Menopause is the time in a woman’s life when she stops having menstrual periods for at least one year due to significantly decreased production of estrogen. The years leading up to this point are called perimenopause, which means “around menopause.” Menopause marks the end of the reproductive years and the average age is 51 years. One of the most common, early, signs that menopause may be approaching is a change in menstrual periods. One or more periods may be skipped. The amount of flow may become lighter or heavier, and bleeding may last a shorter or longer time than usual. Even though periods tend to be irregular around the time of menopause, it is advised to notify a healthcare provider if you experience unusual bleeding patterns such as heavy bleeding with clots, prolonged bleeding, and/or bleeding after sex or between periods. At some point, the ovaries do not make enough estrogen to sustain menstrual periods and they stop. A woman can also have surgical menopause when her ovaries are surgically removed. Menopause symptoms are usually more severe after the ovaries have been removed because the hormone levels decrease abruptly rather that over a long period of time. Although the removal of the uterus (a hysterectomy) ends menstrual periods, it will not cause menopause unless the ovaries also are removed. If the ovaries remain after surgery, most women will go through menopause around the normal age.
Menopause is a natural part of aging. The lower amounts of estrogen during menopause cause changes in a woman’s body. These changes occur over time and they can go unnoticed or cause bothersome symptoms. Each woman responds differently to menopause changes. Some women notice little difference in their bodies. However, others may find it difficult to cope with their symptoms. The most common signs and symptoms are hot flashes, sleep problems, headaches, vaginal and urinary tract changes, emotional changes, bone loss, joint aches, and skin/hair/nail changes.
The most common symptom of menopause is hot flashes. Up to 75% of menopausal women in the United States will have them at some point. A hot flash is a sudden feeling of heat that rushes to the upper body and face causing reddening of the skin and sweating. Hot flushes can happen at any time, last a few seconds or several minutes, and occur from a few times a month to multiple times a day. Thus they can be severely bothersome and embarrassing, and they may interfere with daily life.
Sleep problems, including insomnia, are another common problem facing post-menopausal women. Hot flashes can cause a lack of sleep if they occur at night. Too little sleep can affect your mood, health, and ability to cope with daily activities.
Loss of estrogen can causes changes in the vagina such as increased dryness and thinning of the lining, which can lead to pain during sexual intercourse. In addition, these changes can make the vagina more prone to infection, which can cause burning and itching. The urinary tract also changes with menopause. The urethra (the tube that carries urine from the bladder) can become dry, inflamed, or irritated. Some women may need to urinate more often. Women may have an increased risk of bladder infection after menopause.
Bone loss is a normal part of aging. At menopause, the rate of bone loss increases due to the decreased production of estrogen. Osteoporosis, which can result from this bone loss, increases the risk of breaking bones. The bones of the hip, wrist, and spine are affected most often.
The estrogen produced by women’s ovaries before menopause protects them from heart attacks and stroke. When less estrogen is made after menopause, women lose much of this protection. The risk of heart attack and stroke then increases.
Menopause does not have to affect your ability to enjoy sex. Although the lack of estrogen may make the vagina dry, vaginal lubricants can help moisten the vagina and make sex more comfortable. There are a number of over-the-counter lubricants available. If you do not like one product, try another. Regular sex may help the vagina keep its natural elasticity. If you have been having sex on a regular basis, you may not notice any major changes during menopause. If you have not been sexually active for a while, you may want to talk with your partner and perhaps your doctor, too, about ways to make sex more comfortable. Some women find that they have less interest in sex around and after menopause. Lower hormone levels may decrease the sex drive. It may affect your ability to have an orgasm, or it may take longer for you to reach orgasm. You are not completely free of the risk of pregnancy until 1 year after your last period. Until this time, if you do not wish to become pregnant, it is important to use a method of birth control. Keep in mind you still need to prevent sexually transmitted diseases (STDs). If you are at risk for sexually transmitted diseases, use a latex condom. Men, too, may find that their sex drives decrease as they age. It may take an older man longer to achieve an erection and ejaculate, or he may have problems with impotence. Impotence usually is caused by physical or medical problems, or it may be caused by medications. In many cases, impotence can be treated with success.
Your Body’s Hormones
Hormones are substances that control when and how certain organs work. They are made by glands in the body, but also can be made in a lab. Androgens, so-called male hormones, are made by the ovaries (two glands on either side of the uterus) in women and by the testes in men. In women, androgens are used by the ovaries to make estrogen, the so-called female hormone. The ovaries make estrogen from puberty until menopause. Even after menopause, the ovaries continue to make androgens (testosterone). In women, the hormone estrogen plays a key role in the reproductive system. Changes in the level of estrogen lead to menstrual periods each month. Estrogen also affects a woman’s bones and the health of her heart and blood vessels. Estrogen is made during the entire menstrual cycle. It causes the lining of the uterus (the endometrium) to thicken each month. The amount of estrogen produced by the ovaries decreases as a woman ages. At some point, the ovaries stop making enough estrogen to thicken the uterine lining. This is when the menstrual periods stop and menopause occurs. The average age when a woman has her last menstrual period is 51 years, but the normal range is from ages 45 to 55 years. If a woman’s ovaries are removed during surgery, her estrogen level will decrease suddenly. In most women, this brings on symptoms of menopause.
Women can take hormones to relieve symptoms of menopause. When a woman chooses to take hormone therapy, her options depend on whether she has had her uterus removed. A woman who has had her uterus removed can take just estrogen. This is because using estrogen alone causes the lining of the uterus to grow and increases the risk of endometrial cancer. To reduce this risk, your doctor will recommend using a combination of estrogen and another hormone called progestin if you have a uterus. The progestin keeps the lining of the uterus from growing too much.
Uses of Hormone Therapy
Hormone therapy can help relieve the symptoms of low estrogen levels including hot flushes, vaginal dryness and irritation, urethral irritation, headaches, sleep problems, mood changes, and decrease the risk of osteoporosis. The decision to take hormone therapy depends on your personal needs.
Concerns and Risks
Like most treatments, hormone therapy is not free of risk. Using a progestin seems to mildly increase the risk for breast cancer. Also, monthly bleeding may resume. Although bleeding may occur for only a short time, many women do not want to have menstrual cycles at all and may find this side effect bothersome.
Findings of the Women’s Health Initiative, a study by the National Institutes of Health, raised concerns about the risks of hormones for postmenopausal women. Because of these findings, the U.S. Food and Drug Administration (FDA) announced that all products used for postmenopausal women that contain estrogen must include a warning label stating that prolonged use of these hormones could increase the risk of heart attacks, strokes, blood clots, and breast cancer for some women.
The study results suggest that the increased risk of health problems from hormone therapy may vary from woman to woman depending on how far a woman is past menopause. For example, a woman who is 15 years past menopause may be at greater risk than a woman who is 2 years past menopause. A woman should take the smallest dose of hormone therapy that works for her, for the shortest possible time. For this reason, women who are prescribed these drugs to treat vaginal dryness should consider using a local vaginal estrogen cream or ring since it does not have the same risks as systemic therapy.
When women choose to take hormone replacement therapy, those who have a uterus are prescribed an estrogen and a progestin combination, and those who have had their uterus removed (hysterectomy) are prescribed an estrogen-alone method. The amount of each hormone needed to prevent symptoms varies from person to person. Over time, changes in the dose may be needed. Hormone therapy can be given in variety of ways including oral pills, transdermal (skin) patches/sprays, or vaginal creams, pills, or rings. Sometimes, your doctor may prescribe other non-hormonal medications to manage symptoms or to protect against various conditions.
There are other options to that may relieve menopause symptoms, such as antidepressants, herbal products, or bioidentical hormones. For many of these products there are limited facts available. Some products may be helpful in the short-term treatment of symptoms, whereas others are not. Still others may cause harm. Herbal products and bioidentical hormones are not approved by the FDA.
Although most women do not get depressed during menopause, there is treatment available for women who do. Antidepressants, selective serotonin reuptake inhibitors (SSRIs), can help lessen mood symptoms in some menopausal women. These drugs also may have the added benefit of helping to relieve hot flushes. Discuss the side effects with your doctor.
Herbal products may help relieve some symptoms of menopause for some women. There are many different types of products available. What works for some women may not work for others. Soy products may help relieve some symptoms of menopause, such as hot flushes and vaginal dryness. Black cohosh, a North American plant that may act like estrogen, may help reduce hot flushes. These products are not FDA approved or regulated and may have side effects and risks.
Bioidentical hormones are hormones from plants that are combined together (compounded) by a pharmacist using instructions from a doctor. These hormones have the same risks as hormone therapies approved by the FDA and may have additional risks.
When taking hormone therapy or other medications, you should follow your doctor’s advice carefully and get regular checkups. Let your doctor know if you have any unexpected vaginal bleeding. Follow-up visits will include a review of your reasons for taking hormone therapy, a blood pressure check, and breast and pelvic exams. A Pap test and a mammogram also may be included.