Understanding Histamine Intolerance During Menopause

Consultations about menopause should be holistic and at Health in Menopause we aim to gain an understanding of each woman’s overall health. Sometimes our consultations uncover health issues that may have been previously overlooked or only become apparent during the menopause journey.

What is histamine?

Histamine is a vital chemical in your body playing crucial roles in your immune and digestive systems, and as a messenger (neurotransmitter) in the brain influencing your sleep, mood, sex drive and thought processes.

Histamine is made in several cells in the body, especially in those called mast cells. In addition to the histamine you make in your body, you also take it in through your diet.

Your body gets rid of histamine in two main ways: the histamine you have ingested though diet is eliminated by an enzyme called Diamine Oxidase (DAO) and the histamine your body makes is eliminated by an enzyme called Histamine-N-Methyl Transferase (HNMT). The optimal situation is that your body eliminates the histamine efficiently so there is not a toxic accumulation.

What is histamine intolerance?

Think of a bath with the taps turned on and the plughole open – if more water is coming through the taps than can drain away down the plughole, there will be overflow.

Histamine Intolerance is the result of an overflow or excess accumulation of histamine.

This can cause a large number of potentially debilitating symptoms affecting several systems of the body:

Skin: hives, flushing, itching, eczema
Respiratory: rhinitis (constant runny nose), sinusitis, wheeze, shortness of breath, chronic cough
Gut: acid reflux, nausea, constipation, diarrhoea, bloating, wind
Vascular: dizziness, fainting, migraine, oedema (fluid retention), palpitations
Neurological: irritability, anxiety, brain fog, insomnia, fatigue, tinnitus
Other: joint pains, breast pain, painful and/or heavy periods, bladder pain syndrome

While there are a lot of potential symptoms, the way histamine intolerance presents is unique to each person. Most people have one or a few predominating issues rather than all of the symptoms listed above.

Symptoms tend to be intermittent and come and go depending on the amount of histamine in your body at any given time. To make matters more complicated, many of the symptoms overlap with and can be falsely attributed to the menopause, or to other conditions.

Why does histamine intolerance happen?

There are a number of different reasons histamine intolerance may develop in an individual. In simple terms, there may be too much histamine being produced or ingested, not enough histamine being eliminated, or a combination of both.

There are many foods and drinks that contain higher amounts of histamine and/or provoke more histamine to be released by your mast cells. Examples of these are alcohol, aged or fermented foods, cured meats, smoked fish, spinach, strawberries, tomatoes, aubergine and avocado. Foods such as these can contribute to an excessive accumulation of histamine. If a person is taking in too much histamine in their diet, it may overwhelm their body’s ability to eliminate it.

Alternatively, or in addition to this, the elimination of histamine may be impaired for other reasons. There are genetic reasons why some people have less effective DAO and/or HNMT enzymes – going back to the bath water analogy, their plugholes are permanently smaller. This is one of the reasons that histamine intolerance can sometimes run in families.

The DAO enzyme is also under the influence of other factors that are not genetic. It may be that their plughole is partially blocked (deregulated) by various medications such as non-steroidal anti-inflammatory drugs (e.g. ibuprofen), various painkillers, or antidepressants. Ironically, these types of medications are often given in an attempt to treat the symptoms being experienced but inadvertently worsen the underlying cause. The efficient elimination of the metabolites of estrogen also depends on some genetic and gut-related factors, so suboptimal issues with this can also lead to higher levels of circulating histamine.

Individuals with poor gut health will struggle to eliminate histamine efficiently. This could be due to conditions like inflammatory bowel disease or coeliac disease, or because the gut microbiome is disordered due to a poor diet or antibiotic use, for example.

Chronic stress is also a contributing factor to histamine intolerance as histamine release from mast cells increases under the influence of cortisol – the ‘stress hormone’.

Histamine intolerance is also a feature that has been commonly seen in those with Long Covid. This appears to relate to the Covid19 virus triggering hypersensitivity of the mast cells (known as Mast Cell Activation Syndrome) and therefore increasing histamine levels.

Why is histamine intolerance an issue during menopause?

Estrogen and histamine have a very close relationship, hence why the issue can arise at menopause when estrogen levels change.

Estrogen stimulates mast cells to release histamine (turning the taps on more) and it deregulates DAO (making the plughole smaller or blocked).

Histamine also encourages greater release of estrogen from the ovaries forming a vicious cycle where more histamine leads to more estrogen and more estrogen leads to more histamine.

You are therefore most vulnerable to the effects of histamine when your estrogen is at its highest – this is usually at puberty and then again during the perimenopause when there are sharp fluctuations of estrogen.

Many women in their 40s reaching perimenopause (often unbeknown to them) feel they have developed new allergies or intolerances perhaps to alcohol or certain foods, or they find that conditions such as hay fever, eczema or asthma appear for the first time or worsen.

If you’re still having periods, your estrogen level peaks midcycle (when ovulating) and then again to a lesser extent just before your period starts. Because of this, it’s common to notice symptoms of histamine intolerance at these times in your cycle. You might feel very sniffly or flush easily after drinking wine but only at these times of the month. Making a note of these symptoms and at what point in your cycle they occur can be very helpful in identifying the problem.

While women who start taking estrogen as part of HRT see an improvement in their menopause symptoms, they might notice a worsening in symptoms that relate to histamine intolerance. This is why it’s important that your menopause doctor knows your medical history well before starting HRT and reviews your symptom progress regularly once you are taking HRT to look for any potential tell-tale signs of histamine intolerance.

Do I have histamine intolerance?

It can be very difficult to know if you have this issue. Very few people, including many healthcare professionals have ever heard of it. It is not currently a recognised condition in conventional medicine but tends to fall more in the realm of functional medicine and nutrition.

Many sufferers have noticed some of the symptoms at various times but as they fluctuate so much and have so many other potential causes, it is unusual for anybody to have joined the dots before.

Many people believe their symptoms reflect an allergy to something, but they haven’t been able to pin down exactly what, and tests may have been inconclusive. This would be true as histamine intolerance is not an allergy to one particular thing, but a cumulative effect of too much histamine in the body.

There is no specific test to diagnose histamine intolerance. Usually, the most helpful indicator is to keep a food-symptom diary to identify your triggers.

Individual reactions to histamine vary greatly so your contributing or ‘trigger’ foods may be different to someone else’s.

Ideally alongside a nutritionist or dietitian, you can then work on removing the suspected trigger foods and slowly reintroduce them one by one to develop a personalised protocol diet. You can also take antihistamines during this time.

It is possible to have blood tests to measure DAO levels, but as these vary from day to day, they are not that useful as a sole indicator of histamine intolerance (and they are not usually available on the NHS).

Some people choose to pursue personalised DNA analysis to look at their ‘Histamine Pathways’ (looking at both the DAO and HNMT genes) and this is only available privately. While your DNA may play a complementary role in building overall understanding and informing management, by itself it is not adequate to diagnose histamine intolerance.

Eliminating histamine is not an easy process and the advice and expertise of a nutritionist or dietician experienced in HIT management will be valuable to avoid becoming deficient in certain nutrients.

Altering your diet to manage histamine intolerance takes time to get right. It is sensible to think of it as a project that should ultimately lead to you enjoying a diverse range of healthy and delicious foods.

A note of caution: If you have a history of disordered eating and are considering restricting your diet to help with histamine intolerance, it’s essential that you work alongside a qualified health professional to do this and discuss it with your care team to help you weigh up that any potential benefit is greater than the risk of a relapse of your disordered eating.

What should I do if I think I have histamine intolerance?

It is always important to consult with your doctor about any health concerns you have and to rule out any alternative medical conditions that may be masquerading as something similar to histamine intolerance.

As mentioned, this is not a condition that is widely recognised so we recommend preparing yourself with information before seeing your doctor, such as reading this booklet. Make notes about your symptoms and timing of symptoms and how it relates to your diet or lifestyle or other medications that you have noticed.

The following measures can be taken to try and improve histamine intolerance:

Diet and gut health: Under the advice of a nutritionist, develop a protocol to improve your gut health and undergo a trial of dietary exclusion and reintroduction. See the table below for a more comprehensive guide to higher histamine foods and lower histamine alternatives. A probiotic may be helpful but needs to be one that is suitable for those with histamine intolerance. It is best to cook fresh food when following a low histamine diet and quickly cool and freeze leftovers. Histamine levels of foods increase when they are left in the fridge.

Antihistamines: Think of these as towels for mopping up any overflowing water. They will reduce the damage caused (symptoms) but they won’t deal with the underlying problem. There are different types of antihistamines, predominantly H1 and H2 blockers. H1 blockers can be bought over the counter (cetirizine, loratadine, fexofenadine for example). Sometimes it can be helpful to combine these with H2 blockers, particularly if stomach acid is an issue, but these are currently only available on prescription.

Supplements: There are a variety of vitamins and mineral supplements that can be helpful in optimising the processing of histamine but these can differ from person to person for example, vitamin B, vitamin C, magnesium, copper. Quercetin is a supplement (occurring naturally in apples) which helps to stabilise mast cells. There are DAO supplements available to buy over the counter or online. These may be helpful to take 30 minutes before a meal that you know will contain histamine however, they are not generally recommended for regular use and can be expensive. There are other potential options which may be helpful if trials with the above suggestions are not effective enough, such as Toxaprevent and other prescribed medications acting as mast cell stabilisers.

Reduction of stress: Being able to reduce stress helps reduce the release of histamine from mast cells. This may be achieved with yoga, meditation, breathing exercises or simply any activities that you enjoy and find calming. (Physical exercise can be variable from person to person in terms of its effects on histamine).

Adjustments to HRT: While estrogen can potentially worsen histamine related issues, both progesterone and testosterone as part of HRT will usually help stabilise mast cells. It is also important to note that HRT can help improve gut health and therefore may also help histamine intolerance. It’s important to individualise your HRT regime if you have histamine intolerance.

Your guide to histamine amounts in food

Food Group	Higher Histamine	Lower Histamine
Vegetables	Avocado, aubergine, tomatoes, spinach, mushrooms, pickled vegetables	All other fresh vegetables
Fermented Foods	Kimchi, kefir, kombucha fermented dairy (milks, cheese, live yoghurts), sauerkraut, pickled vegetables, soy sauce, miso	None
Fruit	Citrus (orange, lime, lemons, grapefruit), plums, strawberries, banana, pineapple, kiwi, papaya	All other fruits
Meats	Cured or aged meats (deli meats, bacon, salami, hotdogs)	Fresh or frozen fresh meats
Fish/Seafood	Most seafood, especially smoked and canned fish, shellfish and crustaceans	Freshly caught white fish or frozen at source
Eggs	Eggs (fried, scrambled, poached etc.)	Very fresh eggs, eggs baked into foods (pancakes, cakes etc.)
Dried fruits	Dried fruits that contain sulphur dioxide	Dried fruit with no sulphur dioxide and preservatives
Legumes and pulses	Chickpeas, beans, lentils, butter beans, navy beans, black beans, kidney beans, black eyed beans, soy. This includes hummus etc.	There is some evidence to suggest that pressure cooking dried legumes or cooking and discarding the water reduces the amine level. Sprouted legumes may also be more tolerable
Grain, wheat and flour	Really mixed evidence but usually well tolerated. Sourdough can sometimes be problematic as it is fermented	Breads, rice, pasta, cereals oats, quinoa, potato, teff, buckwheat, pastries seem to be tolerated well
Nuts and seeds	All except those listed in Lower Histamine section	Pumpkin seeds, sunflower seeds, sesame seeds, chia seeds, flax seeds, hempseeds, pinenuts, brazil nuts, almonds, pecans, hazelnuts, chestnuts
Dairy	All fermented dairy foods from cow, goat, sheep. This includes yoghurt, kefir, fermented cheeses, sour cream	Fresh dairy e.g. fresh milk, cottage cheese, quark, fresh curd, mozzarella, ricotta, cheese spread
Dairy alternatives	Fermented plant yoghurts and milks (live coconut products)	Plant milks are usually well tolerated, even if they are made from nuts/seeds. Fortified with calcium is wise to ensure calcium requirements are met.
Condiments and seasoning	Some vinegars. Depending on the amount – mayonnaise, pickles, soy sauce, miso, fish sauce, tamari, yeast extract	Apple cider vinegar is generally well tolerated in histamine intolerance, but most vinegar is not. Opt for ACV without the ‘mother’
Sugar, sweets, chocolate	Dark or milk chocolate, cocoa, cacao	White chocolate is better tolerated. Sugar cane, honey, maple syrup
Alcohol	Mostly high but especially wine, champagne, beer and cider	Spirits – gin and vodka
Teas, coffee drinks	Green and black teas, coffee, kombucha, kefirs & other fermented drinks. Tomato & tropical juice	Water, low histamine fruit drinks, herbal teas