Menopause

(Change of Life, Climacteric)

The Facts

Menopause is the time when a person's menstrual periods stop and their ovaries stop releasing eggs. A person is considered menopausal once they have gone a year without having a menstrual period. Therefore, the exact time of a person's final menstrual period can only be pinpointed by counting backwards after the fact.

Although most menstruating people go through menopause around age 50, normal menopause can happen any time between the age of 40 and 60. The last periods are usually more irregular and have less blood flow. However, some people's periods don't change at all.

Along with normal or natural menopause, there is also premature menopause. Premature menopause occurs before the age of 40 and can be caused by a variety of things, such as removal of the ovaries, autoimmune disorders, endocrinological reasons, or cancer therapy. Medical interventions, such as a hysterectomy (when the uterus is removed), may also prevent menstruation. If the ovaries are removed as well, production of the hormones estrogen and progesterone are stopped, causing the symptoms of menopause.

The Causes

Menopause is a normal part of the aging process. Follicle stimulating hormone (FSH) and luteinizing hormone (LH) are secreted by the pituitary gland as part of the normal menstrual cycle. They stimulate the ovary to produce estrogen and progesterone and to release an egg. As a person ages, their ovaries don't respond to FSH or LH as strongly as they used to. Over time, less and less estrogen and progesterone are produced and the person stops releasing eggs.

Premature menopause can be genetic or it can be caused by autoimmune diseases. These diseases produce antibodies that can damage the ovaries. Surgical removal of the ovaries causes artificial menopause, as can chemotherapy or radiation therapy to the pelvis to treat cancer.

Smoking, malnutrition, and living at a high altitude can also lower the expected age of menopause.

Symptoms And Complications

Before their periods stop completely, a person might experience a variety of unpleasant symptoms, including hot flashes, irritability, night sweats, loss of bladder control, urinary infection, vaginal dryness, and pain during intercourse. These symptoms may also continue after menopause. Around this time, an individual may notice a variation in their cycle length as a sign of menopausal transition.

About 75% of menopausal people have hot flashes. During a hot flash, the person's head and neck will become red and warm, and they may perspire a lot. A hot flash usually lasts from 30 seconds to 5 minutes and may be followed by a chill. Hot flashes can start up to 2 years before menopause, are at their worst for the 2 years after menopause, and gradually decrease over 6 years. Most menopausal people experience hot flashes for less than 7 years, though some may experience them for 15 years or more.

Fluctuating hormone levels may cause a person to feel irritable, tired, and nervous. They might also have trouble sleeping, have headaches, have breast tenderness, feel dizzy, or have a rapid or irregular heartbeat. Lack of estrogen makes the skin of the vagina thinner, causing vaginal dryness, itching, irritation, or burning. It can also cause pain during intercourse. Unlike hot flashes, vaginal symptoms do not tend to improve over time. Some people may experience poor bladder control and, occasionally, aching muscles and joints.

Postmenopausal people are more likely to have osteoporosis, which is a thinning of the bones. People with osteoporosis can break their hips and backbones easily. Older people may not even have to fall in order to break a bone. People lose about 3% to 5% of their bone mass every year during the first 5 years after menopause. After 5 years, they lose about 1% to 2% of bone mass yearly. Smoking, heavy drinking, lack of exercise, and not getting enough calcium in the diet can increase the risk of bone loss.

Making A Diagnosis

A doctor will make a diagnosis based on the person's symptoms, past medical history, a physical exam, and rarely laboratory tests of hormone levels. Before any treatment is started, doctors may conduct breast and pelvic exams and measurements of blood pressure and height.

Treatment And Prevention

Because each person's experience with menopause is unique, treatment depends on the symptoms that are most bothersome.

Hot flashes

Hot flashes can be treated with prescription medications and lifestyle changes.

Prescription medications that may help with hot flashes include hormone therapy, antidepressants, anti-seizure medications (e.g., gabapentin, pregabalin), oxybutynin, and clonidine*. When hormone therapy is used, estrogen is the primary hormone used. People with a uterus who are taking estrogen should also take a progestin (e.g., medroxyprogesterone, progesterone, or megestrol acetate) to prevent the increased risk of endometrial cancer caused by estrogens alone.

Antidepressants such as paroxetine, escitalopram, citalopram, or venlafaxine may help with hot flashes.

People who experience hot flashes before reaching menopause may benefit from taking hormone therapy to help with symptoms.

Since hormone therapy has side effects and long-term risks, it's important for the individual and their doctor to weigh the benefits and the risks of using it and to use the lowest dose needed to control symptoms.

Hormone therapy can be taken daily or in cycles. With cyclic therapy, hormones are taken on certain days of the month and the individual will have bleeding, similar to a light period, every month. With continuous or daily therapy, hormones are taken every day. There is no monthly bleeding, but the individual may have spotting (small amounts of irregular bleeding) during the first 3 to 6 months and up to a year of continuous therapy. Talk to your doctor about which method would be best for you.

People who have taken estrogen over long periods of time, without any breaks, may have a greater risk of developing breast cancer, although the increase in risk is small. An individual risk-benefit assessment and regular monitoring are required. In general, estrogen should not be taken if an individual has, or has ever had, breast cancer, advanced endometrial cancer, or abnormal vaginal bleeding.

The terms "natural" and "synthetic" are often used to describe the different types of estrogens and progestins. These terms can be misleading because they can be used to mean different things. Sometimes the term "natural" is used to describe the chemical structure of the hormone (exactly the same as the hormones normally produced by the human body), but other times it's used to describe where the hormone comes from (e.g., from plants or animals). What's most important is not whether the hormone is natural or synthetic, but whether you're receiving the medication, dose, and dosage form that are most appropriate for you.

Currently, there is not enough evidence to support the use of alternative and herbal medication, such as black cohosh, for reducing menopause symptoms. Keep in mind that you should speak to your doctor or pharmacist before trying any herbal medication, especially if you have other medical conditions or are taking other medications.

Lifestyle changes that may help reduce the discomfort of hot flashes include:

avoiding hot drinks or foods
avoiding bright lights if they trigger headaches
consuming cold drinks or foods
dressing in layers
exercising regularly
learning relaxation techniques or controlled breathing
losing weight if you're overweight
sleeping in a cool, dark room
using a fan or air conditioner
wearing cotton or other natural fabrics

Vaginal dryness

When vaginal dryness or painful intercourse is the most bothersome symptom, prescription medications, non-prescription/alternative therapies, or lifestyle changes may offer some relief.

Medications that can help with vaginal dryness are estrogen inserted into the vagina via various forms (e.g., tablets, rings, or creams). These medications supply estrogen directly to the vagina rather than through the bloodstream the way pills, patches, or skin gels do.

Non-prescription or alternative therapies for vaginal dryness include vaginal moisturizers with hyaluronic acid, water-based lubricants, or vitamin E cream.

Lifestyle changes that can help with vaginal dryness include:

decreasing stress in your life
quitting smoking
having sex or masturbating more often
spending more time on foreplay

Poor bladder control can be helped by weight loss (for people who are overweight), pelvic floor strengthening exercises, or vaginal pessaries. Medication may also be used to help with bladder control.

People who experience excessive anxiety and irritability during menopause may be prescribed an antidepressant to help with these symptoms.

To prevent the bone loss that comes with menopause, people should reduce their alcohol consumption and cigarette use, and make sure to get enough calcium and vitamin D each day (1,200 mg of calcium and at least 800 units of vitamin D per day - note that your doctor may recommend a higher dose of vitamin D in some cases and may prescribe medication to help strengthen bones), through your diet and, if needed, supplements. Exercise and resistance training, also called weight training or strength training, helps prevent osteoporosis and control weight.

To maintain a healthy heart, quit smoking, maintain a healthy body weight, exercise regularly, and eat a healthy, balanced diet. Depending on your risk factors for heart disease, your doctor may recommend medications to reduce your risk, including medications to control your blood pressure or cholesterol.

Keep in mind that menopause is a normal stage in a person's life. Natural menopause cannot be prevented.

*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For information on a given medication, check our Drug Information database. For more information on brand names, speak with your doctor or pharmacist.