Today women can expect to live nearly one third of their lives in and after their menopause years. This information covers the basics though there is much controversy in particular regarding hormone replacement therapy. Further documents and news bulletins can be found on this site by entering "menopause" into the search box at the top of the site window. Be sure to search within the "Article" option as opposed to just the "Title" search option. Menopause is the time in a woman's life when she stops having menstrual periods. The years leading up to this point are called perimenopause, or "around menopause." Menopause marks the natural end of the reproductive years that began in puberty. The average age that women go through menopause is 51. Most women enjoy a healthy lifestyle for years afterward. This article describes the physical changes that may occur around menopause and what you can do to stay healthy during this time.

What Is Menopause? The Menstrual Cycle Estrogen is a hormone made mainly by the ovaries, two glands on either side of the uterus. The ovaries make estrogen from puberty until menopause. Estrogen is made during the entire menstrual cycle. It causes the lining of the uterus, the endometrium, to thicken each month. On about day 14 of your menstrual cycle, an egg is released from one of the ovaries. It moves into one of the two fallopian tubes connected to the uterus. If the egg is not fertilized, no pregnancy occurs. The levels of hormones then drop. This signals the uterus to shed its lining. This shedding is your monthly period.

Estrogen and Menstrual Changes As menopause nears, the ovaries make less estrogen. One of the earliest signs that menopause may be approaching is a change in your menstrual periods. You may skip one or more periods. The amount of flow may become lighter or heavier. Bleeding may last a shorter or longer time than is usual for you. Abnormal bleeding can sometimes be a sign of a problem in the uterus or its lining. Even though periods tend to be irregular around the time of menopause, you should be aware of bleeding that is not normal for you. Call your doctor if you:

  • Have a change in your monthly cycle
  • Have very heavy bleeding with clots
  • Have bleeding that lasts longer than normal
  • Bleed more often than every three weeks
  • Bleed after sex

At some point, the ovaries stop making enough estrogen to thicken the lining of the uterus. This is when the menstrual periods stop. A small amount of estrogen is made by other glands and body fat after menopause. Women who are very overweight may not have symptoms of menopause because their extra body fat allows them to make estrogen even after the ovaries stop working.

Early Menopause Early menopause can occur when a woman's ovaries suddenly stop working or are removed. With surgery, there is a sudden loss of estrogen. This may trigger severe symptoms. Women who have early menopause may need to take hormones to replace those made by the ovaries. Although the removal of the uterus (a hysterectomy) ends menstrual periods, it will not cause early menopause unless the ovaries are removed too. If the ovaries remain after surgery, most women will go through menopause around the normal age.

What to Expect Menopause is a natural part of aging. The lower amounts of estrogen that come with menopause will cause changes in your body. These changes occur slowly, over time. Menopause, however, is different for everyone. Some women notice little difference in their bodies or moods. Others may find it difficult to cope with their symptoms.
Hot Flushes The most common symptom of menopause is hot flushes (hot flashes). As many as 75 percent of menopausal women in the United States will have them. A hot flush is a sudden feeling of heat that spreads over the body. Hot flushes can happen at any time, day or night. They can be mild or severe. A hot flush usually lasts 30 seconds to several minutes. Some women will have hot flushes for a few months, some for a few years, and some not at all.

Sleep Problems A lack of sleep may be one of the biggest problems you face as you approach menopause. Too little sleep can affect your mood, health, and ability to cope with daily activities. Some women have less rapid eye movement, known as REM, sleep. This is the stage of sleep when you dream. REM sleep makes up about 20 percent of an adult's normal sleep cycle. Without it, you may wake up without feeling rested. Some may find it takes longer to get to sleep. Hot flushes, however, are the main cause of lack of sleep, often waking a woman from a deep sleep.

Vaginal and Urinary Tract Changes Loss of estrogen causes changes in the vagina. Its lining may become thin and dry. These changes can cause pain during sexual intercourse. They can also make the vagina more prone to infection, which can cause burning and itching. Tissues in the urinary tract also change with age. The urethra, the tube that carries urine from the bladder, can become dry, inflamed or irritated. Some women may need to urinate more often. Women may have an increased risk of bladder infection after menopause.

Bone and Other Body Changes Bone loss is a normal part of aging. At menopause, the rate of bone loss increases. Such bone thinning, called osteoporosis, increases the risk in older women of breaking bones. The bones of the hip, wrist and spine are most often affected. The estrogen produced by women's ovaries before menopause protects them from heart attacks and stroke. When less estrogen is made after menopause, women lose much of this protection. The risk of heart attack and stroke then increases.

Emotional Changes Menopause does not cause sudden mood swings or depression. However, the change in hormone levels may make you feel nervous, irritable or very tired. These feelings may be linked to other symptoms of menopause, such as lack of sleep. If you are under a lot of stress, the changes of menopause may be harder to manage. Many women in midlife are going through major life changes anyway. There may be stress in the family as time passes and roles change. There may stress related to money or your job. Some women may be watching children leave home and are learning to deal with the "empty nest." Some are saddened that they can no longer have children. And more often, women find themselves part of the "sandwich generation," becoming caretakers for their children, grandchildren, and their aging parents. If you find it hard to cope, talk about your feelings with your partner, a close friend, a counselor, or your doctor.

Sexuality Menopause does not have to affect your ability to enjoy sex. Although the lack of estrogen may make the vagina dry, estrogen replacement and vaginal lubricants can help moisten the vagina and make intercourse more comfortable. There are a number of lubricants available without a prescription. If you don't like one product, try another. Regular sex may help the vagina keep its natural elasticity. If you have been having sex on a regular basis, you may not notice any major changes during menopause. If you have not been sexually active for a while, you may want to talk with your partner and perhaps your doctor, too, about ways to make sex more comfortable. Some women find that they have less interest in sex around and after menopause. Lower hormone levels may decrease sex drive. It may affect your ability to have an orgasm, or it may take longer for you to reach orgasm. Men, too, may find that their sex drive decreases as they age. It may take an older man longer to achieve an erection and ejaculate, or he may have problems with impotence. Impotence is usually caused by physical or medical problems, or it may be caused by medications. In many cases, impotence can be treated with success. Talk with your partner about how you feel. Communication is key during this time of changes. This may a good time to experiment with your sex life. You and your partner may want to try different positions or engage in longer foreplay. There are many "how-to" books and videos available as guides. Sex often becomes more enjoyable at this stage of life. Older couples may be more experienced and know how to please each other. They may have more privacy and time.

Birth Control Despite the signs of menopause, you still may be able to get pregnant. You are not completely free of the risk of pregnancy until you have not had a menstrual period for one year. You can choose from the following birth control methods during this time:

  • Birth control pills - safe for women over 40 who don't smoke
  • Hormonal implants (Norplant) and injections (Depo-Provera)
  • Intrauterine device (IUD)
  • Barrier methods - includes the diaphragm, male and female condom, and spermicides
  • Sterilization - tubal ligation ("tying the tubes") for women and vasectomy for men

Because birth control pills contain estrogen, they can be an excellent choice for many women. Birth control pills have the added benefit of protecting you against heart disease and some forms of cancer. Not having sex at certain times in the menstrual cycle is a natural family planning method used by some women. However, this method is not reliable around menopause because ovulation is not regular.
The Gynecologic Visit Routine visits to your doctor for breast, pelvic, and rectal exams are recommended for all women (see box). Your doctor will do a Pap test to screen for cancer of the cervix. Between visits you should examine your breasts once a month.

Your Periodic Health Evaluation (ages 40-60)
Routine Tests How Often
Pap test Doctor and patient   to decide after three   normal annual   tests, if low risk
Cholesterol Every 5 years
Mammography Every 1-2 years   until age 49,   then annually
Fecai occult blood test Annually after   age 50
Sigmoldoscopy Every 3-5 years   after age 50

Depending on your age, your doctor may also perform a mammogram. (Women over age 40 should have a mammogram every 1 to 2 years, and then every year beginning at age 50.) You will also be asked about your general health and medical history. Based on this exam, your doctor can suggest treatment suitable and safe for you. If you have problems at any time, however, contact your doctor. Don't wait until your next checkup.

Hormone Replacement Therapy After your gynecologic exam, your doctor may recommend hormone replacement therapy. Hormone replacement therapy helps relieve the symptoms of menopause. It replaces female hormones no longer made by the ovaries. Depending on your situation, you may begin hormone replacement therapy before menopause. If you are taking birth control pills, they will be stopped when you begin treatment. Estrogen is usually given along with progestin, a synthetic version of the hormone progesterone. This helps reduce the risks of using estrogen alone. The progestin may be taken every day with estrogen, or estrogen may be taken on some days and the progestin added on others. Hormone treatment is most often prescribed in the form of pills. Sometimes, estrogen is given through a patch placed on the skin. Estrogen creams, used in the vagina, can treat dryness, but do not work as well against other symptoms. New ways to give hormones are being studied. They include vaginal suppositories, injections and implants.

Benefits Most of the symptoms of menopause can be eased by taking estrogen. Estrogen is used to treat the main symptom of menopause, hot flushes. It also relieves vaginal dryness. Hormone replacement therapy that includes a progestin lowers the risk of endometrial cancer. Estrogen can also help to minimize changes in organ tissues that can cause urinary tract problems. Hormone replacement therapy can also protect against cardiovascular (heart) disease. Estrogen raises the "good" high-density lipoprotein (HDL) cholesterol in the bloodstream. HDL cholesterol keeps cholesterol from building up in artery walls. At the same time, estrogen lowers "bad" low-density lipoprotein (LDL) cholesterol. Estrogen, therefore, helps to keep arteries clear. Estrogen protects against bone loss. Hormone replacement therapy is the most effective way to slow bone loss after menopause and prevent osteoporosis. Hormone replacement therapy may protect against Alzheimer disease. This disease causes serious mental confusion and memory loss. It is more common in women than men.

Risks Like any treatment, hormone replacement is not free of risk. Using estrogen alone can increase the risk of endometrial cancer because estrogen causes the lining of the uterus to grow. Taking a progestin will help reduce the risk of uterine problems. The drawback of using a progestin is that menopausal women may start monthly bleeding again. Although bleeding may occur only for a short time, many women don't want to go through having menstrual periods again. An issue of great concern to women is whether hormone therapy increases the risk of breast cancer. There have been many studies of this issue, with most showing no increase in risk. A report by the American Cancer Society of 422,000 postmenopausal women followed for nine years reported that the use of hormone therapy was linked to a significantly decreased risk of fatal breast cancer. Although this is reassuring, a definite recommendation cannot yet be made. If there is an increased risk of hormone therapy increasing breast cancer, the increase appears to be small, especially compared with the risks of disease that estrogen prevents. For long-term use, the incidence might rise from 10 women per 10,000 per year to 13 women per 10,000 per year.

Staying Healthy Good Nutrition Eating a balanced diet will help you stay healthy before, during and after menopause. It's important to eat a variety of foods to make sure you get all the essential nutrients. Choose a low-fat, low-cholesterol diet. Also, be sure to include enough calcium in your diet to help build strong bones. Women older than 50 should be getting 1,000 mg of calcium each day if they are taking hormone replacement therapy and 1,500 mg each day if they are not. It is hard to get enough calcium from eating dairy products and certain vegetables, so you should consider using calcium supplements. Ask your pharmacist about which brands contain calcium carbonate - these brands are better at slowing bone loss.
Exercise Exercise is very important, especially as you get older. Regular exercise slows down bone loss and improves your overall health. Follow a program of regular weight-bearing exercise, such as walking and aerobics.
Finally... Menopause is a natural event. Today women can expect to live one third of their lives after menopause. The physical changes that occur around menopause should not prevent you from enjoying this time of your life. To function at your best, you should:

  • Exercise regularly
  • Eat a balanced diet that contains enough calcium
  • Consider hormone replacement therapy
  • Visit your doctor for routine checkups

Discuss any problem you may have with your doctor. This will help him or her find any serious problems and decide whether treatment is right for you.

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