New Menopausal Client: Where to Begin?

(This is a sample entry from the SAFM Q&A Treasure Chest, a tool with hundreds of entries to support students with their client needs. Students get unlimited access as part of SAFM’s functional medicine training program.)

Student Question:

My client is 53 years old and has just gone through menopause (no period for 1 year).  I would like to clarify what you would advise the first step be, when I speak with my client on our first session.  Here are relevant issues I noted based on info I could find in the database:

• Menopause – she has gained 10 pounds in the last year
• She has been running for the last 8 months in an effort to lose weight, but has only seen herself gain more – perhaps excessive exercise?
• The client drinks alcohol in the evenings (would be hard for her to give up)
• Drinks coffee every morning
• Wakes up in the middle of the night with hot flashes
• Said for the first time in her life she has belly fat

She has fatigue and had a partial thyroidectomy back when she was 28 (overactive, never diagnosed as Grave’s).  I know you recommend ground flaxseeds and chaste tree berry.

In terms of education and recommendations, how much can we effectively cover in the first session?   On one hand, I want to take a slow-but-steady approach, but on the other, I just really want her to see results up front so she can get excited about her health.  With your clients, do you usually recommend they wean themselves off of certain items that are contributing to their challenges or go cold turkey in an effort to heal?   What would you recommend for breakfast? She typically eats either a bagel, toast, or oatmeal so I was thinking of having her start with sticking to the oatmeal and adding the flaxseed as an easy first step.

What would you advise?  I am also interested in learning more about your overall style of running client sessions.  What are key aspects you would mentor me to be aware of in creating an effective session?   And what clinical courses might help me to learn more in-depth about this kind of issue?

SAFM’s Answer:

Keep in mind that women can have drastically different experiences going through menopause, so making detailed note of your specific client’s complaints and needs is critical (vs. any generalized “approach to menopause”).  Sex Hormone Balance, Dysfunction, and Assessment course covers this topic in great detail. 

Various clients prefer all sorts of different pacing and detail in their sessions.  I would not cover more than 3 topics in a single session, but I would definitely do more than one, especially right as you begin.   Regardless, check in with them at the very end of your first few sessions until you are well aligned.  Ask, “How did this feel to you?”  Say “Everyone is different.  I want to make sure this pacing feels good to you, as I can easily work more aggressively or more moderately, depending on your needs.  Does what we talked about today feel workable for you to complete in the next two weeks?  Do you feel comfortable? ”  In my experience, it’s best to err on the side of a bit more information (more perceived value), and then it’s key to seek their feedback on pace overtly.

Because rapid relief is critical to galvanizing a new client’s commitment to working with you AND their belief in their ability to feel better, I focus on supporting them with their top complaints.  I also think a focus on education is particularly key overall but especially in the first session.  A key tenet is how much the overall body changes in response to menopause but that menopause is not a “medical event”.  What felt like an optimal lifestyle *before* is likely not going to serve her optimally now at all.  So the body is asking us to be open to change.  We are also moving from an ovary-dominant phase of life to an adrenal-dominant phase of life (more on this below).  Imbalances that women have been ignoring/tolerating in the past may worsen and become impossible to ignore now.  Help to create a positive and powerful placebo effect by positioning this as an opportunity for awareness and growth vs. a frustrating, annoying, disruptive time of life.

Choosing a “weaning” or “cold turkey” approach is highly dependent on the personality and mindset of each unique client.  Don’t guess.  Ask them what they believe works best for themselves in terms of making sustainable change.  I usually start with a cold-turkey proposal and then adjust my approach based on their reaction.

Given what you share, I might focus on all of the following in the first 2 sessions, covering a few topics with a particular focus on education:

In your first session, I would discuss the fact that post-menopause, the adrenal gland is the only tissue that makes notable progesterone.  In fact, the ovaries do continue to produce small amounts of estrogen, and of course, adipose tissue (body fat) is endocrine tissue and continues to provide estrogen.  While overall hormone levels go down in menopause, having a balance between estrogen and progesterone is still important!  So hormone balance in menopause is highly dependent on effective stress management (mindset to prioritize one’s care and ease is key!).  Regular and sound sleep, self-care, having support…all of these aspects become more important, not less.  With ongoing stress,  the HPATG axis will shift hormone balance from the adrenals, providing insufficient progesterone to keep estrogen receptors primed.   Women can indeed have estrogen dominance due to rock-bottom progesterone (and perhaps overload with xenoestrogens) but still have hot flashes due to dramatic *fluctuations* in estrogenic effects.

Keep in mind that beverages like coffee and alcohol are not necessarily negative lifestyle choices, but in the case of hot flashes, they can both definitely be exacerbating factors.  These are common!  But they can be daunting choices given ongoing “coping” habits.  Remember to focus on education and see what choices are inspiring to this client.

• Weaning usually works best for coffee (vs. cold turkey elimination).  See if she is open to switching from coffee to black or green tea.  Exploring a variety of teas can be a run distraction from drinking less coffee.
• Explore with your client how much and how often she drinks alcohol.   See if she is open to just a 5-day trial of drinking no alcohol at all to observe how it does or doesn’t change her body’s response.  An “experiment” proposal like this often feels much less daunting to a client than the prospect of “maybe you should stop drinking alcohol”.   Or if that’s not acceptable, perhaps a trial of drinking only every third day (to see the contrast) and not drinking beer or wine specifically (which tend to be worse in terms of triggering hot flashes, especially red wine) but rather a lower-sugar drink based on distilled spirits (e.g. vodka with soda water and a splash of cranberry juice).
• I have had many clients who noticed dramatic reductions in hot flashes simply by drinking less alcohol (or by at least not drinking wine at all) and drinking less coffee.

Blood sugar fluctuations will exacerbate hot flashes.  It’s important that her breakfast includes some protein and a good dose of healthy fat.  Indeed, I would eliminate the bagels/toast entirely.  Following your line of thinking on starting with something she likes, perhaps a small portion of oatmeal (with the ground flax  – an easy way to incorporate it) along with 1/4 cup of mixed seeds/nuts is a better choice.  However, I would indeed right away explore if she is also open to experimenting with a higher protein breakfast (e.g. two eggs with some mixed greens, a sprinkle of seeds, and perhaps some avocado and other fruit) for a few days in a row to see if/how it makes her feel better.  Post-menopause, many women find the need to modify their diet to a lower glycemic one in order to retain the metabolism they enjoyed pre-menopause.   I usually recommend eliminating all sweetened beverages and all-grain flours with a strong focus on vegetables, nuts/seeds, and fruits.  Make sure that she is not choosing dinner foods that are likely to result in a blood sugar crash several hours afterward (e.g. pizza, pasta, sugary dessert) further disrupting sleep.  Fasting insulin and HbA1c are straightforward markers that might give her greater insight into any insulin resistance (more in-depth testing such as a glucose tolerance test an option to characterize it further if issues are indicated by this data).  The Reversing Diabetes clinical course covers this topic in detail.

Yes, I agree with adding 2 Tbsp daily of ground flaxseed.  You mentioned chaste tree berry which, I find, tends to help more women in perimenopause than post-menopause (while the ovaries are still producing some progesterone).  In this case, I would recommend maca root (e.g. Feminessence).  Herbal extracts such as dong quai, red clover, and black cohosh can all be helpful in boosting estrogen; some women need overtime to ramp up to use 2-3x the typical dose of these types of supplements in order to see a therapeutic effect.

I would also cover the potential value of lab data, whether you cover that in your own scope of practice or simply want to educate her on the value of advocating with her physician her desire to learn more about her body.  It is typically better for labs to be run soon in order to capture an accurate baseline vs. later after numerous changes have been implemented.

In terms of the big picture, I think it’s absolutely critical to get a current thyroid panel for this client (specifically at least TSH, Free T4, Free T3, Reverse T3, and TPO/Tg antibodies).  With the prior history of (usually autoimmune) hyperthyroid, there may be another AI dynamic at play driving some of her weight challenges.  You don’t mention any medications, but with a partial thyroidectomy, she might be taking some sort of thyroid hormone replacement (typically a synthetic T4-only drug) that may not be working optimally for her now at all.  All hormones affect each other.  Highly fluctuating estrogen levels or net estrogen dominance (a common state for obese women in menopause due to very low progesterone) may now be affecting her previous thyroid stability (e.g. levels of bound vs. free hormones or levels of cortisol that are highly elevated or suppressed).   I am particularly suspicious of these dynamics regarding her weight gain.

I also recommend a urinary hormone test (e.g. DUTCH).  Conventional medicine focuses primarily on estrogen in menopause, but indeed low cortisol (from sustained stress) and low progesterone (also due to menopause, but perhaps exacerbated by stress as well) often play a dominant role in symptoms.   I often find that my clients who struggle with hot flashes almost entirely at night (vs. during the day) have low overnight cortisol (due to low adrenal output), and this is a root cause that must be addressed directly for relief.  Ample cortisol is key for maintaining optimal blood sugar during periods of fasting.   The body may experience a surge of adrenaline (perceived as a “hot flash”) if cortisol is too low in an effort to force the liver to release/convert glycogen to glucose.  If there is insulin resistance and higher fasting insulin, this dynamic will just be exacerbated.  The HPATG Axis: Adrenal/Thyroid Balance and Dysfunction course covers these topics in great detail.

You are right that aggressive exercise might not be helping her, but I would likely leave this topic to a follow-on session, as it can often be more daunting to give up an activity that contributes endorphins for stress relief (and continuing this regimen may just give her enough support to allow the alcohol elimination trial).  It will be key to have in mind a palatable alternative substitute when you have this discussion (e.g. moderate yoga, weight training).  Sometimes having adrenal lab data can also help to educate and inspire the client that the body is asking for change.