Menopause

Answer 1

Definition

Menopause is the transition period in a woman's life when her ovaries stop producing eggs, her body produces less estrogen and progesterone, and menstruation becomes less frequent, eventually stopping altogether.

Alternative Names

Perimenopause; Postmenopause

Causes, incidence, and risk factors

Menopause is a natural event that normally occurs between the ages of 45 and 55.

Once menopause is complete (called postmenopause) and you have not had a period for 1 year, you are no longer at risk of becoming pregnant.

The symptoms of menopause are caused by changes in estrogen and progesterone levels. The ovaries make less of these hormones over time. The specific symptoms and how significant (mild, moderate, or severe) they are varies from woman to woman.

A gradual decrease of estrogen generally allows your body to slowly adjust to the hormonal changes. Hot flashes and sweats are at their worst for the first 1 - 2 years. Menopause may last 5 or more years.

Estrogen levels may drop suddenly after some medical treatments, as is seen when the ovaries are removed surgically (called surgical menopause). Chemotherapy and anti-estrogen treatment for Breast cancer are other examples. Symptoms can be more severe and start more suddenly in these circumstances.

As a result of the fall in hormone levels, changes occur in the entire female reproductive system. The vaginal walls become less elastic and thinner. The vagina becomes shorter. Lubricating secretions from the vagina become watery. The outside genital tissue thins. This is called atrophy of the labia.

Symptoms

In some women, menstrual flow comes to a sudden halt. More commonly, it slowly stops over time. During this time, the menstrual periods generally become either more closely or more widely spaced. This irregularity may last for 1 - 3 years before menstruation finally ends completely. Before this the cycle length may shorten to as little as every 3 weeks.

Common symptoms of menopause include:

• Heart pounding or racing
• Hot flashes
• Night sweats
• Skin flushing
• Sleeping problems (insomnia)

Other symptoms of menopause may include:

• Decreased interest in sex, possibly decreased response to sexual stimulation
• Forgetfulness (in some women)
• Irregular menstrual periods
• Mood swings including irritability, depression, and anxiety
• Urine leakage
• Vaginal dryness and painful sexual intercourse
• Vaginal infections
• Joint aches and pains
• Irregular heartbeat (palpitations)

Signs and tests

Blood and urine tests can be used to measure changes in hormone levels that may signal when a woman is close to menopause or has already gone through menopause. Examples of these tests include:

• Estradiol
• FSH
• LH

A pelvic exam may indicate changes in the vaginal lining caused by declining estrogen levels. The doctor may perform a bone density test to screen for low bone density levels that occur with osteoporosis.

Treatment

Treatment with hormones may be helpful if you have severe symptoms such as hot flashes, night sweats, mood issues, or vaginal dryness.

Discuss the decision to take hormones thoroughly with your doctor, weighing your risks against any possible benefits. Pay careful attention to the many options currently available to you that do not involve taking hormones. Every woman is different. Your doctor should be aware of your entire medical history when considering prescribing hormone therapy.

If you have a uterus and decide to take estrogen, you must also take progesterone to prevent endometrial cancer (cancer of the lining of the uterus). If you do not have a uterus, progesterone is not necessary.

HORMONE THERAPY

Several major studies have questioned the health benefits and risks of hormone replacement therapy, including the risk of developing breast cancer, heart attacks, strokes, and blood clots.

Current guidelines support the use of HT for the treatment of hot flashes. Specific recommendations:

• T may be started in women who have recently entered menopause.
• HRT should not be used in women who started menopause many years ago.
• The medicine should not be used for longer than 5 years.
• Women taking HT should have a baseline low risk for stroke, Heart disease, blood clots, or breast cancer.

To reduce the risks of estrogen therapy and still gain the benefits of the treatment, your doctor may recommend:

• Using estrogen or progesterone regimens that do not contain the form of progesterone used in the study
• Using a lower dose of estrogen or a different estrogen preparation (for instance, a vaginal cream rather than a pill)
• Having frequent and regular pelvic exams and Pap smears to detect problems as early as possible
• Having frequent and regular physical exams, including breast exams and mammograms

See also: Hormone therapy for more information about taking hormone therapy.

ALTERNATIVES TO HT

There are some medications available to help with mood swings, hot flashes, and other symptoms. These include low doses of antidepressants such as paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), and fluoxetine (Prozac), or clonidine, which is normally used to control high blood pressure. Gabapentin is also effective for reducing hot flashes.

LIFESTYLE CHANGES

The good news is that you can take many steps to reduce your symptoms without taking hormones:

• Avoid caffeine, alcohol, and spicy foods
• Dress lightly and in layers
• Eat soy foods
• Get adequate calcium and vitamin D in food and/or supplements
• Get plenty of exercise
• Perform Kegel exercises daily to strengthen the muscles of your vagina and pelvis
• Practice slow, deep breathing whenever a hot flash starts to come on (try taking six breaths per minute)
• Remain sexually active
• See an acupuncture specialist
• Try relaxation techniques such as yoga, tai chi, or meditation
• Use water-based lubricants during sexual intercourse

Complications

Postmenopausal bleeding may occur. This bleeding is often nothing to worry about. However, your health care provider should always check any postmenopausal bleeding, because it may be an early sign of other problems, including cancer.

Decreased estrogen levels are also associated with the following long-term effects:

• Bone loss and eventual osteoporosis in some women
• Changes in cholesterol levels and greater risk of heart disease

Calling your health care provider

Call your health care provider if:

• You are spotting blood between periods
• You have had 12 consecutive months with no period and suddenly vaginal bleeding or spotting begins again

Prevention

Menopause is a natural and expected part of a woman's development and does not need to be prevented. However, there are ways to reduce or eliminate some of the symptoms of menopause.

You can reduce your risk of long-term problems such as osteoporosis and heart disease by taking the following steps:

• Control your blood pressure, cholesterol, and other risk factors for heart disease.
• Do NOT smoke. Cigarette use can cause early menopause.
• Eat a low-fat diet.
• Get regular exercise. Resistance exercises help strengthen your bones and improve your balance.
• If you show early signs of bone loss, talk to your doctor about medications that can help stop further weakening.
• Take calcium and vitamin D.

References

Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society. Menopause. July/August 2008;15(4)584-602.

Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007 Mar 20;115(11):1481-501.

Nelson HD. Menopause. Lancet. 2008 Mar 1;371(9614):760-70.

North American Menopause Society. Estrogen and progestogen use in peri- and postmenopausal women: March 2007 position statement of The North American Menopause Society. Menopause. 2007;14:168-182.

National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Feb. 2008. Accessed July 23, 2008.

Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007 Apr 4;297(13):1465-77.

U.S. Preventive Services Task Force. Hormone therapy for the prevention of chronic conditions in postmenopausal women: recommendations from the U.S. Preventive Services Task Force. Ann Intern Med. 2005;142:855-860

Answer 2

Definition

Menopause is time in a woman's life when her periods (menstruation) eventually stop and the body goes through changes that no longer allow her to get pregnant. It is a natural event that normally occurs in women age 45 - 55.

Alternative Names

Perimenopause; Postmenopause

Causes, incidence, and risk factors

During menopause, a woman's ovaries stop making eggs and they produce less estrogen and progesterone. Changes in these hormones cause menopause symptoms. Periods occur less often and eventually stop. Sometimes this happens suddenly. But most of the time, periods slowly stop over time.

Menopause is complete when you have not had a period for 1 year. This is called postmenopause. Women who are post-menopausal can no longer get pregnant.

Surgical menopause is when medical treatments cause a drop in estrogen. This can happen if your ovaries are removed, or if you receive chemotherapy or hormone therapy for breast cancer.

Symptoms

Symptoms vary from woman to woman. They may last 5 or more years. Some women may have worse symptoms than others. Symptoms of surgical menopause can be more severe and start more suddenly.

The first thing you may notice is that your periods start to change. They might occur more often or less often. Some women might get their period every 3 weeks. This might last for 1-3 years before the periods completely stop.

Common symptoms of menopause include:

• Menstrual periods that occur less often and eventually stop
• Heart pounding or racing
• Hot flashes, usually worst during the first 1-2 years
• Night sweats
• Skin flushing
• Sleeping problems (insomnia)

Other symptoms of menopause may include:

• Decreased interest in sex, possibly decreased response to sexual stimulation
• Forgetfulness (in some women)
• Headaches
• Mood swings including irritability, depression, and anxiety
• Urine leakage
• Vaginal dryness and painful sexual intercourse
• Vaginal infections
• Joint aches and pains
• Irregular heartbeat (palpitations)

Signs and tests

Blood and urine tests can be used to look for changes in hormone levels. Test results can help your doctor determine if you are close to menopause or if you have already gone through menopause.

Tests that may be done include:

• Estradiol
• FSH
• LH

Your health care provider will perform a pelvic exam. Decreased estrogen can cause changes in the lining of the vagina.

Bone loss increases during the first few years after your last period. Your doctor may order a bone density test to look for bone loss related to osteoporosis.

Treatment

Treatment for menopause depends on many things, including how bad your symptoms are, your overall health, and your preference. It may include lifestyle changes or hormone therapy.

HORMONE THERAPY

Hormone therapy may help if you have severe hot flashes, night sweats, mood issues, or vaginal dryness. Hormone therapy is treatment with estrogen and, sometimes, progesterone.

Talk to your doctor about the benefits and risks of hormone therapy. Your doctor should be aware of your entire medical history before prescribing hormone therapy (HT). Learn about options that do not involve taking hormones.

Several major studies have questioned the health benefits and risks of hormone therapy, including the risk of developing breast cancer, heart attacks, strokes, and blood clots.

Current guidelines support the use of HT for the treatment of hot flashes. Specific recommendations:

• HT may be started in women who have recently entered menopause.
• HT should not be used in women who started menopause many years ago, except for estrogen vaginal creams.
• The medicine should not be used for longer than 5 years.
• Women taking HT have a low risk for stroke, heart disease, blood clots, or breast cancer.

To reduce the risks of estrogen therapy, your doctor may recommend:

• A lower dose of estrogen or a different estrogen preparation (for instance, a vaginal cream or skin patch rather than a pill)
• Frequent and regular pelvic exams and Pap smears to detect problems as early as possible
• Frequent and regular physical exams, including breast exams and mammograms

If you have a uterus and decide to take estrogen, you should also take progesterone to prevent cancer of the lining of the uterus (endometrial cancer). If you do not have a uterus, you do not need progesterone.

See also: Hormone therapy

ALTERNATIVES TO HORMONE THERAPY

There are other medicines available to help with mood swings, hot flashes, and other symptoms. These include:

• Antidepressants, including paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), and fluoxetine (Prozac)
• A blood pressure medicine called clonidine
• Gabapentin, a seizure drug that also helps reduce hot flashes

DIET AND LIFESTYLE CHANGES

Hormones are not always needed to reduce symptoms of menopause. There are many steps you can take to reduce symptoms.

Diet changes:.

• Avoid caffeine, alcohol, and spicy foods
• Eat soy foods. Soy contains estrogen
• Get plenty of calcium and vitamin D in food or supplements

Exercise and relaxation techniques:.

• Get plenty of exercise.
• Do Kegel exercises every day. They strengthen the muscles of your vagina and pelvis.
• Practice slow, deep breathing whenever a hot flash starts to come on. Try taking six breaths a minute.
• Try yoga, tai chi, or meditation.

Other tips:

• Dress lightly and in layers.
• Keep having sex.
• Use water-based lubricants or a vaginal moisturizer during sex.
• See an acupuncture specialist.

See also: Managing menopause at home

Complications

Some women have vaginal bleeding after menopause. This is often nothing to worry about. However, you should tell your health care provider if this occurs. It may be an early sign of other health problems, including cancer.

Decreased estrogen levels have been linked with some long-term effects, including:

• Bone loss and osteoporosis in some women
• Changes in cholesterol levels and greater risk of heart disease

Calling your health care provider

Call your health care provider if:

• You are spotting blood between periods
• You have had 12 consecutive months with no period and suddenly vaginal bleeding or spotting begins again, even if it is a very small amount

Prevention

Menopause is a natural and expected part of a woman's development and does not need to be prevented. You can reduce your risk of long-term problems such as osteoporosis and heart disease by taking the following steps:

• Control your blood pressure, cholesterol, and other risk factors for heart disease.
• Do NOT smoke. Cigarette use can cause early menopause.
• Eat a low-fat diet.
• Get regular exercise. Resistance exercises help strengthen your bones and improve your balance.
• If you show early signs of bone loss or have a strong family history of osteoporosis, talk to your doctor about medications that can help stop further weakening.
• Take calcium and vitamin D.

References

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 420, November 2008: hormone therapy and heart disease. Obstet Gynecol. 2008 Nov;112(5):1189-92.

Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010 Jan-Feb;17(1):25-54; quiz 55-6.

North American Menopause Society. Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010 Mar;17(2):242-55.

Col NF, Fairfield KM, Ewan-Whyte C, Miller H. In the clinic. Menopause. Ann Intern Med. 2009 Apr 7;150(7):ITC4-1-15.

Brunner RL, Aragaki A, Barnabei V, et al. Menopausal symptom experience before and after stopping estrogen therapy in the Women's Health Initiative randomized, placebo-controlled trial. Menopause. 2010 Sep-Oct;17(5):946-54.

Freeman EW, et al. Efficacy of Escitalopram for Hot Flashes in Healthy Postmenopausal Women. JAMA. 2011; 305(3): 267-274.

Reviewed By

Review Date: 09/13/2011

David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Bellevue, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine.