You mention joint pain, weight gain, and food cravings in addition to hot flashes as symptoms of menopause. Menopause has such a variety of symptoms, depending on each individual. Lifestyle matters more; exercise is more important; adequate sleep and good nutrition—all of these have a greater impact to quality of life now than they did previously.
I wish I could tell you there is good data suggesting vitamins have a favorable impact on menopausal symptoms, but the trials looking at the specific supplements you mention and others suggest no benefit greater than placebo. But, hey, placebo has about a 30-percent response rate in any trial, so there is certainly no harm in using them. They provide some general vitamins that will not be harmful, and may help if you aren’t getting them in your diet.
The symptoms you mention could all potentially benefit from hormone therapy (HT). The loss of estrogen is huge for most women, and the loss of progesterone to some extent as well. For many women the only way to address symptoms adequately is to consider HT. More and more data suggests that HT is beneficial for women specifically with weight gain; that was a lead article in one of my journals just this week.
It’s a complicated journey that is nuanced, and each woman needs to assess her own symptoms and goals and determine the best approach to managing through menopause. It’s difficult to address all of the treatment options in a single Q&A. You might find the North American Menopause Society (NAMS) website helpful: menopause.org. They cover many issues related to menopause.
Recently I had the privilege of interviewing Dr. Joan Vernikos for my podcast series “Fullness of Midlife,” which are conversations with interesting people about health, love, life, and meaning. Dr. Joan was director of Life Sciences at NASA until 2000 when she “retired” to write and speak (some retirement!) about some of the groundbreaking research she had conducted from her special perch at NASA.
You can listen to the entire interview here, but I wanted to also distill the pertinent bits for MiddlesexMD readers.
As you might imagine, the effect of gravity, or lack thereof, is a fundamental concern for scientists at NASA. Astronauts are exposed to low-gravity environments, sometimes for months at a time, which has wide-ranging and deleterious effects on bones and organs, blood and cardiovascular systems. During her time at NASA, Dr. Joan specialized in the effects of gravity on the human system.
But here’s the thing: Dr. Joan came to understand that gravity operates on earthbound humans in similar ways! When we are upright and moving around, we are subject to the full effects of gravity pulling us to the center of the earth vertically. But when we are horizontal, lying in bed, for example, gravity’s pull is spread evenly throughout our bodies and is much less intense—similar to the experience of astronauts. “…The changes that accompanied lying in bed… 24 hours a day… are very similar to those we see in astronauts. Granted, maybe a little less intense,” said Dr. Joan.
Interestingly, these metabolic changes don’t happen when we sleep at night. Normal sleep appears to have a restorative, “detoxing” effect on the body and the brain, which is also important to good health.
Since the few astronauts who actually spent time living in micro-gravity were harder to find than subjects willing to lie in bed, Dr. Joan began studying the effects of long stretches of time spent horizontally. She found, for example, that after about four days “very significant changes” began to happen in the way her subjects metabolized fluids, in the cardiovascular system, and in stress responses. Of course, as with astronauts, these changes mostly were reversed when the test subjects got up and walked around or the astronauts came back to earth, and gravity took over.
Then, Dr. Joan visited a friend’s elderly mother who was bedridden, and she realized the low-gravity changes she’d been studying looked a lot like aging. Was there a link between our increasingly sedentary culture and the symptoms of early aging? Dr. Joan feels that the chronic diseases of the elderly—diabetes, cardiovascular problems, obesity, bone loss and muscle wasting—are happening at younger ages, even in childhood, because we no longer allow gravity to do its work. We sit too much and move too little.
Dr. Joan hypothesized that the body is meant to move all day long, and in the not-so-distant past, that happened pretty naturally. Our grandparents “…bent over and reached up and made beds and cleaned and washed and gardened. And went and bought groceries and walked home or rode a bicycle, or whatever.”
Following several studies, Dr. Joan feels that simply standing up is “fundamental” to countering the effects of inactivity. Simply standing up and then moving around reverses the micro-gravity effects of lying in bed—or of aging. Trouble is, we don’t live like our grandparents. More likely, we sit for hours in front of one screen or another in the office and at home. Then, if we’re disciplined, we might exercise a few times a week.
Exercising, while good in itself, isn’t enough to counteract the effect of sitting around for hours every day. Our bodies are designed to move, to work against gravity. That, not sitting, is our normal state, the result of eons of evolution.
After her 2011 book, “Sitting Kills, Moving Heals,” was published, a slew of new research supported the hypothesis she’d developed from her work at NASA: Long periods of inactivity have deleterious health effects. “…sitting makes worse absolutely everything. Whether you’re talking about cancer—prostate, breast cancer, cardiovascular conditions, stroke, metabolic conditions, diabetes, obesity—you name it, it makes it worse,” said Dr. Joan. (Here, for example, is NPR’s report on recent studies of aging subjects. The conclusion? If you don’t walk now, you might not be able to later.)
So, what should we do, especially if we’re still working and chained to a desk all day—but even if we’re retired and reading or knitting? Fortunately, the solution is simple. “Stand up!” says Dr. Joan. Go to the watercooler, the bathroom, just take a break every 30 minutes or so. You don’t need to hop on a treadmill or take a 30-minute walk, just stand up and move for a few minutes. You won’t lose weight or tone your muscles with this regimen; it isn’t meant to take the place of exercise and a healthy diet, but it’s a good habit to develop if you regularly sit for hours every day.
Gravity is your friend, says Dr. Joan. Embrace it!
In previous posts, we discussed why menopausal weight gain is such a game-changer, and we explored how to limit the damage through dietary changes. Now, we’ll talk about the second critical key for maintaining—or regaining—a healthy weight after menopause.
You know what I’m gonna say.
Exercise. Not only does a regular exercise regimen help you burn more calories, which is what weight loss is all about, but it can also give you a higher quality of life and actually stave off illness.
Longitudinal studies have found that people who are more fit at midlife have lower levels of chronic illnesses, such as heart failure, diabetes, Alzheimer’s disease, colon and lung cancers, as they age. Although other factors, such as heredity, play a role, in general, higher fitness levels were strongly linked with lower rates of major chronic illnesses. “Compression of morbidity” is when debilitating illness doesn’t happen until close to the end of life—and people with healthy, active lifestyles tend to have compression of morbidity.
How’s that for paybacks?
I can tell you from personal experience that a regular, moderately challenging exercise regimen relieves stress, helps you sleep better, reduces the “aches and pains” associated with aging, and helps you to keep up with normal activities of daily life. It regulates your bowels and your moods. And simply feeling stronger and more capable physically helps you to feel more capable and in control of your life generally.
However, I will also say that maintaining a serious (and by serious, I mean regular and moderately challenging) exercise regimen is not easy. It takes time and self-discipline. It makes you sweat. It makes you breathless and it might make you sore.
Not only that, you have to approach exercise differently in your golden years than you did before. You won’t be able to just take off running without a serious warm up; you’ll have to watch your form more carefully; you’ll want to opt for low-impact exercise. Your postmenopausal exercise regimen should contain four elements:
Lately, high intensity interval training (HIIT) is recommended to increase the effectiveness of an aerobic workout. In this regimen you alternate bursts of higher activity, such as jogging, with a less active period, such as walking. This gives you an “afterburner” effect in which your muscles continue to burn oxygen after the period of high activity. This AARP article has a good explanation of the benefits of HIIT.
Arguably, the hardest part about exercise is getting started. If you have any health conditions that might limit your activity, such as high blood pressure or arthritis, you need to talk with your doctor about what exercises you should and shouldn’t do.
Ideally, you should find a gym with classes or a trainer to get you started—to make sure you’re using correct form, and to show you how to use the machines. Yoga or Tai chi classes with experienced teachers are fantastic and motivational for establishing an exercise regimen.
If this isn’t practical or possible for you, you might turn to the internet for videos and programs. You want substance, knowledgeable leaders, and safety, not razzle-dazzle. Try Fitness Blender (free workout videos and programs for all levels of fitness), Daily Burn, ($15/month; variety of workouts, including yoga, tailored to age and fitness level) or Yoga Today ($15/month with a discount for yearly membership; many workouts tailored to fitness level).
The next hardest part of an exercise regimen is continuing. You will miss days; you will have days in which you don’t work as hard as you should. After a few missed sessions, starting again is hard. That’s just how it goes. You start over; you don’t quit.
Part of the battle is finding a program that works for you—one that is varied, challenging (you are progressively lifting heavier, going longer and faster), but that isn’t killing you. Soreness is good; pain is bad. Move carefully without overextending or snapping joints. Always warm up and cool down.
This is your new normal: a clean diet, a daily exercise regimen that alternates weight training and aerobic exercise and incorporates stretching and balance segments.
I promise you that every ounce of effort invested in a healthy diet and regular exercise will return to you many-fold in a much higher quality of life now and in lower risk of chronic illness down the road. Let me know how it goes and send me any questions you may have. This stuff is too important to overlook.
During menopause, weight is easy to gain (in fact, some weight gain is almost inevitable) and hard to lose, for all the reasons we mentioned in the last post: metabolic change, loss of muscle mass, hormonal change, sleep deprivation, and stress.
So, ladies, if you’re just entering menopause—heads up! Game-changer ahead! Women who enter menopause close to their ideal weight have a better chance of maintaining it; however, women who tend to yo-yo or who have a hard time maintaining a healthy weight will tend to end up at the high end of their weight range.
Whatever you did in your 30s to keep your weight in check isn’t going to work anymore. You’ve lost about 20 percent of your muscle mass and you need about 200 fewer calories per day you enter your 50s and 60s. Forewarned is forearmed, as they say. Simply recognizing this fact may help you step away from the hamster wheel of yore and toward a regimen that actually works.
The good news is that the best weight management strategy—the one that will work for the long haul—will also keep you stronger, more flexible, healthier, and capable of maintaining an active lifestyle for far longer. You’ll be able to travel, garden, play with the grandkids, get up off the floor, carry heavier loads, and remain generally pain-free.
The bad news is that it’s hard. A realistic and effective strategy to maintain a healthy weight requires self-discipline and lifestyle change. For the rest of your life. As you’ve probably guessed, you have to get serious about exercise and your diet—how much and what kind of food you put in your mouth.
Sure, you can go on a killer diet; you can take medications that will help you lose weight. But you probably already know the drill here—without lifestyle change, you’ll put it right back on and then some. Only now, you’re much more vulnerable to a host of serious, life-altering ailments, such as joint problems, diabetes, and cardiovascular trouble.
So let’s talk about ways of eating that work for older women. We’re not talking about draconian measures that you’ll have a hard time maintaining. In fact, overly rigorous dieting can actually cause you to lose muscle mass and slow your metabolism even more, which is the last thing you need right now.
“My body has changed, so I’ve got to change with it. I can’t do what I did 20 years ago and expect to stay slim,” says nutritionist and co-author of The Full Plate Diet Dr. Diana Fleming in this article.
Staying fit and trim after menopause is no picnic, but feeling healthy, capable, and in control of your life is worth every uneaten ounce of chocolate.
As if the hot flashes, mood swings, night sweats, and sexual challenges weren’t enough, now you can add weight gain to the menopausal whammy.
That’s right. In case you hadn’t noticed (fat chance!), women tend to gain about 10-15 pounds on average—from 3 to 30 pounds is the typical range—during and after menopause. And because our entire metabolic mechanism is different now, that weight is blessedly hard to take off.
“I feel like my body has betrayed me,” said one of my patients.
“Prior to menopause I was able to maintain a weight loss of 70 pounds. I see that 25 pounds have come back and nothing I seem to do is helping,” said another woman.
Weight gain during menopause isn’t totally related to “the change.” Lifestyle, genetics, and, yes, hormonal fluctuation all play their respective roles, for better or for worse. But the weight goes on, and the way that happens is different from weight gain in previous years.
So, if you’re accustomed to losing weight easily—or not gaining it in the first place—this development may come as a puzzling and unpleasant surprise. And if you struggle with your weight, be forewarned: The deck is about to be reshuffled, and that struggle may become harder yet. The single bright spot is that you’re in a very big boat with a lot of other menopausal gals—up to 90 percent of us gain weight during this transition, according to this article.
Menopausal weight gain is different because:
In order to effectively tackle this unsettling turn of events and to grasp why the things you did before aren’t working now, it helps to understand the underlying mechanism.
For one thing, muscle mass, which is an efficient burner of calories, slowly decreases with age. Now, even your resting metabolism (when you aren’t active) is lower. Adding insult to injury, loss of estrogen compounds this effect. Studies of lab animals suggest that estrogen has a regulating effect on appetite and weight gain. Animals with lower estrogen levels ate more and moved less.
When the ovaries stop producing estrogen, fat cells tend to take over. Ovaries produce estradiol, a “premium” estrogen; fat cells produce estrone, which is a weak, inefficient estrogen. This hormonal change increases the body’s efficiency at depositing fat, especially, we find, around the abdomen.
A recent study confirmed that certain proteins and enzymes that enable cells to store more fat and to burn it less become more active in post-menopausal women. “Taken together, these changes in bodily processes may be more than a little surprising—and upsetting—for women who previously had little trouble managing their weight,” comments Sylvia Santosa, assistant professor in Concordia University’s Department of Exercise Science in this article.
You got that right, sister.
Menopause packs a couple more weight-inducing changes: insomnia and stress. When you don’t sleep well (and who does, what with night sweats and cratering mood swings?), levels of ghrelin, known as the “hunger hormone,” rise and levels of the “fullness hormone” leptin drop. That’s why you get the nighttime munchies. A study of over 1,000 volunteers (The Wisconsin Sleep Cohort Study) found that those who slept less had higher ghrelin levels and lower leptin levels—and also had a higher body mass index (BMI), i.e. they weighed more.
And we all know what stress eating does to our waistline.
So, what’s a stressed-out, sleep-deprived, menopausal woman to do? It’s a challenge, without doubt. However, when we understand the mechanism—what’s happening to our bodies on a biological level—then we realize that doing what we did before isn’t going to work. We need to change up the paradigm if we want to control our weight and maintain a healthy, active post-menopausal lifestyle.
This paradigm shift involves a different approach to both diet (Note: I did not say dieting!) and exercise. No magic pharma pill or painless regimen. Still, we can regain control of the bathroom scales despite the slings and arrows of our slowing metabolism and estrogen-storing fat cells. And honestly, we might end up with better health habits than we ever had before.
First, let’s get the lay of the land, even though it’s probably all review to you. To identify whether you’re overweight, the best (although not perfect) determinate is your Body Mass Index (BMI). It’s a simple calculation of your weight-to-height ratio, and it’s a more accurate assessment than weight alone.
(Here’s a tool to determine your BMI.)
Generally, a BMI score between 25 and 29.9 is considered overweight and over 30 is obese. If you fall within that range, you’ve probably heard all the risk factors associated with obesity, so I won’t reiterate.
But there are a few facts about obesity and sexual function—and aging in general—that might be helpful to know. While there’s some hemming and hawing about whether menopause and aging cause weight gain, there’s general agreement that fat deposits tend to redistribute themselves around the belly during menopause. Also that we tend to lose both muscle mass and metabolic efficiency as we age, making it easier to gain weight and harder to lose it.
So, if you’re heading into your menopausal years packing too many pounds, this might be a good time to tackle the problem. You’re on the cusp of a cascade of hormonal, metabolic, and physical change that will only exacerbate it.
Beyond the risk factors you’ve already heard, probably many times, obesity carries some very specific issues regarding sexual health. The most obvious? Sexual health tracks overall physical health. If you’re in good health, you’ll probably have more sex and enjoy it more. (Consider more and better sex one tempting carrot for losing weight.) Plus, studies repeatedly show that sex, in and of itself, is good for your health and sense of wellbeing.
You probably know that obesity is linked to higher risk for cardiovascular problems. For men, this often compromises blood flow to the penis, resulting in difficulty with erection and, consequently, with libido. A similar problem occurs in women.
“We are beginning to see that the width of the blood vessels leading to the clitoris in women is affected by the same kind of blockages that impact blood flow to the penis,” says Susan Kellogg, PhD, in this article about sex and weight.
Blood flow—and thus sensitivity—to the genitals often decrease during menopause, so coupled with excess avoirdupois, sexual sensitivity receives a double whammy.
A little targeted exercise to improve genital blood flow (as well as muscle mass in general) is a good place to begin. You don’t have to work out like Jane Fonda—a little of the right stuff goes a long way. “Any activity that increases blood flow to the large muscle groups in the thighs, buttocks, and pelvis—such as yoga, brisk walking, or cycling for 20 minutes three times a week is also going to bathe the genitals with better circulation,” Kellogg says.
Additionally, don’t neglect your pelvic floor. Excess weight puts extra stress on those overlooked muscles that hold a bunch of your abdominal organs in place. With menopause women tend to lose muscle tone as well, further affecting the pelvic floor. Lots of Kegel exercises will help increase circulation and tone that critical area.
Aging and the menopausal transition pose challenges to any woman’s self-image. As we’ve mentioned before, it’s hard to feel sexy when you’re focused on sags, bags, wrinkles, and cellulite. For obese women, body image can become a serious hurdle to pleasurable sex—or to having sex at all.
There are two ways to skin this cat, and they’re not mutually exclusive. You can begin to address with your overall health issues—and you don’t have to be the Biggest Loser to see significant improvement. Baby steps count, too. Small weight loss and a steady, gradual approach to improving your health can yield significant improvement in quality of life and improved self-image.
“I've noted that very often when patients start to take better care of themselves, they also report a substantial increase in their interest in sex. I think participation in a healthy lifestyle really helps, even if you don't lose the extra pounds,” says Martin Binks, PhD, director of behavioral health at Duke University's Diet and Fitness Center in Durham, North Carolina.
And you can also work on your self-image from within. If you feel sexy, you are sexy. “Don't buy into society's idea of the perfect sexual body, and do allow your own sexuality and sensuality to thrive inside the body you have,” says Abbie Aronowitz, PhD.
A lot more research is needed to tease out the connections between obesity, aging, sexual desire, and performance. The hormonal dance in women is delicate and not well understood, and that may be compounded for those who go into menopause with extra weight. The good news is that small gains reap big rewards, both for sex and life in general.
I rarely recommend water pills unless a patient is in heart failure and we need to decrease the fluid load on her heart and kidneys.
Bloating is usually related to gastrointestinal issues, and water pills don't address those issues. When the kidneys are functioning properly, they're getting rid of excess fluid; water pills put you at risk for depleting needed fluid or becoming dehydrated. Better options are to reduce salt intake and (counter-intuitively) to drink water.
My take on water pills for weight loss is the same: It's not a safe long-term solution.
I assume that your hormone therapy is oral or transdermal and systemic. There isn't evidence that says hormone therapy contributes to weight gain. In fact, some of the research suggests that it can be helpful in maintaining a healthy weight.
Based on my experience, I believe hormone therapy is weight neutral—although if it makes you feel better and sleep better, it can be very helpful to an overall healthy lifestyle, which includes exercise and a good diet.
This is a common question; unfortunately, it’s complicated to answer. First let me say that while I know weight gain affects many women’s sense of being desirable, what I read and my own informal research suggests it’s rarely an issue for their partners (some of whom are, in fact, oblivious—in a good way—and just as attracted as ever).
There does seem to be a physiologic drive to deposit fat during the menopause transition. The theory is that fat produces estrogen (estrone—a relatively weak estrogen), so in the presence of impending organ failure (menopause) and loss of estrogen from the ovaries (estradiol-the major, more important estrogen) that will occur, the body does its defensive thing: It deposits fat, really efficiently and effectively.
Unfortunately, estrone doesn’t provide many favorable effects. The major location for depositing fat is the midsection. Women who have yo-yoed in weight over the years seem to struggle more; those fat cells seem to remember readily how to deposit fat. Even women who have no weight gain during this transition will have a waist circumference increase of up to two inches.
Minimizing the weight gain starts with maintaining a healthy weight over time; those who are most successful in this transition benefit from years of stability at a healthy body weight leading into those years.
Those menopause transition years will be an added challenge, so start to make small healthy changes early on. Women lose muscle mass quite readily at this time of life, so work to maintain or gain muscle with strength training activities.
It’s a fact of life that at this point, it takes more effort to get the same results, requires more dietary caution and exercise, and leaves little room for not paying attention. My motto: You’re now high maintenance; behave like it!
Sexual health always follows general health, so it's hard to enjoy sexual health with other chronic conditions. Obesity is a known risk factor for heart disease, stroke, sleep apnea and other breathing problems, and osteoarthritis, among other things, and is associated with depression. Unfortunately, not sexy things to think about! And even more unfortunate is the fact that weight gain is common among women experiencing perimenopause; some say that a woman in her 40s and 50s typically gains a pound a year.
I know it's hard to hear, but it's most important to put "first things first," to get regular exercise, achieve and maintain a healthy weight, develop and honor regular sleep habits, and eat healthily both in amount and type of food. Exercise and activity will benefit you most. Yoga might be a good starting point, since it's low impact; it's also been proven to help women sexually, including with pelvic health. If you start there, you can add more aerobic activities as you're able.
Having a health care provider who can help you untangle the issues associated with obesity and menopause can be extremely helpful. If you're not confident in your current resource, you might look for someone certified by the North American Menopause Society. NAMS has a provider locator on their website.
There's no easy single answer for any of us: We're complicated creatures. Start small and keep moving in the right direction—but, most importantly, start!