Menopause is the time when a woman's menstrual periods stop and her ovaries stop releasing eggs. A woman is considered menopausal once she has gone a year without having a menstrual period. Therefore, the exact time of a woman's final menstrual period can only be pinpointed by counting backwards after the fact.
Although most women go through menopause around age 50, normal menopause can happen any time between the age of 40 and 60. The last periods are usually more irregular and have less blood flow. However, some women's periods don't change at all.
Along with normal or natural menopause, there is also premature menopause. Premature menopause occurs before the age of 40 and can be caused by a variety of things, such as removal of the ovaries, autoimmune disorders, endocrinological reasons, or cancer therapy. Medical interventions, such as a hysterectomy (when the uterus is removed), may also prevent menstruation. If the ovaries are removed as well, production of the hormones estrogen and progesterone are stopped, causing the symptoms of menopause.
Menopause is a normal part of the aging process. Follicle stimulating hormone (FSH) and luteinizing hormone (LH) are secreted by the pituitary gland as part of the normal menstrual cycle. They stimulate the ovary to produce estrogen and progesterone and to release an egg. As a woman ages, her ovaries don't respond to FSH or LH as strongly as they used to. Over time, less and less estrogen and progesterone are produced and the woman stops releasing eggs.
Premature menopause can be genetic or it can be caused by autoimmune diseases. These diseases produce antibodies that can damage the ovaries. Surgical removal of the ovaries causes artificial menopause, as can chemotherapy or radiation therapy to the pelvis to treat cancer.
Smoking, malnutrition, and living at a high altitude can also lower the expected age of menopause.
Symptoms and Complications
Before her periods stop completely, a woman might experience a variety of unpleasant symptoms, including hot flashes, irritability, night sweats, loss of bladder control, urinary infection, vaginal dryness, and pain during intercourse. These symptoms may also continue after menopause. Around this time, women may notice a variation in their cycle length as a sign of menopausal transition.
About 75% of women have hot flashes. During a hot flash, the woman's head and neck will become red and warm, and she may perspire a lot. A hot flash lasts from 30 seconds to 5 minutes and may be followed by a chill. Hot flashes can start up to 2 years before menopause, are at their worst for the 2 years after menopause, and gradually decrease over 6 years. About 60% of women experience hot flashes for less than 7 years and up to 15% experience them for 15 years or more.
Fluctuating hormone levels may cause a woman to feel irritable, tired, and nervous. She might also have trouble sleeping, have headaches, have breast tenderness, feel dizzy, or have a rapid or irregular heartbeat. Lack of estrogen makes the skin of the vagina thinner, causing vaginal dryness, itching, irritation, or burning. It can also cause pain during intercourse. Unlike hot flashes, vaginal symptoms do not tend to improve over time. Some women may experience poor bladder control and, occasionally, aching muscles and joints.
Postmenopausal women are more likely to have osteoporosis, which is a thinning of the bones. Women with osteoporosis can break their hips and backbones easily. Older women may not even have to fall in order to break a bone. A woman loses 3% to 5% of her bone mass every year during the first 5 years after menopause. After 5 years, she loses from 1% to 2% of bone mass yearly. Smoking, heavy drinking, lack of exercise, and not getting enough calcium in the diet can increase a woman's risk of bone loss.
Making the Diagnosis
A doctor will make a diagnosis based on a woman's symptoms, past medical history, a physical exam, and laboratory tests of hormone levels.
Treatment and Prevention
Because each woman's experience with menopause is unique, treatment depends on the symptoms that are most bothersome.
Hot flashes can be treated with prescription medications and lifestyle changes.
Prescription medications that may help with hot flashes include hormone therapy (estrogen with or without progestin) in pill, patch, or skin gel form, and clonidine*. Women with a uterus who are taking estrogen should also take a progestin (e.g., medroxyprogesterone, progesterone, or megestrol acetate) to prevent the increased risk of endometrial cancer caused by estrogens alone.
Women who experience hot flashes before reaching menopause may benefit from taking hormone therapy to help with symptoms.
Since hormone therapy has side effects and long-term risks, it's important for a woman and her doctor to weigh the benefits and the risks of using it and to use the lowest dose needed to control symptoms.
Hormone therapy can be taken daily or in cycles. With cyclic therapy, hormones are taken on certain days of the month and women will have bleeding, similar to a light period, every month. With continuous or daily therapy, hormones are taken every day. There is no monthly bleeding, but women may have spotting (small amounts of irregular bleeding) during the first 3 to 6 months of continuous therapy. Talk to your doctor about which method would be best for you.
Women who have taken estrogen for more than 5 years may have a greater risk of developing breast cancer, although the increase in risk is small. An individual risk-benefit assessment and regular monitoring are required. In general, estrogen should not be taken if a woman has, or has ever had, breast cancer, advanced endometrial cancer, or abnormal vaginal bleeding.
The terms "natural" and "synthetic" are often used to describe the different types of estrogens and progestins. These terms can be misleading because they can be used to mean different things. Sometimes the term "natural" is used to describe the chemical structure of the hormone (exactly the same as the hormones normally produced by the human body), but other times it's used to describe where the hormone comes from (e.g., from plants or animals). What's most important is not whether the hormone is natural or synthetic, but whether you're receiving the medication, dose, and dosage form that are most appropriate for you.
Currently, there is not enough evidence to support the use of alternative and herbal medication, such as black cohosh, for reducing menopause symptoms. Keep in mind that you should speak to your doctor or pharmacist before trying any herbal medication, especially if you have other medical conditions or are taking other medications.
Lifestyle changes that may help reduce the discomfort of hot flashes include:
- avoiding hot drinks or foods
- avoiding bright lights if they trigger headaches
- consuming cold drinks or foods
- dressing in layers
- exercising regularly
- learning relaxation techniques or controlled breathing
- losing weight if you're overweight
- sleeping in a cool, dark room
- using a fan or air conditioner
- wearing cotton or other natural fabrics
When vaginal dryness or painful intercourse is the most bothersome symptom, prescription medications, non-prescription/alternative therapies, or lifestyle changes may offer some relief.
Medications that can help with vaginal dryness are estrogen inserted into the vagina via various forms (e.g., tablets, rings, or creams). These medications supply estrogen directly to the vagina rather than through the bloodstream the way pills, patches, or skin gels do.
Non-prescription or alternative therapies for vaginal dryness include vaginal moisturizers, lubricants, or vitamin E cream.
Lifestyle changes that can help with vaginal dryness include:
- decreasing stress in your life
- quitting smoking
- having sex or masturbating more often
- spending more time on foreplay
Poor bladder control can be helped by weight loss (in women who are overweight), pelvic floor strengthening exercises, or vaginal pessaries. Medication may also be used to help with bladder control.
Women who experience excessive anxiety and irritability during menopause may be prescribed an antidepressant to help with these symptoms.
To prevent the bone loss that comes with menopause, women should reduce their alcohol consumption and cigarette use, and make sure to get enough calcium and vitamin D each day (1,200 mg of calcium and at least 800 units of vitamin D per day - note that your doctor may recommend a higher dose of vitamin D in some cases and may prescribe medication to help strengthen bones), through your diet and, if needed, supplements. Exercise and resistance training, also called weight training or strength training, helps prevent osteoporosis and control weight.
To maintain a healthy heart, quit smoking, maintain a healthy body weight, exercise regularly, and eat a healthy, balanced diet. Depending on your risk factors for heart disease, your doctor may recommend medications to reduce your risk, including medications to control your blood pressure or cholesterol.
Keep in mind that menopause is a normal stage in a woman's life. Natural menopause cannot be prevented.
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