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Menopause

Menopause occurs when you have gone 12 consecutive months without a menstrual period. Changing levels of estrogen and progesterone, two female hormones made in the ovaries, lead to symptoms like hot flashes and vaginal dryness. Menopause is a natural part of aging and marks the end of the female reproductive years.

OVERVIEW

 

What is menopause?

Menopause is a stage in life when you stop having your monthly period. It’s a normal part of aging and marks the end of your fertile, reproductive years. Menopause typically occurs in your late 40s to early 50s. However, people who have their ovaries surgically removed undergo “sudden” surgical menopause.

Why does menopause happen?

Natural menopause — menopause that’s not caused by surgery or another medical condition — is a normal part of aging. Menopause is defined as a complete year without menstrual bleeding, in the absence of any surgery or medical condition that may cause bleeding to artificially stop such as hormonal birth control, overactive thyroid, high prolactin, radiation or surgical removal of the ovaries.

As you age, the reproductive cycle begins to slow down and prepares to stop. This cycle has been continuously functioning since puberty. As menopause nears, your ovaries make less of a hormone called estrogen. When this decrease occurs, your menstrual cycle (period) starts to change. It can become irregular and then stop. Physical changes can also happen as your body adapts to different levels of hormones. The symptoms you experience during each stage of menopause (perimenopause, menopause and postmenopause) are all part of your body’s adjustment to these changes.

How long does menopause last?

Menopause is a point in time when you’ve gone 12 consecutive months without a menstrual cycle. The time before menopause can last eight to 10 years (Peri-menopause). The time after menopause (post-menopause) will last until the end of your life. The average age of menopause in the World is approximately 51 years old.

What hormonal changes happen during menopause?

The traditional changes we think of as “menopause” happen when your ovaries no longer produce high levels of hormones. The ovaries are the reproductive glands that store eggs and release them into the Fallopian tubes. They also produce the female hormones estrogen and progesterone as well as testosterone. Together, estrogen and progesterone control menstruation. Estrogen also influences how your body uses calcium and maintains cholesterol levels in the blood.

As menopause nears, your ovaries no longer release eggs into the Fallopian tubes, and you’ll have your last menstrual cycle.

How does natural menopause occur?

Natural menopause is the permanent ending of menstruation that is not brought on by any type of medical treatment. For people undergoing natural menopause, the process is gradual and is described in three stages:

Perimenopause or “menopause transition”: Perimenopause can begin eight to 10 years before menopause when the ovaries gradually produce less estrogen. It usually starts when you’re in your 40s. Perimenopause lasts up until menopause, the point when the ovaries stop releasing eggs. In the last one to two years of perimenopause, the drop in estrogen accelerates. At this stage, many people may experience menopause symptoms. But you are still having menstrual cycles during this time and can get pregnant.

Menopause: Menopause is the point when you no longer have menstrual periods. At this stage, your ovaries have stopped releasing eggs and producing most of their estrogen. Menopause is diagnosed when you’ve gone without a menstrual period for 12 consecutive months.

Post-menopause: This is the name given to the time after you have not had a period for an entire year (the rest of your life after going through menopause). During this stage, menopausal symptoms, such as hot flashes, may ease for many people. However, some people continue to experience menopausal symptoms for a decade or longer after the menopause transition. As a result of a lower level of estrogen, those in the postmenopausal phase are at increased risk for several health conditions, such as osteoporosis and heart disease.

What is premature menopause?

Menopause, when it occurs between the ages of 45 and 55, is considered “natural” and is a normal part of aging. But, some people can experience menopause early, either as a result of surgical intervention (like removal of the ovaries) or damage to the ovaries (such as from chemotherapy or radiation). Menopause that occurs before the age of 45 is called early menopause. Menopause that occurs at 40 or younger is considered premature menopause. When there this no medical or surgical cause for premature menopause it’s called primary ovarian insufficiency.

SYMPTOMS AND CAUSES

What are the symptoms of menopause?

You may be transitioning into menopause if you begin experiencing some or all of the following symptoms:

  • Hot flashes (a sudden feeling of warmth that spreads over the body).
  • Night sweats and/or cold flashes.
  • Vaginal dryness; discomfort during sex.
  • Urinary urgency (a pressing need to urinate more frequently).
  • Difficulty sleeping (insomnia).
  • Emotional changes (irritability, mood swings, mild depression).
  • Dry skin, dry eyes or dry mouth.

People who are still in the menopause transition (perimenopause) may also experience:

  • Breast tenderness.
  • Worsening of premenstrual syndrome (PMS).
  • Irregular periods or skipping periods.
  • Periods that are heavier or lighter than usual.

Some people might also experience:

  • Racing heart.
  • Headaches.
  • Joint and muscle aches and pains.
  • Changes in libido (sex drive).
  • Difficulty concentrating, memory lapses (often temporary).
  • Weight gain.
  • Hair loss or thinning.

These symptoms can be a sign that the ovaries are producing less estrogen or a sign of increased fluctuations in hormone levels. Not all people get all of these symptoms. However, those affected with new symptoms of racing heart, urinary changes, headaches or other new medical problems should make sure there is no other cause for these symptoms.

What are hot flashes and how long will I have them?

Hot flashes are one of the most frequent symptoms of menopause. It’s a brief sensation of heat. Hot flashes aren’t the same for everyone and there’s no definitive reason that they happen. Aside from the heat, hot flashes can also come with:

  • A red, flushed face.
  • Sweating.
  • A chilled feeling after the heat.

Hot flashes not only feel different for each person, but they also can last for various amounts of time. Some people only have hot flashes for a short period of time during menopause. Others can have some kind of hot flash for the rest of their life. Typically, hot flashes are less severe as time goes on. The intensity, frequency and duration of hot flashes differ for each individual.

What triggers a hot flash?

There are quite a few normal things in your daily life that could set off a hot flash. Some things to look out for include:

  • Caffeine.
  • Smoking.
  • Spicy foods.
  • Alcohol.
  • Tight clothing.
  • Stress and anxiety.
  • Hot weather.

Can menopause cause facial hair growth?

Yes, increased facial hair growth can be a change related to menopause. The hormonal change your body goes through during menopause can result in several physical changes to your body, including more facial hair than you may have had in the past. This is caused by testosterone being relatively higher than estrogen. If facial hair becomes a problem for you, waxing or using other hair removers may be options.

Is having a hard time concentrating and being forgetful a normal part of menopause?

Unfortunately, concentration and minor memory problems can be a normal part of menopause. Though this doesn’t happen to everyone, it can happen. If you’re having memory problems during menopause, call your healthcare provider. Several activities have been shown to stimulate the brain and help rejuvenate your memory. These activities can include:

  • Doing crossword puzzles and other mentally stimulating activities like reading and doing math problems.
  • Cutting back on passive activities like watching TV.
  • Getting plenty of exercise.

Keep in mind that depression and anxiety can also impact your memory. These conditions can be linked to menopause.

Can menopause cause depression?

Your body goes through a lot of changes during menopause. There are extreme shifts in your hormone levels, you may not sleep well because of hot flashes and you may experience mood swings. Anxiety and fear could also be at play during this time. All of these factors can lead to depression.

If you experience any of the symptoms of depression, talk to your healthcare provider. During your conversation, your provider will tell you about different types of treatment and check to make sure there isn’t another medical condition causing your depression. Thyroid problems can sometimes be the cause of depression.

Are there any other emotional changes that can happen during menopause?

Menopause can cause a variety of emotional changes, including:

  • A loss of energy and insomnia.
  • A lack of motivation and difficulty concentrating.
  • Anxiety, depression, mood changes and tension.
  • Headaches.
  • Aggressiveness and irritability.

All of these emotional changes can happen outside of menopause. You have probably experienced some of them throughout your life. Managing emotional changes during menopause can be difficult, but it is possible. Your healthcare provider may be able to prescribe a medication to help you (hormone therapy or an antidepressant). It may also help to just know that there is a name to the feelings you are experiencing. Support groups and counseling are useful tools when dealing with these emotional changes during menopause.

How does menopause affect my bladder control?

Unfortunately, bladder control issues (also called urinary incontinence) are common for people going through menopause. There are several reasons why this happens, including:

  • Estrogen. This hormone plays several roles in your body. It not only controls your period and promotes changes in your body during pregnancy, estrogen also keeps the lining of your bladder and urethra healthy.
  • Pelvic floor muscles. They support the organs in your pelvis — your bladder and uterus. Throughout your life, these muscles can weaken. This can happen during pregnancy, childbirth and from weight gain. When the muscles weaken, you can experience urinary incontinence (leakage).

Specific bladder control problems that you might have can include:

  • Stress incontinence (leakage when you cough, sneeze or lift something heavy).
  • Urge incontinence (leakage because your bladder squeezes at the wrong time).
  • Painful urination (discomfort each time you urinate).
  • Nocturia (feeling the need to get up in the night to urinate).

Will I start menopause if I have a hysterectomy?

During a hysterectomy, your uterus is removed. You won’t have a period after this procedure. However, if you kept your ovaries (removal of your ovaries is called an oophorectomy) you may not have symptoms of menopause right away. If your ovaries are also removed, you will have symptoms of menopause immediately.

DIAGNOSIS AND TESTS

 

How is menopause diagnosed?

There are several ways your healthcare provider can diagnose menopause. The first is discussing your menstrual cycle over the last year. Menopause is unique in that it is diagnosed after the fact. If you have gone a full year (12 straight months) without a period, you have entered menopause and may be postmenopausal.

MANAGEMENT AND TREATMENT

 

Can menopause be treated?

Menopause is a natural process that your body goes through. In some cases, you may not need any treatment for menopause. When discussing treatment for menopause with your provider, it’s about treating the symptoms of menopause that disrupt your life. There are many different types of treatments for the symptoms of menopause. The main types of treatment for menopause are:

  • Hormone therapy.
  • Non-hormonal treatments.

It’s important to talk to your healthcare provider while you are going through menopause to craft a treatment plan that works for you. Every person is different and has unique needs.

What is hormone therapy for menopause like?

During menopause, your body goes through major hormonal changes, decreasing the amount of hormones it makes, particularly estrogen and progesterone. Estrogen and progesterone are produced by the ovaries. When your ovaries no longer make enough estrogen and progesterone, hormone therapy can be used as a supplement. Hormone therapy boosts your hormone levels and can help relieve some symptoms of menopause. It’s also used as a preventative measure for osteoporosis.

There are two main types of hormone therapy:

  • Estrogen therapy (ET): In this treatment, estrogen is taken alone. It’s typically prescribed in a low dose and can be taken as a pill or patch. ET can also be given to you as a cream, vaginal ring, gel or spray. This type of treatment is used after a hysterectomy. Estrogen alone can’t be used if you still have a uterus.
  • Estrogen Progesterone/Progestin Hormone Therapy (EPT): This treatment is also called combination therapy because it uses doses of estrogen and progesterone. Progesterone is available in its natural form, or also as a progestin (a synthetic form of progesterone). This type of hormone therapy is used if you still have your uterus.

Hormone therapy can relieve many of the symptoms of menopause, including:

  • Hot flashes and night sweats.
  • Vaginal dryness.
  • Irritability and mood swings.
  • Hair loss.

Are there any risks to hormone therapy?

Like most prescribed medications, there are risks for hormone therapy. Some known health risks include:

  • Endometrial cancer (only increased if you still have your uterus and are not taking progestin together with the estrogen).
  • Gallstones and gallbladder issues.
  • Blood clots.
  • Deep vein thrombosis.
  • Pulmonary embolism.
  • Stroke.

These risks are lower if you start hormone therapy within 10 years of menopause. After that point, your risk for cardiovascular diseases is higher.

A correlation exists between severe hot flashes and night sweats and your risk for cardiovascular disease. Healthcare providers may suggest starting hormone therapy if you have these severe symptoms since it’s an indicator for future cardiovascular risk.

Going on hormone therapy is an individualized decision. Discuss all past medical conditions and your family history with your healthcare provider to understand the risks versus benefits of hormone therapy for you.

What are non-hormonal therapies for menopause?

Though hormone therapy is a very effective method for relieving menopause symptoms, it’s not the perfect treatment for everyone. Non-hormonal treatments include changes to your diet and lifestyle. These treatments are often good options for people who have other medical conditions or have recently been treated for breast cancer. The main non-hormonal treatments that your provider may recommend include:

  • Changing your diet.
  • Avoiding triggers to hot flashes.
  • Exercising.
  • Joining support groups.
  • Prescription medications.

Diet

Sometimes changing your diet can help relieve menopause symptoms. Limiting the amount of caffeine you consume every day and cutting back on spicy foods can make your hot flashes less severe. You can also add foods that contain plant estrogen into your diet. Plant estrogen (isoflavones) isn’t a replacement for the estrogen made in your body before menopause. Foods to try include:

  • Soybeans.
  • Chickpeas.
  • Lentils.
  • Flaxseed.
  • Grains.
  • Beans.
  • Fruits.
  • Vegetables.

Avoiding triggers to hot flashes

Certain things in your daily life could be triggers for hot flashes. To help relieve your symptoms, try and identify these triggers and work around them. This could include keeping your bedroom cool at night, wearing layers of clothing, or quitting smoking. Weight loss can also help with hot flashes.

Exercising

Working out can be difficult if you are dealing with hot flashes, but exercising can help relieve several other symptoms of menopause. Exercise can help you sleep through the night and is recommended if you have insomnia. Calm, tranquil types of exercise like yoga can also help with your mood and relieve any fears or anxiety you may be feeling.

Joining support groups

Talking to other people who are also going through menopause can be a great relief for many. Joining a support group can not only give you an outlet for the many emotions running through your head, but also help you answer questions you may not even know you have.

Prescription medications

Prescription medications such as estrogen therapy (estrogen in a cream, gel or pill), birth control pills and antidepressants (SSRIs and SNRIs) can help manage symptoms of menopause like mood swings and hot flashes. Prescription vaginal creams can help relieve vaginal dryness. A seizure medication called gabapentin has been shown to relieve hot flashes. Speak with your healthcare provider to see if non-hormonal medications could work for managing your symptoms.

OUTLOOK / PROGNOSIS

 

Can I get pregnant during menopause?

The possibility of pregnancy disappears once you are postmenopausal, you have been without your period for an entire year (assuming there is no other medical condition for the lack of menstrual bleeding). However, you can get pregnant during the menopause transition (perimenopause). If you don’t want to become pregnant, you should continue to use some form of birth control until you have gone fully through menopause. Ask your healthcare provider before you stop using contraception.

For some people, getting pregnant can be difficult once they’re in their late 30s and 40s because of a decline in fertility. However, if becoming pregnant is the goal, there are fertility-enhancing treatments and techniques that can help you get pregnant. Make sure to speak to your healthcare provider about these options.

What are the long-term health risks associated with menopause?

There are several conditions that you could be at a higher risk of after menopause. Your risk for any condition depends on many things like your family history, your health before menopause and lifestyle factors (smoking). Two conditions that affect your health after menopause are osteoporosis and coronary artery disease.

Osteoporosis

Osteoporosis, a “brittle-bone” disease, occurs when the inside of bones become less dense, making them more fragile and likely to fracture. Estrogen plays an important role in preserving bone mass. Estrogen signals cells in the bones to stop breaking down.

People lose an average of 25% of their bone mass from the time of menopause to age 60. This is largely because of the loss of estrogen. Over time, this loss of bone can lead to bone fractures. Your healthcare provider may want to test the strength of your bones over time. Bone mineral density testing, also called bone densitometry, is a quick way to see how much calcium you have in certain parts of your bones. The test is used to detect osteoporosis and osteopenia. Osteopenia is a disease where bone density is decreased and this can be a precursor to later osteoporosis.

If you have osteoporosis or osteopenia, your treatment options could include estrogen therapy.

Coronary artery disease

Coronary artery disease is the narrowing or blockage of arteries that surround the heart muscle. This happens when fatty plaque builds up in the artery walls (known as atherosclerosis). This buildup is associated with high levels of cholesterol in the blood. After menopause, your risk for coronary artery disease increases because of several things, including:

  • The loss of estrogen (this hormone also contributes to healthy arteries).
  • Increased blood pressure.
  • A decrease in physical activity.
  • Bad habits from your past catching up with you (smoking or excessive drinking).

A healthy diet, not smoking and getting regular exercise are your best options to prevent heart disease. Treating elevated blood pressure and diabetes as well as maintaining cholesterol levels with medications for selected at-risk people are the standards of care.

Will hormone therapy help prevent long-term health risks?

The benefits and risks of hormone therapy vary depending on a woman’s age and her individual history. In general, younger people in their 50s tend to get more benefits from hormone therapy as compared to those who are postmenopausal in their 60s. People who undergo premature menopause are often treated with hormone therapy until age 50 to avoid the increased risk that comes from the extra years of estrogen loss.

LIVING WITH

 

Can menopause affect sleep?

Some people may experience trouble sleeping through the night and insomnia during menopause. Insomnia is an inability to fall asleep or stay asleep at night. This can be a normal side effect of menopause itself, or it could be due to another symptom of menopause. Hot flashes are a common culprit of sleepless nights during menopause.

If hot flashes keep you awake at night, try:

  • Staying cool at night by wearing loose clothing.
  • Keeping your bedroom well-ventilated.

Avoiding certain foods and behaviors that trigger your hot flashes. If spicy food typically sets off a hot flash, avoid eating anything spicy before bed.

Can menopause affect my sex life?

After menopause, your body has less estrogen. This major change in your hormonal balance can affect your sex life. Many people experiencing menopause may notice that they’re not as easily aroused as before. Sometimes, people also may be less sensitive to touch and other physical contact than before menopause.

These feelings, coupled with the other emotional changes you may be experiencing, can all lead to a decreased interest in sex. Keep in mind that your body is going through a lot of change during menopause. Some of the other factors that can play a role in a decreased sex drive can include:

  • Having bladder control problems.
  • Having trouble sleeping through the night.
  • Experiencing stress, anxiety or depression.
  • Coping with other medical conditions and medications.

All of these factors can disrupt your life and even cause tension in your relationship. In addition to these changes, the lower levels of estrogen in your body can cause a decrease in the blood supply to the vagina. This can cause dryness. When you don’t have the right amount of lubrication in the vagina, it can be thin, pale and dry. This can lead to painful intercourse.

Don’t be afraid to talk to your healthcare provider about any decreases you are experiencing in your sex drive. Your provider will discuss options to help you feel better. For example, vaginal dryness can be treated with over-the-counter, water-soluble or silicone lubricants. Your healthcare provider can also prescribe estrogen or nonestrogen hormones to treat the vaginal tissue. This may be prescribed in a low-dose cream, pill or vaginal ring.

Do all menopausal people experience a decrease in sexual desire?

Not all people experience a decreased sexual desire. In some cases, it’s just the opposite. This could be because there’s no longer any fear of getting pregnant. For many, this allows them to enjoy sex without worrying about family planning.

However, it’s still important to use protection (condoms) during sex if not in a monogamous relationship. Once your doctor makes the diagnosis of menopause, you can no longer become pregnant. However, when you are in the menopause transition (perimenopause), you can still become pregnant. You also need to protect yourself from sexually transmitted infections (STIs) by wearing a condom. You can get an STI at any time in your life (even if you are not getting a period). STIs like HPV (human papilloma virus) can lead to cervical cancer.

Will I still enjoy sex after menopause?

You should still be able to enjoy sex after menopause. Sometimes, decreased sex drive is related to discomfort and painful intercourse. After treating the source of this pain (vaginal dryness), many people enjoy intimacy again. Hormone therapy can also help many people. If you are having difficulties enjoying sex after menopause, talk to your healthcare provider.

Can menopause be a positive time of life?

Menopause can certainly be a positive time of life. Too often, myths foster misconceptions about this normal process of aging. Although menopause can cause some noticeable and uncomfortable changes, these can be effectively managed.

FREQUENTLY ASKED QUESTIONS

 

How do I know if I’m in menopause?

You will know you have reached menopause when you have gone 12 consecutive months without a menstrual period. Contact your healthcare provider if you have any type of vaginal bleeding after menopause. Vaginal bleeding after menopause could be a sign of a more serious health issue like endometrial cancer.

Can I have an orgasm after menopause?

Yes, you can still have an orgasm after menopause. An orgasm may feel hard to achieve once you have reached menopause, but there is no physical reason to prevent you from having an orgasm. Using lubricants and increasing foreplay can help with discomfort. Try to be open with your partner about your feelings and talk to them about what feels good.

Do men go through menopause?

Andropause, or male menopause, is a term given to describe decreasing testosterone levels in men. Testosterone production in men declines much more gradually than estrogen production in women at about 1% per year. Healthcare providers often debate calling this slow decline in testosterone menopause since it’s not as drastic of a hormone shift and doesn’t carry the same intensity of side effects as menopause in women. Some men will not even notice the change because it happens over many years or decades. Other names for the male version of menopause are age-related low testosterone, male hypogonadism or androgen deficiency.

Can I get pregnant if I have gone through menopause?

No, you can’t get pregnant after menopause because ovulation is no longer occurring. Once you have gone 12 months without a period, you are considered to have reached menopause.

Menopause is a natural and normal part of the aging process. Once you are in menopause, you have gone 12 months without a menstrual period. It is common to experience symptoms like vaginal dryness and hot flashes. Be open with your healthcare provider about the symptoms you’re experiencing and how they impact your quality of life. They can recommend treatments to manage your symptoms and make you more comfortable.

Dr Mark Opperman

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