My breast cancer diagnosis at age 37 had some unexpected consequences – and chief among them is early menopause. Throughout my treatment, chemotherapy induced chemical menopause, and then after chemotherapy I had regular shots to suppress my ovaries that put me into short-term menopause. As part of my prevention plan (my cancer was estrogen positive and estrogen is produced mostly in the ovaries) I had my ovaries removed at age 39 and a little later I shifted from tamoxifen to an aromatase inhibitor, Arimidex. And just like that I was postmenopausal.

While I have been laser-focused on my cancer prevention plan (which included my personal war against estrogen), there is little discussion of the downside of early menopause and the suppression and loss of estrogen and progesterone, including:

• • Estrogen is protective against cardiac disease
  • Estrogen may be protective against early cognitive decline
  • Estrogen has a vital role in bone density and muscle mass; each year after age 40 we lose about 1-2% of muscle mass and 1-5% of strength due to age – this is likely accelerated if we go into menopause earlier
  • Estrogen is connected to serotonin to support mood balance and also counterbalances night sweats; progesterone has an anti-anxiety effect
  • Estrogen can support the mitochondria to mitigate free radicals
  • Progesterone and some forms of estrogen can be anti-inflammatory

About a year ago, I had a shift in my own thinking as I was reaching my 5 year cancer survivorship. My main focus for the last few years has been survival and preventing recurrence. While that is still top of mind, I needed to have a shift in strategy to make sure my healthspan can match my lifespan, so some of my tactics changed to counterbalance my 15-year early hormone deficit.

Here are some of my evolving shifts:

Nutrition:

During my cancer treatment and early into survivorship my main focus was managing my blood sugar through the ketogenic diet and fasting. Both these tactics help lower blood sugar, insulin, IGF1 and as a result mitigate mtOR that can fuel cancer growth. They can also put you into more of a catabolic (breakdown) state, which I felt over time especially with my active lifestyle. I wasn’t fueling my body as an “athlete” or active person, I was fueling myself as a cancer patient – and likely spent a lot of time in a low energy availability state. So in general I increased my fuel by shortening my fasts (I was doing a lot of 24+ hour fasts and now focus on daily 16-18 hour fasts with early time restricted eating) and fueling for my activity through some of the ways below. I’ve also been diving into nutrition genomics – how your genes impact your dietary patterns and I have some snps that make me more sensitive to carbohydrates and saturated fats and that are supported through protein and fiber for satiety.

Protein:

I have been playing around with mixing up my macronutrients with a larger emphasis on protein. There are many controversies surrounding protein and my viewpoint has changed over time, from trending more vegan to being very focused on quality animal proteins and now making sure I hit specific protein targets so I get the right ratios of amino acids to fuel my body. Many researchers are challenging the RDA’s recommendation about 0.8 grams per kg of body weight, suggesting the target should be around 1.2-1.7 per kg of body weight or 0.75 to 1 gram per gram of ideal body weight may be a general target for those interested in body composition and muscle growth to ensure the right level of amino acids are available for muscle protein synthesis. Of interest to me was understanding that as we age our body’s ability to use protein declines – so as we age we may need to increase protein. In addition to daily protein targets, I’ve adjusted my meal protein targets to 25-40 grams per meal to ensure I am getting the right ratio of amino acids at each sitting and to support my satiety.

As a cancer survivor I can’t ignore the research around protein and the ability to raise mTOR and IGF-1. If I was actively treating cancer, I would take a slightly different approach to my protein targets and allow for more times of catabolism  (however protein is very important for those going through cancer treatments). In regards to the research, isolating protein as the main risk factor fueling cancer risk and growth – I believe that is in the context of a chronic overexpression of mTOR due to a high calorie, high glucose / insulin and high protein diet and in regards to isolating specific amino acids.

Carbs:

I continue to focus on building meals that are lower in carbs but high in fiber to keep glucose and insulin down – as there is an undeniable connection between your metabolic heath and cancer. Additionally, menopause on its own can put some people in a more insulin resistant state which can lead to unwanted body composition and metabolism changes. I am especially mindful because fat cells can increase the negative forms of estrogen, which I have been trying to mitigate through medication and surgery.

My focus is to eat a variety of nature-carbs focused on brightly colored vegetables, low glycemic fruits and herbs, spices and tea. Polyphenols and antioxidants in nature-carbs can promote resilience against toxins and oxidative stress to our cells. And the fiber in plant foods support the gut to produce beneficial short chain fatty acids that can reduce inflammation and support energy! I still believe in the benefits of ketones, and go through phases of nutritional (vs therapeutic) ketosis.

Exercise

For me, exercise is a daily habit just like brushing my teeth. Over the years, my focus on different parts of my physical fitness have varied – from heavy cardio to crossfit to yoga and so on. Exercise is imperative for all aspects of health and longevity. Research has shown that cancer survivors who exercise have improved outcomes and risk reduction. Exercise is directly linked to V02 max, one of the top predictors of longevity as it measures your cardiorespiratory fitness.

Strength

For me, switching from tamoxifen (which can maintain bone mass) to an aromatase inhibitor (AI) slightly changed my focus on exercise. While I have always had a focus on weight lifting, I wasn’t purposeful about it. Changing to the AI raises my risk of osteopenia and osteoporosis, as does being in menopause.  In general estrogen is essential for muscle stem cell function and one of the main drivers of muscle mass and strength in women. There is a way to replace or replicate the signal estrogen has in muscle mass – and that is lifting heavy. Part of my focus for the past year has been to increase my strength through more lifting sessions, and a focus on progressive overload (continuing to lift more and heavier). I recently read the book Next Level by Stacy Sims, PHD and she explains it like this: by lifting heavy, you send your muscles an anabolic signal that says we need to be strong to overcome this stress. That stimulates lean mass and signals to your body to decrease central and total body fat. It is never too early or too late to start increasing your strength!

HIIT

Another change in menopause is loss of power with a decline in our fast-twitch muscle fibers. This is where high intensity interval training comes into play. I have been focusing on sprinting as my main stimulus for maintaining and increasing my power (and my lean muscle mass). HIIT also has an amazing impact on our mitochondria, can suppress cancer tumors, stimulate autophagy and reduce inflammation. It’s also a great way to use up excess glucose to support my goals around metabolic flexibility. The great thing about HIIT and sprinting is that your exercise session should be short and hard, so it can easily fit into a regular practice – I aim for 6-10 intervals of 30 seconds on; 1 minute rest and the workout only takes 15-20 minutes including my warm up and cool down.

Cardio

In talking about exercise and health span, we can’t forget V02 max. V02 max is an indicator of cardiorespiratory fitness and an independent risk factor for all cause mortality. For me, the cancer therapies I took to target my cancer were cardiotoxic and put my heart at risk. So much so, many people with cancer end up dying from heart disease. In addition, according to the American Heart Association, women who are menopausal by 40 had a 40% increased risk of developing coronary heart disease compared to women who did not go through early menopause (however surgical menopause women were excluded from the study). I believe that’s where a focus on healthy whole foods with an emphasis on high quality fats and brightly colored fruits and vegetables come into play, along with a focus on cardiovascular fitness. V02 max is associated with the body’s ability to deliver oxygen throughout the body – think of it like your engine. It has a significant influence in survival rates of people with cardiovascular disease and cancer. This is where my regular endurance training comes into play. We can increase our V02 max by extended zone 2 training – this is where I like to bring in my jogs, trail runs, hot yoga and swims – and higher intensity targeted V02 max training intervals.

Mobility

In addition to strength, sprints and cardio – I believe there is a big place for mobility and yoga. As we age, and in menopause, our ligaments change and we can be more prone to injury. Keeping flexible, maintaining balance and proprioception are all preventative so we can continue to exercise through our lifespan.

Purposely Focused

As my focus continues to evolve, so do my strategies and tactics to eat, move and live with purpose. For me, it will be an evolving balance between my identity of being a cancer survivor and my goals to optimize my body to support my active lifestyle for the next four to five decades! And as a reminder, this is my plan specific to my needs and activity level – which might not be right for your goals and where you are now.

As my goals have shifted from survivorship to my healthspan, I am tracking a few different metrics as I go through my 40’s and am deeper postmenopausal to ensure I am maintaining or making progress towards my goals. I visited my local DexaFit for a Dexa scan, V02 max and resting metabolic rate testing. I did my Dexa in 2022 and now in 2023 so I can have results to trend:

Lean body mass (Dexa scan): my goal is to gain a few pounds of lean body (muscle) mass and I am making slow improvements
Bone mineral density (Dexa scan): my goal is maintain or increase my bone density and T-Score
Visceral fat (Dexa scan): my goal is to maintain 0 visceral fat
Body fat % (Dexa scan): goal to maintain body fat percentage around 18-25%; I dropped it from 25 to 18% over the past year but I give myself flexibility within this zone
V02 max (Apple watch or V02 test): my goal is to maintain or increase my V02 max (it’s at 40 – superior for my age – but I think room for improvement)
Continuing to monitor blood markers such as: fasting insulin, glucose, triglycerides, cholesterol, A1C, IGF1, homocysteine, CRP (I have seen improvement in all since altering my diet and exercise)
The most important biometric of all: I feel great!

There are many other biological impacts of menopause I didn’t have a chance to address, however nutrition and fitness directly impacts most of them from hot flashes and anxiety to early cognitive decline.

As a takeaway, if you are near or in menopause – make sure you are purposeful about your nutrition by managing your blood sugar and ensuring adequate protein, healthy fats and fiber, and have a focused exercise routine to offset the natural decline in strength and power.

Resources

If you are interested in some resources on the muscle-centric view of health…

I recently completed Dr. Peter Attia’s new book Outlive, and he is a big proponent of many forms of exercise as the main antagonist against premature aging. A good read or listen if you have time!
I enjoy the work of Dr. Gabrielle Lyon and her focus on muscle-centric medicine (tedtalk)
Dr. Stacy Sims is a exercise physiologist and nutrition scientist who focus on the performance of women (Next Level book on menopause and active life)