Definition, Description, Causes and symptoms, Diagnosis, Treatment, Alternative treatment, Prognosis, Prevention
Menopause represents the end of menstruation. While technically it refers to the final period, it is not an abrupt event, but a gradual process. Menopause is not a disease that needs to be cured, but a natural life-stage transition. However, women have to make important decisions about "treatment," including the use of hormone replacement therapy (HRT).
Many women have irregular periods and other problems of "pre-menopause" for years. It's not easy to predict when menopause begins, although doctors agree it is complete when a woman has not had a period for a year. Eight out of every 100 women stop menstruating before age 40. At the other end of the spectrum, five out of every 100 continue to have periods until they are almost 60. The average age of menopause is 51.
There's no mathematical formula to figure out when the ovaries will begin to scale back either, but a woman can get a general idea based on her family history, body type, and lifestyle. Women who began menstruating early will not necessarily stop having periods early as well. It is true that a woman will likely enter menopause at about the same age as her mother. Menopause may occur later than average among smokers.
Causes and symptoms
Once a woman enters puberty, each month her body releases one of the more than 400,000 eggs that are stored in her ovaries, and the lining of the womb (uterus) thickens in anticipation of receiving a fertilized egg. If the egg isn't fertilized, progesterone levels drop and the uterine lining sheds and bleeds.
By the time a woman reaches her late 30s or 40s, her ovaries begin to shut down, producing less estrogen and progesterone and releasing eggs less often. The gradual decline of estrogen causes a wide variety of changes in tissues that respond to estrogen—including the vagina, vulva, uterus, bladder, urethra, breasts, bones, heart, blood vessels, brain, skin, hair, and mucous membranes. Over the long run, the lack of estrogen can make a woman more vulnerable to osteoporosis (which can begin in the 40s) and heart disease.
As the levels of hormones fluctuate, the menstrual cycle begins to change. Some women may have longer periods with heavy flow followed by shorter cycles and hardly any bleeding. Others will begin to miss periods completely. During this time, a woman also becomes less able to get pregnant.
The most common symptom of menopause is a change in the menstrual cycle, but there are a variety of other symptoms as well, including:
- hot flashes
- night sweats
- mood swings/irritability
- memory or concentration problems
- vaginal dryness
- heavy bleeding
- hair changes
- heart palpitations
- sexual disinterest
- urinary changes
- weight gain
The clearest indication of menopause is the absence of a period for one year. It is also possible to diagnose menopause by testing hormone levels. One important test measures the levels of follicle-stimulating hormone (FSH).
However, as a woman first enters menopause, her hormones often fluctuate wildly from day to day. For example, if a woman's estrogen levels are high and progesterone is low, she may have mood swings, irritability, and other symptoms similar to premenstrual syndrome (PMS). As hormone levels shift and estrogen level falls, hot flashes occur. Because of these fluctuations, a normal hormone level when the blood is tested may not necessarily mean the levels were normal the day before or will be the day after.
If it has been at least three months since a woman's last period, an FSH test might be more helpful in determining whether menopause has occurred. Most doctors believe that the FSH test alone can't be used as proof that a woman has entered early menopause. A better measure of menopause is a test that checks the levels of estrogen, progesterone, testosterone and other hormones at mid-cycle, in addition to FSH.
When a woman enters menopause, her levels of estrogen drop and symptoms (such as hot flashes and vaginal dryness) begin. Hormone replacement therapy can treat these symptoms by boosting the estrogen levels enough to suppress symptoms while also providing protection against heart disease and osteoporosis, which causes the bones to weaken. Experts disagree on whether HRT increases or decreases the risk of developing breast cancer. A Harvard study concluded that short-term use of hormones carries little risk, while HRT used for more than five years among women 55 and over seems to increase the risk of breast cancer.
There are two types of hormone treatments: hormone replacement therapy (HRT) and estrogen replacement therapy (ERT). HRT is the administration of estrogen and progesterone; ERT is the administration of estrogen alone. Only women who have had a hysterectomy (removal of the uterus) can take estrogen alone, since taking this "unopposed" estrogen can cause uterine cancer. The combination of progesterone and estrogen in HRT eliminates the risk of uterine cancer.
Most physicians do not recommend HRT until a woman's periods have stopped completely for one year. This is because women in early menopause who still have an occasional period are still producing estrogen; HRT would then provide far too much estrogen.
Most doctors believe that every woman (except those with certain cancers) should take hormones as they approach menopause because of the protection against heart disease, osteoporosis, and uterine cancer and the relatively low risk of breast cancer. Heart disease and osteoporosis are two of the leading causes of disability and death among post-menopausal women.
Critics say the benefit of taking hormonal drugs to ease symptoms isn't worth the risk of breast cancer. Since menopause isn't a disease, many argue that women shouldn't take hormones to cure what is actually a natural process of aging. Advocates of HRT contend that the purpose of taking hormones is not to "treat" menopause but to prevent the development of other diseases.
There are risks with HRT and there are risks without it. In order to decide whether to take HRT, a woman should balance her risk of getting breast cancer against her risk of getting heart disease, and decide how bad her menopause symptoms are. Most doctors agree that short-term use of estrogen for those women with symptoms of hot flashes or night sweats is a sensible choice as long as they don't have a history of breast cancer.
For a woman who has no family history of cancer and a high risk of dying from heart disease, for example, the low risk of cancer might be worth the protective benefit of avoiding heart disease. Certainly, for Caucasian women aged 50 to 94, the risk of dying from heart disease is far greater than the risk of dying of breast cancer.
Women are poor candidates for hormone replacement therapy if they have:
- had breast or endometrial cancer
- a close relative (mother, sister, grandmother) who died of breast cancer or have two relatives who got breast cancer before age 40
- had endometrial cancer
- had gallbladder or liver disease
- blood clots or phlebitis
Some women with liver or gallbladder disease, or who have clotting problems, may be able to go on HRT if they use a patch to administer the hormones through the skin, bypassing the liver.
Women would make a good candidate for HRT if they:
- need to prevent osteoporosis
- have had their ovaries removed
- need to prevent heart disease
- have significant symptoms
Taking hormones can almost immediately eliminate hot flashes, vaginal dryness, urinary incontinence (depending on the cause), insomnia, moodiness, memory problems, heavy irregular periods, and concentration problems. Side effects of treatment include bloating, breakthrough bleeding, headaches, vaginal discharge, fluid retention, swollen breasts, or nausea. Up to 20% of women who try hormone replacement stop within nine months because of these side effects. However, some side effects can be lessened or prevented by changing the HRT regimen.
The decision should be made by a woman and her doctor after taking into consideration her medical history and situation. Women who choose to take hormones should have an annual mammogram, breast exam, and pelvic exam and should report any unusual vaginal bleeding or spotting (a sign of possible uterine cancer).
A new type of hormone therapy offers some of the same protection against heart disease and bone loss as estrogen, but without the increased risk of breast cancer. This new class of drugs are known as anti-estrogens. The best known of these anti-estrogens is raloxifene, which mimics the effects of estrogen in the bones and blood, but blocks some of its negative effects elsewhere. It's called an anti-estrogen because for a long time these drugs had been used to counter the harmful effects of estrogen that caused breast cancer. Oddly enough, in other parts of the body these drugs mimic estrogen, protecting against heart disease and osteoporosis without putting a woman at risk for breast cancer.
Like estrogen, raloxifene works by attaching to an estrogen "receptor," much like a key fits into a lock. When raloxifene clicks into the estrogen receptors in the breast and uterus, it blocks estrogen at these sites. This is the secret of its cancer-fighting property. Many tumors in the breast are fueled by estrogen; if the estrogen cannot get in the cell, then the cancer stops growing.
Women may prefer to take raloxifene instead of hormone replacement because the new drug doesn't boost the breast cancer risk and doesn't have side effects like uterine bleeding, bloating, or breast soreness. Unfortunately, the drug may worsen hot flashes. Raloxifene is basically a treatment to prevent osteoporosis. It doesn't help with common symptoms and it is unclear if it has the same protective effect against heart disease as estrogen does.
The ovaries also produce a small amount of male hormones, which decreases slightly as a woman enters menopause. The vast majority of women never need testosterone replacement, but it can be important if a woman has declining interest in sex. Testosterone can improve the libido, and decrease anxiety and depression; adding testosterone especially helps women who have had hysterectomies. Testosterone also eases breast tenderness and helps prevent bone loss. However, testosterone does have side effects. Some women experience mild acne and some facial hair growth, but because only small amounts of testosterone are prescribed, most women don't appear to have extreme masculine changes.
Birth control pills
Women who are still having periods but who have annoying menopausal symptoms may take low-dose birth control pills to ease the problems; this treatment has been approved by the FDA for perimenopausal symptoms in women under age 55. HRT is the preferred treatment for menopause, however, because it uses lower doses of estrogen.
Some women also report success in using natural remedies to treat the unpleasant symptoms of menopause. Not all women need estrogen and some women can't take it. Many doctors don't want to give hormones to women who are still having their periods, however erratically. Indeed, only a third of menopausal women in the United States try HRT and of those who do, eventually half of them drop the therapy. Some are worried about breast cancer, some can't tolerate the side effects, some don't want to medicate what they consider to be a natural occurrence.
Herbs have been used to relieve menopausal symptoms for centuries. In general, most herbs are considered safe, and there is no substantial evidence that herbal products are a major source of toxic reactions. But because herbal products aren't regulated in the United States, contamination or accidental overdose is possible. Herbs should be bought from a recognized company or through a qualified herbal practitioner.
Women who choose to take herbs for menopausal symptoms should learn as much as possible about herbs and work with a qualified practitioner (an herbalist, a traditional Chinese doctor, or a naturopathic physician). Pregnant women should avoid herbs because of unknown effects on a developing fetus.
The following list of herbs include those that herbalists most often prescribe to treat menstrual complaints:
- black cohosh (Cimicifuga racemosa): hot flashes and other menstrual complaints
- black currant: breast tenderness
- chaste tree/chasteberry (Vitex agnus-castus): hot flashes, excessive menstrual bleeding, fibroids, and moodiness
- evening primrose oil (Oenothera biennis): mood swings, irritability, and breast tenderness
- fennel (Foeniculum vulgare): hot flashes, digestive gas, and bloating
- flaxseed (linseed): excessive menstrual bleeding, breast tenderness, and other symptoms, including dry skin and vaginal dryness
- gingko (Gingko biloba): memory problems
- ginseng (Panax ginseng): hot flashes, fatigue and vaginal thinning.
- hawthorn (Crataegus laevigata): memory problems, fuzzy thinking
- lady's mantle: excessive menstrual bleeding
- mexican wild yam (Dioscorea villosa) root: vaginal dryness, hot flashes and general menopause symptoms
- motherwort (Leonurus cardiaca): night sweats, hot flashes
- oat (Avena sativa) straw : mood swings, anxiety
- red clover (Trifolium pratense): hot flashes
- sage (Salvia officinalis): mood swings, headaches, night sweats
- valerian (Valeriana officinalis): insomnia
Natural estrogens (phytoestrogens)
Proponents of plant estrogens (including soy products) believe that plant estrogens are better than synthetic estrogen, but science has not yet proven this. The results of smaller preliminary trials suggest that the estrogen compounds in soy products can indeed relieve the severity of hot flashes and lower cholesterol. But no one yet has proven that soy can provide all the benefits of synthetic estrogen without its negative effects.
It is true that people in other countries who eat foods high in plant estrogens (especially soy products) have lower rates of breast cancer and report fewer "symptoms" of menopause. While up to 80% of menopausal women in the United States complain of hot flashes, night sweats, and vaginal dryness, only 15% of Japanese women have similar complaints. When all other things are equal, a soy-based diet may make a difference (and soy is very high in plant estrogens).
The study of phytoestrogens is so new that there aren't very many recommendations on how much a woman can consume. Herbal practitioners recommend a dose based on a woman's history, body size, lifestyle, diet, and reported symptoms. Research has indicated that some women were able to ease their symptoms by eating a large amount of fruits, vegetables, and whole grains, together with four ounces of tofu four times a week.
What concerns some critics of other alternative remedies is that many women think that "natural" or "plant-based" means "harmless." In large doses, phytoestrogens can promote the abnormal growth of cells in the uterine lining. Unopposed estrogen of any type can lead to endometrial cancer, which is why women on conventional estrogen-replacement therapy usually take progesterone (progestin) along with their estrogen. However, a plant-based progesterone product can sometimes be effective alone, without estrogen, in assisting the menopausal woman in rebalancing her hormonal action throughout this transition time.
Many women find that yoga (the ancient meditation/exercise developed in India 5,000 years ago) can ease menopausal symptoms. Yoga focuses on helping women unite the mind, body, and spirit to create balance. Because yoga has been shown to balance the endocrine system, some experts believe it may affect hormone-related problems. Studies have found that yoga can reduce stress, improve mood, boost a sluggish metabolism, and slow the heart rate. Specific yoga positions deal with particular problems, such as hot flashes, mood swings, vaginal and urinary problems, and other pains.
Exercise helps ease hot flashes by lowering the amount of circulating FSH and LH and by raising endorphin levels that drop while having a hot flash. Even exercising 20 minutes three times a week can significantly reduce hot flashes.
Regular, daily bowel movements to eliminate waste products from the body can be crucial in maintaining balance through menopause. The bowels are where circulating hormones are gathered and eliminated, keeping the body from recycling them and causing an imbalance.
This ancient Asian art involves placing very thin needles into different parts of the body to stimulate the system and unblock energy. It is usually painless and has been used for many menopausal symptoms, including insomnia, hot flashes, and irregular periods. Practitioners believe that acupuncture can facilitate the opening of blocked energy channels, allowing the life force energy (chi) to flow freely. This allows the menopausal woman to keep her energy moving. Blocked energy usually increases the symptoms of menopause.
Acupressure and massage
Therapeutic massage involving acupressure can bring relief from a wide range of menopause symptoms by placing finger pressure at the same meridian points on the body that are used in acupuncture. There are more than 80 different types of massage, including foot reflexology, Shiatsu massage, or Swedish massage, but they are all based on the idea that boosting the circulation of blood and lymph benefits health.
Some women have been able to control hot flashes through biofeedback, a painless technique that helps a person train her mind to control her body. A biofeedback machine provides information about body processes (such as heart rate) as the woman relaxes her body. Using this technique, it is possible to control the body's temperature, heart rate, and breathing.
Menopause is a natural condition of aging. Some women have no problems at all with menopause, while others notice significant unpleasant symptoms. A wide array of treatments, from natural to hormone replacement, mean that no woman needs to suffer through this time of her life.
Menopause is a natural part of the aging process and not a disease that needs to be prevented. Most doctors recommend HRT for almost all post-menopausal women, usually for a few years. When HRT is then stopped, symptoms should be mild or non existent. But HRT is not only useful in lessening the symptoms of menopause; it also protects against heart disease and osteoporosis.
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Laith Farid Gulli, M.D.
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