By Joanne Pizzino, MD, MPH

We tend to think that menopause is all about hormones, right? Therefore, taking hormones should provide relief for hot flashes, vaginal dryness, weight gain, moodiness, hair loss, and more. As a physician who has been prescribing bio-identical hormone therapy (BHRT) for women for nearly two decades, I can say that prescription hormones alone often provide only partial answers.

Let’s drop back a step and consider what is actually going on during this biologically-programmed transition.  If there is one overarching fact to remember about hormones, it is that they all act together, like different instruments playing together in a symphony. Most women remember that they had an abrupt change from being a “girl,” then suddenly starting to cycle, transforming them into a woman overnight. The reality of menopause is that it is a much more gradual process, with changes often happening over several years. The eventual cessation of ovarian hormones and egg production is a planned, natural physiologic development. However, we often ignore that the adrenal glands all along have been producing estrogen, progesterone and testosterone along with the stress hormone, cortisol. And, the adrenal glands are supposed to continue to do this for the rest of our lives.

The Importance of Cortisol

We can actually live without estrogen and progesterone, but we cannot live even a short time without cortisol. Cortisol is the hormone that not only manages stress, but also controls blood glucose and our immune system response to invaders. The body will “rob Peter to pay Paul” to keep the cortisol going, and progesterone is the immediate direct chemical precursor to cortisol. While the high-fat, high-carb Western diet is often blamed for contributing to menopausal symptoms, our intensely stressful lifestyles also directly contribute to this through the brain-organ feedback loop known as the hypothalamic-pituitary-adrenal axis. One of the biggest contributors to perimenopausal symptoms in the decade leading up to cessation of cycling is actually stress. The need to make cortisol to deal with the stress uses up the progesterone, causing estrogen excess relative to progesterone. This can lead to irregular cycles, sleep disturbance and premenstrual mood disorders.

The Autonomic Nervous System: Maintaining Balance

The things that most people define as “stress” are actually the sympathetic nervous system on overdrive. The autonomic nervous system is the way evolution has programmed our bodies to stay in balance. It has two branches, the sympathetic nervous system (SNS) which produces fight/flight/freeze reactions to danger, and the parasympathetic nervous system (PNS) which controls rest, digestion and repair. The SNS was designed to only be called into play for short periods of time a few times during an animal’s lifespan. And, if we were to watch a gazelle run away from a lion, once it had saved its life, we would see that it has to discharge this tremendous amount of energy that it used to do this. It would snort, and stomp and shake to let the energy fall back to healthy levels. But we humans do not do this after traumatic or dangerous situations. And we have stress that continues 24/7, like pandemics and wars.

There is no pharmacological or herbal/nutrient supplement that overcomes the brain’s perception that it is in danger. Although there are some substances that can help, in the end, we must rely on lifestyle methods to change the effects of the stress on the body. Many people feel helpless to control the outward circumstances that trigger the sympathetic fight/flight/freeze reactions, but modern psychoneurimmunology points the way. The most well-proven way to harness the power of the PNS is with meditation or breathwork practices. In fact, it is such a powerful way to change the body with the mind, that a specific dosage has been determined: One must do these parasympathetic-enhancing practices for 20 minutes at least three times per week to get the physical benefits.

Managing Menopause:
Diet, Movement, Supplements, and Stress Management

So how does all of this apply to menopause? First, we want to manage the effects of stress on the body. In some cases, we cannot choose to make the stress go away, but we can reduce the effects on the body. This is where a clean diet starts to make a difference. Eating lots of the colorful phytonutrients found naturally in fruits and vegetables, eliminating processed foods, avoiding pesticides and artificial chemicals, gives us a one-two punch. Phytonutrients are antioxidants and detoxifiers to reduce impact of physical and mental/emotional stressors, and, we eat less artificial chemicals that signal danger to the body. This also benefits us by reducing refined sugars and starches which require us to use a lot of cortisol to balance the overload of simple carbohydrates. Remember the symphony? The tune they are playing is “keep the blood glucose steady by regulating metabolism.”

Next, we want regular exercise. Not only is the gazelle better able to run in times of true danger if she keeps her muscles tuned, the exercise can act like the discharge of excess energy the gazelle used after it saved its life. When we do our mindfulness and breathwork, we give the SNS a break, allowing all the rest/digest/repair signals to do their jobs.

Included in the healing power of nature are various herbs and nutrients which directly support the adrenal glands. Vitamin C and many B-vitamins are essential to production of cortisol, metabolizing estrogen, and producing neurotransmitters. Phosphatidylserine can modulate the effects of stress on brain tissue and gut lining. Well-known herbs, called adrenal adaptogens support the adrenal glands to adjust to our changing levels of stress. These are herbs such as ashwagandha, rhodiola, panax ginseng, magnolia officinalis, schizandra and holy basil. We often find mixtures of these have a symbiotic effect, and can also be timed to support daytime or nighttime symptoms.

If these considerable natural forces are not solving all the concerns, we may want to use bio-identical hormones in as low a dosage as we can to aid memory, sleep, libido, and vaginal dryness. Bio-identical means that the hormones have the same chemical structure that a woman’s body makes, not what horses or laboratories make. Space does not permit going into the potential side effects of these powerful natural chemicals. Suffice it to say estrogen can have very real risks for women with increased cardiovascular risk factors. And we never recommend it be taken orally for managing menopause.

Resources abound to help you clean up your diet, find the right exercise routine, design your unique meditation practice, and even find OTC adrenal adaptogens. We cannot more strongly recommend that you implement those lifestyle choices—which doubly benefit by turning on anti-aging—before making the decision about whether prescription drugs are the best solution for your concerns. And, to minimize confusion about pharmaceuticals vying for market share, and avoid on-line hormone “mills,” get a clear view of all options by working with a Functional Medicine physician who focuses on whole person wellbeing.