Definition
Menopause is the cessation of a woman's reproductive ability, the opposite of menarche. Menopause is usually a natural change; it typically occurs in women in midlife, during their late 40s or early 50s, signalling the end of the fertile phase of a woman's life.
Menopause is commonly defined by the state of the uterus and the absence of menstrual flow or "periods", but it can instead be more accurately defined as the permanent cessation of the primary functions of the ovaries. What ceases is the ripening and release of ova and the release of hormones that cause both the build-up of the uterine lining, and the subsequent shedding of the uterine lining (the menses or period).
The transition from a potentially reproductive to a non-reproductive state is normally not sudden or abrupt, occurs over a number of years, and is a consequence of biological aging. For some women, during the transition years the accompanying signs and effects (including lack of energy, hot flashes, and mood changes) can be powerful enough to significantly disrupt their daily activities and sense of well-being. In those cases various different treatments can be tried.
Medically speaking, the date of menopause (in a woman with an intact uterus) is the day after the final episode of menstrual flow finishes. "Perimenopause" is a term for the menopause transition years, the time both before and after the last period ever, while hormone levels are still fluctuating erratically.
"Premenopause" is a term for the years leading up to menopause.
"Postmenopause" is the part of a woman's life that occurs after the date of menopause; once a woman with an intact uterus (who is not pregnant or lactating) has gone a year with no flow at all she is considered to be one year into post menopause.
Signs
During the menopause transition years, as the body responds to the rapidly fluctuating and dropping levels of the body's own hormones, a number of effects may appear. Not every woman experiences bothersome levels of these effects; the degree to which they occur varies greatly from person to person.
The majority of women find that their menstrual periods are gradually becoming more erratic, and the timing of the start of the flow usually becomes more and more difficult to predict. In addition the duration of the flow may be considerably shorter or longer than normal, and the flow itself may be significantly heavier or lighter than was previously the case, including sometimes long episodes of spotting.
It is not uncommon to have a 2-week cycle when an ovulation has been skipped. Further into the process it is common to skip periods for months at a time, and these skipped periods may be followed by a heavier period. The number of skipped periods in a row often increases as the time of last period approaches. If a woman keeps a written record of all the erratic episodes of flow, she will know how many months have passed with no flow at all, and thus will be able to know at what date she reached postmenopause, which is important medical information that will subsequently frequently be requested by doctors.
Effects such as formication (crawling, itching, or tingling skin sensations), may be associated directly with hormone withdrawal. Effects that are caused by the extreme fluctuations in hormone levels (for example hot flashes and mood changes) will usually disappear or improve significantly once the perimenopause transition is completely over, however, effects that are due to low estrogen levels (for example vaginal atrophy and skin drying) will continue after the menopause transition years are over.
Hot flashes and mood changes are the most commonly mentioned symptoms of perimenopause, but in a 2007 study, lack of energy was identified by women as the most distressing effect. Other effects can include palpitations, psychological effects such as depression, anxiety, irritability, memory problems and lack of concentration, and atrophic effects such as vaginal dryness and urgency of urination.
One way of assessing the impact on women of some of these menopause effects are the Greene Climacteric Scale questionnaire, the Cervantes Scale and the Menopause Rating Scale
General
Hot flashes (aka hot flushes), also including night sweats, and, rarely, cold flashes. Technically known as vasomotor instability, i.e. the inability to regulate body temperature properly.
Possible but contentious increased risk of atherosclerosis
Migraine
Rapid heartbeat
Dysfunctional bleeding as part of menstruation.
Women approaching menopause often experience this due to the hormonal changes that accompany the menopause transition. In post-menopausal women however, any genital bleeding is an alarming symptom that requires an appropriate study to rule out the possibility of malignant diseases, however, spotting or bleeding may simply be related to vaginal atrophy, a benign sore (polyp or lesion) or may be a functional endometrial response. The European Menopause and Andropause Society has released guidelines for assessment of the endometrium, which is usually the main source of spotting or bleeding.
Urogenital atrophy
Thinning of the membranes of the vulva, the vagina, the cervix, and also the outer urinary tract, along with considerable shrinking and loss in elasticity of all of the outer and inner genital areas.
Itching
Dryness
Watery discharge
Urinary frequency
Urinary incontinence may worsen the menopause-related quality of life, although urinary incontinence is more related to obstetric events than to menopause
Urinary urgency
Increased susceptibility to inflammation and infection, for example vaginal candidiasis, and urinary tract infections
Skeletal
Back pain
Joint pain, Muscle pain
Osteopenia and the risk of osteoporosis gradually developing over time
Skin, soft tissue
Breast atrophy
Breast tenderness ± swelling
Decreased elasticity of the skin
Formication (itching, tingling, burning, pins, and needles, or sensation of ants crawling)
Skin thinning and becoming drier
Psychological
Depression and/or anxiety
Fatigue
Irritability
Memory loss, and problems with concentration
Mood disturbance
Sleep disturbances, poor or light sleep, insomnia, and daytime sleepines
Sexual
Painful intercourse
Decreased libido
Problems reaching orgasm
Cohort studies have reached mixed conclusions about medical conditions associated with the menopause. For example, a 2007 study found that menopause was associated with hot flashes; joint pain and muscle pain; and depressed mood.In the same study, it appeared that menopause was not associated with poor sleep, decreased libido, and vaginal dryness. However, in contrast to this, a 2008 study did find an association with poor sleep quality.
Treatment
Menopause itself is a normal part of life and not a disease that requires treatment. However, treatment of associated symptoms is possible if these become substantial or severe.
Oral contraceptive pills
Oral contraceptive pills are another form of hormone therapy often prescribed for women in perimenopause to treat irregular vaginal bleeding.
Prior to treatment, a doctor must exclude other causes of erratic vaginal bleeding. Women in the menopausal transition tend to have considerable breakthrough bleeding when given estrogen therapy. Therefore, oral contraceptives are often given to women in the menopause transition to regulate menstrual periods, relieve hot flashes, as well as to provide contraception. The list of contraindications for oral contraceptives in women going through the menopause transition is the same as that for premenopausal women.
Local (vaginal) hormone and non-hormone treatments
There are also local (meaning applied directly to the vagina) hormonal treatments for the symptoms of vaginal estrogen deficiency. Local treatments include the vaginal estrogen ring (Estring), vaginal estrogen cream, or vaginal estrogen tablets. Local and oral estrogen treatments are sometimes combined for this purpose.
Vaginal moisturizing agents such as creams or lotions (for example, K-Y Silk-E Vaginal Moisturizer or KY Liquibeads Vaginal Moisturizer) as well as the use of lubricants during intercourse are non-hormonal options for managing the discomfort of vaginal dryness.
Applying Betadine topically on the outer vaginal area, and soaking in a sitz bath or soaking in a bathtub of warm water may be helpful for relieving symptoms of burning and vaginal pain after intercourse.
Other pharmaceutical therapies for menopause
Antidepressant medications: The class of drugs known as selective serotonin reuptake inhibitors (SSRIs) and related medications have been shown to be effective in controlling the symptoms of hot flashes in up to 60% of women. Specifically, venlafaxine (Effexor), a drug related to the SSRIs, and the SSRIs fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), desvenlafaxine (Pristiq), and citalopram (Celexa) have all been shown to decrease the severity of hot flashes in some women. However, antidepressant medications may be associated with side effects, including decreased libido or sexual dysfunction.
Other medications: Other prescription medications have been shown to provide some relief for hot flashes, although their specific purpose is not the treatment of hot flashes. All of these may have side effects, and their use should be discussed with and monitored by a doctor. Some of these medications that have been shown to help relieve hot flashes include the antiseizure drug gabapentin (Neurontin) and clonidine (Catapres), a drug used to treat high blood pressure.
Alternative medical therapies for menopause
Plant estrogens (phytoestrogens, isoflavones)
Isoflavones are chemical compounds found in soy and other plants that are phytoestrogens, or plant-derived estrogens. They have a chemical structure that is similar to the estrogens naturally produced by the body, but their effectiveness as an estrogen has been estimated to be much lower than true estrogens. Their estrogen potency has been estimated to be only 1/1000 to 1/100,000 of that of estradiol, a natural estrogen.
Two types of isoflavones, genistein and daidzein, are found in soy beans, chick peas, and lentils, and are considered to be the most potent estrogens of the phytoestrogens.
Studies have shown that these compounds may help relieve hot flashes and other symptoms of menopause. In particular, women who have had breast cancer and do not want to take hormone therapy (HT) with estrogen sometimes use soy products for relief of menopausal symptoms.
There is also a perception among many women that plant estrogens are "natural" and therefore safer than HT, but this has never been proven scientifically. Further research is needed to fully characterize the safety and potential risks of phytoestrogens.
Vitamin E
Some women report that vitamin E supplements can provide relief from mild hot flashes, but scientific studies are lacking to prove the effectiveness of vitamin E in relieving symptoms of menopause. Taking a dosage greater than 400 international units (IU) of vitamin E may not be safe, since some studies have suggested that greater dosages may be associated with cardiovascular disease risk.
Black Cohosh
Black cohosh is an herbal preparation that has been popular in Europe for the relief of hot flashes. This herb has become more and more popular in the U.S., and the North American Menopause Society does support the short-term use of black cohosh for treating menopausal symptoms, for a period of up to six months, because of its relatively low incidence of side effects when used short term. However, there have still been very few scientific studies done to establish the benefits and safety of this product. Research is ongoing to further determine the effectiveness and safety of black cohosh.
A large study known as the Herbal Alternatives for Menopause Trial (HALT) tested the effectiveness of different herbal or alternative ingredients versus estrogen therapy or placebo for the relief of menopausal symptoms. After one year of therapy, there was no significant reduction in the frequency or severity of hot flashes in women receiving any of the herbal preparations (including a group who received black cohosh) when compared to placebo at any of the follow-up times (3, 6, and 12 months).
Other alternative therapies
There are many supplements and substances that have been advertised as "natural" treatments for symptoms of menopause, including licorice, dong quai, chasteberry, and wild yam. Scientific studies have not proven the safety or effectiveness of these products.
Lifestyle factors in controlling the symptoms and complications of menopause
Many of the symptoms of menopause and the medical complications that may develop in postmenopausal women can be lessened or even avoided by taking steps to lead a healthy lifestyle. Regular exercise can help protect against cardiovascular disease as well as osteoporosis, and exercise also has known mental health benefits. Proper nutrition and smoking cessation will also reduce your risk of cardiovascular disease.
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