A Functional Medicine approach to perimenopause

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The Perimenopause Upgrade- How to turn perimenopause madness into a win (part 2)

Perimenopause triggers – part 2

Continuing on from part 1

8) Gut and vaginal microbiome

In the previous blog post we spoke about the often times dwindling testosterone and thyroid, and with it libido.

To make things worse, often it isn’t only a drop in hormones that makes you less likely to get sweaty under the sheets, but the fact that your vagina may be drier and intercourse more painful than it used to me.

It used to be thought that vaginal atrophy is a result of dropping estrogen levels, but luckily newer research has shown that it isn’t just about that. It is further linked to vaginal microbiome dysbiosis, aka not having of the good kind of bacteria in your vagina, especially a type called lactobacillus. Often women experience recurring yeast and thrush infections throughout their reproductive years, which are usually a sign of that imbalance in the vaginal microbiome. If that then collides with a drop in estrogen and less sexual activity, with regular intercourse being an important factor in keeping the vaginal wall lubricated and strong, these factors all combine to lead to that dreaded vaginal atrophy and dryness, and in return, less sexual activity.

The microbiome, aka the different bacteria and yeast inside us, don’t only matter in the vagina. Our gut microbiome, residing inside our large intestine, play an important piece of the perimenopause puzzle. Many of us have slowly but surely developped an overgrowth of pathogenic bacteria and yeast, such as H. pylori, candida albicans, and bacteria overgrowing in the wrong places (stomach and small intestines, where they really shouldn’t be), combined with not enough of the good type of bacteria over the past decades. Why? Use of antibiotics, which usually wipe out not only the bad bacteria, but also the good ones. The problem? The bad ones often hide out in a biofilm, and come back quicker, along with fungal species like candida, which don’t get hit by the antibiotics and then have free rain to take over. This, coupled with a diet high in sugars and junk food that feed candida, starve the good bacteria, stress and excess alcohol intake lowering your gut’s immune system … you get the point. By the time we get to our late 30ies or 40ies, our gut bacteria usually aren’t balanced and happy.

But now, what’s the big deal with this? Research shows that having gut dysbiosis leads to recirculation of estrogens, makes your bile sticky and your body less able to do its daily detox job, causes low grade inflammation, and contributes to autoimmunity by allowing food intolerances to develop, nutrient absorption to be tampered with, and so much more.

In summary, a healthy microbiome, with enough of the good guys, keeping the bad guys in check, is key! (1, 2)

9) Nutrient deficiencies

Another important piece to the perimenopause puzzle, and how smooth or rocky your transition may be, are nutrients. Whether or not you are getting enough minerals, vitamins, protein, fats, etc to support all the pathways in your body, create and break down hormones, neurotransmitters such as serotonin and GABA, keep your brain, heart, muscle and all other cells healthy and functioning properly, make sure your immune system is strong enough to fight of lingering infections, yet calm and selective enough to not go rogue (autoimmune), and more.

You had some of them tested, and your GP said your levels are fine? As with many other lab markers, what goes under a ‘normal reference range’ may be far from being optimal.

Many of the women I see are normal, yet below optimal in their vitamin D, B9 and 12, zinc, iron, iodine, just to name a few, contributing to less than optimal functioning and symptoms. If your cells are chronically starved off oxygen, such as what happens when iron, B9 and 12 are below optimal, they cannot do their functions properly. If you aren’t getting enough omega 3s, your body will be more likely to be chronically inflamed, your cell membranes won’t be able to do their job as well nor communicate with one another.

The different protein building blocks, called amino acids, are needed to make lean muscle, keep you satiated, your thyroid and metabolism up to speed, skin and nails strong and radiant, and production of neurotransmitters such as serotonin and GABA strong.

Most know vitamin C is important for fighting off free radicals, but it is also important to keep your collagen production up, keeping your connective tissue healthy, such as skin, joints, and the linings of your organs!

Another often overlooked category are cruciferous vegetables. These super foods are needed to make our very own antioxidant glutathione, to keep free radical damage at bay, but also to support our liver to break down hormones, get rid of toxins, create a healthy and non-stagnating bile (bye gallstones), and more.

I will get into how and what best to eat in detail in the section on how to implement the diet & lifestyle tweaks in a following blog post.

10) Low grade inflammation, free radical damage & an overburdened detox system

If one wants to dig a little deeper, and really optimise their overall health, not just for a smooth perimenopause transition, but also anti-ageing and increased health span, you may want to give your body the treat of a full make-over. Factors such as long-term chronic inflammation, accumulation of environmental toxins and subsequent free radical damage and overburdened detoxification organs such as your liver, lymph and kidneys, are the less obvious factors to look at, but likely play in the background and making your other efforts difficult to properly succeed.

Factors to look at, that contribute to that low grade inflammation and free radical damage, are IgG food intolerances, lingering infections such as from Epstein Barr virus, cytomegalovirus, candida albicans, heavy metals such as aluminum, mercury, tin and lead, plastics, highly processed junk foods, and more. When testing my patients in their 40ies, most of these have accumulated over time, leaving their bodies more vulnerable to the hormonal changes that are coming at them. If budget allows, it may be a great idea to get a general check-up of all these factors, see where you stand, and address them accordingly for a best chance of a smooth perimenopause transit.

11) And eventually … low estrogen and its downstream effects on serotonin

But what about low estrogen, you may ask? Why would most GPs speak about low estrogen as the main culprit of all perimenopause dilemmas, yet I haven’t mentioned it? Here we go.

Estrogen does drop, and does contribute to a lot of the typical symptoms, yet I wanted for you to be aware that that’s not the be all end all to perimenopausal trouble. In fact, more often than not, estrogen stays fairly high for much longer, while all the other factors we have discussed cause the issues, until at last, estrogen drops. However, please note that very skinny women may be low in estrogen much earlier on, and may benefit from estrogen increasing strategies already then. Best here, as always, is to test (around day 21 of your cycle), rather than to guess.

During reproductive years, estrogen gets mostly made in the ovaries. Fat tissue and the adrenal glands, located at the top of each kidney, also make small amounts of estrogen, as does fat tissue, the liver, heart, muscle, bone and brain. Once ovarian estrogen production drops, as happens with menopause (and prior), the other organs have to take over, but overall estrogen production will drop to much lower than during reproductive years (3).

Despite the drop in estrogen being a natural occurrence in every female’s life cycle, it depends on the other organs’ capacity to take over and produce just enough estrogen to keep you healthy. Estrogen is important for bone, brain, heart health, a hourglass shaped body, moistness of your vagina, lush hair and skin, insulin sensitivity, and more. Hence the higher risk of neurodegenerative and cardiovascular incidences past menopause, along with frailty and osteoporosis.

If we have been chronically stressed out, we may have burned through our adrenal glands, and they may be less willing and able to pick up the slack once ovarian production ceases. One way of our body to try and negate this is to ramp up fat cells and insulin resistance, and as a result that dreaded muffin top.

Estrogen is also tightly linked to serotonin, both its production and efficiency, predisposing one to a higher risk of depression once it drops, but also contributing to vasomotor symptoms (hot flashes) and blood clotting.  

Many of you may know serotonin from its role in promoting happiness. Depressed people are often on SSRI drugs, selective serotonin reuptake inhibitors, which make serotonin float around for longer to do its job.

Alongside estrogen and noradrenaline, serotonin is also part of our temperature regulation gauge in the brain. Decreases in serotonin and estrogen, and increases of noradrenaline, cause a narrowing of our ‘thermoneutral zone’, beyond which we experience hot flashes.

Hot flashes often interfere with sleep, but it isn’t just about the heat and discomfort. The neurotransmitters noradrenaline, serotonin with its downstream product melatonin, and GABA are major players in sleep, as are cortisol and blood sugar levels.

In the vascular system, estrogen and serotonin have been shown to individually alter clotting, cholesterol, vasoconstriction, and heart attacks. Both high and low levels of E2 have been associated with increased risk of thromboembolism; high levels result in increased clot formation, while low levels result in slower clot breakdown. Low estrogen has been linked with higher cholesterol levels, and research now believes this to be due to serotonin! Serotonin incorporates cholesterol into cell membranes, making them more fluid and healthy, while taking it out of the blood stream (4).

As we can see, there are many factors involved in perimenopausal symptoms, and luckily, many different angles by which we support a smoother transit.

Stay tuned for the next blog post, in which I will dive into the different diet, lifestyle and supplement tweaks you can use to prevent, optimise and support this time in your life.

Until then, leave comments below to let me know if you thought this was helpful, if you have questions, or topics you’d like for me to address! Much love,

Mirthe xx

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It is my goal to empower you to become the CEO of your health trajectory, preventing and optimising with precision and science backed strategies to live your best life & thrive.

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It is my goal to empower you to become the CEO of your health trajectory, preventing and optimising with precision and science backed strategies to live your best life & thrive.

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