Menopause
Perimenopause; Postmenopause
Menopause is the time in a woman's life when her periods (menstruation) stop. Most often, it is a natural, normal body change that occurs between ages 45 to 55. After menopause, a woman can no longer become pregnant.
Menopause is the transition in a woman's life when the ovaries stop releasing eggs, menstrual activity decreases and eventually ceases, and the body decreases the production of the female hormones estrogen and progesterone.
A mammogram is an x-ray picture of the breasts. It is used to find tumors and to help tell the difference between noncancerous (benign) and cancerous (malignant) disease. One breast at a time is rested on a flat surface that contains the x-ray plate. A device called a compressor is pressed firmly against the breast to help flatten out the breast tissue. Each breast is compressed horizontally, then obliquely and an x-ray is taken of each position.
Vaginal atrophy is caused by a drop in estrogen levels. This most often occurs during menopause. In normal conditions, the vaginal wall is elastic and thick, and its lining is ridged and lubricated. In vaginal atrophy, the vagina wall shrinks, and its lining becomes pale, smooth, and dry.
Causes
During menopause, a woman's ovaries stop releasing eggs. Her body produces less of the female hormones estrogen and progesterone. Lower levels of these hormones cause menopause symptoms.
Periods occur less often and eventually stop. Sometimes this happens suddenly. But most of the time, periods slowly stop over time.
Menopause is complete when you have not had a period for 1 year. This is called postmenopause. Surgical menopause takes place when surgical treatments cause a drop in estrogen. This can happen if both of your ovaries are removed.
Menopause can also sometimes be caused by drugs used for chemotherapy or hormone therapy (HT) for breast cancer.
You're a woman nearing middle age. It's that time in your life when your periods are starting to stop and your body is going through changes. You may be starting to have hot flashes that you've heard about before. Could menopause be around the corner? So, what is menopause? Menopause typically happens to women somewhere around the ages of 45 to 55. During menopause, your ovaries stop making eggs and produce less estrogen and progesterone, hormones that play a vital role in pregnancy and how your body uses calcium and maintains healthy cholesterol levels, among other things. Changes in these hormones cause menopause symptoms. You will often begin having fewer periods, and eventually they stop. Menopause is complete when you have not had a period for over a year. Women who are post-menopausal can no longer get pregnant without a donor egg. Symptoms can vary from woman to woman. And these symptoms may last 5 or more years. Also, some women have worse symptoms than others. The first thing you may notice is that your periods start to change. They might occur more often or less often. Some women get their period every 3 weeks during menopause. These changes may last several years before periods completely stop. Other common symptoms include your heart pounding or racing, hot flashes, night sweats, skin flushing, and problems sleeping. You may have a decreased interest in sex, develop forgetfulness, have headaches, and suffer from mood swings, and have vaginal dryness and painful sexual intercourse. Treatment for menopause depends on many things, including how bad your symptoms are, your overall health, and your preference. It may include lifestyle changes or hormone therapy. Hormone therapy may help if you have severe hot flashes, night sweats, mood problems, or vaginal dryness. Hormone therapy is treatment with estrogen and, sometimes, progesterone. Talk to your doctor about the benefits and risks of hormone therapy. Hormone therapy may increase your risk of developing breast cancer, heart attacks, strokes, and blood clots. Topical hormone therapy has some of the benefits and fewer of the risks. Your doctor can tell you about other options besides taking hormones, including antidepressants, a blood pressure medicine called clonidine, and Gabapentin, a seizure drug that can help reduce hot flashes. Lifestyle changes may help in reducing your menopause symptoms, though it's not been proven. You might consider trying to avoid caffeine, alcohol, and certain spicy foods. Or to try eating soy foods and other legumes, because they contain phytoestrogens. You'll want to remember to get plenty of calcium and vitamin D in your food or supplements, and plenty of exercise especially during this time. Consider Kegel exercises every day to strengthen the muscles of the vagina and pelvis. Practice slow, deep breathing if you feel a hot flash coming on. Yoga, tai chi, or meditation may also helpful. After menopause, you may be at risk for bone loss, higher cholesterol, and heart disease, so make sure you work with your doctor to manage or even prevent these problems.
Symptoms
Symptoms vary from woman to woman. They may last 5 or more years. Symptoms may be worse for some women than others. Symptoms of surgical menopause can be more severe and start more suddenly.
The first thing you may notice is that periods start to change. They might occur more often or less often. Some women might get their period every 3 weeks before starting to skip periods You may have irregular periods for 1 to 3 years before they stop completely.
Common symptoms of menopause include:
- Menstrual periods that occur less often and eventually stop
- Heart pounding or racing
- Hot flashes, usually worst during the first 1 to 2 years
- Night sweats
- Skin flushing
- Sleeping problems (insomnia)
Other symptoms of menopause may include:
- Decreased interest in sex or changes in sexual response
- Forgetfulness (in some women)
- Headaches
- Mood swings, including irritability, depression, and anxiety
- Urine leakage
- Vaginal dryness and painful sexual intercourse
- Vaginal infections
- Joint aches and pains
- Irregular heartbeat (palpitations)
Exams and Tests
Blood and urine tests can be used to look for changes in hormone levels. Test results can help your health care provider determine if you are close to menopause or if you have already gone through menopause. Your provider may need to repeat testing your hormone levels several times to confirm your menopausal status if you have not completely stopped menstruating.
Tests that may be done include:
Your provider will perform a pelvic exam. Decreased estrogen can cause changes in the lining of the vagina.
Bone loss increases during the first few years after your last period. Your provider may order a bone density test to look for bone loss related to osteoporosis. This bone density test is recommended for all women at age 65 if they have not already had it. This test may be recommended sooner if you are at higher risk for osteoporosis because of your family history or medicines that you take.
If you've ever watched an apartment or office building under construction, you've seen the metal scaffolding that keeps the building standing upright. Inside your body, bones are the scaffolding that keep you standing upright. As you get older, these supports can weaken. And if they get too weak, you could wind up with a fracture. Let's talk about the bone-thinning condition called osteoporosis. Your internal scaffolding was built when you were young. Calcium and other minerals helped strengthen your bones, provided that you got enough of them from your diet. As you get older, those minerals can start to leech out of your bones, leaving them brittle, fragile, and easily breakable, a condition known as osteoporosis. Women over 50 are especially at risk for osteoporosis because during menopause they lose estrogen, which helps to keep bones strong. The tricky part about osteoporosis is that it's hard to tell you have it. You may not have any symptoms until you've already fractured a bone. Getting a bone density scan, which measures bone thickness, is one way to find out whether you have osteoporosis so you can start treatment right away if you need it. To keep your bones strong, try to get at least 1,200 milligrams of calcium daily, paired with 1,000 international units of vitamin D, which helps your body absorb calcium. You can eat foods that are high in these nutrients, like frozen yogurt, salmon, and low-fat milk, or, if you're not a big fan of fish or dairy, you can take supplements. Weight bearing exercise is also your ally when it comes to strengthening bones. A combination of weight bearing exercises like walking or playing tennis, plus strength training and balance exercises will reduce your risk of getting a fracture if you fall. You will want to get at least thirty minutes of exercise three times a week to see the benefits. And, stop smoking. Cigarette smoke both accelerates bone loss and blocks treatments from being as affective. If you've been diagnosed with osteoporosis, your doctor may recommend drugs called bisphosphonates to prevent further bone damage. Other medicines, including calcitonin, parathyroid hormone, and raloxifene are also treatment options. Don't let bone loss get so far along that you could have a disabling fracture from a minor fall. Start strengthening your bones with diet and exercise while you're still young. As you get older, talk to your doctor about bone density scans, and ask whether you need to take medicine if you're at risk for, or are starting to show signs of osteoporosis. And if your bones aren't as strong as they used to be, avoid falls by wearing shoes that fit well, and clearing clutter on the floor before it can trip you up, and bring you down.
Treatment
Treatment may include lifestyle changes, HT, or both. Treatment depends on many factors such as:
- How bad your symptoms are
- Your overall health
- Your preferences
HORMONE THERAPY
HT may help if you have severe hot flashes, night sweats, mood issues, or vaginal dryness. HT is treatment with estrogen and, sometimes, progesterone.
Talk to your provider about the benefits and risks of HT. Your provider should be aware of your entire medical and family history before prescribing HT.
Several major studies have questioned the health benefits and risks of HT, including the risk of developing breast cancer, heart attacks, strokes, and blood clots. However, using HT for the 10 years after developing menopause is associated with a lower chance of death.
Current guidelines support the use of HT for the treatment of hot flashes. Specific recommendations are:
- HT may be started in women who have recently entered menopause.
- HT should not be used in women who started menopause many years ago, except for vaginal estrogen treatments.
- HT should not be used for longer than necessary. Some women may require prolonged estrogen use due to troublesome hot flashes. This is safe in healthy women.
- Women taking HT should have a low risk for stroke, heart disease, blood clots, or breast cancer.
To reduce the risks of estrogen therapy, your provider may recommend:
- A lower dose of estrogen or a different estrogen preparation (for instance, a vaginal cream or skin patch rather than a pill).
- Using patches appears to be safer than oral estrogen, as it avoids the increased risk for blood clots seen with oral estrogen use.
- Frequent and regular physical exams, including breast exams and mammograms
Women who still have a uterus (that is, have not had surgery to remove it for any reason) should take estrogen combined with progesterone to prevent cancer of the lining of the uterus (endometrial cancer).
ALTERNATIVES TO HORMONE THERAPY
There are other medicines that can help with mood swings, hot flashes, and other symptoms. These include:
- Antidepressants, including paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), and fluoxetine (Prozac)
- A blood pressure medicine called clonidine
- Gabapentin, a seizure drug that also helps reduce hot flashes
DIET AND LIFESTYLE CHANGES
Lifestyle steps you can take to reduce menopause symptoms include:
Diet changes:
- Avoid caffeine, alcohol, and spicy foods.
- Eat soy containing foods. Soy contains estrogen.
- Get plenty of calcium and vitamin D in food or supplements.
Exercise and relaxation techniques:
- Get plenty of exercise.
- Do Kegel exercises every day. They strengthen the muscles of your vagina and pelvis.
- Practice slow, deep breathing whenever a hot flash begins. Try taking 6 breaths a minute.
- Try yoga, tai chi, or meditation.
Other tips:
- Dress lightly and in layers.
- Keep having sex.
- Use water-based lubricants or a vaginal moisturizer during sex if needed due to vaginal dryness.
- See an acupuncture specialist.
Possible Complications
Some women have vaginal bleeding after menopause. This is often nothing to worry about. However, you should tell your provider if this happens, especially if it occurs more than a year after menopause. It may be an early sign of problems such as cancer. Your provider may do a biopsy of the uterine lining, a vaginal ultrasound, or both.
Decreased estrogen level has been linked to some long-term effects, including:
- Bone loss and osteoporosis in some women
- Changes in cholesterol levels and greater risk for heart disease
When to Contact a Medical Professional
Contact your provider if:
- You are spotting blood between periods
- You have had 12 consecutive months with no period and vaginal bleeding or spotting begins again suddenly (even a small amount of bleeding)
Prevention
Menopause is a natural part of a woman's life. It does not need to be prevented. You can reduce your risk for long-term problems such as osteoporosis and heart disease by taking the following steps:
- Control your blood pressure, cholesterol, and other risk factors for heart disease.
- Do not smoke. Cigarette use can cause early menopause.
- Get regular exercise. Resistance exercises help strengthen your bones and improve your balance.
- Talk to your provider about medicines that can help stop further bone weakening if you show early signs of bone loss or have a strong family history of osteoporosis.
- Take calcium and vitamin D.
References
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 141: management of menopausal symptoms. Obstet Gynecol. 2014;123(1):202-216. PMID: 24463691
Lobo RA. Menopause and care of the mature woman: endocrinology, consequences of estrogen deficiency, effects of hormone therapy, and other treatment options. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 14.
North American Menopause Society Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. PMID: 35797481
Rushing J, Skaznik-Wikiel ME, Santoro N. Menopause and perimenopause. In: Robertson RP ed. DeGroot's Endocrinology. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 122.
US Preventive Services Task Force, Grossman DC, Curry SJ, et al, eds. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(15):1592-1599. PMID: 29677309
Van den Beld AW, Lamberts SWJ. Endocrinology and aging. In: Melmed S, Auchus, RJ, Goldfine AB, Koenig RJ, Rosen CJ, eds. Williams Textbook of Endocrinology. 14th ed. Philadelphia, PA: Elsevier; 2020:chap 28.
Version Info
Last reviewed on: 7/12/2023
Reviewed by: John D. Jacobson, MD, Professor Emeritus, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
