Menopause

Overview

Menopause is a normal change in a woman’s life. It occurs when she has her last period. Menopause, however, doesn’t simply happen when menstruation ends—symptoms may begin years before your last period and continue for months or years after.

The age at which menopause occurs varies, but the average age when a woman has her last period is 51. For some, however, menopause occurs in the forties or later in the fifties.

As you approach menopause, levels of estrogen and progesterone (female hormones produced in the ovaries) begin to change, or fall. These changing levels begin to cause the symptoms of menopause. This time of transition, which can start several years before your last period, is known as the menopausal transition or perimenopause. Perimenopause continues for a year after your last period. Once you haven’t had a period for one year, the next phase is called postmenopause, which lasts for the rest of your life.

Causes

Menopause and its symptoms are the result of changing levels of estrogen and progesterone. As mentioned earlier, menopause is a normal and natural part of life. There are, however, several outside factors that can lead to an early menopause. Smoking, for instance, can lead to an early menopause, as can surgeries to remove the uterus and/or ovaries. A hysterectomy, where the uterus is removed, will end menstruation, but won’t cause immediate symptoms of menopause; this is because the ovaries (which produce estrogen and progesterone) are not removed. If the ovaries are removed (an oophorectomy), which usually coincides with removal of the uterus, symptoms of menopause will also occur as menstruation ends.

Symptoms

Your body may go through many changes at midlife, and it’s not always clear which are caused by menopause and which are part of the aging process. Also, because estrogen is used by many parts of your body—not just your reproductive system—lower levels of estrogen can affect your health in several ways.

Changes commonly occurring at midlife that may be related to menopause include:

• Changes in your period. Normal changes in your menstrual cycle including less-regular periods, shorter or longer periods, and more or less bleeding than usual. There are also a few changes that could indicate a medical problem and should be addressed with your doctor; these include periods that come very close together, heavy bleeding, spotting, and periods lasting more than a week.
• Hot flashes. These sudden feelings of heat affect your upper body, causing your face and neck to become flushed. You may also see red blotches on your chest, arms, and back. Hot flashes can be followed by heavy sweating and cold shivering. When they occur at night, hot flashes are called night sweats and can interfere with sleep.
• Problems affecting your vagina or bladder. As your estrogen levels change, your genital area may become drier and thinner. Related problems include pain with intercourse, more vaginal and urinary infections, and trouble with bladder control. Bladder control problems include trouble holding urine long enough to reach the bathroom and urine leaking during exercise, sneezing, coughing, or laughing.
• Sleep. In addition to the potential interruption of sleep by night sweats, some women find it harder in general to get a good night’s sleep at midlife. Issues may include trouble falling asleep, waking during the night, and waking too early.
• Sex. Some women become less interested in sex around the time of menopause, while others feel freer to enjoy it. Practicing safe sex remains important following menopause—though you can’t become pregnant after one full year without a period, you may still be at risk for sexually transmitted diseases, particularly if you have more than one partner or if your partner is having sex with other people. If so, you should always use condoms.
• Changes in mood. For reasons that are not entirely understood, some women become more moody or irritable around the time of menopause. As well as biological changes, stress, feeling tired, a history of depression, or changes within the family (like growing children and aging parents) may contribute to mood changes.
• Changes to your body. Midlife can be associated with losing muscle and gaining fat or becoming thinner, as well as stiff, achy joints and a wider waistline. It’s not known whether these changes are due to reduced estrogen or the general aging process.
• Changes to your memory. Many people find that their memory changes with age. Normal memory problems are short-term and relatively minor (like not being able to immediately recall a familiar word or occasionally misplacing the car keys). If you have more significant signs of memory loss (like forgetting the way home or how to drive a car), you should see your healthcare provider.

Related Health Concerns
Though they’re not symptoms of menopause, there are certain health concerns that can accompany the change as estrogen levels decrease and other changes related to aging occur. Two common concerns for women at midlife include osteoporosis and heart disease.

Osteoporosis. At the time of menopause, women may be at risk of osteoporosis, a condition where bones become weak and break easily. The body continually breaks down old bone and replaces it with new, healthy bone. Because estrogen helps control bone loss, when you lose estrogen during menopause, you body isn’t able to replace as much bone as it loses. Your doctor can test your bone density to determine your risk for osteoporosis as well as discuss ways to prevent or treat it.

Factors that increase risk for osteoporosis include:

• A family history of osteoporosis
• A broken bone while an adult
• Surgery to remove both ovaries before menopause
• Early menopause
• Insufficient calcium throughout life
• Extended bed rest
• Smoking
• Long-term heavy drinking
• Use of certain medications for long periods (glucocorticoids and some anticonvulsants, for example)

Heart disease. A woman’s risk of heart disease increases after menopause. This is likely the result of changing estrogen levels and the aging process. Factors associated with increasing age—like weight-gain and high blood pressure—raise your risk of heart disease. See your doctor regularly to have your blood pressure and cholesterol levels checked and to discuss ways to keep your heart healthy.

Testing

There isn’t one clear method to determine when you’re in the menopausal transition or to predict when you may experience the change. You and your doctor may consider menopausal symptoms, a physical examination, medical history, and certain blood tests for clues about your status. Remember, however, that these are only clues—there’s no definitive test for menopause. Blood tests, for example, are unreliable because the hormones that your doctor may measure—such as estrogen and follicle-stimulating hormone—normally rise and fall during your menstrual cycle.

Treatments

Menopause is a natural change in life, so “treatment” during menopause actually involves treating not menopause itself but the symptoms of menopause and related health concerns. Staying healthy during and beyond menopause is also about more than just making it through this transition—considering that today’s average woman has more than one-third of her life ahead of her after menopause, this is a great time to take action to improve and protect your health.

Managing symptoms of menopause can begin with lifestyle changes designed to improve and maintain your general health; these include:

Don’t smoke or use any tobacco products. Avoid second-hand smoke. If you do smoke, you can benefit from quitting at any age.

Eat a healthy diet. Recommended food selections are low in fat, high in fiber, and include plenty of fruits and vegetables as well as whole-grain foods. You may need to cut back on calories as you age to control weight-gain, but be sure to eat plenty of nutrient-dense foods (foods loaded with protein and vitamins that are low in calories). Make sure you’re getting adequate amounts of vitamins and minerals from food sources or supplements. Calcium and vitamin D, for example, are important for bone health.

Maintain a healthy weight. Your doctor can help you determine a healthy weight, and a balanced diet and regular exercise can help you maintain it.

Stay active, including weight-bearing exercise. Protect your bone health with activities like walking, jogging, dancing, and lifting weights at least three days per week. Other types of physical activity (such as swimming, bicycling, and gardening) are also important, as they support overall health and help you maintain a healthy weight.

You can also directly address some of the symptoms of menopause and related health concerns by doing the following:

• If your doctor has prescribed medications, make sure you take them as prescribed. Health problems around the time of menopause that can be treated with medication include high blood pressure, high cholesterol, and osteoporosis.
• You can manage vaginal discomfort and dryness with a water-based lubricant or vaginal estrogen cream or tablet. Avoid petroleum jelly.
• See your healthcare provider for regular breast and pelvic exams and Pap tests and mammograms. Report immediately to your doctor any changes to your body or health status, like a lump in your breast.
• Get screened for colon and rectal cancer and skin cancer.
• Keep track of your blood cholesterol levels, blood pressure, and blood sugar. Maintaining normal levels of all three can help protect your cardiovascular health.
• Discuss urinary problems (such as infections and leakage) with your doctor. There may be ways to control these problems. Urinary incontinence is also treatable—bladder control training, medicines, implants, or surgery may help.

There are several things you can do to manage hot flashes. Consider the following:

• Determine what might be triggering hot flashes. Keep track of when hot flashes occur and in what circumstances. When possible, avoid situations that seem to trigger them.
• Try to go to a cool place when a hot flash starts.
• To manage night sweats, keep your bedroom cool. A fan may help.
• Dress in layers. This way, you can remove clothing when you get too warm.
• Use sheets and clothing made of fabrics that allow your skin to breath.
• Drink something cold—like water or juice—when a hot flash is starting.
• Some women find that medications, antidepressants in particular, help control hot flashes. Discuss these options with your doctor.

Menopausal Hormonal Therapy
There has been much debate surrounding the use of menopausal hormonal therapy (MHT) to relieve some of the symptoms of menopause and to prevent bone loss around the time of menopause.

Though some women find that taking estrogen (and progesterone, among those who still have a uterus) does provide relief of symptoms like hot flashes, night sweats, and vaginal dryness, there are also risks associated with MHT. Studies have suggested that major health concerns associated with use of MHT include an increased risk of breast cancer and ovarian cancer and cardiovascular risks. Risk varies by type of MHT used (estrogen-plus-progestin versus estrogen alone). Talk with your doctor to determine what type of MHT might be right for you and about its risks and benefits. To minimize these risks, the U.S. Food and Drug administration (FDA) advises that if you choose to try MHT, you do so for the shortest time needed and use the lowest effective dose. Know that your symptoms may return when you stop taking the hormones.

In addition to serious medical concerns associated with MHT, some women also experience additional side effects. These include breast tenderness, spotting or a return of monthly periods, cramping, and bloating. These side effects will sometimes go away on their own or may be alleviated by changing the dose or timing of MHT.

Birth Control Pills
Doctors sometimes recommend birth control pills during perimenopause. Birth control pills can help manage heavy, frequent, or unpredictable periods and can prevent pregnancy. As well, they may help relieve symptoms like hot flashes.

Alternative Approaches

Phytoestrogens. Some women look to non-medical methods to manage the symptoms of menopause. One approach is to increase dietary intake of phytoestrogens, which might work in the body like a weak form of estrogen. These estrogen-like substances are found in food sources including some cereals, vegetables, legumes (soy, for example), and herbs and can also be taken as an herbal supplement. The ability of phytoestrogens to relieve symptoms of menopause, however, has not been determined, and there may be risks associated with their use. It’s important that your talk to your doctor if you’re thinking about eating more foods rich in phytoestrogens or using a supplement.

Bioidentical or “natural hormones.” Estrogen and progesterone can be made from plants such as soy or yams; these so-called natural hormones are supposed to closely resemble hormones naturally produced by the body. A doctor determines the formula for each patient, and a pharmacist puts it together in a process call compounding. There is little data about the safety or efficacy of natural hormones, as they are not regulated or approved by the FDA.

Resources

American College of Obstetricians and Gynecologists

National Institutes of Health Menopausal Hormone Therapy Information

North American Menopause Society

National Institute on Aging Information Center

SOURCES

Women’s Reproductive Health: Menopause. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/reproductivehealth/WomensRH/Menopause.htm. Accessed June, 2010.

Age Page/Menopause. The National Institute on Aging Web site. http://www.nia.nih.gov/HealthInformation/Publications/menopause.htm. Accessed June, 2010.

Menopause. The National Institutes of Health Web site. http://health.nih.gov/topic/Menopause. Accessed June, 2010.