Definition and Facts about Menopause
- Menopause is the time when a woman stops having menstrual periods.
- Many women experience a variety of symptoms as a result of the hormonal changes associated with the transition to menopause. Around the time of menopause, women often lose bone density and their blood cholesterol levels may worsen, increasing their risk of heart disease.
- Signs and symptoms women experience during this transition include:
- Vaginal dryness
- Painful intercourse
- Mood swings
- Weight gain
- Loss of interest in sex (although some women experience an increase in sexual desire)
- The average age of U.S. women at the time of menopause is 51 years. The most common age range at which women experience menopause is 48-55 years.
- Premature menopause is defines as menopause occurring in a woman younger than 40 years. About 1% of women experience premature, or early menopause, which can be caused by premature ovarian failure or cancer.
- Menopause is more likely to occur at a slightly earlier age in women who smoke, have never been pregnant, or live at high altitudes.
- The hormonal changes associated with menopause actually begin prior to the last menstrual period, during a three to five year period sometimes referred to as the perimenopause. During this transition, women may begin to experience menopausal symptoms even though they are still menstruating.
- Surgical menopause is menopause induced by the removal of the ovaries. Women who have had surgical menopause often have a sudden and severe onset of the symptoms of menopause.
What Is Menopause? What Is the Average Age of Menopause?
Menopause refers to the time at which a woman's menstruation stops. It is defined as the absence of menses (a period) for 12 consecutive months. The average age of menopause is 51 years, although this can vary widely.
What Causes Menopause? Does Every Woman Go Through Menopause?
Yes, every woman will experienced Menopause. Menopause occurs due to a complex series of hormonal changes. Associated with the menopause is a decline in the number of functioning eggs within the ovaries. At the time of birth, most females have about 1 to 3 million eggs, which are gradually lost throughout a woman's life. By the time of a girl's first menstrual period, she has an average of about 400,000 eggs. By the time of menopause, a woman may have fewer than 10,000 eggs. A small percentage of these eggs are lost through normal ovulation (the monthly cycle). Most eggs die off through a process called atresia (the degeneration and subsequent resorption of immature ovarian follicles - fluid filled cysts that contain the eggs).
- Normally, FSH, or follicle-stimulating hormone (a reproductive hormone), is the substance responsible for the growth of ovarian follicles (eggs) during the first half of a woman's menstrual cycle. As menopause approaches, the remaining eggs become more resistant to FSH, and the ovaries dramatically reduce their production of estrogen.
- Estrogen affects many parts of the body, including the blood vessels, heart, bone, breasts, uterus, urinary system, skin, and brain. Loss of estrogen is believed to be the cause of many of the symptoms associated with menopause. At the time of menopause, the ovaries also decrease their production of testosterone-a hormone involved in libido, or sexual drive.
How Long Does Menopause Last?
Since a woman reaches menopause at the point in time at which she has not had a period for 12 consecutive months. Menopause itself is not a process, but denotes a point in time when menstruation stops. Women have either reached this point (are post-menopausal) or have not (pre-menopausal or perimenopause). The process of declining hormone levels prior to menopause has been referred to as perimenopause or the menopausal transition. This process can last for up to 10 years or more in some women and is variable in length.
9 Signs and Symptoms of Menopause
- Hot flashes: Hot flashes are the most common symptom of menopause. According to some studies, hot flashes occur in as many as 75% of perimenopausal women. Hot flash symptoms vary among women. Commonly, a hot flash is a feeling of warmth that spreads over the body, lasting from around 30 seconds to a few minutes. Flushed (reddened) skin, palpitations (feeling a strong heartbeat), and sweating often accompany hot flashes. Hot flashes often increase skin temperature and pulse, and they can cause insomnia, or sleeplessness. Hot flashes usually last 2 to 3 years, but many women can experience them for up to 5 years or longer. An even smaller percentage may have them for more than 15 years.
- Urinary incontinence and burning on urination
- Vaginal changes: Because estrogen affects the vaginal lining, perimenopausal women may also have pain during intercourse and may note a change in vaginal discharge.
- Breast changes: Menopause may cause changes in the shape of the breasts.
- Thinning of the skin
- Bone loss: Rapid bone loss is common during the perimenopausal years. Most women reach their peak bone density when aged 25 to 30 years. After that, bone loss averages 0.13% per year. During perimenopause, bone loss accelerates to about a 3% loss per year. Later, it drops off to about a 2% loss per year. No pain is usually associated with bone loss. However, bone loss can cause osteoporosis, a condition that increases the risk of bone fractures. These fractures can be intensely painful and can interfere with daily life. They also can increase the risk of death.
- Cholesterol: Cholesterol profiles also change significantly at the time of menopause. Total cholesterol and LDL ("bad") cholesterol levels increase. Increased LDL cholesterol is associated with an increased risk of heart disease.
- Heart disease risk increases after menopause, although it is unclear exactly how much is due to aging and how much is caused by the hormonal changes that occur at the time of menopause. Women who undergo premature menopause or have their ovaries removed surgically at an early age are at an increased risk of heart disease.
- Weight gain: A three year study of healthy women nearing menopause found an average gain of five pounds during the three years. Hormonal changes and aging are both possible factors in this weight gain.
When to Call Your Doctor
- All perimenopausal and postmenopausal women should see their health care practitioner annually for a full physical exam. This exam should include a breast exam, pelvic exam, and mammogram.
- Women should learn about the risk factors for heart disease and colon cancer from their health care professional and consider being screened for these diseases.
- Women who are still menstruating and are sexually active are at risk of becoming pregnant (even if their periods are irregular). Birth control pills containing low doses of estrogen can be useful for perimenopausal women to prevent pregnancy and to relieve perimenopausal symptoms, such as hot flashes.
- Over-the-counter medications, prescription medications, and lifestyle changes, such as diet and exercise, help control hot flashes and other menopausal symptoms, including high cholesterol and bone loss.
Is There a Test to Diagnose When a Woman Has Reached Menopause?
Blood testing: To determine if a woman is in the perimenopause, a health-care professional may check the follicle stimulating hormone (FSH) level through a blood test.
Bone testing: The standard for measuring bone loss, or osteoporosis, associated with menopause is the DEXA (dual-energy X-ray absorptiometry) scan. The test calculates bone mineral density and compares it to the average value for healthy young women. The World Health Organization defines osteoporosis as more than 2.5 standard deviations below this average value. A condition known as osteopenia indicates less severe bone loss (between 1 and 2.5 standard deviations below the average value).
- The DEXA scan is usually performed before a doctor prescribes medications for osteoporosis to rebuild bone mineral density. The test is a special X-ray film taken of the hip and of the lower bones in the spine. The scan is repeated in one and a half to two years to measure response to treatment.
- Simple bone screening can also be done in ultrasound machines that measure the bone density of the heel. This is merely a screening device. If low bone density is detected, follow-up with a complete DEXA scan may be required.
Heart risk testing: Postmenopausal women may be at risk for heart disease. A doctor can measure cholesterol levels with a simple blood test. If cholesterol levels are high, the doctor can advise women about ways to decrease their risk of heart disease.
Treatments for Menopausal Symptoms
Menopause is not a disease that has a definitive cure or treatment. Health care practitioners, however, can offer a variety of treatments for hot flashes and other menopausal symptoms that become bothersome. Many prescription medications exist to prevent and control high cholesterol and bone loss, which can occur at menopause. Some women do not need therapy, or they may choose not to take medications at all during their menopausal years.
Lifestyle Changes To Ease Symptoms
Hot flashes: Several nonprescription treatments are available, and lifestyle choices can help.
- Many women feel that regular aerobic exercise can help reduce hot flashes, but controlled studies have not proved any benefit.
- Foods that may trigger hot flashes, such as spicy foods, caffeine, and alcohol, should be avoided.
Heart disease: A low-fat, low-cholesterol diet helps to reduce the risk of heart disease.
Weight gain: Regular exercise is helpful in controlling weight.
Osteoporosis: Adequate calcium intake and weight-bearing exercise are important. Strength training (not just lifting weights, but any exercise where you bear your own weight, such as walking, tennis or gardening) can strengthen bones.
Hormone Therapy (HT) or Estrogen Therapy (ET) for Menopausal Symptoms
Estrogens or a combination of estrogens and progesterone (progestin)
Long-term studies of women receiving combined HT with estrogen and progesterone showed an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. Studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer. Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus).
More recently, studies have suggested that the cardiovascular risks associated with hormone therapy may be more relevant for older postmenopausal women rather than those in the perimenopause or early postmenopausal period. The decision regarding hormone therapy, therefore, should be individualized by each woman and her healthcare professional based on her medical history, the severity of the symptoms, and the potential risks and benefits of hormone administration.
Estrogen is available in a variety of forms, including vaginal creams, tablets, and estrogen vaginal rings (for example, Estring), which are mainly useful for vaginal symptoms; skin patches (Vivelle, Climara, Estraderm, Esclim, Alora); transdermal sprays or gels (for example, Evamist); and oral tablets.
Women should undergo a breast exam and mammogram prior to starting estrogen. Once on estrogen, women must be monitored regularly with breast exams and mammograms.
Women who already have heart disease should not use estrogen.
Estrogen therapy does not prevent pregnancy.
Women who take estrogen also tend to have a higher risk of developing:
Bioidentical Hormone Therapy
There has been increasing interest in recent years in the use of so-called "bioidentical" hormone therapy for perimenopausal women. Bioidentical hormone preparations are medications that contain hormones that have the same chemical formula as those made naturally in the body. The hormones are created in a laboratory by altering compounds derived from naturally-occurring plant products. Some bioidentical hormone preparations are made at special pharmacies called compounding pharmacies, which make the preparations on a case-by-case basis for each patient. These individual preparations are not regulated by the FDA, because compounded products are not standardized.
Advocates of bioidentical hormone therapy argue that the products, applied as creams or gels, are absorbed into the body in their active form without the need for "first pass" metabolism in the liver and that their use may avoid potentially dangerous side effects of synthetic hormones used in conventional hormone therapy. However, studies to establish the long-term safety and effectiveness of these products have not been carried out.
Other Medications for Symptom Relief
The class of drugs known as selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) typically used in the treatment of depression and anxiety, has been shown to be effective in reducing menopausal hot flashes. Paroxetine (Brisdelle) is an SSRI that has been approved for the treatment of moderate to severe hot flashed associated with menopause. Another SSRI that has been tested and shown to be effective is venlafaxine (Effexor), although other SSRI drugs may be effective as well.
Clonidine (Catapres) is a drug that decreases blood pressure. Clonidine can effectively relieve hot flashes in some women. Side effects include dry mouth, constipation, drowsiness, and difficulty sleeping.
Gabapentin (Neurontin), a drug primarily used for the treatment of seizures, has also been used successfully to treat hot flashes.
Progestin drugs have also been successfully used to treat hot flashes. Megestrol acetate (Megace) is sometimes prescribed over the short-term to help relieve hot flashes. Serious effects can occur if the medication is abruptly discontinued, and megestrol is not usually recommended as a first-line drug to treat hot flashes. An unpleasant side effect of Megestrol is that it may lead to weight gain.
Several medications may be used for preventing and treating osteoporosis.
- The bisphosphonates, which include alendronate (Fosamax) and risedronate (Actonel), have been shown in clinical trials to reduce bone loss in postmenopausal women and to reduce fracture risk in women who have osteoporosis.
- Raloxifene (Evista), a selective estrogen receptor modulator (SERM), is another therapy for osteoporosis. It reduces bone loss and appears to reduce the risk of back fractures in women with osteoporosis.
- Calcitonin (Miacalcin or Calcimar) is a nasal spray that has been found to reduce the risk of back fractures in women who have osteoporosis.
- A prevention drug that may also be effective is PTH (parathyroid hormone), but this is not a usual first-line treatment.
Herbs and Supplements for Menopausal Symptoms
- Black cohosh (Remifemin) is a commonly used herbal supplement that is believed to reduce hot flashes. However, small German studies that tested black cohosh only followed women over a short time period. The German agency that regulates herbs does not recommend using black cohosh for longer than six months. Side effects can include nausea, vomiting, dizziness, visual problems, slow heartbeat, and excessive sweating. Black cohosh is not regulated by the U.S. Food and Drug Administration, so women must be careful about the safety and purity of this supplement.
- Plant estrogens (phytoestrogens) such as soy protein are a popular remedy for hot flashes, although data on their effectiveness are limited. Phytoestrogens are natural plant estrogens (isoflavones), which are thought to have effects similar to estrogen therapy. The safety of soy in women who have a history of breast cancer has not been established, although clinical studies indicate soy is no more effective for treating symptoms than a placebo. Soy comes from soybeans and is also called miso or tempeh. The best food sources are raw or roasted soybeans, soy flour, soy milk, and tofu. Soy sauce and soy oil do not contain isoflavones.
- Herbals: Inconclusive and conflicting studies indicate that other herbals, such as dong quai, red clover (Promensil), chasteberry (Vitex), yam cream, Chinese medicinal herbs, and evening primrose oil, should be avoided or taken with care under the supervision of a health care professional to avoid unwanted and dangerous side effects and interactions.
- CAM: According to the National Center for Complementary and Alternative Medicine, other nonprescription techniques may relieve the symptoms of menopause. These techniques include meditation, acupuncture, hypnosis, biofeedback, deep breathing exercises, and paced respiration (a technique of slow breathing using the stomach muscles).
Do I Need To Take Calcium Supplements During Menopause?
Menopause cannot be prevented; however, steps can be taken to help reduce the risk factors for other problems associated with menopause. It is recommended that postmenopausal women consume 1200 to 1500 mg of elemental calcium (total diet plus supplements if necessary, and 800 Units of vitamin D daily.
The least expensive way to obtain calcium is through diet. Diet can easily provide 1,000-1,500 mg of calcium daily. The following foods contain calcium:
- One cup of milk (regular or fat-free/skim) - 300 mg
- One cup of calcium-fortified orange juice - 300 mg
- One cup of yogurt (regular or fat-free) - about 400 mg on average
- One ounce of cheddar cheese - about 200 mg
- Three ounces of salmon (including the bones) - 205 mg
Dietary calcium supplements are a good option for women who cannot consume adequate calcium through diet. Calcium carbonate (Caltrate 600, Caltrate 600 Plus D, Caltrate Plus) is the least expensive, although some women complain of bloating. Calcium citrate may be better absorbed by women who take acid-blocking medications, such as ranitidine (Zantac) or cimetidine (Tagamet).
Calcium products made from bone meal, dolomite, or unrefined oyster shells may contain lead and should be avoided. Products with "USP" on the label meet the voluntary quality standards set by the United States Pharmacopeia and are more likely not to contain harmful contaminants.
Women should carefully read the label of calcium supplements to check the exact number of milligrams of elemental calcium in each supplement. The intestinal tract generally does not absorb more than 500 mg of elemental calcium at a time, so calcium intake should be spread out during the day.
Women should not take excessive doses of calcium due to the risk of kidney stones. Women with certain medical conditions, such as sarcoidosis or kidney stones, should consult their health care professionals prior to taking calcium supplements.
Vitamin D plays an important role in calcium absorption, but megadoses should be avoided.