Menopause

What is menopause?

About the same size and shape as an almond, the ovaries are located in the pelvis, one on either side of the uterus. As part of the female reproductive system, ovaries produce eggs and female hormones, namely estrogen and progesterone which determine the shape of a woman's breasts, her body shape, and her pubic hair. The ovaries also regulate the menstrual cycle and pregnancy. Each month as part of the menstrual cycle, an egg is released from one of the two ovaries in a process called ovulation. Ovulation and menstruation occur when a girl or woman is of childbearing age.

Menstruation refers to the shedding of the endometrium, or uterine lining. Every month, in anticipation of housing and nourishing a fertilized egg, the uterus prepares a thick, blood-rich cushion. If fertilization doesn't occur and a fertilized egg doesn't implant in the uterus, this extra blood and tissue are not needed by the body; the uterus then cleanses itself by shedding this lining so that a fresh buildup can occur the following month, in anticipation of a possible pregnancy.¹

The buildup and shedding of the uterine lining is a complex mechanism — a mechanism controlled by the fluctuations in a woman's hormone levels. Each month, the pituitary gland, releases follicle stimulating hormones (FSH) and luteinizing hormones (LH) into the bloodstream, where they can be carried to the ovaries, the tiny sacs that contain all the eggs a woman will ever have. Eggs in the ovaries exist in an inactive form called follicles. During each menstrual cycle, the FSH and LH from the pituitary gland cause one follicle to ripen, and a normal ovum (egg) is released for fertilization. As a normal part of this process, the follicle begins to produce the hormones estrogen and progesterone.²

As a woman nears menopause (from the Greek mens meaning "monthly" and pausis meaning "cessation"), however, estrogen production decreases, and as a result, irregular menstrual cycles will occur. Irregularities may include skipped menstrual periods, and lighter or heavier menstrual flow, and flow with clots. The duration of the menstrual period may change as well. A woman is said to have reached menopause if she has not had a menstrual period in the past 12 consecutive months.

In the Western world, most women experience natural menopause between the ages of 45 to 55, with the average woman reaching menopause at around age 50. Early menopause can occur in women in their thirties, while some women may not experience menopause until they are in their sixties.

Types of menopause

Menopause should not be seen as a medical problem, disease, or illness, but rather, it should be viewed as a natural occurrence representing the end of a woman's fertility. This, of course, assumes a woman enters what's known as natural menopause. Not all women undergo natural menopause: menopause can also be brought on by surgery or be induced. Let's examine surgical, induced, and premature menopause in more detail.

Surgical menopause

A woman may enter "forced" or surgical menopause as a result of a bilateral oophorectomy (removal of both ovaries). This procedure is conducted if a woman has or is suspected of having cervical, endometrial, or ovarian cancer. It is also sometimes performed to treat non-cancerous conditions such as uterine fibroids or endometriosis. Because surgery causes drastic changes in estrogen production, symptoms may be more severe and may also come on more abruptly. Hysterectomy can, although not always, involve bilateral oophorectomy.³

Induced menopause

Induced menopause refers to menopause that occurs when the ovaries are damaged through drugs, chemotherapy, radiation therapy, ovarian malfunction, or x-rays. It should be noted, however, that not all premenopausal women undergoing these procedures will experience induced menopause. Furthermore, even if the ovaries are damaged, the damage is not always permanent.⁴ Menopause is also said to be induced if a woman's ovaries are removed because of uterine cancer or endometriosis.⁵

Premature menopause

Premature menopause refers to menopause that occurs naturally or is induced before age 40.⁶ It can be the result of genetics, autoimmune disorders, premature ovarian failure, induced menopause, or medical procedures such as chemotherapy or radiation therapy.⁷

The stages of natural menopause

Menopause is often used to refer to a point in time, while in actual fact, menopause is actually a process that takes place over the course of several years. The physiological changes that occur in a woman's body during this time are the result of decreasing estrogen levels and may produce a variety of symptoms. Menopausal symptoms most commonly affect women in their forties, although some women in their thirties may also experience symptoms. What is often surprising to many women is the range of symptoms and the age at which symptoms develop.⁸

Terms used to refer to natural menopause and its onset are pre-menopause, used to denote all the reproductive years leading to menopause, and perimenopause (also sometimes known as menopause transition), which includes the time immediately prior to menopause. Post-menopause refers to the time beyond menopause.⁹

Perimenopause

Beginning 8 to 10 years before menopause and affecting women in their forties and occasionally, women in their thirties, perimenopause lasts up until menopause. Perimenopause typically lasts about four years and ends the first year after menopause. It's during perimenopause and the first years immediately following the onset of menopause that the endocrinological, biological, and clinical features of approaching menopause begin. The ovaries gradually produce less estrogen with the decrease in estrogen accelerating in the final one or two years before menopause. Many perimenopausal women experience menopausal symptoms.¹⁰

Irregular periods are common during perimenopause, although other conditions such as hormonal imbalances, birth control pills, pregnancy, fibroids, and cancer can cause abnormalities in menstrual bleeding. Consult with your doctor if you experience any of the following:

• heavy periods or periods accompanied by blood clots
• periods last longer than 7 days
• spotting soon after a period
• spotting after intercourse
• periods occur close together

While during perimenopause—the years before menopause—a woman's periods may be irregular and difficult to predict, she is still ovulating and therefore, still able to become pregnant. Remember that a woman has not reached menopause until she has not had a menstrual period in the past 12 consecutive months. Until this happens, a woman may still become pregnant. Women who do not wish to become pregnant should discuss birth control options with their doctor.¹¹

Menopause

Menopause is the point at which a woman has her last menstrual period. Menopause is diagnosed when a woman has gone 12 consecutive months without a menstrual period.

Post-menopause

Post-menopause refers to the years after menopause. During post-menopause, most women experience a decrease in their menopausal symptoms, although health risks linked to decreased estrogen (e.g. heart disease, osteoporosis, breast cancer, ovarian cancer) increase as a woman ages. (See Menopause and Heart Disease, below.) Medication, hormone therapy and lifestyle changes may reduce the risk of some of these conditions, but because every woman's risk is different, you should talk to your doctor to determine how to reduce your individual risk.¹²

A woman is said to be post-menopausal when she has not had a menstrual period for an entire year; the possibility of pregnancy disappears. Unless a woman is trying to become pregnant, she is well advised to continue using contraception until her doctor determines she is truly post-menopausal. She should also commit to seeing her doctor regularly for routine pelvic exams and screening tests such as PAP smears and mammograms.¹³

Symptoms of menopause

Hot flashes or flush

In addition to the changes in a woman's menstrual cycle discussed above, another very common symptom of menopause is the hot flash or flush, an uncomfortable warm feeling, particularly in the upper body. Hot flashes are commonly triggered by stress, being too hot, or consumption of spicy foods, hot drinks or alcohol. What triggers hot flashes in one woman may not trigger hot flashes in another; each woman is different and the intensity of hot flashes varies greatly. Some hot flashes are nothing more than mildly annoying while others are embarrassing and still others can be debilitating.¹⁴

Night sweats

Hot flashes accompanied by profuse perspiration while sleeping are known as night sweats. Because night sweats often interfere with sleep, women who experience night sweats may become tired and irritable.

Sleep disturbances

Falling estrogen levels can also interfere with normal sleep patterns.

All the result of the body's withdrawal from sex hormones, other symptoms of menopause may include:

Mood changes/mood swings Depression or irritability Changes in short-term memory/forgetfulness Difficulty concentrating Headaches Breast tenderness Uterine fibroids Vaginal dryness Painful intercourse Lowered sex drive Insomnia

Weight gain Joint pain Dry eyes Dry skin Bowel upset Urinary tract infections Frequent urination Incontinence Urine leakage when coughing or sneezing Increase in facial hair Thinning of hair on scalp

Menopausal symptoms, in most women, are minimal and diminish over time. Some may be further diminished through changes in diet and lifestyle and through regular exercise. In fact, there really isn't any reason that menopause should interfere with a woman's vitality and quality of life: the majority of women see menopause as freeing them from birth control and menstrual periods and claim menopause leaves them feeling more empowered and energized than in their younger years.¹⁵

When can I expect to reach menopause?

Since menopause is genetically determined, family history may be able to provide some clues as to when a woman might expect to reach menopause. One should not, however, subscribe to the notion that onset of menopause is linked to the time of a woman's first period or that age at menopause is pre-determined by a woman's race, height, use of oral contraceptives, or the number of children she has borne.

Women who have had their uterus but not their ovaries surgically removed experience menopause several years sooner than if they were to experience natural menopause. Removal of the womb means a woman will no longer have periods. With the ovaries still intact, estrogen will continue to be produced. Thus, as estrogen production decreases with age, such women will experience the same signs of approaching menopause as women with a uterus: hot flashes and night sweats.¹⁶

Interesting also in the link between cigarette smoking and menopause. Smokers and even ex-smokers can experience menopause up to three years earlier than women who have never smoked.¹⁷

Based on the information presented thus far, it's pretty safe to say that women in their forties and fifties who have not had a menstrual period in the past 12 consecutive months and who have hot flashes have reached menopause. However, diagnosis of menopause can be more difficult in younger women, in women with atypical symptoms, or in women who have undergone a hysterectomy. It may be necessary to exclude such conditions as thyroid problems or some forms of cancer, since these can produce thermal abnormalities which may be construed as hot flashes.¹⁸

As seen, the pituitary gland releases follicle stimulating hormones (FSH). A simple blood test can be done to determine a woman's level of circulating FSH; if her FSH blood level is in excess of 30 to 40 MIU/mL, it is said she has reached menopause.¹⁹ This test should not be considered failsafe, however: while results showing high levels of FSH and LH do indicate that the body is trying to stimulate ovulation, they do not reveal whether the effort will be successful. In other words, although high levels of FSH and LH may indicate that a woman is approaching menopause, these levels may also be high in perimenopausal women and in women with irregular menstrual cycles.²⁰

Does menopause increase my risk for heart disease?

While primarily associated with aging, there does exist a link between increased risk of heart disease and a woman's transition through menopause. Prior to menopause, a woman's hormones provide her heart and blood vessels with some protection. However, with menopause and its ensuing reduction in estrogen production, the risk of heart disease increases. In fact, until about age 65, menopausal women are at significantly greater risk than men for developing heart disease. After age 65, however, women's risk is equal to that of men.²¹

For many years, health practitioners routinely prescribed hormone replacement therapy as a means of dealing with the reduced production of estrogen and also as a means of preventing heart disease. Several new studies, however, have shown conclusively that menopausal women who take estrogen alone or estrogen in combination with progestin derive no coronary benefit from hormone therapy. If anything, the studies suggest there may actually be an increased risk of heart disease in women on hormone therapy.²²

Alternatives to hormone therapy

In addition to hormone therapy, alternative treatments such as estrogen cream, antidepressants, soy products and certain herbal supplements may help ease some menopausal symptoms. (See Hot Flashes for more information on some of the alternative and complementary treatments used to treat the symptoms of hot flashes.)

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