Brain fog? Anxiety? Insomnia? Rage?

(Harder than you might think to find a stock image of a pissed off woman)

One of the funny things about going through early menopause aged 40, is that so many of my early-40s friends are now asking me for advice about perimenopausal symptoms: ‘Why can’t I sleep?’ 'Why can’t I think straight?’ ‘What’s happened to my skin?’ ‘Why don’t I want to have sex?’ ‘Why am I so ANGRY ALL THE TIME?’ 

None of it is easy but, I tell them, there is actually a lot that you can do about it.

The first treatment that most people think about is HRT and, while that can be extremely helpful for many (you can even start it while still having periods if struggling with perimenopausal symptoms), there are plenty of reasons why others don’t go down that route. It doesn’t necessarily work for everybody, and some people find they can manage the symptoms without it. Many types of cancer treatment can push your body into early menopause and often you’ll be advised against HRT in these cases (but not always). And there are women with a family history of breast cancer who are anxious about HRT for that reason. That is a whole other debate.

I’m not here to argue for or against HRT. Suffice to say, this week’s edition of Well Well Well is all about the other stuff that you can do. I’ll start off with nutrition and movement, then go into a few of the specific issues. See how you get on, let me know what’s worked for you, and we’ll find the answers together.

NUTRITION

Medical scientist and nutritionist Dr Federica Amati teaches nutrition to Imperial College medical students, so knows her onions. The work that she has done with Zoe on the impact of nutrition during menopause led to her new book, Recipes for a Better Menopause, written in collaboration with award-winning chef Jane Baxter.

The book lays out all of the science around the extraordinary impact of how we eat. Although you probably already, intuitively know how important this is: women in perimenopause and beyond unfortunately show increased inflammation and blood sugar spikes after eating sugary or ultra-processed foods, which explains why the food that you’d eat without thinking in your twenties is now making you feel awful.

When I talk about ‘good nutrition’, these tips from Dr Amati are what I mean…

1. Focus on whole foods first at every meal: leafy greens, fresh herbs, eggs, nuts, vegetables, whole grains, beans, pulses, seeds, fruit, fish and fermented dairy products like kefir and natural yogurt. 

2. The best foods to accompany the menopausal transition are those rich in diversity of fibre and polyphenols, the colourful chemicals found in foods, which basically means lots of colourful plants. Think polyphenol-rich berries and dark green vegetables, as well as fibre-rich nuts, pulses and seeds.

3. Try to have the same 10-hour eating window every day, leaving a 12–14 hour overnight fast.

4. Reduce refined carbohydrates and ultra-processed foods. Remove biscuits, pastries, chocolate bars, sweetened and low-fat yoghurt, ready-made desserts and pre-packaged snack bars from your weekly shop.

5. Help your body keep blood glucose levels in check, by doing 10–20 minutes of brisk movement after meals. Muscles primarily use glucose, making this the simplest way to reduce blood glucose levels.

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MOVEMENT

Moving your body has already been mentioned as part of the nutrition advice above, because one doesn’t work without the other. I could talk all day about the benefits of movement for bone health, brain health, hormonal health, metabolic health, cardiovascular health and general longevity, but I don’t have all day and neither do you. What I will say is that it’s really important to find something that you actually enjoy, and keep doing it. It might be swimming, running, dancing, yoga, pilates, cycling… just try to include some element of weight-bearing and muscle strengthening for your bones. Catie Miller’s Barre Series is about to launch a menopause-specific class online, and Menopause Movement is a training course for fitness professionals that’s working to ensure gyms and fitness centres are more menopause-friendly. Consistency is key, but also feel free to mix it up if you get bored easily. Anything is better than nothing so, if that means doing some squats in the kitchen while looking at your phone, then do it. Do it now!

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SKIN

‘Declining oestrogen means skin becomes more dry and less radiant,’ says clinical facialist Kate Kerr. ‘It also means a drastic reduction in the production of collagen and elastin, resulting in a decrease in elasticity and firmness and an increase in fine lines and wrinkles - not just on the face, but all over the body.’ I’ve certainly noticed this. And, while regular medical-grade facials would of course make a difference, most of us lack the funds and the time to make this happen. 

Again, the stuff that we can all do comes down to lifestyle. ‘Avoid stress, smoking and always wear an SPF,’ says Kate. ‘A healthy diet, exercise and plenty of sleep will support your skin.’ As for what she means by ‘a healthy diet’, she echoes Dr Amati’s advice: ‘Foods containing beta-carotene, such as yellow, red and green leafy vegetables. Think spinach, carrots, sweet potatoes and red peppers.’

If you’re interested in my own skincare recommendations, here’s what works for me:
CeraVe hydrating cleanser is a classic for a reason.
I get through so much Weleda Skin Food; it’s the very best thing for dry skin.
SkinCeuticals C E Ferulic serum causes a sharp intake of breath every time I buy it. At over £150, it’s the most expensive product I’ve ever bought, but I invest in it semi-regularly and really notice the difference when I do.
La Roche Posay make the best SPF (I love the Anthelios Invisible Fluid SPF50+), and I also use their Cicaplast Baume on my post-mastectomy scars.

Finally, cut down or eliminate alcohol if you can - it causes dehydration and dulls radiance. And smile! It makes every face look better.

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SEX

Loss of libido and vaginal dryness can be extremely difficult to talk about, particularly with a man in an NHS lanyard, but there are treatments available so don’t suffer in silence. If you can’t have HRT, for whatever reason, then hopefully you’ve been told about vaginal oestrogen. It’s technically a type of HRT but, since the levels are so low and it’s applied locally (ie. in your vagina), then it doesn’t carry the same perceived risks as systemic HRT. And it’s very effective for vaginal dryness. 

Also effective are vaginal moisturisers and lubricants; the difference being that you use the moisturiser every day (just like you do with your face), and the lubricant is for sex. Please don’t use any fragranced product anywhere near your vagina. There’s a brand called Yes, which uses only organic and natural ingredients, and is available on prescription if you ask your GP.

In terms of libido, a large part of it is in your mind so, while I’m trying not use the awful phrase ‘use it or lose it’ here, you do have to make an effort to get yourself in a sexy frame of mind. If you’re not in a relationship, masturbate! (Slightly odd doctor’s orders but here we are.) Unfortunately most porn, with its extremely young girls being treated appallingly, is unsexy at best and disturbing at worst. But there are lots of options now that are considered female-friendly (I’d consider them ‘decent person-friendly’), such as sexy audio stories from Dipsea or Quinn. 

Some women are evangelical about testosterone gel, which can boost your libido as well as relieving other symptoms such as fatigue, low mood and brain fog. However, it’s very hard to get it prescribed on the NHS, and there is a school of thought that our bodies are not designed to tolerate unbalanced hormones in this way, and longterm effects are unknown. In the meantime, did you know that your muscles stimulate the release of testosterone when you exercise? Yep: exercise makes you sexier!

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YOUR BRAIN

Stress is one of the biggest health issues of the modern world, and Dr Amati says it’s intrinsically linked with our metabolic health. ‘You cannot eat yourself healthy in a state of chronic stress,’ she explains. There are things in life that you can’t control, such as work pressure or worrying about your kids or ageing parents, so focus on what you can. Dr Amati identifies five pillars that can help to mitigate the effects of excess stress: nourishment, movement, mindfulness, enjoyment and socialising. 

‘What’s clear for women going through menopause and beyond is that having close trusted friendships, a support network and a degree of self-knowledge can make the world of difference to how we experience our everyday lives and how we feel about our future as a whole,’ she says. ‘It’s very powerful.’

Menopause also brings mood symptoms, including irrational fear, intense anxiety, dark depressive feelings, dramatic mood swings, loss of confidence and all-consuming rage. Doctors will often prescribe antidepressants, but many women find that they can exacerbate other symptoms, such as weight gain and loss of libido. This is where nutrition and exercise can actually have one of the biggest impacts. Any kind of movement has been shown to release the feel good neurotransmitters dopamine and endorphins. And a Mediterranean diet of loads of veg and no ultra-processed foods was shown to be more effective than antidepressants in a randomised controlled trial of dietary improvement for adults with major depression.

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Problems with memory and concentration come under the umbrella term brain fog, and it’s not helped by this always-on world in which our focus is endlessly pulled in different directions. Finding some kind of regular mindfulness practice (whether listening to a short guided meditation, or simply staring into space for five minutes between meetings) will help to calm your mind, but also do take regular digital breaks. Focus on that Mediterranean diet which, according to Dr Amati’s book, has been shown to reduce cognitive decline and risk of Alzheimer’s by 40%. And try to get 7-8 hours of sleep a night. Which brings us to… 

SLEEP

It’s more important than ever, and harder to come by, since insomnia is one of the most common (peri)menopausal symptoms. In my experience, overthinking it doesn’t help, so use some of these tips below and then put your focus elsewhere.

• Have a regular schedule of going to sleep and waking up around the same time.

• Get outside in daylight soon after waking, to reset your circadian rhythm.

• Your phone has tools to manage screen time, so use them. Set downtime limits.

• Dim as many lights in your home as you can in the hour before bedtime.

• Sugary and ultra-processed foods disrupt sleep, so focus on whole foods.

• Limit caffeine, and avoid alcohol if you can. It’s a big cause of the 3am scaries.

• Do not look at the news before bed.

SUPPLEMENTS

I always caveat any talk of supplements with the reminder (should you need one) that I am not a doctor. I talk to a lot of experts, and their opinions can vary wildly. Many of them argue that we should be able to get everything we need from nutrition without having to supplement, but others say that supplements have their place, particularly when going through something like perimenopause.

In July, the National Institute for Health and Care Excellence (NICE) published draft guidelines for the NHS saying that vitamin B12 is commonly deficient. Symptoms include fatigue, anxiety and brain fog (sound familiar?). BetterYou now do a B12 test kit, which involves a finger prick and will send you detailed results in five days. Their B12 supplement also comes as an oral spray, which is more easily absorbed if you are on an antacid or have bowel issues.

Meanwhile, Wild Nutrition, whose ‘food-grown’ ethos I really like, recently brought out a Perimenopause Complex. ‘It contains a blend of nutrients, researched botanical Saffron Safr’Inside™ and the ayurvedic plant Shatavari,’ says nutritional therapist Sasha Parkin. ‘They play a key role in stress management, supporting mood changes such as anxiety, and immune function and energy.’ Although she stresses it should be used alongside lifestyle steps. ‘Get to know your nervous system; what triggers stress and what proven tools can help - such as exercise, box breathing or meditation,’ she says. ‘Also consider your dietary choices. Include quality oily fish (salmon, mackerel, trout, herring, anchovies, sardines), phytoestrogens (organic soy, flaxseed, edamame, legumes, broccoli), and minimise known triggers of symptoms such as caffeine, alcohol and refined sugar. Weight-bearing exercise and building muscle is also increasingly important for perimenopausal age and beyond.’

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This is such a sprawling topic that, even though this edition is twice as long as normal, I still feel as though I’ve barely scratched the surface. Let me know what I’ve missed, what you think works, what doesn’t, and what still needs a solution. 

This week I’m…

Happy that organisations are now addressing the crash menopause many women face after cancer treatment, notably Maggie’s new menopause campaign, and the incredible Dani Binnington’s Menopause & Cancer nonprofit. If you need support with this, make Dani’s podcast your first port of call.

Pleased to see that 92% of Americans think being in therapy is sexy

Breaking my rule of avoiding blokey self-help books by men who promise to help you ‘make $10k a month online’ because I can’t resist the subtitle on Level Up: Get Focused, Stop Procrastinating and Upgrade Your Life by Rob Dial. Might it finally fix my scattered brain?

Keen to discover interesting new Substacks about health and wellness. If you have one that you love, or if you write one, please comment with it below!