Menopause and Perimenopause

Cause

Menopause is a natural part of aging. As you age, the number and quality of your eggs decline, hormone levels fluctuate, and your menstrual cycle becomes less predictable until it finally stops completely.

Causes of early menopause

Certain lifestyle choices and medical treatments can cause or are linked to an earlier menopause, including:

• Smoking.
• Radiation therapy to or removal of the pituitary gland.
• Chemotherapy.
• Radiation therapy or other treatment to the abdomen or pelvis that damages the ovaries so that they no longer function.
• Genetic and autoimmune diseases.
• Removal of both ovaries (oophorectomy), which causes sudden menopause.
• Low body fat.

Symptoms

The first sign that you are nearing menopause is a change in your menstrual periods. They may become less frequent. And they may be lighter or heavier than you're used to.

Menopause symptoms range from mild (or none) to severe. They include:

• Hot flashes.
• Sleep disturbances (insomnia).
• Emotional changes, such as mood swings or irritability.
• A change in sexual interest or response.
• Problems with concentration and memory that are linked to sleep loss and fluctuating hormones (not a permanent sign of aging).
• Headaches.
• Rapid, irregular heartbeats (heart palpitations).

These symptoms usually go away after 1 or 2 years. But some women have them for several years longer.

Other conditions can cause similar symptoms. Examples include pregnancy; a significant change in weight; depression; anxiety; or uterine, thyroid, or pituitary problems.

Menopause caused by surgery, chemotherapy, or radiation therapy can cause more severe symptoms than usual. Preexisting conditions such as depression, anxiety, sleep problems, or irritability can also make symptoms worse.

Later symptoms

After you stop having menstrual periods, you may get other symptoms, including:

• Drying and thinning of the skin, caused by lower collagen production.
• Vaginal and urinary tract changes, such as:
  • Vaginal dryness, irritation, and itching.
  • An increased risk of vaginal and urinary tract infections (UTIs).
  • Pain with sexual activity.

What Happens

In your late 30s, your egg supply begins to decline in number and quality. As a result, your hormone production changes. You may notice a shortened menstrual cycle and some premenstrual syndrome (PMS) symptoms that you didn't have before.

Gradually, your periods become irregular. This can start as early as your late 30s or as late as your early 50s. It continues for 2 to 8 years before menstrual cycles end.

During this time, your ovaries are sometimes producing too much estrogen and/or progesterone and at other times too little. Your progesterone is likely to fluctuate more than before. This can lead to heavy menstrual bleeding. (If you have heavy or unexpected vaginal bleeding, see your doctor to be sure it isn't caused by a more serious condition.)

About 6 months to a year before your periods stop, your estrogen starts to drop. When it drops past a certain point, your menstrual cycles stop. After a year of no menstrual periods, you are said to have "reached menopause."

During the next year or so, estrogen levels keep going down. This lowers your risk for certain types of cancers (estrogen is linked to some types of cancerous cell growth). But low estrogen also creates some health concerns, such as:

• Bone loss. Low estrogen levels after menopause speed bone loss, increasing your risk of osteoporosis.
• Skin changes. Low estrogen leads to low collagen, which is a building block of skin and connective tissue. It's normal to have thinner, dryer, wrinkled skin after menopause. The vaginal lining and the lower urinary tract also thin and weaken. This condition can make sexual activity difficult. It can also increase the risk of vaginal and urinary tract infections.

Although the reasons aren't well understood, a woman's risk of heart disease increases after menopause. Because heart disease is the number one killer of women, consider your heart risk factors when making lifestyle and treatment decisions.

When to Call a Doctor

Call your doctor if you have:

• Menstrual periods that are unusually heavy, irregular, or prolonged (1½ to 2 times longer than normal).
• Bleeding between menstrual periods, when periods have been regular.
• Renewed bleeding after having no periods for 6 months or more.
• Unexplained bleeding while you are taking hormones.
• Symptoms, such as insomnia, hot flashes, or mood swings, that aren't responding to home treatment and are interfering with your sleep or daily life.
• Vaginal pain or dryness that doesn't improve with home treatment, or you have signs of a urinary tract infection, such as pain or burning during urination or cloudy urine.

Exams and Tests

Your age, your history of menstrual periods, and your symptoms will tell your doctor whether you are near or at menopause. If possible, bring a calendar or journal of your periods and symptoms.

If you have severe symptoms, if your doctor suspects another medical condition, or if you have a medical condition that makes a diagnosis difficult, your doctor may do one or more of the following blood tests:

• A pregnancy test is done if there is a chance that you are pregnant. (This can also be a urine test.)
• A follicle-stimulating hormone (FSH) test can be used to confirm whether you have reached menopause. FSH levels increase during perimenopause and are high after menopause.
• A thyroid-stimulating hormone test is used to see whether irregular menstrual periods or perimenopause-like symptoms are being caused by a thyroid problem.

If you have had no menstrual periods for 1 year, this is a good time to have a full physical exam, with particular focus on your heart health and risk factors for osteoporosis.

Treatment Overview

Menopause is a natural part of aging. But symptoms can be difficult for some women.

If you have trouble sleeping, mood swings, hot flashes, cloudy thinking, heavy menstrual periods, or other symptoms, treatment can help you get through this time more comfortably.

Treatment for menopause symptoms may include:

• Healthy lifestyle habits, including exercise, healthy eating, and quitting smoking. To learn more, see Home Treatment.
• Hormones and other medicines, such as antidepressants. To learn more, see Medications.
• Treatments such as black cohosh and soy. To learn more, see Other Treatment.

Home Treatment

A healthy lifestyle may help you manage menopause symptoms. It can also help lower your risk for heart disease, osteoporosis, and other long-term health problems.

• If you smoke, stop smoking to reduce hot flashes and long-term health risks.
• Exercise regularly to promote both physical and emotional health.
• Limit alcohol intake, which may help to manage or reduce menopause symptoms and long-term health risks.
• Make healthy eating a priority. Cut back on simple sugars and caffeine, which may make menopause symptoms worse. You'll not only feel better but may also prevent long-term health problems.
• Pay attention to how the emotional side of menopause is affecting you. Have a support network, and seek help as needed.
• Make sure you get enough calcium and vitamin D. Eat foods that are rich in calcium. This can help lower your risk of osteoporosis. Ask your doctor if taking a supplement with calcium and vitamin D is right for you. The amount of calcium and vitamin D that you need to take depends on our age, your health, and how much calcium you get from the foods you eat.
• Improve bladder control with regular Kegel exercises.

To manage hot flashes, try keeping your environment cool, dressing in layers, and managing stress.

To improve vaginal dryness, try using a vaginal lubricant.

Medications

Medicines can help you cope with bothersome menopause symptoms. Some medicines contain hormones, and some don't.

Hormone therapy is sometimes used to treat menopause symptoms. But women who use it may have a higher risk of other health problems.

• Menopause: Should I Use Hormone Therapy (HT)?

If your symptoms are the result of early menopause brought on by having your ovaries removed along with your uterus, you may consider estrogen therapy (ET).

• Hysterectomy and Oophorectomy: Should I Use Estrogen Therapy (ET)?

Medicine choices

Hormone medicines

• Birth control pills regulate menstrual bleeding and can relieve symptoms until menopause. They aren't used after menopause.
• Progestin pills and the levonorgestrel IUD release a form of progesterone into the uterus. This reduces heavy, irregular menstrual periods. Some women have side effects.
• Low-dose vaginal estrogen (cream, tablet, or ring) reduces dryness and other tissue changes in and around the vagina.
• Hormone therapy (HT) in pill, patch, vaginal ring, gel, spray, or cream form can be used to treat menopause symptoms.
• Estrogen therapy (ET) is used to prevent symptoms that come with menopause.
• Testosterone with estrogen is sometimes used for menopausal symptoms that don't improve with estrogen therapy.

Non-hormone medicines

• Antidepressants can lower the number and severity of hot flashes. They may also help with irritability, depression, and moodiness.
• Clonidine, a high blood pressure medicine, can reduce the number and severity of hot flashes.
• Gabapentin (Neurontin) is an antiseizure medicine. It can reduce the number and severity of hot flashes.
• Ospemifene (Osphena) is used to reduce vaginal changes that can make sex painful.

Other Treatment

Many women have turned to alternative medicine for menopause symptom relief.

• Mind and body relaxation using breathing exercises. It may reduce hot flashes and emotional symptoms.
• Black cohosh (such as Remifemin) may prevent or relieve menopause symptoms. But the research on black cohosh has had mixed results.
• Soy may improve menopause symptoms. But studies have shown mixed results.
• Yoga (which often includes meditative breathing) and/or biofeedback gives you tools you can use to reduce stress. High stress is likely to make your symptoms worse.

Remember that dietary supplements aren't regulated the way medicines are. It's important to be careful when taking supplements. Tell your doctor what you are taking.

Treatments to avoid

Based on the latest research, some treatments aren't recommended, either because they don't work or because they can cause dangerous effects. These include:

• Angelica.
• DHEA (dehydroepiandrosterone).
• Dong quai.
• Evening primrose.
• Kava.
• Wild yam or natural progesterone creams.