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Resource Description: 
A Q& A about the Women's Health Initiative Postmenopausal Hormone Therapy Trials.
In January, 2002, the Jim Leher NewsHour on PBS aired a segment focusing on the National Institute of Health's announcement it was stopping the largest clinical trial of hormone replacement therapy because the risks outweighed the benefits. Video and a transcript are available on PBS.org. A follow-up to this story aired in June, 2003
The North American Menopause Society is an excellent source of information about menopause. The organization's Website contains a wealth of consumer education materials, plus news articles, referral lists, online subscription for a free e-newsletter, and more.
A good source of information about hormone replacement therapy with a bias toward natural remedies can be found on EarlyMenopause.com.
The Hormone Foundation, public education affiliate of The Endocrine Society, offers plenty of general information about menopause, plus an helpful chart examine the pros and cons of treatments for treating various menopause symptoms.
You'll find extensive information and resources on menopause and hormone therapy on the Website of the National Women's Health Information Center.
The National Cancer Institute provides an informative Q&A on menopausal hormone use.
The American Heart Association provides useful information on menopause and the risk of heart disease and stroke in its site.
For a lighter-hearted, yet very informative view on a range of menopause-related topics, visit the Minnie Pauz site
Episode number: 
112
Transcript: 
Menopause (transcript)

Menopause is a natural part of a woman's aging process. It affects different women in different ways, so it is not surprising that there is confusion about what to expect and how to deal with the symptoms and issues of menopause.  In this episode of Second Opinion, you will learn about the biological process of menopause, what you can do to alleviate its symptoms, and how to make the years after menopause among the best of your life.

Menopause is not a medical illness. And it does not signal the end of life. Menopause is simply the stage in a woman's life when menstruation ends. It is a normal and natural biological process - the aging of your reproductive system - brought on by the gradual loss of estrogen and progesterone , the sex hormones that are secreted by the ovaries.

Women reach menopause at different times in their lives. Most commonly, it occurs on average at age 51, but ages at which menopause begins can vary widely. For some women, this change starts in their early 30s or 40s, while others will not reach menopause until their early 60s.

All women experience menopause differently. For some, menopause poses relatively few problems. Others may be affected by a number of physical and emotional changes, some of which can cause disruption in a woman's life. These include:

  • Irregular menstruation
  • Vaginal and urinary tract changes
  • Decreased fertility
  • Hot flashes
  • Night sweats
  • Sleep disturbances
  • Emotional fragility
  • Changes in physical appearance
  • Increased risk for osteoporosis and coronary heart disease

While menopause itself does not require treatment, the host of symptoms and conditions that can accompany this significant change in your biochemistry can affect your physical and emotional health and lifestyle. Your physician can help you explore a range of options for treating your symptoms and improving your quality of life during this important transition. Among them are:

  • Hormone Therapy (HT)
  • Complementary and alternative medicine
  • Healthy diet and regular exercise
  • Medications
 

Quick Facts

Menopause is not a medical illness. It is a natural biological process that all women go through.  Knowing what to expect and how to deal with the changes that occur during menopause is vital to making a smooth transition.

Although it is rare for a woman to have menopause before age 40, it can happen anytime between the ages of 30 and the mid-50s, and even later. Often, the onset of menopause is earlier for smokers than for nonsmokers.

Only a few generations ago, few women lived beyond menopause. Today, most women today will live more than half their lives after menopause.

Blood and urine tests, and vaginal smears can be used to measure hormone levels that may indicate when a woman is close to menopause or has already gone through menopause. Examples of these tests include: FSH, Estradiol, and LH.

Approximately 75% of women report some bothersome symptoms during menopause, but the severity and frequency of symptoms varies from woman to woman. The most common symptoms are hot flashes and vaginal atrophy (when tissue of the vagina becomes thinner, drier, and more delicate, and begins to shrink).

You do not have to suffer or "tough out" the physical, emotional, and biological symptoms of menopause. Your physician can familiarize you with many different options that are available for relieving bothersome menopausal symptoms, avoiding menopause-related complications, and improving your overall health during this key phase of your life.

A woman can become pregnant during perimenopause, even if periods are irregular. Precautions should be taken if pregnancy is not wanted.

Depression is not a symptom of menopause.  While there may be a relationship between changes in estrogen levels and a woman's mood, other factors may also influence mood shifts. These include stress, family changes (marital issues, children leaving home, etc.), and feeling fatigued.

Ask Your Doctor

Provided by Judith Hsia M.D.
Women's Health Initiative Investigator
George Washington University

This list of questions is a good starting point for discussion with your doctor; however, it is not a comprehensive list.

  1. I've heard that many women lose bone strength at menopause. How often should I get my bone density checked?
  2. Since I've learned that heart disease is the leading cause of death for women, I'd like to reduce my risk. What is my blood pressure? What should it be?
  3. I understand LDL-cholesterol, the so-called "bad" cholesterol, rises and the good cholesterol (HDL-cholesterol) falls at menopause. How often should I get my lipid profile checked?
  4. Can I have a copy of my lipid profile for my records? What is my LDL-cholesterol target?
  5. I've heard that a healthy weight in relation to height is assessed as Body Mass Index, which should be between 18 and 25. What's my body mass index?
  6. What would I have to weigh to be in the healthy body mass index range?
  7. How often should my blood sugar be checked? What is my blood sugar and what should it be?
  8. If I don't have menopausal symptoms, like hot flashes, is there any reason to take estrogen?
  9. I do have hot flashes, are there any alternatives to taking hormones?
  10. What are the risks with hormones?

Key Point 1

Menopause is a natural biological process that begins when your body starts making less estrogen and progesterone as a result of changes in ovarian function.

Until recently, menopause was shrouded in misconceptions and myths. The scientific truth is that menopause is a natural biological process and a normal part of aging.

At birth, your ovaries contain as many as two million egg-containing follicles. As you mature and start ovulating, your follicle reserve steadily declines. When the supply is exhausted, your ovaries stop producing estrogen and progesterone, the sex hormones which have been responsible for regulating your periods over the years.

As menopause approaches, ovulation and estrogen production become erratic and may cause your periods to become irregular.  As estrogen levels drop, the level of follicle-stimulating hormone (FSH) rises, trying to stimulate your ovaries to produce more estrogen and maintain your menstrual cycle .

Rising levels of FSH can be a good indicator that you have started your transition into menopause. But day-to-day hormone levels are not a reliable indication of where you are in the menopausal transition. There are a number of physical symptoms, described below, that also serve as indicators that you are entering menopause.

Stages

Bear in mind that menopause is actually a multi-stage process that takes place over years, and the amount of time it takes to complete the process may vary widely from woman to woman.  While different health professionals may define the stages of menopause in different ways, the following descriptions will help you gain a better understanding of the process.

  • Pre-menopause: Some people use pre-menopause and perimenopause interchangeably. Others use it to define the time when a woman is just starting to experience irregular periods but is showing no signs of classic menopausal symptoms, such as hot flashes or vaginal dryness. Still others use pre-menopause to describe a longer span of time prior to perimenopause, sometimes starting as early as your mid-30s.
  • Perimenopause: Some define perimenopause as the transitional time before menstruation stops. Others extend the definition past your final menstrual period for one to two years. While the average timeframe for perimenopause is about four years, it can last up to ten years and still be considered normal.
  • Menopause: Menopause refers specifically to the date of your last period. Doctors pinpoint your final period once you haven't had one for 12 months. This is the point when you no longer have periods or need to be concerned about getting pregnant. This term is commonly used to refer to the entire process - three of the four stages including perimenopause and post-menopause. Menopause also can occur suddenly with early failure of the ovaries, such as when a woman has her ovaries removed, or chemotherapy is used to fight cancer.
  • Post-menopause: This stage begins with your final period and lasts the rest of your life. While the signs and symptoms of menopause diminish over a year or two, you are at increased risk for longer-term health problems (including osteoporosis) related to low estrogen, and you should work with your doctor to manage them.

Signs and symptoms

Although some women have no menopausal symptoms aside from their periods ending, most experience one of more of the following symptoms, many of which improve over time or can be treated under a doctor's care.

  • Hot flashes
    Hot flashes - also known as hot flushes - are the most common early symptom when estrogen levels decrease. When less estrogen is secreted, your capillaries expand irregularly, causing hot sensations in the face, neck, and chest. You may experience hot flashes for a year or so, but symptoms can persist for five years or more. Irritation, impatience, anxiety, and worry may also accompany hot flashes.
  • Night sweats and sleep disturbance
    Your usual sleep patterns may undergo dramatic changes because of night sweats, which are brought on by hot flashes. You may awaken suddenly with soaking night sweats followed by chills. You may have trouble falling back to sleep or achieving a sound, restful sleep. Too little sleep may affect your mood and overall health.
  • Changes in physical appearance
    Following menopause, fat that once was concentrated in your hips and thighs may find a new home above your waist and in your abdomen. Other notable changes may include weight gain, a loss of fullness in your breasts, and thinning hair. And, even though your estrogen level has decreased, your body continues to produce tiny amounts of the male hormone testosterone, which may result in the appearance of coarse hairs on your chin, upper lip, chest and stomach.
  • Emotional changes/moodiness
    As you move through menopause, you may experience a number of emotional changes, including mood swings, irritability, anxiety, depression, sensitivity, fatigue, and forgetfulness. In the past, these symptoms were attributed primarily to hormonal fluctuations. Today we know that other factors may contribute to these mood changes. These include stress, insomnia, and life events such as the illness or death of a loved one, children leaving home, job loss, financial crisis, and retirement, which may also occur at this stage in a woman's life.
  • Decreased fertility
    When ovulation begins to fluctuate, you are less likely to become pregnant. Until you stop ovulating, however, pregnancy is still possible.
  • Decreased sex drive
    In addition to losing their ability to secrete estrogen, the ovaries no longer produce testosterone - the hormone responsible for sex drive in both men and women. Some women's bodies may still produce the tiny amount needed through the adrenal glands. 
  • Irregular menstruation
    Your menstrual cycle may stop suddenly, or gradually get lighter or heavier and then stop. The irregularity of your periods may be your first signs that menopause is approaching.
  • Vaginal changes
    As your estrogen level falls, the tissues lining your vagina and urethra - the opening to your bladder - tend to become drier, thinner and less elastic. The decrease in lubrication may cause you to experience burning or itching. You may also be more susceptible to infections of your urinary tract or vagina. These changes may also make sexual intercourse uncomfortable or even painful.
  • Loss of bone mass
    Women lose an average of 25% of their bone mass from the time of menopause to age 60, due in large part to the loss of estrogen. Over time, this loss of bone may lead to osteoporosis, a "brittle-bone" disease that contributes to bone fractures.
  • Increased risk of heart disease
    Lower levels of estrogen put you at greater risk for heart disease and stroke.
    A high fat diet, cigarette smoking, high blood pressure, high cholesterol, physical inactivity and obesity increase your risk.
  • Skin ages faster
    After menopause, skin loses elasticity, causing more wrinkles. Although the lack of estrogen is not the main cause, hormone treatment may help the skin maintain elasticity. Also, if you previously experienced adult acne, you may notice that the condition worsens.
  • Breast changes
    The lack of estrogen affects breast size and supporting tissue. After menopause, breasts may stretch, decrease in size, or soften because there is less connective tissue and less glandular tissue.
  • Urinary tract changes
    With the thinning of the lining of the urethra and the weakening of surrounding pelvic muscles, you may experience the need to urinate more frequently. Other symptoms may include frequent bladder infections, painful urination, sudden urinary urgency, and frequent urination during the night. Urinary incontinence may also become a problem. See Second Opinion Incontinence and Urine Leakage episode for more information.
    

Key Point 2

There are things that you can do to alleviate the physical, emotional, and biological symptoms of menopause, including hormone replacement. If estrogen replacement is not an option for you, there are other alternatives including herbal supplements.

Like a fingerprint, the symptoms of menopause are different for every woman. For this reason, the first and most important step toward treating symptoms you are experiencing is to consult with your doctor. He or she will evaluate your symptoms and carefully weigh other important factors, including your medical history, to recommend a course of therapy that is appropriate for your specific needs.

Before meeting with your doctor, you may find it helpful to acquaint yourself with the various forms of treatment, outlined below, that are available today.

Hormone therapy (HT)
Choosing whether or not to use hormone therapy can be one of the most crucial health decisions you face as you age. As with taking any treatment, the decision involves carefully weighing the risks and benefits involved after consulting with your physician.
Hormone therapy (HT) is prescription medication containing one or more female hormones, commonly estrogen plus progestin . Some women - usually those who have had their uterus removed - may receive estrogen-only therapy. HT is used to treat menopause symptoms that include hot flashes, vaginal dryness , mood swings, sleep disorders, and decreased sexual desire. HT may be taken in the form of a pill, a patch, a suppository, vaginal cream or vaginal ring.

Early scientific studies led physicians to believe that HT, in addition to treating menopausal symptoms, might be beneficial for reducing the risk of heart disease and bone fractures caused by osteoporosis (thinning of the bones). A landmark 2002 study called the Women's Health Initiative (WHI) convinced many physicians to revise their recommendations regarding HT. The study concluded that there are potentially serious side effects to HT (including strokes, heart attacks, breast cancer, blood clots, and dementia) as well as beneficial effects including reduction of colon cancer. 

However, hormone therapy continues to play an important role for many women who have reached menopause. Another recent study suggests that the benefits of short-term hormone therapy may outweigh the risks for certain women, provided that their symptoms (hot flashes, vaginal discomfort and osteoporosis) are severe enough and that their risk of heart attack and stroke is relatively low.

The bottom line? If you are considering any form of HT, you and your doctor should carefully evaluate your entire medical history to determine if this type of therapy is appropriate for you.

Alternative treatments

Many women who are concerned about the risks associated with hormone therapy may seek relief from their menopausal symptoms though alternative therapies, including herbal remedies, nutritional supplements, soy foods, and phytoestrogens . There are scores of products on the market and sales have soared in recent years.

To learn more, link to The National Institutes of Health publication, Postmenopausal Hormone Therapy

This succinct and easy-to-read online pamphlet provides a comprehensive overview of a variety of alternative and conventional therapies, plus practical suggestions for what you can do to relieve many menopause symptoms.

While it is worthwhile to investigate all of your treatment options, keep in mind that few high-quality scientific studies have been done to test effectiveness and safety of many alternative therapies. Some hold potential for significant side effects and risks. So, before beginning any health treatment, conventional or alternative, you should first consult with your doctor, who can help you assess the benefits and risks based on medical history and current health condition.

    

Key Point 3

Life is not over at the onset of menopause. It is a natural event and can be a good time of life if you take care of yourself.

 Contrary to the age-old view that life is a downhill slide after menopause, many women today find that their post-menopausal years rank among the richest of their lives. Two major immediate benefits are that you no longer have to deal with your periods and your risk of getting pregnant drops to zero.

As you move though this transition in your life, the most important thing you can do to stay youthful and active is to lead a healthy lifestyle, which includes good nutrition and regular physical exercise. Doing so may help relieve some of your menopause symptoms, enhance the effectiveness of any treatments you may choose, and contribute to the reduction of long-term health risks, including heart disease and osteoporosis.

Good nutrition

As you age, your nutritional requirements change. A woman in the premenopause stage should consume about 1,000 mg of calcium daily. According to the National Institutes of Health, postmenopausal women should aim for 1,500 mg of calcium per day if they are not using hormone therapy (HT), or 1,000 mg/day if they are using HT.

Vitamin D is also very important for calcium absorption and bone formation. According to a 1992 study, women with postmenopausal osteoporosis who took vitamin D for three years, significantly reduced their risk of spinal fractures. This issue is controversial, however, as vitamin D can cause kidney stones, constipation, or abdominal pain, especially in women with kidney problems.

Other nutritional guidelines recommended by the National Research Council of the National Institutes of Health include:

  • Eat foods low in fat, saturated fat, and cholesterol. Fat intake should be less than 30 percent of your daily calorie intake.
  • Consume fruits, vegetables, and whole grain cereal products, especially those high in vitamin C and beta carotene. People of all ages should consume 20 to 30 grams of fiber daily.
  • Avoid foods and drinks with processed sugar. Many of these products contain empty calories and promote weight gain.
  • Avoid salt-cured and smoked foods such as sausages, smoked fish, ham, bacon, bologna, and hot dogs. These foods are high in sodium, which can lead to high blood pressure, a serious risk for aging women.

Exercise and fitness

Exercise has been associated with reduction in hot flashes, improved sleep and better mood control (Note: Always consult your physician before starting an exercise program, particularly if you have been inactive. He or she can recommend a program that is tailored to your individual requirements.).  Regular sexual activity has led to improved vaginal lubrication and wall thickening in many women.

Menopausal women often experience weight gain, possibly associated with declining estrogen levels. Boosting your activity level will help you avoid weight gain. Regular exercise, which is especially important as you get older, benefits the heart and bones and helps you keep your weight under control.

Women who are physically inactive are more likely to suffer from coronary heart disease, obesity, high blood pressure, diabetes, and osteoporosis. Inactivity may also contribute to other problems including chronic back pain, insomnia, poor circulation, weak muscles, loss of bone mass, and depression. To help prevent some of these problems, take up walking, jogging, biking, swimming, dancing, or other aerobic activities. Weight-bearing exercises such as walking, running, and moderate weight training help to increase bone mass, which is particularly important because postmenopausal women are at higher risk for osteoporosis and bone fractures.

Regular exercise may also help improve your mood, thanks to hormones called endorphins, which are released in the brain during vigorous physical activity. The mood-elevating effect of endorphins can last for several hours and can help you fight stress.

Tips for healthy living after menopause:

  • Eat a low-fat, high-fiber diet rich in fruits, vegetables, and whole grains. Reduce consumption of saturated fats.
  • Do not smoke. Smoking is a major risk factor for heart disease .
  • Exercise regularly. Even moderate exercise is beneficial.
  • Maintain a healthy weight.
  • Manage high blood pressure and keep cholesterol and triglycerides within recommended levels to reduce your risk for heart disease.
  • Reduce stress using relaxation techniques or regular exercise.
  • Avoid excess alcohol.
  • Get plenty of rest.

Medline Plus

Medline Description: 

Conduct an off-site search for Menopause information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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