3 / Beyond Surviving Menopause: How to Help Your Body Adapt

Once the symptoms that are making everyday life miserable are being addressed, menopause care can move into a different phase.

Now we are no longer asking only how to stop a hot flush or get through another sleepless night. We can start asking what changing estrogen and progesterone signalling means for the rest of the body and what we can do to support those systems over the next decades.

This is where I think a functional medicine approach becomes genuinely useful.

Menopause does not affect one isolated hormone pathway. Estrogen receptors are found in the brain, bone, muscle, liver, adipose tissue, blood vessels and genitourinary tissues. The hormonal transition therefore interacts with metabolism, glucose regulation, inflammation, bone turnover, muscle function, cardiovascular risk and the gut liver pathways involved in estrogen metabolism.

We cannot stop ovarian ageing. But there is a great deal we can influence around it.

Start with insulin sensitivity

One of the most important changes around menopause is not simply weight gain but a tendency for body fat to redistribute towards the abdomen and visceral compartment.

Visceral fat is metabolically different from the fat stored underneath the skin. Greater visceral adiposity is strongly associated with insulin resistance and cardiometabolic risk.

Insulin resistance means that tissues such as skeletal muscle, liver and adipose tissue do not respond as efficiently to insulin. The pancreas compensates by producing more insulin to maintain glucose control, which means fasting glucose can remain normal for quite some time while insulin concentrations are already higher.

This is why I don't want women focusing only on weight or fasting glucose.

Improving insulin sensitivity means giving muscle regular work, reducing prolonged sitting, moving after meals, getting sufficient sleep, eating adequate protein and fibre and reducing the amount of refined and ultra processed food that makes up the diet.

It also means addressing excess visceral fat where it is present.

We covered these mechanisms much more deeply in the Weight and Metabolism journey, but they belong here too because menopause and metabolic health do not exist in separate compartments.

Build muscle once your body has the capacity to do it

Once sleep and severe symptoms are reasonably controlled, muscle moves much higher up the priority list.

Skeletal muscle is one of the body's major sites for glucose disposal. Muscle contraction can stimulate glucose uptake through mechanisms that are partly independent of insulin, while regular training improves insulin sensitivity over time.

Muscle also becomes increasingly important because lean mass and strength tend to decline with ageing, and the menopause transition may add to adverse changes in body composition.

This is why strength training after menopause is not primarily about burning calories.

It is about preserving metabolically active tissue, glucose handling, physical function and independence.

Progressive resistance exercise two or three times a week is a sensible goal for many women, adjusted to fitness, medical history and current capacity. A woman who has barely slept for six months may need to stabilise first. A healthy woman who has already trained for years needs considerably more challenge.

The intervention should fit the woman.

Protect bone before you know you are losing it

Bone is continuously remodelled. Osteoclasts break down old bone and osteoblasts build new bone.

Estrogen helps regulate that balance. As estrogen falls around menopause, osteoclast activity increases and bone resorption accelerates. Bone loss can therefore become particularly rapid around the final menstrual period and early postmenopausal years. You cannot feel this happening.

This is why osteoporosis prevention needs to start before the first fracture.

Resistance training and appropriate weight bearing and impact exercise provide mechanical signals that help preserve bone. Adequate protein contributes to the bone matrix. Calcium and vitamin D are important, but neither works in isolation from the rest of the system.

Risk matters too. Early menopause, previous fractures, low body weight, smoking, family history, prolonged corticosteroid treatment and certain medical conditions can all increase osteoporosis risk and may justify earlier bone density assessment.

Understand what cortisol is actually doing

Cortisol is another hormone that needs a better menopause conversation.

Cortisol is produced through the hypothalamic pituitary adrenal axis and is essential for blood pressure regulation, glucose availability, immune signalling and the normal stress response.

We do not want to eliminate it.

The problem arises when chronic psychological or physiological stress is layered onto poor sleep, under recovery, illness, excessive exercise, inadequate food intake or other ongoing demands.

That environment can affect mood, appetite, glucose regulation and sleep, all of which can make the menopause transition harder to manage.

So rather than automatically testing cortisol or taking products designed to "lower" it, I prefer to look at what is driving the stress response.

Sometimes the most sophisticated intervention is considerably less glamorous than the supplement marketed for it. Restore sleep. Eat enough. Recover from exercise. Treat pain. Reduce alcohol. Create periods during the day when your nervous system is not continuously responding to another demand.

Your liver really does detoxify estrogen

This deserves a proper explanation because estrogen metabolism is often either oversimplified or dismissed as wellness language.

The liver plays a major role in the biotransformation and clearance of estrogens.

In phase I metabolism, cytochrome P450 enzymes hydroxylate estrogens including estradiol and estrone into different metabolites.

Those metabolites can then undergo phase II conjugation. Important pathways include glucuronidation, sulfation and methylation. Conjugation generally makes compounds easier for the body to transport and eliminate.

Estrogen metabolites can then leave the body through urine or be secreted into bile and enter the intestine.

So yes, hepatic detoxification pathways absolutely are involved in estrogen metabolism.

Where I become cautious is when this correct physiology is turned into the claim that every woman with menopause symptoms has "poor estrogen detoxification" and therefore needs a detox product.

The liver needs sufficient energy, amino acids, vitamins and minerals to perform its normal enzymatic work. Metabolic liver disease and excessive alcohol are far more important concerns than whether you have bought the correct detox powder.

Cruciferous vegetables contain compounds that can influence enzymes involved in xenobiotic and estrogen metabolism, which makes them useful foods within a varied diet.

But supporting estrogen metabolism is not the same thing as trying to remove as much estrogen as possible.

During and after menopause, estrogen is already becoming less available.

The goal is healthy metabolism and clearance, not indiscriminate estrogen elimination.

The gut and liver are part of the same estrogen pathway

Some estrogen conjugates produced by the liver are secreted into bile and reach the intestine.

Here the microbiome becomes relevant.

Certain intestinal bacteria produce beta glucuronidase enzymes that can remove glucuronic acid from conjugated estrogens. Once deconjugated, some estrogen can be reabsorbed through the intestinal wall and returned to the circulation.

This enterohepatic recycling is one reason researchers have become interested in what is often called the estrobolome, the collection of microbial genes capable of metabolising estrogens.

This is genuine and fascinating physiology.

What we do not yet have is enough clinical evidence to tell an individual woman that her menopause symptoms are caused by an abnormal estrobolome or that a specific probiotic will correct it.

So I would support the gut in the ways for which we have much stronger evidence: adequate fibre, plant diversity, legumes, nuts, seeds, fruit, vegetables, fermented foods where tolerated and regular bowel function.

Constipation matters here too. Good elimination is part of normal gastrointestinal and biliary clearance.

The gut participates in estrogen metabolism, but we are not yet at the point where an expensive microbiome test can reliably tell us how to "balance" a woman's estrogen.

Think about inflammation as a network

Low grade chronic inflammation often accompanies insulin resistance, excess visceral adiposity, smoking, poor sleep and metabolic disease.

Adipose tissue itself is an endocrine and immune organ. With increasing visceral adiposity, the profile of cytokines and adipokines produced by that tissue changes, creating a metabolic environment associated with poorer insulin sensitivity.

Estrogen also interacts with immune signalling, which makes the menopause transition relevant to this picture.

But inflammation is not one disease and hs CRP is not a diagnosis.

If inflammatory load appears elevated, I want to look for the drivers. Visceral fat, poor glucose regulation, smoking, periodontal disease, inadequate sleep, alcohol, inactivity, chronic inflammatory disease and dietary quality all deserve consideration.

The functional medicine question is not simply "How do I lower inflammation?"

It is what is generating the signal?

Use phytoestrogens intelligently

Phytoestrogens are plant compounds capable of interacting with estrogen receptors, but they are considerably weaker than endogenous estradiol and their effects differ between compounds and tissues.

Soy isoflavones are the best studied.

One particularly interesting compound is daidzein. Certain intestinal bacteria can convert daidzein into equol, which has stronger affinity for estrogen receptors than its precursor.

Not everyone has the microbial capacity to produce equol efficiently, which may be one reason women respond differently to soy and soy isoflavones.

Clinical studies suggest soy isoflavones can modestly reduce hot flushes in some women, but results are inconsistent and they should not be presented as a natural equivalent of estrogen therapy.

Traditional soy foods such as tofu, tempeh, edamame and unsweetened soy milk have another advantage. They provide protein and useful nutrients regardless of whether they noticeably change menopause symptoms.

Flaxseed provides lignans, another group of phytoestrogens, together with fibre and alpha linolenic acid.

I think of these foods as useful biological inputs, not hormone replacement.

Alcohol deserves more attention than most supplements

If we are going to talk seriously about estrogen metabolism, liver health, sleep and breast health, alcohol cannot be the elephant sitting quietly in the corner.

Alcohol is metabolised predominantly in the liver and regular intake adds to hepatic metabolic workload. It can fragment sleep, and some women find that it aggravates hot flushes or night sweats.

Alcohol consumption is also an established modifiable risk factor for breast cancer.

That does not mean every woman must become completely abstinent.

But if you are investing money in supplements intended to improve estrogen metabolism while drinking several evenings each week, I would look at the alcohol before buying another capsule.

A few alcohol free weeks can also be an excellent personal experiment. Look at sleep, hot flushes, energy, anxiety and appetite and see whether anything changes.

Correct deficiencies rather than treating menopause with supplements

This is where functional medicine should become precise.

Heavy perimenopausal bleeding can cause iron depletion. Iron deficiency can then contribute to fatigue, poor exercise tolerance, hair shedding, headaches and palpitations.

Vitamin B12 deficiency can produce fatigue and neurological symptoms.

Vitamin D status becomes relevant to bone health.

Inadequate protein becomes particularly important when we are trying to preserve muscle and bone.

These are identifiable problems with identifiable interventions.

That is very different from taking a generic menopause supplement containing twenty ingredients because it promises to "balance hormones."

I would rather identify what is missing, correct it appropriately and then reassess symptoms.

Supplements can be useful.

They should have a reason for being there.

Do not let menopause hide another diagnosis

Menopause symptoms overlap with an enormous number of other conditions.

Hypothyroidism can produce fatigue, constipation, changes in weight, hair loss and low mood.

Iron deficiency can cause exhaustion, headaches and palpitations.

Insulin resistance can contribute to increasing abdominal adiposity and fatigue.

Sleep apnoea can cause severe daytime tiredness and cognitive problems.

Depression and anxiety can affect sleep, concentration, appetite and libido.

This is where the functional medicine instinct to look at the whole system becomes particularly valuable.

Perimenopause may explain many symptoms.

But it should never prevent us from asking whether something else is happening at the same time.

Where hormone therapy fits

Hormone therapy is a medical treatment option, not a compulsory next stage of menopause and not a replacement for the work we have discussed throughout this series.

For women with significant vasomotor or other menopause related symptoms, systemic menopausal hormone therapy can be considered after individual assessment of symptoms, medical history, contraindications, risks and preferences. It remains the most effective pharmacological treatment for vasomotor symptoms, although effective non hormonal treatments also exist.

Some regulated preparations contain estradiol and micronised progesterone, hormones chemically identical to those produced in the human body. These are sometimes described as body identical hormones.

This needs to be distinguished from custom compounded bioidentical hormone therapy. Compounded preparations are sometimes promoted as individually tailored or inherently safer, but major professional bodies do not consider them proven safer or more effective than regulated hormone therapies.

Systemic hormone therapy is not something I believe should automatically be prescribed simply because a woman has reached menopause. Current guidance does not recommend routine hormone "replacement" in women undergoing menopause at the usual age, nor systemic hormone therapy for preventing ageing, weight gain, dementia or cardiovascular disease.

Local vaginal estrogen deserves separate consideration because it is used specifically for genitourinary syndrome of menopause and produces much lower systemic exposure than systemic therapy.

And for women who do not want or cannot use systemic hormone therapy, evidence based non hormonal options for troublesome vasomotor symptoms include selected SSRIs and SNRIs, gabapentin and neurokinin targeted therapies, among others.

The appropriate question is not whether hormone therapy is good or bad.

It is whether this particular intervention is appropriate for this particular woman and this particular problem.

The goal is resilience, not perfect hormone levels

The deeper we go into menopause physiology, the clearer something becomes.

There is no single lever.

Estrogen metabolism involves the liver and intestine. Insulin signalling involves muscle, liver and adipose tissue. Bone responds to endocrine signals, mechanical loading and nutritional status. Stress, sleep and metabolic function interact. The microbiome participates in the metabolism of compounds entering and leaving the body.

This is why the idea of taking one supplement to "balance female hormones" has never made much sense to me.

We need to support the systems that are changing.

Improve insulin sensitivity. Preserve muscle. Protect bone. Support normal hepatic detoxification and elimination. Feed a diverse microbiome. Correct genuine nutrient deficiencies. Reduce excessive alcohol. Treat sleep problems. Identify metabolic disease. Investigate symptoms that do not fit.

Then use targeted medical treatment where the potential benefit justifies it.

That is much closer to what personalised menopause care should look like.

Which biomarkers I recommend checking

The tests I choose depend on the problem we are investigating.

For cardiometabolic health, this may include fasting glucose, HbA1c, triglycerides, HDL C, LDL C, non HDL cholesterol and ApoB, with fasting insulin where it adds useful clinical information.

For unexplained fatigue, heavy bleeding, poor exercise tolerance or hair changes, full blood count and ferritin deserve consideration.

For possible thyroid dysfunction, TSH and free T4 are appropriate starting tests.

Depending on diet, symptoms and medical history, vitamin B12, folate and vitamin D may also be appropriate.

For liver and metabolic health, ALT, AST and GGT can provide useful information, although normal liver enzymes do not rule out metabolic liver disease.

And I do not routinely order large reproductive hormone panels simply because a woman has entered perimenopause. Estradiol, progesterone and FSH fluctuate considerably during the transition, which can make isolated measurements difficult to interpret.

That is exactly where we go next.

Your next step

By now, we have moved from understanding what your hormones are doing, to stabilising the symptoms that are making life difficult, to understanding the deeper systems affected by the menopause transition.

The final question is what we should actually measure.

Next: Do You Actually Need Hormone Tests in Menopause?

In the final article, we will look at FSH, estradiol, progesterone and testosterone, when reproductive hormone testing is genuinely useful, when it can be misleading and which non hormone blood markers may actually tell us more about why you don't feel well.

You can also explore more articles, free and paid resources, my book and programmes in the Hormones and Menopause section of Feel Good Menopause.