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Menopause & Gut Health

Jun 6, 2025 18 min readBy Entegro Health

Menopause is one of the most under-served subjects in medicine and one of the most over-sold in the supplement aisle. Those two things are related, and between them they have produced a great deal of confident writing about your gut that isn’t true.

A woman with short gray hair in a rust cardigan standing among green foliage in a glasshouse

We make a liquid probiotic, so treat what follows with the suspicion you would apply to anyone selling you something. It also means we went and read the papers. A woman in perimenopause is being told a great many confident things right now, and she deserves to know which of them come with a citation and which don’t. Everything below is sourced, and where the evidence runs out we say so.

Before anything else: bloating that is new or won’t go away needs a doctor

Current gynecology guidance names “new and unexplained gastrointestinal symptoms (abdominal pain, increased abdominal size/bloating, and difficulty eating/early satiety)” among the reasons a woman should have a pelvic examination²⁰. Those are the classic presenting symptoms of ovarian cancer, and it is most often found in women around this age.

So please treat this as the first and most important thing in the article. See a clinician — not a supplement — for any of these:

Bloating that is new, persistent, or getting worse
A waistband that is changing without a change in weight
Feeling full after very little food
Unintentional weight loss
Any bleeding after menopause
Blood in your stool
A change in bowel habit lasting more than a few weeks

The rest of this article is about ordinary, unremarkable digestive changes. It is not a way of deciding whether yours are ordinary. That is your doctor’s job.

What actually changes

The endocrinology here is well established. Across the menopausal transition, “declines in the number of remaining ovarian follicles lead to decreased and variable production of the ovarian reproductive hormones estradiol and progesterone.” At menopause itself, “complete depletion of ovarian follicles leads to loss of ovarian production of estradiol and progesterone, which stay low for the remainder of a woman’s life.” After that, “peripheral tissues (mainly adipose tissue) become the primary producers of estrogens, derived from adrenal androgen precursors”¹.

Hold on to that last sentence. It matters later, and it is the reason the gut becomes more interesting after menopause rather than less.

Does the gut microbiome change too? Probably — less clearly than you will read elsewhere

Almost every article on this subject tells you flatly that microbial diversity drops after menopause. Here is what the evidence actually looks like when you line it up.

The largest study ever done ran shotgun metagenomics on stool from 2,300 people — 295 premenopausal women, 1,027 postmenopausal women and 978 men. Its finding, in its own words: postmenopausal women “trended toward lower gut microbiome diversity and altered overall composition compared to premenopausal women”². Trended toward. After adjusting for age, the difference did not reach conventional significance.

The only published meta-analysis on the question pooled three case-control studies and found that “the Shannon diversity index increased after menopause, but no differences were found”³. Of the studies tabulated in the field’s own current review, several found no difference in diversity at all, and one found diversity higher after menopause¹.

Nobody has yet followed the same women through the transition. So menopause and simply getting older have never been told apart.

The honest summary is the one the review itself gives: research “suggests that menopause is associated with lower gut microbiome diversity and a shift toward greater similarity to the male gut microbiome, however more research is needed in large study populations to identify replicable patterns”¹. Something is probably happening. It is smaller and less certain than the confident version you have been reading.

And it isn’t a symptom

You will sometimes see “reduced microbial diversity” listed alongside bloating and weight gain, as though it were something you feel. It isn’t. Alpha diversity is a number that comes out of a sequencing run — there is no sensation attached to it, and no way to know yours without sending off a sample. Treat it as a research measure, not a symptom to go looking for.

The estrobolome, and which way it actually points

This is the most interesting idea in the subject and the one most often reported backwards, so it is worth doing properly.

The term was coined in 2011, in a review about cancer, and the authors were careful to flag it as a proposal: “We postulate that an important contribution of the human gut microbiota to host physiology is a functional estrobolome, the aggregate of enteric bacterial genes whose products are capable of metabolizing estrogens”⁴.

The mechanism is real and rather elegant. Your liver packages estrogens for disposal by attaching a sugar group to them, and sends them into the gut in bile. Some gut bacteria carry enzymes — beta-glucuronidases — that snip that group off again, freeing the estrogen to be reabsorbed instead of excreted. As the original paper put it, an estrobolome rich in those enzymes “promotes reabsorption of free estrogens that contribute to the host’s total estrogen burden”⁴. The first experimental confirmation that gut enzymes can actually do this arrived only in 2019⁵, and there turn out to be hundreds of structurally distinct versions of the enzyme across the human microbiome⁶ — only some of which act on estrogens at all.

Now the direction, which is where a lot of writing on this goes astray.

More gut activity means more estrogen, not less

You will read that a healthier gut helps you clear estrogen, or lighten the “burden” of it. The one study that measured this directly in people found the opposite. In postmenopausal women and in men, “levels of total urinary estrogens… were very strongly and directly associated with all measures of fecal microbiome richness and alpha diversity”⁷. More diversity went with more estrogen. In premenopausal women, the two were “completely unrelated”⁷.

That makes sense once you look at what the enzymes do: they free estrogen for reabsorption rather than excretion. And it fits the physiology of the audience. A woman in perimenopause is not carrying a surplus of estrogen. She is running short of it.

The “lighten the estrogen burden” framing comes from a different literature entirely — cancer risk research in women with high lifetime estrogen exposure. It does not transfer to menopause, and applying it here gets the arrow pointing the wrong way.

The version that survives contact with the evidence is the more interesting one anyway. Once the ovaries stop, gut recycling becomes one of the few remaining inputs to your estrogen supply. The review puts it carefully: because postmenopausal women “lack ovarian hormone production and have very low levels of estrogens and progesterone, enterohepatic recycling of hormones by the gut microbiota may be an important determinant of systemic estrogens and progesterone levels after menopause”¹. The gut may matter more for your hormones after menopause than it ever did before — because there is less competition.

There is exactly one human trial in which a probiotic moved the needle, and reading it closely is instructive. The researchers screened 84 strains across 16 species and found four with the relevant enzyme activity. They then gave the best of them — Levilactobacillus brevis KABP052 — to peri- and postmenopausal women for twelve weeks, and reported “significantly higher levels of estradiol… and estrone… in the probiotic versus placebo group”⁸. Higher. The authors called the study “exploratory” and said it “formed the basis for future investigations”⁸; a 2025 review summarised the size of the effect as up to a 26% increase over twelve weeks⁹.

Why that trial is not about us

Eighty-four strains screened to find four. That tells you the property is rare and strain-specific — it is not something “probiotics” do as a category. Flourish declares its organisms at species level, and was not selected for beta-glucuronidase activity. So we make no claim that Flourish supports the estrobolome, in either direction. If anyone tells you their probiotic does, ask which strain and which trial.

Two women sitting close together on a pale sofa, holding hands and talking

Two neat explanations that don’t hold up

The standard account goes like this: estrogen keeps your bowels regular, progesterone relaxes the gut, and losing both is why digestion goes sideways at midlife. It is tidy, it is repeated everywhere, and both halves of it have been tested directly — in exactly this population, in a randomized trial.

At the Mayo Clinic, 49 postmenopausal women were randomized to a week of micronized progesterone, estradiol, both, or placebo, and had whole-gut transit measured by scintigraphy. The results: “There was a significant overall effect of progesterone on colonic transit with shorter AC emptying t½ and significantly greater colonic GC at 48 h. No transit endpoints were altered by oestradiol or combined hormonal treatment relative to placebo. Oestradiol and progesterone resulted in looser stool consistency. Withdrawal of the hormone supplement was not associated with significant alteration in transit”¹⁰.

Three findings, three problems for the tidy story. Estradiol moved nothing at all. Progesterone sped the gut up and loosened stool — so losing it points away from constipation, not toward it. And taking the hormones away, which is the whole premise, changed nothing either.

The progesterone half doesn’t survive its own logic, come to that. If a hormone relaxes gut muscle, losing it gives you less relaxation, not more discomfort. The explanation and the conclusion were pointing in opposite directions before anyone measured anything.

So is anything actually happening?

Yes, probably — and you are not imagining it. In a study of 228 women at a women’s health practice, “38% of postmenopausal women reported altered bowel function, in contrast to 14% of premenopausal ones”¹¹. Flatulence and heartburn were also more common. That is a real difference and it is worth saying out loud, because women in this life stage are routinely told their symptoms are nothing.

But the same study did not adjust for age, and its authors said so: “the possible role of aging on symptom perception—regardless of hormonal status—cannot be ruled out”. And in a detail that undercuts the hormone story entirely, “estrogen use did not affect gastrointestinal symptoms in any of the two groups”¹¹.

The honest position: more women report digestive changes at this stage of life. The causes are probably several — aging, pelvic floor changes, medications, sleep, diet and stress among them — and the specific contribution of falling estrogen is not established. You will also see new food intolerances listed as a menopause symptom. We went looking for evidence of that and could not find any, so we are not going to tell you it happens.

It isn’t weight gain. It’s body composition — and that is more useful to know

This is our favorite finding in the whole subject, because the true version is far more actionable than the version everyone repeats.

The Study of Women’s Health Across the Nation followed women longitudinally with DXA scans through the transition. What it found: “Fat and lean mass increased prior to the transition. At the start of the transition, rate of fat gain doubled, and lean mass declined… Weight climbed linearly during premenopause without acceleration at the transition. Its trajectory became flat after”¹².

In the authors’ own conclusion: “there is no discernable change in rate of weight gain at the start of the [transition]”¹². Midlife weight gain is aging. What menopause does is change what your body is made of — twice the rate of fat gain, and muscle going the other way.

A woman stretching on an exercise mat in a city park in the morning, with small dumbbells and a water bottle beside her

This matters more than the scale does. In a follow-on SWAN analysis of 539 women, each standard deviation of lean mass lost across the transition was associated with a 63% greater fracture hazard afterwards¹³ — and that was independent of bone density. The authors’ conclusion: “Mitigating [transition]-related body composition changes may reduce fracture risk”¹³.

The intervention with the best evidence behind it at this life stage is lifting things. We don’t sell that.

Resistance training and eating enough protein are what act on lean mass. We have no product in that fight and nothing to gain by telling you, which is roughly why you should believe us.

What the evidence supports for your gut

Fiber — with an honest catch

A meta-analysis of fiber supplementation for chronic constipation found that “113 of 147 (77%) patients assigned to fibre responded to therapy, compared with 61 of 140 (44%) allocated to placebo”, with significantly better stool frequency and consistency¹⁴.

And now the catch, from the same paper: “Flatulence was significantly higher with fibre compared to placebo”, and the authors concluded that fiber “is moderately effective, but also causes moderate gastrointestinal side effects”¹⁴.

We are telling you the downside on purpose. If bloating is your main complaint, more fiber may make it worse before it makes it better, and a lot of women give up in week two thinking it isn’t working. Go up slowly, and give it time.

A person in a striped apron slicing mushrooms on a wooden board beside wholemeal rolls, lettuce, lemons, tomatoes and fresh herbs

What actually treats hot flashes — and it is not us

This is the paragraph that costs us something, and we are printing it anyway.

The Menopause Society’s 2022 position statement is unambiguous: “Hormone therapy remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture.” For women under 60 or within ten years of menopause and without contraindications, “the benefit-risk ratio is favorable”; for women starting more than ten years out, it “appears less favorable”¹⁵.

And the awkward one

The same society’s 2023 statement on non-hormonal options lists what is recommended for hot flashes — cognitive-behavioral therapy, clinical hypnosis, SSRIs/SNRIs, gabapentin, fezolinetant — and then lists what is not. On that second list, at their two highest evidence levels: “supplements/herbal remedies”¹⁶.

That includes us. Flourish is not a treatment for hot flashes, has never been studied for them, and we are not suggesting otherwise. If your vasomotor symptoms are bothering you, the conversation to have is with a clinician about hormone therapy or the non-hormonal options above — not with a supplement company.

And mood?

The best trial we could find gave 66 postmenopausal women probiotic yogurt or ordinary yogurt for six weeks. Anxiety and stress subscale scores came out slightly lower in the probiotic group (p = 0.044 and p = 0.046), while depression and sleep quality showed no significant difference at all, and the authors wrote that “further studies are needed to obtain a definite conclusion”¹⁷.

Two borderline p-values on subscales, with the other outcomes null, in 66 women, over six weeks. That is a hint, not a finding — and it is a long way from the confident line you will see elsewhere about probiotics easing mood swings and brain fog. We are not going to make it.

A woman in a knitted jumper sitting cross-legged on a sofa holding a mug, looking towards a window, with large houseplants beside her

Where Flourish fits

One woman handing a bottle of Flourish Original to another, both holding it with both hands

Flourish is a fermented living liquid. It pours, you can measure a dose, and there is no capsule to swallow. Some women like having live cultures in the daily routine the way they like having yogurt or kefir in it, and that is a perfectly good reason to take it. It is the reason we would give.

It is not a hormone product, it is not a treatment for menopausal symptoms, and we have not run a trial on it.

One thing we won’t tell you about the liquid format

Liquid probiotics are often sold as being “more bioavailable,” more easily absorbed, or faster-acting than capsules. We are not going to say any of that, because none of it can be backed up.

There is no head-to-head evidence — not one published or registered trial comparing a liquid probiotic against a capsule on any clinical endpoint, in any population, at any age. “Faster-acting” names no endpoint at all, so it cannot be substantiated even in principle.

And “more easily absorbed” is the wrong idea from the start. A probiotic is meant to work in the gut, not be absorbed out of it. A bacterium that gets into the bloodstream is a bacteraemia — an adverse event, occasionally a serious one. Absorption is the thing you want a probiotic not to do.

What is true about the format is duller and checkable: it pours, it can be measured, and nobody has to swallow a capsule.

Species, not strains — and why the difference matters here

Flourish contains 11 species. That is deliberately not the same word as “strains”: a strain designation requires the genus and species name plus a specific culture-collection or commercial identifier¹⁹ — roughly the difference between “a golden retriever” and “this particular golden retriever, with papers.”

That distinction runs through everything above. Nearly every positive finding in this article belongs to a named strain, tested on its own. It is worth knowing which one you are being sold whenever a product cites research — ours included.

The one thing the consensus definition does allow at species level is modest and we will stick to it: well-studied species at an adequate dose can reasonably be said to support a healthy digestive tract¹⁸. That is the claim. Anything about hormones, mood, bones or menopausal symptoms would need strain-level evidence we do not have.

Two older women sitting together at a table in a busy community café, one leaning in laughing with an arm around the other

What we would actually say

Something is changing, you are not imagining it, and the research on menopause and the gut is genuinely interesting — particularly the possibility that your gut matters more for your hormones now than it used to, because there is less competing with it. That is a real idea and it deserves better than being sold to you backwards.

The things with the best evidence behind them at this stage of life are unglamorous: lift something heavy a couple of times a week, eat enough protein, build up fiber slowly, and take your symptoms to a clinician who will take them seriously. If you would also like live cultures in your day, we are glad to sell you some. We just aren’t going to pretend they are hormone therapy.

About this article

Written by: Kelsy Armstrong, Entegro Health | Originally published: June 2025

Important information

This article is for general education and isn’t a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions about a medical condition, and never disregard or delay professional advice because of something you have read here. Please see the red-flag list at the top of this article.

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Sources

Peters, B. A., Santoro, N., Kaplan, R. C., & Qi, Q. (2022). Spotlight on the gut microbiome in menopause: current insights. International Journal of Women’s Health, 14, 1059–1072 — narrative review; “more research is needed in large study populations to identify replicable patterns.” Source
Peters, B. A., Lin, J., Qi, Q., Usyk, M., Isasi, C. R., Mossavar-Rahmani, Y., et al. (2022). Menopause is associated with an altered gut microbiome and estrobolome, with implications for adverse cardiometabolic risk in the Hispanic Community Health Study/Study of Latinos. mSystems, 7(3), e00273-22 — n=2,300; postmenopausal women “trended toward” lower diversity. Source
Yang, M., Wen, S., Zhang, J., Peng, J., Shen, X., & Xu, L. (2022). Systematic review and meta-analysis: changes of gut microbiota before and after menopause. Disease Markers, 2022, 3767373 — “The Shannon diversity index increased after menopause, but no differences were found.” Source
Plottel, C. S., & Blaser, M. J. (2011). Microbiome and malignancy. Cell Host & Microbe, 10(4), 324–335 — origin of the term “estrobolome”: “the aggregate of enteric bacterial genes whose products are capable of metabolizing estrogens.” Source
Ervin, S. M., Li, H., Lim, L., Roberts, L. R., Liang, X., Mani, S., & Redinbo, M. R. (2019). Gut microbial beta-glucuronidases reactivate estrogens as components of the estrobolome that reactivate estrogens. Journal of Biological Chemistry, 294(49), 18586–18599 — first experimental evidence, in vitro, across 35 enzymes. Source
Pollet, R. M., D’Agostino, E. H., Walton, W. G., Xu, Y., Little, M. S., Biernat, K. A., et al. (2017). An atlas of beta-glucuronidases in the human intestinal microbiome. Structure, 25(7), 967–977.e5 — 3,013 total and 279 unique enzymes across six structural classes. Source
Flores, R., Shi, J., Fuhrman, B., Xu, X., Veenstra, T. D., Gail, M. H., et al. (2012). Fecal microbial determinants of fecal and systemic estrogens and estrogen metabolites: a cross-sectional study. Journal of Translational Medicine, 10, 253 — in men and postmenopausal women, urinary estrogens were “very strongly and directly associated” with microbiome richness and diversity (R≥0.50, P≤0.003); in premenopausal women, “completely unrelated.” Source
Honda, S., Tominaga, Y., Espadaler-Mazo, J., Huedo, P., Aguiló, M., Perez, M., et al. (2024). Supplementation with a probiotic formula having beta-glucuronidase activity modulates serum estrogen levels in healthy peri- and postmenopausal women. Journal of Medicinal Food, 27(8), 720–727 — 84 strains screened to find 4; exploratory, industry-conducted; estradiol 31.62 vs 25.12 pg/mL at 12 weeks. Source
Bolgova, O., Shypilova, I., & Mavrych, V. (2025). Natural strategies to optimize estrogen levels in aging women: mini review. Frontiers in Aging, 6, 1706117 — “probiotics containing L. brevis KABP052 increased circulating estrogens by up to 26% over 12 weeks.” Source
Gonenne, J., Esfandyari, T., Camilleri, M., Burton, D. D., Stephens, D. A., Baxter, K. L., et al. (2006). Effect of female sex hormone supplementation and withdrawal on gastrointestinal and colonic transit in postmenopausal women. Neurogastroenterology & Motility, 18(10), 911–918 — randomized, n=49, scintigraphy; “no transit endpoints were altered by oestradiol”; progesterone accelerated transit; withdrawal changed nothing. Source
Triadafilopoulos, G., Finlayson, M., & Grellet, C. (1998). Bowel dysfunction in postmenopausal women. Women & Health, 27(4), 55–66 — n=228; 38% vs 14% reported altered bowel function; “estrogen use did not affect gastrointestinal symptoms in any of the two groups”; authors note aging could not be ruled out. Source
Greendale, G. A., Sternfeld, B., Huang, M., Han, W., Karvonen-Gutierrez, C., Ruppert, K., et al. (2019). Changes in body composition and weight during the menopause transition. JCI Insight, 4(5), e124865 — SWAN, longitudinal DXA; rate of fat gain doubled and lean mass declined at the transition, but “no discernable change in rate of weight gain.” Source
Shieh, A., Karlamangla, A. S., Karvonen-Gutierrez, C. A., & Greendale, G. A. (2023). Menopause-related changes in body composition are associated with subsequent bone mineral density and fractures: Study of Women’s Health Across the Nation. Journal of Bone and Mineral Research, 38(3), 395–402 — n=539; each standard deviation of lean mass loss associated with a 63% greater fracture hazard (p=0.001). Source
Christodoulides, S., Dimidi, E., Fragkos, K. C., Farmer, A. D., Whelan, K., & Scott, S. M. (2016). Systematic review with meta-analysis: effect of fibre supplementation on chronic idiopathic constipation in adults. Alimentary Pharmacology & Therapeutics, 44(2), 103–116 — 77% vs 44% responded; “flatulence was significantly higher with fibre compared to placebo”; quality of evidence low. Source
The North American Menopause Society (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767–794 — “hormone therapy remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause.” Source
The North American Menopause Society (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573–590 — “supplements/herbal remedies” listed as not recommended for vasomotor symptoms (Levels I–II). Source
Shafie, M., Homayouni Rad, A., Mohammad-Alizadeh-Charandabi, S., & Mirghafourvand, M. (2022). The effect of probiotics on mood and sleep quality in postmenopausal women: a triple-blind randomized controlled trial. Clinical Nutrition ESPEN, 50, 15–23 — n=66, 6 weeks; anxiety and stress subscales p=0.044 and p=0.046; depression and sleep not significantly different. Source
Hill, C., Guarner, F., Reid, G., Gibson, G. R., Merenstein, D. J., Pot, B., et al. (2014). Expert consensus document: The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nature Reviews Gastroenterology & Hepatology, 11(8), 506–514 — class-level benefit accepted for supporting a healthy digestive tract; immune and gut–brain benefits excluded as “probably more strain-specific.” Source
Binda, S., Hill, C., Johansen, E., Obis, D., Pot, B., Sanders, M. E., et al. (2020). Criteria to qualify microorganisms as “probiotic” in foods and dietary supplements. Frontiers in Microbiology, 11, 1662 — “proper strain designation is therefore composed of two main parts: the official genus, species (and subspecies) names… followed by a strain designation.” Source
Evans, D., Goldstein, S., Loewy, A., & Altman, A. D. (2019). No. 385 — Indications for pelvic examination. Journal of Obstetrics and Gynaecology Canada, 41(8), 1221–1234 — names “new and unexplained gastrointestinal symptoms (abdominal pain, increased abdominal size/bloating, and difficulty eating/early satiety)” among indications for pelvic examination. Source