Menopause - what is, signs and symptoms

What is Menopause

A woman’s last menstrual period, the end of MENSTRUATION and the closure of a woman’s FERTILITY. Though researchers understand the cascade of physiologic events that results in menopause, the triggering factors remain a mystery though many researchers believe a key triggering mechanism is the loss of viable eggs (ova). Doctors consider a woman to have reached menopause when she has experienced one continuous year (12 contiguous months) without menstrual periods. However, the common perception of menopause encompasses the period of time, often years, preceding menopause. Some people call this time PERIMENOPAUSE (“around menopause”).

Signs and Symptoms of the Menopause

Though menopause is a natural life shift, not a health condition or disorder, many women experience discomforts as their bodies rebalance after HORMONE levels shift. Most notable among these discomforts are HOT FLASHES, irregular menstrual periods or abnormal vaginal bleeding, and mood changes. Not all women experience all or even any of these discomforts; some women experience additional or different discomforts such as joint pain and HEADACHE. The transition of menopause is a uniquely individual passage.

Indications of Menopause

The most defining indication of menopause is the discontinuation of menstruation. In most women this occurs as a gradual process during which menstrual periods become increasingly irregular both in timing and quality. A woman may have three periods that are three weeks apart and last eight or nine days each, have one three-day period six weeks later, then not have another period for four months. This pattern may extend over three to five years, during which a woman typically experiences other indications that her hormone levels are fluctuating and dropping. Such indications commonly include

• vaginal dryness and painful sexual intercourse
• hot flashes and night sweats
• tendency to cry, mood swings, and irritability
• difficulty sleeping
• diminished ability to concentrate and memory difficulties
• decreased LIBIDO (sex drive)
• anxiety or DEPRESSION

Some women barely notice any of these indications and other women find that they interfere with nearly all aspects of their lives. There are few clinical answers to explain the broad range of experience, nor to predict what course a particular woman’s menopause experience will take. There is some indication that a woman tends to have an experience similar to her mother’s, though whether the reasons are cultural or physiologic remains unknown.

Relieving Menopause Discomforts

There are numerous approaches to relieving the discomforts of menopause, some of which are clinical and others that are alternative and lifestyle. The more a woman understands the changes that are occurring in her body and the natural course they represent, the more effectively she can cope with their effects and choose methods of relief that are appropriate for her health status and her degree of discomfort. Many women find the most effective solutions involve a mix of methods, and that the mix changes as menopause progresses.

Hormone replacement therapy (HRT)

For the last half of the 20th century doctors treated menopause with hormone replacement therapy (HRT), hormone supplementation to elevate the levels of ESTROGENS and PROGESTERONE in the BLOOD circulation. The intent of HRT was to bring up these levels enough to relieve discomforts without restoring the menstrual cycle. Doctors also believed HRT helped protect a woman from CARDIOVASCULAR DISEASE (CVD) and OSTEOPOROSIS, two conditions that can have dire consequences as a woman ages. The foundation for this belief was the sharp rise in incidence of HEART ATTACK and the high rate of osteoporosis among women after menopause who did not take HRT. It seemed that women who took HRT were less likely to have either condition. Many American women took HRT for the last half of their lives.

However, extensive clinical studies began to show in the early 2000s that contrary to these popular perceptions, HRT did not have a protective effect against CVD and had perhaps a limited protective benefit for osteoporosis. Further, HRT significantly increased the risk for some types of HORMONE-DRIVEN CANCERS, such as BREAST CANCER and ENDOMETRIAL CANCER. In 2002 health agencies withdrew recommendations for routine long-term HRT, advising that doctors instead prescribe timelimited hormone supplementation to relieve menopausal discomforts only when they interfered with a woman’s QUALITY OF LIFE. Under the current standard of practice guidelines most women should not take hormone supplementation for longer than two years, with a trial off the supplementation every six months to assess whether it remains necessary. Each woman’s individual health circumstances require her doctor’s careful evaluation to determine whether hormone supplementation is appropriate.

There is a sizable group of health-care professionals who prescribe BIHRT (bio-identical hormone replacement therapy). BIHRT utilizes hormones such as estradiol, progesterone, and testosterone that are chemically identical to those found in the woman’s body. It is felt by many that not only do they not pose the same health risks as were identified in the WHI study but do actually provide numerous health benefits.

Nonhormonal approaches

Selective serotonin reuptake inhibitors (SSRIs), a class of ANTIDEPRESSANT MEDICATIONS, have emerged as effective therapies to relieve hot flashes. Doctors usually prescribe these medications at doses lower than those typically used to treat depression. Researchers do not know the precise mechanisms through which SSRIs relieve hot flashes.

There are numerous alternative or complementary approaches to relieve menopausal discomforts, some of which show evidence of their success through clinical studies. Among them include ACUPUNCTURE, SOY, and the medicinal herb BLACK COHOSH, all to relieve hot flashes, and wild yam cream to relieve vaginal dryness. Soy and black cohosh contain PHYTOESTROGENS, plant-based substances that are similar to human estrogens and bind with estrogen receptors in the body, though with less intensity than endogenous estrogens. Wild yams contain a plant-based form of progesterone.

Other remedies are widely believed to provide relief but lack evidence, either because studies have not been done or have produced inconclusive or conflicting results. Among these are black cohosh to relieve mood swings and irritability and DONG QUAI, soy, and red clover to relieve hot flashes and other discomforts. Evening primrose oil and vitamin E supplements appear to help with relaxation and sleep.

Changes That Occur with Menopause

Estrogen has multiple and powerful actions in a woman’s body and the decline of its presence after menopause results in changes that affect all body systems. One such action is a diminished ability to repair collagen structures in the body such as ligaments, tendons, and the SKIN. The loss of collagen may affect the ligaments in the abdomen that support the UTERUS, particularly in women who have given birth, resulting in UTERINE PROLAPSE. A good number of women experience URINARY INCONTINENCE as a result of weakening of the muscles that control the flow of URINE; KEGEL EXERCISES often improve or prevent this. The skin thins and becomes less elastic, resulting in wrinkles. Sebaceous secretions also diminish, causing the skin to become dry. The mucous lining of the VAGINA thins as well, resulting in reduced vaginal secretions. The more fragile vagina may produce symptoms such as burning and itching (VAGINITIS) and discomfort during SEXUAL INTERCOURSE.

Changes in collagen also affect the walls of the arteries, causing them to become less flexible and less able to relax (dilate). As well, estrogen plays a key role in the METABOLISM of cholesterol and fatty acids. As estrogen levels drop the body handles these lipids less efficiently. Consequently HYPERLIPIDEMIA, ATHEROSCLEROSIS, and HYPERTENSION (high BLOOD PRESSURE) become more common after menopause. In addition, loss of estrogen (specifically estradiol) can contribute to HYPOTHYROIDISM and increased CORTISOL potentially leading to INSULIN RESISTANCE. Estrogen also acts as a natural selective serotonin reuptake inhibitor (SSRI) so its loss contributes to increased DEPRESSION. Nutritious EATING HABITS and daily physical exercise become especially important to maintain cardiovascular health in light of these changes.

Estrogen is also essential for maintaining the content of calcium and other bone-building minerals. After menopause calcium more easily leaves the bones and is less easily absorbed into the blood circulation from dietary sources, a double effect that can rapidly result in osteoporosis. More than two thirds of women over age 65 have some degree of osteoporosis. Calcium supplementation in combination with RESISTANCE EXERCISE (also called weight-bearing exercise) helps the bones to retain the calcium they require to remain dense and strong.

See also AMENORRHEA; BONE; BONE DENSITY; CHOLESTEROL, ENDOGENOUS; EXERCISE AND HEALTH; GENERAL ANXIETY DISORDER (GAD); HYSTERECTOMY; MEDICINAL HERBS AND BOTANICALS; MENARCHE; PREMATURE OVARIAN FAILURE (POF).

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