Menopause

Perimenopause & Menopause at a glance:

• Menopause is a milestone in a woman's life, and a natural consequence of aging. It signals the end of a woman's fertility, a point when she is no longer able to become pregnant.
• Every woman is born with a limited number of eggs, which are stored in the ovaries. The ovaries produce progesterone and estrogen. These hormones regulate menstruation and ovulation.
• As women grow older, production of hormones by the ovaries decreases. Menopause occurs when the ovaries stop releasing eggs and a woman stops menstruating. Usually this follows a 3- to 5-year period when a woman's estrogen level gradually begins to decline. This period is called perimenopause.
• In the United States, the average age for a woman to go through menopause is 52, but it can occur anytime in the early 40s to late 50s. Some factors can cause this premature condition, including genetics, autoimmune disorders, illness, chemotherapy, radiation, surgical removal of the ovaries with or without removal of the uterus, smoking, or higher body mass index.

Stages

For those women undergoing natural menopause (not brought on by any type of medical or surgical treatment) the process is gradual. It usually follows three stages:

Perimenopause

This initial stage usually begins several years before the natural condition. During this time, ovaries gradually produce fewer hormones. During the last few years of perimenopause, estrogen decreases more rapidly. At this point, some women will experience menopause-like symptoms. Perimenopause lasts until the ovaries stop producing eggs.

Menopause

This occurs at the point when it has been a year since a woman's last period. The ovaries have stopped producing eggs and most of their estrogen.

Postmenopause

Postmenopause defines the years after menopause. Most symptoms decrease or cease for most women. The loss of estrogen poses some health risks as a woman ages.

Premature menopause

Some women experience this premature condition. This can be a result of genetics, autoimmune disorders, illness, chemotherapy, radiation, surgical removal of the ovaries (with or without removal of the uterus) or smoking.

Other possible conditions include:

• Induced menopause: When the ovaries are removed for medical reasons such as endometriosis or cancer it can cause this condition. Treatments such as radiation or chemotherapy can also cause this.
• Premature ovarian failure: A woman's ovaries produce progesterone and estrogen. The levels of these two hormones can change if the ovaries stop releasing eggs prematurely. If this happens before a woman turns 40, this is called premature ovarian failure. This condition is not always permanent.

Symptoms of Perimenopause & Menopause

Menopause technically does not occur until a woman has not had a menstrual period for a period of one year. However, symptoms of menopause can occur up to five years before menopause, during the period known as perimenopause. Talk to your health provider if symptoms of menopause are affecting your quality of life.

Menopause & Perimenopause symptoms may include:

Irregular periods

Changes in the menstrual cycle may be one of the first symptoms. Some women will skip an occasional period, others may have a period every two to three weeks. Others may not have a menstrual cycle for months.

Vaginal dryness

Decreasing estrogen levels can lead to decreased lubrication and inflammation of the vagina as a result of thinning and shrinking of tissues. This may be accompanied by itching or discomfort. Some women may experience pain during sex.

Hot flashes/night sweats

The term “hot flash” generally refers to a sudden feeling of heat in the upper body. It may start in the chest or face and spread. Skin on the face or neck may redden, and the woman may begin to sweat. Some women experience a racing heartbeat.

Hot flashes often occur in the first year after a woman’s last period. If hot flashes occur at night, they are often referred to as “night sweats.”

Urinary problems

Some women may become more susceptible to urinary tract infections or may feel the need to urinate more frequently.

Weight gain

Some women may experience weight gain during perimenopause or menopause, and find that there is more fat buildup around the abdomen.

Trouble sleeping

Sleeping problems are a common symptom of menopause. Some women have trouble with night sweats; others have difficulty falling and staying asleep. Sleep disturbance may also be caused by anxiety or insomnia.

Mood swings

Many women experience mood swings during perimenopause and menopause. Some of this may be caused by poor sleep or a lack of sleep.

Trouble focusing or learning

Some women find that they have trouble focusing or learning, or feel as though they have a “mental fog.” One study found that women may not be able to learn as well as usual shortly before menopause when compared with other stages in their lives. Short-term memory problems are also a common symptom of menopause. Fortunately, these issues tend to resolve once a woman has gone for one full year without a menstrual period.

Hair loss

Thinning hair is a symptom of menopause in some women.

Menopause and Its Impact on Bone and Heart Health

Menopause can cause many changes in a woman’s body. It can also affect some chronic medical conditions, including:

Osteoporosis and menopause

Bone mineral density normally begins to decline when a woman is in her 40s. When a woman hits menopause, estrogen levels decrease. Since estrogen helps to produce and keep strong healthy bones, this sudden hormonal level drop can affect bone strength.

The combination of aging and hormonal changes can lead to osteoporosis. This deterioration in the quantity and quality of bone can lead to an increased risk of bone fracture.

Osteoporosis literally means “porous bones.” It is sometimes called a “silent disease” because bone loss often occurs without symptoms.

Screening for osteoporosis

Osteoporosis can be picked up before it leads to fractures. Current recommendations include that ALL women have a screening bone density test by age 65. For some, however (see Risk factors for osteoporosis below), earlier screening may make sense and can pick up disease before it becomes a major health problem. A woman’s clinical care provider can help direct her to the most appropriate testing based on her risks.

Risk factors for osteoporosis

Women are four times more likely to have osteoporosis than men. Bone density begins to decline around age 30, and women over age 50 (who are often menopausal) are at the greatest risk of developing osteoporosis.

Other risk factors include:

• Family history of osteoporosis
• Ethnicity (studies have found that Asian and Caucasian women are more likely to develop osteoporosis)
• Petite bone structure
• Some medications, such as steroids, increase the risk of osteoporosis.

Treatment of osteoporosis

While there is no complete cure for osteoporosis, the goal of treatment is the prevention of bone fractures by slowing bone loss and increasing bone density and strength. Treatment methods include:

• Maintaining a healthy lifestyle by getting exercise, curtailing alcohol intake and quitting smoking
• Medication may be prescribed to stop bone loss and build bone strength.

Taking calcium and vitamin D supplements is often suggested. There is mixed medical evidence that adding calcium and vitamin D supplements to the diet will improve bone density or help avoid osteoporosis. If a woman chooses to take these supplements, she should be aware that too much calcium can be harmful to her health.

It is important to aim for a total calcium intake that is not more than 1,000 mg a day (if taking hormone therapy) or 1 500 mg a day (if not taking hormone therapy). This should be achieved with a combination of dietary intake and supplements, if they are needed. Vitamin D3 in doses of 1,000-2,000 IU per day have not been shown to cause harm and may help maintain normal vitamin D levels.

Cardiovascular disease effect of menopause

Before going through menopause, women have a decreased risk of stroke and heart disease as compared to men. However, during menopause, a women’s risk of cardiovascular disease increases.

The reasons that heart disease risk rises for women after menopause are not well understood. Estrogen appears to play a role, but randomized clinical trials of estrogen treatment to prevent heart disease have not demonstrated reduced heart disease outcomes in women who took estrogen for up to seven years.

Postmenopausal women should be screened for the risk factors for heart disease, such as high blood pressure, high cholesterol, and prediabetes or diabetes. These problems should be treated if they arise. Maintaining a normal body weight and engaging in regular exercise are the best treatments a woman can do to protect her heart health throughout her lifetime.

Cardiovascular disease and menopause

Before going through menopause, women have a decreased risk of stroke and heart disease as compared to men. However, during menopause, a women’s risk of cardiovascular disease increases.

The reasons that heart disease risk rises for women after menopause are not well understood. Estrogen appears to play a role, but randomized clinical trials of estrogen treatment to prevent heart disease have not demonstrated reduced heart disease outcomes in women who took estrogen for up to seven years.

Postmenopausal women should be screened for the risk factors for heart disease, such as high blood pressure, high cholesterol, and prediabetes or diabetes. These problems should be treated if they arise. Maintaining a normal body weight and engaging in regular exercise are the best treatments a woman can do to protect her heart health throughout her lifetime.

Menopause Treatment

Approximately 70 percent of all women approaching menopause will experience symptoms of menopause. The symptoms may begin in perimenopause and last for the whole menopause transition. Some women experience these symptoms for the rest of their lives.

Menopause is not a disease to be cured, but rather a natural process of aging in a woman’s body. The symptoms indicate changing levels of the hormones estrogen, progesterone and testosterone.

Some symptoms can be relieved through medication, but this is not the only treatment solution. Here are several options:

Lifestyle changes as menopause treatment

Eating right and getting plenty of exercise can help to minimize the symptoms of menopause, and will help maintain overall good health.

Getting plenty of exercise and participating in stress reduction activities may be helpful. Cognitive behavioral therapy and hypnosis have been shown to reduce hot flashes in some studies. Dressing lightly and layering clothing are common ways that women adapt to unexpected hot flashes. For problems with vaginal dryness, moisturizers and non-estrogen based lubricants can be beneficial.

Prescription medicine menopause treatment

Women struggling with menopausal symptoms should talk to their doctor about treatment options. The most commonly prescribed and most effective drug therapy for menopausal symptoms is hormone therapy (HT).

For women who still have their uterus, treatment with estrogen and progesterone (combination hormone replacement therapy) can be prescribed. Women who have had a hysterectomy are prescribed estrogen alone.

Hormone therapy

In the past, HT was widely recommended and was believed to have a role in preventing the development of chronic diseases of aging such as heart disease, osteoporosis and even dementia.  Multiple clinical trials have failed to demonstrate a long-term benefit of HT for any of these outcomes.  One trial by the Women’s Health Initiative also documented some risks associated with long term use of HT.

For women with a uterus who take estrogen plus progesterone or progestin, the risk of breast cancer was found to increase slowly over time. Women who had a hysterectomy and took estrogen only had a decreased risk of breast cancer but an increased risk of stroke. Both treatments, which were given in pill form, increased the risk of blood clots.

Follow-up studies of the participants in the Women’s Health Initiative trials have looked at very long-term health almost 20 years later, and overall there is not an increase in risk of mortality associated with taking hormones or not taking hormones.

A woman’s health status and family history will help her physician advise on whether she is a good candidate for HT and how long it should be taken. For most women, hot flashes subside but it can take 10 years or more for some, and for others hot flashes never go away. Fortunately, for those who cannot take HT or who do not want to take HT, there are alternatives.

Other menopause medications

Fezolinetant (Veozah) is a new, Food and Drug Administration (FDA) approved medication that treats hot flashes at the level of the brain where they originate. It is non-hormonal and has not been in widespread use for a long time. However, it has been studied in more than one thousand women to date and demonstrates relief of hot flashes that is almost as good as that achieved with hormone therapy.

Fezolinetant cannot be used in conjunction with medications that are metabolized by an enzyme called CYP1A2 inhibitors and it requires some additional monitoring for safety. A healthcare provider can help women determine whether this medication is appropriate for them.

Paroxetine mesylate (Brisdelle) is also FDA approved for the treatment of hot flashes. It is an antidepressant medication that was found to also have effectiveness for this purpose. It is not as effective as HT or fezolinetant.

Other medications in the antidepressant class of drugs such as venlafaxine (Effexor), citalopram (Celexa) and escitalopram (Lexapro) have also been shown in clinical studies to be effective against hot flashes, although not as good as HT. Gabapentin (Neurontin) and oxybutynin (Ditropan) have also been shown to be helpful for hot flashes. A woman’s doctor can help her select a non-hormone treatment that is right for her.