The Journal

Perimenopause

Perimenopause: navigating the future

Protein, Muscle, Sleep and the map that fits you

Dr Amy Shacaluga·12 September 20269 min read

If you are in perimenopause, or hovering near it, take a breath. Feeling different in your body does not mean you have failed a wellness test. The scales can stay almost still while the mix of fat and muscle quietly changes. That is common, and it is not a personal failing.

This note is a starting map for you. Precision Health here means we match the next step to what is loudest in your picture: sleep, strength, glucose, joints, culture, training age. Lifestyle leads. Medicines and herbal options sit inside that plan, not on top of it. Educational information only, not personal medical advice, and not for emergencies. If you need urgent care, call 999 or NHS 111.

How we grade what we say. A soft traffic light sits as a dot after the claim, so you can see how sure the evidence is, not how fashionable it is.

• 🟢 Green: solid enough to use as a starting point, still with “this is your picture.”
• 🟡 Amber: useful, with real limits. Small trials, mixed results, not menopause-specific, or product quality varies.
• 🔴 Red: interesting, heavily marketed, or not a first move.

Numbers in square brackets, like [1], point to a paper or guideline we have actually checked. If we only saw the abstract, we say so. A podcast is a prompt for questions, not a citation.

What is changing (and what the scale misses)

Body composition. Across the menopause transition, fat gain often speeds up and lean mass (muscle and related tissue) dips a little. The two can cancel, so weight barely moves.[1]

🟢 Green

So we watch how you actually feel and function: strength, waist trend, energy, sleep, mood, and glucose risk. Your training history, pelvic floor, joints, and culture all change the next step. What works on average is not automatically what you need.

Lifestyle first: muscle, food, sleep

Strength. You can get stronger after the transition. In women around 40 to 60, structured exercise improves lean mass a little and strength more clearly, especially resistance training (weights, bands, bodyweight, hills) a few times a week.[2] UK guidance is clear that keeping muscle and strength matters in menopause care.[10]

🟢 Green

Muscle size. Light activity is not always enough if the goal is building muscle. Strength often rises before size does.[3] Higher training volume can still help later, though that evidence is thinner.[4][5]

🟡 Amber

In real life: break long sitting. Keep walking. Add small resistance work twice a week, then progress when sleep and recovery allow. Hard depleting sessions on an exhausted baseline are a poor first move.

Protein. The familiar 0.8 g/kg/day is closer to a minimum than a midlife target. Expert groups often suggest about 1.0 to 1.2 g/kg/day for healthy older adults, and a little more when you train. If you have kidney disease, check the number with your own clinician first.[6] Extra protein helps lean mass mainly with resistance work; protein alone is a weak lever.[7] Around 1.2 g/kg/day is a practical range for many well women who train, not a universal 2.0 g/kg rule, and not “1 g per pound for everyone.”[6][7]

🟡 Amber

Food first. Plant proteins can support muscle when you mix sources across the day.[9] A solid protein portion at meals does the job: eggs, fish, dairy or fortified soya, legumes, tofu, poultry, nuts and seeds. Bars and powders are optional tools, not a moral upgrade. A rigid 45-minute “window or you lose it” rule is not proven long-term law for every midlife woman.[6][8]

🟡 Amber

Sleep. Poor sleep can nudge insulin sensitivity and appetite the wrong way. Protect it as a metabolic lever: regular timing, morning light, a calmer last hour, and a talking therapy designed for menopause sleep and flushes when night sweats are driving the night.[10] If snoring, pauses in breathing, or unrefreshing sleep sound familiar, mention that. It may be worth checking for sleep apnoea.

🟡 Amber

Podcasts often get the direction right (lift, eat enough protein) and the protocol wrong. Treat them as questions, not a care plan.

Precision pointers (make this yours)

Match the next step to what is loudest this season. None of these cancel the others.

• Sleep, exhaustion, or night sweats first: gentle repeatable movement. Tiny resistance work only if you can recover. Sleep care, and HRT when flushes are the driver, can sit now, not after you “earn” it.[10]
• Waist, glucose, or a PCOS / PMOS history: muscle is a glucose sink. Resistance work plus protein with carbohydrate (not “naked” carbs). A stable scale still deserves a glucose check if risk is already higher.
• Tender joints or pelvic floor: change the how, not the whether. Bands, water, slower tempo still count.
• You already lift: progress volume when recovery allows. Skip someone else’s beginner on-ramp and skip their 1 g per pound rule.
• Lean, under-fuelled, or the plate has quietly shrunk: enough food first. Restriction is a poor menopause plan.
• Kidney disease, complex medicines, or an eating-disorder history: do not self-prescribe a higher protein number.

Medicines and herbal options (inside the plan)

Medicines can be necessary. They belong inside a personalised plan, beside lifestyle, not as a verdict on it.

HRT. It can be a good option for bothersome flushes and night sweats, decided together with your clinician: combined versus oestrogen-only, a tablet versus through-the-skin, dose, how long, and your own risks. It is not used to prevent heart disease or dementia, and it does not replace loading your muscles.[10] Other non hormonal options can also be discussed to support these symptoms.

🟢 Green

We always look at herbal choices alongside this, never instead of it. Quality and interactions vary. Check with a clinician or pharmacist first, especially if you take other medicines, have thyroid or autoimmune disease, a breast-cancer history, liver or kidney disease, or you might be pregnant.

Chamomile. Helps sleep quality more clearly than insomnia itself. The ritual counts: warm, uncaffeinated, lights down.[11]

🟡 Amber

A note from clinic. My go-to is an evening chamomile. Cover the cup or pot while it steeps so the scent-oils stay in the tea, not the kitchen. Five to ten minutes is plenty. Use hot, not furiously boiling, water. It is a small ritual, not a sleeping pill.

Ashwagandha. A modest stress/sleep helper in people in general. Not a hormone treatment, and not a menopause-specific medicine. Check first if you take thyroid medication or sedatives, have an autoimmune condition, or you are pregnant or trying to conceive.[12]

🟡 Amber

Magnesium. Plausible for sleep; trials mixed. Best discussed in clinic with regards to magnesium combinations. Go gently if kidneys are not well.[13]

🟡🔴 Amber to red

Melatonin. A clock tool, not a sleeping pill. In the UK this is a prescription conversation, not a shop default.

🟡 Amber

Isoflavones and black cohosh. There is some evidence they may ease flushes. UK guidance notes that products vary and they can interact with other medicines. Food-first soy is a calmer first step than an unregulated capsule.[10]

🟡 Amber

St John’s wort. Some flush signal, and serious drug interactions (including tamoxifen, anticoagulants, anticonvulsants, and the pill).[10][14]

🔴🟡 Red to amber

Pick one herbal option that matches what is loudest, give it a time-limited try, and stop if it does not help.

A gentle place to begin

1. Name what is loudest (sleep, strength, waist or glucose, joints, mood).
2. Build toward resistance training two to three days a week, progressing when recovery allows.
3. Eat enough, with protein in a pragmatic range for you (often around 1.2 g/kg/day if your kidneys and clinician picture allow), from food first.
4. Protect sleep. Chamomile can be the evening cue. HRT or a herbal option we have graded only if that conversation fits you.
5. Review when life or your body changes. No podcast protocol required.

If this resonated, stay with the Journal. When you want care shaped around your own pattern, consultations are available in Penarth and by video across the UK via dramyshacaluga.co.uk.

References

1. Greendale GA, Sternfeld B, Huang M, et al. Changes in body composition and weight during the menopause transition. JCI Insight. 2019;4(5):e124865. PMID: 30843880.
2. 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;23:606. PMID: 37964288.
3. Isenmann E, Kaluza D, Havers T, et al. Resistance training alters body composition in middle-aged women depending on menopause: a 20-week control trial. BMC Womens Health. 2023;23:526. PMID: 37803287.
4. Nascimento de Oliveira Júnior G, de Sousa JFR, Carneiro MAS, et al. Resistance training volume enhances muscle hypertrophy, but not strength in postmenopausal women: a randomized controlled trial. J Strength Cond Res. 2022;36(5):1216-1221. PMID: 32569127.
5. Nunes PRP, Kassiano W, Castro-e-Souza P, 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. PMID: 38744142.
6. Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013;14(8):542-559. PMID: 23867520.
7. Nunes EA, Colenso-Semple L, McKellar SR, et al. Systematic review and meta-analysis of protein intake to support muscle mass and function in healthy adults. J Cachexia Sarcopenia Muscle. 2022;13(2):795-810. PMID: 35187864.
8. Devries MC, McGlory C, Bolster DR, et al. Protein leucine content is a determinant of shorter- and longer-term muscle protein synthetic responses at rest and following resistance exercise in healthy older women: a randomized, controlled trial. Am J Clin Nutr. 2018;107(2):217-226. PMID: 29529146.
9. Black KE, Matkin-Hussey P. The impact of protein in post-menopausal women on muscle mass and strength: a narrative review. Physiologia. 2024;4(3):266-285. DOI: 10.3390/physiologia4030016.
10. National Institute for Health and Care Excellence. Menopause: identification and management. NICE guideline NG23 (updated Nov 2024). nice.org.uk
11. Hieu TH, Dibas M, Surya Dila KA, et al. Therapeutic efficacy and safety of chamomile for state anxiety, generalized anxiety disorder, insomnia, and sleep quality: a systematic review and meta-analysis of randomized trials and quasi-randomized trials. Phytother Res. 2019;33(6):1604-1615. PMID: 31006899.
12. Fatima K, Malik J, Muskan F, et al. Safety and efficacy of Withania somnifera for anxiety and insomnia: a systematic review and meta-analysis. Hum Psychopharmacol. 2024;39(6):e2911. PMID: 39083548.
13. 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):121-128. PMID: 35184264.
14. Ioannides C. Pharmacokinetic interactions between herbal remedies and medicinal drugs. Xenobiotica. 2002;32(6):451-478. PMID: 12160480.