What is menopause?

7 months ago Uncategorised

What is Menopause?

Menopause is a normal biological event that occurs when a woman’s ovaries stop producing the female hormones oestrogen and progesterone, and menstrual cycles end. All women will, at some stage in their life, pass through the Menopause.

When does menopause start?

For most women this typically occurs from mid-40s to the late 50s. The average age of natural menopause is 51. Earlier than 40 is considered premature menopause.

Most women have 2 ovaries, each containing a fixed number of eggs, or ova. If the egg is not fertilised then it results in the lining of the uterus being shed termed the menstrual flow. During the menopause the function of the ovaries slows down and hormone levels drop as they are no longer needed for fertility and child-bearing. Most women reach menopause naturally when their body decreases the amounts of hormones produced.

On average, it is estimated that levels of oestrogen drop to 40% of previous levels as ovaries stop producing oestrogen. During menopause the body will continue to try and ovulate and attempt to release a hormone called FSH (follicle stimulating hormone).

The body registers that ovulation is not taking place which results in additional FSH being released in a further effort to trigger ovulation. As the production of oestrogen declines, the body’s adrenal glands (which are responsible for producing stress hormones) take over in an attempt to compensate for the reduction of oestrogen, by producing a different form of oestrogen known as oestrone.

What are the different stages of menopause?

Pre-menopause: periods are still regular but the first symptoms (such as hot flushes and mood swings) may appear.
Perimenopause: the function of the ovaries decline, the periods become irregular and symptoms may be more severe.
Post-menopause: this stage lasts from the last period onwards.

How do I know if I’ve experienced menopause?

It usually takes 12 months of no menses (periods), before a woman can be certain that she has experienced the menopause.

What are the common symptoms during menopause?

For some women, when the body stops producing hormones, it can become a difficult time of uncomfortable symptoms which can be sudden and severe. However, there are many women who do not suffer any symptoms at all or experience only very mild symptoms.

For those that do experience symptoms they can last for several years. Symptoms can vary from woman to woman and can include any of the following;

Brain fog: Hormones such as oestrogen and progesterone have a direct effect on the brain and play important roles in many aspects of brain function, therefore, any imbalance of these hormones can impact the way the brain functions and lead to changes and alterations in brain chemistry and cognition that affect mood and cognitive abilities. Declining levels of oestrogen for example in women going through the menopause may cause memory problems and mood fluctuations.
Insomnia: Adequate sleep is essential for our health and hormone regulation but for women going through the menopause disrupted sleep can be a common complaint. Symptoms such as anxiety, hot flushes or night sweats which occur as a result of declining levels of oestrogen can be unsettling and may contribute to insomnia.
Vaginal dryness: Oestrogen plays an important role in maintaining the integrity of the tissues of the vagina as it helps maintain lubrication, elasticity, and thickness of the vaginal walls. When oestrogen levels decline during and after menopause, the tissues of the vagina can become thin, dry and inflamed, causing irritation and discomfort.
Hot flushes: or night sweats are the most common symptoms associated with menopause. They are often accompanied by an increased heart rate and occur in response to a spike in adrenaline triggered by the stress response and as a result of oestrogen imbalance. The triggered stress response and the activation of adrenaline interferes with the bodily system that controls body temperature, known as the Hypothalamus.
Depression: Studies show that menopause increases susceptibility to depression and anxiety due to fluctuating levels of oestrogen, which affect the production of the neurotransmitters serotonin and GABA, both of which are involved in regulation of mood.
Weight gain: is common during menopause and occurs primarily as a result of the hormonal changes that take place throughout this transitional period. During menopause, the adrenal glands have to work a bit harder, and as a result of being overstimulated, they produce higher levels of stress hormones, namely Cortisol, which triggers the release of Glucose. Glucose that is not needed as fuel for energy, is then surplus in the body and deposited as visceral fat. Weight gain that is associated with hormonal changes typically leads to fat accumulation around the abdomen region (otherwise known as visceral body fat), resulting in changes to body composition and body shape and is associated with increased health risks.
Whilst cortisol is involved in several important functions in the body, too much cortisol in the body can cause blood sugar management issues, leading to increased appetite and cravings, particularly for sugary refined carbohydrates. It is therefore important for women going through the menopause to maintain normal cortisol levels and to minimise excess levels in order to avoid weight gain.
Anxiety/Irritability: The body’s adrenal glands are under additional strain when a woman goes through the menopause since the adrenal glands compensate for the lack of oestrogen by producing an alternative form of oestrogen, known as oestrone. Since the main job of the adrenal glands is to produce stress hormones such as cortisol, the demand on the adrenal glands increases. This additional demand on the adrenal glands can lead to adrenal dysfunction and can result to ‘adrenal fatigue’. Adrenal fatigue is commonly associated with symptoms such as anxiety, irritability, sleep disorders, cravings, depression, headaches, blood sugar imbalances and fatigue.
Declining libido: due to physiologic changes, which can include altered nerve function, vaginal secretions and painful intercourse, all of which affect sexual response and are regulated by oestrogen production. Other factors may include depression (oestrogen fluctuations interfere with serotonin production), marital status, body image.
Poor hair/nail condition: oestrogen plays an important role in water retention and keratin production. Since keratin is the main protein that makes up the nails and the hair, declining levels of oestrogen can lead to thinning and dryness of the hair and nails, leaving both brittle and weak, and susceptible to breakage.
Skin ageing: Declining levels of oestrogen can impact the health and appearance of the skin. This is because low levels of oestrogen can cause drying of the skin and loss of collagen, elasticity and skin strength, which can lead to the appearance of fine lines and wrinkles.
Joint pain: Oestrogen plays an essential role in musculo-skeletal health, including the bones and joints. Declining levels of oestrogen can lead to increased inflammation and swelling of the joints which can result in pain and discomfort or ‘aching joints’ and an increased risk of inflammatory disorders such as osteoarthritis. Post-menopausal women are at an increased risk of bone fractures and of bone disorders due to low bone mass and structural deterioration of bone tissue.

How do I manage and improve menopause?

One of the main ways we can help alleviate or minimise unwanted symptoms of menopause is to ensure that the adrenal glands are healthy leading up to and during the many phases of the menopause.

Stress Management: Whilst it may not always be possible to completely avoid stress particularly as stress can come in many forms; whether it be physical or psychological, it is important to find ways to help you manage and protect yourself from the effects of stress on the body to avoid over burdening and overworking the adrenal glands.

Hydration: Drinking sufficient amounts of water keeps us well hydrated and helps counteract stress by encouraging the circulation of nutrients. Water also helps to flush out old circulating hormones from the body which is important since hormones that are not excreted from the body through the correct pathways can be detrimental to our health, with the potential of leading to oestrogen dominant conditions. The recommended amount for water intake is 2 litres per day (equivalent to approximately 8 small glasses). Herbal and fruit teas count towards daily intake, but caffeinated drinks do not.

Adequate sleep: Getting adequate amounts of sleep helps us to feel revitalised, refreshed and energised, ready to take on the challenges of the day. Lack of sleep or interrupted sleep can have a profound effect on our day to day lives and can have a significant impact on our emotional wellbeing, stress levels and energy levels as well as our hormones. The recommended amount is a minimum of 7 hours per night for an adult.

Exercise: Important for both mental and emotional wellbeing, exercise can increase feel good endorphins as well as improving resistance to stress. Exercise has been shown to help improve energy levels, sleep and mood and reduce stress and anxiety. Furthermore, physical exercise increases muscle mass, which in turn helps to speed up metabolism and aid weight management. Swimming, walking, yoga and tai chi are all gentle forms of exercise that many people find really help their stress levels. According to research, sedentary women are more likely to have moderate or severe hot flushes compared with women who exercise. Furthermore, one trial reported a reduction of menopause symptoms immediately after aerobic exercise.

Take time to relax: It is important to take time out and relax in order to keep cortisol within normal ranges and maintain normal adrenal function. Listening to soothing music, reading a book or practising meditation may all help induce relaxation and maintain healthy cortisol levels. Epsom salt baths containing magnesium sulphate are thought to be particularly useful in aiding relaxation, as magnesium can be absorbed directly through the skin.

Blood sugar management: Maintaining balanced blood sugar levels helps to maintain normal cortisol levels-supporting adrenal function and by doing so will also help to reduce cravings, control appetite, regulate mood and help to sustain energy levels. There are many ways in which you can support healthy blood sugar levels:

Eat little and often: it is important to avoid going for long periods of time without eating as blood sugars will be low and hunger/cravings will be intensified. It is recommended not to go longer than 3 hours without food to help maintain balanced blood sugar levels.

Increase protein intake: Protein helps slow down the release of glucose into the bloodstream, helping to balance blood sugar levels. It also helps you to keep fuller for longer and can be helpful in preventing cravings. Protein can also help with weight management as it helps to increase lean muscle mass by increasing basal metabolic rate which in turn helps to burn fat. Healthy sources of protein include lean white meat, fish, beans and pulses, nuts and seeds.

Low-GI complex carbohydrates: Also help to slow down the release of sugar from foods into the bloodstream, helping to achieve a better overall metabolic balance of blood sugar and insulin. Examples of complex carbohydrates that are low GI include:

Wholegrains such as oats, rice, quinoa, amaranth and teff grains, all of which are nutrient dense, fibre-rich, and provide a slower release of energy and since they are excellent sources of B vitamins these foods can help to balance hormones.

Healthy fats: The body requires both Omega 3 and 6 fats for many metabolic functions including oestrogen production. Essential fats also slow down the rate at which the stomach empties, boosts metabolism, balances blood sugar levels, increases cell membrane responsiveness to insulin, reduces inflammation and reduces the stress response. Healthy fats also help lubricate the joints, skin and vagina. These ‘healthy fats’ are found in:

Oily fish such as salmon, trout, tuna, mackerel, sardines and herring
Nuts and seeds such as walnuts, pumpkin seeds, sunflower seeds and linseeds/flaxseeds. Flaxseed is also thought to help stimulate metabolism.
Avocado, and cold-pressed, unrefined flaxseed oils.

Fibre: It is very important to consume plenty of dietary fibre since fibre helps to remove toxins and old or excessive hormones from the body. Fibre also helps to slow down the release of sugar into the bloodstream, helping to balance blood sugar levels, manage cortisol production and consequently help support adrenal gland function. Good sources of fibre include wholegrains, fruits and vegetables which will also provide antioxidants and essential vitamins and minerals.

What should I avoid during menopause?

Stimulants such as tea and coffee, processed and refined foods place extra stress on the adrenal glands and trigger the stress response, leading to surges in glucose and cortisol release and fat storage, as a consequence.

Caffeine: this should be avoided on an empty stomach to help minimise the stress response. Furthermore, caffeine also triggers the body to overheat causing increasing the risk of hot flushes and depletes the body of important nutrients.

Alcohol: also a stimulant and should be minimised in the diet whilst addressing menopause symptoms. Alcohol has a detrimental impact on blood sugar levels and can trigger hot flushes. It is also high in calories contributing to weight gain. Red wine is reported to have health benefits, attributed to the content of resveratrol, however it is advised to consume any alcohol, including red wine in moderation.

Refined sugar: It is important to minimise processed and refined sugar in the diet where possible as sugar causes a rapid rise in glucose levels in the bloodstream, disrupting blood sugar levels and stimulating the adrenal glands to release extra cortisol. Not only can this put additional strain on the adrenal glands, but additional glucose release can also lead to fat accumulation around the middle. Examples of refined sugar in the diet include:

Milk chocolate
Pastries
Biscuits and cakes and refined carbohydrates (white flour products, white bread, white pasta, and white rice)
Fruit juices
Shop-bought sauces and soups
Processed foods (ready meals).

Which vitamins and nutrients should I take during Menopause?

Specific vitamins and minerals and herbs may also help target specific symptoms including specialist plant nutrients called phytoestrogens. These are found in soya based foods particularly.

Phytoestrogens: They exert a mild oestrogenic effect which means if oestrogen levels are too high, the plant oestrogens bind to the receptors preventing the oestrogen from working and effectively lowering oestrogen. But conversely if oestrogen levels are too low, phytoestrogens can also work to enhance the levels of naturally diminishing oestrogen, improving the balance of oestrogen to other hormones such as progesterone and helping to address symptoms that way. Phytoestrogens are therefore said to have a hormonal BALANCING effect. Phytoestrogen rich foods include:

Ground flaxseeds
Good quality soya products such as tofu, organic soya milk, miso, tempeh, and beans and pulses such as chickpeas, edamame beans and lentils.
Wholegrains such as oats, quinoa, barley, rice and fruits to include apples, plums, cherries, grapes
Vegetables such as broccoli, carrots, rhubarb, celery.
Herbs and spices include cinnamon, sage, garlic, ginseng.

B vitamins and vitamin C: It is known that stress depletes the body of many important nutrients, particularly the water-soluble vitamins- B & C. Both of these nutrients are essential for health of the nervous system and reducing the effects of stress and stress hormones, which as discussed earlier can lead to fat storage around middle area. B Vitamins are also essential for energy production, energy metabolism and aiding in the insulin response associated with blood sugar levels. Vitamin C, B5 and B6 in particular have been shown to support adrenal function and balance hormones. Furthermore, vitamin C has been shown to help burn 30% more fat when used in conjunction with exercise.

B vitamins are found in:

Wholegrains
Brown rice
Fish
Eggs
Oats
Nuts and seeds
Lean white meat
Dark green leafy vegetables

Vitamin C is found in:

Berries ie: black currants
Citrus fruits ie: grapefruit, lemons, mangos, oranges and papays
Green vegetables ie: asparagus, avocados, broccoli, brussels sprouts, kale

Magnesium: helps balance the nervous system and is involved in the production of adrenal hormones and therefore helps to support adrenal function. It is believed deficiency of magnesium increases our susceptibility to stress, according to research. Furthermore, a deficiency of this mineral is thought to be a risk factor for obesity and osteoporosis in postmenopausal women, according to studies. Food sources of magnesium include; fish, dark green leafy vegetables, avocado’s, apricots, apples, bananas, brown rice, watercress and wholegrains.

Vitamin E: Vitamin E has been shown to protect the adrenal glands from free radical damage during the stress response. It is a powerful antioxidant needed for the health of the skin and the mucous membranes-areas that may need additional support throughout and following menopause. Food Sources of vitamin E include:

Avocados
Cold pressed vegetable oils
Legumes, nuts and seeds
Whole grains

Chromium: acts as a cofactor for insulin and is essential for normal insulin function and therefore can help to stabilise blood sugar levels and encourage the uptake of glucose into the cells to be used as energy, as opposed to being stored as fat. Chromium supplementation has been shown to help with improved body composition in overweight individuals and may also help to regulate food intake and reduce cravings, according to studies.

Zinc: is needed for the production of stress hormones including insulin. Studies have shown that stress depletes levels of zinc and also that supplementing with zinc helps to control cortisol. Furthermore, low zinc levels have been linked to anxiety and obesity, according to studies. Dietary sources of zinc include:

Green leafy vegetables
Wholegrains
Nuts and seeds
Seafood

Calcium, magnesium Vitamin D & Vitamin K: Oestrogen is an important hormone for maintaining bone density and therefore osteoporosis can be a concern for women following menopause. Nutrients which are important for bone density include vitamin D3, vitamin K2, magnesium and calcium and therefore will be of particular use for women during and after menopause.

Ashwagandha: is a herb that has been traditionally used to reduce stress and enhance wellbeing. It is considered to be an adaptogen which means that it helps the body adapt to the effects of stress. Studies have shown that the mechanisms of Ashwagandha include the ability to control cortisol and regulate the internal stress response system. Ashwagandha has been shown in studies to be effective for the relief of mild to moderate symptoms during perimenopause. Furthermore, Ashwagandha may be beneficial for blood sugar regulation, attributed to its reported ability to stimulate cells to take in glucose from the bloodstream, according to research.
aguulp’s role in the menopause:

aguulp for biome – probiotic for menopause

Research shows that the gut microbiome has a strong influence on the production of serotonin within the gut since commensal bacteria within the gut stimulate the production of serotonin via the intestinal cells. Therefore, supporting the balance of the microbiome within the gut is important for both serotonin production and the maintenance of stable mood, which is particularly important for women going through menopause as changes to mood is a common symptom during this period of time.

The microbiota plays an important role in the communication system between the brain and the gut and therefore probiotics may exert a beneficial effect on psychological problems such as stress and anxiety, according to studies. Systematic reviews and meta-analyses have shown that probiotics can improve and alleviate symptoms of depression and anxiety. To discover more about the gut-brain axis, read our blog.

Research has also shown that probiotics can exert beneficial effects on skin health and ageing. Whilst research is in its infancy, the connection between gut health and skin health is the focus of ongoing studies and it has been proposed that probiotics play an important role in improvements to skin barrier function, restoring acidic skin pH, alleviating oxidative stress (free radical damage) and the reduction of photoaging.

Furthermore, the natural ageing process of the skin is associated with microbial imbalance, according to studies. Emerging research suggests that the gut microbiota may play an important role in bone health with the mechanism of action thought to be the potential of the intestinal microbiota (and probiotics) to modulate bone health via the regulation of mineral absorption which is vital for healthy bones. It has been suggested that one strain of bacteria in particular- known as Lactobacillus Casei in particular, could increase lumbar bone mineral density in postmenopausal women, according to a meta-analysis of randomised controlled trials.

aguulp for gut – prebiotic for menopause

Collagen: a type of structural protein found in bone, skin, hair, connective tissue (ligaments and tendons), intervertebral disks, the cornea of the eye, dentine in the teeth, arteries, and in smaller amounts in cartilage. It helps to increase the strength and elasticity in the skin as it is a significant structural component of the dermis- the inner layer of the skin. Declining levels of collagen in the body is part of the natural ageing process but is known to be accelerated following menopause due to low oestrogen levels.

Supplemental collagen has been shown to boost the body’s own natural collagen production. Studies have also shown the use of a collagen supplement can provide a therapeutic benefit when used in relation to conditions affecting areas where collagen is naturally found in the body.

Vitamin D & Calcium: Research has shown that adequate storage levels of vitamin D maintain bone strength and might help prevent osteoporosis in postmenopausal women. Among postmenopausal women, supplements of both vitamin D and Calcium result in small increases in bone mineral density throughout the skeleton, according to research. Researchers have also found that women with a higher intake of dietary vitamin D have a lower risk of early menopause compared with women who have lower intakes.

Furthermore, Vitamin D deficiency is associated with the same risk factors associated with the menopause beyond bone health such as cardiovascular, metabolic, cognitive and affective disorders, and therefore it is recommended that sufficient vitamin D status should be obtained in all peri and postmenopausal women.

Vitamin C: Essential for collagen formation, vitamin C is an important antioxidant that helps protect against free radical damage to the skin. It is considered a key nutrient for anti-aging of the skin. Vitamin C is also important for the health of the adrenal glands and in addition has been shown to help with weight maintenance when combined with exercise.

Lysine: Lysine is an essential amino acid which helps to rebuild the collagen matrix. It cannot be made by the body and therefore must be obtained through the diet or from supplementation. Lysine has been shown to have a specific benefit to the skin and is fundamental in the synthesis of collagen.

Zinc: is needed for the production of stress hormones including insulin which can help support adrenal function and blood sugar management. Studies have shown that stress depletes levels of zinc and also that supplementing with zinc helps to control cortisol, which we know can be detrimental to the body in many ways when in excess.

In addition, low zinc levels have been linked to anxiety and obesity, according to studies which are common issues during and following menopause. Furthermore, zinc supplementation has been shown to improve sexual function in post-menopausal women, including aspects such as sexual desire, arousal, orgasm, satisfaction, vaginal moisture, and pain during intercourse.

aguulp for brain – brain supplement for menopause

Acetyl-L-Carnitine: has been shown to help improve low mood and memory function in some studies, both of which are common symptoms of menopause which are often associated with ‘brain fog’ and can occur as a result of declining levels of oestrogen- which we know has a direct effect on the brain and plays an important role in many aspects of brain function, including memory and mood.

L-Theanine-L: an amino acid which is believed to have a positive effect on mental performance. It is described as a relaxing agent without the sedative effect. It is also reported to exert stress relieving properties and improve attention span, all of which can be important aspects to address during menopause.

L-Tyrosine: Tyrosine is a precursor of adrenaline and neurotransmitters involved in mood regulation. It has also been shown to prevent cognitive decline and improve memory- all of which are many aspects of brain function that can be impacted by menopause.

Citicoline: a brain chemical that occurs naturally in the body. Citicoline is believed to increase chemicals in the brain that are involved in brain function, including specifically, cell communication and has been shown to help improve both memory and depression, according to studies. Memory problems and depression are common symptoms associated with menopause.

Phosphatidylserine: a chemical that has many functions in the body but specifically for brain function, it is vital for the maintenance of the brain cells. Phosphatidylserine is required for healthy nerve cell membranes and myelin, the protective layer that surrounds the nerves. It supports human cognitive functions including:

the formation of short-term memory
the consolidation of long-term memory
the ability to create new memories
the ability to retrieve memories
the ability to learn and recall information
the ability to focus attention and concentrate
the ability to reason and solve problems
language skills
the ability to communicate

B vitamins: B vitamins in general contribute to the maintenance and protection of cells from oxidative stress and the maintenance of normal skin.

Vitamin B2: Vitamin B2 contributes to the normal function of the nervous system. It is involved in many bodily functions, specifically relating to brain health it helps the absorption of vitamin B6, which is critical for normal brain function.

Vitamin B6: Pyridoxine is needed for normal brain function. It plays a critical role in brain chemistry because it is involved in the manufacture of all amino acid neurotransmitters such as serotonin, dopamine, melatonin, epinephrine etc. Deficiency of B6 is associated with depression, cognitive decline and memory problems. B6 has been shown to help prevent mood and anxiety related problems and also help regulate hormones. Furthermore, vitamin B6 has also been shown in studies to be associated with a decreased risk of bone fractures in women.

Vitamin B12: contributes to normal functioning of the nervous system. It is required for the proper function and development of the brain, nerves, blood cells, and many other parts of the body. Low levels of vitamin B12 have been associated with neurocognitive disorders. A deficiency has been shown to cause depression, especially in the elderly. Some studies have also shown supplementation with B12 can reverse impaired mental function as a result of B12 deficiency.

Lemon Balm Extract: Lemon balm has been shown in some studies to be useful for the treatment of anxiety and stress. It is believed to contain chemicals that seem to have a sedative, calming effect. Lemon Balm has been shown to be particularly useful for the treatment of acute menopausal syndrome, according to studies.

References

Madison, A. and Kiecolt-Glaser, J.K. (2019) “Stress, depression, diet, and the gut microbiota: human–bacteria interactions at the core of psychoneuroimmunology and nutrition,” Current opinion in behavioral sciences, 28, p. 105. doi:10.1016/J.COBEHA.2019.01.011.
el Dib, R. et al. (2021) “Probiotics for the treatment of depression and anxiety: A systematic review and meta-analysis of randomized controlled trials,” Clinical nutrition ESPEN, 45, pp. 75–90.

Minayo, M. de S., Miranda, I. and Telhado, R.S. (2021) “A systematic review of the effects of probiotics on depression and anxiety: an alternative therapy?,” Ciencia & saude coletiva, 26(9), pp. 4087–4099.

Prevalence | Background information | Osteoporosis – prevention of fragility fractures | CKS | NICE (2022). (Accessed: 6 October 2022).

Huidrom, S., Beg, M.A. and Masood, T. (2020) ‘Post-menopausal Osteoporosis and Probiotics’, Current Drug Targets, 22(7), pp. 816–822.

Collins, F.L. et al. (2017) ‘The Potential of Probiotics as a Therapy for Osteoporosis’, Microbiology spectrum, 5(4).

Yu, Jiawei et al. (2021) ‘Probiotic supplements and bone health in postmenopausal women: a meta-analysis of randomised controlled trials’, BMJ Open, 11(3), p. e041393.
Ivarsson T, Spetz AC, Hammar M. Physical exercise and vasomotor symptoms in postmenopausal women. Mauritas 1998;29:139-46.

Hammar M, Berg G, Lindgren R. Does physical exercise influence the frequency of postmenopausal hot flushes? Acta Obstet Gynecol Scand 1990;69:409-12.

Slaven L, Lee C. Mood and symptom reporting among middle-aged women: the relationship between menopausal status, hormone replacement therapy, and exercise participation. Health Psychol 1997;16:203-8.

Thornton MJ. Estrogens and aging skin. Dermatoendocrinol. 2013 Apr 1;5(2):264-70. doi: 10.4161/derm.23872. PMID: 24194966; PMCID: PMC3772914.

Raine-Fenning NJ, Brincat MP, Muscat-Baron Y. Skin aging and menopause : implications for treatment. Am J Clin Dermatol. 2003;4(6):371-8. doi: 10.2165/00128071-200304060-00001. PMID: 12762829.

Leventhal JL. Management of Libido Problems in Menopause. Perm J. 2000 Summer;4(3):29–34. PMCID: PMC6220606.

Alblooshi S, Taylor M, Gill N. Does menopause elevate the risk for developing depression and anxiety? Results from a systematic review. Australas Psychiatry. 2023 Apr;31(2):165-173. doi: 10.1177/10398562231165439. Epub 2023 Mar 24. PMID: 36961547; PMCID: PMC10088347.

Boyajian JL, Ghebretatios M, Schaly S, Islam P, Prakash S. Microbiome and Human Aging: Probiotic and Prebiotic Potentials in Longevity, Skin Health and Cellular Senescence. Nutrients. 2021 Dec 18;13(12):4550. doi: 10.3390/nu13124550. PMID: 34960102; PMCID: PMC8705837.

Proksch E, Segger D, Degwert J, Schunck M, Zague V, Oesser S. Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study. Skin Pharmacol Physiol. 2014;27(1):47-55. doi: 10.1159/000351376. Epub 2013 Aug 14. PMID: 23949208.

Dai Z, Wang R, Ang LW, Yuan JM, Koh WP. Dietary B vitamin intake and risk of hip fracture: the Singapore Chinese Health Study. Osteoporos Int 2012 Dec 13. Epub ahead of print
LeBoff MS, Kohlmeier L, Hurwitz S, Franklin J, Wright J, Glowacki J. Occult vitamin D deficiency in postmenopausal US women with acute hip fracture. JAMA 1999;251:1505-11.
Cranney C, Horsely T, O’Donnell S, Weiler H, Ooi D, Atkinson S, et al. Effectiveness and safety of vitamin D. Evidence Report/Technology Assessment No. 158 prepared by the University of Ottawa Evidence-based Practice Center under Contract No. 290-02.0021. AHRQ Publication No. 07-E013. Rockville, MD: Agency for Healthcare Research and Quality, 2007.

Purdue-Smithe AC, Whitcomb BW, Szegda KL, Boutot ME, Manson JE, Hankinson SE, Rosner BA, Troy LM, Michels KB, Bertone-Johnson ER, 2017: Vitamin D and calcium intake and risk of early menopause; Am J Clin Nutr. 2017 Jun;105(6):1493-1501. doi: 10.3945/ajcn.116.145607. Epub 2017 May

Ryan-Harshman M, Aldoori W. Vitamin B12 and health. Can Fam Physician. 2008 Apr;54(4):536-41. PMID: 18411381; PMCID: PMC2294088.

Health Quality Ontario. Vitamin B12 and cognitive function: an evidence-based analysis. Ont Health Technol Assess Ser. 2013 Nov 1;13(23):1-45. PMID: 24379897; PMCID: PMC3874776.

Kennedy DO. B Vitamins and the Brain: Mechanisms, Dose and Efficacy–A Review. Nutrients. 2016 Jan 27;8(2):68. doi: 10.3390/nu8020068. PMID: 26828517; PMCID: PMC4772032.

Thakur K, Tomar SK, Singh AK, Mandal S, Arora S. Riboflavin and health: A review of recent human research. Crit Rev Food Sci Nutr. 2017 Nov 22;57(17):3650-3660. doi: 10.1080/10408398.2016.1145104. PMID: 27029320.
Kennedy DO, Scholey AB, Tildesley NT, Perry EK, Wesnes KA. Modulation of mood and cognitive performance following acute administration of Melissa officinalis (lemon balm). Pharmacol Biochem Behav. 2002 Jul;72(4):953-64. doi: 10.1016/s0091-3057(02)00777-3. PMID: 12062586.

Kennedy DO, Little W, Scholey AB. Attenuation of laboratory-induced stress in humans after acute administration of Melissa officinalis (Lemon Balm). Psychosom Med. 2004 Jul-Aug;66(4):607-13. doi: 10.1097/01.psy.0000132877.72833.71. PMID: 15272110.

Mazaheri Nia L, Iravani M, Abedi P, Cheraghian B. Effect of Zinc on Testosterone Levels and Sexual Function of Postmenopausal Women: A Randomized Controlled Trial. J Sex Marital Ther. 2021;47(8):804-813. doi: 10.1080/0092623X.2021.1957732. Epub 2021 Jul 27. PMID: 34311679.

Kargozar R, Azizi H, Salari R. A review of effective herbal medicines in controlling menopausal symptoms. Electron Physician. 2017 Nov 25;9(11):5826-5833. doi: 10.19082/5826. PMID: 29403626; PMCID: PMC5783135.