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), you can no longer become pregnant.

The symptoms of menopause are caused by changes in estrogen and progesterone levels. As the ovaries become less functional, they produce less of these hormones and the body responds accordingly. The specific symptoms you experience and how significant (mild, moderate, or severe) varies from woman to woman.

In some women, menstrual flow comes to a sudden halt. More commonly, it tapers off. During this time, your menstrual periods generally become either more closely or more widely spaced. This irregularity may last for 1 to 3 years before menstruation finally ends completely.

A gradual decrease of estrogen generally allows your body to slowly adjust to the hormonal changes. When estrogen drops suddenly, as is seen when the ovaries are removed surgically (called surgical menopause), symptoms can be more severe.

Because hormone levels fall, 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 decreases. This is called atrophy of the labia.

Symptoms

The potential symptoms include:

• Decreased sex drive
• Hot flashes and skin flushing
• Insomnia
• Irregular menstrual periods
• Mood swings including irritability, depression, and anxiety
• Night sweats
• Spotting of blood in between periods
• Urinary tract infections
• Vaginal dryness and painful sexual intercourse
• Vaginal infections

In addition, the long-term effects of menopause include:

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

Signs and tests

Blood and urine tests can be used to measure hormone levels that may indicate 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

Menopause is a natural process. Treatment with hormones may be helpful if you experience debilitating symptoms such as hot flashes, night sweats, 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.

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 REPLACEMENT THERAPY

For years, hormone replacement therapy (HRT) was the main treatment for menopause symptoms. Many physicians believed that HRT was not only good for reducing menopausal symptoms, but also reduced the risk of heart disease and bone fractures from osteoporosis. However, the results of a major study called the Women's Health Initiative has led physicians to change their recommendations.

In fact, this important study was stopped early because the health risks outweighed the benefits. Women taking the hormones did see some benefits. But they had a greatly increased risk for breast cancer, heart attacks, strokes, and blood clots.

If your symptoms are severe, you may still want to consider HRT for short-term use (2-4 years) to reduce vaginal dryness, hot flashes, and other symptoms.

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

• Using estrogen/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

ALTERNATIVES TO HRT

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
• 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 to preserve the elasticity of your vagina
• See an acupuncturist
• Use relaxation techniques like yoga, tai chi, or meditation
• Use water-based lubricants during sexual intercourse

There are also 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.

Complications

Estrogen is responsible for the buildup of the lining of the uterine cavity. During the reproductive years, this buildup is shed (menstruation). This usually happens about once a month.

The menopausal decrease in estrogen prevents this buildup from occurring. However, hormones produced by the adrenal glands are converted to estrogen, and sometimes this will cause postmenopausal bleeding.

This bleeding is often nothing to worry about, but because it may also be an early indication of other problems, including cancer, your physician should always check any postmenopausal bleeding.

Decreased estrogen levels are also associated with an increased risk of developing osteoporosis and possibly an increased risk of cardiovascular 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 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 that accompany menopause.

You can reduce your risk of long-term problems like osteoporosis and heart disease in the following ways:

• 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.
• Exercise regularly, including doing resistance exercises, to strengthen your bones.
• 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

Weismiller D. The perimenopause and menopause experience: an overview. Clin Fam Practice. 2002; 4(1).

Stenchever, MA. Comprehensive Gynecology, 4th ed. St. Louis, Mo: Mosby, Inc.; 2001:1217-1250.

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.

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.