Dealing With The Menopause Part 2 | Triage Thoughts Ep. 224

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This is the second part of our menopause series, and it builds directly on the first. In Part 1 we covered what menopause actually is, the training considerations that go with it, and the health risks that rise once a woman reaches the perimenopausal and post-menopausal years. If you have not listened to or read that first part, we would strongly suggest starting there. It lays down the framework, and we are not going to repeat all of it here. This time we focus on the nutrition considerations that become more specific and more important during this transition, along with a set of practical lifestyle changes.

One thing worth saying up front. General nutrition advice often gets ignored because it feels too vague, like it applies to everyone and therefore to no one. People tend to assume the problems will happen to someone else. Menopause changes that. It points the advice at a specific group of people going through a specific transition, and suddenly it is worth paying attention. These nutritional considerations are exactly the things that make the biggest difference to the health risks that come with this stage of life, from cardiovascular disease and bone health through to symptoms, sleep and mental health.

Why The Loss Of Oestrogen Changes The Picture

Before menopause, women are afforded a degree of protection by oestrogen. It confers a number of benefits across the body, including effects on vascular health and cognitive health, and it shifts the balance of certain health risks compared with men. Heart disease, for example, is more prominent in male populations. Some of that gap is a kind of selection effect, because it is generally accepted that women get screened for heart disease less often, so it is found less often. But there are also mechanistic reasons to think men carry more cardiovascular risk earlier, partly because they do not have the same protective hormonal profile.

After menopause that protection falls away. As we covered in Part 1, there is a large hormonal shift, with oestrogen and progesterone effectively flat-lining. Some of that change is welcome. Plenty of people are relieved to be done with a monthly period, for instance. But it also brings a more male pattern of health issues. The things that female hormones were quietly protecting against are no longer being protected against, and cardiovascular health becomes a much bigger priority.

A simple example makes this concrete. Imagine a woman and her husband eating broadly the same diet for years. He gets his blood lipids checked and his HDL is not great and his LDL is a little high, while hers come back excellent. It is easy to assume the difference is purely genetic. But a large part of that difference is hormonal. He might be told to make changes, or even to consider a statin, earlier in life. She might reasonably look at her own results and decide it is not an issue for her. Then she reaches perimenopause, gets her lipids checked again, and is taken aback: the HDL that was always high has dropped, and the LDL that was always in a good range has climbed.

The wider point is that hormones let you get away with a lot. We all know the feeling of being able to get away with poor habits in our teens and twenties. Women keep a version of that protection for longer, and then lose much of it through the perimenopausal and menopausal transition. The unfortunate side of that is people often arrive at this point with habits that were never really tested, and without much practice at genuinely good nutrition. To be clear, we are not talking about the calorie or aesthetic side of things here. We are talking about good, healthful eating patterns.

Nutrition For Heart Health And Insulin Resistance

The hormonal shift affects lipid and glucose metabolism, raising the risk of metabolic syndrome, obesity and diabetes, and increasing insulin resistance. Cardiovascular disease is the greatest cause of death for women in this age group, so this is where nutrition attention should go first. Rather than jumping straight to statins or anything else, the sensible move is to look honestly at what your diet is mostly made of and build from there.

A good starting question is where your carbohydrates come from. Are they mostly whole-grain versions, fruit and vegetables, or are they mostly white bread, bagels and processed, higher-GI foods? The general recommendation is to lean away from higher-GI foods and towards whole-grain carbohydrates, fruit and veg, with a lot of your carbohydrate coming from vegetables. Cruciferous vegetables are particularly worth prioritising.

Insulin resistance sounds frightening, but it simply means your body has become a little less responsive to the signal of insulin. It can be improved, and one of the easiest levers is movement. Non-insulin-mediated glucose uptake is just a way of saying that contracting your muscles helps pull glucose into them without needing insulin to do the work. A short walk of around ten minutes after a meal is a simple, effective way to do this. Over time, being active in this way tends to improve insulin sensitivity, so the increased resistance that can appear in this transition is not a fixed sentence. Going through menopause does not mean you are simply stuck with it.

There is an honest tension in advice like this. Telling someone to go for a ten-minute walk after meals can sound patronising, as if they had not thought of it, and there are real barriers: where you live, your job, children, and a hundred other things. But the simplicity is exactly why it works, and it is genuinely effective. The same goes for carbohydrate timing for women who exercise. Having more of your carbohydrate around training, particularly a higher-carbohydrate meal after training, takes advantage of greater glucose uptake into the muscle and can be helpful.

Walking after meals has a further benefit. Oestrogen is involved in normal gut function, including gastric motility, so as it falls many perimenopausal and post-menopausal women experience more digestive symptoms: IBS-type complaints, bloating, constipation, and changes in bowel habit on the same diet they always ate. Getting up and moving after a meal can ease some of those symptoms too.

For fats, the priority is keeping saturated fat to roughly below 10% of daily intake, and ideally replacing some of it with unsaturated fats. A simple swap, like cooking with olive oil instead of butter, is far easier to sustain than overhauling the whole diet, and it is genuinely impactful. Most people also do not get enough omega-3, which mainly comes from oily fish such as salmon and mackerel. Omega-3 benefits both cardiovascular health and cognition, so if you are not eating oily fish regularly, supplementing is worth considering.

One practical warning on saturated fat: judge it over a whole week, not a few good days. Because of the way fat is stored, people often look at a tidy Monday-to-Thursday and feel reassured, then ignore weekends where intake jumps to something like 50 grams a day on a 2,000-calorie budget. The same logic applies to alcohol. People say they do not really drink much, then have a large number of units across the weekend. The weekly total is what matters.

Cardiovascular Risk Builds Slowly, So Small Changes Compound

Heart disease is about cumulative risk over time. It is essentially a marathon event that develops across decades. The average age of menopause is around 51, but reaching that age does not flip a switch where heart disease suddenly appears. Atherosclerotic plaques can begin building even in the teenage years, but for most people their twenties are not when they are thinking about cardiovascular risk, even though arguably they should be.

The downside of a slow process is that it can be ignored for a long time. The upside is that small changes compound in your favour. If you start thinking about this in your twenties you are well ahead. But if you only start as you approach perimenopause, that is still genuinely worthwhile. The question is never whether you are too late. You are not. The accumulation of risk is gradual, and so is the benefit of better choices, so the small switches add up over time.

This is also where it pays to get your blood lipids checked, and to make that part of a routine metabolic and hormonal panel from your GP, particularly through your 50s and 60s. You do not need to do this every few weeks. The aim is to know where you stand, because you could have something like an inherited cholesterol problem and simply not be aware of it. Testing also tells you whether the dietary changes you are making are actually moving the markers you want to move.

This is firmly preventative health, and it is the first line of intervention rather than the whole story. Diet can only do so much. Your doctor might look at your panel and see that your saturated fat is already low, your LDL is still high, and there are other risk factors at play, such as ApoB or lipoprotein(a). In that situation the diet is doing its job and the conversation moves on. That is precisely why this is something to discuss with your doctor, who can advise at an individual level rather than relying on a general rule.

Body Fat Redistribution And The Truth About A Slowing Metabolism

Body composition is one of the main reasons people engage with health and fitness professionals at this stage, and two things change at once.

First, fat distribution shifts. Before menopause women tend to carry more fat on the hips and legs, a pattern driven in part by a high density of oestrogen receptors in the lower body. This subcutaneous fat is relatively benign. As oestrogen flat-lines, fat is more likely to be stored around the midsection, a more male pattern, and more of it ends up as visceral fat around the organs, which is the least favourable kind to carry.

Second, there is the famous talk of a slowing metabolism. It is real, but it is multifactorial, and it is not unique to women. Resting metabolic rate declines with age in men too. Two factors do most of the work, and neither is mysterious.

The first is muscle mass, or more precisely lean body mass, which is one of the main determinants of resting metabolic rate. When people say their metabolism has slowed, the great majority of the time that is tied to a loss of lean mass. Through this transition there is a double effect: the loss of oestrogen’s favourable influence on building and retaining muscle, layered on top of muscle that has probably been quietly lost for years. Many people stay somewhat active, perhaps three gym sessions a week, but the activity is not intense, often not resistance training, and so it does not provide a strong enough stimulus to retain, let alone build, muscle. Age-related muscle decline, sarcopenia, adds to this and is itself a major cause of ill health in older adults.

The second factor is everyday activity, what we call non-exercise activity thermogenesis, or NEAT. This is your steps, fidgeting and general moving about, and it adds up to a large amount of energy for many people. Some research suggests the difference between people can be as much as 2,000 calories a day purely from NEAT. Lifestyles tend to drift toward less of it: in your twenties you walk and commute and physically move a lot, then a car, a more sedentary job and quieter evenings reduce it. Even a difference of around 150 calories a day, sitting in a small surplus, compounds into accumulated body fat over a decade.

Put those together and you get the intersection people experience as a dramatically slowed metabolism: a slow drift into surplus because activity has fallen, combined with a loss of muscle that lowers daily energy expenditure. Crucially, muscle also gives the body its shape. It is entirely possible to end up lighter on the scale than you were years ago, say 60 kilos rather than 70, and yet look softer, because what you have lost is around 10 kilos of muscle while carrying a little more body fat. Being lighter does not automatically mean leaner.

All of this is why we cannot hand anyone a tidy formula that says perimenopause changes your metabolism by a fixed percentage, so adjust your calories by a set amount. It varies enormously between individuals.

Calories And Protein: The Levers You Can Actually Pull

Even though we cannot give a universal formula, the practical approach is clear enough. Protein is relatively easy to anchor. A rough working figure is around a gram per pound of body weight, which is a blanket statement that can be refined a great deal, but it gives you a starting point. From there you shift toward more complex carbohydrates, watch saturated fat, and to do any of that properly you need to know where your overall calories sit.

Finding your calorie level still takes the same trial and adjustment everyone goes through to find maintenance, and then to decide how much to lose or gain. There is no shortcut here, and we genuinely wish there were. Lifestyle often changes around this age too, with grown children, more senior and often more sedentary work, and less day-to-day movement, all of which feed into the picture alongside the hormonal changes.

Protein deserves particular attention, for muscle and for bone. General protein recommendations for women run somewhere around 1.2 to 1.8 grams per kilogram of body weight per day for a sedentary person, which is actually not very much. A post-menopausal woman should be at the higher end of that, and an exercising post-menopausal woman should be higher still, certainly around 2 grams per kilogram per day. Yet real-world intakes are often startlingly low. Many men who eat meat find these targets easy, but many women, including women in their twenties as well as their 50s and 60s, find the higher range genuinely hard to reach.

It matters more after menopause because muscle protein synthesis becomes harder to trigger, a phenomenon often described as anabolic resistance. You need the combination of protein and training, and a larger protein stimulus than before. In practical terms, a younger woman might do well with around 25 to 30 grams of protein after training, whereas a woman of 40 and over is better aiming for around 30 to 40 grams post-exercise, deliberately taking it as a larger bolus to stimulate the muscle. To get the most from each feeding, you also want enough of the essential amino acids, notably leucine, which helps trigger muscle protein synthesis. This is not only about muscle. The same protein and amino acid intake feeds into bone modelling and remodelling, and there are wider benefits, including effects on endothelial function that tie back to cardiovascular risk.

Two patterns make this harder in practice. Many older women drift toward small portions of everything and, in particular, eat less meat and fewer protein sources, sometimes ending up close to a white-bread-and-biscuits diet, which is just about the worst design you could pick for bone and metabolic health. That drift is often linked to a reduced appetite, which itself follows from doing less exercise and being less active in general. And for the many women who follow a plant-based diet, hitting a higher protein target is harder still, both for total protein and for getting the full spectrum of essential amino acids, unless meals are deliberately combined to cover them.

Despite the difficulty, getting protein right is one of the most transformative changes available, with knock-on benefits for metabolic health, for building and retaining muscle, for insulin sensitivity, and for bone health, partly because adequate protein is associated with better calcium absorption. If we had to name a first intervention, it would usually be getting protein into a good place.

The honest catch is that there is no universal protein cheat sheet, because it has to be individualised to your tastes and requirements. You can either invest the time yourself, learning which sources you like and building a diet around them, or you can outsource it. Plenty of people assume nuts are a strong protein source, for example, when they are not especially high, so educating yourself on where protein actually comes from is part of the work. Building intake up slowly is far more sustainable than leaping from 50 grams to 150 overnight, and even people who feel they are eating a lot of protein are often still well under 100 grams. This is where coaching earns its place: not as a sales pitch, but because a good coach helps you expedite a process that is, for most people, a genuine struggle.

Looking After Your Bones

By this stage the aim is largely to maintain what you have, rather than to keep building bigger muscles or denser bones. That maintenance goal is exactly why laying down good bone mass earlier in life matters so much: you want bone to spare as you move through this transition, because osteoporosis and osteopenia become more relevant. The training recommendations from Part 1 already cover the exercise side of bone health, so here the focus is nutrition. Protein, as above, is the foundation. After that come the better-known players: calcium and vitamin D, with vitamin K and magnesium playing supporting roles.

Dairy is a standout source of calcium, and it also delivers protein and fat. It was heavily demonised for a long time, but for those who tolerate it, options like Greek yoghurt and protein yoghurts make it an easy daily contributor to bone health. The hosts noted that calcium needs are higher in this age group, so it is a marker worth being deliberate about rather than leaving to chance.

Vitamin D helps calcium be absorbed. We mostly make it from sunlight, which is in short supply in Ireland, so supplementing, especially through winter, can be valuable. It is fat-soluble and can be toxic at very high levels, so if you are planning a high dose it is sensible to get your level tested by your GP first, even though toxicity is rare here. In practice you can simply start with a lower dose and still see benefit. A modest dose, such as 1,000 IU, will not push most people to the top of the reference range; a higher dose like 5,000 IU can sit someone comfortably in the middle even if they get reasonable sun. Around 40% of the European population is estimated to be clinically or sub-clinically deficient, so a small dose is, for most people, a reasonable default. The flip side also matters: if someone is genuinely deficient, a token 400 IU a few days a week will not correct it quickly. In a hospital setting, someone presenting with a fracture and a low level might be put on something like 50,000 IU weekly, which shows how far a tiny dose falls short. If bone health is a real concern, getting tested is worth it.

Calcium is a good example of why a second pair of eyes on your diet helps, ideally a dietitian, since they can prescribe specific foods and doses in a way a nutritionist or coach cannot. Dairy illustrates the individuality involved. Only around 30% of the world can comfortably digest the lactose in dairy, so for many listeners, including a lot in India, Africa and the United States, recommending dairy is not actually good advice. You can be of European descent and not tolerate it, and of East African descent and tolerate it well; it is an individual trait, not a neat racial divide. One of us could happily drink large volumes of milk, while someone else reacts badly to the smallest amount.

If dairy is not for you, calcium can come from other places: bony fish with edible bones, such as kippers, and certain vegetables, though some of those are higher in oxalates that can blunt the calcium they contain. We are not going to list every calcium-rich food, because that is exactly the kind of thing to work through with someone for your own situation. And in the modern age you can simply supplement if the other sources do not suit you. As ever with supplements, the specific dose is a conversation for your doctor or dietitian. For those who do not eat meat, calcium-set tofu is a neat option, since it brings protein and calcium together, with the soya contributing plant oestrogens as well, a topic we will return to in the next episode.

Vitamin K helps direct calcium into the bones, and you will see it in many bone-health supplements alongside calcium and vitamin D. The main dietary source is green leafy vegetables, and if you eat enough fruit and veg, particularly leafy greens, you should generally be covered without a dedicated supplement. There are different types of vitamin K, which we will not get into here. The important caution is that vitamin K can interfere with blood thinners, particularly warfarin, so it is not something to start blindly. Vitamin K does have wider benefits, helping ensure calcium goes where it should rather than into the arteries, which supports vascular health, but precisely because of those vascular effects and the warfarin interaction, this is one to discuss with your doctor rather than self-prescribe after reading that it is the missing key for your bones.

Magnesium is another strong one for bone health, and it supports the absorption of calcium and vitamin D. It is involved in a huge number of enzyme processes and is used up fairly readily. It is not especially hard to get from food, mainly from whole grains and greens, but most people do not eat specifically to top it up, and many simply cannot eat enough leafy greens to hit a good level, so a supplement can be effective. Magnesium is bound to ATP in our cells, which is part of why it turns up so often in advice on sleep and muscle relaxation. It does not simply force relaxation; it allows the body to relax by letting ATP work properly. That matters because sleep is a metabolically active, energetically costly process, and a muscle’s resting state is actually semi-contracted, so relaxing it is an active process. For menopausal women dealing with hot flushes or disturbed sleep, magnesium can help support restful sleep, which ties bone health together with sleep and stress. Form matters: magnesium oxide tends to have a strong laxative effect, drawing water into the gut, which is occasionally what someone wants but usually not. A better-absorbed form is preferable, and magnesium bisglycinate is a reasonable default, partly because many people also run a little short on glycine. Beyond bone health, magnesium supports muscle building and broader metabolic and cardiovascular health, including vascular relaxation.

We will come back to plant oestrogens, the phytoestrogens found in soya and various leafy greens, in the next episode when we talk about hormones, even though they are really a dietary topic.

Under-Eating After Menopause: A Hidden Risk

There is a flip side to calories that often gets missed: chronic under-eating. We have previously discussed low energy availability and RED-S in the context of normally cycling women, where a low energy state drives metabolic and hormonal problems. A reasonable question is whether this still matters once the menstrual cycle is gone. It does, and it is likely to become more relevant as more women in this generation take up exercise and sport.

The complication is that without a menstrual cycle there is no obvious early warning sign. The negative effects can still be present, you are just less likely to notice them quickly. The signs to watch for include a blunted training response, where you stop adapting as you used to, stalling or even regressing on the weights you use, endurance feeling harder than it should, and a higher heart rate than expected on the treadmill or cross trainer. Other clues include more stress fractures, picking up more coughs and colds as immunity suffers, more gut upset such as IBS-type symptoms, nausea, bloating and changes in bowel habit, reduced coordination or general clumsiness, and a suppressed appetite.

For women of reproductive age there are rough thresholds, expressed as calories per kilogram of fat-free mass, with low energy availability commonly placed around 30 calories per kilogram of fat-free mass. For perimenopausal and post-menopausal women these numbers do not translate cleanly, and the research simply is not there yet to define what works. What we do know points to practical adjustments. If you recognise those symptoms, look hard at your training load: you may need to reduce overall volume and favour shorter bouts of higher intensity. And look at energy intake around training, putting more of your food, and ideally your biggest meal, around the time your body is under the most stress.

Eating around training means before and after, not just after. The goal is to avoid dipping into a low energy state. If you train first thing and only eat a large meal afterwards, there is a stretch of the day, the morning, where energy availability is at its lowest at exactly the moment you are loading the body with significant stress. People often ask whether this means they can simply have a big meal after training, and to an extent yes, but only in the context of having eaten enough beforehand or during. For those who genuinely cannot face food before an early session, intra-workout nutrition is an option, or simply something small like a banana beforehand. Realistically you have been fasting for close to 12 hours overnight; going into an hour of training fasted and then not eating for a while afterwards can have large knock-on effects, so getting something small on board first helps.

There is a real overlap here with what used to be called the female athlete triad. Many symptoms of low energy availability mirror the symptoms of menopause: reduced bone health and more fractures, a poorer response to training, difficulty building muscle. The mechanism is similar, because in a low energy state the body effectively stops putting energy toward making hormones, producing a flat-lining that resembles the menopausal picture. This makes things genuinely hard to untangle in the transition itself, where someone in their late forties might assume they have gone through menopause, only for things to shift again once enough food is back on board. Five or ten years past menopause it is far easier to read; in the thick of the transition it is not.

A particularly common and unfortunate trap is that, as body composition changes, people fall back on the only tool they have ever used: cutting calories to lose fat. They drop into a large deficit, perhaps a thousand calories below maintenance, and a few weeks later sense something is more seriously wrong. The counterintuitive reality is that someone already in a low energy state who cuts further will tend to see disimprovements in body composition, energy and training. Often the right move is to bring calories up, particularly around training, and results actually improve. Convincing someone of that during this period is difficult, but it is frequently what is needed. There is no neat booklet for this; you simply have to eat enough, which is hard when it feels as though your body is betraying you.

Lifestyle: Alcohol, Smoking, Sleep And Stress

Hot flushes are the symptom most women will experience, affecting around 80% to varying degrees, and several everyday factors can trigger them.

Alcohol is a notable one, and it overlaps with the earlier point about cardiovascular risk. A reasonable target is to limit intake to around two or three units a day and no more than 14 a week. That can sound generous until you realise how quickly it adds up: two glasses of wine with dinner can easily be around four units depending on glass size, with more at the weekend on top. Beyond the flushes, alcohol tends to wreck sleep for almost everyone, even though many use it as a wind-down, and during a transition where sleep may already be disrupted by hot flushes that is a poor combination. None of this is moralising about drinking. The point is simply that if you are trying to manage symptoms or improve your health, reducing alcohol across the week is one of the clearest pieces of low-hanging fruit, before reaching for supplements aimed at hot flushes. Caffeine and spicy foods can also trigger flushes, so if you are heavily into chilli, easing off for a while to see whether it helps is worth a try.

Smoking matters for two reasons. It is associated with reaching menopause around a year or two earlier than the roughly 51-year average in Ireland and the UK, so stopping is one of the bigger levers for reducing the risk of an earlier menopause. And quite apart from menopause, smoking is bad for cardiovascular health and general health, so the obvious advice holds: do not take it up, and ideally quit. This very probably extends to vaping. We do not have robust long-term data showing exactly how vaping affects the age of menopause, but it still delivers nicotine, and the volumes can be deceptively high, with a single vape often equating to roughly two packets of cigarettes. Nicotine is not necessarily the central villain, but because the data simply is not there, the cautious position is straightforward: you do not need to vape, so do not.

Stress management and sleep are described, almost dismissively, as foundations, and that is the problem: they are such large pillars that they deserve far more focus than they usually get, while often being relatively easy to put in order without much nuance. We have covered both in detail elsewhere, so we will not do a deep dive here.

For sleep, the foundations come first: a consistent sleep and wake time, a regular schedule, a wind-down routine that does not involve alcohol, and the usual healthy sleep habits. Menopause adds confounders, particularly hot flushes and swinging between feeling too hot and too cold at night. Simple environmental changes help: a lighter blanket, lighter nightwear, an open window, a fan, or cooling mattress pads. Sometimes, honestly, there is little to be done, for instance in a genuine heatwave where even minimal bedding is not enough. In that case the realistic approach is to accept some disrupted sleep, expect not to be at your most productive, and, if you have been really struggling, allow some catch-up sleep. We would normally favour a consistent sleep-wake cycle over weekend catch-ups, but where this hormonal transition or sheer heat is wrecking sleep, getting more sleep wins.

On stress, this is a major life change that is not talked about enough, which can leave women feeling isolated, alone or frightened by symptoms. Talking to other women going through the same thing is genuinely important, and so is talking to your mother, which sounds patronising but is one of the best guides you have: she likely experienced similar symptoms, and how she navigated them, and anything that helped, is directly relevant. Support groups serve the same purpose, as does coaching, where having someone to bounce ideas off and look into your situation can help. Cognitive behavioural therapy is also worth mentioning among the approaches to stress. The broader aim is to bring in some form of stress management, whether by outsourcing it to people who can help or by setting your life up to manage stress more effectively. Ideally you are not navigating menopause at the same time as the single biggest project of your life, though life does not always cooperate. As with so much here, the best version is to build good stress-management practices earlier as a baseline, then have additional tools ready for the higher-stress stretches, recognising that this transition is itself a higher-stress state for the body, with extra stress layered on from the surrounding life changes.

What Comes Next

This is not a fully comprehensive, every-last-nuance guide, and a great deal will need to be individualised. The intention is to give you a clear starting point: ideas to launch from, and a way to begin thinking about how you would navigate this stage, or prepare for it. For many listeners it may be 30 years away, for others 10, but having a plan, or even just an idea of how to approach it, lets you start putting things in place now. The single best preparation remains doing resistance training, eating well and building your bone and muscle reserves while you still have the hormonal advantage, so you carry good health into perimenopause and beyond.

There is still more to cover. So far we have focused on managing symptoms and on the foundations of nutrition and training. We have not yet talked about the hormones themselves, beyond what they do and what their absence causes. In the next episode we will look at the options for manipulating hormones, from over-the-counter approaches through to pharmacological treatments a doctor might prescribe, along with the phytoestrogens we flagged earlier. Whenever you start manipulating hormones we would generally advise speaking to your doctor, but plenty of people like to research this themselves so they can walk into an appointment informed, and that is exactly what we will help with next time.