Nutritional Supplements & Exercise considerations in Menopause

General considerations

• Growing evidence suggests that lifestyle factors e.g. diet, Physical activity, smoking and alcohol can all influence health and menopausal symptoms.

• Regardless of menopause, women gain an average of 10kg between the age of 40 and 60; an average of 6.8kg between 50-60yrs.

• Around perimenopause, there is a reduction in BMR (250-300kcal per day). Hormonal changes mean a reduction in fat-free mass and skeletal muscle mass.

• This increases the risk of sarcopenia and predisposes to sarcopenic obesity.

• Oestrogen is protective for cardiovascular disease, so the risks of cardiovascular disease increase post-menopausal.

This extends to cholesterol, glucose and blood pressure homeostasis. The risks of metabolic syndrome in post-menopausal women is 2-3x higher than before menopause.

Considerations(1-3)

• Limitation of saturated fatty acids (no more than 10% of dietary intake) e.g for 1500kcals per day, no more than 17g SF.

• Replacing saturated fat for polyunsaturated fat, especially omega-3s (Grade A recommendation). 

• Dietary fibre of at least 30-45g/day – primarily through wholegrains.

• Reduction of salt intake <5g/day to reduce risk of hypertension.

• Sufficient Vitamin D to reduce risk of osteoporosis. In the winter, there is not enough UV-B radiation to synthesis vitD (at least 1000IU per day).

Sufficient protein intake 0.8g/kg/day with a balanced diet and 1-1.2g/kg/day for those exercising.

Limited menopause related sleep studies have been conducted, however there are other supplements with promising effects on sleep, however the populations of individuals vary and hence not generalisable to menopausal individuals.

• Ashwagandha(4, 5) (see nutrition factfile: https://www.preeventive.co.uk/nutrition/ashwagandha) – some small significant improvements from 2 systematic reviews.

• Tryptophan(6, 7) – early research suggests supplementation >1g can improve some markers of sleep, particularly shortening the ‘wake after sleep onset’.

• Magnesium(8-11) – not enough compelling research to back up sleep related improvements (https://www.preeventive.co.uk/nutrition/magnesium )

Supplements and Evidence Base

Black Cohosh (BC): Binds to receptors within the central nervous system which are involved in thermoregulation, mood and sleep. Studies suggest it does not influence the oestrogen pathway(12).

• Supplementation appears to significantly improve overall menopausal symptoms, including hot flushes and somatic symptoms compared to placebo (22 studies, n=2310 post-menopausal women; 2023)(13).

• Another older study (2021) found supplementation with BC was superior in treating vasomotor and psychological symptoms compared to placebo (35 studies, n=43759 women, 13,096 treated with BC). Furthermore, the authors suggested a dose dependent response and better outcomes when combining BC with St Johns Wort. The outcomes were comparable to low-dose transdermal oestrogen or tibolone and had a better benefit/risk profile(14).

Studies generally used dosages of 20-40mg and generally is considered safe(15).

Soy Isoflavones (SI): These are phytoestrogens found in soy products and are structurally like oestrogen. They are also found in fruits/vegetables particularly legumes. SI contain the active compounds Genistein & Daidzein.

• A 2024 meta-analysis of 5 studies (n=425 post-menopausal women) found supplementation with SI did not improve menopausal symptoms (vasomotor, psychological, physical, sexual and Genito-urinary) or quality of life but did improve levels of depression (High risk of bias in these studies)(16).

• A large 2025 umbrella review of 10 meta-analyses found supplementation with SI was associated with increased bone mineral density (BMD) in the lumbar spine, femoral neck and total hip in perimenopausal and post-menopausal women(17).

• Findings from some of the meta-analyses in the above review found supplementation of SI for at least a year (with at least 50mg/day of genistein) significantly improved BMD (18, 19).

• Supplementation appears to have a positive effect on bone resorption markers (inc: type 1 collagen and pyridinoline) and improves bone mineral parameters (inc calcium, IGF-1 and dec phosphorus levels)(20).

• SI may also improve markers of depression as demonstrated by older meta-analyses(21).

SI do not significantly increase oestrogen levels, they are thought to act more as a selective oestrogen receptor modulators(22) and appear to be protective for breast cancer risk as demonstrated by multiple studies(23).

Red Clover (RC) (Trifolium pratense) is a plant in the Fabaceae (legume) family that is a source of isoflavones with oestrogenic like properties – like soy. It is rich in the isoflavones biochanin A and formononetin.

• One meta-analysis of eight trials (ten comparisons) found a weighted mean difference of –1.73 hot flushes per day (95% CI: –3.28 to –0.18; p = 0.0292), especially in women with ≥5 hot flushes/day, over at least 12 weeks and with doses ≥80 mg/day(24).

Short term appears to be safe (up to 3-6 months) with adverse effects similar to placebo and generally mild + self-limiting(25). Long term data is not well established.

Exercise Considerations

• Exercise training is effective for improving body composition, aerobic training is more effective for fat loss and resistance training is more effective for muscle building (n= 101 studies of 5,697 postmenopausal women)(26). 

• Furthermore, ET improves cardio-respiratory fitness and muscular strength, however, only RT improves upper-body strength (129 studies, n=7,141 postmenopausal women mean age ranging from 53-90)(27). Resistance training with 3 sessions per week, lasting 20-90 min for at least 6 weeks, is most effective(28).

• High volume resistance training yields better results for muscle hypertrophy in older postmenopausal women (14 RCTs, n=588 postmenopausal females, mean age 68)(29).

• Poor balance (a precursor to falls) is most improved by ‘whole-body vibration’, followed by RT and combined exercise (RT + aerobic + balance exercises)(30).

• Yoga (n=24 studies, 2028 participants) was found to improve total menopausal, psychological, somatic, urogenital and sleep related symptoms; as well as BMI and BP. No changes were found with respect to hot flushes or quality of life outcomes(31).

References:

1. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal. 2018;39(33):3021-104.

2. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice: Developed by the Task Force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies With the special contribution of the European Association of Preventive Cardiology (EAPC). European Heart Journal. 2021;42(34):3227-337.

3. Erdélyi A, Pálfi E, Tűű L, Nas K, Szűcs Z, Török M, et al. The Importance of Nutrition in Menopause and Perimenopause-A Review. Nutrients. 2023;16(1).

4. Langade D, Thakare V, Kanchi S, Kelgane S. Clinical evaluation of the pharmacological impact of ashwagandha root extract on sleep in healthy volunteers and insomnia patients: A double-blind, randomized, parallel-group, placebo-controlled study. J Ethnopharmacol. 2021;264:113276.

5. Fatima K, Malik J, Muskan F, Raza G, Waseem A, Shahid H, et al. Safety and efficacy of Withania somnifera for anxiety and insomnia: Systematic review and meta-analysis. Hum Psychopharmacol. 2024;39(6):e2911.

6. Barnard J, Roberts S, Kelly M, Lastella M, Aisbett B, Condo D. Alpha-lactalbumin and sleep: A systematic review. J Sleep Res. 2024;33(5):e14141.

7. Sutanto CN, Loh WW, Kim JE. The impact of tryptophan supplementation on sleep quality: a systematic review, meta-analysis, and meta-regression. Nutr Rev. 2022;80(2):306-16.

8. Chan V, Lo K. Efficacy of dietary supplements on improving sleep quality: a systematic review and meta-analysis. Postgrad Med J. 2022;98(1158):285-93.

9. Rawji A, Peltier MR, Mourtzanakis K, Awan S, Rana J, Pothen NJ, et al. Examining the Effects of Supplemental Magnesium on Self-Reported Anxiety and Sleep Quality: A Systematic Review. Cureus. 2024;16(4):e59317.

10. Mah J, Pitre T. Oral magnesium supplementation for insomnia in older adults: a Systematic Review & Meta-Analysis. BMC Complement Med Ther. 2021;21(1):125.

11. Arab A, Rafie N, Amani R, Shirani F. The Role of Magnesium in Sleep Health: a Systematic Review of Available Literature. Biol Trace Elem Res. 2023;201(1):121-8.

12. Reame NE, Lukacs JL, Padmanabhan V, Eyvazzadeh AD, Smith YR, Zubieta JK. Black cohosh has central opioid activity in postmenopausal women: evidence from naloxone blockade and positron emission tomography neuroimaging. Menopause. 2008;15(5):832-40.

13. Sadahiro R, Matsuoka LN, Zeng BS, Chen KH, Zeng BY, Wang HY, et al. Black cohosh extracts in women with menopausal symptoms: an updated pairwise meta-analysis. Menopause. 2023;30(7):766-73.

14. Castelo-Branco C, Gambacciani M, Cano A, Minkin MJ, Rachoń D, Ruan X, et al. Review & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms - an update on the evidence. Climacteric. 2021;24(2):109-19.

15. Examine.com. Black Cohosh 2025 [Available from: https://examine.com/supplements/black-cohosh/#what-are-black-cohoshs-main-drawbacks.

16. Gençtürk N, Bilgiç F, Kaban HU. The effect of soy isoflavones given to women in the climacteric period on menopausal symptoms and quality of life: Systematic review and meta-analysis of randomized controlled trials. Explore (NY). 2024;20(6):103012.

17. Zhuge L, Chen L, Pan W. Effects of Isoflavone Interventions on Bone Metabolism in Perimenopausal and Postmenopausal Women: An Umbrella Review of Meta-Analyses of Randomized Controlled Trials. Endocr Pract. 2025;31(2):226-35.

18. Inpan R, Na Takuathung M, Sakuludomkan W, Dukaew N, Teekachunhatean S, Koonrungsesomboon N. Isoflavone intervention and its impact on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int. 2024;35(3):413-30.

19. Barańska A, Kanadys W, Bogdan M, Stępień E, Barczyński B, Kłak A, et al. The Role of Soy Isoflavones in the Prevention of Bone Loss in Postmenopausal Women: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2022;11(16).

20. Inpan R, Dukaew N, Na Takuathung M, Teekachunhatean S, Koonrungsesomboon N. Effects of isoflavone interventions on bone turnover markers and factors regulating bone metabolism in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. Arch Osteoporos. 2024;20(1):2.

21.  Li J, Li H, Yan P, Guo L, Li J, Han J, et al. Efficacy and safety of phytoestrogens in the treatment of perimenopausal and postmenopausal depressive disorders: A systematic review and meta-analysis. Int J Clin Pract. 2021;75(10):e14360.

22. Viscardi G, Back S, Ahmed A, Yang S, Mejia SB, Zurbau A, et al. Effect of Soy Isoflavones on Measures of Estrogenicity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Adv Nutr. 2025;16(1):100327.

23. Boutas I, Kontogeorgi A, Dimitrakakis C, Kalantaridou SN. Soy Isoflavones and Breast Cancer Risk: A Meta-analysis. In Vivo. 2022;36(2):556-62.

24. Kanadys W, Barańska A, Błaszczuk A, Polz-Dacewicz M, Drop B, Kanecki K, et al. Evaluation of Clinical Meaningfulness of Red Clover (Trifolium pratense L.) Extract to Relieve Hot Flushes and Menopausal Symptoms in Peri- and Post-Menopausal Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients. 2021;13(4).

25. Myers SP, Vigar V. Effects of a standardised extract of Trifolium pratense (Promensil) at a dosage of 80mg in the treatment of menopausal hot flushes: A systematic review and meta-analysis. Phytomedicine. 2017;24:141-7.

26. Khalafi M, Habibi Maleki A, Sakhaei MH, Rosenkranz SK, Pourvaghar MJ, Ehsanifar M, et al. The effects of exercise training on body composition in postmenopausal women: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2023;14:1183765.

27. Khalafi M, Sakhaei MH, Habibi Maleki A, Rosenkranz SK, Pourvaghar MJ, Fang Y, et al. Influence of exercise type and duration on cardiorespiratory fitness and muscular strength in post-menopausal women: a systematic review and meta-analysis. Front Cardiovasc Med. 2023;10:1190187.

28. Tan TW, Tan HL, Hsu MF, Huang HL, Chung YC. Effect of non-pharmacological interventions on the prevention of sarcopenia in menopausal women: a systematic review and meta-analysis of randomized controlled trials. BMC Womens Health. 2023;23(1):606.

29. Nunes PRP, Kassiano W, Castro ESP, Camilo BF, Cristina-Souza G, Vieira-Souza LM, et al. Higher volume resistance training enhances whole-body muscle hypertrophy in postmenopausal and older females: A secondary analysis of systematic review and meta-analysis of randomized clinical trials. Arch Gerontol Geriatr. 2024;124:105474.

30. Walsh GS, Delextrat A, Bibbey A. The comparative effect of exercise interventions on balance in perimenopausal and early postmenopausal women: A systematic review and network meta-analysis of randomised, controlled trials. Maturitas. 2023;175:107790.

31. Wang H, Liu Y, Kwok JYY, Xu F, Li R, Tang J, et al. The effectiveness of yoga on menopausal symptoms: A systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud. 2025;161:104928.

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