Menopause

Menopause is a transition between two phases of a woman’s life. Menopause is not a disease or an illness. Menopause occurs when a woman permanently stops menstruating (having periods).

Many women experience a variety of symptoms as a result of the hormonal changes associated with the transition through menopause. Around the time of menopause, women often lose bone density and their cholesterol may worsen, increasing their risk of heart disease.

• Premature menopause: The average age of menopause in the United States is 51 years. The most common age range at which women experience menopause is 48-55 years. If menopause occurs in a woman younger than 40 years, it is considered premature. Menopause is considered late if it occurs in a woman older than 55 years. For most women, menopause is a normal occurrence.
  
  

  • Menopause is more likely to occur at a slightly earlier age in women who smoke, have never been pregnant, or live at high altitudes.

  • If premature menopause occurs, a health care provider will check for other medical problems. About 1% of women experience premature menopause.
    
    
• Perimenopause: The hormonal changes associated with menopause actually begin prior to the last menstrual period, during a 3- to 5–year period called perimenopause. During this transition, women may begin to experience menopausal symptoms and may lose bone density, even though they are still menstruating.
  
  
• Surgical menopause: Surgical menopause is the removal of the ovaries. Women who have had surgical menopause have an increased risk of early heart disease and often experience menopausal symptoms, unless they are given medication.

Menopause occurs when a woman's ovaries run out of functioning eggs. At the time of birth, most females have about 1-3 million eggs, which are gradually lost throughout a woman's life. By the time of a girl's first menstrual period, she has an average of about 400,000 eggs. By the time of menopause, a woman may have fewer than 10,000 eggs. A small percentage of these eggs are lost through normal ovulation (the monthly cycle). Most eggs die off through a process called atresia.

• Normally, FSH, or follicle-stimulating hormone (a reproductive hormone), is the substance responsible for the growth of ovarian follicles (eggs) during the first half of a woman’s menstrual cycle. As menopause approaches, the remaining eggs become more resistant to FSH, and the ovaries dramatically reduce their production of a hormone called estrogen.
  
  
• Estrogen affects many parts of the body, including the blood vessels, heart, bone, breasts, uterus, urinary system, skin, and brain. Loss of estrogen is believed to be the cause of many of the symptoms associated with menopause. At the time of menopause, the ovaries also decrease their production of testosterone—a hormone involved in the libido, or sexual drive.

• Hot flashes: Hot flashes are the most common symptom of menopause. According to some studies, hot flashes occur in as many as 75% of perimenopausal women. Hot flash symptoms vary among women. Commonly, the hot flash may begin with a feeling of nausea or a headache, followed by a wave of heat, flushed skin, and palpitations (feeling a strong heartbeat). Hot flashes often increase skin temperature and pulse, and they often cause insomnia, or sleeplessness.  

• Urinary incontinence and burning on urination

• Vaginal changes: Because estrogen affects the vaginal lining, perimenopausal women may also have pain during intercourse and may note a change in vaginal discharge.

• Breast changes: Menopause may cause changes in the shape of the breasts.

• Thinning of the skin

• Bone loss: Rapid bone loss is common during the perimenopausal years. Most women reach their peak bone density when aged 25-30 years. After that, bone loss averages 0.13% per year. During perimenopause, bone loss accelerates to about a 3% loss per year. Later, it drops off to about a 2% loss per year. No pain is usually associated with bone loss. However, bone loss can cause osteoporosis, a condition that increases the risk of bone fractures. These fractures can be intensely painful and can interfere with daily life. They also can increase the risk of death.

• Cholesterol: Cholesterol profiles also change significantly at the time of menopause. Total cholesterol and LDL (bad) cholesterol increase. Increased LDL cholesterol is associated with an increased risk of heart disease.

• Heart disease risk increases after menopause, although it is unclear exactly how much is due to aging and how much is caused by the hormonal changes that occur at the time of menopause. Women who undergo premature menopause or have their ovaries removed surgically at an early age are at an increased risk of heart disease.
  
  
• Weight gain: A 3-year study of healthy women nearing menopause found an average gain of 5 pounds during the 3 years. Hormonal changes and aging are both possible factors in this weight gain.

• All perimenopausal and postmenopausal women should see their health care provider annually for a full physical exam. This exam should include a breast exam, pelvic exam, and mammogram.
  
  
• Women should learn about the risk factors for heart disease and colon cancer from their health care professional and consider being screened for these diseases.
  
  
• Women who are still menstruating and are sexually active are at risk of becoming pregnant (even if their periods are irregular). Birth control pills containing low doses of estrogen can be useful for perimenopausal women to prevent pregnancy and to relieve perimenopausal symptoms, such as hot flashes. Doctors may check the FSH level of women aged 50 years to determine if they have reached menopause.
  
  
• Over-the-counter medications, prescription medications, and lifestyle changes, such as diet and exercise, help control hot flashes and other menopausal symptoms, including high cholesterol and bone loss.

• Blood testing: To determine menopause in women, a health care provider may check the follicle stimulating hormone (FSH) level through a blood test.
  
  
• Bone testing: The standard for measuring bone loss, or osteoporosis, associated with menopause is the DEXA (dual-energy x-ray absorptiometry) scan. The test calculates bone mineral density and compares it to the average value for healthy young women. The World Health Organization defines osteoporosis as more than 2.5 standard deviations below this average value. A condition known as osteopenia indicates less severe bone loss (between 1 and 2.5 standard deviations below the average value).
  
  
• The DEXA scan is usually performed before a doctor prescribes medications for osteoporosis to rebuild bone mineral density. The test is a special x-ray film taken of the hip and of the lower bones in the spine. The scan is repeated in 1 1/2 - 2 years to measure response to treatment.
  
  
• Simple bone screening can also be done in ultrasound machines that measure the bone density of the heel. This is merely a screening device. If low bone density is detected, follow-up with a complete DEXA scan may be required.

Heart risk testing: Postmenopausal women may be at risk for heart disease. A doctor can measure cholesterol levels with a simple blood test. If cholesterol levels are high, the doctor can advise women about ways to decrease their risk of heart disease.

Menopause is not a disease that has a definitive cure or treatment. Health care providers, however, can offer a variety of treatments for hot flashes and other menopausal symptoms that become bothersome. Many prescription medications exist to prevent and control high cholesterol and bone loss, which can occur at menopause. Some women do not need therapy, or they may choose not to take medications at all during their menopausal years.

|Self-Care at Home|

• Hot flashes: Several nonprescription treatments are available, and lifestyle choices can help.
  
  
  • Soy protein is a popular remedy for hot flashes, although data on its effectiveness are limited. Some doctors recommend 60 grams of soy protein, or about 2 cups of soy milk, daily. Soy contains phytoestrogens, or natural plant estrogens (isoflavones), which are thought to have effects similar to estrogen therapy. The safety of soy in women who have a history of breast cancer has not been established, although clinical studies indicate soy is no more effective for treating symptoms than a placebo. Soy comes from soybeans and is also called miso or tempeh. The best food sources are raw or roasted soybeans, soy flour, soy milk, and tofu. Soy sauce and soy oil do not contain isoflavones.
  
  
  
  • Regular aerobic exercise was found to reduce hot flashes.
  
  
  
  • Foods that may trigger hot flashes, such as spicy foods, caffeine, and alcohol, should be avoided.  


• Heart disease: A low-fat, low-cholesterol diet helps to reduce the risk of heart disease.



• Weight gain: Regular exercise is helpful in controlling weight.



• Osteoporosis: Adequate calcium intake and weight-bearing exercise are important. Strength training (lifting weights or using exercise bands in resistance training) can strengthen bones.

|Medications|

• Hot flashes: Hot flashes usually last 2-3 years, but many women can experience them for up to 5 years. An even smaller percentage may have them for more than 15 years. Prescription treatments for hot flashes include clonidine (Catapres), a medication that also lowers blood pressure, and belladonna (Bellergal), which contains a medication called phenobarbital. Bellergal has the potential to become addictive and should only be used for a short period of time. Bellergal also causes sleepiness. Studies are underway using certain antidepressants (known as SSRIs) to determine if they reduce hot flashes.



• Estrogen therapy: Estrogen is a well-established prescription therapy for hot flashes. Estrogen also helps build bone mass, reduces the risk of fractures, and improves cholesterol. Estrogen can be helpful in preventing urinary symptoms and in treating uncomfortable vaginal symptoms.
  
  
  • Some studies suggest women who take estrogen to replace the estrogen their bodies no longer produce may be at reduced risk for colon cancer, although more studies are needed in this area.
  
  
  
  • Recent clinical trial data indicate that combination therapy of estrogen and progesterone increases the risk of heart disease. The decision to take estrogen therapy (ET) can be made by a woman and her doctor after careful discussion about her symptoms, medical history, family medical history, and desires.
  
  
  
  • Estrogen is available in a variety of forms, including vaginal suppositories and creams (which are mainly useful for vaginal symptoms), skin patches (Vivelle, Climara, Estraderm, Esclim, Alora), and oral tablets.
  
  
  
  • Women who have not had a hysterectomy (they still have their uterus) must take estrogen in combination with the hormone progesterone. Estrogen alone increases the risk of abnormal growth in and cancers of the endometrium, or uterine lining. However, this risk is reduced when progesterone is taken along with estrogen on a regular basis. Taking estrogen in combination with progesterone is called hormone therapy (HT).
  
  
  
  • Hormone therapy appears to increase a woman's risk of breast cancer when used for more than 4 years. The Women's Health Initiative (2002), a large clinical trial, found that women who took estrogen and progesterone had an increased risk of breast cancer after 4 years of use. The Nurses' Health Study, which is following more than 120,000 nurses, has found that women who take hormone therapy for more than 5 years have an increased risk of breast cancer, but a reduced risk of heart disease. Researchers from one large study have shown that estrogen alone decreases the risk of hip fracture and increases the rate of stroke.
  
  
  
  • Women should undergo a breast exam and mammogram prior to starting estrogen. Once on estrogen, women must be monitored regularly with breast exams and mammograms.
  
  
  
  • Women who already have heart disease should not use estrogen.
  
  
  
  • Estrogen therapy does not prevent pregnancy.
  
  
  
  • Women who take estrogen also tend to have a higher risk of developing:
     
    • Gallstones  
    
    
    
    • Increased triglyceride levels  
    
    
    
    • Blood clots
    
    
    
    • Vaginal dryness and pain with intercourse


• Bone loss: Several medications may be used for preventing and treating osteoporosis.
  
  
  • The bisphosphonates, which include alendronate (Fosamax) and risedronate (Actonel), have been shown in clinical trials to reduce bone loss in postmenopausal women and to reduce fracture risk in women who have osteoporosis.
  
  
  
  • Raloxifene (Evista), a selective estrogen receptor modulator (SERM), is another therapy for osteoporosis. It reduces bone loss and appears to reduce the risk of back fractures in women with osteoporosis.
  
  
  
  • Calcitonin (Miacalcin or Calcimar) is a nasal spray that has been found to reduce the risk of back fractures in women who have osteoporosis.
  
  
  
  • A prevention drug currently under investigation is the drug PTH (parathyroid hormone).

|Other Therapy|

• Black cohosh (Remifemin) is a commonly used herbal supplement that is believed to reduce hot flashes. However, small German studies that tested black cohosh only followed women over a short time period. The German agency that regulates herbs does not recommend using black cohosh for longer than 6 months. Side effects can include nausea, vomiting, dizziness, visual problems, slow heartbeat, and excessive sweating. Black cohosh is not regulated by the U.S. Food and Drug Administration, so women must be careful about the safety and purity of this supplement.

• Inconclusive and conflicting studies indicate that other herbals, such as dong quai, red clover (Promensil), chasteberry (Vitex), yam cream, Chinese medicinal herbs, and evening primrose oil, should be avoided or taken with care under the supervision of a health care provider to avoid unwanted and dangerous side effects and interactions.
  
  
• According to the National Center for Complementary and Alternative Medicine, other nonprescription techniques may relieve the symptoms of menopause. These techniques include meditation, acupuncture, hypnosis, biofeedback, deep breathing exercises, and paced respiration (a technique of slow breathing using the stomach muscles).

|Prevention|

Menopause cannot be prevented; however, steps can be taken to help reduce the risk factors for other problems associated with menopause. At a 1994 National Institutes of Health Consensus Conference, the recommendation was made that postmenopausal women not on estrogen therapy consume 1,500 mg of calcium daily to prevent loss of bone mineral density. Women on estrogen therapy should consume at least 1,000 mg of calcium daily.

• The least expensive way to obtain calcium is through diet. Diet can easily provide 1,000-1,500 mg of calcium daily. The following foods contain calcium:
  
  
  • One cup of milk (regular or fat-free/skim) - 300 mg 
  
  
  
  • One cup of calcium-fortified orange juice - 300 mg
  
  
  
  • One cup of yogurt (regular or fat-free) - about 400 mg on average
  
  
  
  • One ounce of cheddar cheese - about 200 mg
  
  
  
  • Three ounces of salmon (including the bones) - 205 mg

• Dietary calcium supplements are a good option for women who cannot consume adequate calcium through diet. Calcium carbonate is the least expensive, although some women complain of bloating. Calcium citrate may be better absorbed by women who take acid-blocking medications, such as ranitidine (Zantac) or cimetidine (Tagamet).

• Calcium products made from bone meal, dolomite, or unrefined oyster shells may contain lead and should be avoided. Products with "USP" on the label meet the voluntary quality standards set by the United States Pharmacopeia and are more likely not to contain harmful contaminants.



• Women should carefully read the label of calcium supplements to check the exact number of milligrams of elemental calcium in each supplement. The intestinal tract generally does not absorb more than 500 mg of elemental calcium at a time, so calcium intake should be spread out during the day.



• Women should not take excessive doses of calcium due to the risk of kidney stones. Women with certain medical conditions, such as sarcoidosis or kidney stones, should consult their health care providers prior to taking calcium supplements.



• Vitamin D plays an important role in calcium absorption, but megadoses should be avoided. The National Osteoporosis Foundation recommends 400 International Units (IU) for women and men aged 51-70 years and 600 IU for people aged 71 years and older. Most multivitamins contain 400 IU of vitamin D.

American Heart Association
National Center
7272 Greenville Avenue
Dallas, TX 75231
(800) AHA-USA-1
(800) 242-8721

The Hormone Foundation
8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815-5817
(800) Hormone
(800) 467-6663

Jacobs Institute of Women’s Health
409 12th Street, SW
Washington, DC 20024-2188
(202) 863-4990

North American Menopause Society
PO Box 94527
Cleveland, OH 44101
(440) 442-7550
(800) 774-5342

National Cancer Institute
NCI Public Inquiries Office
6116 Executive Boulevard
Room 3036A
Bethesda, MD 20892-8322
(800) 422-6237

National Osteoporosis Foundation
1232 22^nd Street NW
Washington, DC 20037-1292
(202) 223-2226

National Women’s Health Information Center
8550 Arlington Boulevard, Suite 300
Fairfax, VA 22031
(800) 994-Woman
(800) 994-9662

Office of Dietary Supplements, National Institutes of Health
6100 Executive Boulevard
Room 3B01, MSC 7517
Bethesda, MD 20892-7517
(301) 435-2920

|Web Links|

American Academy of Family Physicians, Very-Low-Dose Birth Control Pills for Perimenopausal Women 

American Heart Association, Menopause and the risk of heart disease and stroke 

National Cancer Institute, Menopausal Hormone Use: Questions and Answers

National Heart, Lung, and Blood Institute, National Institutes of Health, Postmenopausal Hormone Therapy

National Institute on Aging, Menopause: One Woman’s Story, Every Woman’s Story, A Resource for Making Healthy Choices 

National Kidney and Urologic Diseases Information Clearinghouse, Menopause and Bladder Control

Office of Dietary Supplements, National Institutes of Health, Questions and Answers About Black Cohosh and the Symptoms of Menopause

Women's Health Initiative

National Heart, Lung, and Blood Institute, Good Sources of Calcium

menopause, the change, perimenopause, climacteric, postmenopause, surgical menopause, hot flash, estrogen, hormone replacement therapy, HRT, hormone therapy, HT, estrogen replacement therapy, ERT, estrogen therapy, ET, Women's Health Initiative, osteoporosis, bone loss, osteopenia, FSH, follicle-stimulating hormone, menstruation, menarche, vaginal dryness, ovaries, period, monthly cycle, osteoporosis prevention, black cohosh, ovulation

Author: James N Anasti, MD, Program Director, Professor, Department of Obstetrics and Gynecology, St Luke's Hospital, Temple University School of Medicine.

Coauthor(s): Erin Marcus, MD, Assistant Professor, Department of Internal Medicine, Division of General Medicine, University of Miami School of Medicine.

Editors: Richard Harrigan, MD, Associate Professor, Department of Emergency Medicine, Temple University Hospital, Temple University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.