Rubin Raju, M.D.
Birthing Centers, Obstetrics & Gynecology (OB-GYN), Women's Health
Speaking of HealthOpioid-free anesthesia: The future of pain managementFebruary 26, 2018
Speaking of HealthWhy you should screen early and vaccinate against cervical cancerFebruary 12, 2018
Let’s pause to learn more about menopause.
Menopause can be a blessing for those with a history of heavy periods and pelvic pain, but it also can be a curse for others with new-onset frequent and disturbing hot flashes, drenching sweats, sleepless nights, horrible mood swings, vaginal dryness and urinary disturbances.
Menopause is defined as the cessation of the menses and is recognized to have occurred after one year of no menses. In the United States, an estimated 6,000 women reach menopause every day, and over 2 million every year. With an average life expectancy of 81, women are spending greater than a third of their lives in menopause.
Here are some questions on menopause you might be thinking of:
Am I in menopause?
If you have not had a period in the last consecutive 12 months, and there are is no obvious cause for it (such as hormonal medications, thyroid problems, pregnancy or a prolactin disorder), you might be in menopause. There is a blood test called a follicle stimulating hormone and, if elevated, it can suggest menopause or perimenopause. This blood test is not necessary for diagnosing menopause, however.
Symptoms associated with menopause include:
- Hot flashes — The most common symptom, present in up to 80 percent of women
- Vaginal dryness — Up to 47 percent of women
- Sleep disturbances — Up to 46 percent of women
- Sexual dysfunction — Apart from vaginal dryness, could include pain with intercourse and decreased desire
- Urinary symptoms — Increased frequency of urination, increased infections
- New-onset depression — 2 1/2 times more likely
These symptoms can begin before menopause (the final menstrual period) during a phase called menopause transition. Hot flashes typically peak during the first two years after your last period, lasting, on average, for three to five years. In some women, hot flashes can last for 10 years of more. Perimenopause includes the menopause transition phase and lasts up to one year after menopause.
When and why does menopause happen?
Natural menopause happens when the ovaries permanently stop releasing an egg every month. The median age of natural menopause is 51. At birth, the ovaries contain about 1 to 2 million eggs contained in follicles. A significant proportion of these eggs undergo death through a process called atresia, leaving only 400,000 eggs at the time menstruation begins. With each menstrual cycle, roughly a thousand follicles are recruited, but only one of these matures to become the dominant egg that gets released into the fallopian tubes in preparation for a potential pregnancy through a process called ovulation. Follicles produce estrogen. On average, a woman ovulates about 400 eggs a lifetime. Once the ovaries run out of follicles, the estrogen levels drop and natural menopause is said to occur. This natural drop in the estrogen, in particular, a form of estrogen called estradiol, usually is gradual and leads to the symptoms associated with menopause and perimenopause. After menopause occurs, the body continues to produce a weaker form of estrogen called estriol, which helps mitigate the symptoms.
When menopause happens before age 40, it is called premature ovarian failure. Premature ovarian failure can be caused by autoimmune disease, a history ovarian surgery, chemotherapy, radiation, Turner syndrome and Fragile X syndrome. Surgical menopause happens after the surgical removal of ovaries. Induced menopause is menopause caused surgical removal (i.e., surgical menopause) and by medications, such as Lupron, used for treatment of gynecological problems, such a pelvic pain and heavy bleeding.
What are long-term health risks associated with menopause?
The lack of estrogen affects various systems in the body:
- Bone: There is a rapid loss of bone density during the immediate years following menopause from the lack of estrogen. This can lead to weakening of bones and an increase risk of fracture from trivial injury, especially fractures of the hip, wrist or spine. A balanced diet and routine exercise can help maintain bone integrity.
- Heart and blood vessels: The estrogen produced before menopause protects against heart attacks and stroke. The decline in estrogen, along with other risks factors, such as high cholesterol, high blood pressure and a sedentary lifestyle, leads to an increased risk of heart attacks and stroke. Thus, it is important to eat healthy and maintain a normal diet.
- Bladder and vaginal tissue: With decreasing estrogen, the lining of the vaginal canal becomes thinner, dryer and less elastic. This can lead to pain during sexual intercourse and an increased susceptibility to vaginal infections. This same lack of estrogen can lead to the urethra becoming inflamed and irritated, leading to more frequent urination and urinary infections. Lubricants and vaginal estrogen can help with these symptoms.
What is hormone replacement therapy? Am I eligible for it? Is it safe?
Hormone replacement therapy involves replacement of the estrogen hormones to help alleviate distressing menopause-related symptoms. If you have a uterus, you also will require progesterone to prevent excessive thickening of the uterine lining that can lead to pre-cancer or cancer of the uterus.
Currently, hormone replacement is approved and considered safe for use in relief from moderate to severe hot flashes and night sweats, moderate to severe genitourinary symptoms (urgency, frequency, vaginal dryness), in the prevention of osteoporosis and for women who have had their ovaries surgically removed or have undergone menopause early. In these cases, it is recommended to start hormone replacement within the first 10 years of menopause. Surgical removal of ovaries leads to a more abrupt drop in estrogen levels and more drastic symptoms and often is benefited by hormone replacement.
New studies suggest potential benefits for mood, sleep and joint aches. In women with a history of stroke, heart attack, increased risk of blood clots, history of clots in the lungs of legs, breast cancer, estrogen-dependent cancers, allergy to estrogen, liver dysfunction and/or unexplained vaginal bleeding, hormone replacement therapy should be used with caution. Vaginal estrogen in the form of a cream or ring can be used in women who are more bothered by the genitourinary symptoms of vaginal dryness, urgency and increased frequency of urination. Low-dose topical formulations of testosterone, along with estrogen replacement, have been shown to improve sexual satisfaction in postmenopausal women. Testosterone therapy has not yet been approved by the U.S. Food and Drug Administration for use in women and can be associated with theoretical risks of abnormal lipid panels, clitoral enlargement, abnormal hair growth and acne.
Are there any nonhormonal medications useful in managing menopausal symptoms?
The FDA has approved Paroxetine, an antidepressant, for hot flashes associated with menopause. It can be used in women who have contraindications to traditional hormone replacement or who are not keen on using hormonal medications. Other nonhormonal medications, such as Gabapentin, Pregabalin and Clondine, have also been used for managing hot flashes.
Do natural remedies help with menopausal symptoms?
Phytoestrogens, such as soybeans, herbal remedies (St. John’s wort, black cohosh, ginseng, etc.) and vitamins, have been proposed to help with menopausal symptoms. In the U.S., none of these complementary medicines have been FDA approved for the use in menopause. Most existing studies have not shown that these have had much benefit over placebo in helping with menopausal symptoms. A Chinese herb called dang hui has shown some benefit for mild hot flashes. There also was marginal reduction in hot flashes (one less hot flash a day) with vitamin E supplementation (800 IU/day).
Are there any lifestyle modifications that can help with my hot flashes?
Yes. Exercise, avoidance of caffeine and alcohol, a well-balanced diet, dressing in layers, maintaining a low temperature in your surroundings and consuming cool drinks can help reduce the severity of your symptoms.
Are there any useful resources on menopause online?
The North American Society for Menopause provides useful information and updates on the latest research in menopause. The website also includes a menopause blog that is interesting to read with valuable information. Also, never hesitate in bringing up menopause with your primary care provider or OB-GYN provider.