What Happens During Menopause?

• Menopause is defined as the absence of menstrual periods for 12 months. It is the time in a woman's life when the function of the ovaries ceases.
• The process of menopause does not occur overnight, but rather is a gradual process. This so-called perimenopausal transition period is a different experience for each woman.
• The average age of menopause is 51 years old, but menopause may occur as early as the 30s or as late as the 60s. There is no reliable lab test to predict when a woman will experience menopause.
• The age at which a woman starts having menstrual periods is not related to the age of menopause onset.
• Symptoms of menopause can include abnormal vaginal bleeding, hot flashes, vaginal and urinary symptoms, and mood changes.
• Complications that women may develop after menopause include osteoporosis and heart disease.
• Treatments for menopause are customized for each woman.
• Treatments are directed toward alleviating uncomfortable or distressing symptoms.

Menopause is defined as the state of an absence of menstrual periods for 12 months. The menopausal transition starts with varying menstrual cycle lengths and ends with the final menstrual period. Perimenopause is a term sometimes used and means "the time around menopause." It is often used to refer to the menopausal transitional period. It is not officially a medical term but is sometimes used to explain certain aspects of the menopause transition in lay terms. "Postmenopausal" is a term used as an adjective to refer to the time after menopause has occurred. For example, doctors may speak of a condition that occurs in "postmenopausal women." This refers to women who have already reached menopause.

Menopause is the time in a woman's life when the function of the ovaries ceases. As a result, she can no longer become pregnant. The ovary (female gonad), is one of a pair of reproductive glands in women. They are situated in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones such as estrogen. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.

The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle and pregnancy. Estrogens also protect the bone. Therefore, a woman can develop osteoporosis (thinning of bone) later in life when her ovaries do not produce adequate estrogen.

The average age of menopause is 51 years old. However, there is no way to predict when an individual woman will have menopause or begin having symptoms suggestive of menopause. The age at which a woman starts having menstrual periods is also not related to the age of menopause onset. Most women reach menopause between the ages of 45 and 55, but menopause may occur as earlier as ages 30s or 40s, or may not occur until a woman reaches her 60s. As a rough "rule of thumb," women tend to undergo menopause at an age similar to that of their mothers.

Symptoms and signs related to the menopausal transition such as irregularities in the menstrual cycle, can begin up to 10 years prior to the last menstrual period.

Menopause is a single point in time and not a process; it is the time point in at which a woman's last period ends. Of course, a woman will not know when that time point has occurred until she has been 12 consecutive months without a period. The symptoms of menopause, on the other hand, may begin years before the actual menopause occurs and may persist for some years afterward as well.

It is important to remember that each woman's experience is highly individual. Some women may experience few or no symptoms of menopause, while others experience multiple physical and psychological symptoms. The extent and severity of symptoms varies significantly among women. It is also important to remember that symptoms may come and go over an extended period for some women. This, too, is highly individual. These symptoms of menopause and perimenopause are discussed in detail below.

Irregular vaginal bleeding may occur as a woman reaches menopause. Some women have minimal problems with abnormal bleeding during the prior time to menopause whereas others have unpredictable, excessive bleeding. Menstrual periods (menses) may occur more frequently (meaning the cycle shortens in duration), or they may get farther and farther apart (meaning the cycle lengthens in duration) before stopping. There is no "normal" pattern of bleeding during the perimenopause, and patterns vary from woman to woman. It is common for women in perimenopause to have a period after going for several months without one. There is also no set length of time it takes for a woman to complete the menopausal transition. A woman can have irregular periods for years prior to reaching menopause. It is important to remember that all women who develop irregular menses should be evaluated by their doctor to confirm that the irregular menses are due to perimenopause and not as a sign of another medical condition.

The menstrual abnormalities that begin in the perimenopause are also associated with a decrease in fertility, since ovulation has become irregular. However, women who are perimenopausal may still become pregnant until they have reached true menopause (the absence of periods for one year) and should still use contraception if they do not wish to become pregnant.

Hot flashes are common among women undergoing menopause. A hot flash is a feeling of warmth that spreads over the body and is often most pronounced in the head and chest. A hot flash is sometimes associated with flushing and is sometimes followed by perspiration. Hot flashes usually last from 30 seconds to several minutes. Although the exact cause of hot flashes is not fully understood, hot flashes are likely due to a combination of hormonal and biochemical fluctuations brought on by declining estrogen levels.

There is currently no method to predict when hot flashes will begin and how long they will last. Hot flashes occur in up to 40% of regularly menstruating women in their forties, so they may begin before the menstrual irregularities characteristic of menopause even begin. About 80% of women will be finished having hot flashes after five years. Sometimes (in about 10% of women), hot flashes can last as long as 10 years. There is no way to predict when hot flashes will cease, though they tend to decrease in frequency over time. They may also wax and wane in their severity. The average woman who has hot flashes will have them for about five years.

Sometimes hot flashes are accompanied by night sweats (episodes of drenching sweats at nighttime). This may lead to awakening and difficulty falling asleep again, resulting in unrefreshing sleep and daytime tiredness.

Night sweats (episodes of drenching sweats at nighttime) sometimes accompany hot flashes. This may lead to awakening and difficulty falling asleep again, resulting in unrefreshing sleep and daytime tiredness.

Vaginal symptoms occur because the tissues lining the vagina becoming thinner, drier, and less elastic as estrogen levels fall. Symptoms may include vaginal dryness, itching, or irritation and/or pain with sexual intercourse (dyspareunia). The vaginal changes also lead to an increased risk of vaginal infections.

The lining of the urethra (the transport tube leading from the bladder to discharge urine outside the body) also undergoes changes similar to the tissues of the vagina, and becomes drier, thinner, and less elastic with declining estrogen levels. This can lead to an increased risk of urinary tract infection, feeling the need to urinate more frequently, or leakage of urine (urinary incontinence). The incontinence can result from a strong, sudden urge to urinate or may occur during straining when coughing, laughing, or lifting heavy objects.

Women in perimenopause often report a variety of thinking (cognitive) and/or emotional symptoms, including fatigue, memory problems, irritability, and rapid changes in mood. It is difficult to determine exactly which behavioral symptoms are due directly to the hormonal changes of menopause. Research in this area has been difficult for many reasons.

Emotional and cognitive symptoms are so common that it is sometimes difficult in a given woman to know if they are due to menopause. The night sweats that may occur during perimenopause can also contribute to feelings of tiredness and fatigue, which can have an effect on mood and cognitive performance. Finally, many women may be experiencing other life changes during the time of perimenopause or after menopause, such as stressful life events, that may also cause emotional symptoms.

Many women report some degree of weight gain along with menopause. The distribution of body fat may change, with body fat being deposited more in the waist and abdominal area than in the hips and thighs. Changes in skin texture, including wrinkles, may develop along with worsening of adult acne in those affected by this condition. Since the body continues to produce small levels of the male hormone testosterone, some women may experience some hair growth on the chin, upper lip, chest, or abdomen.

Certain medical and surgical conditions can influence the timing of menopause.

Surgical removal of the ovaries

The surgical removal of the ovaries (oophorectomy) in an ovulating woman will result in an immediate menopause, sometimes termed a surgical menopause, or induced menopause. In this case, there is no perimenopause, and after surgery, a woman will generally experience the signs and symptoms of menopause. In cases of surgical menopause, women often report that the abrupt onset of menopausal symptoms results in particularly severe symptoms, but this is not always the case.

The ovaries are often removed together with the removal of the uterus (hysterectomy). If a hysterectomy is performed without removal of both ovaries in a woman who has not yet reached menopause, the remaining ovary or ovaries are still capable of normal hormone production. While a woman cannot menstruate after the uterus is removed by a hysterectomy, the ovaries themselves can continue to produce hormones up until the normal time when menopause would naturally occur. At this time, a woman could experience the other symptoms of menopause such as hot flashes and mood swings. These symptoms would then not be associated with the cessation of menstruation. Another possibility is that premature ovarian failure will occur earlier than the expected time of menopause, as early as one to two years following the hysterectomy. If this happens, a woman may or may not experience symptoms of menopause.

Cancer chemotherapy and radiation therapy

Depending upon the type and location of the cancer and its treatment, these types of cancer therapy (chemotherapy and/or radiation therapy) can result in menopause if given to an ovulating woman. In this case, the symptoms of menopause may begin during the cancer treatment or may develop months following the treatment.

Premature ovarian failure

Premature ovarian failure is defined as the occurrence of menopause before the age of 40. This condition occurs in about 1% of all women. The cause of premature ovarian failure is not fully understood, but it may be related to autoimmune diseases or inherited (genetic) factors.

Because hormone levels may fluctuate greatly in an individual woman, even from one day to the next, hormone levels are not a reliable method for diagnosing menopause. There is no single blood test that reliably predicts when a woman is going through the menopausal transition, so there is currently no proven role for blood testing to diagnose menopause. The only way to diagnose menopause is to observe the lack of menstrual periods for 12 months in a woman in the expected age range.

Menopause itself is a normal part of life and not a disease that requires treatment. However, treatment of associated symptoms is possible if these become substantial or severe.

Estrogen and progesterone therapy

Hormone therapy (HT), or menopausal hormone therapy (MHT), consists of estrogens or a combination of estrogens and progesterone (progestin). This was formerly referred to as hormone replacement therapy (HRT). Hormone therapy controls the symptoms of menopause-related to declining estrogen levels (such as hot flashes and vaginal dryness), and HT is still the most effective way to treat these symptoms. But long-term studies (the NIH-sponsored Women's Health Initiative, or WHI) of women receiving combined hormone therapy with both estrogen and progesterone were halted when it was discovered that these women had an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. These risks were most pronounced in women over 60 taking hormone therapy. Later studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer. Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus) in postmenopausal women who have not had their uterus surgically removed.

Hormone therapy is available in oral (pill), transdermal forms (for example, patches and spray such as Vivelle, Climara, Estraderm, Esclim, Alora). Transdermal hormone products are already in their active form without the need for "first pass" metabolism in the liver to be converted to an active form. Since transdermal hormone products do not have effects on the liver, this route of administration has become the preferred form for most women.

There has been interesting in recent years in the use of so-called "bioidentical" hormone therapy for perimenopausal women. The hormones are created in a laboratory by altering compounds derived from naturally occurring plant products. Some of these so-called bioidentical hormone preparations are made at compounding pharmacies that make the preparations on a case-by-case basis for each patient. The does not regulate individual FDA compound preparations because compounded products are not standardized. Bioidentical hormone therapy products are typically applied as cream or gels. Studies to establish the long-term safety and effectiveness of these products have not been carried out, and expert panels currently do not recommend the use of custom-compounded hormone therapies.

In summary, the decision about hormone therapy is a very individual decision in which the patient and doctor must take into account the inherent risks and benefits of the treatment along with each woman's own medical history. It is currently recommended that if hormone therapy is used, it should be used at the smallest effective dose for the shortest possible time. It is currently recommended that hormone therapy be used if the balance of risks and benefits is favorable for the individual woman.

Oral contraceptive pills

Oral contraceptive pills are another form of hormone therapy often prescribed for women in perimenopause to treat irregular vaginal bleeding. Women in the menopausal transition tend to have considerable breakthrough bleeding when given estrogen therapy. Therefore, oral contraceptives are often given to women in the menopause transition to regulate menstrual periods, relieve hot flashes, as well as to provide contraception. They are not recommended for women who have already reached menopause, because the dose of estrogen is higher than that needed to control hot flashes and other symptoms. The contraindications for oral contraceptives in women going through the menopause transition are the same as those for premenopausal women.

Local (vaginal) hormone and non-hormone treatments

There are also local (meaning applied directly to the vagina) hormonal treatments for the symptoms of vaginal estrogen deficiency. Local treatments include the vaginal estrogen ring (Estring), vaginal estrogen cream, or vaginal estrogen tablets. Local and oral estrogen treatments are sometimes combined for this purpose.

Vaginal moisturizing agents such as creams or lotions (for example, K-Y Silk-E Vaginal Moisturizer or KY Liquibeads Vaginal Moisturizer) as well as the use of lubricants during intercourse are non-hormonal options for managing the discomfort of vaginal dryness.

Antidepressant medications: The class of drugs known as selective serotonin reuptake inhibitors (SSRIs) and related medications has been shown to be effective in controlling the symptoms of hot flashes in up to 60% of women. Specifically, venlafaxine (Effexor), a drug-related to the SSRIs, and the paroxetine (Paxil, Brisdelle), desvenlafaxine (Pristiq), citalopram (Celexa), and escitalopram (Lexapro) have all been shown to decrease the severity of hot flashes in some women. However, antidepressant medications may be associated with side effects, including decreased libido or sexual dysfunction.

Other medications: Other prescription medications have been shown to provide some relief for hot flashes, although their specific purpose is not the treatment of hot flashes. All of these may have side effects, and their use should be discussed with and monitored by a doctor. Some of these medications that have been shown to help relieve hot flashes include the antiseizure drug gabapentin (Neurontin) and clonidine (Catapres), a drug used to treat high blood pressure.

Plant estrogens (phytoestrogens, isoflavones)

Isoflavones are chemical compounds found in soy and other plants that are phytoestrogens, or plant-derived estrogens. There is a perception among many women that plant estrogens are "natural" and therefore safer than HT, but medical researchers haven't proven this scientifically. Most scientific studies have not shown a benefit of phytoestrogens in controlling hot flashes. In addition, there is concern that some phytoestrogens might act like estrogen in some tissues of the body. Therefore, many experts recommend that women who have a history of breast cancer avoid phytoestrogens.

Vitamin E

Some women report that vitamin E supplements can provide relief from mild hot flashes, but scientific studies are lacking to prove the effectiveness of vitamin E in relieving symptoms of menopause. Taking a dosage greater than 400 international units (IU) of vitamin E may not be safe, since some studies have suggested that greater dosages may be associated with cardiovascular disease risk.

Black Cohosh

Black cohosh is an herbal preparation promoted for the relief of hot flashes. Clinical trials show that black cohosh is actually no more effective than placebo in controlling hot flashes.

Other alternative therapies for menopause symptoms

There are many supplements and substances that have been advertised as "natural" treatments for symptoms of menopause, including licorice, dong Quai, chaste berry, and wild yam. Scientific studies have not proven the safety or effectiveness of these products.

In women for whom oral or vaginal estrogens are deemed inappropriate, such as breast cancer survivors, or women who do not wish to take oral or vaginal estrogen, there are varieties of over-the-counter vaginal lubricants. However, they are probably not as effective in relieving vaginal symptoms as replacing the estrogen deficiency with oral or local estrogen.

Many of the symptoms of menopause and the medical complications that may develop in postmenopausal women can be lessened or even avoided by taking steps to lead a healthy lifestyle.

• Regular exercise can help protect against cardiovascular disease and osteoporosis. Exercise also has proven mental health benefits.
• Proper nutrition
• Stop smoking

Which types of doctors treat menopausal symptoms?

The symptoms of menopause are often treated by a woman’s gynecologist. Primary care providers, including family medicine specialists and internists, may also treat the symptoms of menopause.

Osteoporosis

Osteoporosis is the deterioration of the quantity and quality of bone that causes an increased risk of fracture. The density of the bone (bone mineral density) normally begins to decrease in women during the fourth decade of life. However, that normal decline in bone density is accelerated during the menopausal transition. Consequently, both age and the hormonal changes due to the menopause transition act together to cause osteoporosis. Medications to treat osteoporosis are currently available and pose less risk than hormone therapy. Therefore, hormone therapy is not recommended for prevention or treatment of osteoporosis.

Cardiovascular disease

Prior to menopause, women have a decreased risk of heart disease and stroke when compared with men. Around the time of menopause, however, a women's risk of cardiovascular disease increases. Heart disease is the leading cause of death in both men and women in the U.S.

Coronary heart disease rates in postmenopausal women are two to three times higher than in women of the same age who have not reached menopause. This increased risk for cardiovascular disease may be related to declining estrogen levels, but in light of other factors, medical professionals do not advise postmenopausal women to take hormone therapy simply as a preventive measure to decrease their risk of heart attack or stroke.