CONDITIONS

What Is Menopause

Menopause, sometimes referred to as “the change of life” is the time in a woman’s life when she stops menstruation. Since menopause is a natural occurrence in the female body, all women experience menopause at some point in their lives, typically between the ages of 45 and 55 (median age 51). Menopause is considered to have arrived when a woman has not had a menstrual period for 12 consecutive months (without any other identifiable physiological or biological cause) and is brought on by a decrease in the ovarian production of estrogen and progesterone.

According to the American Congress of Obstetricians and Gynecologists (ACOG), while life expectancy has increased over the years, the age of menopause has not changed during the past few centuries. ACOG reports that no link has been found between the age of natural menopause and use of oral contraceptives, socio-economic or marital status, race, or age at menarche. Cigarette smoking (even former cigarette smoking) can cause a woman to reach menopause two years prior to women who never smoked.

Perimenopause, meaning “around menopause,” is the period of time that leads up to the last menstruation and menopause. Perimenopause typically starts when women are in their 40s but may happen as early as the 30s. During this time, women may experience menstrual irregularities, menstruation without ovulation (release of the egg), and symptoms similar to those of menopause (hot flashes, vaginal dryness, etc.)

A report about menopause released by ACOG in 2011, the most recent year for which data are available, stated that an estimated 6,000 US women reach menopause every day. Due to America’s aging population, the number of women who will be older than 55 is estimated to be 46 million by the year 2020.

ACOG also noted that with increasing life expectancy, many women will spend up to 40% of their lives in the postmenopausal stage. Half of all women who reach age 50 will live to be at least age 80.

What Causes Menopause

Menopause is a natural stage of the female body brought on by the ovaries’ decreased production of estrogen and progesterone. As estrogen and progesterone levels decrease, the woman no longer ovulates (her ovaries stop making and releasing eggs) and menstruation ceases.

Risk Factors For Menopause

Menopause is a natural phenomenon, but as your hormones fluctuate you can be at risk of developing other conditions. Therefore it is vital to work closely with your gynecologist so he or she can help you navigate safely through “the change.”

The following conditions may arise as complications of menopause:

  • Osteoporosis. The lack of estrogen that occurs during menopause can accelerate bone loss and loss of bone tissue. This bone loss can cause osteoporosis, a condition, which can lead to hip, wrist, and spine fractures. Approximately 80% of the 44 million Americans with osteoporosis or low bone mass are women. Approximately 50% of women older than 50 will suffer an osteoporosis-related bone fracture, and one-third of white women ages 65 and older will have a fracture of the spine in their lifetime.
  • Urinary Incontinence. It is not uncommon for menopausal women to experience urinary leakage during physical activities ranging from laughing to jogging. According to the North American Menopause Society, reduced levels of estrogen starting around menopause can cause thinning of the lining of the urethra, the short tube that passes urine from the bladder out of the body. The surrounding pelvic muscles also may weaken with aging, a process known as “pelvic relaxation.” As a result, women at midlife and beyond are at increased risk for urinary incontinence, or the involuntary leakage of urine. Urinary incontinence can be treated with techniques such as kegel exercises and bladder training, which aim to help strengthen the muscles responsible for the release of urine, or through medication, vaginal/urethral inserts, and surgical options.
  • Cardiovascular Disease. Since estrogen protects women against cardiovascular disease, once menopause begins and the estrogen level drops, women can be at a higher risk for disorders such as high blood pressure, high cholesterol, heart disease and stroke. According to the American Heart Association, an overall increase in heat attacks occurs about ten years after menopause.
  • Diabetes. During menopause women develop high testosterone levels along with the drop in estrogen and progesterone. This combination can affect blood sugar levels and lead to insulin resistance that causes diabetes and hypoglycemia. However, this claim has been contradicted by recent study by researchers at the University of Michigan that reported no difference was seen in diabetes risk for pre-menopausal and post-menopausal women.

Diagnosing Menopause

Menopause is often self-diagnosed as it is a natural occurrence of the female body and women who are approaching the menopausal age are expecting the change to occur and are familiar with the symptoms.

Gynecologists or general practitioners can also help to determine whether your symptoms are a result of menopause or another condition. Factors he or she may take into account include:

  • Age. Perimenopause typically begins in your mid-forties, and the median age of menopause is 51.
  • Change in monthly periods. Changes in menstrual flow and period frequency can be a sign of perimenopause or other conditions. A span of 12 or more months since your last period is typically an indicator of menopause.
  • Symptoms. Symptoms such as hot flashes, vaginal dryness, night sweats, mood swings, and memory lapses can be signs of menopause. Other symptoms, such as fever and abdominal cramping, could point at another cause (i.e. infection of your causes)
  • FSH (follicle-stimulating hormone) test. An FSH test is a test that determines if you are nearing menopause based on the level of follicle-stimulating hormone in the blood. This test is not effective if you are taking the birth control pill, which can cause changes in blood FSH levels. Since menopause symptoms are relatively standard and recognizable, FSH tests are not typically administered unless a doctor suspects your symptoms could possibly be caused by another condition and is attempting to definitely identify menopause as the cause.

Symptoms of Menopause

Some women may experience only a few symptoms of menopause while others experience many.

Symptoms of menopause may include:

  • Night Sweats and Hot Flashes (Vasomotor Symptoms). For those lucky enough not to know what it is, a hot flash is a feeling of warmth that spreads across your body. Of the approximately 40 % of women in their forties who experience hot flashes, 80 % will no longer have them at five years. Hot flashes typically last between 30 seconds and five minutes. According to the American Congress of Obstetricians and Gynecologists, about two-thirds of North American postmenopausal women experience hot flashes, and an estimated 10-20% of those women experience severe hot flashes. Night sweats (drenching sweats) might accompany the hot flashes, which can lead to disrupted sleep. Approximately 75% of women experience hot flashes and night sweats at some point during perimenopause.
  • Irregular Vaginal Bleeding. Some women experience minimal abnormal bleeding while in perimenopause while others have excessive abnormal bleeding. Menstruation may occur more frequently or get farther apart, and such irregularities can occur for years before menstruation stops entirely. Because irregular vaginal bleeding can be a sign of many of conditions, it is essential to visit your doctor to confirm that the cause is menopause.
  • Vaginal Changes. As the estrogen levels in the body fall, the tissues lining the vagina become thinner and dryer. This can cause itching, irritation, and pain during sexual intercourse.
  • Psychological Symptoms. During perimenopause, many women find themselves experiencing memory problems, irritability, and rapid changes in mood. To be considered a sign of menopause, psychological symptoms must be in combination with other menopausal symptoms, as stress and other factors can cause almost identical symptoms.
  • Other Physical Changes. The distribution of fat may change with menopause, which can cause weight gain. The texture of your skin may change, leading to wrinkles or adult acne. Given that your body is continuing to produce small levels of the male hormone testosterone, some women experience hair growth on the chin, chest or upper lip.

Prognosis

Menopause is a natural, unavoidable process. Perimenopause, the time leading up to menopause, may last anywhere from a few months to 10 years, with 4 years being the average duration. Women typically experience menopausal symptoms for 4 or 5 years, though many symptoms may stop sooner or last into the postmenopausal phase. Symptoms such as hot flashes and mood changes are most severe from ages 53 to 65.

Because the symptoms can last for several years, it is best to do everything you can to make the time as comfortable as possible. This can be done through medications, alternative treatments, and lifestyle changes.

Living With Menopause

Though menopause symptoms may be disruptive and last several years, there are lifestyle changes you can make that add immeasurably to your quality of life during “the change”:

  • Exercise regularly. Aim for 20 to 30 minutes 5 days a week, and vary the routines – walking, swimming, etc., so you don’t get bored. Exercise can help regulate moods, rebuild lost muscle and bone tissue, strengthen the muscles responsible for urinary incontinence, and prevent weight gain. Researchers at Pennsylvania State University found that menopausal women who exercise may experience fewer hot flashes in the 24 hours following physical activity.
  • Don’t smoke. Smoking has been found to cause early onset menopause symptoms as well as increase the severity of symptoms. A recent study has found that a genetic variant found mainly in white women places smokers at an even higher risk of early onset menopause – as early as nine years in the heaviest of smokers.
  • Maintain a Healthy Weight. A study done at Kaiser Permanente and published in Menopause found that losing just 10 pounds helped relieve menopausal symptoms, in particular hot flashes.
  • Consider the Advantages. You no longer have to deal with your periods and you don’t have to worry about an unplanned pregnancy. However, be sure to continue using contraception until at least 12 months have passed without a period and always have a new partner use a condom in order to protect you from STDs, including HIV/AIDS.
  • Consider hormone replacement therapy or alternative treatments

Screening

Since menopause is not an illness but a natural, unavoidable, event, there is no screening done for menopause.

Medication And Treatment

Approximately 55% of women going through menopause don’t do anything at all to treat symptoms. In a woman’s reproductive years, the ovaries produce estrogen and progesterone during the ovulatory cycle to prepare the uterus for a possible pregnancy. During menopause, the ovarian production of both of these hormones essentially ceases. Estrogen helps maintain good bone density, regulates body temperature, and helps maintain vaginal lubrication and elasticity. When estrogen and progesterone levels drop, many women experience symptoms that can be bothersome, like hot flashes, night sweats, palpitations, sexual problems, forgetfulness, and more. Many women benefit from increasing their hormone levels with a form of treatment called hormone replacement therapy (HRT) that helps reduce and manage menopausal symptoms.

Hormone replacement therapy can use either estrogen, progestin (a form of progesterone designed to protect against endometrial cancer), or a combination of the two, and can come in a variety of delivery modes. ACOG and the U.S. Preventative Services Task Force both advise against long-term hormone therapy to prevent diseases. Hormone treatment may help prevent osteoporosis, but long-term hormone treatment increases your risk of blood clots, heart attacks, stroke, and other problems. One study published in the April 4th 2007 issue of JAMA found that women who begin hormone therapy early, within 10 years of menopause, seem to have less of a risk of heart disease than women who wait until they are older to start taking the medication. A second study published in JAMA in 2008, researchers found that the risks of hormone therapy outweigh the benefits. If you do elect to take hormone therapy, ACOG recommends using the lowest dose that works for only as long as you need it.


Estrogen-only medications are prescribed to raise estrogen levels in post-menopausal women without uteruses and women who have undergone a bilateral oophorectomy (both ovaries removed). Women with uteruses should not take estrogen-only medications due to the risk of estrogen overgrowth, which could lead to the development of certain cancers including endometrial cancer. Estrogen-only medication can treat many symptoms of menopause, but it has been proven to be most effective in reducing hot flashes and night sweats. Local estrogen vaginal creams are most effective in treating vaginal dryness and discomfort. Patients taking estrogen observe a 65-90% decrease in the severity of hot flashes due to treatment. One recent study suggests that early, short-term estrogen treatment without progestin can protect you from heart disease later in life—but this is still new, and needs more research. Women with uteruses are recommended to take an estrogen-progesterone combination medication, which puts them at a lower risk for endometrial cancer.

According to the FDA, common side effects of estrogen-only therapy include:

  • Headaches
  • Painful or tender breasts
  • Vaginal spotting
  • Stomach cramps/ Bloating
  • Nausea and vomiting
  • Hair loss
  • Fluid retention
  • Vaginal yeast infection

Rarer, more serious side effects include:

  • Stroke or blood clots
  • Endometrial Cancer in women who still have their uterus and who do not use progestin with estrogen-only medicines
  • Dementia in women 65 years and older
  • Gallbladder disease or high triglyceride (cholesterol) levels that could lead to problems with your pancreas
  • Vision loss caused by a blood clot in the eye
  • Liver Problems
  • High Blood Pressure
  • Severe allergic reactions

Progestin-only medications. Progestogen-only medications initially underwent clinical studies for menopause treatment as a possibly lower risk alternative to estrogen-only medications. However, studies have not found progestogen-only treatment to be effective for treating menopause symptoms. Progestogen-only treatments can be combined with estrogen-only treatments to lower the risk of endometrial cancer.

Common side effects for progestin-only medications include:

  • Sleepiness
  • Drowsiness
  • Cough
  • Acne
  • Breast tenderness
  • Joint pain

Estrogen-Progestin medications combine both estrogen and progesterone in a single dose. These lower the risk of endometrial cancer but may increase the risk of breast cancer.

According to the FDA, the most common side effects of estrogen-progestin medicines include:

  • Headaches
  • Painful or tender breasts
  • Vaginal spotting
  • Stomach cramps/ Bloating
  • Nausea and vomiting
  • Hair loss
  • Fluid retention
  • Vaginal yeast infection

Rarer, more serious side effects include:

  • Heart attack or stroke
  • Blood clots
  • Breast cancer
  • Dementia in women 65 years and older
  • Gallbladder disease or high triglyceride (cholesterol) levels that could lead to problems with your pancreas
  • Vision loss caused by a blood clot in the eye
  • Liver problems
  • High blood pressure
  • Severe allergic reactions

Talk to your doctor about which type of hormone replacement therapy is right for you.

Do not take HRT if you:

  • Have vaginal bleeding
  • Have had breast or uterine cancer
  • Have a bleeding disorder
  • Have liver disease
  • Have had a blood clot, heart attack or stroke
  • Have allergic reactions to hormone medications

Complementary and Alternative Treatment

There are ways to treat the symptoms of menopause without hormone replacement therapy. These include:

Herbal Medicines. Research has shown that several herbal medicines may be useful in treating many menopausal symptoms. Before taking natural or herbal products, discuss with your doctor, who will be able to notify you of any health risks and potential interactions with medications. Because natural products used for menopausal symptoms can have side effects and can interact with other botanicals or supplements or with medications, research in this area is addressing safety as well as efficacy. Some findings from this research are highlighted below.

  • Black cohosh (Actaea racemosa, Cimicifuga racemosa). This herb has received more scientific attention for its possible effects on menopausal symptoms than have other botanicals. Studies of its effectiveness in reducing hot flashes and other symptoms have had mixed results.
    • A study funded by NCCAM and the National Institute on Aging (NIA) found that black cohosh, whether used alone or with other botanicals, did not relieve hot flashes and night sweats in postmenopausal women or those approaching menopause. In the same study, black cohosh also had no effect on gynecological problems such as vaginal dryness and abnormal bleeding.
    • Other research suggests that black cohosh does not act like estrogen, as once was thought.
    • A 2012 systematic review of 16 randomized clinical trials that included more than 2,000 women was unable to draw any conclusions about the effectiveness of black cohosh on menopausal symptoms. This was primarily due to the wide differences in how the studies were performed.
    • United States Pharmacopeia experts suggest that women should discontinue use of black cohosh and consult a health care practitioner if they have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice. There have been several case reports of hepatitis (inflammation of the liver), as well as liver failure, in women who were taking black cohosh. It is not known if black cohosh was responsible for these problems. Although these cases are very rare and the evidence is not definitive, scientists are concerned about the possible effects of black cohosh on the liver.
  • Dong quai (Angelica sinensis). Only one randomized clinical study of dong quai has been done. The researchers did not find it to be useful in reducing hot flashes. Dong quai is known to interact with, and increase the activity in the body of, the blood-thinning medicine warfarin. This can lead to bleeding complications in women who take dong quai.
  • Ginseng (Panax ginseng or Panax quinquefolius). The 2005 NIH panel concluded that ginseng may help with some menopausal symptoms, such as mood symptoms and sleep disturbances, and with one’s overall sense of well-being. However, ginseng has not been found helpful for hot flashes.
  • Kava (Piper methysticum). According to the 2005 NIH panel, there is no evidence that kava decreases hot flashes, although it may decrease anxiety. Furthermore, it is important to note that kava has been associated with liver disease. The U.S. Food and Drug Administration (FDA) has issued a warning to patients and providers about kava because of its potential to damage the liver.
  • Red clover (Trifolium pratense). The 2005 NIH panel found no consistent or conclusive evidence that red clover leaf extract reduces hot flashes. A large clinical trial and several reviews of the research literature concluded that red clover had no significant beneficial effects on menopausal symptoms. A review of the research literature also found no apparent evidence of adverse events from short-term use (up to 16 weeks). However, the same review noted the lack of data on the safety of long-term use. There are some concerns that red clover, which contains phytoestrogens, might have harmful effects on hormone-sensitive tissue (for example, in the breast and uterus).
  • Soy. The scientific literature includes mixed results on soy extracts for hot flashes. Some studies find benefits, but others do not. Although information on adverse effects is limited, soy extracts appear to be generally safe when taken for short periods of time. However, long-term use of soy extracts (which also contain phytoestrogens) has been associated with thickening of the lining of the uterus. Phytoestrogens occur naturally in plants and act like estrogens in some tissues, including bone and cardiovascular tissue. Plants rich in phytoestrogens have been studied for treating menopause symptoms. However, much remains to be learned about these plant products, including their effects in the human body. Doctors caution that certain women need to be particularly careful about using phytoestrogens, especially:
    • Women who have had or are at increased risk for diseases or conditions that are affected by hormones, such as breast, uterine, or ovarian cancer
    • Women who are taking medications that increase estrogen levels in the body, such as birth control pills; menopausal hormone therapy; or a type of cancer drug called selective estrogen receptor modulators (SERMs), such as tamoxifen.

Dietary supplements. Certain dietary supplements can help to restore deficiencies that may occur as a result of decreased estrogen and progesterone production. These include:

  • DHEA. DHEA is a naturally occurring substance that is changed in the body to the hormones estrogen and testosterone. DHEA is manufactured and sold as a dietary supplement. A few small studies have suggested that DHEA might possibly have some benefit for hot flashes and decreased sexual arousal, although small randomized controlled trials have shown no benefit. Because levels of natural DHEA in the body decline with age, some people believe that taking a DHEA supplement can help treat or prevent conditions related to aging; however, there is no scientific evidence to support this notion. Concerns have been raised about whether DHEA is safe and effective. Its long-term effects, risks, and benefits have not been well studied, and it remains unclear whether it might increase the risk for breast or prostate cancer. There is the possibility that even short-term use of DHEA supplements might have detrimental effects on the body. Before using DHEA for any purpose, people should talk to their health care provider about potential benefits and risks.
  • Calcium.Calcium helps protect against osteoporosis and bone loss. Women 51 and older need 1,200 mg of calcium per day. Calcium can be found in milk, fortified cereals and soy milks, dairy products, green leafy vegetables, and tofu.
  • Vitamin D. Vitamin D helps your body absorb calcium, so it is just as important as calcium when it comes to bone health. Sunlight is the best source of vitamin D. While it protects you from harmful rays that can cause skin cancer, sunblock can also block out the rays needed for vitamin D production. Only a couple of minutes of exposed sun exposure are needed to absorb the right amount of sunlight for normal vitamin D levels. Make sure that for time longer than that you protect yourself with sunblock. Vitamin D can also be found in food (fortified milks, cheese, tuna) and can be taken in pill form.

Bioidentical Hormone Replacement Therapy or BHRT, is a marketing term that is not recognized by the FDA. It is a term used to describe medications that are prepared in specialized pharmacies. BHRT may contain any variation of hormones including estrone, estradiol, estriol, progesterone, and testosterone. Compounded bioidentical hormones are often marketed as natural and safe alternatives to conventional hormone therapy prescription medications. However, compounded formulas are often inconsistent and can vary depending on the batch or the pharmacist. While FDA-approved hormone preparations have been tested for efficacy, purity, safety, and potency, there is a lack of scientific evidence surrounding BHRT and the safety and efficacy of these compounds. As a result, compounded bioidentical hormones are not approved by the FDA. For additional information, see the FDA publication Bio-Identicals: Sorting Myths from Facts

Acupuncture. Studies have shown that acupuncture, which aims to restore the bodily flow of energy through the insertion of needles into acupuncture points around the body, can help to reduce the severity of hot flashes and night sweats. Research on the efficacy of acupuncture as a menopause treatment is limited, and patients should talk to their general practitioners before beginning treatment.

Care Guide

Apart from hormone therapy and alternative treatments, there are many lifestyle changes you can make to help alleviate your menopause symptoms:

  • Eat a healthy, balanced diet. Vitamins and minerals like calcium and vitamin D are essential in maintaining bone health and overall health for aging women to protect against menopause-related conditions like osteoporosis. Eat a balanced diet that includes plenty of fruits and vegetables, and take supplements to make up for any nutritional deficits if needed.
  • Try a meditation practice. A 2010 review of 21 papers assessed mind and body therapies for menopausal symptoms. The researchers found that yoga, tai chi, qi gong, and meditation-based programs may be helpful in reducing common menopausal symptoms including the frequency and intensity of hot flashes, sleep and mood disturbances, stress, and muscle and joint pain.
  • Exercise can help regulate moods, rebuild lost muscle and bone tissue, strengthen the muscles responsible for urinary incontinence, and prevent weight gain. Researchers at Pennsylvania State University found that menopausal women who exercise may experience fewer hot flashes in the 24 hours following physical activity.
  • Have a support system to help you cope with your toughest menopause symptoms. Find family, friends, and medical professionals that you feel comfortable sharing your experience with.
  • Educate yourself on menopause so you can be prepared for the symptoms when they come and know best how to deal with them.
  • Don’t smoke. Smoking has been found to cause early onset menopause symptoms as well as increase the severity of symptoms. A recent study has found that a genetic variant found mainly in white women places smokers at an even higher risk of early onset menopause – as early as nine years in the heaviest of smokers
  • Know that you’re not alone. Being a witness to your body’s changes through menopause can be tough, but know that it is something that all women will experience at some point in their lives. Approximately 6000 women reach menopause each day, and an estimated 46 million women will be post-menopausal by the year 2020.

Questions For Your Doctor

The North American Menopause Society, a leading source of information about menopause for 25 years, has developed a competency examination to set essential standards for health providers in order to assure high-quality care for women at menopause and beyond. All licensed healthcare providers are eligible to sit for this examination. Those who pass have demonstrated their expertise in the field and are awarded the credential of NCMP or NAMS Certified Menopause Practitioner. To find an NCMP in your area, click here. When you arrive at the site, type in your zip code and click “Search Now”.

Questions For A Doctor

Here are some questions to ask:

  • Should I have an examination to rule out other causes for my symptoms?
  • What can I expect as I go through menopause?
  • Where can I get more information about menopause?
  • What is my risk of developing diseases related to the loss of estrogen such as heart disease, osteoporosis, and hypertension? What can I do to decrease my risk?
  • Can you explain the potential benefits and risks of hormone therapy?

Resources

September is Menopause Awareness Month (MAM). According to the website, MAM’s goal is to educate people about menopause and “shine light on innovations in menopausal science and technology”.

For more information about menopause, visit:

The North American Menopause Society, a leading source of information and support for 25 years.

Red Hot Mamas, the nation’s largest menopause education program providing mid-life women’s health information and support, was founded in 1991. Red Hot Mamas programs have been offered in over 200 hospitals and physician practices in the US and Canada.

The National Institute on Aging, the National Institutes of Health, has reliable information on all aspects of menopause

The American Congress of Obstetricians and Gynecologists has a section devoted to information about menopause.

The Menopause Makeover has suggestions for meals, a 8-step plan for well-being during menopause, and a list of health calculators.

Menopause Mondays is a weekly e-newsletter with breaking news and advice.

For more information about post-menopausal hormone therapy, visit this page on the National Institutes for Health site.

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