Menopause

Overview

The change of life. The end of fertility. The beginning of freedom. Whatever people call it, menopause is a unique and personal experience for every woman. It's a natural event that marks the end of fertility and childbearing years. Technically, menopause results when the ovaries no longer release eggs and decrease production of the sex hormones estrogen, progesterone and, to a lesser extent, androgen. Menopause is said to have occurred when a woman has not had a period for 12 months.

Menopause & the Reproductive Cycle

Reproduction
During the reproductive years, a gland in the brain generates hormones that cause an egg from the ovaries to be released from its follicle each month. As the follicle develops, it produces the sex hormones estrogen and, after ovulation, progesterone, which results in a thickened uterine lining. This enriched lining is prepared to receive and nourish a fertilized egg, which could develop into a fetus. If fertilization does not occur, estrogen and progesterone levels drop, the lining of the uterus breaks down and menstruation occurs.

Perimenopause
For reasons unknown, your ovaries gradually begin to function less efficiently during your mid-to-late 30s. In your late 40s, the process accelerates along with greater hormone fluctuations. This affects ovulation and levels of the hormones estrogen and progesterone. During this transition period, called perimenopause, you may experience irregular menstrual cycles and unpredictable episodes of menstrual bleeding. By your early to mid-50s, your periods will likely end.

Most women can tell if they are approaching menopause because their menstrual periods start changing. The "menopause transition" is a term used to describe this time, as is perimenopause.

Menopause
But menopause itself—as defined by health care professionals—is a woman's final menstrual period, which can be confirmed after she goes 12 consecutive months with no period, and no other biological or physiological cause can be identified; it also may occur when both ovaries are surgically removed or damaged. Until that time, a woman in her late 40s or 50s may still be able to get pregnant, despite irregular periods.

Medical Intervention
Although the majority of women experience "natural" or spontaneous menopause, some women may experience menopause due to a medical intervention. Surgically removing both ovaries, a procedure known as bilateral oophorectomy, triggers menopause at any age. Induced menopause can also occur if the ovaries are damaged by radiation, chemotherapy or certain drugs. Some medical conditions also may cause menopause to occur earlier.

Naturally Occurring
Just as every woman's body is unique, each woman's menopause experience will be highly personal. In fact, some women experience no physical symptoms at all, except the end of their menstrual periods.

Early Menopause
Although the average age for menopause in the United States is 51, menopause can occur as early as your 30s and, rarely, as late as your 60s. However, there is no correlation between the time of a woman's first period and her age at menopause. In addition, age at menopause is not influenced by race, height, the number of children a woman has had or whether she took oral contraceptives for birth control.

Early menopause is defined as occurring at any age younger than 45. Menopause that occurs in women younger than 40 is called premature menopause or premature ovarian failure and can occur naturally. But symptoms of premature menopause, such as irregular periods, may signal an underlying condition, so it is important to discuss any symptoms with your health care professional.

What influences the time of menopause? Genetics are a key factor. The age at which your mother stopped her periods may be similar to when you stop your menstrual periods. And women who smoke cigarettes experience menopause two years earlier, on average, than nonsmoking women.

Symptoms of Menopause

About four to eight years prior to natural menopause, typically in a woman's late 40s, menopause-related changes may begin. One of the most common and annoying symptoms you may notice during your 40s is that your periods become irregular. They may be heavy one month and very light the next. They may get shorter or last longer. You may even begin to skip your period every few months or lose track of when your periods should start and end. These symptoms are caused by irregular estrogen and progesterone levels.

Levels of hormones vary erratically and may be higher or lower than normal during any cycle. For example, if you don't ovulate one month—which is common for women in their late 40s—progesterone isn't produced to stimulate menstruation, and estrogen levels continue to rise. This can cause spotting throughout your cycle or heavy bleeding when menstruation does start.

One note of caution: although irregular menstrual periods are common as you get closer to menopause, they can also be a symptom of uterine abnormalities or uterine cancer. See your health care professional as soon as possible if your periods stop for several months and then start again with spotting or heavy bleeding; if you have irregular spotting; if you have bleeding after intercourse; or if you start bleeding after menopause.

Be sure to mention any menstrual irregularities during regular checkups. Uterine biopsy and vaginal ultrasound and, occasionally, transabdominal ultrasound may be used to evaluate these symptoms and determine whether they are caused by abnormalities in the uterus. Irregular spotting can also be a symptom of cervical cancer, which may be picked up by a Pap or HPV test (see screening recommendations in Treatment section).

Other changes and signs of menopause include:

• Hot flashes (sudden warm feeling, sometimes with blushing)
• Night sweats (hot flashes that occur at night, often disrupting sleep)
• Fatigue (probably from disrupted sleep patterns)
• Mood swings
• Vaginal dryness
• Fluctuations in sexual desire or response
• Difficulty sleeping
• Achiness
• Bladder issues like urinary tract infections or incontinence
• Headaches

Menopause-Related Health Conditions
Although there is a wide range of possible menopause-related conditions, most women experiencing natural menopause only have mild disturbances during the perimenopausal years. However, you should be aware that there are at least two major health conditions that can develop in the post-menopausal years: coronary artery disease and osteoporosis.

Your body's estrogen helps protect against plaque buildup in your arteries. It does this by helping to raise HDL cholesterol (good cholesterol), which helps remove LDL cholesterol (the type that contributes to the accumulation of fat deposits called plaque along artery walls). It also helps blood vessels dilate to promote better blood flow. As you age, your risk for developing coronary artery disease (CAD)—a condition in which the veins and arteries that take blood to the heart become narrowed or blocked by plaque—increases steadily. Heart attack and stroke are caused by atherosclerotic disease, in most cases.

Your body's own estrogen helps prevent bone loss and works with calcium and other hormones and minerals to build bones. Your body constantly builds and remodels bone through a process called resorption and deposition. Up until around age 30, the body makes more new bone than it breaks down. But once estrogen levels start to decline, this process slows down.

By menopause, your body breaks down more bone than it rebuilds. In the years immediately after menopause, some women may lose as much as 20 percent of their bone mass in the first five to seven years following menopause. Although loss of bone density eventually levels out, in the years ahead, keeping bone structures strong and healthy to prevent osteoporosis becomes more of a challenge. Osteoporosis occurs when bones become too weak and brittle to support normal activities.

Not all women develop heart disease or osteoporosis. Many more things affect your heart and your bones than estrogen alone. For example, exercise improves your cardiovascular system—your heart, lungs and blood vessels—at any age. It can help decrease high blood pressure, a concern for half of women over age 60, and can help maintain bone mass. It can also help reduce weight gain, a major risk factor for heart disease, diabetes and many other health conditions common to older women.

You are never too old to begin or continue exercising. A simple walking routine for 30 minutes four to five days a week can provide health benefits. There are other exercise options. Talk to your health care professional about which ones fit your lifestyle and medical needs.

If your bones are strong and healthy as you enter menopause, you'll have better bone structure to sustain you as you age. Bone loss varies from woman to woman. You can improve bone strength as you age by exercising regularly and making sure you get enough calcium in your diet or from supplements. Exercise also helps improve balance, muscle tone and flexibility, which can diminish with aging. Weakness in these areas can lead to more frequent falls, broken bones and longer healing periods.

Women today can expect to live as much as one-third of their lives beyond menopause. The years following menopause can be healthy years, depending on how you take care of yourself.

Diagnosis

Menopause is diagnosed when a woman who has a uterus has not had a menstrual period for one year.

Some of the more common signs of the menopause transition (a term that refers to the five or more years around the time of menopause) that may prompt a woman to seek consultation with a qualified health care professional include:

• Hot flashes
• Vaginal dryness
• Urinary tract infections or painful urination
• Stress incontinence (leaking of urine)
• Night sweats
• Insomnia
• Headaches
• Heart palpitations
• Forgetfulness
• Mood changes
• Anxiety and irritability
• Diminished concentration
• Decreased sexual desire

Ask your health care professional about any changes you notice. And remember, menopause is not a disease; it is another life stage. (The changes listed above have not all been scientifically proven to be related to menopause.)

As part of the evaluation of symptoms that may be caused by menopause, your health care professional will carefully assess your symptoms and administer a thorough physical examination. You will also be asked to provide a complete medical history; be sure to include information about your family medical history.

Laboratory tests may include baseline serum chemistry studies, lipid evaluation and hormonal evaluation. Other tests may include:

• Pap test
• Mammography
• Bone density screening
• Assessment of the uterine lining, when indicated
• Pelvic ultrasound screening, when indicated

Menopause is associated with consistently increased follicle stimulating hormone (FSH) levels. In perimenopausal women, elevated FSH levels are sometimes detected; however, this FSH elevation is often intermittent (and therefore unreliable), so the ultimate determining factor in knowing whether you have experienced menopause is if you have not had a period for 12 consecutive months.

Treatment

Menopause Management

Many women pay close attention to their gynecological health during their younger years and start to ignore it after menopause. Your wellness plan after menopause should include, at minimum, annual visits to a health care professional. These visits should include:

• A mammogram every one to two years, depending on age and family history. The decision may be based on personal preference and a shared discussion with your OB/GYN. Women with a high risk for breast cancer may also have an MRI.
• Gynecologic exams as recommended by your health care professional. (Note that medical organizations have varying recommendations for pelvic exams, and Medicare only covers a pelvic exam every two years.)
• A Pap test every three years or a Pap test combined with an HPV (human papillomavirus) test every five years until age 65.Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, a history of cervical cancer or moderate to severe cervical dysplasia or a weakened immune system due to organ transplant, chemotherapy or chronic steroid use may need more frequent Pap tests.
  
  Women who are age 65 or older and who have had adequate prior screening with normal results and who are not at high risk for cervical cancer may stop getting Pap tests. Ask your health care professional about what's best for you.
• To look for polyps and colon cancer in women of average risk, the American Cancer Society recommends a colonoscopy every 10 years; a flexible sigmoidoscopy every five years; a double-contrast barium enema every five years; or a CT colonography (virtual colonoscopy) every five years. As an alternative, you may be able to do a stool DNA test every three years; a fecal immunochemical test (FIT) once a year; or a guaiac-based fecal occult blood test (gFOBT) once a year. If one of these less invasive tests is positive, the next step will be a colonoscopy. The American College of Gastroenterology recommends African Americans start screening for colon cancer at age 45 rather than 50. Talk to your health care professional about which screening tests are best for you and when you should be tested.
• Blood pressure check at least every two years starting at age 20 (more often if it's chronically high), and blood cholesterol screening every four to six years starting at age 20 (more often if it's chronically high or you have other risk factors for heart disease or stroke); ask your health care professional for guidance.
• Bone density screenings, such as a dual-energy X-ray absorptiometry (DEXA or DXA) if you are over age 65, or at a younger age if you are at risk for developing osteoporosis; ask your health care professional about how often you should have this test.
• Annual screenings for diabetes (again, your health care professional may tell you this test is needed less frequently, depending on your risk factors).
• Thyroid function testing as recommended by your health care professional.
• Age-appropriate flu shots and other immunizations.

Discuss any unusual or uncomfortable symptoms with your health care professional. Keep track of medications that you take and ask your health care professional or pharmacist about potential drug interactions, if you are told to take a new medication. Be sure to discuss with your health care professional any alternative medical treatments or herbal products you use or may wish to use.

The Menopause Transition

As your body transitions into menopause (a process that typically lasts about four to eight years) you may notice some physical and emotional changes. The most common include:

• Irregular menstrual periods
• Hot flashes
• Vaginal dryness
• Urinary tract infections
• Stress incontinence
• Night sweats
• Insomnia
• Headaches
• Heart palpitations
• Forgetfulness
• Mood changes
• Anxiety and irritability
• Diminished concentration

There are a variety of options available to relieve these symptoms, if you find they interfere with your lifestyle. Discuss your symptoms and your concerns with your health care professional to determine which options make the most sense for you.

The following tips may be recommended to relieve the most common menopausal symptoms:

Hot flashes. Although no one knows for sure what causes hot flashes, they're believed to be the result of a narrowing of the temperature range that normally tells the brain to adjust your internal temperature. The pituitary gland in your brain increases the amount of follicle stimulating hormone (FSH) and luteinizing hormone (LH) aimed at the ovaries. Falling estrogen levels and the increase in FSH and LH levels disturb your body's internal temperature. This creates instability in your vasomotor balance and results in a hot flash.

About 75 of every 100 women approaching or going through menopause have hot flashes, which usually last for about three to five years. Hot flashes may get more intense and more frequent around your last menstrual period and then taper off, usually stopping after one to five years. About 10 percent to 15 percent of women will have significant hot flashes that persist more than 10 years after the last menstrual period, although they do tend to get better over time. Some women continue to have hot flashes past age 70.

During a hot flash, you may experience a sudden sensation of heat in your face, neck and chest. You may sweat profusely and your pulse may become more rapid. Some women get dizzy or nauseous. A hot flash typically lasts about two to four minutes—which can seem like an eternity. For some women hot flashes are intolerable, occurring at inconvenient moments or at night, disrupting sleep.

There are a variety of strategies for coping with hot flashes. Hormone therapy (estrogen alone or estrogen plus progesterone) may be prescribed at an appropriate dose for an appropriate time. There are other medical options, as well as herbal remedies, but lifestyle strategies may be the easiest and quickest changes to try first:

• Dress in layers that may be removed if you find you're getting too warm.
• Sleep in a cool room.
• Drink plenty of water.
• Avoid hot foods such as soups, spicy foods, caffeinated foods and beverages and alcohol, which can trigger hot flashes.
• Try to decrease stress.
• Exercise regularly.
• Breathe deeply and slowly, if you feel a hot flash starting; rhythmic breathing may help to "turn down" the heat of a hot flash or prevent it from starting altogether.
• Use a hand-held fan.

Insomnia. Sleep is often a casualty of menopause, whether it is interrupted by hot flashes (called night sweats when they occur at night) or difficulty falling or staying asleep. Hormonal ups and downs are partly responsible. Plus, as you age, your sleep patterns may change. Older people may sleep less, awaken earlier and go to sleep sooner or later than they did at younger ages.

Lifestyle changes for coping with insomnia include:

• Sleep in a cool room to help relieve hot flashes that may be disturbing your sleep. In hot weather, you may want to lower your bedroom thermostat at night and use a small fan to keep air circulating. If you sleep in night clothes, keep a clean, dry change at bedside, so you can change quickly and get back to sleep. If you share your bed with a partner, consider using an electric blanket with dual controls.
• Exercise regularly.
• Set and keep a regular routine and hour for going to sleep.
• Drink a glass of warm milk right before bedtime but avoid other foods.
• Avoid alcoholic beverages or smoking before sleep.
• Avoid watching TV in bed (some programs are anything but relaxing!).
• Practice relaxation techniques like deep breathing.
• Review any medications you are taking to see if they may cause sleeplessness.

Mood swings. For reasons still not well understood, declining and fluctuating estrogen levels during the menopausal transition can cause emotional highs and lows and irritability. Lack of sleep due to night sweats may also contribute to feeling irritable and depressed. Though your periods are coming to an end, you may continue to experience the symptoms of premenstrual syndrome (PMS). In fact, emotional symptoms may worsen for some women as they approach menopause. You may also notice that you've lost interest in sex. Declining estrogen and changes in estrogen/testosterone ratios in women at this time may lower your sex drive.

Lifestyle strategies for coping with mood swings and sexuality concerns include:

• Make physical activity part of your schedule; exercise can improve mood and make you feel better about yourself.
• Try relaxation techniques such as meditation or massage, which can be calming and reduce irritability.
• Discuss your symptoms and what may be causing them with your partner; try different approaches to intimacy.

Vaginal dryness and frequent urinary tract infections. Estrogen, a natural hormone produced by the body, helps keep the vagina lubricated and supple. Following menopause, as estrogen levels decline, the vagina becomes drier and the vaginal wall thins. Sex may become painful. The wall of the urethra becomes thinner, too, as estrogen levels fall, and increases the risk of more frequent urinary tract infections. Urine leakage may become a problem as muscle support for the bladder and urethra weakens. (This may also occur from strain on tissues as a result of childbirth). Vaginal dryness and bladder symptoms can get worse over time.

Strategies for coping with vaginal dryness and frequent urinary infections include:

• Use nonhormonal vaginal creams or gels (prescription or nonprescription).
• If moisturizers and lubricants are not enough, vaginal estrogen (a prescription medication) is available as creams, rings or tablets. You can also try prasterone, a prescription form of the hormone dehydroepiandrosterone (known as DHEA) or an oral nonhormonal medication (ospemifene) that helps with painful sex.
• Drink plenty of water to help your body stay hydrated.
• Use long-lasting vaginal moisturizers.
• Exercising to maintain muscle tone.
  
  Practice Kegel techniques to strengthen the pelvic floor muscles that support the bladder and urethra. Kegel exercises help firm the vaginal canal, control urine flow and enhance orgasm. To make sure you know how to contract your pelvic floor muscles correctly, try to stop the flow of urine while you're going to the bathroom. If you can do this, you've found the right muscles. (You can ask your health care professional to check your Kegel tone at your next gynecological visit.)
  
  To do Kegel exercises, empty your bladder and sit or lie down. Contract your pelvic floor muscles for three seconds, then relax for three seconds. Repeat 10 times. Once you've perfected the three-second contractions, try doing the exercise for four seconds at a time and then resting for four seconds, repeating 10 times. Gradually work up to keeping your pelvic floor muscles contracted for 10 seconds at a time, relaxing for 10 seconds in between. Aim to complete a set of 10 exercises, three times a day.
• Tell your health care professional about any medications you're taking. Some may worsen vaginal dryness. Also, if you have a urinary tract infection, you may need antibiotics.

Heart palpitations. Some women in their late 40s are frightened by their hearts beating fast in their chests for no apparent reason. This symptom, called a heart palpitation, is caused by the heart beating irregularly or missing one or two beats. Though this symptom can be associated with several types of serious heart-related conditions, it is also common during the transition to menopause and typically is not related to heart disease. For example, a woman's heart rate can increase seven to 15 beats during a hot flash.

If you think you are experiencing heart palpitations:

• See your health care professional immediately if you have shortness of breath; pounding or irregular heartbeat; dizziness; nausea; pain in the neck, jaw, arm or chest that comes and goes; or tightness in the chest. Any could be a sign of a serious heart condition.
• Ask your health care professional to rule out conditions that may cause heart palpitations, such as thyroid disorders.
• Ask your health care professional about appropriate options for relieving heart palpitations, such as decreasing caffeine, and whether any medications are needed.

Forgetfulness or difficulty concentrating. During and after the menopause transition, many women are troubled to find they have difficulty remembering things, experience mental blocks or have trouble concentrating. Not getting enough sleep or having sleep disrupted can contribute to memory and concentration problems. Stress associated with major life changes—such as caring for aging parents or having your children leave home—can also interfere with sleep. However, the latest research shows memory declines during menopause are likely independent processes resulting in part from hormonal fluctuations rather than from stress or sleep deprivation. In fact, research shows memory loss during menopause is real and differs from the type of memory loss that results from aging in general.

Although the memory changes some women experience during the menopausal transition may be due in part to hormonal changes, it's not recommended that women take HT to prevent memory decline, however.

Other strategies for coping with memory problems and lack of concentration include:

• Recognize that these symptoms may be caused by menopausal changes and aging and don't put pressure on yourself.
• Rely on strategies for remembering things, such as developing daily reminder lists or messages to help get you through periods of forgetfulness.
• Practice stress-reduction techniques, such as deep breathing exercises, yoga and meditation, and try to be physically active on a regular basis.

If you find the strategies you've tried don't relieve your discomfort, ask your health care professional about medical options. Medical strategies to relieve various menopausal symptoms include:

Oral contraceptives. Oral contraceptives can help ease symptoms associated with menopause, including irregular periods and mood swings, among others. Typically, oral contraceptives are recommended to women who are still having periods. For many women in their 40s, oral contraceptives provide the added benefit of preventing pregnancy. Still, taking oral contraceptives close to menopause can make it difficult to determine when you have stopped menstruating. Women who smoke, have high blood pressure, experience migraines associated with aura or have diabetes, a history of gall bladder disease or blood clotting disorders should not use oral contraceptives. Discuss your health history with your health care professional and ask for guidance on this treatment option.

If you're considering taking hormones other than oral contraceptives to manage menopausal symptoms, be aware that the doses of estrogen and progesterone typically taken to manage menopausal symptoms are not adequate to provide protection against an unwanted pregnancy. A woman who is still fertile must use contraceptives containing higher levels of hormones or use additional birth control methods in addition to hormone replacement.

Antidepressant medication. One antidepressant medication, paroxetine 7.5 mg (Brisdelle), is approved for treating hot flashes. This is a low-dose version of the antidepressant Paxil. Other antidepressants, such as venlafaxine (Effexor) and fluoxetine (Prozac) may offer some relief from hot flashes but are not FDA-approved for treatment of hot flashes.

Cardiovascular medication. Low doses of the blood pressure drug clonidine (Catapres) or the anti-seizure medication gabapentin (Neurontin) may also help ease hot flashes in some women. These drugs are not FDA-approved for hot flashes, however, and unpleasant side effects are common.

Menopausal Hormone Therapy

Estrogen therapy came on the market more than 75 years ago, and many women viewed it as the "fountain of youth." Once prescribed as the first choice for the long-term prevention of osteoporosis and heart disease, as well as for short-term relief of menopausal symptoms such as hot flashes, hormone therapy is now only prescribed for the management of menopausal symptoms in women without certain risk factors, such as a history of breast cancer, coronary artery disease and a previous blood clot or stroke.

Hormone therapy comes in several forms: estrogen can be given alone or combined with progesterone or with a synthetic progestin. When combined with progestin, it is called hormone therapy (HT). It is given only to women who still have their uterus because progesterone reduces the risk of uterine cancer that comes with supplemental estrogen.

When given as estrogen alone, hormone therapy is called estrogen therapy (ET). It is typically given to women who no longer have a uterus.

Postmenopausal hormone therapy comes in a variety of forms: pills, creams, skin patches, vaginal rings and injections.

Some hormones are called "bioidentical," meaning they are chemically, i.e., molecularly, identical to the substance as it occurs in your body. These hormones, however, don't come from your body (or another woman's body). Most bioidentical estrogens and progesterone come from soy (estrogen) or yams (progesterone).

They are also not "natural," or in their natural state, when you take them. To create a hormone women can use, the plant or animal-based hormones are synthesized, or processed, through a several-step process in a laboratory.

There are two main types of bioidentical hormones: those that are approved by the U. S. Food and Drug Administration (FDA) and commercially available with a prescription, such as Estrace, Climara, Vivelle, EstroGel, Divigel and Estrasorb, and those that are produced on an individual basis for women, in compounding pharmacies. The North American Menopause Society does not recommend compounded hormone products.

A synthetic hormone is a mass-produced molecular compound created in the laboratory that act as estrogens but are not exactly the same. Prempro, for instance, is a combination of two synthetic hormones.

All hormones—synthetic and bioidentical—are made in the laboratory and work in the same way: by binding in a kind of lock-and-key process to special proteins on cell surfaces called receptors. Once a hormone locks onto these receptors, the messages from that hormone can be transferred to the cell.

Before deciding on any type of hormone therapy, a woman should discuss her personal health history with her health care professional, because studies, opinions and recommendations regarding HT have varied throughout the years.

In the 1970s, a study found that women who had a uterus and took estrogen therapy had an increased risk of developing cancer of the lining of the uterus. However, it was noted that the addition of progesterone or a synthetic progestin lowered the risk to that of women not taking estrogen.

In the 1980s and 1990s some studies appeared demonstrating that women who took estrogen therapy after menopause had reduced risks of heart disease and osteoporosis. However, the National Institutes of Health (NIH) suggested that a randomized, double- blind study be done to see whether estrogen really helped to prevent heart disease.

This NIH study, known as the Women's Health Initiative (WHI), looked at two groups of women: women who had had a hysterectomy were given estrogen only (or a placebo) and women who went through natural menopause and had not had a hysterectomy were given estrogen and a synthetic progestin or a placebo.

The study was stopped early, in 2002, because, after about five years, women in the estrogen and progestin group had a very slight increase in cases of breast cancer, and no decrease in heart disease was noted. The estrogen-only study continued for about two more years. In that group, the data showed a statistically insignificant decrease in breast cancer and no decrease in heart disease.

Many women panicked when they heard about the increased risk in breast cancer. And many questions arose about the heart disease issue.

The WHI study was later found to be flawed for several reasons. Most notably, it looked at women starting hormone therapy between the ages of 50 and 79, with the average participant being 63 years old when starting therapy. Additionally, the increased risk of being diagnosed with breast cancer was seen only after five-plus years of therapy. Also, only one dosage of estrogen and progestin was used for the study. And the absolute risk noted was very small: eight women per 10,000 per year.

A number of additional studies looked at the relationship between hormone therapy and heart disease. Most indicate that hormone therapy must be started reasonably close to the time of menopause to have any heart benefits. If a woman goes through menopause very early—significantly before age 50—her risk of developing heart disease is quite high if she does not take hormone therapy. However, in a woman who undergoes a standard menopause, hormone therapy should not be initiated solely to prevent heart disease.

Much research also has been done regarding breast cancer and hormone therapy.

In Europe, studies show that micronized progesterone, not the synthetic variety, is not associated with any significant increased risk of breast cancer. More studies are ongoing. And there is now a new medication being used to protect the lining of the uterus during estrogen therapy, instead of using progesterone or progestins. This medication, bazedoxifene, is combined with estrogen in a drug called Duavee. Bazedoxifene is a cousin of tamoxifen, the medication used to treat breast cancer. No increased risk of breast cancer has been noted with its use, but studies are continuing.

Another concern about oral estrogen therapy is the slight increased risk of blood clots, as well as strokes. Europe studies show that transdermal estrogens, administered through patches or gels, do not increase the risk of blood clots. Some small studies show no increased risk of strokes with low-dose transdermal estrogens.

An 18-year follow-up of the WHI study shows no increased mortality from any diseases in the estrogen and progestin users, which is reassuring.

Also important: All studies on estrogen therapy show protection from osteoporosis.

So, what's a woman to do?

The North American Menopause Society issued new guidelines on hormone therapy in 2017. It says that hormone therapy is quite safe and helpful in reducing symptoms of menopause such as hot flashes and vaginal dryness, particularly for women under the age of 60 and within 10 years of menopause. Hormone therapy is typically initiated to treat menopause symptoms early in the menopause transition when a woman is most symptomatic.

NAMS says the advantages outweigh the risks for women who are symptomatic. The organization notes that estrogen therapy has been shown to prevent bone loss and fracture.

While it's true that menopausal symptoms do decrease within the first five years of menopause for most women, some women deal with persistent symptoms. These women may continue with hormone therapy. NAMS recommends women use the "appropriate dose for the appropriate duration," to be evaluated by each woman and her health care professional.

The FDA advises health care professionals to prescribe postmenopausal hormone therapies at the lowest possible dose and for the shortest possible length of time to achieve treatment goals.

For women who aren't confident that their health care professionals have expertise in dealing with menopausal issues, visit the website of the North American Menopause Society to help locate a North American Menopause Society Certified Menopause Practitioner.

Alternatives to Hormone Therapy

For heart protection. Lifestyle strategies for cardiovascular health include exercise, not smoking, maintaining a healthy weight and limiting salt and alcohol. A balanced diet rich in vegetables, fruits and fish, and low in saturated fat can also provide some heart-health benefits.

Your health care professional may prescribe medication to reduce cholesterol and blood pressure levels and reduce your risk of heart disease.

For reduced sex drive. Testosterone is a hormone that plays an important role in women's bodies. Often thought of incorrectly as exclusively a male sex hormone, testosterone is secreted by the ovaries and adrenal gland and is natural to the female body. Surgical menopause (removal of the ovaries) may have a negative effect on sex drive, and testosterone therapy is sometimes prescribed to help.

Testosterone is not FDA approved for the treatment of low libido, however, and we don't know what doses are appropriate for women. Too much testosterone may not help with sexual desire but may, instead, make you feel agitated, overly aggressive and/or depressed. Higher doses can cause masculinizing side effects that may not go away after stopping therapy, such as facial and body hair growth, acne, an enlarged clitoris, a lowered voice and muscle weight gain.

Testosterone may also be associated with adverse heart-related conditions, such as increased risk for atherosclerosis. There are currently no FDA-approved testosterone-alone preparations for women, although it is often prescribed "off-label" for women. There's a specific prescription combination estrogen (esterified estrogens) and testosterone (oral methyltestosterone) pill called Syntest DS that may help combat testosterone deficiency. Do not use Syntest if you have liver disease; a recent history of heart attack, stroke or circulation problems; a hormone-related cancer such as breast or uterine cancer; abnormal vaginal bleeding; or if you are pregnant or breast-feeding. It also increases your risk of endometrial hyperplasia, which may lead to cancer of the uterus.

Since the safety of taking testosterone for extended periods has not been established, women should be very cautious when considering this type of hormone treatment. Discuss the risks and benefits with your health care professional.

Osteoporosis. Lifestyle changes shown to improve bone density in young women and prevent fractures in older women include dietary calcium and avoiding smoking and excessive alcohol consumption. Weight-bearing exercise is quite helpful, if approved by your health care provider.

Additionally, several prescription drugs are available to treat and/or prevent osteoporosis.

Herbal Remedies

Some women report that vitamin and herbal supplements are helpful in managing menopausal symptoms. For instance, phytoestrogens—naturally occurring compounds in certain plants, herbs and seeds—are similar in chemical structure to estrogen and produce estrogen-like effects.

Soy products (tofu, tempeh, soy milk, soy burgers and roasted soy nuts), certain herbs (red clover) and legumes (chickpeas, lentils and various kinds of beans) contain specific types of phytoestrogens called isoflavones. These are healthy foods that are excellent sources of protein and calcium and can be added to your diet.

Some studies show that the isoflavones (weak, plant-derived estrogens) in soy foods and dietary supplements can reduce mild hot flashes. But most studies show they are no more effective than a placebo. Talk to your health care professional before taking any form of isoflavones. Some oncologists have expressed concern about breast cancer survivors using soy products. If you have breast cancer (or have had it), talk with your oncologist before trying soy and soy isoflavones.

Black cohosh has been widely used in Europe for the treatment of hot flashes, and it has become more popular among U.S. women who want something to curb their hot flashes. The supplement's safety record is good, but there is limited research supporting its effectiveness in treating menopausal symptoms. Talk to your doctor about black cohosh before taking any form of the supplement.

There is also no scientific evidence to support the effectiveness of evening primrose oil, ginseng, kava, licorice, sage and dong quai root. Discuss any herbal or vitamin supplements you are considering taking with your health care professional. Bear in mind that studies related to their effectiveness are sparse, and the FDA doesn't oversee the production of supplements and does not require manufacturers to prove their products are safe. Also be aware that high doses of certain vitamins and herbal supplements can be dangerous. For example ephedra used in some weight-loss products has potentially serious side effects. Mixing herbal supplements with some prescription drugs can also be dangerous. So again, be sure to tell your health care professional everything you take.

Prevention

You can't stop menopause, but you can prepare for its arrival. These strategies can help make your transition to menopause and your postmenopausal years healthy:

• Be prepared for how and why your body will change.
• Be informed about health issues after age 50.
• Develop a wellness plan that includes regular health screenings, regular exercise and a healthy diet throughout the years ahead.
• To improve your cardiovascular health and decrease your risk for osteoporosis, avoid smoking, weight gain and excessive alcohol consumption. (Moderate drinking for women is defined as one drink per day equaling one 12-ounce bottle of beer or wine cooler; one 5-ounce glass of wine; or 1.5 ounces of 80 proof distilled spirits, according to the National Institute on Alcohol Abuse and Alcoholism. Anything beyond that is considered excessive. Drinking as little as two drinks a day increases risk of breast cancer.)
• Eat a balanced diet.
• Consider strength-training exercises and other weight-bearing exercises to increase your bone strength to prevent fractures as you age. Women should also take a daily vitamin D supplement of at least 600 IU.

Women today don't have to surrender to old age. Life after menopause can be as healthy, independent and fulfilling as any of the younger stages of a woman's life; many postmenopausal women find their lives more satisfying.

Facts to Know

1. After age 55, more than half of all deaths in women are caused by heart disease. And despite being thought of as a man's disease, more women die from heart disease than men. Women can protect themselves against heart disease by not smoking, eating a healthy diet and getting regular exercise.
2. There is a direct relationship between osteoporosis—a disease in which bones lose calcium and become brittle and more likely to fracture—and the lack of estrogen after menopause. Early menopause (before age 45) and any other extended period during which hormone levels are low and menstrual periods are absent can cause a decrease in bone mass.
3. About 6,000 women in the United States reach menopause every day for a total of more than 2 million per year.
4. In one study, 80 percent of women in menopause reported no decrease in quality of life, and 75 percent felt they had no loss in their attractiveness.
5. According to the North American Menopause Society, most women—about 62 percent—report positive attitudes toward menopause.
6. Some women continue to experience premenstrual syndrome (PMS) symptoms as they approach menopause. These symptoms can include swollen or tender breasts, bloating, nausea and moodiness.
7. Fertility decreases gradually as menopause approaches. However, you can still get pregnant, even if your periods are irregular. A significant number of unintended pregnancies occur in women aged 40 to 44. Thus the need for reliable contraception remains important.
8. As estrogen levels decline, vaginal tissue and tissue in the lower urinary tract become thinner, drier and less supple, causing painful intercourse and more frequent urinary tract infections in some women. Osteoporosis and heart disease are other consequences of declining estrogen levels in the decades following menopause.
9. As you approach menopause, you may notice that you feel more irritable and moodier than usual. Some researchers believe this moodiness is due to the changes in your estrogen levels, but others think it may be more the result of the other symptoms that accompany menopause, such as hot flashes and fatigue, coupled with other stressors that often plague women in middle age. Severe depression, however, is not a symptom of menopause.

Questions to Ask

Review the following Questions to Ask about menopause so you're prepared to discuss this important health issue with your health care professional.

1. How many women in my age group do you treat? What percentage does this number represent of your total practice?
2. Are you comfortable treating perimenopausal and postmenopausal women? If not, can you refer me to a colleague who is?
3. Do you consider yourself up-to-date on treatment options for perimenopausal and postmenopausal health concerns, including hormone therapy and other medical therapies?
4. Can you arrange for evaluations for osteoporosis and heart disease? At what age should I have these evaluations?
5. If I am interested in alternative therapies, will you work with me to help identify those that might be helpful or refer me to someone who is a safe and knowledgeable practitioner?
6. I don't feel well in several different ways. Are my symptoms due to menopause or another condition?
7. How do I know if my on-again, off-again bleeding is perimenopause or another problem?
8. My sex drive is low. Can this be due to menopause or other factors in my life?
9. Will my incontinence stop after menopause, and what can I do about it now?
10. Can you discuss the most recent research about hormone therapy and its safety with me? How do the benefits and risks of hormone therapy apply to my personal health needs?

Key Q&A

Lifestyle Tips

1. Cooling off those hot flashes without hormone therapy
   Try dressing in light layers that can be taken off when a hot flash starts; using a hand-held fan (battery operated or manual); and taking a tepid or cool shower before bedtime. For some women, alcohol or caffeine can trigger hot flashes, so it may help to avoid these substances. If stress brings on hot flashes, try relaxation techniques, such as deep breathing and meditation.
2. Weight gain at menopause common but not inevitable
   Most women gain weight, especially in their midsection, around menopause. This midlife weight gain is partly because of hormonal changes associated with menopause. However, weight gain is also associated with inadequate physical activity, and women tend to be less physically active as they grow older. To avoid weight gain, reduce calorie intake and make exercise a priority. In fact, you may need to eat less and exercise more than you did when you were younger to lose weight or to maintain a healthy weight because your metabolism naturally slows as you age.
3. Calcium, vitamin D key to bone health, overall health
   Adequate calcium intake—in the presence of adequate levels of vitamin D—plays a major role in reducing the incidence of osteoporosis, a bone-thinning disease that can lead to fractures. In addition, calcium also appears to have beneficial effects in several non-skeletal disorders, such as high blood pressure, colorectal cancer, obesity and kidney stones. According to the National Osteoporosis Foundation, women aged 19 through 49 should get 1,000 mg of elemental calcium, and, to ensure adequate calcium absorption, 400 to 800 IU per day of vitamin D. Women 50 years of age and older should get 1,200 mg of calcium and 800 to 1,000 IU of vitamin D per day. Calcium is best absorbed from whole foods, or in supplement doses of 500 mg or less at a time, so split your 1,000 to 1,200 mg into two or three doses.
   
   Because it's best to get calcium through food, calculate your daily dairy intake first. For example, eight ounces of milk or yogurt or an ounce of hard cheese has about 300 mg of calcium. For women over 50, subtract that from 1,200 and then take the amount of supplemental calcium needed.
4. Vaginal dryness easily conquered
   As estrogen levels drop at menopause, the vagina's natural lubricants decline, resulting in dryness and itching that can make intercourse painful. The paradox is that regular sexual activity that leads to orgasm can help keep the vagina moist. Before intercourse, try inserting a nonprescription water-soluble lubricant around the opening and a small amount into the vagina. You may also try long-lasting vaginal moisturizers. If nonprescription remedies don't help, talk to your health care professional about vaginal estrogens, vaginal DHEA or an oral nonhormonal medication like ospemifene.

Organizations and Support

For information and support on Menopause, please see the recommended organizations, books and Spanish-language resources listed below.

American Menopause Foundation (AMF)
Address: 350 Fifth Avenue, Suite 2822
New York, NY 10118
Email: menopause@earthlink.net

Association of Reproductive Health Professionals (ARHP)
Website: https://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

Hormone Foundation
Website: https://www.hormone.org
Address: 8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815-5817
Hotline: 1-800-HORMONE (1-800-467-6663)
Email: hormone@endo-society.org

MGH Center for Women's Mental Health
Website: https://www.womensmentalhealth.org
Address: Perinatal and Reproductive Psychiatry Program Simches Research Builiding
185 Cambridge St Suite 2200
Boston, MA 02114
Phone: 617-724-7792

National Women's Health Network (NWHN)
Website: https://www.nwhn.org
Address: 1413 K Street, NW, 4th floor
Washington, DC 20005
Hotline: 202-682-2646
Phone: 202-682-2640
Email: nwhn@nwhn.org

North American Menopause Society (NAMS)
Website: https://www.menopause.org
Address: Post Office Box 94527
Cleveland, OH 44101
Phone: 440-442-7550
Email: info@menopause.org

Red Hot Mamas
Website: https://www.redhotmamas.org
Address: 7712 Georgetown Chase
Roswell, GA 30075
Phone: 770-640-1018
Email: info@redhotmamas.org

Books

100 Questions & Answers About Menopause
by Ivy M. Alexander and Karla A. Knight

A Gynecologist's Second Opinion
by William H. Parker and Rachel L. Parker

Could It Be...Perimenopause?
by Steven R. Goldstein and Laurie Ashner

Dr. Susan Love's Menopause and Hormone Book: Making Informed Choices
by Susan M. Love and Karen Lindsey

Is It Hot In Here? Or Is It Me? The Complete Guide to Menopause
by Barbara Kantrowitz and Pat Wingert Kelly

Making Love the Way We Used to…or Better: Nine Secrets to Satisfying Midlife Sexuality
by Alan M. M. Altman and Laurie Ashner

New Menopausal Years, The Wise Woman Ways: Alternative Approaches for Women 30-90
by Susun S. Weed

Menopause: Questions You Have... Answers You Need
by Annette Thevenin Doran and Lisa Bonnell Samalonis

The Menopause Sourcebook
by Gretchen Henkel

Mind over Menopause: The Complete Mind/Body Approach to Coping With Menopause
by Leslee Kagan, Herbert Benson, and Bruce Kessel

The Premature Menopause Book: When the "Change of Life" Comes Too Early
by Kathryn Petras

Menopause: The Silent Passage, Revised and Updated
by Gail Sheehy

This Is Not Your Mother's Menopause: One Woman's Natural Journey Through Change
by Trisha Posner

Yale Guide to Women's Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin and Carol V. Wright

Spanish-language resources

Medline Plus: Menopause
Website: https://www.nlm.nih.gov/medlineplus/spanish/menopause.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

The Hormone Foundation
Website: https://www.hormone.org/pacientes-y-cuidadores/la-menopausia-y-la-perdida-de-masa-osea
Address: The Hormone Foundation
8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815
Hotline: 1-800-HORMONE
Email: hormone@endo-society.org