From a purely biological standpoint a woman's life may be divided into those years of development leading up childbearing capacity (birth to the onset of menses), her reproductive years (generally accepted to be age 15 – 45) and the years that follow. The years that follow represent a transition point in the aging process. During the first part of the transition (age 45 – approximately age 51) women still menstruate but begin to show a sharp decline in fertility (very few women have the capacity to become pregnant after age 45) though they may still ovulate and menstruate. During the latter part of the transition ovulation ceases entirely, menstrual flow is brought to a halt and the signs and symptoms of menopause become evident.

The menopausal years become a time of transition—a time in which women reassess not just their bodies, but their roles as mothers, partners and members of their communities. Healthy women may spend 40-50% of their lives in the years that follow menopause. Unfortunately, we live in a culture that devalues women (and men) as we age and the result is that many women may dread these years associating them with a loss of femininity, sexuality and vitality. However, these years also provide women with an increased sense of perspective, wisdom, purpose, self-esteem and freedom.

Curiously, while many younger women dread the aging process few in their 50s, 60s and beyond would want to "go back". The knowledge and insight gained by aging women is well-worth the price of seeing an "older" woman in the mirror.

What is menopause?

Menopause is that time in a woman's life when her ovaries literally "run out" of eggs (oocytes).
"What!," you say, "I thought it was when a woman stopped having periods!" And so the confusion begins.

A mature egg (oocytes) ready for release

The absence of menstrual periods doesn't necessarily mean a woman is menopausal. For instance, many women undergo hysterectomies (without removal of their ovaries) in their 30s and 40s and have normal ovarian function. Still other women undergo some form of endometrial ablation or endomyometrial resection (click here), have no periods and yet are many years from becoming menopausal. To make it more confusing, some women have menopausal symptoms—including hot flashes and disabling night sweats while still having periods.

In order to understand menopause we need to redefine what has been the accepted medical standard for menopause—a period that starts once a woman has endured 12 months without a period. As you will see, this isn't a particularly useful definition as a woman has to "wait" a year before becoming "officially" menopausal.

So we'll come back to my definition. Menopause happens when a woman's ovaries no longer have eggs to produce. When egg production is no long possible estrogen levels begin to fall—in some women this happens gradually while in others it appears to be a dramatic event. But it is the fall in estrogen levels that produce many of the symptoms associated with menopause.

Why does menopause happen?

When a "girl fetus" is still inside her mother's womb and 20 weeks old from conception, her ovaries have about 2 millions immature eggs called oocytes. These oocytes will mature around the time of puberty and will eventually be the "eggs" that are released at ovulation. However, by the time that girl "fetus" becomes a newborn baby almost 75% of her oocytes have already disappeared—leaving her with about a half million immature eggs. Women are born with all the oocytes they're ever going to have. Every passing year they lose eggs until they "run out". When all of their eggs are gone they've reached menopause.

During their reproductive years their eggs grow in little "bubbles" on the surface of the ovary called follicles. Under normal circumstances these follicles start growing with the onset of each cycle and form an "ovulation" cyst (or follicular cyst) that eventually releases the mature (fertilizable) egg. The follicle is also responsible for the production of estrogen and progesterone. In other words, female hormone production and egg development are inseparable. When ovarian egg production stops estrogen and progesterone levels fall dramatically.


How do most women experience menopause?

Since it's very difficult to determine when a woman "runs out" of eggs we rely on other signs and symptoms that coincide with that time frame just prior to menopause. Some women have almost no symptoms of menopause while others have a great many. Generally, these symptoms start 1-5 years prior to menopause though the onset of these symptoms does not actually predict when menopause will occur.

This raises an important point—there is no test that will reliably predict when menopause will occur. The tests that are available will confirm that "menopause has happened" but not "it's about to happen".

The symptoms of approaching menopause (depletion of egg supply by the ovaries) include

• Change in bleeding patterns
• Hot flashes and night sweats and insomnia
• Anxiety, irritability and depression
• Difficulty concentrating on tasks
• Palpitations
• Diminished sex drive
• Vaginal dryness
• Onset or worsening of urinary incontinence


About 75% of women will experience some of these symptoms. The majority of women with menopausal symptoms require no treatment. Perhaps the most disabling symptoms that women experience are related to night sweats and hot flushes. Frequently, these symptoms cause marked sleep disturbance and may be the real cause of other concomitant symptoms--difficulty concentrating on tasks, anxiety, irritability and depression.

Some symptoms occur just prior to menopause (perimenopause)—hot flushes, night sweats, sleep disturbance, palpitations, anxiety, depression, irritability and diminished sex drive. The severity of these symptoms depends on how rapidly estrogen levels are falling. Other symptoms may not occur until many years after menopause—vaginal dryness or the onset of urinary incontinence.

When does menopause occur?

The average age of menopause in the United States is about 51. About one out of twenty women have late menopause (after age 55) while another 5% stop having periods between the ages of 40 and 45 (early menopause). The age of menopause is reduced by two years in women who smoke. Other factors that affect the age of menopause include a history of type 1 diabetes, a shorter cycle length during adolescence and a family history of early menopause.

Can I tell if I'm approaching menopause?

The frustrating reality is that there is great variation among women. Some women have few if any symptoms at age 50 and may be 1-5 years away from menopause. Other women have hot flashes at age 45 and may still be 1 – 7 years away from menopause. So the simple answer is no—you can't predict when you'll be menopausal. But the question is this—does it matter?

I know it sounds like a ridiculous question but the truth is that menopause isn't treated according to whether or not you still have eggs left or estrogen is still being produced by the ovaries. Menopause is primarily treated because of symptoms that a woman experiences—hot flashes, night sweats, palpitations, insomnia, etc. Whether or not you're still having periods and still producing estrogen these symptoms can still be addressed. You don't need to be "officially" menopausal to get relief of these symptoms.

A word about "definitions"

If you surf the web enough you'll find many varying and confusion definitions. Among these terms you'll find "menopausal transition", "perimenopause", "menopause" and "post-menopause". These terms are arbitrary and often based on menstrual characteristics along with some symptoms. Unfortunately, they are not useful definitions as far as a particular woman is concerned. If a 48 year old woman asks whether or not she is "perimenopausal"—a term that means nothing more than "around the time of the menopause" the technical answer will depend on whether or not her menses are regular and how long they last. She may not fit the medical definition of perimenopause but still be a year or less from menopause.

So the bottom line is this: avoid the confusion in trying to define exactly where you are in the menopause "process". After all, menopause is just another aging process—in this case the aging of the reproductive organs. Instead of trying to define where you are in the aging process, focus on whether or not you're feeling well, having symptoms or concerned about other aspects of menopause including the loss of skin elasticity, bone health, vaginal dryness or other menopause-related issue.

What is surgical menopause?

Most women undergo a "natural menopause"—the slow loss of ovarian oocytes (eggs) over a period of time associated with the gradual decline in estrogen and progesterone production. However, some women may require surgery for removal of one or more ovaries. Fortunately, few women require the surgical removal of their ovaries that still function but this may happen with women who have pelvic masses, severe pelvic inflammatory disease (with ovarian abscesses), ovarian cancer, uterine cancer and even some pre-malignant conditions of the ovary. When surgical menopause occurs (removal of both ovaries) there is a sudden and dramatic reduction in estrogen and progesterone levels often leading to immediate symptoms—particularly hot flashes and night sweats.


The Symtoms of Menopause—Understanding them

Bleeding patterns — Women experience a variety of alterations in their normal menstrual periods. What happens at this "stage" can be very variable. In general the years leading up to menopause are the result of declining progesterone production followed by the cessation of ovulation and declining estrogen production. The decline in progesterone production manifests itself with shorter cycle length. The "cycle length" is calculated from the first day of one period to the first day of the next period. In other words you might find the length of your cycle (normally 27-30 days) become shorter (22-26 days). In addition, they may become somewhat irregular with "cycles" varying from three to five weeks apart. Other common manifestations of declining progesterone production may be a shortening of your period itself. Normal menstrual periods vary from 3-7 days. You might notice that your periods last fewer days and even become lighter. Some women notice that they begin spotting prior to the onset of normal menstrual flow. All of these changes are the result of declining progesterone and estrogen production.

With the progression of menopause women often skip periods entirely. However, never assume a missed period, is "normal" unless you can be certain you're not pregnant—if in doubt pick up a home pregnancy test.

Hot Flushes, night sweats and insomnia—Hot flashes occur in about 75% of menopausal women. Some women experience hot flashes while they are still having periods while others experience it only after complete cessation of their menses. The cause of hot flashes is unknown though most scientists feel that the base of the brain (hypothalamus) and the thermoregulatory center of the brain are at the core of the problem as they respond to estrogen withdrawal.

Hot flashes, typically lasting 2-4 minutes, begin suddenly seeming to emanate from the face and upper chest before spreading outward. This sudden "overheating" is often followed by the exact opposite—chills and shivering as the body attempts to regulate its core temperature. Hot flashes can occur as often as every hour during the day and night to once every few days. They are often associated with palpitations and insomnia. Women often describe a feeling of wanting "to throw off the blankets" during the night associated with profound insomnia. Not surprisingly women who experience such profound sleep disturbance are often "moody" and "grouchy" the next day—who wouldn't be?

Even pre-menopausal women may experience occasional hot flashes—this is not to be taken as a sign of imminent menopause. As women approach menopause—the so-called "perimenopause" hot flashes become more common.

Most women who experience significant hot flashes will have them for more than one year. Left untreated most hot flashes will stop within a few years, though a small number of women (5-10%) will have them beyond the age of 70. In the U.S. hot flashes are least common among Japanese and Chinese women and most common among African-American women. Women who are obese are more likely to suffer from hot flashes as are women who smoke and don't get much physical exercise.

As already noted, hot flashes occur can occur at any time—day or night. During the day time they can cause discomfort and social embarrassment. At night, they are often associated with chronic insomnia. Women who suffer frequent hot flashes at night often have unrelenting insomnia which leads to fatigue, irritability, depression and difficulty concentrating. These symptoms aren't really symptoms of menopause as much as they are symptoms of chronic sleep disturbance.

Difficulty concentrating on tasks—Whether or not this is truly the result of menopause, insomnia associated with hot flashes and night sweats or an independent estrogen-related problem is not clear. There is a subset of women who do not have sleep disturbance but have difficulty concentrating on job-related tasks that do improve on hormone replacement therapy.

Diminished sex drive—The loss of sexual energy in the menopausal and perimenopausal age bracket is a complex issue that may or may not be related to a simple hormonal change. There are many reasons that women often have declining sexual energy at this time in their lives. Some of the reasons include depression, loss of energy, the demands of their job and family as well as the complexity of their relationship with their sexual partner. Nonetheless there are many women who have had very rewarding sexual relations well into their late 40s and early 50s that suddenly find themselves unenthusiastic about sex.

In addition to the loss of estrogen—which leads to a decrease in blood flow to the vagina and vulva, there is the loss of testosterone (another hormone made by the ovary) which appears to play an important role in sexual desire. Testosterone replacement has received little attention compared to estrogen replacement for a variety of reasons—there is no FDA approved drug for testosterone replacement in women and the fact that women are quite concerned (often unnecessarily) that testosterone may cause a sudden increase in the growth of unwanted hair.

Vaginal dryness—Estrogen loss and its associated effect on blood flow to the vagina and vulva diminishes the quality and quantity of vaginal lubrication. Over a period of years the vagina also undergoes some degenerative (atrophic) changes causing the vaginal wall to become shorter and narrower. This is especially true in women who are not sexually active for a period of years. Both vaginal dryness and atrophy appear to respond well to a combination of hormone replacement.

The "Treatment" of Menopause—A review of options

The "treatment" of menopause is a lengthy topic well beyond the scope of this website. Menopause is not a disease that needs to be treated. However, there are symptoms associated with menopause for which women may seek relief or signs (laboratory or x-ray evidence) for which health care providers may suggest treatment.
Generally, treatment is aimed at one of the following:

• The symptoms of "approaching" menopause
• Change in bleeding patterns
• Hot flashes and night sweats and insomnia
• Anxiety, irritability and depression
• Difficulty concentrating on tasks
• Palpitations
• Diminished sex drive
• The symptoms of established menopause
• Vaginal dryness and atrophy
• Onset or worsening of urinary incontinence
• Osteoporosis
• An increased risk of cardiovascular disease and strokes

Treatment of "approaching" Menopause

Menstrual abnormalities--Many women experience a variety of menstrual disorders (click here). Most of these abnormalities require no treatment whatsoever. Some women, however, do experience very troublesome symptoms during the perimenopausal years such as heavy vaginal bleeding, inter-menstrual spotting and even continuous vaginal bleeding. Oftentimes, the patient may select from a host of options including the option of simple observation.

Hot flashes, night sweats and insomnia—These so-called "vasomotor" symptoms are probably the leading reason women seek consultations regarding this transitional phase of life. While many women can tolerate mild hot flashes and a variety of other menopausal-related issues, frequent hot flashes associated with sleep disturbance can be debilitating. Unquestionably, the most effective treatment for moderate to severe hot flashes remains estrogen therapy. For women who have a uterus the estrogen must be balanced with a progestational agent to prevent uterine (endometrial) cancer. Women without a uterus may take estrogen alone.

Non-hormonal treatments that work with lesser degrees of success, and unfortunately a greater number of undesirable side effects include SSRIs (selective serotonin reuptake inhibitors) such as Prozac, Zoloft, Celexa and Lexapro.

Gabapentin (Neurontin), an anti-seizure medication, has been used with various degrees of success. Other medications that seems to work reasonably well include synthetic progestins (Megace, norethindrone, Depo-Provera and oral Provera) and Clonidine.

Many medical and non-medical sources have advocated remedies such as red clover, black cohosh, flaxseed and vitamin E. Despite great enthusiasm for these methods they appear to work no better than a placebo when studied with rigorous scientific methods. In scientific studies that looked at ginseng, dong quai, evening primrose oil, acupuncture, wild yam and progesterone creams, they offered no symptom relief over placebos.

Anxiety, irritability and depression—There are many reasons why women (and men) experience anxiety, irritability and depression. When these symptoms are related to sleep disturbance they are easily remedied by alleviating the cause of the sleep disturbance—usually hot flashes and night sweats. Obviously, there are many other reasons that women may experience anxiety and depression during this phase of life and therefore not all of these symptoms should be automatically attributed to the hormonal fluctuations associated with menopause.

Difficulty concentrating on tasks—Even women who experience little sleep disturbance often report that their ability to concentrate on work-related tasks often improves while taking hormone replacement therapy—suggesting that the loss of estrogen itself can cause difficulty concentrating independent of its effect on sleep. However, this particular symptom rarely presents as an isolated complaint and when it does other explanations should be sought.

Diminished sex drive—There are many reasons for diminished sex drive and all-too-often an attempt is made to "explain-it-away" by invoking the hormonal changes associated with menopause. Without question, the loss of estrogen and testosterone produce a decline in sexual energy, sexual function and orgasmic capacity. However, many women who report a loss of sexual energy also report many other emotional issues concerning their partner which may be more important contributors to a loss of sex drive. In general, women who've had a satisfying sexual relationship with a partner and gradually notice a decline in their sexual appetite often respond well to hormone replacement therapy. In general, replacement with testosterone, causes a fairly rapid return of sexual feelings in women who are otherwise in good health and who enjoy a rich and healthy relationship.

Symptoms of Established Menopause

Vaginal dryness and atrophy—There are many treatments for vaginal dryness. Your choice will depend on whether or not you are experiencing other menopausal-symptoms and to what extent they are interfering with your quality of life. The treatments can be as simple as vaginal lubricants for the simple replacement of lubrication or more involved if one is concerned about forestalling vaginal atrophy. Vaginal atrophy is a late symptom of menopause and generally takes 5-10 years to develop after the onset of menopausal hot flashes. It is caused by prolonged estrogen loss and results in a shortening and narrowing of the vagina. Additionally, the tissues of the vagina become thin and easily traumatized with intercourse. Most experts agree that vaginal or oral estrogens plan an important role in the prevention and treatment of vaginal atrophy.

Onset and worsening of urinary stress incontinence (USI)—Urinary incontinence is common and often bothersome enough to be the cause of social embarrassment. Typically these symptoms start or worsen during the perimenopause since the tissues of the bladder and its supporting structures are estrogen dependent. It is important to discuss these symptoms with your health care provider so that the true source of the problem can be isolated and treatment offered.

Osteoporosis—Click here

Increased risk of cardiovascular disease and strokes—Click here

A Word about Hormone Replacement Therapy (HRT)

The issue of whether or not you should take hormone replacement therapy is a complex one and involves an evaluation of the advantages and potential risks of taking hormones. There is no "right" answer to the question "do I need hormones?" Menopause is not a disease but a stage of life that every woman experiences differently. The decision over whether you should or should not take hormones will depend on a variety of factors including:

• Your own emotional predisposition to the use of hormones
• The severity of your symptoms
• Your overall risk for heart disease, in the case of estrogen/progestin combinations
• Your overall risk for breast cancer, in the case of estrogen
• Whether or not accepting even the small risks associated with HRT is worth the improvement in your symptoms.
• The length of time you may require HRT

The final decision, of course, will be yours. Our interest is in providing you with the best and most recent information.

Breast cancer is the most common cancer among American women and the third most common cause of cancer deaths—behind lung and colon cancer. In 2006 over 210,000 women were diagnosed with breast cancer and that same year over 40,000 deaths occurred as a result of breast cancer. That same year almost 80,000 women's lives were lost to lung cancer and over 56,000 were lost to colon cancer.

According to the Centers for Disease Control breast cancer is the second leading cause of death in women ages 45-54, the fifth leading cause of death in women age 55-64. For more information regarding the role of breast cancer in women's health see the CDC website at http://www.cdc.gov/nchs/fastats/deaths.htm.

Current information suggests that as many as one in six women have a lifetime probability of developing breast cancer and one in nine will develop invasive breast cancer. The reason for the difference is that some women develop a very early stage of breast cancer called DCIS (ductal carcinoma in situ), which is non-invasive.

Since the early 1980s the incidence of breast cancer had risen and probably reflected the results of increasing public awareness of the need for screening mammograms. As a result of vigorous public awareness campaigns breast cancer is increasingly diagnosed in its early stages when it is more likely to be cured. Fortunately, the incidence of breast cancer in the past few years has actually declined slightly.

About one-half of breast cancer cases can be explained by known risk factors such as age of onset of menstrual periods, age at menopause and various benign diseases of the breast. Another 10% of breast cancers are associated with a positive family history.

What are the risk factors for breast cancer?

The risk factors for breast cancer include:

Age-The incidence of breast cancer rises sharply with age until about the age of 45-50 when the rise continues but at a less pronounced rate. The incidence increases with age until about age 75-80 at which time it doesn't appear to change much.

Race and Ethnicity-The highest rates of breast cancer occurs in Caucasian women (141 cases per 100,000 women. The rates are lower in African American women (119 per 100,000), Asian women (97 per 100,000), Hispanic/Latina women (90 per 100,000) and American Indians (55 per 100,000). Despite the fact that African-American women have a lower incidence of breast cancer than Caucasian women they have a higher mortality rate from breast cancer. This may be due to the advanced stage of the disease at the time of its discovery and may also be due to a more aggressive form of the cancer found in African American women

Benign breast disease-There is an increased likelihood of breast cancer in women with benign conditions of the breast that fall into a category known as "proliferative lesions". This does not include fibrocystic change. About one in twenty breast lumps, when biopsied, reveal 'atypical hyperplasia'. This means the cells are not cancer, but are growing abnormally. Atypical hyperplasia does increase your risk of breast cancer by 2-5 times the average.

Socioeconomic factors-Women of higher socioeconomic status are at greater risk for breast cancer. This may reflect the fact that women of a higher educational, occupational and economic status tend to delay childbearing, have fewer children and have their first child later in life. This trend may also reflect the fact that these same women tend to utilize mammography more often than women in lower socioeconomic classes.

Lifestyle and Dietary factors-Moderate alcohol intake increases the risk of certain types of breast cancer and this effect appears to be more pronounced in women who take hormone replacement therapy.

Dietary factors-The Nurse's Health Study revealed an association between large amounts of red meat intake and certain pre-menopausal breast cancers. There is also some information that intake of low-fat dairy products may protect against breast cancer.

Despite the relationship between caffeine intake and benign fibrocystic disease of the breast, there is no relationship between caffeine intake and breast cancer.

Weight-Women with a higher body mass index (BMI) have an increased risk of post-menopausal breast cancer. Women who weight over 80 kg (176 lbs) have a 25% increased risk of breast cancer compared to women who weigh less than 60 kg (132 lbs). Obesity also increases the risk of mortality from breast cancer.

Height-Women over 5'9" tall are 20% more likely to develop breast cancer than women under 5'3" tall.

Age at onset of menses and age of menopause-Early onset of menstrual periods and late menopause seem to be associated with an increased risk of breast cancer. It appears that the longer a woman is exposed to estrogens the greater the likelihood of developing breast cancer. Women, for instance, that undergo removal of both ovaries before the age of 40 reduce their lifetime risk of breast cancer by 50%.

Parity-Women who've never given birth to a child have a 1.2 to 1.7 relative risk of developing breast cancer.

Age at first delivery-The younger a woman is at the time of her first delivery the less likely she is of developing breast cancer.

Abortion-The best available data compiled by the National Cancer Institute concludes that there is no relationship between a history of an elective abortion(s) and subsequent development of breast cancer. See www.cancer.gov/cancerinfo/ere)

Breast feeding-There does seem to be some protective effect of breast feeding against developing breast cancer. This appears to be related to the length of breast feeding and the number of children nourished in this fashion.

Bone density-There also seems to be a relationship between low bone density and a lower incidence of breast cancer. The common culprit may be estrogen. Low levels of estrogen are bad for bone density but may be protective against breast cancer.

Hormone Replacement Therapy-The exact relationship between hormone replacement therapy and breast cancer is still a subject of debate. The Women's Health Initiative Study, published in 2002 (http://www.nhlbi.nih.gov/whi/) did conclude that there was an important relationship between breast cancer and the use of estrogen and progestin replacement therapy.

Family History-A positive family history is only reported by 15-20% of women diagnosed with breast cancer. The risk of breast cancer for a woman with one affected first-degree relative (mother or sister) is 1.8 times that of women without a family history. With two affected first degree relatives the risk increases to 2.93-fold. The risk is greatest in women whose relative was diagnosed before the age of 30.

Genetic Mutations-BRCA1 and BRCA2 are major genes related to hereditary breast cancer. In some studies women with inherited BRCA1 or BRCA2 mutations have up to an 80% chance of developing breast cancer during their lifetime and are more likely to have it at a younger age than women who are not born with one of these gene mutations. Women who have inherited certain mutations in these genes have a high risk of developing breast, ovarian and several other types of cancer during the course of their lives. Melanoma and lymphoma are also more common among people who have BRCA2 mutations. BRCA mutations are found most often in Jewish women of Ashkenazi (Eastern Europe) origin but are also seen in African American and Hispanic women.

History of radiation therapy to the chest-This includes women who've undergo radiation therapy to the chest for Hodgkins disease. The risk is increased in women who've undergone radiation between the ages of 10 and 30.

Additional risk factors-Other risk factors for breast cancer include a history of uterine, ovarian or colon cancer. Also, a prior history of breast cancer increases the predisposition toward developing future disease.

How can I calculate my own risk of developing breast cancer?

You can even go on line at http://www.cancer.gov/bcrisktool/ and use a calculation tool that will help you determine your own individual risk for developing this disease.

What are the symptoms of breast cancer?

Fortunately, modern screening allows most women to detect cancers well before they produce any symptoms. However, it's important to consult a health care provider should you have any of these symptoms.