Alternate Names: Change of life; Climacteric

Causes and Risks:

Menopause (also called the "change of life" or climacteric) is a natural event in a woman’s life, which normally occurs between the ages of 40 and 55. On average, menopause begins at about age 51. During menopause, ovulation (egg production) ceases, eliminating the possibility of pregnancy, and menstruation becomes less frequent and eventually stops. In some women, menstrual activity stops suddenly, but usually it tapers off, both in amount and duration of flow, and frequently the menstrual periods become more closely or more widely spaced. This irregularity may last for 2 or 3 years before menstruation finally ceases.

The symptoms of menopause are caused by changes in estrogen and progesterone levels. As the ovaries become less functional, they produce less estrogen/progesterone and the body subsequently reacts. Some women experience few if any symptoms, while others experience various symptoms ranging from mild to fairly severe. This variation is normal. A gradual decrease of estrogen allows the body to slowly adjust to the hormone change, but in some women a sudden decrease in estrogen level occurs, causing severe symptoms. This result is often seen when menopause is caused by surgical removal of the ovaries (surgical menopause).

Estrogen is responsible for the buildup of the epithelial lining of the uterine cavity. During the reproductive years this buildup occurs and is then shed (menstruation) on a monthly basis (usually). The menopausal decrease in estrogen prevents this buildup from occurring. However, androgenic hormones produced by the adrenal glands are converted to estrogen, and sometimes this will cause postmenopausal bleeding. This is usually nothing to worry about, but because postmenopausal bleeding may be an early indication of other problems, including cancer, a physician should always check any postmenopausal bleeding.

A reduction in estrogen is associated with a number of side effects that can be very annoying. Hot flashes, caused by an increase of blood flow in the blood vessels of the face, neck, chest and back, and vaginal dryness, caused by thinning of the tissues of the vaginal wall, are the two side effects most frequently experienced. The mood changes and lack of sex drive that are also sometimes associated with menopause may result partially from the hormone decrease, but may also result from having to adjust to hot flashes and vaginal dryness. In addition to these side effects there are others that may go undetected for many months or years. Decreased estrogen levels increase the risk for osteoporosis (loss of calcium from the bones, causing bone fragility), which sometime isn’t detected until a bone fracture occurs.

Prevention:

Menopause is a natural and expected part of a woman’s development and does not need to be prevented. However, there are ways (both medical and non-medical) to reduce or eliminate some of the symptoms that accompany menopause.

Symptoms:

Symptoms, when present, may include:

• hot flashes and skin flushing
• mood changes
• decreased libido (sex drive)
• irregular menstrual periods
• vaginal dryness

Signs and Tests:

A Pap smear may indicate changes in the vaginal lining (mucosa) caused by changes in estrogen levels. Blood and urine tests can be used to measure the levels of estrogen, progesterone, and plasma estradiol and estrone (part of the reproductive steroid group).

Examples of tests of this type include:

• 17-hydroxycorticosteroids
• 17-OH progesterone
• serum progesterone
• estradiol - test
• FSH

Treatment:

Natural menopause usually requires no treatment. Surgical menopause that occurs prior to natural menopause may require estrogen replacement therapy (ERT). Not all postmenopausal women may need to be treated with ERT. Each woman should discuss her individual risks and benefits with her health care provider.

Many physicians recommend estrogen replacement therapy to:

• reduce the undesirable symptoms of menopause
• help decrease vaginal drying
• prevent osteoporosis after menopause

Some side effects of estrogen replacement therapy include:

• vaginal bleeding
• breast tenderness
• nausea
• vomiting
• abdominal bloating
• uterine cramps

To reduce the risks of estrogen replacement therapy and still gain the benefits of the treatment, physicians may recommend:

• adding progesterone to the estrogen
• adding testosterone to the estrogen
• using the lowest possible dose of estrogen
• having frequent and regular physical exams, including a pelvic examination and Pap smear to detect problems as early as possible

Numerous studies have been done on the effects of ERT and the results are conflicting. ERT reduces the severity of hot flashes and vaginal dryness, and helps to prevent osteoporosis. These effects are strongly supported by previous studies and agreed upon by physicians. Some long-term studies have suggested that ERT helps to prevent heart disease, although recent studies have been conflicting. Promising new research studies have suggested that ERT may help prevent Alzheimer’s disease, although the results are too preliminary to regard seriously. Some studies show an associated increase in uterine and breast cancers, while others don’t. Some show an increase in sex drive; others show a decrease. Rather than helping depression during menopause, estrogen may actually make it worse. Incidence of liver tumors and gallbladder disease may also increase, while the risk of colon cancer may decrease. Studies showed that endometrial cancer was associated with ERT, but when progesterone was added to the therapy (hormone replacement therapy, or HRT), that association disappeared. The addition of testosterone may decrease the amount of nausea experienced with ERT, but may also decrease the positive cardiovascular effect that estrogen alone might have. There are now many ongoing research studies investigating the effects of menopause. The results of these studies may help physicians advise their patients on how to effectively manage menopause. Until more is known about ERT and HRT, women should weigh the benefits and the possible risks against the symptoms being experienced. Thorough discussion with a physician is recommended.

Prognosis:

Although menopause is a difficult period for some, most women will experience menopause without long-term problems. Many women report an increase in energy, more self-confidence, and a better attitude.

Complications:

Decreased estrogen levels are associated with an increased risk of developing osteoporosis and an increased risk of cardiovascular disease.

Call for an appointment with your health care provider if you are a woman older than age 40 who is experiencing the symptoms of menopause and would like treatment for them. Specifically:

• irregular menstrual periods
• hot flashes
• vaginal dryness

Call if you are postmenopausal and are experiencing any bleeding.

Also call if you are experiencing the symptoms of menopause and you are under age 40.