleep and how to improve your sleep, check out this article from Adam Brown.

Menopause also brings higher risks of increased blood pressure and heart disease, Kapoor adds — two health complications that women with diabetes are already more likely to develop. Speak with your healthcare professional about what you can do to keep your heart and arteries healthy.

Be aware of vaginal or urinary infections, especially yeast or urinary tract infections. Both diabetes and hormone changes during menopause can increase the risk of these infections.

Remember to check your blood glucose levels if you’re feeling sweaty or moody. Something that you think is related to high or low blood sugars may be related to menopause instead (and may not require a dose of insulin or some glucose tabs to treat).

How to manage menopause with diabetes:

  • Measure blood glucose levels frequently
  • Talk with your healthcare professional about adjusting insulin or medication dosing
  • Exercise daily, eat a balanced diet, and don’t smoke
  • Measure blood pressure regularly
  • Monitor changes in weight

Does diabetes affect menopause?

It’s unclear how diabetes may affect the timing of perimenopause and menopause. A 2001 study found that women with type 1 diabetes undergo menopause earlier than women without diabetes, but research in 2014 did not support that conclusion. However, the 2001 research was done at a time when current diabetes technologies (such as continuous glucose monitors, insulin pumps, and even fast-acting insulin) were either less common, less sophisticated, or not yet invented. With these tools, it’s now possible for people with diabetes to have blood sugar readings closer to those of people without diabetes. This may explain why diabetes doesn’t always play a role in when perimenopause and menopause occur.

What is the role of hormone therapy?

Perimenopause symptoms can last several years beyond menopause, though some people sail through the transition without much discomfort. Others are so bothered by the side effects that they seek medical attention and take hormone therapy (HT) – such as supplemental estrogen with or without a progesterone-like hormone – to reduce symptoms.

There is no specific recommendation on HT for women with diabetes. According to a 2012 review of medical research, “there is a lack of evidence around the use of HT in women with type 1 diabetes,” calling for more research in the area.

Women with type 2 diabetes “are more vulnerable to having the disease worsen after menopause due to weight gain and increase in belly fat. This risk can be reduced somewhat by using HT,” Kapoor said. A 2001 study of more than 15,000 women with type 2 diabetes found that women in their 60s who were taking HT had average A1C levels that were lower than women who were not on HT.

Advice on navigating menopause, with or without diabetes

“Just as I advise all my patients going through menopause, pay attention to lifestyle,” said Kapoor. “Especially in their 40s and 50s, women should pay an even greater attention to what they eat and how much they exercise. Women who enter menopause already overweight face an uphill task to try to keep their weight at a healthy level.”

Kapoor suggests getting at least 30-45 minutes of aerobic exercise at least five days a week, and to keep a close eye on food intake. Because of the metabolic and hormonal changes that come with menopause, eating the same way in midlife as you did as a younger person will very likely bring on weight gain.

“Oftentimes, women will say, ‘I haven’t changed anything; I’m eating the same way I used to in my 20s or 30s,’ and that is exactly why,” said Kapoor, “People need to cut back on calories as they get older.” The type of food on our plate can determine the daily caloric intake; eating a diet with more carbohydrates tends to be calorie-dense. Kapoor advises lower carb eating to manage weight or to lessen weight gain before and during menopause.

“My biggest advice for weight management for women going through menopause is related to lifestyle: healthy eating habits and a regular exercise program,” Kapoor concluded.

Management of menopause: a view towards prevention

Posted by

0


Summary

Women spend approximately one-third of their lives with menopause, which occurs around 50 years of age. It is now appreciated that several important metabolic and cardiovascular disease risks emerge during the menopausal transition. Many important conditions occur 10–15 years after menopause, including weight gain and obesity, metabolic syndrome, diabetes, osteoporosis, arthritis, cardiovascular disease, dementia, and cancer; therefore, the occurrence of menopause heralds an important opportunity to institute preventative strategies. These strategies will lead to improved quality of life and decreased mortality. Various strategies are presented for treating symptoms of menopause and diseases that are asymptomatic. Among several strategies is the use of hormone therapy, which has efficacy for symptoms and osteoporosis, and can improve metabolic and cardiovascular health. When instituted early, which is key, in younger postmenopausal women (under 60 years) oestrogen has been found to consistently decrease mortality with a favourable risk–benefit profile in low-risk women. Prospective data show that long-term therapy might not be required for this benefit.

Hypothyroidism more prevalent during late perimenopause, postmenopause

Posted by

0


The prevalence of hypothyroidism — overt and subclinical — is higher among women during the late menopause transition and postmenopause compared with premenopause, according to study findings.

Mira Kang

Seungho Ryu

“Accumulated data on menopausal transition suggest that the late menopausal transition stage, among other stages, seems to be the most critical period during which various menopausal symptoms and measurable physiologic changes are likely to manifest,” Mira Kang, MD, PhD, associate professor and vice chief information officer of the data management committee at Samsung Medical Center in Seoul, South Korea, and Seungho Ryu, MD, PhD, professor at the Center for Cohort Studies, Total Healthcare Center at Kangbuk Samsung Hospital, told Healio. “Our findings add to the existing line of evidence, reflecting an increasing trend in the occurrence of abnormal thyroid function in the late menopausal stage. It would be of interest to find out what mechanisms or factors play into the increased prevalence of the hypothyroid state during the late transition period in future investigations.”

Overt hypothyroidism prevalence increases in late perimenopause and postmenopause
The prevalence of over hypothyroidism is significantly higher in women during late perimenopause and postmenopause compared with premenopause. Data were derived from Kim Y, et al. Thyroid. 2022;doi:10.1089/thy.2021.0544.

Kang, Ryu and colleagues collected data from 53,230 women aged 40 years or older (mean age, 47.1 years) who participated in the Kangbuk Samsung Health Study at the Kangbuk Samsung Hospital Total Healthcare Center in Seoul and Suwon, South Korea, and had a health examination performed between 2014 and 2018. The Stages of Reproductive Aging Workshop + 10 criteria were used to determine menopausal stages. Electroluminescence immunoassays were conducted to measure serum thyroid-stimulating hormone, free thyroxine and free triiodothyronine levels.

The findings were published in Thyroid.

Free T3 and TSH levels were highest in the study cohort during postmenopause. Free T4 levels were similar between premenopause and postmenopause.

In multivariable-adjusted analysis, the prevalence of overt hypothyroidism was higher in late perimenopause (adjusted prevalence ratio [aPR] = 1.61; 95% CI, 1.12-2.3) and postmenopause (aPR = 1.66; 95% CI, 1.16-2.37) compared with premenopause (P = .002). Similarly, the prevalence of subclinical hypothyroidism was higher during late perimenopause (aPR = 1.22; 95% CI, 1.06-1.4) and postmenopause (aPR = 1.24; 95% CI, 1.07-1.44) compared with premenopause (P = .001). No increased prevalence in overt and subclinical hyperthyroidism was observed during the different menopausal stages.

“There is substantial resemblance between symptoms of menopause and those of thyroid abnormalities, such as weight gain, fatigue, cold intolerance, mood swings and anxiety,” Kang and Ryu said. “Thus, existing thyroid problems may easily go overlooked, thereby delaying treatment. Thyroid dysfunction, if left untreated, may be associated with significant morbidity and impaired quality of life, and, in women approaching menopause, thyroid dysfunction may exacerbate certain menopausal symptoms. Therefore, it is critical that the prevalence and risk distributions of thyroid abnormalities across different stages of menopausal transition be clearly defined to facilitate timely intervention.”

More women had a serum TSH level of greater than 5 IU/mL during late menopause transition (aPR = 1.26; 95% CI, 1.11-1.43) and postmenopause (aPR = 1.29; 95% CI, 1.13-1.48) compared with premenopause (P < .001). A higher prevalence of low free T4 levels was observed during late perimenopause (aPR = 1.76; 95% CI, 1.24-2.51) and postmenopause (aPR = 1.9; 95% CI, 1.34-2.68) compared with premenopause (P < .001). Women were more likely to have low free T3 levels of less than 2 pg/mL during late perimenopause compared with premenopause (aPR = 2.4; 95% CI, 1.36-4.23; P =.014).

Kang and Ryu said longitudinal studies are needed to assess temporal associations between menopausal stages and thyroid function.

“In addition, the clinical and prognostic significance of thyroid dysfunction in women during the menopausal transition should also be explored.” Kang and Ryu said. “Lastly, since our population consisted of Korean women, our findings need to be extended to populations of other ethnicities.”

PERSPECTIVE

Arti Bhan, MD, FACE)

Arti Bhan, MD, FACE

Thyroid dysfunction is common in women and frequently manifests at the time of puberty, pregnancy and menopause. Symptoms related to menopause and thyroid disorders can overlap, leading to delayed diagnosis and treatment of underlying thyroid disease. There are data suggesting that adequate treatment of thyroid disorders can improve climacteric symptoms, thereby improving quality of life and possibly reducing the need for estrogen supplementation.

The authors conducted a cross-sectional study of 53,230 Korean women aged 40 years or older and stratified them by menopausal stages. Thyroid hormone levels were measured, and an increased prevalence of overt and subclinical hypothyroidism was observed in the late transition and postmenopausal stages. Subclinical and overt hyperthyroidism were not associated with menopause.

Current guidelines do not recommend routine screening for thyroid dysfunction in asymptomatic individuals. However, case-finding is recommended in women at increased risk for hypothyroidism or with symptoms. Diagnosis of thyroid disorders during menopause is important as thyroid hormone concentration can affect the intensity and frequency of menopausal symptoms. In addition, undiagnosed thyroid disease can affect cardiovascular health and increase long-term morbidity. This study suggests that screening women for thyroid dysfunction during the menopausal transition is prudent.

Arti Bhan, MD, FACE

Endocrine Today Editorial Board Member

Division Head, Endocrinology

Henry Ford Health System

Greater fat mass, lower fat-free mass characterize metabolic changes in perimenopause

Posted by

0


Compared with pre- and postmenopausal women, women in perimenopause had increased fat mass, decreased fat-free mass and greater percent body fat, elevating cardiometabolic risks, according to study results.

“Perimenopause may be the most opportune window for lifestyle intervention, as this group experienced the onset of unfavorable body composition and metabolic characteristics,” Abbie E. Smith-Ryan, PhD, CSCS*D, FNSCA, FACSM, FISSN, associate professor in exercise physiology, director of the applied physiology laboratory and co-director of the Human Performance Center at the University of North Carolina at Chapel Hill, and colleagues wrote.

Abbie E. Smith-Ryan, PhD, CSCS*D , FNSCA, FACSM, FISSN
Smith-Ryan is an associate professor in exercise physiology, director of the applied physiology laboratory and co-director of the Human Performance Center at the University of North Carolina at Chapel Hill.

Smith-Ryan and colleagues aimed to determine body composition, fat distribution and metabolism at rest and during exercise among premenopausal, perimenopausal and postmenopausal women.

The cross-sectional study included 72 women aged 35 to 60 years. Researchers assessed body composition via a four-compartment model; fat distribution using DXA-derived android to gynoid ratio; metabolic measures with indirect calorimetry; and lifestyle factors via surveys. They employed one-way analyses of variance and one-way analyses of covariance covaried for age and levels of estrogen and progesterone to compare groups.

Height, weight and BMI were comparable between the three groups.

According to results, despite a similar fat mass and fat-free mass between groups, premenopausal women demonstrated decreased body fat percent compared with perimenopausal women (mean difference, –10.29%; P = .026). Compared with perimenopausal women, premenopausal women had lower android to gynoid ratio (mean difference, –0.16; P = .031). The groups had comparable resting energy expenditure.

In addition, premenopausal women experienced increased fat oxidation during moderate intensity cycle ergometer exercise compared with postmenopausal women (mean difference, 0.09 g per minute; P = .045), whereas change in respiratory exchange ratio between rest and moderate intensity exercise was decreased in premenopausal women compared with perimenopausal (mean difference, –0.05; P = .035) and postmenopausal (mean difference, –0.06; P = .04) women.

In other data, premenopausal women had significantly fewer menopause symptoms than perimenopausal (mean difference, – 6.58; P = .002) and postmenopausal (mean difference, –4.63; P = .044) women. Researchers also reported similarities between groups in lifestyle factors, such as diet and physical activity.

“To prevent unwanted changes in resting metabolism, as well as metabolic flexibility, it is possible that menopausal women should engage in activities that help maintain lean mass (ie, resistance exercise) as well as retain or increase oxidative capacity (ie, moderate to high intensity exercise),” researchers wrote. “Ultimately, future cross-sectional investigations and longitudinal interventions should be designed to target perimenopausal women to determine if menopause-related shifts in body composition and metabolism are preventable with sustainable nutrition and exercise modifications.”

Perimenopause may be best time to prevent poor body composition, metabolic outcomes

Posted by

0


Lifestyle intervention may be most effective in perimenopause, as women experience the onset of poor body composition and metabolism associated with menopause, according to a study.

“I have a passion for improving the health and well-being of women,” Abbie Smith-Ryan, PhD, associate professor of exercise physiology at the University of North Carolina, Chapel Hill, told Healio. “So many women buy into misinformation, or information on how to be healthy and feel good is unclear.”

According to researchers, perimenopause is "characterized by the onset of vasomotor symptoms, accelerated adverse changes in body composition and increased risk of chronic diseases." Source: Adobe Stock
According to researchers, perimenopause is “characterized by the onset of vasomotor symptoms, accelerated adverse changes in body composition and increased risk of chronic diseases.”

Postmenopause may encompass up to 40% of a woman’s life, according to the study, which was published in Menopause.

“The length and cost of this transition to menopause is characterized by the onset of vasomotor symptoms, accelerated adverse changes in body composition and increased risk of chronic diseases including osteoporosis, cardiovascular disease and metabolic syndrome,” the researchers wrote. “Ultimately, the burden of this transition known as perimenopause is associated with decreased quality of life, productivity and potentially hindered personal and intimate relationships.”

To examine the onset of these changes throughout the menopausal transition, Smith-Ryan and colleagues conducted a cross-sectional study of 72 women aged 35 to 60 years who were premenopausal, perimenopausal or postmenopausal. They measured participants’ body composition using a four-compartment model — which evaluated bone mineral content, total body water, fat mass and body mass — resting energy expenditure (REE) and metabolic flexibility during sub-maximum physical activity at in-person visits.

Participants completed lifestyle behavior surveys prior to the visits.

‘Much larger change from pre- to perimenopause’

Although height, weight and BMI were similar between all three groups, premenopausal women had a significantly lower body fat percentage than perimenopausal women. This remained significant when controlling for estradiol and progesterone.

Android-to-gynoid ratio was also significantly lower in premenopausal women than in perimenopausal women. Again, the difference remained significant when controlling for hormones.

Abbie Smith-Ryan, PhD

Abbie Smith-Ryan

“We anticipated somewhat of a linear change in body composition and metabolism,” said Smith-Ryan, who is also an adjunct associate professor in the department of nutrition, director of the Applied Physiology Laboratory and co-director of the Human Performance Center. “For example, an increase in fat mass, decrease in muscle and lowered metabolic rate with age. However, we identified that there is a much larger change from pre- to perimenopause. Additionally, the changes that we saw were more than would be seen when attributed to aging alone.”

Visceral adipose tissue, extracellular content and waist-to-hip ratio were similar across groups, as was REE.

During moderate intensity exercise, fat oxidation was significantly greater in premenopausal women compared with postmenopausal women. However, the difference was no longer significant when the researchers controlled for hormone use..

An analysis of overall metabolic flexibility — measured as change in resting exchange ratio (RER) — showed there were significant differences for RER during moderate exercise. Premenopausal women had significantly lower difference in RER than perimenopausal women and postmenopausal women.

Survey responses

Self-reported survey responses revealed that sleep quality, physical activity and diet were similar between groups.

Compared with premenopausal women, perimenopausal and postmenopausal women reported significantly more menopause symptoms, and peri- and postmenopausal women reported symptoms at similar rates. When controlling for hormone use, those findings remained significant between pre- and peri-menopausal women only. .

“To prevent unwanted changes in resting metabolism, as well as metabolic flexibility, it is possible that menopausal women should engage in activities that help maintain lean mass (ie, resistance exercise) as well as retain or increase oxidative capacity (ie, moderate to high intensity exercise),” Smith-Ryan and colleagues advised.

Since each participant attended only one visit, the researchers warned that some of the hormone variability and lower RER values seen in perimenopausal women may be due to unpredictable hormone fluctuations. Other limitations included self-reported data and the study’s longitudinal design.

“We are planning and hoping to explore some mechanistic views of what is happening to the muscle during this transition, as some other data from our lab (that is in review) suggests that muscle and protein kinetics are driving a lot of these changes,” Smith-Ryan said. “Additionally, we are exploring the impact of hormonal contraception on some of these same outcomes.”

The researchers called perimenopause the “most opportune” time for lifestyle intervention.

“Ultimately, future cross-sectional investigations and longitudinal interventions should be designed to target perimenopausal women to determine if menopause-related shifts in body composition and metabolism are preventable with sustainable nutrition and exercise modifications,” Smith-Ryan and colleagues wrote.

PERSPECTIVE

BACK TO TOP Stephanie Faubion, MD, MBA)

Stephanie Faubion, MD, MBA

This study by Smith-Ryan and colleagues demonstrated that unfavorable body composition and metabolic changes start in perimenopause rather than after menopause. As expected, resting energy expenditure declined across the menopause transition. Also important to note is that unfavorable body composition changes occurred in peri- and postmenopausal women despite increased reported physical activity in these two groups compared with premenopausal women. Additionally, there were adverse changes in exercise metabolism in peri- and postmenopausal women compared with premenopausal women, meaning that peri- and postmenopausal women weren’t getting the same metabolic impact from exercise as premenopausal women. The authors suggested that because these changes appear to begin in perimenopause, interventions in this group of women might be needed to mitigate some of these changes, specifically an increase in percent fat and abdominal adiposity.

These results are entirely consistent with what I hear from my patients. That is, that they haven’t changed anything — they are eating like they always have and exercising like they always have (or more) and are still fighting body composition changes and can’t seem to lose weight. I usually start the conversation by validating what my patients are noting and further affirming that they won’t be able to utilize exercise alone to combat the issue. Some of these changes are related to aging (both men and women lose muscle mass and gain weight starting in midlife), but some of these changes are related to menopause and the loss of estrogen, particularly the body composition changes.

So, what is the solution? It’s important to level set the expectation that our bodies are not the same at age 55 as they were at age 20. So, should we just give up and accept all of these changes? That’s not a great answer either, as abdominal adiposity is dangerous and represents a significant cardiovascular risk, even in normal weight women. Further, it is important to remember that heart disease is the number one killer of women. What I typically suggest is maximizing fruit and vegetable intake; cutting caloric intake overall, particularly simple carbohydrates (don’t forget to include alcohol in this category); and maintaining or increasing aerobic activity. Resistance training is also helpful in maintaining muscle mass (muscle burns more calories than fat does). Even small changes can make a big difference in overall health, such that going down a pant size is a win, even if the scale doesn’t change.

Finally, I agree with the authors in suggesting that we should start education and lifestyle measures before women hit menopause, but I would go a step further and advocate for education on the menopause transition and initiation of lifestyle changes while women are still premenopausal. These changes catch most women off-guard, and we need to be more proactive with anticipatory guidance given that menopause is a universal event for women.

Stephanie Faubion, MD, MBA

Director, Mayo Clinic Center for Women’s Health

Medical Director, the North American Menopause Society