Menopause and perimenopause

Menopause is the end of menstruation. It occurs with the last menstrual period. It's not a disease. It simply marks the end of a woman's ability to bear children. Perimenopause is the time around menopause, when a woman's body adjusts from normal ovulation to menopause. It can begin up to six years before menopause, when hormone levels begin to decline, and lasts through the 12 months following the last menstrual period.


Causes/associated factors
Menopause can occur naturally or be brought on early. Natural menopause, which typically occurs between ages 40 and 58, happens when the ovaries stop producing estrogen and progesterone. For premenopausal women, early or premature menopause can result from various medical treatments.
Natural menopause occurs when the ovaries stop producing the hormones that are responsible for menstruation. Menopause is part of the natural aging process. Menopause is verified when you haven't had a period for one year. In the United States, the average age of menopause is 51. Family history may affect the timing of menopause. Women often reach menopause at about the same time as other female family members. If you smoke, you may reach menopause up to two years earlier than you would have if you had not smoked. Other factors that may be associated with earlier menopause include having heart disease, never bearing a child, and using birth control pills. Being overweight and having borne more than one child may be associated with later menopause.

Perimenopause, also known as climacteric, is the time around menopause. Hormone levels often begin to decline when women are in their early 40s. During this time you may begin to notice changes in your period and experience various symptoms. Pregnancy can still occur during perimenopause if you have an intact reproductive system.

Early menopause (or premature menopause) can be induced in premenopausal women with various medical treatments. For instance, it occurs after the surgical removal of both ovaries (oophorectomy). Surgical menopause causes a sudden drop in the body's hormone level, rather than a slow decline. This sudden hormone loss usually causes intense menopausal symptoms. If your uterus is removed but the ovaries are left in place (a hysterectomy), your periods will stop but you will not experience any other adverse menopausal symptoms at this time. You'll probably experience menopause two to three years earlier than you would have gone through natural menopause.

Certain medications, such as the use of danazol or menotropins for endometriosis, may stop menstruation and cause temporary menopause. This isn't really menopause, however, since it's temporary. Certain types of chemotherapy or radiation therapy of the pelvic area can also cause temporary or even permanent menopause.

Early menopause can also occur without medical intervention. It may be genetic or due to a medical condition, such as an autoimmune disease (rheumatoid arthritis, for example). Menopause is considered early if it occurs before the age of 40. Sometimes, a reversible medical problem can stop periods for a while. The symptoms may be the same, but this isn't true menopause.

Postmenopause is the years following menopause. The early postmenopausal years (the first four or five years) are particularly significant, since more rapid changes, such as bone loss, occur during this time.


Signs/symptoms
During perimenopause, symptoms range from mild to severe and may last for months to years. Before menopause, you may notice your menstrual periods becoming shorter, longer, irregular, lighter or even heavier. Finally they stop completely.
Hot flashes are the next most common symptom, affecting up to 85 percent of women. They're often described as a sudden feeling of heat that spreads from the waist or chest toward the neck, face and upper arms. They're often accompanied by sweating and a feeling of being hot all over. They may be followed by a chill. Hot flashes typically last from 30 seconds to five minutes. When they occur at night, they are called night sweats and can contribute to poor sleep.

You may also notice other symptoms, such as:

mood changes
lack of concentration and memory difficulty
difficulty sleeping
changes in sexual desire
vaginal dryness and painful intercourse
more frequent urination
difficulty controlling urination (urinary incontinence)
more frequent urinary tract infections
weight gain
joint or muscle pains
fatigue
lightheadedness
headaches
palpitations (sensation that the heart's pounding, beating irregularly or skipping beats)
skin wrinkles
Because these symptoms can sometimes be related to factors other than menopause, it's best to discuss them with your doctor.

Also consult your doctor if you notice:

very heavy bleeding, possibly with clots
bleeding between periods
bleeding after intercourse
periods occurring more often than every three weeks
periods lasting longer than a week

Diagnosis
Diagnosis is typically based on your symptoms and a physical exam. Menopause is generally confirmed after 12 months without menstruation. If in doubt, your doctor may recommend estrogen and follicle stimulating hormone blood tests (FSH). FSH is secreted by the pituitary gland. It stimulates the ovaries to produce estrogen. During perimenopause, the pituitary secretes more FSH in an attempt to make the ovaries produce more estrogen. When your estrogen level is low and your FSH level remains at or above 25 to 30 mlU/ml, then perimenopause is probable. The test may need to be done more than once, since hormone levels fluctuate during perimenopause. If you're using hormonal contraceptives such as birth control pills, these tests cannot be done.

Treatment
Various treatment options are available for the symptoms and long-term effects of perimenopause and menopause, including self-care measures, medications and alternative therapies.
Self-care
If you have mild symptoms, medical treatment may not be necessary. You may want to try these self-care tips for some menopause symptoms:

Hot flashes: Pay attention to what may trigger your hot flashes, such as stress, caffeine, hot drinks, alcohol, and hot or spicy foods. You may want to keep track in a diary. Avoid triggers whenever possible. Keep room temperatures cool, and try wearing thin layers of cotton clothing that can be removed easily. Vitamin E is sometimes used for hot flashes, but research has not yet shown if it is effective.

Difficulty sleeping: Avoid smoking, alcohol, caffeine, large meals and other stimulants, especially at bedtime. Exercise regularly and try relaxation techniques such as gentle stretching or deep, slow breathing.

Vaginal dryness: Try over-the-counter vaginal lubricants (such as Atroglide or K-Y lubricant) or vaginal moisturizers (such as Replens or K-Y moisturizer). It's OK to continue sexual activity -- in fact, sexual stimulation may contribute to vaginal health.

Urinary incontinence: Kegel exercises may improve your symptoms. Simply contract your vaginal muscles as if you were stopping the flow of urine. Repeat 10 to 15 times several times a day.

Urinary tract infections: For prevention, drink plenty of water or clear fruit juice every day. Urinate soon after you feel the urge, and wipe from front to back after urination or a bowel movement. Wash the area between your vagina and anus every day, as well as before and after sex. Also, be sure to urinate after sex. Avoid using feminine hygiene sprays, scented soaps or other products near your vaginal area. Also, wear cotton underwear and hosiery with cotton crotches.

Medication
Several types of medications are available to help reduce or eliminate the symptoms and long-term effects of perimenopause and menopause. If you're considering medication, discuss the risks and benefits with your doctor.

Hormone replacement therapy: Your doctor may recommend hormone replacement therapy (HRT) to help reduce or eliminate the symptoms and long-term effects of perimenopause and menopause by restoring certain hormones to premenopausal levels. HRT usually refers to taking the hormone estrogen by itself or along with the hormone progesterone. When estrogen is taken by itself, it may also be called estrogen replacement therapy (ERT). Despite the advantages, some potential risks are involved with the use of hormones. Take the decision seriously, and get the best information you can from reliable medical sources. Because of the risks of HRT, the U.S. Food and Drug Administration (FDA) recommends that it be used only to treat the symptoms of menopause, and even then in the smallest effective dose for the shortest possible time.

Hormone therapy may not be recommended if you have:

uterine bleeding from an unknown cause
a triglyceride level over 500 (triglycerides are fats in the blood that the body produces from sugar, alcohol or excess calories)
uncontrolled high blood pressure
a history of blood clots
liver disease
gall bladder disease
a personal history of cancer, especially breast or uterine cancer
risk factors for breast cancer, such as a family history
Depending on your symptoms and medical history, estrogen may be taken in pill or tablet form; as a vaginal cream, suppository or ring; regular shots; or as patches applied to the skin. When progesterone is taken along with estrogen, it's usually in pill or patch form. Dosages vary. For example, HRT in the form of a patch uses a lower dose of hormone, which is absorbed directly into the bloodstream through the skin.

Benefits of hormones: Hormones may relieve some symptoms of perimenopause and menopause, including hot flashes, night sweats, mood changes, difficulty sleeping, vaginal dryness, uncomfortable intercourse, frequent urinary tract infections and fatigue.
Hormones can significantly reduce the risk of fractures related to osteoporosis (bone density loss that leads to brittle bones). More than 50 percent of all women eventually develop osteoporosis-related fractures. The protective benefits of HRT on bones are discontinued once HRT is stopped, however.

Combination HRT may also reduce the risk of colorectal cancer. However, combination HRT is not prescribed to help prevent colorectal cancer, because the risks from treatment are considered greater than the benefits.

Lower doses of hormones may have fewer risks and side effects. HRT in the form of a skin patch has a lower risk of gallbladder problems and elevated triglycerides. (Triglycerides are fats in the blood that the body produces from sugar, alcohol or excess calories.) Vaginal forms of estrogen have fewer side effects, since only a small amount of medication is absorbed into the bloodstream. They are helpful in treating urinary and vaginal symptoms.


Risks of hormones: Vaginal forms of estrogen may not stop hot flashes, improve cholesterol levels, or prevent osteoporosis. Lower doses of hormones may not be as effective in relieving symptoms and preventing the long-term effects of menopause.
If you still have a uterus, taking estrogen by itself increases the risk of endometrial cancer (cancer of the tissue that lines the uterus). Therefore, estrogen by itself is only recommended for women who no longer have a uterus. New research also shows that the long-term estrogen use may increase the risk of developing ovarian cancer.

In the past, hormone replacement therapy was prescribed to reduce the risk of death from heart disease, a leading cause of death in postmenopausal women. However, a study by the Women's Health Initiative (WHI) was stopped in 2002 when researchers discovered that the combination therapy of estrogen and progestin does not prevent heart disease as it was earlier thought. Instead, it actually appears to place women at greater risk of developing breast cancer or having a heart attack, stroke, and blood clots in the lungs and legs. The combination therapy used in the study was conjugated equine estrogens at 0.625 milligrams and medroxyprogesterone acetate at 2.5 milligrams (brand name Prempro). The study did not investigate newer HRT combinations using different estrogens and progestins. Another part of the WHI study addressed the effects of taking estrogen alone. This study was stopped early when researchers found a possible increase in the risk of stroke in women taking estrogen therapy. Itor mild cognitive impairment in women over age 65 who take estrogen alone.

Side effects from hormone replacement therapy may also occur. As your body adjusts to the medication, some of these may disappear, however. Depending on the dosage and type of therapy you take, possible side effects include:


uterine bleeding (especially during the first 12 months of treatment if progesterone and estrogen are taken every day)
nausea
abdominal bloating
gallbladder disease
headaches
dizziness
mood changes
breast swelling or tenderness
swelling or temporary weight gain due to fluid retention
Clonidine: Clonidine (Catapres) is another medication that's used to treat hot flashes. It's also used to lower blood pressure and prevent migraine headaches. It's available in the form of a pill or skin patch.

Benefits of clonidine: This medication may relieve hot flashes. If hot flashes continue, they may be less severe.

Risks of clonidine: Side effects may include dizziness, dry mouth, constipation, drowsiness and weakness.
Antidepressants: Certain low-dose antidepressants may be prescribed to treat hot flashes or other menopause symptoms. However, research does not yet prove that they're effective, and they may have unwanted side effects.

Testosterone: Low doses of testosterone are sometimes used with estrogen to improve sexual function after menopause. Although testosterone is primarily a male sex hormone, it's also produced by the ovaries to help regulate various body functions. Declining testosterone levels during menopause may lead to memory loss and decreased energy and sex drive. Testosterone and estrogen are available in pill form (Estratest, for example).

Benefits of testosterone: It may improve sexual function, but more research is needed. It also appears to improve the effects of estrogen therapy, and it may be possible to take less estrogen.

Risks of testosterone: Serious side effects have not been noted. Further research is needed.
Selective estrogen receptor modulators (SERMs): A new classification of drugs called selective estrogen receptor modulators (SERMs) mimic the effects of estrogen in certain body tissues. Raloxifene (Evista) is a commonly prescribed SERM. During menopause, they may be used to prevent or treat osteoporosis.

Benefits of SERMs: These medications increase bone density, reduce the risk of bone fractures due to osteoporosis, and lower levels of fat in the blood. They don't affect breast or uterine tissue, so they don't increase your risk of cancer in these organs.

Risks of SERMs: These medicines may increase your risk of developing a blood clot in a vein, which can break off and travel to the lungs. Therefore, they're not recommended for women with a history of thrombophlebitis (inflammation of a vein caused by a blood clot). The most common side effects are hot flashes and leg cramps.
Biphosphonates: Biphosphonates are used during menopause to prevent and treat osteoporosis. Alendronate (Fosamax) and risedronate (Actonel) are commonly prescribed biphosphonates.

Benefits of biphosphonates: These medications increase bone density by inhibiting bone breakdown and slowing bone removal. They significantly significantly decrease the risk of fractures.

Risks of biphosphonates: These medications can cause irritation of the throat and esophagus, and must be taken on an empty stomach with 6 to 8 ounces of water. You must then remain upright and not eat or drink for at least 30 minutes. They are generally well tolerated. Side effects may include nausea, heartburn, abdominal pain and muscle pain.
Calcitonin: Calcitonin is a hormone naturally produced by the thyroid gland. Bone loss is triggered when calcitonin levels drop. To slow bone loss, calcitonin regulates bone metabolism and calcium levels in the blood. You can take calcitonin as a daily injection or through a nasal spray. Calcitonin is an option for postmenopausal women who can't take or tolerate other medications for osteoporosis.

Benefits of calcitonin: This medication may decrease the risk of fractures from osteoporosis.

Risks of calcitonin: Side effects may include facial flushing, nausea, frequent urination or rash. Allergic reactions are possible. You may have nasal irritation if you use the nasal spray or mild inflammation at the injection site.
Alternative therapies
Various alternative therapies are used to treat the symptoms of perimenopause and menopause. Research has not proved the effectiveness of many of them, however. Two that show promise are phytoestrogens and black cohosh.

Phytoestrogens: Phytoestrogens found in certain foods have been found to act like estrogen in the body. Isoflavones, a type of phytoestrogen, are found in soy-based foods such as tofu and soy milk. Other sources of isoflavones include fruits, legumes and red clover. Researchers are currently studying the effectiveness of isoflavanoids in preventing menopause complications.

Benefits of phytoestrogens: Early data suggests a degree of protection from heart disease. The U.S. Food and Drug Administration (FDA) now allows soy rich foods to be labeled "capable of decreasing the risk of heart disease." Isoflavanoids may also help combat symptoms related to menopause, such as mild hot flashes.

Risks of phytoestrogens: This early data also indicates that natural estrogens do not have the same harmful effects on breast and uterine tissue that other estrogens may have. There is still much unknown about isoflavanoids, however. Consult your physician before making any dietary changes, especially if you have a history of breast cancer.
Black cohosh: Black cohosh is an herb that's sometimes used for up to 6 months to treat hot flashes and other menopause symptoms. Research on this herb continues. Side effects such as stomach discomfort, headaches and weight problems have been noted, however. Long-term effects are unknown.


Complications
Again, menopause is associated with osteoporosis, heart disease and other serious conditions associated with aging.
Osteoporosis develops in about 45 percent of all postmenopausal women. Before menopause, estrogen helps retain the calcium in your bones. During menopause, bones begin to lose up to 3 percent of their calcium per year. Eventually, bone tissue breaks down faster than it can form and the bones become weak and brittle. If you're at risk for osteoporosis, discuss treatment options with your doctor.

Heart disease is the leading cause of death in postmenopausal women. Estrogen helps increase high-density lipoprotein (HDL or "good") cholesterol. When estrogen levels fall during perimenopause and menopause, HDL levels also fall. In turn, low-density lipoprotein (LDL or "bad") cholesterol increases and raises your risk of heart disease. If you're at risk for heart disease, discuss treatment options with your doctor.


Considerations
Explore your feelings and attitudes about this time in your life and what it signifies for you. Recognize that any accompanying mood changes may be due to emotional as well as physical factors. Other life changes, such as a child leaving home or caring for aging parents, often play a role.
Although some women experience symptoms of depression during menopause, there is no clear evidence that menopausal changes cause depression. In fact, most women maintain a positive outlook through this time. To combat depressive symptoms, exercise regularly, get plenty of sleep, and eat healthfully. If necessary, counseling or medication may be helpful.


Pregnancy-specific information
Pregnancy can still occur during perimenopause. Remember to discuss family planning with your doctor. Most contraception forms can be used during perimenopause, but your specific needs and risks must be taken into consideration.

Senior-specific information
Postmenopause continues throughout your senior years.

Prevention
Although you can't prevent menopause, you can minimize the long-term negative effects.
If you smoke, quit. Smoking increases your risk of heart disease, osteoporosis and early onset menopause, and it can lead to lung and other cancers. (The earlier you go through menopause, the higher your risk of developing osteoporosis and heart disease.)

Eat a healthful, low-fat diet and lose weight if you're overweight to help prevent heart disease.

To help prevent osteoporosis, make sure your diet is high in calcium. If you don't have enough calcium in your blood, it will be taken from your bones. Unfortunately, the ability to absorb calcium and produce vitamin D, which is needed for calcium absorption in the intestines, decreases with age. Premenopausal women and postmenopausal women on hormone replacement therapy should consume at least 1,000 milligrams of calcium a day. Recommendations vary from 1,200 to 1,500 milligrams for postmenopausal women who are not taking estrogen. Women who have low bone mineral density should get 400 to 800 international units (IU) of vitamin D a day.
Excellent food sources of calcium include dairy products, canned salmon and sardines with bones, and dark green leafy vegetables such as broccoli, collard greens and dried beans. Calcium supplements can complement your diet without adding fat or calories. If necessary, your doctor may recommend calcium and vitamin D supplements.


To strengthen your bones and increase bone formation, try weight-bearing exercises such as walking. Regular exercise can also reduce your risk of heart disease.
In addition, it's important to practice preventive medicine. Many medical organizations believe it's important to do a monthly breast self-exam and have a yearly clinical breast exam. However, recent studies have shown that monthly breast self-exams do not appear to decrease the number of deaths due to breast cancer. The U.S. Preventive Services Task Force recently cited a link between breast self-exam and an increase in benign breast lump biopsies. They state that no evidence exists to recommend either for or against doing a breast self-exam or routine clinical breast exam alone to screen for breast cancer.

The debate on the timing of mammography also continues. Some health care professionals recommend regular mammograms every one to two years beginning at age 40 and annually beginning at age 50. The U.S. Preventive Task Force recommends mammograms every one to two years, with or without clinical breast examination, for women ages 40 and older.

Consult your doctor to find out if you need earlier or more frequent screenings or exams. Also see your doctor for regular pelvic exams to screen for vaginal, ovarian and cervical cancers. Your doctor may want to see you more often depending on your individual circumstances.