Menopause: Overview

Menopause is the series of changes that occur when a woman's body no longer releases eggs and the ovaries produce significantly lower amounts of the hormones estrogen and progesterone. It typically occurs between the ages of 45 and 55, but it can happen earlier or later. The average age at the beginning of menopause in the United States is 51. It is technically defined as going without a menstrual cycle for 12 consecutive months when there is no other cause for this change. Aging is the chief cause of menopause.

Natural menopause is preceded by a period of transition known as perimenopause, which can begin anytime between a woman's early 30s and (rarely) her late 60s. Perimenopause may end in the course of several months or unfold over many years. Pregnancy is still possible during this time period.

Hormones and menopause

During a woman's reproductive years, every month her ovaries produce estrogen and progesterone to help prepare the body to receive and nourish a fertilized egg. When fertilization does not occur, estrogen and progesterone levels decrease, causing the lining of the uterus to break down and setting the stage for menstruation.

The process that leads to menopause usually begins in a woman's middle to late 30s, when the ovaries' production of estrogen and progesterone begins to fluctuate. Hormone levels vary even more during a woman's 40s and may cause irregular menstrual cycles. By the mid 50s, menstruation cycles typically cease altogether.

Menopause can cause many health problems, including hot flashes, vaginal dryness and thinning of the bones (osteoporosis). Many women try to ease these symptoms by taking hormone replacement therapy consisting of synthetic estrogen or an estrogen/progesterone combination.

Menopause can be a difficult adjustment, but for most women it is a completely normal part of life. Taking the proper steps in anticipation of these changes, being health conscious and maintaining a positive attitude can help you to live a healthy, productive life during and after menopause.

Early menopause

A variety of factors, listed below, can result in early menopause.

• Surgery. Menopause can occur as the result of an operation to remove the uterus (hysterectomy) and ovaries (oophorectomy). This kind of surgery is often necessary to treat women with conditions such as uterine cancer, ovarian cancer or endometriosis. The symptoms of menopause usually appear immediately after surgery, rather than occurring gradually as they do in natural menopause. The symptoms women experience are often more severe after surgical menopause than with menopause that occurs naturally.
  
  In some cases, women will have their uterus removed but their ovaries will be left in place. Although these women are no longer able to bear children and do not menstruate, they will not experience premature menopause, as the ovaries will continue to produce hormones. However, women in this situation may still experience hot flashes because the surgery may disrupt the supply of blood to the ovaries. In addition, if a woman has her uterus removed, she may experience menopause a year or two earlier than would have happened otherwise.
  
  
• Genetics. The age at which a woman enters menopause often corresponds closely with her mother's age at menopause. So women whose mothers went through early menopause are more likely to do so themselves.
  
  
• Cancer treatments. Radiation to the pelvic area or chemotherapy can damage the ovaries and trigger menopause. The younger a woman is when she has these treatments, the less likely she is to experience premature menopause.
  
  
• Smoking. Tobacco use may cause menopause to occur up to two years earlier than normal.
  
  
• Chromosome defects. Chromosome defects can (rarely) trigger the premature onset of menopause. For example, women born without a second X chromosome or born without part of one of the X chromosomes have a condition known as Turner syndrome. In this disorder, the ovaries do not develop as they would normally. This leads to early menopause.
  
  
• Autoimmune diseases. The body's immune system sometimes mistakenly attacks part of the reproductive system. Autoimmune diseases such as thyroid disease and rheumatoid arthritis can damage the ovaries and prevent them from making female hormones.

Premature menopause increases the risk for osteoporosis later in life and severely restricts a woman's ability to have children in the future. Women who still want to become pregnant should talk to their physician about donor egg programs.

Menopause: Signs, Symptoms & Diagnosis

The first sign of oncoming menopause is usually a fluctuation in the menstrual cycle. This period of transition is known as perimenopause. Menopause does not occur until a woman has not had a menstrual period for 12 consecutive months (and no other biological or physiological cause for this phenomenon can be identified).

During perimenopause and menopause, a woman may experience several symptoms typically associated with the changes taking place in the body. These symptoms often include:

• Hot flashes. These cause a feeling of warmth in the face, neck or chest. The intensity of a hot flash can range from mild to severe. According to the U.S. Food and Drug Administration (FDA), about 85 percent of women approaching or going through menopause have hot flashes.
  
  
• Night sweats and difficulty sleeping. A lack of sleep can make other symptoms worse and make a woman feel tired, stressed or tense.
  
  
• Changes in vaginal tissue. These changes may include thinning, dryness, itchiness or a burning sensation. In some cases, sex may become painful (dyspareunia).
  
  
• Thinning of bones (osteoporosis). Some women may lose as much as 20 percent of their bone mass. There is an increased risk of fractures of the hip, spine, wrist and other bones. In some cases, fractures of the spine can result in slumped-over posture and a loss of height.
  
  
• Abnormal vaginal bleeding or spotting. While this is a common sign of menopause, you should see a physician if you experience it and you have not had a period for 12 consecutive months. It can sometimes be a side effect of birth control pills or hormone replacement therapy or a sign of other conditions including cancer, hormonal imbalance or noncancerous growths in the lining of the uterus (fibroids).
  
  
• Mood changes including mood swings, depression and irritability. Some researchers believe these emotions are caused by changes in the brain due to the decrease in estrogen production. Others think menopausal symptoms such as sleep problems, hot flashes and fatigue are responsible.
  
  
• Urinary problems. You may have urinary problems during menopause, such as leaking (sometimes after a cough or sneeze), burning or pain when urinating (dysuria). The thinning of the urethra that happens at this time may result in an increase in urinary tract infections (UTIs).
  
  
• Increased risk of heart problems. Estrogen helps raise levels of HDL cholesterol ("good" cholesterol). This in turn helps remove LDL cholesterol ("bad" cholesterol), which can contribute to plaque buildup in the arteries. As estrogen levels drop, there is increased risk of this buildup, which can lead to coronary artery disease (narrowing or blocking of the veins and arteries to the heart).
  
  
• Heart palpitations. You may experience episodes of a sudden pounding in the chest. Though heart palpitations can be harmless, they can also be a sign of a major health disorder. For this reason, you should seek medical care if you experience them.
  
  
• Memory or concentration problems. The source of these symptoms is not clearly understood. It is thought that they may be related to factors such as stress or lack of sleep.
  
  
• Lack of interest in sex or changes in sexual response. [Qy: Please provide more detail like all other items in list.] Decreasing estrogen levels cause various changes in the vaginal tissue (e.g., vaginal dryness, reduced blood flow to the genital area, reduced vaginal sensitivity), which can in turn affect a woman's sexual desire and ability to orgasm. As a result, the sexual response cycle often takes longer or may be less intense in postmenopausal women.
  
  Changing hormone levels also can produce emotional changes (e.g., mood swings) that can make some women feel less interested in sex. Insomnia, weight gain and other side effects of menopause can also contribute to a lack of sexual desire.
  
  
• Changes in physical appearance. After menopause, weight that previously was settled in a woman's hips and thighs may shift to her waist. The breasts may lose their fullness, wrinkles may form and hair on the head may thin. As estrogen levels drop, the small amount of testosterone that a woman produces may have a more pronounced effect on her body and she may develop coarse hair on the chin, upper lip, chest and abdomen.

The severity of these symptoms will almost certainly vary. Some fortunate women experience few symptoms. For most women, many symptoms fade over time, whether or not they receive treatment for them.

Diagnosing menopause

To determine whether the absence of menstrual periods is caused by menopause, a physician will perform a physical examination and compile your medical history. The physician may also perform a number of tests that may help reveal whether or not menopause has occurred.

For example, a blood test that reveals the level of follicle-stimulating hormone (FSH) is frequently used. FSH is made in the pituitary gland in the brain and circulates in the blood to stimulate the ovaries to make estrogen and progesterone. Once the ovaries stop making these hormones, the pituitary gland compensates by making more FSH. FSH levels greater than 25 to 40 mIU/ml (milli-international units per milliliter) are a sign of menopause. The U.S. Food and Drug Administration (FDA) has approved a home urine test kit that measures follicle-stimulating hormone in a urine sample.

A physician may also test you for levels of estradiol, a type of estrogen whose levels fall in the body once the ovaries fail. You may also be tested for luteinizing hormone (LH), the hormone that triggers ovulation. Higher levels may indicate that menopause has occurred.

Once you have entered menopause, it becomes even more important to monitor aspects of your health that may be affected by the associated hormonal changes. Tests that can help a physician monitor your postmenopausal health include:

• Pap smear. The surface of the cervix is scraped and analyzed for signs of cancer or other disorders of the cervix, uterus or other pelvic organs.
  
  
• Mammography (or mammogram). This annual X-ray of the breast area can reveal signs of breast cancer.
  
  
• Bone density screening. This can be used to help detect signs of osteoporosis, a thinning of the bones that can be accelerated by low levels of estrogen. Women with osteoporosis are at greater risk for fractures of the wrist, hip and spine due to a decrease in bone density.

Menopause: Treatment Options

Menopause is a natural part of a woman's life cycle and is impossible to prevent. However, you can take steps to lessen symptoms and minimize discomfort once it begins. The most common form of treatment for menopause-related problems is hormone replacement therapy (HRT).

HRT replaces the hormones estrogen and progesterone, which are lost during menopause. It may be taken in various forms, including pills, skin patches, vaginal creams, vaginal rings, suppositories or injections. HRT helps relieve symptoms and prevent diseases linked to menopause. About 6 million American women take a combination of estrogen and synthetic progesterone after menopause, according to the National Heart, Lung and Blood Institute.

Hormones are chemical substances that carry instructions from one group of cells to another. The two most important sex hormones are estrogen and testosterone. They contribute to the development of sexual characteristics and reproduction. Both women and men produce estrogen and testosterone. However, women have much higher proportions of estrogen, whereas men have much greater proportions of testosterone.

Estrogen appears to offer women a number of important health benefits. It helps prevent bone loss, helps prevent buildup of plaque in the arteries, keeps the vagina lubricated and supple, and keeps the lining of the urethra from thinning, which helps prevent urinary tract infections.

During the years just prior to menopause (around age 50), the ovaries begin to shrink, causing levels of estrogen and another hormone called progesterone to drop. When estrogen is no longer produced in large amounts by the ovaries, menstruation stops. At the same time, without estrogen the woman may experience various adverse symptoms including hot flashes and vaginal dryness. She is also at a higher risk for heart disease, osteoporosis, Alzheimer's disease and other health problems.

Some of the benefits of HRT during and after menopause include:

• A reduction in the symptoms associated with menopause, such as:
  
  
  • Hot flashes. A feeling of warmth in the face, neck and chest, sometimes accompanied by night sweats or headaches.
    
    
  • Vaginal dryness. During menopause, vaginal skin may become dry and thin. Sex may become painful, and the woman may experience vaginal itching (pruritus) or burning.
    
    
  • Mood swings.
  
  
  
• Protection against certain diseases. Hormones are known to help prevent colon cancer and osteoporosis (a thinning and weakening of the bones). (Earlier claims that HRT helps prevent heart disease have not been supported by further research.)

If you are receiving HRT, it is likely that you will take one of the following:

• Estrogen. This HRT option is usually reserved only for women who no longer have a uterus. It can be made synthetically from plants and other sources, or made from the urine of pregnant horses.
  
  
• Estrogen with progesterone. This is the primary type of HRT given to women who still have a uterus. The progesterone helps prevent overgrowth of cells (hyperplasia) in the lining of the uterus that can lead to cancer. Progesterone that is made synthetically is called progestin. Another form of progesterone is known as "natural progesterone" or "micronized progesterone." It is very similar to the natural hormone.

It is usually recommended that women remain on HRT from several months to a few years. For years, physicians regularly prescribed HRT for all menopausal and postmenopausal women, even if their symptoms were not bothersome. However, the Woman's Health Initiative revealed health risks associated with HRT that have made physicians more cautious about prescribing these drugs. Sponsored by the National Institutes of Health, this 15-year study of more than 160,000 postmenopausal women ended in 2002. Because of this study, the current recommendation is for most menopausal women not to take HRT indefinitely.

However, HRT is often used on a long-term basis for preventing osteoporosis in women whose risk of getting the disease outweighs the risk of treatment. HRT can reduce the amount of calcium lost from the bones as a woman ages.

Other nonestrogen drugs that can be used to prevent osteoporosis include bisphosphonates (such as alendronate and risedronate) and selective estrogen receptor modulators (such as raloxifene). However, these drugs are relatively new, so how they affect the body over the long term is not entirely understood.

Many health risks are now known to be associated with HRT. Some of the most serious include blood clots, breast cancer and uterine cancer. The U.S. Food and Drug Administration (FDA) currently requires manufacturers of estrogen medications to include information about these risks in revised labeling that accompanies the drugs.

Still, the likelihood of side effects due to HRT is low. If you are of menopausal or postmenopausal age, discuss with your physician whether or not HRT is right for you.

If you choose not to undergo HRT, you can still take several steps to improve your health:

• Have regular checkups with your physician.
• Avoid tobacco products.
• Eat a balanced diet and maintain a healthy body weight.
• Ask a physician about taking calcium and vitamin D supplements to improve the health and strength of your bones.
• Exercise.
• Check blood pressure, cholesterol and blood sugar.
• Schedule breast exams and mammograms.

Menopausal symptoms can range from annoying to severe and can be extremely disruptive to your life. However, certain lifestyle changes and, in some cases, medications can lessen the impact that menopause has on your life, making this inevitable change as unobtrusive as possible.

Menopause: Dealing Day-to-Day

Although you cannot prevent menopause, you can take steps, as listed below, to reduce the symptoms. Most menopausal and post-menopausal women lead full, healthy and active lives.

1. Talk to your doctor about hormone replacement therapy

   Hormone replacement therapy (HRT) involves taking synthetic estrogen or a combination of estrogen and synthetic progesterone, known as progestin. Some of the benefits of HRT are:

   • Reducing hot flashes
   • Relieving vaginal dryness
   • Slowing bone loss
   • Alleviating mood swings and depression

   Although HRT is often effective at controlling symptoms, recent studies have revealed that it increases the risk of several health problems. These include:

   • Blood clots
   • Breast cancer
   • Gallbladder disease
   • Heart attack
   • Stroke

   For this reason, be sure to consult with a physician about the pros and cons of HRT. If you have certain health conditions, you will not be a candidate for HRT. Some of these conditions include:

   • Cancers of the breast and uterus
   • History of stroke or heart attack
   • History of blood clots
   • Liver disease

   In some cases, alternative medications can be taken to help strengthen bones and to treat other menopause-related problems.

2. Exercise regularly

   Try to get at least 30 minutes of exercise on most days of the week. Weight-bearing exercises such as walking, running or dancing can help strengthen bones. This can help protect a woman from osteoporosis, a thinning of the bones that often occurs after menopause. Strengthening the bones at a younger age decreases osteoporosis risk later in life. But even those with osteoporosis can still strengthen their bones through weight-bearing exercise. In addition to creating a structured exercise routine, you can increase your activity level by doing the following:

3. • Parking at the end of the parking lot or a block away and briskly walking to a destination.
     
     
   • Taking the stairs instead of the elevator.
     
     
   • Taking walks during breaks at work.
     
     
   • Getting involved in activities and sports such as softball, tennis, golf or dancing.
     
     
   • Playing games such as tag with children instead of computer games.
   3. Quit smoking

      Smoking increases bone loss, probably because it decreases the production of estrogen and reduces the body's ability to absorb calcium.

   4. Eat a healthy diet

      Eat plenty of whole-grain products, vegetables and fruits. Choose foods low in fat and cholesterol and get enough calcium and vitamin D to keep your bones strong. Menopausal and postmenopausal women need about 1,500 milligrams of calcium a day. In addition, you should not have more than one alcoholic drink a day.

   5. Maintain a healthy weight

      Maintaining a weight deemed healthy by a physician will help you manage the symptoms of menopause.

   6. Continue to have regular medical examinations

Physical exams should include checks of bone density, blood pressure, cholesterol and blood sugar. Gynecological exams should include an annual breast exam, including a mammogram, and an annual pelvic examination, with a Pap smear every one to three years (depending on your health history).

7. Address symptoms

   Although good health and sound lifestyle choices can reduce the likelihood of symptoms, it is likely that you will experience at least some ill effects associated with menopause. The list below details these and discusses steps that can be taken to reduce their severity.

   
   
   • Hot flashes. Try to avoid triggers such as warm environments, hot or spicy foods, alcohol, caffeine and stress. All of these can worsen hot flashes. Dressing in layers, exercising regularly and using a fan in the home or workplace can also help you reduce or prevent hot flashes.
     
     Hot flashes can be upsetting and frustrating, particularly if they are intense. Don't be alarmed, however, as hot flashes are not usually a sign of a medical problem. Rather they are a normal biological reaction to fluctuating hormone levels in a woman's body.
     
     Health experts from a wide variety of disciplines, including bioengineering, physiology and the behavioral sciences, are conducting research to understand the causes of hot flashes and to better determine which treatments work and which do not.
     
     
   • Memory problems. A physician can recommend mental exercises to improve your memory during menopause. Adequate sleep and regular physical activity may also help prevent any memory problems you might otherwise experience.
     
     
   • Mood swings. Getting enough sleep and regular physical activity can often help combat mood swings during menopause. Physicians can also recommend relaxation exercises or prescribe antidepressant medication if necessary. A support group may also be helpful.
     
     
   • Sleeping problems. Regular exercise during menopause can help you sleep better (but don't do it close to bedtime). Avoiding alcohol, caffeine, large meals and work right before bedtime can also help prevent sleep problems. Finally, to improve sleep patterns, avoid napping, go to bed and get up at the same times every day, and keep your bedroom at a constant, comfortable temperature.
     
     
   • Vaginal dryness. Over-the-counter vaginal lubricants are available if you have vaginal dryness. Prescription estrogen replacement creams might also offer relief. Talk to your physician if this is a concern of yours.

Menopause: Key Q&A

When does menopause usually occur?
Menopause occurs when a woman's body no longer releases eggs, and her ovaries substantially reduce production of the hormones estrogen and progesterone.

A woman is considered to have entered menopause when she goes without a menstrual cycle for 12 consecutive months. In most cases, this happens between the ages of 45 and 55, although sometimes it occurs much earlier or later.

How can I tell if I am in menopause?
If you have not had a period for a year and no other biological or physiological cause can be determined, you are in menopause.

To find out if there is another cause, a physician can take several steps such as performing a physical examination, taking a medical history and conducting a test for luteinizing hormone (LH).

What causes early menopause?
Menopause most often occurs as a part of the aging process. Sometimes, however, it may take place prematurely, as with surgical menopause. This occurs when a woman has a hysterectomy (removal of the uterus) and oophorectomy (removal of the ovaries). The symptoms in this case most often occur soon after the surgery and are often more severe than with natural menopause.

Other, less common, causes of premature menopause are genetic predisposition, cancer treatments, smoking, chromosome defects and autoimmune diseases.

What are the most common symptoms of menopause?
Women may experience several symptoms as they enter menopause. The most common include hot flashes (feelings of warmth in the face, neck or chest), night sweats, changes in vaginal tissue (such as thinning, dryness, itchiness or burning), thinning of the bones (osteoporosis), abnormal vaginal bleeding or spotting, mood changes and urinary problems.

The severity of these and other symptoms will often be different from one woman to the next. Some problems, such as hot flashes, gradually fade with time.

What is perimenopause?
Perimenopause is the period of transition between your reproductive years and the onset of menopause. The occurrence of perimenopause is usually characterized by a fluctuation in your menstrual cycle.

However, if you experience abnormal vaginal bleeding or spotting and have not had a period for 12 consecutive months, you should notify your doctor. This can sometimes be a sign of a more serious condition such as cancer, or noncancerous growths in the lining of the uterus. It is also a possible side effect of birth control pills or hormone replacement therapy (HRT) or a result of a hormonal imbalance.

Can I prevent or reduce menopause symptoms?
There is no way to prevent the onset of menopause. However, you can take steps to reduce the severity of the symptoms. The most common method of achieving this is through HRT.

HRT is often effective at reducing the frequency of hot flashes, relieving vaginal dryness, slowing the loss of bone density and evening out your mood. However, HRT can present health risks, so be sure to consult with your physician regularly if this treatment is an option for you.

You may also be able to lessen the burden of menopause by exercising regularly, not smoking, eating a healthy diet, avoiding alcohol, staying fit and having regular doctor visits, though you will likely still experience some symptoms.

Menopause: Fast Facts

Menopause: Questions to Ask Your Doctor

Basic questions

1. At what age will I most likely begin menopause?
2. How will I know when I am entering menopause?
3. What symptoms can I expect to experience during menopause?
4. Can I become pregnant during perimenopause? How often does this occur?
5. What common side effects of menopause should I be concerned about? What steps can I take to relieve these effects?
6. At what point will I be considered postmenopausal?

Hormone replacement therapy (HRT) questions

1. Am I a candidate for hormone replacement therapy (HRT)?
2. When is the best time to start HRT?
3. Will I need any tests prior to starting on the medications?
4. How quickly will I notice relief from menopausal symptoms once I start on HRT?
5. How long will I stay on HRT?
6. Is one type of HRT better for me than another?
7. How will I benefit from using HRT?
8. What are my risks if I use HRT?
9. After starting HRT, will I need any additional monitoring?
10. What are the signs that HRT is causing problems?

Lifestyle changes

1. Are there any particular forms of exercise I should avoid?
2. What would you consider a healthy weight for me to maintain?
3. What dietary restrictions (if any) do you recommend?
4. How often can I drink alcohol?
5. Will I still enjoy sex?
6. Can you refer me to a support group?

Ayurvedic Remedies for Menopause

• Vata dominated menopause
• Pitta dominated menopause
• Kapha dominated menopause

• Anemia, Weakness,
• Feeling of intense heat in your body on some occasions
• Profuse sweating at night
• Excessive falling of hair,
• Irregular menstrual periods with excessive or scanty bleeding,
• Burning and increased frequency of micturation,
• Vaginal dryness and itching
• Joint pain,
• Oedema,
• Irritable nature,
• Sleeplessness Lassitude.