You may think of menopause as the time when your menstrual periods stop permanently. But doctors define menopause as the time after 12 months have passed since your last period. Although your mother or grandmother may have called menopause the change, it isn't a single event. Instead, it's a series of changes that can start in your 30s and 40s and last into your 50s or even 60s.
Menopause was once considered an estrogen deficiency disorder. But menopause is a natural biological process, not a medical problem. Although it's associated with hormonal, physical and psychosocial changes in your life, menopause isn’t the end of your youth or your sexuality. Several generations ago, few women lived beyond menopause. Today, you may spend as much as one-third to one-half your life after menopause.
Fortunately, much more is known about menopause than when your mother or grandmother experienced it. You can also now do more to relieve bothersome symptoms, avoid complications and improve your health and vigor during this important phase of your life.
Every woman experiences menopause differently. Even the age at which menopause begins may be unique to you. Some women reach menopause in their 30s or 40s, and some in their 60s, but menopause most often occurs between the ages of 50 and 51.
Your symptoms are also likely to be very individual. You may breeze through menopause with few symptoms. Or you may experience a number of physical and emotional changes, including:
- Irregular menstruation. Your cycle may stop suddenly, or gradually get lighter or heavier
and then stop. The unpredictability of your period may be your first clue that menopause is
approaching.
- Decreased fertility. When ovulation begins to fluctuate, you're less likely to become
pregnant. Until you haven’t had a period for a year, however, pregnancy is still possible.
- Vaginal changes. As your estrogen level declines, the tissues lining your vagina and
urethra — the opening to your bladder — become drier, thinner and less elastic. With decreased
lubrication you may experience burning or itching, along with increased infections of the urinary
tract or vagina. These changes may make sexual intercourse uncomfortable or even painful.
- Hot flashes. As your estrogen level drops, your blood vessels may expand rapidly, causing
your skin temperature to rise. This can lead to a feeling of warmth that moves upward from your chest
to your shoulders, neck and head. You may sweat, and as the sweat evaporates from your skin, you may
feel chilled, weak and slightly faint. Your face might look flushed, and red blotches may appear on
your chest, neck and arms. Hot flashes can last from 30 seconds to as long as 30 minutes, but most
subside in 2 to 3 minutes. The frequency of hot flashes varies. You may have one an hour, or have them
only occasionally. They can occur any time during the day or night. They may also be a part of your
life for a year or more, or you may never have them.
- Sleep disturbances and night sweats. Night sweats are often a consequence of hot flashes.
You may awaken from a sound sleep with soaking night sweats followed by chills. You may have
difficulty falling back to sleep or achieving a deep, restful sleep. About one in four midlife women
experience insomnia. Lack of sleep may affect your mood and overall health.
- Changes in appearance. After menopause, the fat that once was concentrated in your hips and
thighs may settle above your waist and in your abdomen. You may notice a loss of fullness in your
breasts, thinning hair and wrinkles in your skin. If you previously experienced adult acne, it may
become worse. Although your estrogen levels drop, your body continues to produce small amounts of the
male hormone testosterone. As a result, you may develop coarse hair on your chin, upper lip, chest and
abdomen.
- Emotional changes. As you go through menopause, you may experience mood swings, be more
irritable or be more prone to emotional upset. In the past these symptoms were attributed to hormonal
fluctuations. Yet other factors may contribute to these changes in mood, including stress, insomnia
and life events that can occur in this stage of adulthood — such as the illness or death of a parent,
grown children leaving home or retirement.
Menopause begins naturally when your ovaries start making less estrogen and progesterone. During your reproductive years, these hormones regulate your monthly cycles of ovulation and menstruation. In your late 30s the amount of progesterone your body produces diminishes, and the remaining eggs from your ovaries are less likely to be fertilized. Eventually your menstrual periods will stop, and you can no longer become pregnant. Because this process takes place over years, menopause is commonly divided into the following two stages:
- Perimenopause. This is the time you begin experiencing menopausal symptoms even though
you're still ovulating. Your hormone levels rise and fall unevenly, and you may have hot flashes and
variations in your periods. For instance, your flow may be irregular, or heavier or lighter than
usual. This is a normal process leading up to menopause and may last 4 to 5 years or more.
- Postmenopause. Once 12 months have passed since your last period, you are considered
postmenopausal. Your ovaries no longer produce estrogen or progesterone, and they don't release eggs.
Menopause is usually a natural process. But certain surgical or medical treatments can bring on menopause earlier than expected. These include:
- Hysterectomy. A hysterectomy that removes your uterus but not your ovaries usually doesn't
cause menopause. Although you no longer have periods, your ovaries still release eggs. But an
operation that removes both your uterus and ovaries (total hysterectomy and bilateral oophorectomy)
does cause menopause. There is no perimenopausal phase. Instead, your periods stop immediately, and
you're likely to have hot flashes and other menopausal symptoms.
- Chemotherapy and radiation therapy. These cancer therapies can induce menopause. But they
usually do so gradually, and you may have months or years of perimenopausal symptoms before you
actually reach menopause.
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When to seek medical advice
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It's important to see your doctor during both perimenopause and postmenopause for preventive health care as well as care of medical conditions that may occur with aging. Although some problems attributed to aging are unavoidable, others can be helped with lifestyle changes and medical treatments.
Before, during or after menopause, you may also want to see your doctor to discuss the pros and cons of hormone replacement therapy (HRT), which has been shown to relieve many of the symptoms of menopause and protect against osteoporosis. If you decide on HRT, your doctor can work with you to customize the type and amount of hormones you take and the length of time you take them. Your doctor can also discuss other approaches you may want to use to help relieve your symptoms.
If you've skipped a period, but aren't sure you've started menopause, you may want to see your doctor to confirm you're not pregnant. He or she may take a medical history, do a pelvic examination and, if appropriate, recommend a pregnancy test.
It's also important to seek medical advice if you have bleeding from your vagina after menopause. Sometimes hormone replacement therapy can cause bleeding, but you should discuss any postmenopausal bleeding with your doctor.
Usually no laboratory test is needed to confirm menopause. The signs and symptoms are enough to tell most women they have begun going through the process. If you have concerns about irregular periods or hot flashes, talk with your doctor. In some cases it may be important to rule out other problems.
Your doctor can check your level of follicle-stimulating hormone (FSH) and estrogen (estradiol) with a blood test. FSH levels increase and estradiol levels decrease as menopause occurs. If your FSH level is above 30 and your estradiol less than 20, you've probably gone through menopause. If these levels are checked while you're still on the pill, these tests need to be done at the end of your hormone-free week.
Several chronic medical conditions tend to appear after menopause. By becoming aware of the following conditions, you can take steps to help reduce your risk:
- Cardiovascular disease. At the same time your estrogen levels decline, your risk of
cardiovascular disease increases. Coronary heart disease is the leading cause of death in women as
well as in men. In fact, women are 10 times more likely to die of heart disease than of breast cancer.
Yet you can do a great deal to reduce your risk of heart disease. This includes stopping smoking,
reducing high blood pressure, getting regular aerobic exercise and eating a heart-healthy diet.
- Osteoporosis. During the first few years after menopause, you lose calcium from your bones
at a much faster rate, which increases your risk of osteoporosis. Osteoporosis causes bones to become
brittle and weak, leading to an increased risk of fractures. Postmenopausal women are especially
susceptible to fractures of the hip, wrist and spine. That's why it's particularly important during
this time to get adequate calcium — 1,200 to 1,500 milligrams (mg) daily — and vitamin D — 400 to 800
international units (IU) daily. It's also important to engage in regular, weight-bearing exercise to
keep your bones strong.
- Stress urinary incontinence. As the tissues of your vagina and urethra lose their
elasticity, you may experience stress urinary continence — a condition that may cause you to leak
urine during coughing, laughing or lifting — for the first time, or it may worsen.
- Weight gain. As your body’s metabolism — the rate at which you burn calories — slows and
estrogen levels decline, your body weight and shape will likely change. You may need to eat less —
perhaps as much as 200 to 400 fewer calories a day — and exercise more, just to maintain your current
weight.
Menopause itself requires no medical treatment. Instead, treatments focus on relieving your symptoms and on preventing or lessening chronic conditions that may occur during the postmenopausal years. Treatments include:
- Hormone replacement therapy (HRT). This therapy, which provides a low dose of estrogen,
often in combination with progestin, has been shown to be effective in treating many of the symptoms
of menopause, such as hot flashes, vaginal dryness and discomfort with intercourse. HRT may be taken
in a variety of forms — including pill, patch, cream or vaginal ring — and customized to fit each
woman's needs. Women who have had a hysterectomy take HRT as estrogen alone, also referred to as
estrogen replacement therapy, or ERT. Most other women who take HRT are advised to use a combination
of estrogen and progestin because progestin helps protect against uterine cancer. HRT taken as
estrogen alone or as a combination therapy protects against bone loss and osteoporosis. Oral ERT
raises levels of high-density lipoprotein (HDL) cholesterol — the "good" cholesterol — and lowers
levels of low-density lipoprotein (LDL) — the "bad" cholesterol. Researchers are also investigating
the benefits of HRT in offering protection from Alzheimer's disease, macular degeneration and
colorectal cancer.
But not all effects of HRT are positive. HRT increases your risk of blood clots and gallbladder and
heart diseases. And taking HRT as a combination therapy — estrogen with medroxyprogesterone acetate
(such as Prempro) — for several years or more may increase your risk of breast cancer. All combination
HRT regimens can cause irregular vaginal bleeding, particularly during the first year of use. Further
study is needed to determine to what extent estrogen-only therapy increases your risk of breast
cancer. The long-term benefits of HRT are therefore under intense scrutiny.
- Bisphosphonates. These nonhormonal medications, which include alendronate (Fosamax) and
risedronate (Actonel), are used for the prevention or treatment of osteoporosis. Although they don't
provide the same protection for your bones as estrogen, they effectively reduce both bone loss and
your risk of fractures. Aldendronate may cause gastrointestinal problems and irritation of your
esophagus.
- Selective estrogen receptor modulators (SERMs). SERMs are among a group of drugs that
includes raloxifene (Evista). They have some of the beneficial effects of estrogen, especially
improved bone strength, but no increased risk of breast cancer or uterine bleeding. But these
medications tend to cause, rather than relieve, hot flashes, and increase your risk of blood clots and
gallstones.
Before deciding on any form of treatment, be sure to talk with your doctor about your options and the risks and benefits involved in each.
Fortunately, many of the symptoms associated with menopause are temporary. But you can take steps now to help reduce or prevent their effects:
- If you’re experiencing hot flashes, get regular exercise, dress in layers and try to pinpoint what
triggers your hot flashes. For many women, triggers may include hot beverages, spicy foods, alcohol,
hot weather or a warm room.
- For vaginal dryness or discomfort with intercourse, use over-the-counter water-based vaginal
lubricants (Astroglide, K-Y jelly) or moisturizers (Replens, Vagisil). Staying sexually active also
helps these problems.
- If you have trouble sleeping, avoid caffeinated beverages and exercise right before bedtime.
Practicing relaxation techniques such as deep breathing, guided imagery and progressive muscle
relaxation can be very helpful. You can find a number of books and tapes on different relaxation
exercises.
- If you experience night sweats, wear cool cotton clothing to bed and keep an extra set handy.
- Exercise your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve
some forms of urinary incontinence.
- Eat a balanced diet that includes a variety of fruits, vegetables and grains and that limits fats,
oils and sugars. In particular, make sure your intake of calcium is at least 1,200 to 1,500 mg. If
you’re not taking estrogen, ask your physician about additional calcium supplements.
- Don’t smoke. Smoking increases your risk of heart disease, stroke, cancer and a range of other
health problems. It may also increase hot flashes and bring on earlier menopause.
- Exercise regularly. Thirty minutes most days is a good goal to protect against cardiovascular
disease, diabetes and osteoporosis. It also can help reduce stress. Try a combination of
weight-bearing aerobic activities, such as walking, jogging and dancing, and strength-training
exercises. Just staying physically active each day by taking stairs instead of an elevator or by
parking farther away and walking to your destination also can make a difference.
- Schedule regular checkups. Talk with your doctor about how often you should have mammograms, Pap
tests and other screening tests.
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Complementary and alternative medicine
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Many new approaches are available to treat the symptoms of menopause. Below are several complementary and alternative treatments that have been or are being studied:
- Phytoestrogens. These estrogens occur naturally in certain foods. There are two types of
phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, chickpeas and other
legumes. Lignans are found in flaxseeds, whole grains and some fruits and vegetables. Researchers
first became interested in phytoestrogens when they noted that women in Japan and China, who eat diets
high in phytoestrogens, have far fewer menopausal symptoms and a much lower incidence of heart disease
and osteoporosis than women in the West. Soy, whole grains, fruits and vegetables should be part of
any healthy diet. Whether the relatively weak estrogens in these foods can relieve menopausal symptoms
remains to be seen.
- Wild yams. Wild yams, which contain substances similar to progesterone, are often touted as
a treatment for menopausal symptoms. Although many women note benefits, how yams may work is uncertain
because the substances in them seem to have no biological effects in humans.
- Vitamin E and evening primrose oil. These substances have reportedly helped breast
tenderness, but studies haven’t been able to prove their effectiveness.
- Black cohosh. Black cohosh — originally a Native American remedy — has shown some promise
in relieving hot flashes, but is generally not recommended for use longer than 6 months.
Be sure to consult your doctor before taking any herbal treatments or dietary supplements for symptoms of menopause. Herbal products can interfere or interact with other medications you may be taking.
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July 15, 2002 —
