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Menopause

Definition

Natural menopause is the end of menstruation and childbearing capability that occurs in most women around the ages of 50 to 52. Known as the "change of life," menopause is the last stage of a gradual biological process in which the ovaries reduce their production of female sex hormones estrogen and progesterone.

Surgical menopause is the end of menstruation and childbearing capability that occurs as a result of the woman's ovaries and/or uterus being removed.

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Description

Ovaries begin to decline in hormone production during the mid-30s and typically continue to decline to around the age of 47; this phase is called perimenopause. During this phase, the process accelerates and hormones fluctuate more, causing irregular menstrual cycles and unpredictable episodes of heavy bleeding. By the early to mid-50s, menstruation ends; this phase is called menopause. Two or three years following menopause is the phase called climacteric.

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Causes and Risk Factors

The age when a woman has her last period is not known to be related to race, body size or age of first menstruation. Menopause may occur several years earlier or later then the median age of 51.

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Symptoms

During perimenopause, estrogen production is low and the ovaries stop producing eggs. As estrogen levels decline, certain signs (or symptoms) of menopause occur. The first sign is a change in the woman's menstrual cycle. Periods may skip or occur more often, and the flow may be heavier or lighter than usual.

The most common symptoms are hot flashes or hot flush. The hot flash may begin before a woman has stopped menstruating and may continue for a couple of years after menopause. A hot flash can be defined as a sudden sensation of intense heat in the upper part or all of the body. The face and neck may become flushed with red blotches, appearing on the chest, back and arms. It is usually accompanied by perspiration and may last a few seconds to several minutes. For some women, the feeling of heat is followed by a feeling of chills. The hot flash may be particularly disturbing during sleep.

Vaginal dryness is another common symptom of menopause. With advancing age, the walls of the vagina become thinner, dryer and less elastic. These changes may lead to painful intercourse.

Four or five years after the final menstrual period, there is an increased chance of urinary tract and vaginal infections. The symptoms include having to go to the bathroom often, feeling an urgent need to urinate, not being able to urinate, or having to go often during the night.

Other symptoms of menopause may include headache/migraines, mouth discomfort (pain and burning, altered taste sensations, dry mouth and sensitive gums), night sweats, fatigue, heart palpitations, anxiety, poor concentration, poor memory, loss of sex drive/sexual pleasure, breast tenderness, insomnia, mood swings and irritability.

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Diagnosis

There are telltale symptoms, such as changes in menstrual pattern and the onset of hot flashes, which offer diagnostic clues.

Menopause is suspected when there is a long interval without periods in a woman around the age of 50, particularly if a woman has hot flashes or a low estrogen profile. The low estrogen profile can be discovered during a physical examination by means of an atrophic vaginal smear, the absence of vaginal mucus, or an atrophic endometrium (diagnosed by a biopsy).

In younger women, if the menses have been absent for one year, there may be a strong reason to diagnose menopause. Blood and urine levels of several hormones can be measured to help assess a woman’s menopausal status, including estrogen, progesterone, estradiol and estrone.

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Treatment

The changes in menopause can be relieved by giving replacement estrogen in place of the hormone that is no longer made by the body. Estrogen Replacement Therapy (ERT) is a regimen of taking estrogen supplements to ease or diminish the discomforts of menopause. Additionally, ERT assists in restoring blood cholesterol balance, protecting heart and blood vessels, reducing bone loss (osteoporosis), reinstating vaginal secretions and strengthening the urinary tract. Progestin/progesterone used in combination with estrogen is called Hormone Replacement Therapy (HRT).

ERT/HRT is an individualized choice, and the benefits and risks should be discussed thoroughly with the woman and her doctor before beginning therapy.

Types Of ERT

There are three (3) types of replacement therapy:

1. Estrogen alone via a pill (Premarin, Ogen, Estrace or ethinyl estradiol), a cream (Premarin or Dienestrol) or as a transdermal or skin patch (Estraderm or Estracomb).

2. Cyclical therapy: Estrogen taken daily via a pill or via a patch and a separate progesterone pill (such as Provera) for a certain number of days per month.

3. Continuous therapy: Estrogen plus low dose progesterone in one or two pills taken every day.

Doctors may also suggest androgen (male) hormones, such as testosterone, when a woman has had a sudden, premature menopause after ovary removal.

Benefits Of ERT

  • reduced frequency and severity of hot flashes

  • relief from mood swings

  • relieves vaginal dryness and discomfort

  • reduces the risk of cardiovascular (heart) disease

  • prevents osteoporosis

  • lowers risk of colon cancer

  • improves mental functioning of women with mild to moderate Alzheimer's disease

  • improves memory

  • cuts the risk of tooth loss (in non-smokers)

  • longer life - still under investigation

  • decreases urinary incontinence

  • helps prevent depression

Risks Of ERT

  • may produce premenstrual type symptoms such as swelling, bloating, breast tenderness, mood swings and headaches

  • possible risk of developing asthma

  • increases the risk of endometrial cancer (may be countered by adding progesterone)

  • stimulation of the growth of uterine fibroids and endometriosis

  • increases risk of gallstones

  • increases risk of blood clots

  • weight gain

  • decreases an accurate mammogram reading

Note: About 10 percent of all women receiving ERT experience minor side effects. These include swollen breasts, nausea, vaginal discharge, headaches, fluid retention, weight gain and an increase in blood pressure. Also, it is controversial with respect to whether ERT increases or decreases the risk of breast and uterine cancer. Studies show conflicting results about these.

Who Should And Shouldn't Consider ERT/HRT?

Women who should consider ERT/HRT are:

  • women "at risk" for heart disease. The risk factors of heart disease include high blood pressure, high blood cholesterol levels, diabetes, a family history of heart disease, a sedentary lifestyle, being overweight, smoking and being over the age of 55.

  • women with a family history of osteoporosis

  • slender white or Asian women, because they are at increased risk for osteoporosis

  • women who experience menopause before age 45, naturally or due to hysterectomy

If the woman has chosen to begin replacement therapy, she must also decide how long she will want to continue this therapy. Women taking ERT/HRT solely to ease hot flashes and other menopausal symptoms will need therapy for only one to five years, until the conditions subside. However, to reduce the risk of heart disease and osteoporosis replacement therapy is recommended for a longer period of time. The decision to continue or stop should be discussed with the doctor. At that time, the woman and her physician will way the risks and benefits of ERT/HRT as well as gauge her risk for heart disease and osteoporosis.

Additionally, the woman who has chosen hormone replacement therapy should have an annual pelvic, mammogram and breast exam, alert her doctor about any unusual vaginal bleeding or spotting and ask for an annual biopsy of the uterine lining if she still has a uterus and is taking estrogen only.

Women who should not consider ERT/HRT are:

  • women who have or had breast cancer or a family history of breast cancer

  • women with abnormal or unexplained vaginal bleeding

  • women who have or had uterine fibroids

  • women with a history of blood clots

  • women with active liver disease or gallbladder disease

If the woman has chosen not to begin replacement therapy because of the factors listed above, there are alternatives to hormone replacements.

Alternatives To Hormone Replacement

If the woman is thinking of foregoing replacement therapy she may want to consider the following drug and non-drug methods of alleviating some of the annoyances of menopause.

  • For hot flashes: Several prescription drugs offer limited relief: synthetic progesterone (Cycrin, Megace or Provera), methyldopa (Aldomet), clonidine (Catapres), synthetic androgen (Danazol), synthetic steroid (Org-OD14) and Bellergal-S. Non-drug measures include avoiding caffeine, alcohol, spicy foods and hot drinks, as well as introducing exercise and relaxation techniques into the daily life. Non-traditional forms of treatment include aromatherapy, homeopathy, acupuncture, herbal medicines (such as ginseng, evening primrose oil, red raspberry leaf tea, dong quai and blackhash), and massage.

  • For painful intercourse due to vaginal dryness: Staying sexually active, using lubricating jelly (such as Astroglide, Replens, Lubrin and K-Y Jelly) and applying a vaginal cream (such as Estrace or Premarin) once or twice a week can help minimize the discomfort. Non-traditional treatment includes the consumption of phytoestrogens, which are found in soy-based foods.

  • For urinary tract infections: Using an estrogen cream, drinking plenty of liquids and urinating as frequently and completely as possible.

  • For osteoporosis prevention: Several prescription drugs offer treatment and preventive options: calcitonon (Miacalcin) for treatment of osteoporosis and alendronate (Fosamax) for prevention of osteoporosis. Additionally, taking 1500 mg of calcium and 400 IU of vitamin D each day as well as 45 to 60 minutes of weight-bearing exercise four times a week can also help in the prevention of this problem.

  • For heart disease: To reduce the risk of heart disease doctors recommend eating a low-fat, high fiber diet, exercising regularly, stopping smoking, and maintenance of a normal body weight.

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Self Care

Many women find they can cope with hot flashes by:

  • dressing in layers that can be removed

  • wearing natural fabrics

  • drinking cold rather than hot beverages

  • keeping rooms cooler

  • sleeping with fewer blankets

  • avoiding alcohol

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Questions to Ask Your Doctor

Could the irregularity in the menstrual pattern and/or the hot flashes be caused by stress or medication?

How do you determine estrogen levels?

Will taking calcium help prevent osteoporosis?

If estrogen and other hormone replacement are given, what are the side effects?

Does estrogen replacement therapy increase the risk of breast cancer or uterine cancer?

Will there be mood swings or depression while going through menopause? If so, what measures do you recommend to help relieve these symptoms?

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