As my patients reach their forties and start noticing changes in their menstrual cycles, they often start thinking about menopause. Their older sisters, co-workers, and friends may be lamenting hot flashes and night sweats. They may hear stories about their mother’s transition to menopause.
Questions I often hear from patients as they near menopause include, “What will happen to my body?” “How will I change?” “Will it be hard or easy?” “How long will it last, and what do I need to do?” I have found that educating women about the process is most useful in helping them decide how they will approach this phase. Here I have answered some of the most common questions on the topic.
What is menopause?
Menopause is a time of transition that all women experience when monthly cycling ceases, marking the end of reproductive life. The ovaries have served their function of providing eggs and hormones that make reproduction possible. Menopause is technically defined as the absence of spontaneous cycles for 12 months.
To comprehend why this occurs, it’s necessary to understand what happens during the monthly cycle. The ovaries have thousands of immature eggs at birth. A woman’s reproductive life begins with puberty. During each monthly cycle, several eggs are recruited from both ovaries to go through the final development stages needed for fertilization. During this process cells around the developing eggs produce estrogen in the early part of the cycle and progesterone after ovulation. These hormones have vital roles in communicating with the brain and preparing other organs, such as the uterus, to sustain a pregnancy.
When no pregnancy occurs, hormone levels fall, the endometrium is sloughed (as a monthly period), and the pituitary gland sends messages to the ovaries to start again. Over several decades, beginning with the onset of menstruation, a woman’s eggs age and ovarian function declines. The ability to reproduce is lost, and menses end at menopause. This may occur naturally or as a result of surgery or illness. In most women menopause occurs around age 50 to 51. The age range is generally 45 to 55 years old.
What is perimenopause?
Perimenopause occurs over the months and years preceding and following menopause. With aging, the feedback loop between the ovaries and the brain is harder to maintain. Ovarian function declines, hormone levels swing more widely, periods change, and energy levels can fluctuate from euphoric to depressed. Agitation, hot flashes, night sweats, difficulty concentrating, and headaches are all possible symptoms. These changes can be mild or dramatic.
The good news is that this stage does not last forever. It does, however, often last beyond the last menstrual period because the ovaries gradually cease to produce estrogen over a year or two, occasionally longer, after menopause. This gradual tapering off of hormones is good; it allows the body to adapt, and the changes are less pronounced.
What are the most common symptoms of menopause?
Although the first years following cessation of menses are still considered perimenopause, they are more commonly referred to as postmenopause. There is now very little fluctuation in estrogen levels, and progesterone is no longer secreted by the ovaries in the absence of ovulation.
For some women this is the beginning of a new phase of relative calmness and is often much better tolerated than perimenopause. Some women find they feel better than they have for a long time. Other women will note mild symptoms—feeling warmer, for instance—but are not greatly affected. A healthy lifestyle, engagement with friends and family, and involvement in work and the community can help make this a very positive and rewarding time in life.
For other women, however, the classic symptoms—the ones everyone talks about—can be quite bothersome and disruptive, especially during the first two to three years after periods cease. The loss of estrogen is associated with numerous effects; the most well known are hot flashes and night sweats, also known as vasomotor symptoms. These are caused by changes in the temperature regulation system. They general fade with time but can persist indefinitely in a small percentage of women. Other noticeable changes are in sleep patterns, fatigue, weight gain, joint aches, concentration, vaginal dryness, change in libido, hair loss, loss of bone density, fine wrinkles, and involuntary loss of urine. Some changes are readily apparent; others take years to develop. These are the symptoms that frequently cause women to seek help.
Are there effective treatments for menopause?
For many women treatment is not necessary. Adjustments in lifestyle may be adequate. Consistent exercise and weight management promote energy and a sense of well-being. While not replacements for estrogen, vitamins and nutritional supplements can be helpful. Bisphosphonates have replaced estrogen as the primary treatment for excessive bone loss (osteoporosis). When mood changes are the only bothersome symptom, antidepressants can be effective. Sleep disorders sometimes require medication but are often manageable with mild, over-the-counter options.
What is the role of hormone therapy?
For some women the effects of estrogen loss are very disruptive, especially in the early years, and hormone replacement is necessary when quality of life is significantly affected. Hormone replacement therapy (HRT), primarily estrogen, initially became available to large numbers of women in the 1960s and was used to relieve hot flashes. Beneficial effects on long-term bone health were the primary reasons why women continued with HRT as a means to prevent osteoporosis. Since results from the Women’s Health Initiative that were published in 2002 raised concerns about long-term safety of hormone treatments in older women, HRT has evolved.
Today HRT is used primarily during perimenopause, when symptoms of estrogen loss tend to be the most acute. Many products are available, and most are produced from plant-derived substances, which are equally effective and safe. The major differences are in the delivery systems; there are pills, lozenges, skin patches, creams and gels, as well as vaginal tablets, rings, and creams. If a woman still has her uterus, progesterone is added to inhibit growth of the endometrial lining. Dosing is tailored to each woman to achieve relief of symptoms with the lowest possible dose. Hormone testing is generally not necessary before prescribing.
While most women tolerate hormone replacement without serious consequences, underlying medical conditions and family history may raise concerns about long-term use. Therefore extended use is reserved for women whose symptoms persist after the immediate postmenopausal years, with annual review between women and their healthcare providers about benefits and potential risks.
What should women know about their general health or any long-term health conditions related to menopause?
In terms of health, women have an advantage over men until menopause. Over the decade following menopause, aging of the cardiovascular system speeds up, and by her sixties a woman’s risk of cardiovascular disease is approximately the same as a man’s. Appropriate management of weight, blood pressure, diabetes, and cholesterol are ever more important. Maintenance of bone health can be achieved with adequate vitamin D and calcium intake. Colon cancer screening is equally as important for women and men and generally begins around age 50. Mild symptoms of urinary incontinence can increase over time, but treatments may be available and consultation with a gynecologist is encouraged.
The postmenopausal years last for decades, for possibly a third of a woman’s lifetime. Think of this as a new beginning. Focus on the positives: make time for fun and laughter, set new goals, and keep mentally and physically active. With attention to long-term health, women are able to live active, productive lives into their seventies, eighties, and even nineties.
Catherine E. Crim, MD, is a gynecologist physician and surgeon in the Portland, Oregon, area. A native of Connecticut, she received her bachelor’s degree in biology from the University of California at Santa Cruz and received her medical degree from the University of California at Davis. After completing her residency in obstetrics and gynecology, she migrated to Oregon to join her extended family. After practicing obstetrics for several years, she now focuses on gynecology, with a special interest in health education and menopause. She sees patients of all age groups, with many different concerns. Dr. Crim practices at Northwest Gynecology Center, a division of Women’s Healthcare Associates LLC, a private, independent group practice and the largest women’s healthcare organization in Oregon. Visit them on the web at whallc.com or join the women’s health conversation at facebook.com/WomensHealthcare AssociatesLLC.