Articles

Menopause

Introduction

By definition, menopause is the transition period between the reproductive years of a woman’s life and the cessation of ovarian function. Unless brought about by surgery or other causes, natural changes in a woman’s body generally occur around the age of 50. At this time a decrease in the production of hormones in the ovaries occurs. Changes occur in the levels of four main hormones of the normal menstrual cycle including estrogen, progesterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). These changes in hormonal production, termed the climacteric, are found in a process that begins when a woman is in her 40's and may end during her 70's.

After a woman has menstruated for 30 years, estrogen levels begin to decline. At this time, there is essentially no progesterone produced by the ovaries. However, the adrenal glands continue to produce both estrogen and progesterone in small quantities. There needs to be a balance in the amount of estrogen and progesterone – the reason for hormonal replacement therapy (HRT).

Menopause not only causes unwanted symptoms such as hot flashes and insomnia, it also increases a woman’s risk for serious problems such as osteoporosis and cardiovascular disease. Therapy for menopausal women should address not only the climacteric symptoms, but should also address cardiovascular support and prevention of osteoporosis.

For the women that initially make a decision to use estrogen replacement therapy, 20 percent never fill the prescription; 20 percent discontinue within the first nine months; 10 percent take the therapy intermittently; 50 percent drop the therapy after one year; and 70 percent are not on the therapy after five years. For many women, estrogen therapy is not an option that they will consider, they have had an adverse event, or the use of estrogens for them is contraindicated. It therefore becomes important to consider natural approaches as adjunctive and supportive therapies.

Statistic

North American Menopause Society, 2000.

    The median age for onset of perimenopause is 47.5 years. In the US, there are an estimated 41.75 million women over the age of 50. Most women spend 1/3 to 1/2 of their life in post menopause. Smoking has been identified as a cause of early menopause.
  • Spontaneous menopause occurs at the average age of 51.4 years in Western women.
  • The menopause transition lasts an average of 4 years.
  • In 2000, there were 45.6 million postmenopausal American women, 39.9 million of these women are over the age of 51.

Signs and Symptoms

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Not available

Climacteric Complaints

    Hot flashes, usually presented as vasodilation of the face, neck, chest and back Insomnia Mild to moderate depression Arthralgias/myalgias Edema Palpitations Headaches Vaginal dryness Increased sweating

Physical Changes

  • Supporting structures (sphincter muscles of the bladder and rectum) may lose muscle tone
  • Breast size, shape, and firmness may be altered
  • Skin wrinkling and loss of tone may occur due to decreased collagen structures
  • Body fat may be redistributed to areas such as thighs and hips. 
  • Bone mass and strength may decrease.
  • Metabolic rate may slow, increasing chances of weight gain.
  • Nervous system changes such as emotional changes, tiredness, insomnia, forgetfulness, headaches, anxiety, irritability, and depression may occur. 
  • Cardiovascular system - an increased risk of cardiovascular disease, including atherosclerosis (hardening of the arteries), chest pains, and high blood pressure. Hot flashes may also be prevalent, causing an increase in sweating, heart palpitations, redness and flushing, and dizziness.
  • Genitourinary tract - vaginal dryness and irritation may occur, making sexual intercourse painful. There may be a loss of sex drive, an increased formation of urinary cysts and an increase in bladder and urinary tract infections.
  • Musculoskeletal changes - Osteoporosis is a major problem of menopause and declining estrogen levels. Problems with calcium metabolism cause bone thinning, joint, bone, and muscle aches, bone fractures, and an eventual decrease in height.  

Treatment Options

Conventional

Role of Estrogen: Estrogens are hormones that prepare the endometrial cells of the uterus for pregnancy. Estrogens (estradiol and estrone) have many functions in the body, including:

    Cause ovulation, helping to rebuild the lining of the uterus following menstruation. Assist in the development of secondary sex characteristics, including breast development and distribution of body hair. Promote cholesterol balance and nourish the blood and circulatory system. Improve bone density and strength by increasing calcium and phosphate absorption. Increase the softness, smoothness, thickness, and elasticity of the skin.

Estrogen deficient women usually start menopause early and have the most severe symptoms. A deficiency in estrogen can be a major cause of infertility, menopausal symptoms, osteoporosis, and increased risk of heart disease.

Role of Progesterone: Progesterone prepares the lining of the womb for pregnancy and implantation and decreases uterine contractions. Progesterone normally maintains fluid balance, acting as a natural diuretic, by increasing sodium and water elimination from the body. Progesterone deficiency may cause various mild to severe symptoms. This deficiency may be largely responsible for causing premenstrual syndrome (PMS). The adrenal glands produce progesterone throughout the entire menstrual cycle, whereas the ovaries only produce it in significant amounts during the premenstrual phase of the cycle. Progestins (progesterone and medroxyprogesterone) have a balancing effect on estrogen. When progesterone levels drop to near zero, estrogen dominance occurs with side effects including:

    Water retention, swelling (edema) Fatigue, lack of energy Breast swelling Premenstrual mood swings Loss of sex drive Uterine fibroids Cravings for sweets Weight gain, fatty deposits in thighs and hips Cold hands, cold feet (low thyroid)

The addition of medroxyprogesterone to estrogen was reported to potentially negate some of the beneficial changes of estrogen, most notably the increase in HDL cholesterol levels. (1) However, progestin therapy has been reported to offset the increase in triglycerides seen with unopposed estrogen replacement. Estrogen dominance may not mean that a woman has too much estrogen - it may simply be that the progesterone component is out of balance.

Hormonal Replacement Therapy (HRT): Hormonal replacement is supplemental hormonal therapy with synthetic estrogen, usually including a progestin. HRT influences many aspects of health: climacteric symptoms, osteoporosis, cardiovascular disease (although a recent study has reported that HRT may not be as beneficial in heart disease as once believed), (2) breast and endometrial cancer, thrombosis and emboli, and Alzheimer's disease. (3) A decision to use HRT may depend on a woman's individual views of the menopausal transition, the postmenopausal phase, and its consequences. Health providers and patients should be thoroughly informed about the symptoms associated with hormonal deprivation, the associated risks of osteoporosis and cardiovascular disease, and the potential risks of HRT when used in these afflictions.

In exchange for benefits, women on synthetic estrogens may suffer from irregular vaginal bleeding and may have an increased chance of breast cancer and/or endometrial cancer. (4) , (5) Progestin use combined with estrogen has been shown to decrease the incidence of uterine cancer. (6) For many women, synthetic estrogens may be undesirable, or their doctor may not recommend synthetic estrogens due to a pre-existing condition. Contraindications to taking synthetic HRT should be discussed with a doctor, but include the following:

Contraindications to the Use of Hormonal Replacement Therapy (HRT)

Cancer Cardiovascular disease
Diabetes Hypertension
Smoking High cholesterol levels
Tendency to gain weight Fluid retention
Liver disease Breast cancer
Fibrocystic breast disease Thrombophlebitis or thromboembolism
Unexplained vaginal bleeding Uterine fibroids
Endometriosis Gall bladder disease
Mental disorders Anxiety and depression
Irritable bowel syndrome

Besides uterine and breast cancer, synthetic estrogens have been reported to also cause fluid retention and may increase the severity of asthma and migraines, among other problems. (7) , (8)

Concerns Regarding the use of Hormone Replacement Therapy (HRT): In July of 2002 a study was published greatly questioning not only the benefits of HRT but also the now confirmed risks of using HRT. (9) The concern arose from the results of one of the trials being conducted by The Women's Health Initiative (WHI). Since 1993 the WHI has enrolled over 160,000 postmenopausal women between the ages of 50 and 79 in one of several trials evaluating strategies designed to promote health and well-being as women age. In one of the trials, 16,608 of these women who were randomly placed in one of two groups; a placebo group or a group taking a combination prescription tablet containing 0.625mg of conjugated estrogens and 2.5mg of medroxyprogesterone acetate.

The design was to follow the women enrolled in the trial for 8.5 years. However, after an average follow-up time of just 5.2 years, the trial was stopped because a routine review of the data found that the women on the hormone combination had an increased risk of breast cancer. Other large trials have raised similar concerns as the WHI trial, (10) , (11) but the WHI was the first to confirm this increase breast cancer risk in healthy women with a uterus.

Other concerns were found as well. From the data of the WHI trial, if you had 10,000 women taking estrogen and progestin and compared that group to a similar group taking placebo, over a 1-year period the women using the hormone combination would experience the following;

    7 more events related to coronary heart disease 8 more strokes 8 more blood clots in the lungs, known as pulmonary embolisms 8 more cases of invasive breast cancer
However, the study did show some benefit to using the hormone combination because this same group of 10,000 women would have;
    6 fewer cases of colorectal cancer 5 fewer hip fractures

It is important to note that though this trial raises great concern about the use of HRT, these results only pertain to the use of this combination and dose of estrogen and progestin. At this point we do not know whether other combinations, doses or the use of estrogen alone provides a greater benefit or a greater risk. In fact, the WHI has decided to continue all other trials in progress including one evaluating diet, calcium and vitamin D supplementation and even one evaluating the use of estrogen alone in women who no longer have a uterus. (12)

Nutritional Supplementation


Calcium

Conventional measures after menopause include estrogen replacement therapy and calcium supplementation. The most important element associated with bone mineral density is calcium. Microcrystalline calcium hydroxyapatite (MCHC) is a well absorbed form of calcium derived from bovine whole bone meal and processed under specific guidelines to eliminate contaminants sometimes found in bone meal. Preliminary studies suggest that supplementing with MCHC relieves back pain associated with osteoporosis, reduces parathyroid overactivity, and could prevent and possibly restore bone loss. (13) , (14)


Magnesium

Supplementing with magnesium can improve menopausal symptoms and risk factors, especially the risk of osteoporosis. Magnesium aids in calcium transport, absorption, and utilization. Studies show that low levels of dietary magnesium correlate with decreased bone mineral density. (15) , (16) Magnesium also aids in the relaxation of skeletal muscles, lending a mild tranquilizing effect. (17) It is recommended that the magnesium-calcium ratio be maintained at 1:2 to prevent postmenopausal bone loss. Magnesium aspartate or citrate salt forms are recommended for optimum absorption.


Gamma Oryzanol

A small Japanese study involving 40 women evaluated the use of gamma-oryzanol on menopausal symptoms and lipid peroxide levels. Thirty-six reported symptom improvement of various types and intensities for hot flashes, weakness, joint pain, muscle pain, headaches, insomnia, nervousness, and/or melancholia. Some women with adverse lipid profiles demonstrated improvement on several lipid measures. (18)


Soy Isoflavones

In cultures where soy products are consumed in abundance, women’s health problems, certain cancers, and cardiovascular disease are reported to be less prevalent. (19) Increasing the dietary intake of soy products increases the intake of phytoestrogens, which weakly mimic the effects of endogenous estrogens. Soy isoflavones (genistein and daidzein) are rich in phytoestrogens and are thought to reduce menopausal symptoms, support bone mineralization, and decrease the risk of certain cancers. (20) , (21) , (22) , (23)

There has been recent interest in the reported use of soy isoflavones in women for decreasing bone loss caused by estrogen deficiency. (24) , (25) Results indicate that genistein may exhibit estrogenic action in bone and bone marrow, possibly aiding in the regulation of B-lymphopoiesis in the prevention of bone loss, without exhibiting estrogenic action in the uterus.

Ipriflavone is a synthetic isoflavone. Numerous studies have evaluated ipriflavone and its impact on the maintenance of bone density. Various sample sizes and study designs have supported the use of this isoflavone for the maintenance of bone density. (26) , (27) , (28) , (29) Opposing results have been noted when ipriflavone was evaluated in postmenopausal osteoporotic women. An extensive prospective, randomized, double-blind, placebo-controlled study involved 474 women and lasted 4 years. Two hundred milligrams of ipriflavone three times a day was compared to placebo, with both groups receiving a calcium supplement. This study demonstrated that ipriflavone did not prevent bone loss. (30)

Epidemiological studies have noted that soy consumption is associated with a lowered risk of cancers, including breast cancer. (31) Evidence in support for these claims has come from studies with cultured human breast cancer cells (32) and animal models of breast cancer. (33) , (34) Researchers concluded that in the case of breast cancer risk, the beneficial effects of soy and soy isoflavones occur prior to and during puberty by accelerating the rate of differentiation of the epithelial cells of the breast. (35)

Another consideration important to menopausal health is that soy intake is associated with a reduction in cardiovascular risk due to cholesterol regulating effects. Researchers have concluded in a study on the effects of soy protein on cardiovascular health that soy supplementation use results in significant improvements in lipid and lipoprotein levels, blood pressure, and the perceived severity of the vasomotor symptoms of menopause. (36) It has also been reported in an animal study that the isoflavones in soy protein improve cardiovascular risk factors without negative effects on the reproductive system. (37) In October 1999, the FDA authorized the use of a health claim that foods containing soy protein included in a diet low in saturated fat and cholesterol may reduce the risk of coronary heart disease (CHD) by lowering blood cholesterol levels. Scientific studies indicate that 25 grams of soy protein daily in the diet is needed to show a significant cholesterol lowering effect.

More study is warranted before recommending isoflavones for estrogen positive breast cancer because it has been reported that the soy isoflavone genistein stimulates the growth of estrogen-dependent breast cancer cells in vivo in a dose-dependent manner. (38) , (39) Genistein has also negated the inhibitory activity of tamoxifen in women with certain estrogen positive breast tumors. (40) Thus, women with estrogen positive breast cancer or who are on tamoxifen should limit their intake of isoflavones until more is known about the effects of phytoestrogens on breast tumors in this patient population.


Dehydroepiandrosterone (DHEA)

DHEA has exhibited some promise in easing the symptoms of menopause. As women get older and approach menopause, their DHEA levels begin to decrease. One study showed that among the group of women studied, the older women with lower DHEA levels had more symptoms of depression. (41) Other studies have linked low DHEA levels to depression. (42) A study evaluating depression and DHEA levels in the elderly showed that scores on depression tests improved with DHEA supplementation. (43) Other studies have confirmed that overall mental health is not as good in peri- and postmenopausal women when DHEA levels are low. (44)

In postmenopausal women, DHEA supplementation has improved sexual arousal. (45) A study involving 120 postmenopausal women between the ages of 51 and 99 has noted that good DHEA-sulfate levels are directly related to good bone mineral density. (46) One study suggests that long-term use of DHEA may decrease certain cardiovascular risks in postmenopausal women. (47) Also, in postmenopausal women, DHEA has shown similar hormonal effects as estrogen-progestin replacement therapy. (48)


Melatonin

Melatonin levels decrease as we age with a distinct difference noted between premenopausal women and postmenopausal women. (49) Most hormone levels change with age as well. One study evaluating the relationship between hormones, melatonin and menopause noted that menopausal women with the lowest levels of melatonin were able to appropriately influence these hormones while taking a melatonin supplement in the evening. These women also reported a better mood and less signs of depression. (50)

Another study was completed evaluating premenopausal and menopausal women who were also experiencing either insomnia, depression, obesity or hyperprolactinemia. Overnight urine levels of melantonin were found to be low in women with insomnia and obesity. The study was unable to determine the role of melatonin in obesity, however it was suggested that women experiencing sleep disorders could possibly benefit from melatonin supplementation. (51) Reviews of medical literature have also suggested a beneficial role of melatonin in menopausal women experiencing insomnia. (52)


Vitamin C, Vitamin D

Bone loss and decreases in bone mineral density is inevitable as we age. It is important to slow this process, maintain strong healthy bones and thus decrease the risk of bone fractures. According to the National Osteoporosis Foundation, over half of Americans older than 50 have low bone mineral density and 80% of them are women. (53) Especially when used with other therapies, numerous studies have supported the use of vitamin C to help support bone mineral density. (54) , (55) , (56) , (57)

Vitamin D is one of the primary regulators of calcium absorption. Deficiencies are frequently found in postmenopausal women with or at risk for osteoporosis. (58) , (59) , (60) , (61) Considering this relationship, vitamin D insufficiency may have an effect on bone strength. (62)

Herbal Supplementation


Black Cohosh

Black cohosh rhizome has been reported to have phytoestrogenic properties. (63) The isoflavone formononetin has been reported to have estrogenic activity in laboratory rats. (64) Formononetin was reported to act as a competitor with estrogen in binding to uterine cells ex vivo. Clinical studies have reported positive effects on menopausal and postmenopausal complaints when using standardized extracts of black cohosh. (65) , (66) , (67)

Most of the clinical research for black cohosh has been completed using a proprietary product, Remifemin®. Remifemin® is a standardized preparation of 1mg triterpene glycosides calculated as 27-deoxyacetin. Though now debated the triterpenoid 27-deoxyactein has been reported to produce estrogen-like effects in humans. (68) In a controlled study, black cohosh tablets, standardized to 1mg of 27-deoxyactein, were given to 110 female patients in a university gynecological clinic. Patients received two tablets twice daily for two months. Half the patients took the black cohosh tablet, and half took a placebo. At the end of the required treatment period, both groups were tested for luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, as increases in LH levels have been found in menopausal individuals complaining of hot flashes. There was no significant effect on the FSH serum concentration reported in either group. This study reported the positive effects that black cohosh has on LH suppression in menopausal women, with an estrogen-like manner. It should be noted, however, that naturally occurring estrogen in the body also affects the release of FSH through receptor binding; so even though black cohosh has estrogenic properties in the body, it does not have the exact pharmacology as naturally occurring estrogen.

The same proprietary preparation was evaluated in a study comparing a dose response without a placebo control in more than 120 women. Vaginal cytology was one of the measures in the study as were levels of "gynecologically relevant hormones". Due to the lack of change in vaginal cytology and non-significant changes in hormone levels, the investigators concluded the presence of a nonestrogenic effect. Additionally, the various efficacy and tolerability measures indicated an improvement in menopausal symptoms. (69)

Also, the constituent cimicifugoside is reported to affect the hypothalamus-pituitary system, producing a hormonal balancing effect in the female reproductive system. (70) The hypothalamus and pituitary glands control many aspects of human biochemistry, including hormonal release and regulation.


Chasteberry

Chasteberry has a long folk history of use in women’s health. Chasteberry has been recommended for use in mild to moderate symptoms in endometriosis, menopause and PMS. The actual activity of the constituents of chasteberry is not fully established at this time, though studies point to a progesterone-like component and effect (71) , (72) , (73) as well as stimulation of luteinizing hormone (LH) and inhibition of follicle stimulating hormone (FSH). (74) , (75) Because of this activity, vitex has been recommended for a variety of female complaints, such as PMS, amenorrhea, menopausal symptoms, endometriosis and hyperprolactinemia. (76) , (77) , (78)


Red Clover

There has been a great deal of research and reviews on the effects of phytoestrogens (or plants that contain chemical entities that have estrogenic activities in the body) as they relate to menopausal symptoms. (79) Research has focused on the red clover extract, which contains four principle phytoestrogens (biochanin A, fomonontein, genistein, and daidzein), all with reported levels of estrogen-like activity. (80) A proprietary extract of red clover (Promensil™), standardized to the phytoestrogen content, has gained a great deal of attention in the management of menopause and related symptoms. Studies involving this extract have demonstrated a range of response from no advantage over placebo to a statistically significant improvement in certain menopausal symptoms. (81) , (82)


Dong Quai

Dong quai is generally considered when evaluating options for relieving the symptoms of menopause. However, numerous studies evaluating the use of dong quai for that purpose have not had promising results. One indicated that dong quai showed only weak estrogen receptor activity (83) whereas another stated it was no more helpful than placebo in treating menopausal symptoms. (84) Reviews of the medical literature question the benefit of dong quai in treating menopausal symptoms as well. (85) , (86) , (87) One study even noted that dong quai stimulated cell growth of a specific type of breast cancer. (88)


American Ginseng

A study involving 384 postmenopausal women compared the use of ginseng to placebo for relief of related symptoms. Benefit was seen for depression and general well-being and health. However, no advantage was seen for hot flashes and physical changes that occur to the vagina and surrounding area. This study seems to indicate that the beneficial effects seen may not be related to hormonal-like effects anticipated. (89)

Since ginseng is commonly used to treat menopausal symptoms, studies have evaluated not only the estrogen-like activity but also the potential of ginseng to stimulate the growth of certain types of breast cancer cells. Though no activity on estrogen receptors was noted in a laboratory study, ginseng stimulated cell growth of a specific type of breast cancer. (90) A second laboratory study evaluating the same type of breast cancer cells had opposite results. Compared to estradiol, American ginseng did not increase cell growth. In fact, when tested with certain drugs designed to fight breast cancer, cell growth was actually decreased. (91)


Evening Primrose

A study evaluated the use of gamolenic acid (gamma-linolenic acid, an omega-6 fatty acid) for the relief of menopause associated flushing and sweating. The treatment group received evening primrose oil as the source of gamolenic acid and vitamin E. This group was compared to a placebo group. Although there was a reduction in the maximum number of night time flushes, the study concluded that overall, gamolenic acid was no better than placebo in treating menopausal flushing. (92)

Homeopathic

Kali carbonicum

Typical Dosage: 6X or 6C, 30X or 30CWeary; Anxious; Weakness in the legs; Stabbing, burning pains with perspiration

Lachesis mutus

Typical Dosage: 6CHot flashes and left-sided ovarian discomfort; Symptoms worse in morning; Tender breasts; Morning headache

Sepia

Typical Dosage: 6X or 6C, 30X or 30CDysmenorrhea; Irritability; Cold; Weepy; Craving sweet or salty foods; Sallow patches; Flooding during period

Acupuncture & Acupressure

Wang has combined acupuncture and herbal medicine to treat Menopausal Syndrome. The herbal formula used is a modified Tian Ma Gou Teng Yin, and the key acupunture points are the elbow and knee joints (LI 4, and Liv 3) and Sanyinjiao (Sp 6). (93)

Mu has focused on the Eight Liuzhu (multiple abscess) Acupoints (Lu 7, SI 3, P 6, Sp 4, K 6, St 25) to treat Menopausal Syndrome. (94) While Yang has used the ear-pressure method to treat Menopausal Syndrome. (95)

Traditional Chinese Medicine

Menopause

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Diet & Lifestyle

    Eat a healthy diet low in animal fats, consisting of plenty of fresh vegetables and fruits (organic where possible). Eat whole, unprocessed foods, no preservatives. Drink plenty of quality water (either reverse osmosis, bottled, or filtered). Limit meats and increase soy products, legumes, and whole grains. Limit refined sugars. No carbonated beverages – high phosphate content may bind calcium. Eat olive oil in foods to replace other oils (extra virgin, cold pressed) and eat cold water fishes (salmon, cod) at least two times a week for essential fatty acids. Limit carbohydrates and eat on a regular schedule to limit blood sugar fluctuations. Limit alcohol and caffeine consumption. Exercise regularly.

It is recommend that patients increase their consumption of soy products, including tofu, soy milk, and tempeh. The best dietary sources of isoflavones are soy milk (30mg/8 ounces), tofu (35 mg/one-half cup), tempeh (35mg/one-fourth cup), roasted soy nuts (60 mg/one-fourth cup) and soy protein powder (approximately 60 mg/two scoops). Not all soy foods contain isoflavones. Soy foods made from soy protein concentrate may have little if any isoflavones.

The FDA allows manufacturers of soy protein food products to claim a reduction in the risk of heart disease for their food product if it meets the following qualifications per serving:

    6.25 g of soy protein low fat (less than 3 grams) low saturated fat (less than 1 gram) low cholesterol (less than 20 mg) sodium values less than 480 mg for an individual food, less than 720 mg for a main dish and less than 960 mg for an entire meal (96)

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

Hormone Assessment

Insulin: This hormone lowers blood glucose and promotes glucose storage by stimulating the synthesis of glycogen and fatty acids. Following a meal, carbohydrates stimulate the pancreatic cells to release insulin. Insulin is used in the synthesis of fatty acids and ultimately triglycerides. It is believed that insulin has a significant regulatory role in gonadal function in females, influencing the climacteric response. (97)

    Estrogen: The role of estrogen in osteoporosis has been investigated at length and correlations have been postulated. It is possible that assessment of estrogen may be useful in the monitoring of CVD and osteoporosis risk. It should be noted, however, that osteoporosis is a disease of multifactorial origin, and estrogen assessment should only be a part of a complex evaluation and intervention program. (98) Estradiol: Estradiol production stops or diminishes during menopause. Estradiol levels are useful in distinguishing menstrual abnormalities and can be useful in determining replacement therapy for reduction of menopausal symptoms. Estradiol levels have been related to mood during menopause. (99) Estradiol levels also decrease with a high-fiber diet. Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH): FSH, when released from the anterior pituitary, promotes maturation of the ovarian follicle, producing estrogen. Rising FSH levels give rise to LH. Together, they induce ovulation in women. FSH has not been seen as a reliable marker in the diagnosis of the stages of menopause due to the difficulty in interpreting its fluctuations. (100) FSH and/or LH are increased in hot flashes. LH levels are increased immediately following menopause, perhaps due to alterations in the feedback mechanisms stimulating its production controls, or perhaps specifically due to the influences of diminishing estrogen levels. Progesterone: It is commonly recommended that bone density be monitored during menopause. It is suggested that progesterone levels have a direct bearing on mineral absorption in bone. (101) Progesterone replacement therapy may increase IGF-1 concentration in bone and result in bone density increase. (102) Testosterone: This androgen functions primarily as a reproductive hormone; however, evidence suggests it plays a significant role in bone health through its influence on maintaining a positive balance of sodium, potassium, calcium, and phosphorus.

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