Menopause

Menopause is the time in a woman’s life when she stops having menstrual periods. The years leading up to this point are called perimenopause, or “around menopause.” Menopause marks the end of the reproductive years that began in puberty.

The average age that women go through menopause is 51 years. Most women enjoy a healthy lifestyle for years afterward. This pamphlet explains:

What Is Menopause?

The ovaries, two glands on either side of the uterus, make estrogen from puberty until menopause. Estrogen is made during the entire menstrual cycle. It causes the lining of the uterus (the endometrium) to thicken each month.

On about day 14 of your menstrual cycle, an egg is released from one of the ovaries. This is called ovulation. After ovulation, progesterone levels increase. If the egg is not fertilized, no pregnancy occurs. This causes the levels of estrogen and progesterone to decrease. This signals the uterus to shed its lining. This shedding is your monthly period.

As menopause nears, the ovaries make less estrogen. One of the earliest and most common signs that menopause may be approaching is a change in your menstrual periods. You may skip one or more periods. The amount of flow may become lighter or heavier. Bleeding may last a shorter or longer time than is usual for you.

Even though periods tend to be irregular around the time of menopause, you should be aware of bleeding that is not normal for you. This could be a sign of a problem. Talk to your doctor if you:

• Have a change in your monthly cycle
• Have very heavy bleeding with clots
• Have bleeding that lasts longer than normal
• Bleed more often than every 3 weeks
• Bleed after sex or between periods

At some point, the ovaries stop making enough estrogen to thicken the lining of the uterus. This is when the menstrual periods stop.

Menopause also can occur when a woman’s ovaries are surgically removed. This may trigger severe symptoms because the hormone levels decrease all at once.

Although the removal of the uterus (a hysterectomy) ends menstrual periods, it will not cause menopause unless the ovaries also are removed. If the ovaries remain after surgery, most women will go through menopause around the normal age.

What to Expect

Menopause is a natural part of aging. The lower amounts of estrogen that come with menopause will cause changes in your body. These changes occur over time. Menopause is different for everyone. Some women notice little difference in their bodies. Others may find it difficult to cope with their symptoms.

Hot Flushes

The most common symptom of menopause is hot flushes (hot flashes). As many as 75% of menopausal women in the United States will have them. A hot flush is a sudden feeling of heat that rushes to the upper body and face. The skin may redden like a blush. You also may break out in a sweat. A hot flush may last from a few seconds to several minutes or longer.

Hot flushes can happen at any time—day or night. They can be mild or severe. Hot flushes may come a few times a month or several times a day, depending on the woman. Some women will have hot flushes for a few months, some for a few years, and some not at all. Even though hot flushes are a nuisance, are sometimes embarrassing, and may interfere with daily life, they are not harmful.

Sleep Problems

Hot flushes can cause a lack of sleep by often waking a woman from a deep sleep. A lack of sleep may be one of the biggest problems you face as you approach menopause. Too little sleep can affect your mood, health, and ability to cope with daily activities. Some women have less rapid eye movement—known as REM—sleep. This is the stage of sleep when you dream. REM sleep makes up about 20% of an adult’s normal sleep cycle. Without it, you may wake up without feeling rested. Some women approaching menopause also may find it takes longer to get to sleep.

Vaginal and Urinary Tract Changes

Loss of estrogen causes changes in the vagina. Its lining may become thin and dry. These changes can cause pain during sexual intercourse. They also can make the vagina more prone to infection, which can cause burning and itching.

The urinary tract also changes with age. The urethra (the tube that carries urine from the bladder) can become dry, inflamed, or irritated. Some women may need to urinate more often. Women may have an increased risk of bladder infection after menopause.

Bone and Other Body Changes

Bone loss is a normal part of aging. At menopause, the rate of bone loss increases. Osteoporosis, which can result from this bone loss, increases the risk of breaking bones in older women. The bones of the hip, wrist, and spine are affected most often.

The estrogen produced by women’s ovaries before menopause protects them from heart attacks and stroke. When less estrogen is made after menopause, women lose much of this protection. The risk of heart attack and stroke then increases.

Emotional Changes

Menopause does not cause depression. However, the change in hormone levels may make you feel nervous, irritable, or very tired. These feelings may be linked to other symptoms of menopause, such as lack of sleep.

If you are under a lot of stress, the changes of menopause may be harder to manage. Many women in midlife are going through major life changes anyway. There may stress related to money or your job. Some women may be watching children leave home and are learning to deal with the “empty nest.” Some are saddened that they can no longer have children. More often, women find themselves part of the “sandwich generation,” becoming caregivers for their children, grandchildren, and their aging parents. If you find it hard to cope, talk about your feelings with your partner, a close friend, a counselor, or your doctor.

Sexuality

Menopause does not have to affect your ability to enjoy sex. Although the lack of estrogen may make the vagina dry, vaginal lubricants can help moisten the vagina and make sex more comfortable. There are a number of over-the-counter lubricants available. If you do not like one product, try another.

Regular sex may help the vagina keep its natural elasticity. If you have been having sex on a regular basis, you may not notice any major changes during menopause. If you have not been sexually active for a while, you may want to talk with your partner and perhaps your doctor, too, about ways to make sex more comfortable.

Some women find that they have less interest in sex around and after menopause. Lower hormone levels may decrease the sex drive. It may affect your ability to have an orgasm, or it may take longer for you to reach orgasm.

You are not completely free of the risk of pregnancy until 1 year after your last period. Until this time, if you do not wish to become pregnant, it is important to use a method of birth control. Keep in mind you still need to prevent sexually transmitted diseases. If you are at risk for sexually transmitted diseases, use a latex condom.

Men, too, may find that their sex drives decrease as they age. It may take an older man longer to achieve an erection and ejaculate, or he may have problems with impotence. Impotence usually is caused by physical or medical problems, or it may be caused by medications. In many cases, impotence can be treated with success.

The Gynecologic Visit

Routine health care, even if you are not sick, can help detect problems early. You should visit your doctor once a year to have regular exams and tests. Certain tests should be done regularly for all women in your age group (see Table 1).

During a routine exam, your doctor will measure your weight and blood pressure and may check your skin and body overall to be sure everything is normal. During a routine gynecologic exam, your doctor will check your breasts for lumps or discharge, check your abdomen to see if there are any problems with your ovaries or uterus, inspect your vulva and vagina, and may examine your rectum. Your doctor may do a Pap test to check for changes in cells that could lead to cancer of the cervix. Between visits you may want to perform a breast self-exam once a month. Depending on your age, your doctor may recommend that you have a mammogram. You also will be asked about your general health and medical history, including:

• Your health history
• Your diet
• Your exercise habits
• Whether you smoke or drink alcohol or use drugs
• Whether you take any medications

If you have problems at any time, contact your doctor. Do not wait until your next checkup.

Hormone Therapy

Hormone therapy can help relieve the symptoms of menopause. It can replace female hormones no longer made by the ovaries. In some cases, you may begin hormone therapy before menopause. If you are taking birth control pills, they will be stopped when you begin treatment.

For women with a uterus, estrogen usually is given along with progestin—a synthetic version of the hormone progesterone. This helps reduce the risk of cancer of the lining of the uterus that occurs when estrogen is used alone. The progestin may be taken every day with estrogen, or estrogen may be taken on some days and the progestin added on others.

Hormone treatment is most often prescribed in the form of pills, vaginal rings, or patches placed on the skin. Estrogen creams and tablets, used in the vagina, can treat dryness, but do not work as well for other symptoms.

Benefits

Estrogen is used to treat the main symptom of menopause—hot flushes. It also relieves vaginal dryness and can help to relieve some changes that can cause problems in the urinary tract. Estrogen protects against bone loss. Hormone therapy slows bone loss after menopause and helps prevent osteoporosis. Estrogen also can help reduce the risk of colon cancer.

Risks

Like any treatment, hormone therapy is not free of risk. In women with a uterus, using estrogen alone can increase the risk of endometrial cancer because estrogen causes the lining of the uterus to grow. Taking a progestin along with estrogen will help reduce the risk of uterine problems. The drawback of using a progestin is that it seems to increase the risk of breast cancer. Also, menopausal women may start bleeding again. Although bleeding may occur only for a short time, many women find this bleeding bothersome.

The Women’s Health Initiative, a study by the National Institutes of Health, raised concerns about the risks of hormones for postmenopausal women. Because of these findings, the U.S. Food and Drug Administration (FDA) announced that all products for use by postmenopausal women that contain estrogen should include a warning label stating that prolonged use of these hormones could increase the risk of heart attacks, strokes, blood clots, and breast cancer for some women. The study results suggest that the increased risk of health problems from hormone therapy may vary from woman to woman depending on how far a woman is past menopause. For example, a woman who is 15 years past menopause may be at greater risk than a woman who is 2 years past menopause. You should take the smallest dose of hormone therapy that works for you, for the shortest amount of time. You and your doctor should decide whether this treatment is right for you. Women who are prescribed these drugs to treat vaginal dryness may want to consider using a topical cream or gel product.

Other Therapies

If a woman does not take hormone therapy, there are some other options for preventing bone loss, such as bisphosphonates or selective estrogen receptor modulators (SERMs). A medication called calcitonin slows the breaking down of bone. It can be given by injection or nasal spray. Bisphosphonates are used to increase bone density and reduce the risk of fractures. Parathyroid hormone also is used for this purpose.

Women can take SERMs to help treat or prevent some of the bone problems that can occur during menopause. SERMs are a type of medication that strengthen tissues of the bones. SERMs may be a good choice for women who need protection from osteoporosis, but cannot or do not want to take hormone therapy.

Staying Healthy

Good Nutrition

Eating a balanced diet will help you stay healthy before, during, and after menopause. It is important to eat a variety of foods to make sure you get all the essential nutrients. Choose a low-fat, low-cholesterol diet. Also, be sure to include enough calcium in your diet to help maintain strong bones. Women aged 51 years and older need 1,200 mg of calcium per day. The National Institutes of Health recommends 1,500 mg of calcium per day for postmenopausal women who do not take hormone therapy and all women older than 65 years. Be aware, however, that your body can only absorb about 500 mg of calcium at one time. If you take more, try to divide it into two doses.

It is hard to get enough calcium from eating dairy products and certain vegetables, so you should consider using calcium supplements. Ask your pharmacist about a supplement to slow bone loss.

Calcium cannot be absorbed without vitamin D. Milk that is fortified with vitamin D is one of the best sources. Another is sunlight. You also can use vitamin D supplements. A woman should take the recommended daily amount of vitamin D, which is 10 micrograms for women aged 51–70 years.

Exercise

Exercise is very important, especially as you get older. Regular exercise slows down bone loss and improves your overall health. Follow a program of regular weight-bearing exercise, such as walking and aerobics.

Finally…

Menopause is a natural event. Today, women can expect to live one third of their lives after menopause. The physical changes that occur around menopause should not prevent you from enjoying this time of your life. To function at your best, you should:

• Exercise regularly.
• Eat a balanced diet that contains enough calcium.
• Visit your doctor for routine checkups.

Glossary

Estrogen: A female hormone produced in the ovaries that stimulates the growth of the lining of the uterus.

Fecal Occult Blood Test: A test of a stool sample for blood, which could be a sign of cancer of the colon or rectum.

Hormone Therapy: Treatment in which estrogen, and often progestin, is taken to relieve the symptoms caused by the low levels of hormones produced by the body.

Impotence: The inability in a male to have an erection or to sustain it until ejaculation or intercourse takes place.

Mammogram: An X-ray of the breast, used to detect breast cancer.

Osteoporosis: A condition in which the bones become so fragile that they break more easily.

Pap Test: A test in which cells are taken from the cervix and examined under a microscope.

Sexually Transmitted Diseases: Diseases that are spread by sexual contact, including chlamydial infection, gonorrhea, genital warts, herpes, syphilis, and infection with human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]).

Sigmoidoscopy: Test in which a slender device is placed into the rectum and lower colon to detect cancer.