Out of Touch on Menopause
Poorly understood and undertreated, menopause affects half the world's population at any given time. Yet, many women don't seek help for their symptoms because they don't know it's an option.
STORY AT-A-GLANCE
About half the world’s population is in the midst of menopause, but comparatively little attention is paid to this transition — or how to effectively treat it
A menopause series published in The Lancet shined some much-needed light on the topic of menopause, but critics called the research out of touch, tone-deaf and inaccurate
Many women don’t seek help for menopausal symptoms, and those that do often find themselves in a disjointed medical system that positions pharmaceuticals as the answer to treat each symptom
Menopausal symptoms are often blamed on low estrogen, but research suggests menopause is not a condition of estrogen deficiency, but rather excess
Menopause marks the end of menstruation. Technically, a woman enters menopause 12 months after her last period, but perimenopause begins years earlier, bringing with it a range of symptoms unique to each woman. About half the world's population is in the midst of this natural life stage at any given time,1 yet comparatively little attention is paid to this transition — or how to effectively treat it.
There's even debate over whether menopause needs to be "treated" at all. A menopause series published in The Lancet shined some much-needed light on the topic, noting, "Many women feel unsupported as they transition menopause."
However, while arguing for an approach to "empower women with high-quality information, tools to support decision making, empathic clinical care, and workplace adjustments as needed," critics suggest The Lancet series is at best out of touch and, at worst, tone-deaf and inaccurate. Dr. Mary Claire Haver, a certified menopause specialist and a certified culinary medicine specialist from Tulane University, wrote:2
"Despite the encouraging headline, the series was awash with misstatements that do not reflect the lived experience of women in this stage of life or our clinical experience in treating them. In several cases, The Lancet authors relied on outdated data to make their case."
Unfortunately, there's a lot of misunderstandings about the best way to feel your best during menopause. While most conventional treatments focus on estrogen, this is not the answer and will likely cause far more harm than good.
Is Menopause Over-Medicalized?
The Lancet series suggests that focusing on a medicalized view of menopause can be "disempowering for women, leading to over-treatment and overlooking potential positive effects, such as better mental health with age and freedom from menstruation, menstrual disorders, and contraception."3 But according to Haver:4
"This confusing statement smacks of misogyny; it seems to critique the idea that the menopausal transition — a life phase associated with the dysregulation of multiple biological systems that introduce heightened vulnerability to many organ systems due to the decline in circulating sex hormones — is something that women should endure without medical interventions."
Indeed, perimenopause, or the menopausal transition, may begin around the ages of 45 to 55, lasting an average of seven years, but sometimes spanning a decade or more. This is a natural process that doesn't require medical intervention, but which can sometimes benefit from it.
Each woman's journey is different, as during perimenopause production of the hormones estrogen and progesterone, which are produced by the ovaries, varies.5 As estrogen levels decrease, it can lead to a variety of symptoms. According to the National Institute on Aging:6
"The menopausal transition affects each woman uniquely and in various ways. The body begins to use energy differently, fat cells change, and women may gain weight more easily. You may experience changes in your bone or heart health, your body shape and composition, or your physical function."
Sometime during the mid-40s, shifting hormone levels typically begin, as egg cells, which are surrounded by granulosa cells that produce hormones, are reduced in numbers. During this time, eggs are released less frequently, leading to irregular menstrual cycles.
Because perimenopause and menopause are complex and unique to the individual, working with a holistic health care practitioner can help you develop a comprehensive health care plan to address your symptoms, which can include not only hot flashes and night sweats but also trouble sleeping, along with:7
Breast tenderness
Fatigue
Dry skin
Hair loss/texture changes
Headaches and/or migraines
Heart palpitations
Joint pain
Weight gain
Low libido
Urinary leaks and urgency
Brain fog
Forgetfulness
Impaired short-term memory
Inability to focus
Inattentiveness
Poor word retrieval
Anxiety
Difficulty concentrating
Feeling not like yourself
Impatience
Irritability
Low motivation or energy
Mood swings
Tearfulness
Most Women Go Through Menopause Without Getting Help
Haver took issue with The Lancet's claim that, "Most women navigate menopause without the need for medical treatments," suggesting, "The more accurate statement would be that most women navigate menopause without being given the option of medical treatments."8 According to Haver:9
90% of women are not educated about menopause
More than 73% of women don't treat their symptoms because they don't know it's an option
In the U.S., only 7% of ob-gyns, internal medicine and family medicine doctors feel prepared to treat a menopausal woman, even though they agree it's important to do so
Unfortunately, those that do seek help often find themselves in a disjointed medical system that positions pharmaceuticals as the answer to treat each symptom. Armed with nothing but Band-Aids to temporarily cover up the underlying hormonal imbalances, many women are left to suffer. Haver notes:10
"The painful reality for many patients is that clinicians repeatedly fail to recognize their symptoms of menopause that extend beyond the classic vasomotor symptom of hot flashes. These include inflammatory conditions, cardiac and neurological issues, sexual dysfunction, and sleep and mood disorders.
Women frequently find themselves referred to numerous specialists to address the multitude of symptoms associated with menopause, with each symptom being tackled individually; clinicians unable to connect the dots, akin to playing a game of whack-a-mole with symptoms. How is this reality not the ultimate in over-medicalization?
... And in the series, alternative pharmaceuticals, such as anticholinergics, SSRIs, statin therapy, pain medications, osteoporosis drugs, neurokinin receptor agonists are painted as all benefit and little risk. Patients then are left with a cabinet full of prescription medications, costly medical bills and negligible relief. This is the true over-medicalization of menopause, just not in the way the authors of The Lancet series suggest."
Mood Changes and Depression Are Common in Menopause
The Lancet series suggests there's "no compelling evidence" that anxiety, bipolar disorder or psychosis increase during the menopause transition, but Haver called this statement "shocking."
"Research has shown a four-fold increase in risk of depressive symptoms,11 and a two-and-a-half-fold increase the diagnosis of major depressive disorder12 — risks greatest in women with vasomotor symptoms. Also, the rate of antidepressant use for women has been shown to double after age 40,"13 she says.14
As one paper in Scientific Reports notes, "... human menopause is a dynamic neurological transition that significantly impacts brain structure, connectivity and metabolic profile during midlife endocrine aging of the female brain."15
Besides the physiological challenges of menopause, women in this age group also may experience greater stress during midlife as they are caring for elderly parents, raising children and often juggling a career, which can contribute to depression.
Mood changes are so common that research describes the menopausal transition as a "period of biologic vulnerability with noticeable physiologic, psychological, and somatic symptoms," including a higher vulnerability to depression.16
Women with a history of depression are up to five times more likely to be diagnosed with major depressive disorder during menopause.17 And although it shouldn't be considered "normal" to be depressed during this time, women in perimenopause have nearly double the rate of depression as women who haven't yet entered this stage.18
Menopausal Women Have Normal Estrogen Levels in Tissues
Low estrogen is often said to be a hallmark of menopause and is often treated with hormone replacement therapy involving estrogen, which I don't recommend.
As Bulgarian bioenergetic researcher Georgi Dinkov explained in our interview, estrogen is carcinogenic and antimetabolic, radically reducing the ability of your mitochondria to create cellular energy in a form of ATP by depending on aerobic glycolysis (the Warburg effect), which radically impairs oxidative phosphorylation.
This further contributes to its carcinogenic effect. What's more, Georgi says, estrogen synthesis typically does not decline with age, and administering estrogen is not the panacea to menopause relief that it's purported to be:19
"That's another big myth that we need to address. Talk to any doctor and they'll tell you, 'Menopause is a condition of severe progesterone and estrogen deficiency. We've done countless tests of the blood and we've seen that estrogen levels and progesterone levels are undetectable.'
That's expected because most of the estradiol — which is the main estrogen both for males or females — and progesterone are of ovarian origin in females. In other words, if the ovaries atrophy, yes, you will expect to see declining levels of the steroids in the blood because the ovaries are not working so well. In fact, eventually they fail.
However, another thing that's probably not well known, even among doctors, is that every cell in the body expresses the enzyme aromatase and contains the machinery to synthesize its own estrogen from circulating precursors. And those circulated precursors are always there, usually cholesterol, which, by the way, rises with age.
So that would imply that if we test tissues, even in menopausal women, we should see increase in estrogen — especially in women that are having problems with their health — versus decrease, which is what's seen in the blood. And every test I've seen on biopsies done confirms that.
In 2022, a Chinese group published a very large study with Chinese women where they measured the levels of more than 20 different hormones in hair ... which is kind of like a surrogate for what's going on in the tissues because hair grows out of cells called follicular cells.
Basically, the levels of steroids in these cells are probably representative of what gets deposited into a hair. If you look at the estrogen levels of these women, which span all age groups, estrogen levels not only did not decline with age, they actually slightly increased ...
So, to me, that gives you very strong evidence that estrogen is really not what we're being told it is, in the sense that you can freely administer it and will restore youthfulness in menopausal women."
Low Progesterone — Not Low Estrogen — Drives Night Sweats
Vasomotor symptoms, more often known as hot flashes and night sweats (hot flashes that occur at night), affect 50% to 75% of women during the menopausal transition.20 What exactly are hot flashes — the characteristic sign of menopause? The North American Menopause Society (NAMS) explains:21
"Although their exact cause still isn't fully understood, hot flashes are thought to be the result of changes in the hypothalamus, the part of the brain that regulates the body's temperature. If the hypothalamus senses that a woman is too warm, it starts a chain of events to cool her down. Blood vessels near the surface of the skin begin to dilate (enlarge), increasing blood flow to the surface in an attempt to dissipate body heat.
This produces a red, flushed look to the face and neck in light-skinned women. It may also make a woman perspire to cool the body down. Women may sense their hearts beating faster. A cold chill often follows a hot flash. A few women experience only the chill ...
Some hot flashes are easily tolerated, some can be annoying or embarrassing, and others can be debilitating ... Most women experience hot flashes for 6 months to 2 years, although some reports suggest that they last considerably longer — as long as 10 years, depending on when they began. For a small proportion of women, they may never go away."
Estrogen is conventionally used to reduce hot flashes, but, again, this is problematic. Research, in fact, shows that it's low progesterone — not low estrogen — that's linked with night sweats. In one study, progesterone supplementation significantly improved night sweats and sleep quality among perimenopausal women.22
Further, blocking estrogen and/or taking dehydroepiandrosterone (DHEA) prevents many menopausal symptoms and related conditions, including obesity and insulin resistance.23 As noted in the blog To Extract Knowledge From Matter, which is inspired by the work of the late Ray Peat:24
"Based on this study,25 one can/should conclude that: 1) menopause is NOT a condition of estrogen deficiency, but rather an excess; 2) an antiestrogen is thus likely beneficial for most/all symptoms of menopause; 3) osteoporosis, obesity, insulin resistance and diabetes, even in absence of menopause, are likely driven by excess estrogen and opposing estrogen can be beneficial; 4) DHEA mimics the effects of an antiestrogen when used in proper doses and is synergistic when used with an antiestrogen."
Natural Help for Menopausal Symptoms
I take three hormones that I believe most adults can benefit from: Progesterone, DHEA and pregnenolone. For perimenopausal and menopausal women, progesterone may be especially useful.
That said, before you consider using progesterone it is important to understand that it is not a magic bullet, and that you get the most benefit by implementing a Bioenergetic diet approach that allows you to effectively burn glucose as your primary fuel without backing up electrons in your mitochondria that reduces your energy production.
My new book, "Your Guide to Cellular Health: Unlocking the Science of Longevity and Joy," covers this process in great detail.
Once you have dialed in your diet, an effective strategy that can help counteract estrogen excess is to take transmucosal progesterone (i.e., applied to your gums, not oral or transdermal), which is a natural estrogen antagonist.
I do not recommend transdermal progesterone, as your skin expresses high levels of 5-alpha reductase enzyme, which causes a significant portion of the progesterone you're taking to be irreversibly converted primarily into allopregnanolone and cannot be converted back into progesterone.
Ideal Way to Administer Progesterone
Please note that when progesterone is used transmucosally on your gums as I advise, the FDA believes that somehow converts it into a drug and prohibits any company from advising that on its label. This is why companies promote their progesterone products as "topical."
However, please understand that it is perfectly legal for any physician to recommend an off-label indication for a drug to their patient. In this case progesterone is a natural hormone and not a drug and is very safe even in high doses. This is unlike synthetic progesterone called progestins that are used by drug companies, but frequently, and incorrectly, referred.
Dr. Ray Peat has done the seminal work in progesterone and probably was the world's greatest expert on progesterone. He wrote his Ph.D. on estrogen in 1982 and spent most of his professional career documenting the need to counteract the dangers of excess estrogen with low LA diets and transmucosal progesterone supplementation.
He determined that most solvents do not dissolve progesterone well and discovered that vitamin E is the best solvent to optimally provide progesterone in your tissue. Vitamin E also protects you against damage from LA. You just need to be very careful about which vitamin E you use as most supplemental vitamin E on the market is worse than worthless and will cause you harm not benefit.
It is imperative to avoid using any synthetic vitamin E (alpha tocopherol acetate — the acetate indicates that it's synthetic). Natural vitamin E will be labeled "d alpha tocopherol." This is the pure D isomer, which is what your body can use. There are also other vitamin E isomers, and you want the complete spectrum of tocopherols and tocotrienols, specifically the beta, gamma, and delta types, in the effective D isomer.
There are also other vitamin E isomers, and you want the complete spectrum of tocopherols and tocotrienols, specifically the beta, gamma, and delta types, in the effective D isomer. As an example of an ideal vitamin E you can look at the label on our vitamin E in our store. You can use any brand that has a similar label.
You can purchase pharmaceutical grade bioidentical progesterone as Progesterone Powder, Bioidentical Micronized Powder, 10 Grams for about $40 on many online stores like Amazon. That is nearly a year's supply, depending on the dose you choose.
However, you will need to purchase some small stainless steel measuring spoons as you will need a 1/64 tsp which is 25 mg and a 1/32 tsp which is 50 mg. A normal dose is typically 25 to 50 mg and is taken 30 minutes before bed, as it has an anti-cortisol function and will increase GABA levels for a good night's sleep.
If you are a menstruating woman, you should take the progesterone during the luteal phase or the last half of your cycle, which can be determined by starting 10 days after the first day of your period and stopping the progesterone when your period starts.
If you are a male or non-menstruating woman you can take the progesterone every day for four to six months and then cycle off for one week. The best time of day to take progesterone is 30 minutes before bed as it has an anti-cortisol function and will increase GABA levels for a good night's sleep.
This is what I have personally doing for over a year with very good results. I am a physician so do not have any problems doing this. If you aren't a physician you should consult one before using this therapy, as transmucosal progesterone therapy requires a doctor's prescription.
Disclaimer: The entire contents of this website are based upon the opinions of Dr. Mercola, unless otherwise noted. Individual articles are based upon the opinions of the respective author, who retains copyright as marked.
The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Dr. Mercola and his community. Dr. Mercola encourages you to make your own health care decisions based upon your research and in partnership with a qualified health care professional. The subscription fee being requested is for access to the articles and information posted on this site, and is not being paid for any individual medical advice.
If you are pregnant, nursing, taking medication, or have a medical condition, consult your health care professional before using products based on this content.
Dr. Anna Cabeca