Menopause is a life stage marked by complex physiological, psychological, and metabolic changes that can substantially affect quality of life. In the years leading up to menopause (the permanent cessation of menstrual periods, with an average age of 52 in the US), women commonly experience vasomotor symptoms such as hot flashes, along with sleep disruption, mood changes, weight redistribution, and fatigue. These changes intersect directly with nutrition, physical activity, stress, and circadian rhythm health.^1-7 Although these symptoms may last two to eight years and often begin in the late 30s or early to mid-40s, many women receive incomplete or unsupportive guidance, particularly about menopausal hormone therapy (MHT).¹

Ongoing confusion surrounding the benefits and risks of MHT continues to limit informed decision- making in both patients and providers.⁶ Misinterpretation of early clinical trial data, inconsistent media and news outlet messaging, and a limited number of menopause-trained clinicians have contributed to uncertainty and underutilization of evidence-based interventions to control symptoms and support this important transition.⁶ The purpose of this article is to provide healthcare providers with a practical, evidence-informed framework that includes MHT (if appropriate) in an integrated, lifestyle-centered approach to menopause care.

Menopause Physiology

The menopausal transition is characterized by declining ovarian production of hormones estrogen and progesterone, resulting in widespread effects on multiple physiological systems in the body.¹ These changes influence energy balance, body composition, insulin sensitivity, lipid metabolism, and inflammatory pathways. Symptoms peak several years before and one year after menopause.² Many women experience increased central adiposity (sometimes referred to as ‘belly fat’), reduced lean muscle mass, and reduced metabolic rate.^2.6

Estrogen is a hormone that also plays a central role in sleep regulation, thermoregulation, and stress responsiveness. Fluctuations and declines in estrogen contribute to night sweats, hot flashes, and insomnia. Declining hormones during menopause can exacerbate fatigue, mood symptoms, and perceived stress, further complicating symptom management.^2,7

There are significant long-term consequences of declining estrogen levels that include an increased risk of cardiovascular disease, including myocardial infarction/heart attack, stroke, and hypertension, as well as bone and joint disorders, particularly a higher incidence of bone density loss, leading to osteoporosis.² After menopause, LDL (‘bad’) cholesterol rises while HDL (‘good’) often remains stable, and loss of estrogen’s protective effect is associated with increased coronary artery disease. Women also experience accelerated bone loss, with up to 20 percent of bone density lost in the first five years after menopause.² These risks highlight the importance of proactive, multifactorial care that addresses both short-term symptom relief and long-term health preservation.

Menopausal Hormone Therapy: Brief Overview

MHT – previously referred to as hormone replacement therapy (HRT) – refers to supplementing either estrogen alone or in combination with a progestogen to alleviate menopausal symptoms and reduce estrogen deficiency-related health risks.^2,4,6-8 Health care providers with expertise in MHT will assess risk, such as deep vein thrombosis, pulmonary embolism, stroke, breast cancer, gallbladder disease, and urinary incontinence, before starting hormones, discussing risk and benefit with their patients.^2,4,6

The benefits and risks of MHT depend on timing, formulation, dose, and an individual’s health profile. Benefits include substantial relief of vasomotor symptoms, improved sleep quality, preservation of bone mineral density, and potential cardiometabolic improvements.^2,3,7 Low-dose, bioidentical hormones and individualized treatment plans tailored to each person may ease the menopausal transition and help mitigate risk factors, including elevations in cholesterol, blood glucose, insulin resistance, and blood pressure.^2,3 Individualized risk assessment is essential in clinical decision-making.⁹

Lifestyle Foundations in Menopause Care

While hormone therapy can provide symptom relief for many females, it is most effective when embedded within comprehensive lifestyle-based care.^2-4 While much of the literature advises ‘weight loss’ as an intervention, it’s important for health care providers to practice with the understanding that metabolism during and after menopause has changed, and simply eating less or exercising more may not equal weight loss for patients, as it may have at earlier stages of life.⁶

Nutrition

Adequate protein intake supports preservation of lean mass and metabolic function, while fiber-rich diets promote cardiometabolic health and glycemic stability. Emphasis on calcium, vitamin D, magnesium, and vitamin K in the diet, and supplementation if dietary intake is inadequate, supports bone health. Diets rich in fiber-rich fruits, vegetables, whole grains, legumes, and unsaturated fats are associated with reduced cardiovascular risk, better blood lipid profiles, and improved inflammatory profiles.² Soy foods (tofu, tempeh, soymilk, edamame) have been studied for use and efficacy during the menopause transition because of their phytoestrogen isoflavones, which exhibit antioxidant and anti- inflammatory properties.^4,6

Limiting excessive added sugars (above the American Heart Association recommendations of ≤25 g/day), refined carbohydrates, and ultra-processed foods may help mitigate weight gain and insulin resistance commonly observed during menopause.¹⁰ In a cross-sectional study of 305 post-menopausal women in Turkey, daily consumption of ultraprocessed foods was positively associated with the severity of hot flashes, sweating, and sleep problems.¹¹

Physical Activity

Physical activity levels decrease with age, and studies show that only 17% of women at menopause meet the recommended physical activity guidelines.¹² Physical activity can help reduce BMI and enhance insulin sensitivity, improving cardiovascular health.¹² Resistance training is central to maintaining muscle

mass, body composition, bone density, and functional capacity. Two resistance training sessions per week targeting major muscle groups are recommended.¹³ Aerobic activity supports cardiovascular health, metabolic regulation, and mood stability.¹² Because of the many ways that physical activity helps manage common menopause symptoms and may prevent long-term chronic health risks, it should be a pillar of healthcare recommendations for women.

Hot Flashes, Sleep, and Circadian Health

Sleep disturbance is a core symptom of menopause, commonly involving difficulty falling or staying asleep, early awakening, daytime sleepiness, and insomnia disorder. Insomnia is about twice as common in women as in men and increases around the onset of menopause.¹⁴ Addressing night sweats, insomnia, and sleep fragmentation is critical for symptom control and metabolic health.⁵ Sleep strategies that healthcare providers can use to support their clients include optimizing bedroom temperature, establishing consistent sleep schedules, limiting or eliminating evening alcohol or caffeine intake, and addressing comorbid sleep disorders like sleep apnea, restless leg syndrome, or mental health disorders like anxiety and depression, by referring to specialists.

Hot flashes – affecting up to 85% of women near menopause – can be partially addressed by lifestyle interventions such as avoiding triggers like caffeine, alcohol, and spicy foods, cooling the environment (using fans, etc), and wearing layered clothing for quick changes if body temperature shifts.⁵

When vasomotor symptoms drive sleep disruption, MHT or non-hormonal pharmacologic options may be necessary adjuncts to behavioral interventions. Many women are interested in complementary therapies, including herbal remedies like black cohosh and St Johns Wort, but research is weak and mixed on their efficacy, standard dosing, and safety.⁴

Stress Management

Chronic stress and heightened cortisol exposure can worsen vasomotor symptoms, central adiposity, and mood disturbances during the menopausal transition.² Mindfulness practices, massage, cognitive behavioral strategies, social support, and structured physical activity help promote nervous system regulation and psychological resilience.^2,3 Studies have shown that cognitive behavioral therapy (CBT) reduces the impact of vasomotor symptoms in women, with group sessions leading to about a 50 percent reduction in symptom burden sustained for up to six months.¹⁵ One large meta-analysis (N=30 studies including 3,501 women) found that psychosocial interventions such as CBT and mindfulness- based approaches produced statistically significant improvements in anxiety, depression, cognition, and especially quality of life.⁸

Screening for anxiety and depression is essential for menopause care and should be done by qualified providers (or referred to one that can help).⁶ Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs) are used in menopause, both for mental health support as well as for managing hot flashes.^2,4

Practical Takeaways for Providers

Effective menopause care begins with validation and compassion. Many individuals report feeling dismissed or inadequately supported when seeking help for menopausal symptoms. In a survey of 2406 women, 49% of respondents shared their experiences with medical providers regarding menopause care were negative or dissatisfying.16 Normalizing symptom experiences and affirming the legitimacy of care- seeking behavior fosters therapeutic alliance and engagement, helping patients feel heard and supported.¹⁶

Hormone therapy should be framed as one tool within a broader care plan for providers who can prescribe and guide its use. Presenting MHT in addition to nutrition, physical activity, sleep, and stress interventions can promote enhanced benefits.²

Recommendations should be individualized based on symptom burden, personal and family health history, personal preferences, and risk profile. Shared decision-making supports informed choices and improves adherence.

Providers can further enhance care by coordinating across disciplines, including primary care, gynecology, nutrition, behavioral health, and physical therapy, when appropriate.

Resources:

1. What is menopause? NIH: national institute on aging. Available at: https://www.nia.nih.gov/health/what-menopause.
2. Comparetto C, Borruto F. Treatments and management of menopausal symptoms: current status and future challenges. OBM Geriatrics. 2023;7(3):1-47.
3. Cameron CR, Cohen S, Sewell K, Lee M. The art of hormone replacement therapy (HRT) in menopause management. Journal of Pharmacy Practice. 2024;37(3):736-40.
4. Al Wattar BH, Talaulikar V. Non-oestrogen-based and complementary therapies for menopause. Best Practice & Research Clinical Endocrinology & Metabolism. 2024;38(1):101819.
5. Patel B, Dhillo WS. Menopause review: Emerging treatments for menopausal symptoms. Best Practice & Research Clinical Obstetrics & Gynaecology. 2022;81:134-44.
6. Duralde ER, Sobel TH, Manson JE. Management of perimenopausal and menopausal symptoms. Bmj. 2023;382.
7. Pop AL, Nasui BA, Bors RG, et al. The current strategy in hormonal and non-hormonal therapies in menopause—a comprehensive review. Life. 2023;13(3):649.
8. Spector A, Li Z, He L, Badawy Y, Desai R. The effectiveness of psychosocial interventions on non- physiological symptoms of menopause: a systematic review and meta-analysis. Journal of Affective Disorders. 2024;352:460-72.
9. Mukherjee A, Davis SR. Update on menopause hormone therapy; current indications and unanswered questions. Clinical Endocrinology. 2025.
10. American Heart Association. How much sugar is too much? Updated September 23, 2024. Accessed March 9, 2026. https://www.heart.org/en/healthy-living/healthy-eating/eat- smart/sugar/how-much-sugar-is-too-much
11. Karabiyik D, Aslan H, Tari Selçuk K, Tiğli A, Arslan S, Öngün Yilmaz H. Association of ultra- processed food consumption with menopausal symptoms in postmenopausal women. Women & health. 2025;65(5):429-41.
12. Bernier P, Vieira M, Revell AJ. The Intersection of Menopause, Lack of Physical Activity, and Cardiovascular Risk. Nurs Womens Health. 2025;29(1):63-70.
13. Walter F, Schalla J, Bloch W, Diel P, Geisler S, Isenmann E. Analysis of the Additive Effects of Nutritional Strategies in Strength Training Interventions on Body Composition, Muscle Strength and Bone Mineral Density in Postmenopausal Women: A Systematic Review. Sports Medicine- Open. 2026;12(1):5.
14. Polasek D, Santhi N, Alfonso-Miller P, Walshe IH, Haskell-Ramsay CF, Elder GJ. Nutritional interventions in treating menopause-related sleep disturbances: a systematic review. Nutrition Reviews. 2024;82(8):1087-110.
15. Woyka J. Consensus statement for non-hormonal-based treatments for menopausal symptoms. Post Reproductive Health. 2017;23(2):71-5.
16. Richardson MK, Coslov N, Woods NF. Seeking health care for perimenopausal symptoms: Observations from the women living better survey. Journal of Women’s Health. 2023 Apr;32(4):434-44.

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