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Diseases and Conditions
Special to CNN.com
Although your mother or grandmother may have used "the change" to refer to menopause, it isn't a single event. Instead, it's a transition that can start in your 30s or 40s and last into your 50s or even 60s. You may begin to experience signs and symptoms of menopause well before your periods stop permanently. Once you haven't had a period for 12 consecutive months, you've reached menopause.
Menopause is a natural biological process, not a medical illness. Although it's associated with hormonal, physical and psychosocial changes in your life, menopause isn't the end of your youth or of your sexuality. Several generations ago, few women lived beyond menopause. Today, you may spend as much as half of your life after menopause.
Hormone therapy (HT) has been widely used in recent decades to relieve the signs and symptoms of menopause and — doctors thought — to prevent diseases associated with aging. However, new long-term evidence has demonstrated that HT may actually increase your risk of serious health conditions, such as heart disease, breast cancer and stroke.
Estrogen therapy is still a safe, short-term option for some women, but numerous other therapies also are available to help you manage menopausal symptoms and stay healthy during this important phase of your life.
Signs and symptoms
Every woman experiences menopause differently. Even the age at which menopause begins may be unique to you. Some women reach menopause in their 30s or 40s, and some not until their 60s, but menopause most often occurs between the ages of 45 and 55.
Your signs and symptoms also are likely to be very individual. You may breeze through menopause with few signs and symptoms. Or you may experience a number of physical and emotional changes, including:
- Irregular periods. Your menstrual periods may stop suddenly, or gradually get lighter or heavier and then stop. The unpredictability of your periods may be your first clue that menopause is approaching.
- Decreased fertility. When ovulation begins to fluctuate, you're less likely to become pregnant. Until you haven't had a period for a year, however, pregnancy is still possible.
- Vaginal and urinary changes. As your estrogen level declines, the tissues lining your vagina and urethra — the opening to your bladder — become drier, thinner and less elastic. With decreased lubrication you may experience burning or itching, along with increased risk of infections of your urinary tract or vagina. These changes may make sexual intercourse uncomfortable or even painful. You may feel the need to urinate more frequently or more urgently, and you may experience urinary incontinence.
- Hot flashes. As your estrogen level drops, your blood vessels may expand rapidly, causing your skin temperature to rise. This can lead to a feeling of warmth that moves upward from your chest to your shoulders, neck and head. You may sweat, and as the sweat evaporates from your skin, you may feel chilled, weak and slightly faint. Your face might look flushed, and red blotches may appear on your chest, neck and arms. Most hot flashes last from 30 seconds to several minutes, although they can last much longer. The frequency, as well as the duration, of hot flashes varies from person to person. You may have them once every hour or only occasionally. They can occur any time during the day or night. They may be a part of your life for a year or more, or you may never have them.
- Sleep disturbances and night sweats. Night sweats are often a consequence of hot flashes. You may awaken from a sound sleep with soaking night sweats followed by chills. You may have difficulty falling back to sleep or achieving a deep, restful sleep. Lack of sleep may affect your mood and overall health.
- Changes in appearance. Many women gain a modest amount of weight — about 5 pounds on average — during the menopausal transition. The fat that once was concentrated in your hips and thighs may settle above your waist and in your abdomen. You may notice a loss of fullness in your breasts, thinning hair and wrinkles in your skin. If you previously experienced adult acne, it may become worse. Although your estrogen level drops, your body continues to produce small amounts of the male hormone testosterone. As a result, you may develop coarse hair on your chin, upper lip, chest and abdomen.
- Emotional and cognitive changes. You may experience irritability, fatigue, decreased memory and diminished concentration as you approach menopause. These symptoms have sometimes been attributed to hormonal fluctuations. Yet other factors are more likely to contribute to these changes, including sleep deprivation and stressful life events — such as the illness or death of a parent, grown children leaving home or returning home, and retirement.
Menopause begins naturally when your ovaries start making less estrogen and progesterone. During your reproductive years, these hormones regulate your monthly cycles of ovulation and menstruation. In your late 30s, the amount of progesterone your body produces diminishes, and the remaining eggs from your ovaries are less likely to be fertilized. Eventually your menstrual periods stop, and you can no longer become pregnant. Because this process takes place over years, menopause is commonly divided into the following two stages:
- Perimenopause. This is the time you begin experiencing menopausal signs and symptoms, even though you're still ovulating. Your hormone levels rise and fall unevenly, and you may have hot flashes and variations in your periods. For instance, your flow may be irregular or heavier or lighter than usual. This is a normal process leading up to menopause and may last four to five years or longer.
- Postmenopause. Once 12 months have passed since your last period, you've reached menopause. Your ovaries produce much less estrogen and progesterone, and they don't release eggs. The years that follow are called postmenopause.
Menopause is usually a natural process. But certain surgical or medical treatments can bring on menopause earlier than expected. These include:
- Hysterectomy. A hysterectomy that removes your uterus, but not your ovaries, usually doesn't cause menopause. Although you no longer have periods, your ovaries still release eggs. But an operation that removes both your uterus and ovaries (total hysterectomy and bilateral oophorectomy) does cause menopause. There's no perimenopausal phase. Instead, your periods stop immediately, and you're likely to have hot flashes and other menopausal signs and symptoms.
- Chemotherapy and radiation therapy. These cancer therapies can induce menopause, causing symptoms such as hot flashes during the course of treatment or within three to six months.
- Premature ovarian failure. Approximately 1 percent of women experience menopause before age 40. Premature menopause may result from genetic factors or autoimmune disease, but often no cause can be found.
When to seek medical advice
It's important to see your doctor during both perimenopause and postmenopause for preventive health care as well as care of medical conditions that may occur with aging. Although some problems attributed to aging are unavoidable, others can benefit from lifestyle changes and medical treatments.
If you've skipped a period but aren't sure you've started menopause, you may want to see your doctor to determine whether you're pregnant. He or she may take a medical history, do a pelvic examination and, if appropriate, order a pregnancy test.
Always seek medical advice if you have bleeding from your vagina after menopause.
Screening and diagnosis
The signs and symptoms of menopause are enough to tell most women they have begun going through the transition. If you have concerns about irregular periods or hot flashes, talk with your doctor. In some cases further evaluation may be recommended.
Under certain circumstances, your doctor may check your level of follicle-stimulating hormone (FSH) and estrogen (estradiol) with a blood test. As menopause occurs, FSH levels increase and estradiol levels decrease. Your doctor may also recommend a blood test to determine your level of thyroid-stimulating hormone, because hypothyroidism can cause symptoms similar to those of menopause.
Several chronic medical conditions tend to appear after menopause. By becoming aware of the following conditions, you can take steps to help reduce your risk:
- Cardiovascular disease. At the same time your estrogen levels decline, your risk of cardiovascular disease increases. Heart disease is the leading cause of death in women as well as in men. Yet you can do a great deal to reduce your risk of heart disease. These risk-reduction steps include stopping smoking, reducing high blood pressure, getting regular aerobic exercise and eating a diet low in saturated fats and plentiful in whole grains, fruits and vegetables.
- Osteoporosis. During the first few years after menopause, you may lose bone density at a rapid rate, increasing your risk of osteoporosis. Osteoporosis causes bones to become brittle and weak, leading to an increased risk of fractures. Postmenopausal women are especially susceptible to fractures of the hip, wrist and spine. That's why it's especially important during this time to get adequate calcium — 1,500 milligrams daily — and vitamin D — 400 to 800 international units daily. It's also important to exercise regularly. Strength training and weight-bearing activities such as walking and jogging are especially beneficial in keeping your bones strong.
- Urinary incontinence. As the tissues of your vagina and urethra lose their elasticity, you may experience a frequent, sudden, strong urge to urinate (urge incontinence) or incontinence with coughing, laughing or lifting (stress incontinence).
- Weight gain. Many women gain weight during the menopausal transition. You may need to eat less — perhaps as many as 200 to 400 fewer calories a day — and exercise more, just to maintain your current weight.
Menopause itself requires no medical treatment. Instead, treatments focus on relieving your signs and symptoms and on preventing or lessening chronic conditions that may occur with aging. Treatments include:
- Hormone therapy (HT). Results from several recent, long-term studies suggest that benefits of HT use may be outweighed by the risks. One large study called the Women's Health Initiative (WHI), funded by the National Institutes of Health, was halted early when researchers found that women given a certain type of combined estrogen and progesterone were at increased risk of heart attack, stroke and breast cancer. Later results from the WHI study showed that estrogen alone also increased stroke risk, but did not increase breast cancer or heart disease risk. Although these results have changed the landscape for women taking or considering taking estrogen, it's important to put the risks in perspective. In the WHI study, fewer than 10 additional cases each of heart attack, stroke and breast cancer occurred each year among 10,000 women taking combination hormone therapy compared with 10,000 women taking placebo. Estrogen therapy remains the most effective treatment option for menopausal symptoms such as hot flashes and vaginal discomfort. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose needed to provide symptom relief for you.
- Low-dose antidepressants. Venlafaxine (Effexor), an antidepressant related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs), may decrease hot flashes by up to 60 percent. Other drugs in the SSRI class that can be helpful include fluoxetine (Prozac, Sarafem), paroxetine (Paxil, others), citalpram (Celexa) and sertraline (Zoloft). These medications may cause side effects including nausea, dizziness or sexual dysfunction.
- Gabapentin (Neurontin). This drug is approved to treat seizures and is commonly used to manage chronic, nerve-related pain, but it also has been shown to significantly reduce hot flashes. Side effects may include drowsiness, dizziness, nausea and swelling.
- Clonidine (Catapres, others). Clonidine, a pill or patch typically used to treat high blood pressure, may significantly reduce the frequency of hot flashes, but side effects such as dizziness, drowsiness, dry mouth and constipation are common.
- Bisphosphonates. Doctors may recommend these nonhormonal medications, which include alendronate (Fosamax) and risedronate (Actonel), to prevent or treat osteoporosis. These medications effectively reduce both bone loss and your risk of fractures and have replaced estrogen as the main treatment for osteoporosis in women. Side effects may include nausea, abdominal pain and irritation of the esophagus.
- Selective estrogen receptor modulators (SERMs). SERMs are a group of drugs that includes raloxifene (Evista). Raloxifene mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen, such as increased risk of uterine and, possibly, breast cancer. Hot flashes are a common side effect of raloxifene, and you shouldn't use this drug if you have a history of blood clots.
- Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered locally using a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen locally to vaginal tissue, and can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms. Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each.
Fortunately, many of the signs and symptoms associated with menopause are temporary. Take these steps to help reduce or prevent their effects:
- Cool hot flashes. If you're experiencing hot flashes, get regular exercise, dress in layers and try to pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages, spicy foods, alcohol, hot weather and even a warm room.
- Decrease vaginal discomforts. For vaginal dryness or discomfort with intercourse, use over-the-counter water-based vaginal lubricants (Astroglide, K-Y Jelly), moisturizers (Replens, Vagisil) or vaginal estrogen. Staying sexually active also helps.
- Optimize your sleep. If you have trouble sleeping, avoid caffeinated beverages and exercise right before bedtime. Practicing relaxation techniques, such as deep breathing, guided imagery and progressive muscle relaxation, can be very helpful. You can find a number of books and tapes on different relaxation exercises.
- Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.
- Eat well. Eat a balanced diet that includes a variety of fruits, vegetables and whole grains and that limits saturated fats, oils and sugars. Aim for 1,500 milligrams of calcium and 400 to 800 international units of vitamin D a day. Ask your doctor about supplements to help you meet these requirements, if necessary.
- Don't smoke. Smoking increases your risk of heart disease, stroke, cancer and a range of other health problems. It may also increase hot flashes and bring on earlier menopause. It is never too late to benefit from stopping smoking.
- Exercise regularly. Get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis and other conditions associated with aging. More vigorous exercise for longer periods may provide further benefit and is particularly important if you are trying to lose weight. Exercise can also help reduce stress. Try a combination of weight-bearing aerobic activities — such as walking, jogging and dancing — and strength training exercises. Just staying physically active each day by taking stairs instead of an elevator or by parking farther away and walking to your destination also can make a difference.
- Schedule regular checkups. Talk with your doctor about how often you should have mammograms, Pap tests, lipid level (cholesterol and triglyceride) testing and other screening tests.
Complementary and alternative medicine
Many approaches have been promoted as aids in managing the symptoms of menopause. Below are several complementary and alternative treatments that have been or are being studied:
- Phytoestrogens. These estrogens occur naturally in certain foods. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, chickpeas and other legumes. Lignans occur in flaxseeds, whole grains and some fruits and vegetables. Researchers first became interested in phytoestrogens when they noted that women in Japan and China, who eat diets high in isoflavones, report fewer menopausal signs and symptoms and have a lower incidence of heart disease and osteoporosis than do women in the West. Whether the relatively weak estrogens in these foods can relieve menopausal signs and symptoms remains to be seen. Although some women find that adding isoflavones or other phytoestrogens to their daily diets seems to help hot flashes, studies have mostly found them ineffective. In addition, some studies indicate that phytoestrogens may increase breast cancer growth. Other studies indicate that phytoestrogens may inhibit the development of breast cancer. Overall, no compelling data suggest that soy products are harmful if you have breast cancer. But research on this topic is ongoing. If you have had breast cancer, talk to your doctor before supplementing your diet with isoflavone pills.
- Vitamin E. This vitamin occasionally provides relief from mild hot flashes for some women. However, scientific studies haven't proved its overall benefit in relieving hot flashes, and taking more than 400 international units of vitamin E supplements daily may not be safe.
- Black cohosh. This herb is used extensively in Europe for treating hot flashes and has become increasingly popular in the United States, but few scientific studies prove its benefit and safety. The North American Menopause Society supports short-term use of black cohosh for treating menopausal symptoms because it seems to have a low risk of side effects when used for up to six months. But the exact effects of longer term use aren't known. Studies have found that the herb doesn't reduce hot flashes any better than a placebo does.
You may have heard of — or even tried — other dietary supplements, such as dong quai, licorice, chasteberry, evening primrose oil and wild yam (natural progesterone cream). Although some might swear by these remedies, scientific evidence of their safety and effectiveness is lacking.
Be sure to consult your doctor before taking any herbal treatments or dietary supplements for signs and symptoms of menopause. Herbal products can interfere or interact with other medications you may be taking.
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