A Functional Medicine Menopause Protocol: Comprehensive Testing, Nutrition, and Supplements

An estimated 1.3 million women enter menopause annually in the United States. These hormonal shifts, often equated to a "second puberty," manifest physically, mentally, and emotionally. An integrative approach to hormonal support can ease this hormonal transition. 

This article will discuss what menopause is, lab tests that can help individualize treatment options and a sample protocol that can be applied to clinical practice to help women seeking menopausal support.

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What Is Menopause?

Menopause is the normal and permanent cessation of menses for one year that results from estrogen deficiency as ovarian function diminishes. Menopause is one point in a continuum of life stages for women that marks the end of their fertile years. 

After menopause, a woman cannot become pregnant naturally. The menopausal transition typically occurs gradually over many years, beginning with perimenopause, when menstrual cycle irregularities and other hormonal symptoms are first observed. (9, 31, 35)

Natural menopause occurs in three stages: perimenopause, menopause, and postmenopause.

1. During perimenopause, the body begins to make less estrogen and progesterone. This hormonal decline occurs rapidly during the last one or two years of perimenopause. Perimenopause can last from months to ten years, although the average duration is four years. 
2. Menopause is the point in time 12 months after a woman's last menstrual period.
3. Postmenopause is the time after having gone without a menstrual period for 12 months.

For most women, perimenopause begins in their mid-40s, typically 8-10 years before they reach menopause. The average American woman will reach menopause at 51. However, about 5% of women experience early menopause, between ages 40-45, and 1% of women experience premature menopause before age 40 due to premature ovarian insufficiency. (32)

Menopause Signs & Symptoms

In the months to years leading up to menopause, you may notice the appearance of menopausal-related symptoms, which most commonly include:

• Irregular and missed periods
• Temperature fluctuations: hot flashes, chills, and night sweats
• Vaginal dryness and discomfort during sexual intercourse
• Low libido
• Sleep disturbances
• Changes in mood: irritability, mood swings, anxiety, depression
• Weight gain
• Thinning hair
• Dry skin, eyes, and mouth
• Breast changes: loss of fullness, tenderness
• Urinary urgency and frequency (9, 35)

How to Diagnose Menopause

Diagnostic labs are not required to diagnose menopause. However, they can help get to the root of menopausal symptoms and to individualize treatment plans.

Step 1: Clinical Diagnosis

Menopause is a clinical diagnosis, meaning that it can be made based on the patient's age and history. Perimenopause is suspected in women in their 40s who are experiencing longer menstrual cycles or amenorrhea (the absence of menstruation). Natural menopause is diagnosed in women who are not on hormonal forms of birth control after 12 consecutive months of amenorrhea.

Step 2: Hormonal Evaluation

Laboratory evaluation of hormones is not necessary for diagnosis but can help identify the stage of the menopausal transition and confirm that a woman has reached menopause. This can be particularly helpful for women who do not have a uterus.

Follicle-stimulating hormone (FSH) is the preferred diagnostic marker for confirming menopause. It is often tested in conjunction with estradiol. FSH levels consistently elevated above 30 mIU/mL with estradiol levels less than 20 pg/mL support the diagnosis of menopause. These labs are a good starting point for a basic laboratory evaluation of menopausal status:

• Follicle-Stimulating Hormone (FSH) and Estradiol (E2) by Access Med Labs
• Female Hormone Panel by BostonHeart Diagnostics 

During perimenopause, serum FSH and estradiol levels can be misleading due to their inherent variability. A single measurement is an unreliable indicator of menopausal status. Comprehensive salivary and urine hormone tests may provide more beneficial insights into menopausal symptoms. These tests allow for multiple samples to be collected throughout the day and/or month to better capture hormonal variations and more accurately assess hormone levels over time. 

These testing panels offer a more nuanced and dynamic understanding of a patient's hormonal status and symptomology: 

• Menopause Plus + CAR by Genova Diagnostics
• DUTCH Plus by Precision Analytical (DUTCH)

Step 3: Comprehensive Health Screening

Perimenopausal and postmenopausal women are at increased risk for heart disease, osteoporosis, and thyroid disease due to declining hormone levels. This needs to be considered as part of holistic healthcare management to prevent chronic disease and maintain a good quality of life. 

In addition to regular cancer screenings with pap smear, mammogram, and colonoscopy, the following labs can be ordered on an annual basis to assess cardiometabolic and thyroid function:

• Comprehensive Metabolic Panel by Access Med Labs
• Hemoglobin A1c by Access Med Labs
• Lipid Panel Comprehensive by BostonHeart Diagnostics
• Comprehensive Thyroid Panel w/ Antibodies by Precision Point

Additionally, bone mineral density testing should be performed in all women older than 65 years, or sooner in those with additional risk factors for osteoporosis (38). 

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Treatment Plan for Menopause

The fundamental goals of a comprehensive approach to menopause are to provide relief from common menopausal symptoms and prevent age-related diseases. 

Step 1: Optimize Hormone Balance

Here's Why This Is Important:

Managing menopausal symptoms involves controlling the hormones involved.

How Do You Do This?

Creating hormonal balance requires addressing the amount of hormones in circulation and how those hormones are metabolized and eliminated from the body. Both sides of these equations are equally important in creating hormonal harmony. 

Increase Hormone Metabolism and Elimination

Supporting liver detoxification pathways, increasing sweating, and improving daily bowel movements ensures that the body can break down hormones into their respective metabolites and efficiently eliminate them from the body (41). To do so, make sure you are eating food rich in the following nutrients: 

• Indole-3-Carbinol (I3C): cruciferous vegetables, such as cabbage, kale, broccoli, brussels sprouts
• Resveratrol: red grapes, berries, peanuts
• Folate: green leafy vegetables, asparagus, brussels sprouts, liver
• Riboflavin: eggs, meat, and milk
• Vitamin B6: fish, beef, turkey, beans, and nuts
• Vitamin B12: meat, fish, eggs, dairy
• Choline: eggs, liver, soybeans
• Magnesium: green leafy vegetables, legumes, nuts, seeds, whole grains
• Calcium-D-Glucarate: broccoli, brussels sprouts, cabbage, oranges 
• Fiber: whole fruits and vegetables, whole grains, nuts, seeds

Modulate Hormone Receptor Stimulation

Phytoestrogens are plant-derived compounds that mimic the effects of estrogen in the body. There are two major classes of phytoestrogens:

• Isoflavones, found in soybeans
• Lignans, found in flaxseed, whole grains, legumes, fruits, and vegetables

Not only do phytoestrogens help alleviate menopausal symptoms, such as hot flashes, but they have also been shown to support bone and cardiovascular health due to their mild estrogenic effects.

Herbal medicines can also be used for their phytoestrogenic effects. Popular examples include: 

• Red clover extract standardized to contain 40-80 mg total isoflavones daily reduces hot flashes
• Black cohosh standardized extract of 40-160 mg daily reduces the frequency and severity of hot flashes and night sweats 

According to the North American Menopause Society (NAMS), hormone replacement therapy (HRT) remains the most effective treatment for menopausal vasomotor symptoms (hot flashes, night sweats) and genitourinary syndrome (vaginal and urinary symptoms). It can also prevent bone loss and fractures. Hormone therapies should be used at the lowest dose and for the shortest duration needed to meet patient goals. For women under 60 or within ten years of menopause onset without contraindications, the benefit-risk ratio favors treating menopausal symptoms with HRT.

Systemic HRT uses estrogen, progesterone, and/or testosterone in various forms, such as pills, patches, rings, gels, creams, or sprays, to manage systemic symptoms of menopause. Vaginal products provide local estrogen to the vagina in a cream, tablet, or ring form to manage vaginal and urinary menopausal symptoms. (10) 

Step 2: Provide Additional Symptom Relief

Why Is This Important?

Patients should begin to experience a reduction in menopausal symptoms as they start to implement the natural and hormonal therapies discussed above. However, doctors may also recommend additional palliative solutions to address specific bothersome symptoms that interfere with daily activities of living and overall quality of life. 

How Do You Do This?

Nonhormonal pharmaceutical options are available to manage physical and emotional menopausal symptoms, including low-dose serotonin reuptake inhibitor (SSRI) antidepressants, gabapentin, pregabalin, and vaginal moisturizers. (24) 

Natural supplements can also safely and effectively manage menopausal symptoms. Evidence-based examples include: 

• Maca is an adaptogenic herb that can act on the hypothalamus to modulate hormone levels. Research demonstrates that taking 1,000 mg twice daily reduces hot flashes, improves sleep, increases libido, and boosts mood (30, 36). 
• Kava 100-200 mg daily reduces depression, irritability, mood swings, and sleep disturbances (2, 5). 
• Vitamin E 100 IU inserted vaginally treats vaginal dryness and pain as effectively as vaginal estrogen.
• Omega-3 fatty acids (350 mg EPA/50 mg DHA three times daily) reduce hot flash frequency by up to 55%.

Step 3: Support Foundations of Health for Disease Prevention

Why Is This Important?

Not only can our lifestyle choices significantly influence the severity of menopausal symptoms, but they also hold immense sway over our risk of chronic diseases. Therefore, a holistic menopause approach should include exercise and nutritional strategies that can improve overall health, enhance quality of life, and promote longevity.

How Do You Do This?

Weight-bearing exercises like walking, jogging, and resistance training help maintain bone density, reducing the risk of osteoporosis and fractures. Aerobic exercises improve cardiovascular health by enhancing heart function, lowering blood pressure, improving lipid profiles, and maintaining a healthy weight. Staying active regularly can also assist in alleviating menopausal symptoms, including mood swings, sleep disturbances, and hot flashes. 

The Mediterranean diet is backed by a strong level and quantity of evidence for reducing the risk of many age-related diseases. This anti-inflammatory diet emphasizes consuming foods rich in key nutrients required for maintaining hormonal homeostasis and healthy aging. 

Menopause Case Study

You can read about a real case study here: 

How To Address Low Libido Caused By Menopause

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Key Takeaways:

• Menopause is a natural part of a woman's life. For many women, this transition to their post-fertile years can be rocky, accompanied by many uncomfortable symptoms that present new health challenges. However, it doesn't need to be this way. 
• The hormonal changes and increased disease risks associated with menopause necessitate a proactive, age-based approach to healthcare. Many treatment options are available to minimize menopausal symptoms, making the transition manageable – and even enjoyable.