Menopause

Menopause

Definition
Menopause is the permanent end of menstruation and fertility, defined as occurring 12 months after your last menstrual period.



Menopause is a natural biological process, not a medical illness. Even so, the physical and emotional symptoms of menopause can disrupt your sleep, sap your energy and — at least indirectly — trigger feelings of sadness and loss. Menopause can definitively impact a woman's life.



Hormonal changes cause the physical symptoms of menopause, but mistaken beliefs about the menopausal transition are partly to blame for the emotional ones. First, menopause doesn't mean the end is near — you've still got as much as half your life to go. Second, menopause will not snuff out your femininity and sexuality, but can disrupt a female, specially if she is not prepared to manage it. In fact, you may be one of the many women who find it liberating to stop worrying about pregnancy and periods.



Most important, even though menopause is not an illness, you shouldn't hesitate to get treatment if you're having severe symptoms. Many treatments are available, from lifestyle adjustments to hormone therapy.



Symptoms

Technically, you don't actually "hit" menopause until it's been one year since your final menstrual period. In the United States, that happens about age 51, on average.



The signs and symptoms of menopause, however, often appear long before the one-year anniversary of your final period. This period is called PERIMENOPAUSE. They include:



■Irregular periods

■Decreased fertility

■Vaginal dryness

■Hot flashes

■Sleep disturbances

■Mood swings

■Increased abdominal fat

■Thinning hair

■Loss of breast fullness


When to see a doctor



It's important to see your doctor during the years leading up to menopause (perimenopause) and the years after menopause (postmenopause) for preventive health care as well as care of medical conditions that may occur with aging.



If you've skipped a period but aren't sure you've started menopause, you may want to see your doctor to determine whether you're pregnant. He or she may take a medical history, do a pelvic examination and, if appropriate, order a pregnancy test.



Always seek medical advice if you have bleeding from your vagina after menopause, as this may be a sign of a serious medical problem. You should not have any bleeding after menopause.



Causes

■Natural decline of reproductive hormones. As you approach your late 30s, your ovaries start making less estrogen and progesterone, the hormones that regulate menstruation. During this time, fewer potential eggs are ripening in your ovaries each month, and ovulation is less predictable. Also, the post-ovulation surge in progesterone — the hormone that prepares your body for pregnancy — becomes less dramatic. Your fertility declines, partially due to these hormonal effects.



These changes become more pronounced in your 40s. Your menstrual periods may become longer or shorter, heavier or lighter, and more or less frequent, until eventually, your ovaries stop producing eggs, and you have no more periods. It's possible, but very unusual, to menstruate every month right up to your last period. More likely, you'll experience some irregularity in your periods, some will be long some will be short. Sometimes you will even miss period or periods.



■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 and produce estrogen and progesterone. But an operation that removes both your uterus and your ovaries (total hysterectomy and bilateral oophorectomy) does cause menopause, without any transitional phase. Your periods stop immediately, and you're likely to have hot flashes and other menopausal signs and symptoms.

■Chemotherapy and radiation therapy. These cancer therapies can induce menopause, causing symptoms such as hot flashes during the course of treatment or within three to six months.

■Primary ovarian insufficiency. Approximately 1 percent of women experience menopause before age 40. Menopause may result from primary ovarian insufficiency — when your ovaries fail to produce normal levels of reproductive hormones — stemming from genetic factors or autoimmune disease, but often no cause for primary ovarian insufficiency can be found.

Stages of menopause

Because the menopausal transition occurs over months and years, menopause is commonly divided into these stages:



■Perimenopause. This is the time you begin experiencing menopausal signs and symptoms, even though you still menstruate. Your hormone levels rise and fall unevenly, and you may have hot flashes and other symptoms. Perimenopause may last four to five years or longer. During this time, it's still possible to get pregnant, but it's quite unlikely.

■Postmenopause. Once 12 months have passed since your last period, you've reached menopause. Your ovaries produce much less estrogen and no progesterone, and they don't release eggs. The years that follow are called postmenopause.

Complications

Several chronic medical conditions can develop after menopause:



■Cardiovascular disease. When your estrogen levels decline, your risk of cardiovascular disease increases. Heart disease is the leading cause of death in women as well as in men. Yet you can do a great deal to reduce your risk of heart disease. These risk-reduction steps include stopping smoking, reducing high blood pressure, getting regular aerobic exercise, and eating a diet low in saturated fats and plentiful in whole grains, fruits and vegetables.

■Osteoporosis. During the first few years after menopause, you may lose bone density at a rapid rate, increasing 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 important during this time to get adequate calcium and vitamin D — about 1,200 to 1,500 milligrams of calcium and 800 international units of vitamin D daily. It's also important to exercise regularly. Strength training and weight-bearing activities, such as walking and jogging, are especially beneficial in keeping your bones strong.

■Urinary incontinence. As the tissues of your vagina and urethra lose their elasticity, you may experience a frequent, sudden, strong urge to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence).

■Weight gain. Many women gain weight during the menopausal transition. You may need to eat less — perhaps as many as 200 to 400 fewer calories a day — and exercise more, just to maintain your current weight.

Tests and diagnosis


The signs and symptoms of menopause are enough to tell most women they have begun going through the menopausal transition. If you have concerns about irregular periods or hot flashes, talk with your doctor. In some cases further evaluation may be recommended.



Under certain circumstances, your doctor may check your level of follicle-stimulating hormone (FSH) and estrogen (estradiol) with a blood test. As menopause occurs, FSH levels increase and estradiol levels decrease. Your doctor may also recommend a blood test to determine your level of thyroid-stimulating hormone, because hypothyroidism can cause symptoms similar to those of menopause.



Treatments and drugs

Menopause itself requires no medical treatment. Instead, treatments focus on relieving your signs and symptoms and on preventing or lessening chronic conditions that may occur with aging. Treatments include:



■Hormone therapy. Estrogen therapy remains, by far, the most effective treatment option for relieving menopausal hot flashes. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose needed to provide symptom relief for you. These come with their own side effects and risks such as blood clots, increased risk of heart disease and stroke, etc.

■Low-dose antidepressants. Venlafaxine (Effexor), an antidepressant related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs), has been shown to decrease menopausal hot flashes. Other SSRIs can be helpful, including fluoxetine (Prozac, Sarafem), paroxetine (Paxil, others), citalopram (Celexa) and sertraline (Zoloft).

■Gabapentin (Neurontin). This drug is approved to treat seizures, but it also has been shown to significantly reduce hot flashes.

■Clonidine (Catapres, others). Clonidine, a pill or patch typically used to treat high blood pressure, may significantly reduce the frequency of hot flashes, but unpleasant side effects are common.

■Bisphosphonates. Doctors may recommend these nonhormonal medications, which include alendronate (Fosamax), risedronate (Actonel) and ibandronate (Boniva), to prevent or treat osteoporosis. These medications effectively reduce both bone loss and your risk of fractures and have replaced estrogen as the main treatment for osteoporosis in women.

■Selective estrogen receptor modulators (SERMs). SERMs are a group of drugs that includes raloxifene (Evista). Raloxifene mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen.

■Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered locally using a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.

Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each.



Lifestyle and home remedies

Fortunately, many of the signs and symptoms associated with menopause are temporary. Take these steps to help reduce or prevent their effects:



■Cool 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 and even a warm room.

■Decrease vaginal discomfort. Use over-the-counter water-based vaginal lubricants (Astroglide, K-Y) or moisturizers (Replens, Vagisil). Staying sexually active also helps.

■Optimize your sleep. Avoid caffeine and plan to exercise during the day, although not right before bedtime. 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 hot flashes disturb your sleep, you may need to find a way to manage them before you can get adequate rest.

■Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.

■Eat well. Eat a balanced diet that includes a variety of fruits, vegetables and whole grains and that limits saturated fats, oils and sugars. Aim for 1,200 to 1,500 milligrams of calcium and 800 international units of vitamin D a day. Ask your doctor about supplements to help you meet these requirements, if necessary.

■Don't smoke. Smoking increases your risk of heart disease, stroke, osteoporosis, cancer and a range of other health problems. It may also increase hot flashes and bring on earlier menopause. It's never too late to benefit from stopping smoking.

■Exercise regularly. Get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis and other conditions associated with aging. More vigorous exercise for longer periods may provide further benefit and is particularly important if you're trying to lose weight. Exercise can also help reduce stress.

■Try yoga. Preliminary studies show that yoga — an exercise regimen that involves controlled breathing, posing and meditation — may be effective in decreasing the number of hot flashes in perimenopausal women. Yoga classes are often offered at health clubs or through community education programs. Sign up for a class to learn how to perform yoga postures and breathing correctly.

■Schedule regular checkups. Talk with your doctor about how often you should have mammograms, Pap tests, lipid level (cholesterol and triglyceride) testing and other screening tests.

Alternative medicine

Many approaches have been promoted as aids in managing the symptoms of menopause, but not all of them have scientific evidence to back up the claims. Below are some complementary and alternative treatments that have been or are being studied:



■Phytoestrogens. These estrogens occur naturally in certain foods. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, chickpeas and other legumes. Lignans occur in flaxseed, whole grains and some fruits and vegetables. Whether the estrogens in these foods can relieve hot flashes and other menopausal signs and symptoms remains to be seen. Most studies have found them ineffective. Isoflavones have some weak estrogen-like effects, so there's some concern about cancer risk. If you've had breast cancer, talk to your doctor before supplementing your diet with isoflavone pills.

■Vitamin E. This vitamin occasionally provides relief from mild hot flashes for some women. However, scientific studies haven't proved its overall benefit in relieving hot flashes, and taking more than 400 international units of vitamin E supplements daily may not be safe.

■Black cohosh. Black cohosh has been used widely in Europe for treating hot flashes and has been popular among women with menopausal symptoms in the United States. While its safety record has been good, there's no longer much reason to believe that it is effective for menopausal symptom relief.

You may have heard of — or even tried — other dietary supplements, such as dong quai, licorice, chasteberry, evening primrose oil and wild yam (natural progesterone cream). Although some might swear by these remedies, scientific evidence of their safety and effectiveness is lacking.



Be sure to consult your doctor before taking any herbal treatments or dietary supplements for signs and symptoms of menopause. Herbal products can interfere or interact with other medications you may be taking.

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