The Mediterranean Diet and Gut–Brain Axis Health in Menopausal Women: A Narrative Review

Menopause represents a critical biological transition characterized by dramatic hormonal reorganization, chronic low-grade inflammation, and substantial modifications to immune function and metabolic regulation. This comprehensive narrative review synthesizes emerging evidence examining the intersection of Mediterranean dietary patterns and gut microbiota function, and brain health in postmenopausal women. The gut-brain axis—a bidirectional communication system linking gastrointestinal function with central nervous system activity—undergoes significant remodeling during menopause, creating both vulnerability to neuropsychiatric complications and hence, the opportunity for dietary intervention. The Mediterranean diet, characterized by abundant polyphenolic compounds, dietary fiber, omega-3 fatty acids, and phytoestrogens, appears to exert protective effects through multiple interconnected mechanisms including anti-inflammatory actions, enhancement of beneficial microbiota taxa, production of neuroprotective microbial metabolites, support for intestinal and blood-brain barrier integrity, and restoration of estrogen metabolism through estrobolome function. Current evidence indicates that Mediterranean diet adherence is associated with reductions in vasomotor symptoms (40-55%), improvements in sleep quality (43% reduction in disturbances), mood stabilization (39% reduction in mood swings), metabolic benefits (6-8% BMI reduction, 8% fasting glucose improvement), bone health enhancements (18-20% increases in calcium and vitamin D), and cardiometabolic improvements. However, the certainty of evidence remains low-to-moderate due to cross-sectional predominance, reliance on self-reported outcomes, and variable control of confounding variables. This review identifies critical research priorities including well-designed randomized controlled trials with standardized symptom scales, comprehensive microbiota characterization including metabolite profiling, neuroimaging endpoints, and stratification by menopausal stage and baseline adiposity. Until such evidence becomes available, clinicians can confidently recommend Mediterranean dietary patterns as a low-risk, evidence-congruent first-line strategy for menopause management that supports multiple aspects of health while maintaining theoretical potential to enhance gut-brain axis function and promote psychiatric well-being during this critical life transition.