More than 1 million women experience menopause each year in the United States, with over 80% experiencing symptoms. Menopause marks the end of the reproductive stage of life and occurs in all menstruating females. It is defined as the permanent end of menstrual cycles after 12 consecutive months without a period, due to the lack of production of female sex hormones from the ovaries. During the years leading up to menopause, the ovaries produce less and less of the female sex hormones estrogens and progesterone. ‍

Women experience significant physiological changes during this period, including the commonly known vasomotor symptoms such as hot flashes and night sweats. However, the lack of estrogens and progesterone can also impact cardiovascular risk, bone metabolism, body temperature, sleep, and mood. It has also been suggested that the gut microbiome can be influenced by sex hormones, leading to less diversity in the microbiome as sex hormone production decreases. Menopause and gut health are viewed as connected in functional medicine, and an integrative approach that emphasizes increased gut microbiome diversity may help ease menopausal symptoms.

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Understanding the Gut-Hormone Connection

Menopause is a normal transition in women during which many hormonal changes occur over a relatively short period. Over several years, the number of ovarian follicles declines which leads to decreased production of estrogens and progesterone. Menstrual cycles become more variable, and ovulation is not consistent. With the decreased production of estrogens and progesterone, there is an increase in follicle-stimulating hormone (FSH) in the pituitary gland. One of the lab markers indicating post-menopause is a markedly elevated FSH level. Ultimately, there is a complete loss of ovarian follicles, and thus permanent loss of ovarian production of estrogen and progesterone. At this point, there is only a small amount of estrogen produced in adipose and other peripheral tissues by conversion from testosterone. Many symptoms are associated with menopause due to estrogen deficiency such as vasomotor symptoms (migraines, hot flashes, and night sweats), changes in cognitive function (“brain fog”), genitourinary symptoms, changes in mood, increased cardiovascular risk for some patients, and decreased bone strength (osteoporosis and osteopenia).

Interestingly, recent research has suggested that hormonal changes in menopause can also affect gut health. We know that the composition of the gut microbiome changes during the lifespan in response to many factors. However, several studies have shown differences in the gut microbiome between adult men and women, with women having increased diversity in early adulthood but not in older adulthood. These findings suggest sex hormone influence in the gut microbiome, related to aging.

Studies have shown that estrogens and progesterone act as “food” for many bacterial species and higher levels of these hormones promote increased gut microbial diversity. Even more interesting, is the link between estrogen metabolism and gut microbiota. There is a unique microbiome within the gut microbiome, called the estrobolome, that houses bacteria with specialized genes that can help “recycle” metabolized estrogen back into the bloodstream, increasing systemic estrogen levels. In post-menopausal women with very low levels of progesterone and estrogens, this recycling of hormones back into circulation can be very important. The actions of the estrobolome can increase or decrease the bioavailability of estrogens and can influence a woman’s estrogen exposure. There is a gut-hormone connection that, especially in menopause, has the potential to affect gut health, digestion, and gastrointestinal issues.

Common Gut Health Challenges During Menopause 

Gut health challenges can be common in menopause due to hormonal changes. Evidence suggests that sex hormones help maintain the mucosal barrier in the gut, and with the drop in hormones after menopause, increased intestinal permeability occurs. The intestinal gut barrier is the protective layer of the gut that separates harmful microorganisms and substances from absorption into the systemic bloodstream. Intestinal permeability refers to this protective function, and how tightly sealed the mucosal barrier is to prevent absorption of damaging substances. Increased intestinal permeability is commonly referred to as "leaky gut", and allows the entrance of food antigens, microorganisms, and other substances into the circulation which then triggers systemic inflammation. It is this increased intestinal permeability that is thought to cause gastrointestinal symptoms such as bloating, constipation, and changes in gut motility. 

Menopause and gastrointestinal disorders have been linked to increased intestinal permeability, which further increases the risk for gastrointestinal disorders such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Additionally, postmenopausal women had less microbial diversity when compared with premenopausal women, and in this study, the gut microbiome composition significantly varied between patients experiencing menopausal symptoms and patients in menopause but without symptoms.

Gut health should be optimized to best support hormonal function. Nutritional, lifestyle, and complementary treatments can be utilized to promote gut health, especially during the menopause transition.

Functional Medicine Assessment of Gut Health in Menopause

A functional medicine approach to assessing gut health in menopausal women includes a comprehensive evaluation of lifestyle, nutrition, and gut microbiome. Lifestyle and nutritional assessments will be individualized to a woman’s medical history and current symptoms. In addition, the following tests may be helpful to guide treatment recommendations.

Micronutrient Testing

Micronutrient testing will assess any nutrient deficiencies that may be more common during menopause and will help to personalize treatment recommendations. The NutrEval® FMV panel by Genova Diagnostics is a comprehensive test that evaluates antioxidants, vitamins, minerals, fatty acids, and other biomarkers to understand if any nutritional imbalances exist.

Comprehensive Stool Testing

The GI-MAP test evaluates gut pathogens, bacterial infections, yeast overgrowth, viruses, and parasites that can disturb normal microbial balance and cause illness. Additionally, biomarkers related to inflammation, digestion, and immune function are also included. This test can be used to improve intestinal permeability and microbial diversity, which can both be impaired during menopause.

Food Sensitivity Testing

Food sensitivity testing is available through many different companies, such as the P-88 Dietary Antigen test from Precision Point. This may also help identify which foods can trigger autoimmune responses in individuals, leading to increased intestinal permeability. Results can also be used to develop a personalized elimination diet to support gut healing.

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Dietary and Nutritional Interventions

Nutritional support during menopause in general should include whole foods, an anti-inflammatory approach, limiting alcohol, and avoiding processed foods. Increased fiber intake was shown to reduce the incidence of vasomotor symptoms in perimenopausal women. Calcium-rich foods are important to incorporate for bone health, in addition to other health conditions. Foods with high calcium content include dairy, leafy greens, winter squash, edamame, almonds, salmon with bones, and canned sardines. Vitamin D levels can also be evaluated, and then repleted, to ensure adequate absorption of calcium.

‍Phytoestrogens are estrogen-like compounds that come from plants and include isoflavones, stilbene, coumestan, and lignan. Common foods containing phytoestrogens include soybeans, peanuts, grapes, and flaxseeds, among others. Studies have shown the incorporation of phytoestrogens into the diet to reduce vasomotor symptoms of menopause.

Dietary strategies for menopause gut health will emphasize probiotics and prebiotics. Probiotics are living microorganisms that can help to improve the overall colonization pattern of the gut microbiome, increase gut barrier function, and improve immunity. Prebiotics are food for the probiotic microorganisms that live in the gut, and support their optimal functioning, and include inulin, guar gum, resistant starch, and beta-glucans among others. 

Lifestyle Modifications for Gut Health

Managing menopause symptoms through lifestyle will include stress management, physical activity, and prioritizing quality sleep.

Increased stress has been associated with more gastrointestinal complaints, and decreased gut motility which can lead to gut dysbiosis. Utilizing yoga, meditation, and breathing exercises can help to activate the body’s parasympathetic nervous system which supports optimal digestion. Physical activity can help to regulate hormones and also stimulate bone remodeling, which can be effective at preventing osteoporosis associated with menopause. Sleep quality has been shown to affect digestive health and gastrointestinal symptoms. Additionally, irregular sleep patterns may impact the pattern of gut motility. Being active late at night may result in the gut being more active at night as well, and less active during the day, which can lead to bloating and constipation. Chronic sleep deprivation is also associated with gut dysbiosis, and gut dysbiosis is also associated with poor sleep. Lifestyle changes for gut health in menopause involve early bedtimes, mind-body therapies, and regular movement.

Integrative Therapies for Gut Health

Integrative therapies for menopause gut health focus on supporting the hormonal transition, as well as restoring a healthy gut microbiome and normal intestinal permeability.

Several herbal remedies can be effective and safely used to support women through menopause, including black cohosh, red clover, maca, and humulus lupulus L. They contain phytoestrogens and polyphenols, which can mimic the effects of estrogen in the body and thus be helpful in a state of low estrogen, such as menopause.

Black Cohosh (Cimicifuga racemose), is commonly used for hot flashes and mood. The active ingredients N-methylserotonin and triterpenoid isolates are likely partial agonists to serotonin and GABA receptors in the central nervous system. By activating these receptors, beneficial effects on body temperature, sleep, and mood are noticed.

Red Clover, (Trifolium pratense), contains isoflavones and has been used for not only menopause, but also osteoporosis, and high cholesterol.

Maca root, (Lepidium meyenii), is a starchy tuber that grows in the Andes mountains. It is traditionally used to support anxiety and low mood associated with menopause, but may also help with sleep and libido.  

Humulus lupulus L., or Hops, is a familiar ingredient often used in beer. Hops are thought to have an estrogenic effect due to a polyphenol compound known as 8-prenylnaringenin (8-PN). Research is showing hops to help treat vaginal dryness, sleep disturbances, and fatigue associated with menopause. 

It is always very important to consult with your healthcare provider before starting any herbal medication, to ensure there are no drug-herb interactions, and that it is safe to use. Herbal medication can be used to boost the effects of hormone replacement therapy (HRT), or may be considered as a primary option prior to considering HRT.

In addition to supporting the hormonal transition through menopause, some supplements can also be used to support gut health. L-glutamine is an amino acid that is used as food by the cells that line the gut. It helps to maintain a healthy gut lining.  

Aloe is a healing plant, is also useful for gut lining, and has anti-inflammatory properties. Other natural anti-inflammatory products that should be included are omega-3 fatty acids and curcumin.

Complementary approaches to menopause can also include acupuncture, and mind-body therapies to reduce chronic stress which can lead to inflammation, and impair the optimal functioning of the gut and hormones.

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The Impact of Menopause on Gut Health: Key Takeaways

A holistic approach to menopause includes a thorough evaluation of gut health in addition to hormone optimization. The gut microbiome, with the estrobolome, can exert significant physiologic effects and influence hormonal action. A comprehensive strategy will include an individual dietary plan that may be guided by food sensitivity testing, lifestyle modifications to emphasize quality sleep, regular movement, and stress management, as well as the incorporation of herbal medicines and/or hormone replacement therapy. We must recognize that menopause is a transition that all women will inevitably experience, but can be done in a more easeful way by proactively maintaining a healthy gut and lifestyle.