Menopause: A healthy lifestyle guide

Introduction

This leaflet is for women who are experiencing menopausal symptoms and provides general information for them as well as their partners and families

Menopause is a natural part of ageing and occurs usually between the ages of 45-55. Some women can experience an earlier or later menopause. The definition of menopause is the stopping of menstrual periods for 12 months. This happens due to decreasing levels of oestrogen. Symptoms include hot flushes/night sweats, low mood, low libido, difficulty sleeping, vaginal dryness/painful sex and poor memory or concentration levels.

A GP may recommend treatments, such as hormone replacement therapy (HRT) or vaginal oestrogen creams. However, following a healthy lifestyle and changing a few habits can also help to improve symptoms.

Exercise

The NHS guideline for adults recommends at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity of exercise per week. This particularly applies to women experiencing menopausal symptoms. Your weekly exercises can be broken down to small sessions, a mixture of both or all in one go.

What is moderate and vigorous intensity?

Moderate intensity exercise should raise your heart rate. Your breathing increases to a level where you can talk but not sing. Examples are brisk walking, bike riding, water aerobics or even pushing a lawn mower.

Vigorous exercise raises your heart rate, and your breathing changes to only being able to say a few words between breaths. Running, swimming, hockey, football, netball, fast cycling, aerobics or swimming are some options.

Health benefits of exercises

Improving bone density

As oestrogen reduces during the menopause, we start to absorb bone minerals quicker than we can build them. This results in a reduction in bone density which can be a contributing factor to osteoporosis. One in three menopausal women will suffer an osteoporotic fracture which equates to 536,000 people in the UK each year.

The good news is that weight bearing, resistive and low impact exercise can increase bone density. Research shows that a progressive resistance training programme for a minimum of four to six months can positively influence bone density so it’s never too late to start. Walking, climbing stairs, dancing, jumping and running are all classified as weight bearing activities. Muscle strengthening exercises can be lifting weights, using resistance bands or even taking the weight of your own body for example doing press-ups. The Royal Osteoporosis Society recommends two to three sessions of strength training each week. A simple activity could be sitting to standing from your chair without using your arms eight to twelve times.

Cardiovascular System

In simple terms this is your heart, blood vessels and the blood within them. Oestrogen plays a role in maintaining a healthy system by preserving the flexibility of the blood vessels and also helps to control cholesterol. As oestrogen reduces women are at risk of higher blood pressure and the build-up of plaque leading to coronary heart disease, high blood pressure, heart attack or stroke.

Achieving the NHS recommended moderate or vigorous exercise per week you will make a positive effect on your cardiovascular system. Some examples were given under “What exactly is moderate and vigorous intensity?”

Lowering Cortisol Levels

Cortisol is your stress hormone which can interfere with the balance of your hormones, Cortisol can increase your menopausal symptoms and contribute alongside reduced oestrogen to fat deposits around the abdomen. Prior to the menopause these may have been more evenly distributed.

Exercise releases endorphins “feel good” hormones which in turn helps to reduce stress, by reducing your cortisol level, burn calories and make you feel more positive. Breathing techniques, yoga and meditation are great ways to reduce stress (See mental well-being section below).

In summary, exercise which raises your heart rate, improves your heart system and helps to prevent cardiovascular complications. Weight or resistance band training improves muscle and bone strength which reduces the risk of fracture and improves metabolism - this will help with midlife fat deposit spread.

The most important thing is finding exercises that you enjoy doing as you are more likely to stick to them. You can start your exercise at any level and gradually build up over time.

Nutrition

A healthy diet may help to reduce the severity of menopausal symptoms. It will also help protect against long-term health problems associated with the loss of oestrogen, such as heart disease, strokes, and a decrease in bone density.

You may wish to try some of the following to improve your diet:

• Include plenty of foods rich in calcium and vitamin D for bone health. The recommended national intake for calcium is 700mg daily and you should be able to get this from your diet. Good sources include (low-fat) dairy products, canned sardines, salmon, green leafy vegetables, fortified bread and breakfast cereals.
• Sunlight encourages the production of vitamin D. This helps your body absorb calcium which is important in maintaining good bone density. A daily vitamin D supplement containing 10 micrograms is recommended from October to March in England, Wales and Ireland and all year in Scotland.
• Consider portion size. As we get older, we need fewer calories as our metabolic rate slows down. Being overweight has been shown to worsen hot flushes and increase the risk of heart disease, diabetes and vitamin D deficiency. You could try using a smaller plate to help with portion control.
• Eat at least five portions of fruit and vegetables a day.
• Cut down on ultra-processed food and ready meals.
• Reduce refined carbohydrates and in particular sugary foods, which can cause a sharp rise in your blood glucose level and may be followed by a sharp dip leaving you feeling tired and drained, and still hungry.
• Reduce salt intake. The recommended salt intake is no more than 6 grams per day.
• You may wish to try eating foods which contain phyto-oestrogens (isoflavones or lignans). They are similar in structure to oestrogen and may help with symptoms such as hot flushes and vaginal dryness. Isoflavones are in soya beans, green beans, lentils, chickpeas, texturised vegetable protein, tofu and soya drinks. Lignans are found in cereals, linseeds, fruit and vegetables.
• Reduce your intake of caffeine and alcohol as this may help to reduce hot flushes and night sweats. Caffeine, alcohol, spicy food and smoking are also potential triggers for mood swings. Excess alcohol is a risk factor in osteoporosis and fracture. It is recommended that women do not exceed 14 units per week, with some alcohol-free days.
• Give up smoking. Women who smoke have an earlier menopause than non-smokers, have worse flushes and often do not respond as well to tablet form of HRT. Smoking also has a toxic effect on your bones and stops bone density being built up.

Mental well-being

The menopause can affect a woman’s mental well-being. Some women report anxiety, irritability, mood swings, lethargy or lack of energy. These symptoms can directly, or indirectly affect other areas in your life such as sleep and your relationships with others. Try to keep on top of symptoms by following the advice on exercise and nutrition and maintain a good sleep regime.

Cognitive Behavioural Therapy

Cognitive behaviour therapy (CBT) is a brief, non-medical approach that can be helpful for a range of mental health problems. CBT helps people to develop practical ways of managing problems and provides new coping skills and useful strategies. Dealing with anxiety and stress can help the physical symptoms of the menopause. The menopause does not cause anxiety or stress, but consider what might be happening in your life to increase stress. This could be adolescent children, an ageing and ill parent, or a change in your social or work life.

Here are some CBT strategies for coping with hot flushes.

Physical symptoms: Hot flush, sweating, palpitations

Thoughts: Everyone is looking at me, I can’t cope

Feelings: Embarrassed, out of control

Behaviour: Avoid situations, leave room

Paced breathing is an important part of the CBT approach for hot flushes. As with any skill it requires regular practice – breathing from your stomach. At the onset of a flush – relax your shoulders, breathe slowly from your stomach, and concentrate on your breathing. Paced breathing involves focusing on your breathing, accepting that the hot flush will pass and just letting the hot flush flow over you. CBT aims to help you think differently in this situation. Consider adjusting your thoughts to:

• ‘Oh no I can’t cope’ - ‘Let’s see how well I can deal with this one, one flush at a time’
• ‘Everyone is looking at me’ - ‘I will notice my flushes more than other people, they may not notice’
• ‘I am out of control’ - ‘There are things I can do to take control’
• ‘They will go on for ever’ - ‘They will gradually reduce over time’

Please see further Resources at the end of this leaflet for more information.

Mindfulness

Mindfulness is another psychological technique to help manage mental well-being.

Mindfulness is a mental state achieved by focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations, used as a therapeutic technique.

It has been suggested mindfulness can be used to reduce stress, and therefore reduce hot flushes. Please see resources for more information.

Sleep

• Try to get into a routine of going to sleep at the same time each night. This will help your body and mind feel sleepy at the right time. Ensure you factor in the time needed to prepare for your routine. You may need to go to bed earlier to compensate for this.
• The bedroom shouldn’t be a place to watch TV or work. Phones and computers should be removed to avoid the temptation to check emails.
• Think about the environment. Minimise light including “blue light” from telephones etc and noise as much as possible, and ensure a comfortable temperature. A slightly cooler room may help.
• Eating too close to bedtime does not allow your body to fully digest a meal, so try to ensure you have at least a few hours between.
• Sometimes caffeine and alcohol can have a negative effect on the quality of sleep. Be mindful of what and when you are drinking.
• Make sure you are getting enough physical exercise during the day to ensure your body feels tired at night. Try not to “cat-nap” during the day or evening.
• If your mind is full of worries at bedtime, try writing a list of these and make a point to yourself that you will deal with these tomorrow. If you wake during the night anxious about things, it may be helpful to write them down to think about the next day. So, keep paper and pen by your bedside.
• Explore apps that can help you sleep such as ‘Sleepio.’

If you need more support in your mental well-being speak to your GP.

Sexual Activity

The menopause may cause changes in the vagina. Symptoms often include irritation, itchiness and dryness in and around the vagina. For many women this is extremely uncomfortable and often leads to avoiding intimacy with their partner due to the discomfort it may cause. Up to 40% of menopausal women report painful sex.

The reason for this change is a lack of oestrogen to the tissues as our ovaries stop working. Oestrogen plumps up the vaginal tissues and allows elasticity and lubrication. With depletion the tissues become thin and friable losing their elasticity and fatty tissue. The PH in the tissues also changes which means menopausal women may experience more urinary tract infections.

Vaginal atrophy or atrophic vaginitis refers to the changes in the lining of the vagina often experienced after the menopause.

The other hormone that is reduced in the menopause is testosterone, which is responsible for sex drive, libido and the ability to achieve an orgasm.

With the reduction in both oestrogen and testosterone in the menopause, our sex lives may be affected in one way or another. In addition to these symptoms, some women also notice urinary urgency or stress incontinence.

Advice

Tips for washing and hot flushes

• Avoid scented soaps, fabric conditioners and lotions. Try swapping soap to an emollient wash.
• Vaginal douching should be avoided (this is the cleaning of the inside of the vagina with water or other solutions). It can alter the PH balance in the vaginal tissues leading to potential thrush or infections.
• If you are experiencing frequent hot flushes, you may want to think about the clothes that you wear. You could try cottons, lighter weight items, wearing looser garments and maybe layers that you could take off to help cool down.

Vaginal dryness

• This can be treated with a specific vaginal moisturiser. Don’t be tempted to experiment with lotions you would use for other parts of the body. Vaginal moisturisers are available on prescription, to buy online or over the counter.
• Ensure the vaginal atrophy is treated with oestrogen pessaries, oestrogen cream or Estring (this is a soft ring worn inside the vagina for three months that slowly releases a small dose of oestrogen straight to the vagina to reduce dryness.) Your GP can prescribe these. These need to be used in the long term.
• A lubricant can also make sexual activity more comfortable. With lack of natural oestrogen vaginal lubrication decreases and the vaginal tissues become thinner. These changes, which can make sexual penetration less pleasurable, may be overcome with a lubricant used during sexual activity.
• Use a water based or oil based lubricant avoiding unwanted glycerin and parabens.
• KY Jelly, which is used for vaginal examination, is NOT ideal as a moisturiser or lubricant. It contains chemicals which may irritate the skin if used regularly so is best avoided.
• If you experience pain with sexual intercourse, learning to relax the pelvic floor muscles can help where the pelvic floor is engaging too much in order to ’protect’ the vaginal region. Following vaginal pain or irritation, the protective guarding mechanism may come in to play. You may need to see a specialist pelvic health physiotherapist to help you to learn to relax the pelvic floor muscles.
• Keep communication channels open with your partner so they understand what you are feeling and how it is impacting on you.
• Chat to a good friend about your issues too, it helps to share your experience.
• Discuss hormone replacement therapies (HRT) options with your GP.
• Don’t suffer in silence.

Pelvic floor muscle exercises

• Pelvic floor muscles need to be able to work well so they are strong enough to support you and stop any urinary leaking when you cough or sneeze, and help prevent prolapses. Strong muscles also enhance your sex life and orgasm ability. The Squeezy app is a great resource to help improve these muscles.
• If you are experiencing urinary incontinence or prolapse symptoms and your symptoms are not improving please seek further support from your GP or self-refer to physiotherapy.

If you are struggling with any of the issues mentioned then please ask for help from your GP or a local specialist pelvic health physiotherapist. To access physiotherapy you are able to complete a self-referral form on line.

Further Resources

• NICE Guidance: Menopause: Diagnosis and Management (2015) (opens in a new tab)
• The British Menopausal Society (opens in a new tab)
• Manage my menopause (opens in a new tab)
• Menopause Matters (opens in a new tab)
• Positive Pause (opens in a new tab)
• Royal College Obstetrics and Gynaecology: Treatment for symptoms of the menopause (opens in a new tab)
• Osteoporosis – NHS (opens in a new tab)
• Royal Osteoporosis Society (opens in a new tab)
• Menopause - Treatment – NHS (opens in a new tab)
• Menopause - British Nutrition Foundation (opens in a new tab)
• The new natural alternatives to HRT (Author: Marilyn Glenville)
• Menopause and heart and circulatory conditions (opens in a new tab)
• Menopause the change for the better - A Henpicked Easy Guide to the menopause (Editor: Deborah Garlick)
• Cognitive Behavioural Therapy (opens in a new tab)
• What is mindfulness (opens in a new tab) (Video)
• Mindfulness TED talk Andy Puddicombe (opens in a new tab) (Video)
• Breathworks (opens in a new tab)
• Calm App (first 7 days free)
• Insight timer App for mindfulness
• Me and my menopausal vagina (Author: Jane Lewis)
• Dilators: Inspire silicone dilators
• Squeezy App (Pelvic Floor Muscle Exercises)
• Sleepio App (CBT for insomnia)