Menopause

Causes

During menopause, a woman's ovaries stop making eggs and they produce less estrogen and progesterone. Changes in these hormones cause menopause symptoms. Periods occur less often and eventually stop. Sometimes this happens suddenly. But most of the time, periods slowly stop over time.

Menopause is complete when you have not had a period for 1 year. This is called postmenopause. Women who are postmenopausal can no longer get pregnant.

Surgical menopause is when medical treatments cause a drop in estrogen. This can happen if your ovaries are removed or if you receive chemotherapy or hormone therapy for breast cancer.

Symptoms

Symptoms vary from woman to woman. They may last 5 or more years. Some women may have worse symptoms than others. Symptoms of surgical menopause can be more severe and start more suddenly.

The first thing you may notice is that your periods start to change. They might occur more often or less often. Some women might get their period every 3 weeks. This might last for 1 - 3 years before the periods completely stop.

Common symptoms of menopause include:

• Menstrual periods that occur less often and eventually stop
• Heart pounding or racing
• Hot flashes, usually worst during the first 1 - 2 years
• Night sweats
• Skin flushing
• Sleeping problems (insomnia)

Other symptoms of menopause may include:

• Decreased interest in sex, possibly decreased response to sexual stimulation
• Forgetfulness (in some women)
• Headaches
• Mood swings including irritability, depression, and anxiety
• Urine leakage
• Vaginal dryness and painful sexual intercourse
• Vaginal infections
• Joint aches and pains
• Irregular heartbeat (palpitations)

Exams and Tests

Blood and urine tests can be used to look for changes in hormone levels. Test results can help your doctor determine if you are close to menopause or if you have already gone through menopause.

Tests that may be done include:

• Estradiol
• FSH
• LH

Your health care provider will perform a pelvic exam. Decreased estrogen can cause changes in the lining of the vagina.

Bone loss increases during the first few years after your last period. Your doctor may order a bone density test to look for bone loss related to osteoporosis.

Treatment

Treatment for menopause depends on many things, including how bad your symptoms are, your overall health, and your preference. It may include lifestyle changes or hormone therapy.

HORMONE THERAPY

Hormone therapy may help if you have severe hot flashes, night sweats, mood issues, or vaginal dryness. Hormone therapy is treatment with estrogen and, sometimes, progesterone.

Talk to your doctor about the benefits and risks of hormone therapy. Your doctor should be aware of your entire medical history before prescribing hormone therapy (HT). Learn about options that do not involve taking hormones.

Several major studies have questioned the health benefits and risks of hormone therapy, including the risk of developing breast cancer, heart attacks, strokes, and blood clots.

Current guidelines support the use of HT for the treatment of hot flashes. Specific recommendations:

• HT may be started in women who have recently entered menopause.
• HT should not be used in women who started menopause many years ago, except for estrogen vaginal creams.
• The medicine should not be used for longer than 5 years.
• Women taking HT have a low risk for stroke, heart disease, blood clots, or breast cancer.

To reduce the risks of estrogen therapy, your doctor may recommend:

• A lower dose of estrogen or a different estrogen preparation (for instance, a vaginal cream or skin patch rather than a pill)
• Frequent and regular pelvic exams and Pap smears to detect problems as early as possible
• Frequent and regular physical exams, including breast exams and mammograms

If you have a uterus and decide to take estrogen, you should also take progesterone to prevent cancer of the lining of the uterus (endometrial cancer). If you do not have a uterus, you do not need progesterone.

See also: Hormone therapy

ALTERNATIVES TO HORMONE THERAPY

There are other medicines available to help with mood swings, hot flashes, and other symptoms. These include:

• Antidepressants, including paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), and fluoxetine (Prozac)
• A blood pressure medicine called clonidine
• Gabapentin, a seizure drug that also helps reduce hot flashes

DIET AND LIFESTYLE CHANGES

Hormones are not always needed to reduce symptoms of menopause. There are many steps you can take to reduce symptoms.

Diet changes:

• Avoid caffeine, alcohol, and spicy foods.
• Eat soy foods. Soy contains estrogen.
• Get plenty of calcium and vitamin D in food or supplements.

Exercise and relaxation techniques:

• Get plenty of exercise.
• Do Kegel exercises every day. They strengthen the muscles of your vagina and pelvis.
• Practice slow, deep breathing whenever a hot flash starts to come on. Try taking six breaths a minute.
• Try yoga, tai chi, or meditation.

Other tips:

• Dress lightly and in layers.
• Keep having sex.
• Use water-based lubricants or a vaginal moisturizer during sex.
• See an acupuncture specialist.

See also: Managing menopause at home

Possible Complications

Some women have vaginal bleeding after menopause. This is often nothing to worry about. However, you should tell your health care provider if this occurs. It may be an early sign of other health problems, including cancer.

Decreased estrogen levels have been linked with some long-term effects, including:

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

When to Contact a Medical Professional

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 or spotting begins again, even if it is a very small amount

Prevention

Menopause is a natural and expected part of a woman's development and does not need to be prevented. You can reduce your risk of long-term problems such as osteoporosis and heart disease by taking the following steps:

• 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.
• Get regular exercise. Resistance exercises help strengthen your bones and improve your balance.
• If you show early signs of bone loss or have a strong family history of osteoporosis, talk to your doctor about medications that can help stop further weakening.
• Take calcium and vitamin D.

Alternative Names

Perimenopause; Postmenopause

References

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 420, November 2008: hormone therapy and heart disease. Obstet Gynecol. 2008;112:1189-1192.

Management of osteoporosis in postmenopausal women: 2010 position statement of the North American Menopause Society. Menopause. 2010;17:25-54.

North American Menopause Society. Estrogen and progestogen use in postmenopausal women: 2010 position statement of the North American Menopause Society. Menopause. 2010;17:242-255.

Col NF, Fairfield KM, Ewan-Whyte C, Miller H. In the clinic. Menopause. Ann Intern Med. 2009;150:ITC4-1-ITC4-15.

Brunner RL, Aragaki A, Barnabei V, et al. Menopausal symptom experience before and after stopping estrogen therapy in the Women's Health Initiative randomized, placebo-controlled trial. Menopause. 2010;17:946-954.

Freeman EW, et al. Efficacy of escitalopram for hot flashes in healthy postmenopausal women. JAMA. 2011;305:267-274.

Update Date: 9/13/2011

Updated by: David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Bellevue, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine.