Menopause

Menopause is defined as not having a period or spotting for 12 or more months. Menopause occurs when the ovaries stop producing estrogen and progesterone. The average age of natural menopause in the United States is 51, but it can occur anytime between the ages of 40 and 55. Surgery that removes the ovaries will cause immediate menopause. Today, women can expect to live 30 to 40 years after menopause. Menopause is now recognized as a normal part of aging that affects every woman in an individual way. Some women notice little difference in their bodies or moods; others find menopause very uncomfortable and disruptive. Each woman experiences the years leading up to menopause, called perimenopause, differently.

Causes

Beginning in your mid-30s, your ovaries start to change how much estrogen they produce. Estrogen is a hormone that is necessary for menstruation and pregnancy. As you get older, you produce less estrogen and progesterone, until menstruation stops and pregnancy can no longer occur. Perimenopause is the name given to years when estrogen production is declining before menstruation stops. During perimenopause, periods may become less regular and the amount of flow can vary. Changes in natural estrogen levels can affect many parts of the body, including your heart, bones, urinary tract, skin, and hair.

Symptoms

The hormonal changes that occur before and after menopause can cause various symptoms. Although not all women experience them, some of the symptoms of menopause are irregular periods, hot flashes, vaginal dryness, urinary problems, mood changes, and sleep disturbances.

• Irregular periods are often common during the years leading up to menopause. The time between periods may become shorter or longer. The flow may be lighter or heavier than you have experienced. Bleeding between periods or missed periods may also occur.

• Hot flashes describe a flushed feeling that usually begins around the chest and spreads to the neck, face, and arms. This sensation usually lasts 3 to 4 minutes and can occur as often as once an hour. Hot flashes are often followed by sweating and then chills. Hot flashes can occur at anytime and may wake you up at night. These are called night sweats. Three out of four women experience hot flashes. Only one out of three women have symptoms for 5 or more years.

• Vaginal dryness can be the result of reduced estrogen levels in the body. With much less estrogen in the body, the vaginal walls lose elasticity, become thin, and secrete less fluid. A drier, less elastic vagina can mean discomfort or pain during intercourse.

• Loss of bladder control can occur when reduced estrogen levels cause the muscle tone in your urinary tract to decrease. The tube that carries urine from the bladder does not have the necessary pressure and strength to prevent urine from leaking out of the body. This is called incontinence.

• Mood changes and sleep disturbances may occur during perimenopause and after menopause. Scientific studies suggest a relationship between lower hormone levels and depression, moodiness, irritability, fatigue, sleep problems, and psychological symptoms commonly felt during menopause. Researchers have come to believe that lack of adequate sleep as a result of nighttime hot flashes aggravates the moodiness and other psychological symptoms linked with menopause.

Health Problems That Occur at Menopause

When you reach menopause, your risk for heart disease and osteoporosis increases.

Heart disease is the number one cause of death in women. Women may be protected against heart disease until menopause because of the positive effects of natural estrogen on cholesterol and blood vessels. The risk of heart disease increases dramatically after menopause.

Bone is constantly being broken and down and replaced with new bone tissue. Estrogen probably helps prevent or slow the breakdown of bone tissue. When estrogen is lost in menopause, more bone is broken down than is replaced. Bones can become weak, a condition called osteoporosis. Weakened bones are more likely to fracture.

These are changes that may occur at menopause:

• Hot flashes, feeling of intense warmth with flushing in the face, neck and chest; often followed by sweating and chills

• Vaginal dryness; this can make sexual intercourse and vaginal exams uncomfortable and may increase susceptibility to vaginal infections

• Urinary problems such as stress and urge incontinence, burning on urination, and more susceptibility to urinary infections

• Depression

• Problems sleeping

• Mood swings that can be caused by lack of sleep, changing hormone levels, and psychological stress

• Decreased interest in sex and changed sexual response

• Problems concentrating or with memory

Treatment

Hormone therapy (HT) using estrogen combined with progestin, or estrogen alone for women who have had hysterectomies, has been used to reduce symptoms of menopause and to help prevent some of the health risks that increase after menopause. However, the recently complete Women’s Health Initiative Study (WHI) shed new light on the risks and benefits of HT. This study leads the U.S. Preventive Services Task Force (USPSTF) to conclude that long-term use of HT has both benefits and harms and to make the following recommendation (2002). Talk to your health care provider to determine if HT is right for you. 

HT can be used to help manage many of the symptoms of menopause. It can relieve hot flashes, vaginal dryness, and urinary tract symptoms that occur as a result of estrogen deficiency. It can also improve symptoms of irritability and anxiety in many women and may relieve mild depressive symptoms. It is unclear whether HT has a direct effect on mood or whether these effects are due solely to the alleviation of physical symptoms, especially hot flashes and sleep disturbances. HT decreases skin wrinkles in some women. HT should be used for menopausal symptoms with an individualized approach to after a woman and her health care provider evaluate the risks and benefits for her.

There are many different estrogen and progesterone preparations used for HT. Hormone therapy comes in the form of pills, patches, and creams. Your health care provider will work with you to decide what, if any, type of preparation is best for you considering your current symptoms, your health status and medical history.

HT can be administered locally using creams or vaginal rings containing estrogen to relieve symptoms of vaginal dryness, urinary leakage, vaginal or urinary infections, but it does not relieve hot flashes. Locally administered HT does not have the risks associated with HT pills or patches.

Side Effects of Hormone Therapy

About 10 percent of women receiving HT have minor side effects such as breast tenderness, nausea, headaches, fluid retention, or irregular vaginal bleeding. For most women, these side effects disappear quickly and do not interfere with continuing the hormone therapy.

Self-Care Steps for Menopause

• Achieve and maintain a healthy weight to reduce risks for heart disease and some cancers.

• Eat a healthy diet. Eating well contributes to overall good health. A diet that includes a variety of fruits, vegetables, and whole grains is especially important to help prevent heart disease, weight gain, and osteoporosis.

• To help decrease loss of bone density, aim for at least three servings of low-fat dairy products a day. If you do not drink milk, take a calcium supplement with at least 1,000 to 1,500 mg of calcium. Calcium in the form of calcium citrate (in products such as Citracal) is absorbed more completely than other forms of calcium found in supplements (typically calcium carbonate).

• Get adequate amounts of vitamin D. You need 400 to 800 International Units of vitamin D each day. Vitamin D is made in the skin when it is exposed to the sun's ultraviolet rays. The increased use of sunscreens to prevent skin cancers may mean reduce the amount of UV rays to produce vitamin D. People with darker skin are at risk of not producing sufficient vitamin D, because less UV light is able to penetrate the skin to the level where vitamin D is made. For people who may not get enough vitamin D from sunlight, the nutrient can also be found in combination with calcium or other supplements, in milk products that are fortified with vitamin D (skim milk may not have it), and oily fish such as salmon and sardines.

• Exercise regularly. Try to accumulate at least 30 to 60 minutes of moderate-intensity exercise every day. This can help reduce hot flashes and maintain a healthy weight. Exercise can also help prevent depression, osteoporosis, and heart disease. Walk whenever you can, make extra trips around your yard or house, take the stairs instead of the elevator.

• Dress in layers so that you can remove them if you experience a hot flash.

• Use a water-soluble vaginal lubricant during sexual intercourse. Try a product such as K-Y Jelly, Astroglide, Replens, or Surgilube to relieve vaginal dryness. Don't use petroleum jelly products, such as Vaseline. Vaginal creams that contain estrogen applied several times a week can improve vaginal lubrication.

• Urinary incontinence may be reduced by using prescription vaginal estrogen replacement creams and doing exercises to strengthen muscles in the lower pelvis.

• Several alternative treatments have been proposed to treat the symptoms of menopause. Many of these treatments have not been studied in large clinical trials. Although black cohosh has been previously promoted as a treatment for hot flashes, a study reported in the December 2006 Annals of Internal Medicine found that the root was no better than a placebo. Some women have found St. John's wort to be effective in treating mood disorders related to menopause. The use of soy products in the diet such as tofu is controversial. While it may improve symptoms for some women, the phytoestrogens (plant estrogens) that may help relieve hot flashes may also increase the risk of breast cancer.