HRT, libido and the menopause belly: nine steps to improve mid-life health and reduce stress
Fluctuating hormones, weight gain and flagging libido are among the many causes of midlife stress but there are steps you can take to lessen its impact — and it starts with an avocado...
Healthy ageing, mental health and the menopause were highlighted as leading areas of concern by the 100,000 women consulted as part of the 127-page Women’s Health Strategy for England published last year, but wellbeing issues don’t end there. Fluctuating hormones, weight gain and flagging libido are among the many causes of women’s midlife stress, says the GP Dr Anisha Patel. “Women are twice as likely to be diagnosed with anxiety than men, and women are more likely than m
Here are some ways to improve midlife health:
1. Perform a monthly body scan
Breast cancer is the most common female cancer — a woman is diagnosed with the condition approximately every ten minutes. It is most common in women over 50 who have been through the menopause. NHS statistics show that eight out of ten cases are in this age group.
According to the charity Breast Cancer Now, 47 per cent of women do not check their breasts regularly and one in ten have never checked their breasts for unusual changes.
“If you still have periods, it’s best to do it after your period finishes when your breasts tend to be less lumpy and full,” Patel says. “But if it is easier to remember then stick to a regular date such as checking on the first day of every month.”
The charity Breast Cancer UK offers a monthly text reminder for self-checks and says you should check for changes in the way your breasts and nipples look - swollen, inflamed, dimpled or a rash - or any changes in how they feel when you are still or moving. “At the same time as checking your breasts, do a check of other body parts and functions,” Patel says. “Check your skin for new or changing moles and marks.” And look before you flush the toilet. “Know your normal bodily functions so that if anything does change, you will notice this difference.”
2. Don’t ignore screening options
In the UK there are NHS screening programmes for breast, cervical and bowel cancer that are estimated to save almost 9,000 lives a year.
“After breast cancer, bowel and lung cancer are the next most prevalent cancers among women in the UK,” Patel says. “And the five gynaecological cancers - cervical, ovarian, uterine, vaginal and vulval cancer - are also a risk.” She says awareness of symptoms and body changes is important but you should also know your screening options, which include cervical screening from 25 to 64, bowel cancer screening, which starts between 50 and 60 in parts of the UK and continues every two years until the age of 74, and breast cancer screening from 50-71 every three years.
“I was diagnosed with stage 3 bowel cancer at the age of 39 despite no risk factors or family history of the disease,” says Patel, the author of Everything You Hoped You’d Never Need to Know about Bowel Cancer (Sheldon). “You are never too young or too old to have cancer. Screening programmes can pick up cancer at an earlier stage when you often don’t have any symptoms.”
3. Is meno-belly inevitable?
Fluctuations in oestrogen levels around the menopause change the way women’s bodies store fat. As fat shifts from the hips and bottom to the middle from the mid-forties onwards, it can result in the classic rounded middle “apple” shape and the dreaded “meno-belly”. But the menopause is not entirely to blame for midlife weight gain.
“There are other factors acting against us. As we age we also experience as much as an 8 per cent drop in muscle mass per decade past 40 - and this lean mass can be replaced by fat,” Patel says. “Add in lifestyle factors such as dwindling levels of exercise from our forties onwards, increasing alcohol intake, poor sleep and an unbalanced diet and there are lots of contributory factors that make it easier for women to gain weight, but it is by no means inevitable.”
Patel says that HRT shouldn’t lead to weight gain. “A lot of women I see in my clinics are worried that taking HRT will lead to them putting on weight but there is no scientific evidence for this. A small proportion of women might be affected by fluid retention caused by the therapy and it usually settles after a few months. For many women, HRT is a route to weight loss as it treats many of the symptoms that prevent them from exercising such as lethargy and poor sleep, hot flushes and anxiety.”
4. Consume more fibre and fermented foods for gut and hormone health
The health of the gut affects female hormone levels.
“There’s an area of bacteria within the gut microbiome called the estrobolome that has been shown to play a part in metabolising and regulating levels of circulating oestrogen,” says the registered nutritionist Eli Brecher. “If levels of bacteria within the estrobolome are out of balance it can affect circulating hormones within the body.”
The more diverse your diet - and the more packed with fibre - the better for the status of your gut microbiome. “Aiming for 30g of fibre a day from a variety of fruit, pulse, vegetable and wholegrain sources, such as rye bread and porridge oats, and eating plenty of fermented foods such as yoghurt, kimchi, kefir and sauerkraut are fantastic for supporting good gut and related hormonal health,” Brecher says.
5. Eat half an avocado and four tablespoons of olive oil a day
Including healthy fats in the diet becomes more important for women as they get older. “Our hormones are made up of fats so eating enough of them supports hormone health and can help to relieve some menopausal symptoms,” Brecher says. “Salmon, sardines and mackerel, nuts, avocados and olive oil are all great things to include and adopting a low-fat diet is not a good move.”
In one study researchers compared the effect of a Mediterranean-style diet packed with nuts, vegetables, oily fish and supplemented with four tablespoons of extra-virgin olive oil with a low-fat diet in more than 4,000 middle-aged and older women. Results, published in JAMA Internal Medicine, showed that, in a five-year follow-up, the women on the olive oil-rich diet had a 68 per cent lower risk of malignant breast cancer than the women consuming the low-fat diet. Adding a fresh avocado as part of a daily meal has been shown to reduce dangerous, deep visceral abdominal fat over 12 weeks, while replacing saturated fats, such as that from meat and cheese, with two or more servings of avocado a week was associated with a lower risk of heart disease in another study of 68,786 women.
6. Eat more yoghurt, seeds and prunes to boost bones
Osteoporosis affects many more women than men and the Royal Osteoporosis Society says that one in two women over 50 will break a bone because of it. Bone health drops sharply around the time of menopause when levels of bone-protecting oestrogen decrease and both daily weight-bearing exercise - skipping, running, weight-training, tennis or any activity that jolts the bones - and diet are important for preventing brittle bones. Key nutrients include calcium, vitamins K2 and D and magnesium found in whole grains and leafy greens.
“I don’t recommend taking calcium as a supplement as it is easy and more beneficial to obtain from foods including yoghurt, almonds, sunflower and chia seeds, tofu and cheese,” Brecher says. “You need vitamin D for calcium to be absorbed and utilised in the body and, since dietary sources are not great, it is wise to take a 10 microgram supplement of vitamin D all year round from middle age.”
Brecher also recommends eating prunes, which contain bone-friendly vitamin K2 along with phenolic compounds and dietary fibre that combine to boost bone health. Researchers at Penn State University showed that women who consumed 100 grams - about ten prunes - every day for a year improved bone mineral density in their arms and lower spine and those who ate five to ten prunes daily for six months prevented a drop in overall bone mineral density compared to women who ate none.
7. Don’t dismiss heart disease risks and symptoms
Women are twice as likely to die of coronary heart disease, the main cause of a heart attack, as breast cancer in the UK, according to the British Heart Foundation (BHF). There are more than 800,000 women living with coronary heart disease and more than 30,000 women are admitted to a hospital due to a heart attack. “Despite these statistics, heart disease is mistakenly often seen as a male problem,” says Dr Oliver Guttmann, consultant cardiologist at the Wellington Hospital. “Female hormones tend to have a protective effect on the heart, but after the menopause, when oestrogen levels drop, the risk of heart disease rises for women and continues to increase with age.”
Women with diabetes are more likely to develop heart disease than men with diabetes and long-term stress has a greater impact on women’s hearts. Most other risk factors of heart disease, including smoking, being overweight, lack of exercise and raised cholesterol or high blood pressure, are similar for men and women, and should be taken seriously.
Keeping tabs on your blood pressure, a highly controllable risk factor for heart disease, is important. More than a quarter (26 per cent) of women have high blood pressure, according to the charity Blood Pressure UK, yet often it remains undiagnosed. Studies suggest even mildly elevated readings are riskier for women than men.
A normal adult blood pressure is considered to be between 90/60mmHg and 120/80mmHG. The BHF says you can track it with a cheap blood pressure monitor, consulting a GP or nurse if levels remain high for two to three weeks.
Dr Hannah Douglas, a consultant cardiologist at the London Bridge Hospital, who specialises in treating female heart disease, says that warning signs of heart disease are the same for men and women. They include chest pain, fatigue, pain and weakness in an arm or leg and swollen limbs. “In some cases, women dismiss symptoms such as sweating, palpitations, breathlessness and panic attacks as menopausal problems,” Douglas says. “But these are also symptoms of heart disease and if you experience them you really should see a GP to make sure it is nothing serious.”
8. Watch your alcohol intake
Figures from the Institute of Alcohol Studies (IAS) show that about one in seven women in the UK drinks more than the recommended upper limit of 14 units - less than one and a half bottles of wine a week - and there is evidence that alcohol poses a greater risk to women’s physical health at lower consumption levels than men.
A high intake has been linked to hormone disruption and early menopause, according to the IAS, and there is a clear relationship between even moderate drinking and breast cancer risk. Patel says it also raises the risk of bowel, liver, oesophageal and oral cancer, heart disease, stroke and digestive issues, and lowers mood and libido. “Research shows that alcohol use is increasing in women generally and in midlife,” she says. “Some women drink more in a bid to counteract their perimenopausal or menopausal symptoms or age-related mood swings and depression without realising that alcohol, a depressant, can make matters worse.” Stick to no more than 14 units spread over three days of the week.
9. Will taking HRT boost libido?
One in three women suffers low libido at some point and declining hormone levels around the menopause are not the only cause. “No two women are the same and a drop in libido is a natural part of the ageing process,” says Dr Shazia Malik, consultant gynaecologist and obstetrician at the Portland Hospital. “It can be due to a combination of physical, psychological, social and hormonal factors. A decline in testosterone and oestrogen can affect sexual desire and arousal, and in some cases HRT gels and patches to restore oestrogen levels may be considered, but HRT is not for everyone.” More controversial are testosterone supplements, billed as a libido booster for women, but which the British Menopause Society and National Institute for Health and Care Excellence guidance recommend for low libido only after other options have been exhausted.
Levels of testosterone in women decline between the ages of 20 and 40. By the menopause this stabilises and testosterone should not be replaced just because levels are lower than they were, Malik says.
“Testosterone is produced by the adrenal glands and the ovaries in peri and post-menopausal women,” she says. “Promoting testosterone as the essential third component of HRT and claiming it is needed to boost libido is creating unrealistic expectations for women.” Always consult a medical specialist for full hormone replacement options.
