Menopause

Definition
Menopause represents the end of menstruation. While technically it refers to the
final period, it is not an abrupt event, but a gradual process. Menopause is not a
disease that needs to be cured, but a natural life-stage transition. However, women
have to make important decisions about "treatment," including the use of hormone
replacement therapy (HRT).
Description
Many women have irregular periods and other problems of "pre-menopause" for
years. It is not easy to predict when menopause begins, although doctors agree it is
complete when a woman has not had a period for a year. Eight out of every 100
women stop menstruating before age 40. At the other end of the spectrum, five out
of every 100 continue to have periods until they are almost 60. The average age of
menopause is 51.
There is no mathematical formula to figure out when the ovaries will begin to scale
back either, but a woman can get a general idea based on her family history, body
type, and lifestyle. Women who began menstruating early will not necessarily stop
having periods early as well. It is true that a woman will likely enter menopause at
about the same age as her mother. Menopause may occur later than average
among smokers.
Causes and symptoms
Once a woman enters puberty, each month her body releases one of the more than
400,000 eggs that are stored in her ovaries, and the lining of the womb (uterus)
thickens in anticipation of receiving a fertilized egg. If the egg is not fertilized,
progesterone levels drop and the uterine lining sheds and bleeds.
By the time a woman reaches her late 30s or 40s, her ovaries begin to shut down,
producing less estrogen and progesterone and releasing eggs less often. The
gradual decline of estrogen causes a wide variety of changes in tissues that respond
to estrogenincluding the vagina, vulva, uterus, bladder, urethra, breasts, bones,
heart, blood vessels, brain, skin, hair, and mucous membranes. Over the long run,
the lack of estrogen can make a woman more vulnerable to osteoporosis (which can
begin in the 40s) and heart disease.
As the levels of hormones fluctuate, the menstrual cycle begins to change. Some
women may have longer periods with heavy flow followed by shorter cycles and
hardly any bleeding. Others will begin to miss periods completely. During this time,
a woman also becomes less able to get pregnant.

The most common symptom of menopause is a change in the menstrual cycle, but
there are a variety of other symptoms as well, including:
hot flashes
night sweats
insomnia
mood swings/irritability
memory or concentration problems
vaginal dryness
heavy bleeding
fatigue
depression
hair changes
headaches
heart palpitations
sexual disinterest
urinary changes
weight gain
Diagnosis
The clearest indication of menopause is the absence of a period for one year. It is
also possible to diagnose menopause by testing hormone levels. One important test
measures the levels of follicle-stimulating hormone (FSH), which steadily increases
as a woman ages.
However, as a woman first enters menopause, her hormones often fluctuate wildly
from day to day. For example, if a woman's estrogen levels are high and
progesterone is low, she may have mood swings, irritability, and other symptoms
similar to premenstrual syndrome (PMS). As hormone levels shift and estrogen level
falls, hot flashes occur. Because of these fluctuations, a normal hormone level when
the blood is tested may not necessarily mean the levels were normal the day before
or will be the day after.
If it has been at least three months since a woman's last period, an FSH test might
be more helpful in determining whether menopause has occurred. Most doctors

believe that the FSH test alone cannot be used as proof that a woman has entered
early menopause. A better measure of menopause is a test that checks the levels of
estrogen, progesterone, testosterone and other hormones at mid-cycle, in addition
to FSH.
Treatment
When a woman enters menopause, her levels of estrogen drop and symptoms (such
as hot flashes and vaginal dryness) begin. Hormone replacement therapy can treat
these symptoms by boosting the estrogen levels enough to suppress symptoms
while also providing protection against heart disease and osteoporosis, which
causes the bones to weaken. Experts disagree on whether HRT increases or
decreases the risk of developing breast cancer. A Harvard study concluded that
short-term use of hormones carries little risk, while HRT used for more than five
years among women 55 and over seems to increase the risk of breast cancer.
There are two types of hormone treatments: hormone replacement therapy (HRT)
and estrogen replacement therapy (ERT). HRT is the administration of estrogen and
progesterone; ERT is the administration of estrogen alone. Only women who have
had a hysterectomy (removal of the uterus) can take estrogen alone, since taking
this "unopposed" estrogen can cause uterine cancer. The combination of
progesterone and estrogen in HRT eliminates the risk of uterine cancer.
Most physicians do not recommend HRT until a woman's periods have stopped
completely for one year. This is because women in early menopause who still have
an occasional period are still producing estrogen; HRT would then provide far too
much estrogen.
Most doctors believe that every woman (except those with certain cancers) should
take hormones as they approach menopause because of the protection against
heart disease, osteoporosis, and uterine cancer and the relatively low risk of breast
cancer. Heart disease and osteoporosis are two of the leading causes of disability
and death among post-menopausal women.
Critics say the benefit of taking hormonal drugs to ease symptoms is not worth the
risk of breast cancer. Since menopause is not a disease, many argue that women
should not take hormones to cure what is actually a natural process of aging.
Advocates of HRT contend that the purpose of taking hormones is not to "treat"
menopause but to prevent the development of other diseases.
There are risks with HRT and there are risks without it. In order to decide whether to
take HRT, a woman should balance her risk of getting breast cancer against her risk
of getting heart disease, and decide how bad her menopause symptoms are. Most
doctors agree that short-term use of estrogen for those women with symptoms of
hot flashes or night sweats is a sensible choice as long as they do not have a history
of breast cancer.

For a woman who has no family history of cancer and a high risk of dying from heart
disease, for example, the low risk of cancer might be worth the protective benefit of
avoiding heart disease. Certainly, for Caucasian women aged 50 to 94, the risk of
dying from heart disease is far greater than the risk of dying of breast cancer.
Women are poor candidates for hormone replacement therapy if they have:
had breast or endometrial cancer
a close relative (mother, sister, grandmother) who died of breast cancer or have two
relatives who developed breast cancer before age 40
had endometrial cancer
had gallbladder or liver disease
blood clots or phlebitis
Some women with liver or gallbladder disease, or who have clotting problems, may
be able to go on HRT if they use a patch to administer the hormones through the
skin, bypassing the liver.
Women would make a good candidate for HRT if they:
need to prevent osteoporosis
have had their ovaries removed
need to prevent heart disease
have significant symptoms.
Taking hormones can almost immediately eliminate hot flashes, vaginal dryness,
urinary incontinence (depending on the cause), insomnia, moodiness, memory
problems, heavy irregular periods, and concentration problems. Side effects of
treatment include bloating, breakthrough bleeding, headaches, vaginal discharge,
fluid retention, swollen breasts, or nausea. Up to 20% of women who try hormone
replacement stop within nine months because of these side effects. However, some
side effects can be lessened or prevented by changing the HRT regimen.
The decision should be made by a woman and her doctor after taking into
consideration her medical history and situation. Women who choose to take
hormones should have an annual mammogram, breast exam, and pelvic exam and
should report any unusual vaginal bleeding or spotting (a sign of possible uterine
cancer).
Anti-estrogens

A new type of hormone therapy offers some of the same protection against heart
disease and bone loss as estrogen, but without the increased risk of breast cancer.
This new class of drugs are known as antiestrogens. The best known of these antiestrogens is raloxifene, which mimics the effects of estrogen in the bones and
blood, but blocks some of its negative effects elsewhere. It is called an anti-estrogen
because for a long time these drugs had been used to counter the harmful effects of
estrogen that caused breast cancer. Oddly enough, in other parts of the body these
drugs mimic estrogen, protecting against heart disease and osteoporosis without
putting a woman at risk for breast cancer.
Like estrogen, raloxifene works by attaching to an estrogen "receptor," much like a
key fits into a lock. When raloxifene clicks into the estrogen receptors in the breast
and uterus, it blocks estrogen at these sites. This is the secret of its cancer-fighting
property. Many tumors in the breast are fueled by estrogen; if the estrogen cannot
get in the cell, then the cancer stops growing.
Women may prefer to take raloxifene instead of hormone replacement because the
new drug does not boost the breast cancer risk and does not have side effects like
uterine bleeding, bloating, or breast soreness. Unfortunately, the drug may worsen
hot flashes. Raloxifene is basically a treatment to prevent osteoporosis. It does not
help with common symptoms and it is unclear if it has the same protective effect
against heart disease as estrogen does.
Testosterone replacement
The ovaries also produce a small amount of male hormones, which decreases
slightly as a woman enters menopause. The vast majority of women never need
testosterone replacement, but it can be important if a woman has declining interest
in sex. Testosterone can improve the libido, and decrease anxiety and depression;
adding testosterone especially helps women who have had hysterectomies.
Testosterone also eases breast tenderness and helps prevent bone loss. However,
testosterone does have side effects. Some women experience mild acne and some
facial hair growth, but because only small amounts of testosterone are prescribed,
most women do not appear to have extreme masculine changes.
Birth control pills
Women who are still having periods but who have annoying menopausal symptoms
may take low-dose birth control pills to ease the problems; this treatment has been
approved by the FDA for perimenopausal symptoms in women under age 55. HRT is
the preferred treatment for menopause, however, because it uses lower doses of
estrogen.
Alternative treatment

Some women also report success in using natural remedies to treat the unpleasant
symptoms of menopause. Not all women need estrogen and some women cannot
take it. Many doctors don't want to give hormones to women who are still having
their periods, however erratically. Indeed, only a third of menopausal women in the
United States try HRT and of those who do, eventually half of them drop the therapy.
Some are worried about breast cancer, some cannot tolerate the side effects, some
do not want to medicate what they consider to be a natural occurrence.
Herbs
Herbs have been used to relieve menopausal symptoms for centuries. In general,
most herbs are considered safe, and there is no substantial evidence that herbal
products are a major source of toxic reactions. But because herbal products are not
regulated in the United States, contamination or accidental overdose is possible.
Herbs should be bought from a recognized company or through a qualified herbal
practitioner.
Women who choose to take herbs for menopausal symptoms should learn as much
as possible about herbs and work with a qualified practitioner (an herbalist, a
traditional Chinese doctor, or a naturopathic physician). Pregnant women should
avoid herbs because of unknown effects on a developing fetus.
The following list of herbs include those that herbalists most often prescribe to treat
menstrual complaints:
Black cohosh (Cimicifuga racemosa): hot flashes and other menstrual complaints
Black currant: breast tenderness
Chaste tree/chasteberry (Vitex agnus-castus): hot flashes, excessive menstrual
bleeding, fibroids, and moodiness
Evening primrose oil (Oenothera biennis): mood swings, irritability, and breast
tenderness
Fennel (Foeniculum vulgare): hot flashes, digestive gas, and bloating
Flaxseed (linseed): excessive menstrual bleeding, breast tenderness, and other
symptoms, including dry skin and vaginal dryness
Gingko (Gingko biloba): memory problems
Ginseng (Panax ginseng): hot flashes, fatigue and vaginal thinning.
Hawthorn (Crataegus laevigata): memory problems, fuzzy thinking
Lady's mantle: excessive menstrual bleeding

Mexican wild yam (Dioscorea villosa) root: vaginal dryness, hot flashes and general
menopause symptoms
Motherwort (Leonurus cardiaca): night sweats, hot flashes
Oat (Avena sativa) straw: mood swings, anxiety
Red clover (Trifolium pratense): hot flashes
Sage (Salvia officinalis): mood swings, headaches, night sweats
Valerian (Valeriana officinalis): insomnia.
Natural estrogens (phytoestrogens)
Proponents of plant estrogens (including soy products) believe that plant estrogens
are better than synthetic estrogen, but science has not yet proven this. The results
of smaller preliminary trials suggest that the estrogen compounds in soy products
can indeed relieve the severity of hot flashes and lower cholesterol. But no one yet
has proven that soy can provide all the benefits of synthetic estrogen without its
negative effects.
It is true that people in other countries who eat foods high in plant estrogens
(especially soy products) have lower rates of breast cancer and report fewer
"symptoms" of menopause. While up to 80% of menopausal women in the United
States complain of hot flashes, night sweats, and vaginal dryness, only 15% of
Japanese women have similar complaints. When all other things are equal, a soybased diet may make a difference (and soy is very high in plant estrogens).
The study of phytoestrogens is so new that there are not very many
recommendations on how much a woman can consume. Herbal practitioners
recommend a dose based on a woman's history, body size, lifestyle, diet, and
reported symptoms. Research has indicated that some women were able to ease
their symptoms by eating a large amount of fruits, vegetables, and whole grains,
together with four ounces of tofu four times a week.
What concerns some critics of other alternative remedies is that many women think
that "natural" or "plant-based" means "harmless." In large doses, phytoestrogens
can promote the abnormal growth of cells in the uterine lining. Unopposed estrogen
of any type can lead to endometrial cancer, which is why women on conventional
estrogen-replacement therapy usually take progesterone (progestin) along with
their estrogen. However, a plant-based progesterone product can sometimes be
effective alone, without estrogen, in assisting the menopausal woman in
rebalancing her hormonal action throughout this transition time.
Yoga

Many women find that yoga (the ancient meditation/exercise developed in India
5,000 years ago) can ease menopausal symptoms. Yoga focuses on helping women
unite the mind, body, and spirit to create balance. Because yoga has been shown to
balance the endocrine system, some experts believe it may affect hormone-related
problems. Studies have found that yoga can reduce stress, improve mood, boost a
sluggish metabolism, and slow the heart rate. Specific yoga positions deal with
particular problems, such as hot flashes, mood swings, vaginal and urinary
problems, and other pains.
Exercise
Exercise helps ease hot flashes by lowering the amount of circulating FSH and LH
and by raising endorphin levels that drop while having a hot flash. Even exercising
20 minutes three times a week can significantly reduce hot flashes.
Elimination
Regular, daily bowel movements to eliminate waste products from the body can be
crucial in maintaining balance through menopause. The bowels are where
circulating hormones are gathered and eliminated, keeping the body from recycling
them and causing an imbalance.
Acupuncture
This ancient Asian art involves placing very thin needles into different parts of the
body to stimulate the system and unblock energy. It is usually painless and has
been used for many menopausal symptoms, including insomnia, hot flashes, and
irregular periods. Practitioners believe that acupuncture can facilitate the opening of
blocked energy channels, allowing the life force energy (chi) to flow freely. This
allows the menopausal woman to keep her energy moving. Blocked energy usually
increases the symptoms of menopause.
Acupressure and massage
Therapeutic massage involving acupressure can bring relief from a wide range of
menopause symptoms by placing finger pressure at the same meridian points on
the body that are used in acupuncture. There are more than 80 different types of
massage, including foot reflexology, Shiatsu massage, or Swedish massage, but
they are all based on the idea that boosting the circulation of blood and lymph
benefits health.
Key terms
Endometrium The lining of the uterus that is shed with each menstrual period.
Estrogen Female hormone produced by the ovaries and released by the follicles
as they mature. Responsible for female sexual characteristics, estrogen stimulates

and triggers a response from at least 300 tissues, and may help some types of
breast cancer to grow. After menopause, the production of the hormone gradually
stops.
Estrogen replacement therapy (ERT) A treatment for menopause in which
estrogen is given in pill, patch, or cream form.
Follicle-stimulating hormone (FSH) The pituitary hormone that stimulates the
ovary to mature egg capsules (follicles). It is linked with rising estrogen production
throughout the cycle. An elevated FSH (above 40) indicates menopause.
Hormone A chemical messenger secreted by a gland that is released into the
blood, and that travels to distant cells where it exerts an effect.
Hormone replacement therapy (HRT) The use of estrogen and progesterone to
replace hormones that the ovary no longer supplies.
Hot flash A wave of heat that is one of the most common perimenopausal
symptoms, triggered by the hypothalamus' response to estrogen withdrawal.
Hysterectomy Surgical removal of the uterus.
Ovary One of the two almond-shaped glands in the female reproductive system
responsible for producing eggs and the hormones estrogen and progesterone.
Ovulation The monthly release of an egg from the ovary.
Pituitary gland The "master gland" at the base of the brain that secretes a
number of hormones responsible for growth, reproduction, and other activities.
Pituitary hormones stimulate the ovaries to release estrogen and progesterone.
Progesterone The hormone that is produced by the ovary after ovulation to
prepare the uterine lining for a fertilized egg.
Testosterone Male hormone produced by the testes and (in small amounts) in the
ovaries. Testosterone is responsible for some masculine secondary sex
characteristics such as growth of body hair and deepening voice.
Uterus The female reproductive organ that contains and nourishes a fetus from
implantation until birth. Also known as the womb.
Vagina The tube-like passage from the vulva (a woman's external genital
structures) to the cervix (the portion of the uterus that projects into the vagina).
Biofeedback
Some women have been able to control hot flashes through biofeedback, a painless
technique that helps a person train her mind to control her body. A biofeedback
machine provides information about body processes (such as heart rate) as the

woman relaxes her body. Using this technique, it is possible to control the body's
temperature, heart rate, and breathing.
Prognosis
Menopause is a natural condition of aging. Some women have no problems at all
with menopause, while others notice significant unpleasant symptoms. A wide array
of treatments, from natural to hormone replacement, mean that no woman needs to
suffer through this time of her life.
Prevention
Menopause is a natural part of the aging process and not a disease that needs to be
prevented. Most doctors recommend HRT for almost all post-menopausal women,
usually for a few years. When HRT is then stopped, symptoms should be mild or non
existent. But HRT is not only useful in lessening the symptoms of menopause; it also
protects against heart disease and osteoporosis.
Resources
Books
Goldman, Lee, et al., editors. Cecil Textbook of Medicine. 21st ed. W. B. Saunders,
2000.
Goroll, Allan H., et al. Primary Care Medicine. 4th ed. Lippincott Williams & Wilkins,
2000.
Other
Menopause Online Page. http://www.menopause-online.com/links.htm.
Menopause Page. http://www.howdyneighbor.com/menopaus.
Meno Times Online.
http://www.aimnet.com/hyperion/meno/menotimes.index.html.
Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights
reserved.