Menopause is a normal part of a woman's natural aging process and occurs as hormone levels in the body decline. It marks the end of a woman's menstrual periods and her ability to become pregnant without assistance from technology. Menopause is a process that usually begins 2 to 5 years before a woman's last menstrual period. It is completed when 1 full year has passed without a menstrual period.

The symptoms of declining hormone levels can occur before menstrual periods have ended. This period of declining hormones is called the climacteric or perimenopause. Perimenopause can last several years and often includes irregular menstrual periods and other symptoms, such as hot flashes, vaginal dryness, and mood swings.

The term menopause is used to describe the period between the beginning and end of symptoms. A woman who has not had a menstrual period for 1 year or longer is postmenopausal. Menopause is often used to include the perimenopausal and postmenopausal periods.

A woman may say she is in menopause when she is:

• Still having menstrual periods but also has symptoms of approaching menopause, such as hot flashes.
• No longer having menstrual periods.
• No longer having menstrual periods but continues to have other symptoms, such as hot flashes.

What causes menopause?

Menopause occurs when levels of the hormones estrogen, progesterone, and testosterone in a woman's body decline. Decreasing levels of estrogen cause many of the long-term health problems, such as osteoporosis, that can occur after menopause.

For most women, menopause occurs between the ages of 45 and 55.

Menopause can occur naturally or can be the result of:

• Surgical removal of the ovaries (oophorectomy).
• Chemotherapy
• Radiation therapy to the abdomen or pelvis.
• Other medications, such as gonadotropin-releasing hormone analogues (GnRH-As). These medications often cause a "temporary" menopause.

What are the symptoms of menopause?

Although some women have few noticeable symptoms of menopause other than the ending of menstrual periods, most women will have some other symptoms. Symptoms may come and go, and more may develop, as the process of menopause progresses.

Symptoms that generally improve with time include:

• Menstrual period changes.
• Hot flashes.
• Emotional changes, such as mood swings or a change in sexual interest or response.
• Sleep disturbances (insomnia).
• Rapid, irregular heartbeat (heart palpitations).
• Generalized itching.
• Joint pain.
• Headaches.
• Problems with concentration and memory loss.
• Vaginal changes.
• Urinary changes.

Many women report an increase in symptoms such as hot flashes following surgical menopause (hysterectomy or oophorectomy), and these symptoms also seem to be more severe.

How is menopause diagnosed?

A diagnosis of menopause is usually based on your age, history of menstrual periods, symptoms, and the results of a pelvic exam. Additional exams and tests may be needed if symptoms are severe, if other conditions are suspected, or if other concerns make a diagnosis difficult.

Does menopause require treatment?

Menopausal symptoms may not require treatment if they are not severe and do not bother you. If symptoms of menopause do not bother you, discuss them with your health professional at your next regular pelvic exam. Home treatment and medication can be used for severe symptoms.

When to Call a Doctor

Call your doctor if:

• Your menstrual periods are unusually heavy, irregular, or prolonged (1.5 to 2 times longer than normal).
• Bleeding occurs between menstrual periods when periods have been regular.
• Bleeding restarts after periods have stopped for 6 months or more.
• You are considering hormone therapy.
• Unexplained bleeding occurs while you are taking hormones.
• Other symptoms of menopause, such as insomnia, hot flashes, or mood swings, interfere with your normal activities, and home treatment does not relieve them.

Watchful Waiting

If menopausal symptoms are not severe or do not bother you, try home treatment for relief. Discuss symptoms and the need for hormone therapy with your health professional at your next regular exam.

Who to See

The following health professionals can help you manage symptoms of menopause and evaluate menstrual period changes:

• Family practitioner
• Gynecologist
• Internist
• Nurse practitioner
• Physician's assistant

Being diagnosed:

Exams and Tests

A diagnosis of menopause is usually based on your age, history of menstrual periods, symptoms, and the results of your pelvic exam. If symptoms of menopause do not bother you, discuss them with your health professional at your next regular pelvic exam.

Additional exams and tests may be needed if symptoms are severe, other conditions are suspected, or other concerns make a diagnosis difficult. These tests may include:

• Pregnancy test.
• Follicle-stimulating hormone (FSH) level.
• Estrogen level.
• Thyroid level.
• Testosterone level.

If you are taking continuous hormone therapy and have vaginal bleeding after 6 to 12 months of treatment, or if you have irregular bleeding but are not taking hormone therapy, additional tests may be required to determine the cause of the bleeding. These may include:

• Transvaginal ultrasound.
• Endometrial biopsy.

Tests may be needed to look at the endometrium. These may include:

• Hysteroscopy.
• Dilation and curettage (D&C)

Treatment Overview

The treatment of menopausal symptoms is based on their severity.

• If your symptoms do not bother you, treatment may not be needed or you may choose home treatment.
• If your symptoms are bothersome, you may choose to use hormone therapy.

Short-term hormone therapy is used to relieve symptoms such as hot flashes that occur during and immediately after menopause. Short-term therapy may be recommended, depending on:

• The severity of your symptoms.
• The failure of home treatment to control your symptoms.
• Your willingness to tolerate the symptoms of menopause.

Risks and benefits

If you are considering using HRT for your menopausal symptoms, it is important to consider all the risks and benefits of short-term therapy.

The benefits of short-term hormone therapy include:

• Relief of menopausal symptoms, such as hot flashes and sleep disturbances.
• Maintenance of muscle tone and lining of the vagina, reducing vaginal irritation.

The risks of short-term hormone therapy include:

• A small increase in the risk of blood clots causing deep vein thrombosis and pulmonary embolism.
• A small increase in the risk of coronary artery disease.

What to Think About

All of the risks for every type of hormone replacement therapy are not known.

The hormone replacement therapy (HRT) portion of a large set of clinical trials called the Women's Health Initiative was ended 3 years early because of a small but unacceptable increase in the rate of breast cancer among the women taking the combination of estrogen 0.625 mg plus progestin 2.5 mg daily for longer than 4 years. The study also showed an increase in heart attack, stroke, and blood clots in the lungs (pulmonary embolism) and legs (deep vein thrombosis). A different study of the effects of estrogen replacement therapy (ERT), using estrogen without progestin, is ongoing.

If you have used hormone replacement therapy (HRT) long-term and have concerns, call your health professional. If you do not have concerns, discuss the risks and benefits of HRT at your next appointment.

At the time of menopause it is important to discuss your risk for osteoporosis and heart disease with your health professional.

Prevention

Menopause is part of the natural aging process and cannot be prevented.

Sexuality during menopause

Many women do not notice a change in their sexuality during menopause. You may find that the freedom from birth control and menstrual periods increases your sexual interest and pleasure.

Some women have physical symptoms that require adjustments after menopause, such as:

• Vaginal dryness. Lubricate the vagina with a nonprescription lubricant, such as Astroglide or Replens, or a polyunsaturated vegetable oil that does not contain preservatives if sexual intercourse is painful because of vaginal dryness. Avoid using petroleum jelly, such as Vaseline, because it increases the risk of vaginal irritation and infection.
• Loss of vaginal muscle tone. Firm muscle tone will also help prevent other problems, such as the bulging (prolapse) of the bladder or rectum into the vagina.
  • Consider using a vaginal estrogen cream or ring.
  • Have sexual intercourse frequently to help maintain the muscle tone of the vagina.
  • Do Kegel exercises several times each day.

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References:

1. Rodriguez C, et al. (2001). Estrogen replacement therapy and ovarian cancer mortality in a large prospective study of U.S. women. JAMA, 285(11): 1460–1463.

2. Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3): 321–333.

3. American Cancer Society (2002). Cancer Facts and Figures 2002, pp. 1–19. Atlanta: American Cancer Society.

4. Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3): 321–333.

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Researchers: Popular menopause herb may worsen cancer
By Maggie Fox

Last Updated: 2003-07-14 12:45:27 -0400 (Reuters Health)

WASHINGTON (Reuters) - Black cohosh, a herb popular for relieving the hot flashes and some other unpleasant symptoms of menopause, may make cancer more likely to spread, U.S. and Canadian researchers said on Saturday.

The news is yet another blow to women looking for something to safely ease the symptoms of menopause, which range from hot flashes to a higher risk of heart disease and cancer.

  Hormone replacement therapy has been found to worsen the risk of heart disease, stroke, some cancers and Alzheimer's, while some herbal supplements, such as red clover, have been found to do no good.

Many women had been taking black cohosh because it seemed to ease the hot flashes and, because it was herbal, many presumed it was safe. Not so, researcher Vicki Davis of the Mylan School of Pharmacy at Duquesne University in Pittsburgh told a meeting of the American Association for Cancer Research.

She said taking the supplement could endanger a woman who did not know she had cancer. "This stresses that we really need more research into herbal therapies and natural therapies."

Davis and colleagues in her lab and in Canada fed black cohosh to female mice bred so that they are prone to breast cancer. They gave them the daily equivalent of 40 mg of the supplement, the amount normally recommended for menopausal symptoms.

The mice were not any more likely to develop breast cancer in the first place. But those that did develop it were more likely to see a deadly spread of the cancer, Davis said.

Her team found that 27 percent of mice that ate black cohosh had the cancer spread to the lung, compared to 11 percent of the mice that did not eat the herb.

The findings do not prove that using black cohosh could endanger a woman with undiagnosed breast cancer, but Davis said it would be risky to take it. Women who have breast cancer -- or any other form of cancer -- may need to be especially wary, she said.

It is not clear how black cohosh may make cancer more likely to spread, Davis said.

"And one thing we don't know is whether it might accelerate a tumor that might be likely to metastasize or increase the numbers of tumors that would metastasize. But neither one is good," she said.

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Menopause and Hormone Therapy

As you age, significant internal changes take place that affect your production of the two female hormones, estrogen and progesterone. The hormones, which are important in regulating the menstrual cycle and having a successful pregnancy, are produced by the ovaries, two small, oval-shaped organs.

During the years just before menopause, known as perimenopause, your ovaries begin to shrink. Levels of estrogen and progesterone fluctuate as your ovaries try to keep up production of the hormones. You can have irregular menstrual cycles, along with unpredictable episodes of heavy bleeding during a period. Perimenopause usually lasts several years.

Eventually, your periods stop. Menopause marks the time of your last menstrual period. It is not considered the last until you have been period-free for 1 year without being ill, pregnant, breast-feeding, or using certain medicines, all of which also can cause menstrual cycles to cease. There should be no bleeding, even spotting, during that year. Natural menopause usually happens sometime between the ages of 45 and 54.

You also can undergo menopause as the result of surgery. A surgical procedure, called a hysterectomy, removes the uterus and sometimes the ovaries and fallopian tubes as well. You go through menopause if both of your ovaries are removed. Otherwise, the surgery does not affect menopause, which still occurs naturally.

Whether you go through menopause naturally or surgically, symptoms can result as your body tries to adjust to the drop in estrogen levels. These symptoms vary greatly–one woman may breeze through menopause with few symptoms, while another has difficulty. Symptoms may last for several months or years, or persist. The most common symptoms are hot flashes or flushes, sweats, and sleep disturbances. (A hot flash is a feeling of heat in your face and upper body, which may cause the skin to appear flushed or red as blood vessels expand. Hot flashes that occur with severe sweating during sleep are called night sweats.) But the drop in estrogen also can contribute to other symptoms, such as changes in the vaginal and urinary tracts, which can cause painful intercourse, urinary infections, and the need to urinate more often.

To relieve the symptoms of menopause, doctors may prescribe postmenopausal hormone therapy. This can involve the use of either estrogen alone or with another hormone called progesterone, or progestin in its synthetic form. The two hormones normally help to regulate a woman's menstrual cycle. Progestin is added to estrogen to prevent the overgrowth (or hyperplasia) of cells in the lining of the uterus. This overgrowth can lead to uterine cancer. If you haven't had a hysterectomy, you'll receive estrogen plus progestin therapy; if you have had a hysterectomy, you'll receive estrogen-only therapy. Hormones may be taken daily (continuous use) or on only certain days of the month (cyclic use).

They also can be taken in several ways, including orally, through a patch on the skin, as a cream or gel, or with an intrauterine device (IUD) or vaginal ring. How the therapy is taken can depend on its purpose. For instance, a vaginal estrogen ring or cream can ease vaginal dryness, urinary leakage, or vaginal or urinary infections, but does not relieve hot flashes.

Hormone therapy may cause side effects, such as bleeding, bloating, breast tenderness or enlargement, headaches, mood changes, and nausea. Further, side effects vary by how the hormone is taken. For instance, a patch may cause irritation at the site where it's applied.

Postmenopausal Use

Menopause may cause other changes that produce no symptoms yet affect your health. For instance, a woman's risk of developing heart disease begins to rise around menopause. After menopause, women's rate of bone loss increases. The increased rate can lead to osteoporosis, which may in turn increase the risk of bone fractures, usually after age 70.

Through the years, studies were finding evidence that estrogen might help with some of these postmenopausal health risks– especially heart disease and osteoporosis. With more than 40 million American women over age 50, the promise seemed great.

Although erroneously thought of in the past as a "man's disease," heart disease is the leading killer of American women. Women typically develop it about 10 years later than men.

Similarly, menopause is a time of increased bone loss. Bone is living tissue. Old bone is continuously being broken down and new bone formed in its place. With menopause, bone loss is greater and, if not enough new bone is made, the result can be weakened bones and osteoporosis, which increases the risk of breaks. One of every two women over age 50 will have an osteoporosis-related fracture during her life.

Many scientists believed these increased health risks were linked to the postmenopausal drop in estrogen produced by the ovaries and that replacing estrogen would help protect against the diseases.

About Dietary Supplements

If you use dietary supplements to try to ease hot flashes and other menopausal symptoms, you should bear these points in mind: The U.S. Food and Drug Administration (FDA) does not have the authority to approve dietary supplements before they are marketed, and it's important to tell your health care provider that you are taking such remedies.

Dietary supplements are sold over the counter and may contain phytoestrogens: These are estrogen-like substances that come from some plants (such as soy) and plant materials (such as legumes, vegetables, cereals, and some herbs). For instance, these products may contain black cohosh, wild yams, dong quai, and valerian root.

Dietary supplement manufacturers are responsible for making sure that their products are safe. The FDA must show that a dietary supplement is harmful before it can limit the product's use or remove it from the market. Currently, there are no FDA regulations that specifically establish minimum standards for the manufacture of dietary supplements in order to insure their identity (tests to insure that the ingredient is actually what its label claims), purity, quality, strength, and composition. You may want to contact a product's manufacturer before buying it.

Furthermore, the possible effects of the products are not known. Some of the substances they contain are being studied. For example, soy contains plant estrogens, which are being studied to see if they have the same risks and benefits as estrogen.

Some of this research is being supported by the Office of Dietary Supplements, the National Center for Complementary and Alternative Medicine, the National Institute on Aging, and other units of the National Institutes of Health.

Until more is known about these substances, you should use them with caution. Also, as noted, tell your health care provider if you take a dietary supplement or if you increase your intake of dietary phytoestrogens. There may be dangerous side effects. An increase in the level of estrogens in your body could interfere with other prescription medications you are taking or even cause an overdose.