Menopause

Overview

Menopause is the time that marks the end of your menstrual cycles. It's diagnosed after you've gone 12 months without a menstrual period. Menopause can happen in your 40s or 50s, but the average age is 51 in the United States.

Menopause is a natural biological process. But the physical symptoms, such as hot flashes, and emotional symptoms of menopause may disrupt your sleep, lower your energy or affect emotional health. There are many effective treatments available, from lifestyle adjustments to hormone therapy.

Symptoms

In the months or years leading up to menopause (perimenopause), you might experience these signs and symptoms:

• Irregular periods
• Vaginal dryness
• Hot flashes
• Chills
• Night sweats
• Sleep problems
• Mood changes
• Weight gain and slowed metabolism
• Thinning hair and dry skin
• Loss of breast fullness

Signs and symptoms, including changes in menstruation can vary among women. Most likely, you'll experience some irregularity in your periods before they end.

Skipping periods during perimenopause is common and expected. Often, menstrual periods will skip a month and return, or skip several months and then start monthly cycles again for a few months. Periods also tend to happen on shorter cycles, so they are closer together. Despite irregular periods, pregnancy is possible. If you've skipped a period but aren't sure you've started the menopausal transition, consider a pregnancy test.

When to see a doctor

Keep up with regular visits with your doctor for preventive health care and any medical concerns. Continue getting these appointments during and after menopause.

Preventive health care as you age may include recommended health screening tests, such as colonoscopy, mammography and triglyceride screening. Your doctor might recommend other tests and exams, too, including thyroid testing if suggested by your history, and breast and pelvic exams.

Always seek medical advice if you have bleeding from your vagina after menopause.

Causes

Menopause can result from:

• Naturally declining reproductive hormones. As you approach your late 30s, your ovaries start making less estrogen and progesterone — the hormones that regulate menstruation — and your fertility declines.

  In your 40s, your menstrual periods may become longer or shorter, heavier or lighter, and more or less frequent, until eventually — on average, by age 51 — your ovaries stop releasing eggs, and you have no more periods.

• Surgery that removes the ovaries (oophorectomy). Your ovaries produce hormones, including estrogen and progesterone, that regulate the menstrual cycle. Surgery to remove your ovaries causes immediate menopause. Your periods stop, and you're likely to have hot flashes and experience other menopausal signs and symptoms. Signs and symptoms can be severe, as hormonal changes occur abruptly rather than gradually over several years.

  Surgery that removes your uterus but not your ovaries (hysterectomy) usually doesn't cause immediate menopause. Although you no longer have periods, your ovaries still release eggs and produce estrogen and progesterone.

• Chemotherapy and radiation therapy. These cancer therapies can induce menopause, causing symptoms such as hot flashes during or shortly after the course of treatment. The halt to menstruation (and fertility) is not always permanent following chemotherapy, so birth control measures may still be desired. Radiation therapy only affects ovarian function if radiation is directed at the ovaries. Radiation therapy to other parts of the body, such as breast tissue or the head and neck, won't affect menopause.
• Primary ovarian insufficiency. About 1% of women experience menopause before age 40 (premature menopause). Premature menopause may result from the failure of your ovaries to produce normal levels of reproductive hormones (primary ovarian insufficiency), which can stem from genetic factors or autoimmune disease. But often no cause of premature menopause can be found. For these women, hormone therapy is typically recommended at least until the natural age of menopause in order to protect the brain, heart and bones.

Complications

After menopause, your risk of certain medical conditions increases. Examples include:

• Heart and blood vessel (cardiovascular) disease. When 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. So it's important to get regular exercise, eat a healthy diet and maintain a normal weight. Ask your doctor for advice on how to protect your heart, such as how to reduce your cholesterol or blood pressure if it's too high.
• Osteoporosis. This condition causes bones to become brittle and weak, leading to an increased risk of fractures. During the first few years after menopause, you may lose bone density at a rapid rate, increasing your risk of osteoporosis. Postmenopausal women with osteoporosis are especially susceptible to fractures of their spine, hips and wrists.

• Urinary incontinence. As the tissues of your vagina and urethra lose elasticity, you may experience frequent, sudden, strong urges to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence). You may have urinary tract infections more often.

  Strengthening pelvic floor muscles with Kegel exercises and using a topical vaginal estrogen may help relieve symptoms of incontinence. Hormone therapy may also be an effective treatment option for menopausal urinary tract and vaginal changes that can result in urinary incontinence.

• Sexual function. Vaginal dryness from decreased moisture production and loss of elasticity can cause discomfort and slight bleeding during sexual intercourse. Also, decreased sensation may reduce your desire for sexual activity (libido).

  Water-based vaginal moisturizers and lubricants may help. If a vaginal lubricant isn't enough, many women benefit from the use of local vaginal estrogen treatment, available as a vaginal cream, tablet or ring.

• Weight gain. Many women gain weight during the menopausal transition and after menopause because metabolism slows. You may need to eat less and exercise more, just to maintain your current weight.

Diagnosis

Signs and symptoms of menopause are usually enough to tell most women that they've started the menopausal transition. If you have concerns about irregular periods or hot flashes, talk with your doctor. In some cases, further evaluation may be recommended.

Tests typically aren't needed to diagnose menopause. But under certain circumstances, your doctor may recommend blood tests to check your level of:

• Follicle-stimulating hormone (FSH) and estrogen (estradiol), because your FSH levels increase and estradiol levels decrease as menopause occurs
• Thyroid-stimulating hormone (TSH), because an underactive thyroid (hypothyroidism) can cause symptoms similar to those of menopause

Over-the-counter home tests to check FSH levels in your urine are available. The tests could tell you whether you have elevated FSH levels and might be in perimenopause or menopause. But, since FSH levels rise and fall during the course of your menstrual cycle, home FSH tests can't really tell you whether or not you're definitely in a stage of menopause.

Treatment

Menopause requires no medical treatment. Instead, treatments focus on relieving your signs and symptoms and preventing or managing chronic conditions that may occur with aging. Treatments may include:

• Hormone therapy. Estrogen therapy is the most effective treatment option for relieving menopausal hot flashes. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose and the shortest time frame needed to provide symptom relief for you. If you still have your uterus, you'll need progestin in addition to estrogen. Estrogen also helps prevent bone loss. Long-term use of hormone therapy may have some cardiovascular and breast cancer risks, but starting hormones around the time of menopause has shown benefits for some women. Talk to your doctor about the benefits and risks of hormone therapy and whether it's a safe choice for you.
• Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered directly to the vagina using a vaginal cream, tablet or ring. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissues. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.
• Low-dose antidepressants. Certain antidepressants related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs) may decrease menopausal hot flashes. A low-dose antidepressant for management of hot flashes may be useful for women who can't take estrogen for health reasons or for women who need an antidepressant for a mood disorder.
• Gabapentin (Gralise, Horizant, Neurontin). Gabapentin is approved to treat seizures, but it has also been shown to help reduce hot flashes. This drug is useful in women who can't use estrogen therapy and in those who also have nighttime hot flashes.
• Clonidine (Catapres, Kapvay). Clonidine, a pill or patch typically used to treat high blood pressure, might provide some relief from hot flashes.
• Fezolinetant (Veozah). This medicine is a hormone-free option for treating menopause hot flashes. It works by blocking a pathway in the brain that helps regulate body temperature.
• Medications to prevent or treat osteoporosis. Depending on individual needs, doctors may recommend medication to prevent or treat osteoporosis. Several medications are available that help reduce bone loss and risk of fractures. Your doctor might prescribe vitamin D supplements to help strengthen bones.

Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each. Review your options yearly, as your needs and treatment options may change.

Lifestyle and home remedies

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. Dress in layers, have a cold glass of water or go somewhere cooler. Try to pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages, caffeine, spicy foods, alcohol, stress, hot weather and even a warm room.

• Decrease vaginal discomfort. Try an over-the-counter, water-based vaginal lubricant (Astroglide, K-Y jelly, Sliquid, others) or a silicone-based lubricant or moisturizer (Replens, K-Y Liquibeads, Sliquid, others).

  You might consider choosing a product that doesn't contain glycerin, which can cause burning or irritation if you're sensitive to that chemical. Staying sexually active also helps with vaginal discomfort by increasing blood flow to the vagina.

• Get enough sleep. Avoid caffeine, which can make it hard to get to sleep, and avoid drinking too much alcohol, which can interrupt sleep. Exercise during the day, although not right before bedtime. If hot flashes disturb your sleep, you may need to find a way to manage them before you can get adequate rest.
• Practice relaxation techniques. Techniques such as deep breathing, paced breathing, guided imagery, massage and progressive muscle relaxation may help with menopausal symptoms. You can find a number of books and online offerings that show different relaxation exercises.
• Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.
• Eat a balanced diet. Include a variety of fruits, vegetables and whole grains. Limit saturated fats, oils and sugars. Ask your provider if you need calcium or vitamin D supplements to help meet daily requirements.
• Don't smoke. Smoking increases your risk of heart disease, stroke, osteoporosis, cancer and a range of other health problems. It may also increase hot flashes and bring on earlier menopause.
• Exercise regularly. Get regular physical activity or exercise on most days to help protect against heart disease, diabetes, osteoporosis and other conditions associated with aging.

Alternative medicine

Many approaches have been promoted as aids in managing the symptoms of menopause, but few of them have scientific evidence to back up the claims. Some complementary and alternative treatments that have been or are being studied include:

• Plant estrogens (phytoestrogens). These estrogens occur naturally in certain foods. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, lentils, chickpeas and other legumes. Lignans occur in flaxseed, whole grains, and some fruits and vegetables.

  Whether the estrogens in these foods can relieve hot flashes and other menopausal symptoms remains to be proved, but most studies have found them ineffective. Isoflavones have some weak estrogen-like effects, so if you've had breast cancer, talk to your doctor before supplementing your diet with isoflavone pills.

  The herb sage is thought to contain compounds with estrogen-like effects, and there's good evidence that it can effectively manage menopause symptoms. The herb and its oils should be avoided in people who have an allergy to sage, and in pregnant or breast-feeding women. Use carefully in people with high blood pressure or epilepsy.

• Bioidentical hormones. These hormones come from plant sources. The term "bioidentical" implies the hormones in the product are chemically identical to those your body produces. There are some commercially available bioidentical hormones approved by the Food and Drug Administration (FDA). But many preparations are compounded — mixed in a pharmacy according to a doctor's prescription — and aren't regulated by the FDA, so quality and risks could vary. There's no scientific evidence that bioidentical hormones work any better than traditional hormone therapy in easing menopause symptoms. There's also no evidence that they're any less risky than traditional hormone therapy.
• Black cohosh. Black cohosh has been popular among many women with menopausal symptoms. But there's little evidence that black cohosh is effective, and the supplement can be harmful to the liver and may be unsafe for women with a history of breast cancer.
• Yoga. There's no evidence to support the practice of yoga in reducing menopausal symptoms. But balance exercises such as yoga or tai chi can improve strength and coordination and may help prevent falls that could lead to broken bones. Check with your doctor before starting balance exercises. Consider taking a class to learn how to perform postures and proper breathing techniques.
• Acupuncture. Acupuncture may have some temporary benefit in helping to reduce hot flashes, but research hasn't shown significant or consistent improvements. More research is needed.
• Hypnosis. Hypnotherapy may decrease the incidence of hot flashes for some menopausal women, according to research from the National Center for Complementary and Integrative Health at the U.S. National Institutes of Health. Hypnotherapy also helped improve sleep and decreased interference in daily life, according to the study.

You may have heard of or tried other dietary supplements, such as red clover, kava, dong quai, DHEA, evening primrose oil and wild yam (natural progesterone cream). Scientific evidence on effectiveness is lacking, and some of these products may be harmful.

Talk with your doctor before taking any herbal or dietary supplements for menopausal symptoms. The FDA does not regulate herbal products, and some can be dangerous or interact with other medications you take, putting your health at risk.

Preparing for an appointment

Your first appointment will likely be with your primary care provider or a gynecologist.

What you can do

Before your appointment:

• Keep track of your symptoms. For instance, make a list of how many hot flashes you experience in a day or week and note how severe they are.
• Make a list of any medications, herbs and vitamin supplements you take. Include the doses and how often you take them.
• Ask a family member or close friend to accompany you, if possible. You may be given a lot of information at your visit, and it can be difficult to remember everything.
• Take a notebook or notepad with you. Use it to record important information during your visit.
• Prepare a list of questions to ask your doctor. List your most important questions first.

Some basic questions to ask include:

• What kind of tests might I need, if any?
• What treatments are available to minimize my symptoms?
• Is there anything I can do to relieve my symptoms?
• What steps can I take to maintain my health?
• Are there any alternative therapies I might try?
• Do you have any printed material or brochures I can take with me?
• What websites do you recommend?

In addition, don't hesitate to ask questions at any time during your appointment.

What to expect from your doctor

Some questions your doctor might ask include:

• Are you still having periods?
• When was your last period?
• How often do you experience bothersome symptoms?
• How uncomfortable do your symptoms make you?
• Does anything seem to improve your symptoms?
• Does anything make your symptoms worse?