Menopause

menopause

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.

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 Flashes, 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.

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.