Menopause: Adapting to Life's Changes

Menopause is a natural biological process that begins when your body starts making less estrogen and progesterone as a result of changes in ovarian function.

Until recently, menopause was shrouded in misconceptions and myths. The scientific truth is that menopause is a natural biological process and a normal part of aging.

At birth, your ovaries contain as many as two million egg-containing follicles. As you mature and start ovulating, your follicle reserve steadily declines. When the supply is exhausted, your ovaries stop producing estrogen and progesterone, the sex hormones which have been responsible for regulating your periods over the years.

As menopause approaches, ovulation and estrogen production become erratic and may cause your periods to become irregular.  As estrogen levels drop, the level of follicle-stimulating hormone, or FSH, rises, trying to stimulate your ovaries to produce more estrogen and maintain your menstrual cycle .

Rising levels of FSH can be a good indicator that you have started your transition into menopause. But day-to-day hormone levels are not a reliable indication of where you are in the menopausal transition. There are a number of physical symptoms, described below, that also serve as indicators that you are entering menopause.

Stages

Bear in mind that menopause is actually a multi-stage process that takes place over years, and the amount of time it takes to complete the process may vary widely from woman to woman. While different health professionals may define the stages of menopause in different ways, the following descriptions will help you gain a better understanding of the process.

• Pre-menopause: Some people use pre-menopause and perimenopause interchangeably. Others use it to define the time when a woman is just starting to experience irregular periods but is showing no signs of classic menopausal symptoms, like hot flashes or vaginal dryness. Still others use pre-menopause to describe a longer span of time prior to perimenopause, sometimes starting as early as your mid-30s.
• Perimenopause: Some define perimenopause as the transitional time before menstruation stops. Others extend the definition past your final menstrual period for one to two years. While the average timeframe for perimenopause is about four years, it can last up to 10 years and still be considered normal.
• Menopause: Menopause refers specifically to the date of your last period. Doctors pinpoint your final period once you haven't had one for 12 months. This is the point when you no longer have periods or need to be concerned about getting pregnant. This term is commonly used to refer to the entire process — three of the four stages including perimenopause and post-menopause. Menopause also can occur suddenly with early failure of the ovaries, such as when a woman has her ovaries removed or when chemotherapy is used to fight cancer.
• Post-menopause: This stage begins with your final period and lasts the rest of your life. While the signs and symptoms of menopause diminish over a year or two, you are at increased risk for longer-term health problems (including osteoporosis) related to low estrogen, and you should work with your doctor to manage them.

Signs and Symptoms

Although some women have no menopausal symptoms aside from their periods ending, most experience one of more of the following symptoms, many of which improve over time or can be treated under a doctor's care.

• Hot flashes
 Hot flashes — also known as hot flushes — are the most common early symptom when estrogen levels decrease. When less estrogen is secreted, your capillaries expand irregularly, causing hot sensations in the face, neck and chest. You may experience hot flashes for a year or so, but symptoms can persist for five years or more. Irritation, impatience, anxiety and worry may also accompany hot flashes.
• Night sweats and sleep disturbance 
Your usual sleep patterns may undergo dramatic changes because of night sweats, which are brought on by hot flashes. You may awaken suddenly with soaking night sweats followed by chills. You may have trouble falling back to sleep or achieving a sound, restful sleep. Too little sleep may affect your mood and overall health.
• Changes in physical appearance 
Following menopause, fat that once was concentrated in your hips and thighs may find a new home above your waist and in your abdomen. Other notable changes may include weight gain, a loss of fullness in your breasts, and thinning hair. And even though your estrogen level has decreased, your body continues to produce tiny amounts of the male hormone testosterone, which may result in the appearance of coarse hairs on your chin, upper lip, chest and stomach.
• Emotional changes/moodiness
 As you move through menopause, you may experience a number of emotional changes, including mood swings, irritability, anxiety, depression, sensitivity, fatigue and forgetfulness. In the past, these symptoms were attributed primarily to hormonal fluctuations. Today we know that other factors may contribute to these mood changes. These include stress, insomnia and life events, like the illness or death of a loved one, children leaving home, job loss, financial crisis and retirement, which may also occur at this stage in a woman's life.
• Decreased fertility 
When ovulation begins to fluctuate, you are less likely to become pregnant. Until you stop ovulating, however, pregnancy is still possible.
• Decreased sex drive 
In addition to losing their ability to secrete estrogen, the ovaries no longer produce testosterone — the hormone responsible for sex drive in both men and women. Some women's bodies may still produce the tiny amount needed through the adrenal glands.
• Irregular menstruation
 Your menstrual cycle may stop suddenly, or gradually get lighter or heavier then stop. The irregularity of your periods may be your first signs that menopause is approaching.
• Vaginal changes
 As your estrogen level falls, the tissues lining your vagina and urethra — the opening to your bladder — tend to become drier, thinner and less elastic. The decrease in lubrication may cause you to experience burning or itching. You may also be more susceptible to infections of your urinary tract or vagina. These changes may also make sexual intercourse uncomfortable or even painful.
• Loss of bone mass
 Women lose an average of 25 percent of their bone mass from the time of menopause to age 60, due in large part to the loss of estrogen. Over time, this loss of bone may lead to osteoporosis, a "brittle-bone" disease that contributes to bone fractures.
• Increased risk of heart disease
 Lower levels of estrogen put you at greater risk for heart disease and stroke. 
A high fat diet, cigarette smoking, high blood pressure, high cholesterol, physical inactivity and obesity increase your risk.
• Skin ages faster
 After menopause, skin loses elasticity, causing more wrinkles. Although the lack of estrogen is not the main cause, hormone treatment may help the skin maintain elasticity. Also, if you previously experienced adult acne, you may notice that the condition worsens.
• Breast changes
 The lack of estrogen affects breast size and supporting tissue. After menopause, breasts may stretch, decrease in size, or soften because there is less connective tissue and less glandular tissue.
• Urinary tract changes
 With the thinning of the lining of the urethra and the weakening of surrounding pelvic muscles, you may experience the need to urinate more frequently. Other symptoms may include frequent bladder infections, painful urination, sudden urinary urgency and frequent urination during the night. Urinary incontinence may also become a problem.

Key Point 2

There are things that you can do to alleviate the physical, emotional and biological symptoms of menopause, including hormone replacement. If estrogen replacement is not an option for you, there are other alternatives including herbal supplements.

Like a fingerprint, the symptoms of menopause are different for every woman. For this reason, the first and most important step toward treating symptoms you are experiencing is to consult with your doctor. He or she will evaluate your symptoms and carefully weigh other important factors, including your medical history, to recommend a course of therapy that is appropriate for your specific needs.

Before meeting with your doctor, you may find it helpful to acquaint yourself with the various forms of treatment, outlined below, that are available today.

Hormone therapy Choosing whether or not to use hormone therapy can be one of the most crucial health decisions you face as you age. As with taking any treatment, the decision involves carefully weighing the risks and benefits involved after consulting with your physician. 
Hormone therapy is prescription medication containing one or more female hormones, commonly estrogen plus progestin. Some women — usually those who have had their uterus removed — may receive estrogen-only therapy. Hormone therapy is used to treat menopause symptoms that include hot flashes, vaginal dryness, mood swings, sleep disorders and decreased sexual desire. Hormone therapy may be taken in the form of a pill, a patch, a suppository, vaginal cream or vaginal ring.

Early scientific studies led physicians to believe that hormone therapy, in addition to treating menopausal symptoms, might be beneficial for reducing the risk of heart disease and bone fractures caused by osteoporosis (thinning of the bones). A landmark 2002 study called the Women's Health Initiative persuaded many physicians to revise their recommendations regarding hormone therapy. The study concluded that there are potentially serious side effects to hormone therapy (including strokes, heart attacks, breast cancer, blood clots and dementia) as well as beneficial effects including reduction of colon cancer.

Hormone therapy continues to play an important role for many women who have reached menopause. Another recent study suggests that the benefits of short-term hormone therapy may outweigh the risks for certain women, provided that their symptoms (hot flashes, vaginal discomfort and osteoporosis) are severe enough and that their risk of heart attack and stroke is relatively low.

The bottom line? If you are considering any form of hormone therapy, you and your doctor should carefully evaluate your entire medical history to determine if this type of therapy is appropriate for you.

Alternative treatments Many women who are concerned about the risks associated with hormone therapy may seek relief from their menopausal symptoms though alternative therapies, including herbal remedies, nutritional supplements, soy foods and phytoestrogens. There are scores of products on the market and sales have soared in recent years.

To learn more, read the National Institutes of Health publication Postmenopausal Hormone Therapy. This succinct and easy-to-read online pamphlet provides a comprehensive overview of a variety of alternative and conventional therapies, plus practical suggestions for what you can do to relieve many menopause symptoms.

While it is worthwhile to investigate all of your treatment options, keep in mind that few high-quality scientific studies have been done to test the effectiveness and safety of many alternative therapies. Some hold potential for significant side effects and risks. So, before beginning any health treatment, conventional or alternative, you should first consult with your doctor, who can help you assess the benefits and risks based on medical history and current health condition.

It's Not the End of the World

Life is not over at the onset of menopause. It is a natural event and can be a good time of life if you take care of yourself.

Contrary to the age-old view that life is a downhill slide after menopause, many women today find that their post-menopausal years rank among the richest of their lives. Two major immediate benefits are that you no longer have to deal with your periods and your risk of getting pregnant drops to zero.

As you move though this transition in your life, the most important thing you can do to stay youthful and active is to lead a healthy lifestyle, which includes good nutrition and regular physical exercise. Doing so may help relieve some of your menopause symptoms, enhance the effectiveness of any treatments you may choose, and contribute to the reduction of long-term health risks, including heart disease and osteoporosis.

Good Nutrition

As you age, your nutritional requirements change. A woman in the premenopause stage should consume about 1,000 mg of calcium daily. According to the National Institutes of Health, postmenopausal women should aim for 1,500 mg of calcium per day if they are not using hormone therapy, or 1,000 mg/day if they are using HT.

Vitamin D is also very important for calcium absorption and bone formation. According to a 1992 study, women with postmenopausal osteoporosis who took vitamin D for three years, significantly reduced their risk of spinal fractures. This issue is controversial, however, as vitamin D can cause kidney stones, constipation or abdominal pain, especially in women with kidney problems.

Other nutritional guidelines recommended by the National Research Council of the National Institutes of Health include:

• Eat foods low in fat, saturated fat and cholesterol. Fat intake should be less than 30 percent of your daily calorie intake.
• Consume fruits, vegetables and whole grain cereal products, especially those high in vitamin C and beta carotene. People of all ages should consume 20 to 30 grams of fiber daily.
• Avoid foods and drinks with processed sugar. Many of these products contain empty calories and promote weight gain.
• Avoid salt-cured and smoked foods, like sausage, smoked fish, ham, bacon, bologna and hot dogs. These foods are high in sodium, which can lead to high blood pressure, a serious risk for aging women.

Exercise and Fitness

Exercise has been associated with reduction in hot flashes, improved sleep and better mood control. (Note: Always consult your physician before starting an exercise program, particularly if you have been inactive. He or she can recommend a program that is tailored to your individual requirements.) Regular sexual activity has led to improved vaginal lubrication and wall thickening in many women.

Menopausal women often experience weight gain, possibly associated with declining estrogen levels. Boosting your activity level will help you avoid weight gain. Regular exercise, which is especially important as you get older, benefits the heart and bones and helps you keep your weight under control.

Women who are physically inactive are more likely to suffer from coronary heart disease, obesity, high blood pressure, diabetes and osteoporosis. Inactivity may also contribute to other problems, including depression, chronic back pain, insomnia, poor circulation, weak muscles and loss of bone mass. To help prevent some of these problems, take up walking, jogging, biking, swimming, dancing or other aerobic activities. Weight-bearing exercises, like walking, running and moderate weight training, help to increase bone mass, which is particularly important because postmenopausal women are at higher risk for osteoporosis and bone fractures.

Regular exercise may also help improve your mood, thanks to hormones called endorphins, which are released in the brain during vigorous physical activity. The mood-elevating effect of endorphins can last for several hours and can help you fight stress.

Tips for healthy living after menopause:

• Eat a low-fat, high-fiber diet rich in fruits, vegetables and whole grains. Reduce consumption of saturated fats.
• Do not smoke. Smoking is a major risk factor for heart disease .
• Exercise regularly. Even moderate exercise is beneficial.
• Maintain a healthy weight.
• Manage high blood pressure and keep cholesterol and triglycerides within recommended levels to reduce your risk for heart disease.
• Reduce stress using relaxation techniques or regular exercise.
• Avoid excess alcohol.
• Get plenty of rest.

This article reprinted with permission from Second Opinion, a public television health program hosted by Dr. Peter Salgo and produced by WXXI (Rochester, N.Y.),  West 175 and the University of Rochester Medical Center.

By Second Opinion