DRUG INDEX
Menopause Medical Author: Carolyn Janet Crandall, MD, FACP
Medical Editor: William C. Shiel Jr., MD, FACP, FACR
Revising Medical Editor: Dennis Lee, MD
What is menopause?
Menopause is the time in a woman's life when the function of the ovaries ceases. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones such as estrogen. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a fallopian tube to the uterus.
The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle and pregnancy. Estrogens also protect the bone. Therefore a woman can develop osteoporosis (thinning of bone) later in life when her ovaries do not produce adequate estrogen.
Menopause does not occur overnight, but rather is a gradual process of transition. This transition period (known as perimenopause) is different for each woman. Scientists are still trying to identify all the factors that initiate and influence this transition. Women in perimenopause transition typically experience abnormal vaginal bleeding such as erratic periods or abnormal bleeding patterns. Eventually a woman's periods will completely stop as she completes this transition into menopause.
The average age of onset of menopause process is 51 years old. But there is no single method to predict when a woman will enter menopause. The age at which a woman starts having menstrual periods is also not related to the age of menopause onset. As a rough "rule of thumb" women tend to undergo menopause at an age similar to that of their mothers.
When does a woman know she is in menopause?
A woman is in menopause if she has had no menstrual periods (menses) for 12 months and has no other medical reason for her menses to stop. That means she has to be evaluated by her doctor to exclude other medical causes of missed menses.
Are hormone levels or other blood tests helpful in detecting menopause?
Because hormone levels may fluctuate greatly in an individual woman, even from one day to the next, hormone levels are not a reliable indicator for diagnosing menopause. Even if levels are low one day, they may be high the next day in the same woman. There is no single blood test that reliably predicts when a woman is going through menopause, or menopausal transition. Therefore there is currently no proven role for blood testing regarding menopause except for tests to exclude medical causes of erratic menstrual periods other than menopause. The only way to diagnose menopause is to observe lack of menstrual periods for 12 months in a woman in the expected age range.
What are the symptoms of menopause?
The symptoms of menopause can be divided into early and late onset symptoms. Early symptoms include abnormal vaginal bleeding, hot flashes, and mood changes. Late symptoms include vaginal dryness and irritation, osteoporosis, and heart disease. These symptoms are discussed in detail below:
Early Onset Symptoms (Perimenopause)
Abnormal Vaginal Bleeding
Abnormal vaginal bleeding may occur during menopause. Some women have minimal problems with abnormal bleeding during perimenopause whereas others have unpredictable, excessive bleeding. In general, menstrual periods (menses) at first occur more frequently (meaning the cycle shortens in duration), and subsequently get farther and farther apart (meaning the cycle lengthens in duration) until they stop. It is also common for women in perimenopause to get a period after going for several months without one. There is also no set length of time it takes for a woman to complete her menopausal transition, as all women are different. It is important to remember that all women who develop irregular menses should be evaluated by her doctor to confirm that the irregular menses are due to menopause and not as a sign of another medical illness.
Hot Flashes
Hot flashes are common among women undergoing menopause. A hot flash is a feeling of warmth that spreads over the body. A hot flash is sometimes associated with flushing and is sometimes followed by perspiration. The cause of hot flashes is not completely understood; they may be due to fluctuations in hormone levels. There is currently no method to predict when hot flashes will begin and how long they will last in a given woman. Hot flashes can occur in menstruating women in their forty's. Hot flashes in some women can last decade(s). There is no way to predict when hot flashes will cease in a given woman, though they tend to decrease in frequency over time. Hot flashes on average last about 5 years. For more, please read the Alternative Treatments for Hot Flashes article.
Mood Symptoms
There is considerable controversy about exactly which behavior symptoms are due directly to menopause. Moodiness and irritability seem to be linked with menopause, but other symptoms are less clear. The research has been difficult for many reasons. First, mood symptoms are so common to begin with that it is sometimes difficult in a given woman to know if they are due to menopause. Also, to further complicate matters, women can suffer from significant fatigue that may aggravate moodiness. Many other symptoms that women associate with menopause, such as mood swings, could actually be linked with the sleep disturbance itself. Research is now trying to determine what factors can influence mood symptoms during menopause. Factors that have been suspected and are being analyzed for their impact on menopausal mood symptoms include education level, exercise level, familial support system, and history of depression .
Late Onset Symptoms (Postmenopause)
Vaginal Symptoms
Vaginal symptoms tend to begin some years after the cessation of menses. Postmenopausal women (the term for women who have completed their menopausal transition) may experience vaginal dryness, itching, or irritation due to the lack of estrogen. Dyspareunia, or pain with intercourse, can also result from the loss of estrogen.
Osteoporosis
Osteoporosis is the deterioration of the quality of bone that causes an increased risk of fracture. Osteoporosis depletes both the calcium and the protein from the bone, resulting in either abnormal bone quality or decreased bone density, or both. Estrogen loss over many years, such as after menopause, is the most firmly established and common cause of osteoporosis.
The osteoporosis process can operate silently for decades. Some osteoporosis fractures may escape detection until years later. Patients may not thus be aware of their osteoporosis until suffering a painful fracture. The symptoms are then related to the location of the fractures.
For an extensive review of osteoporosis, its treatment and prevention, please read the Osteoporosis article.
Heart disease
Heart disease is the number one killer of women after menopause. One out of two postmenopausal women will develop heart disease, and one out of three will die from it. Although the onset of heart disease in women lags behind the onset in men by about a decade, the occurrence of heart disease increases after menopause. Furthermore, there are actually more women than men who eventually die of heart disease. Being a female over the age of 55 is one of the many risk factors for heart disease.
What are the treatment options for menopause?
Treatments for menopause can be divided based on those symptoms that are present in a given woman at a specific time.
Treatment of Early Onset Symptoms
Abnormal Vaginal Bleeding
Prior to treatment, a doctor excludes other causes of erratic vaginal bleeding. Women in menopausal transition tend to have considerable breakthrough bleeding when given estrogen therapy. Therefore oral contraceptives are often given to women in menopause transition to regulate their periods, relieve hot flashes, as well as to provide contraception. Oral contraceptives are considered safe in healthy, non-smoking women.
Hot Flashes
The choice of medication for treating hot flashes depends on whether a woman is still having periods or not. For women experiencing unpredictable bleeding and hot flashes during menopause transition, oral contraceptives are commonly used (even up to 50 years of age) to control both erratic perimenopausal bleeding vaginal bleeding and hot flashes. For women without periods, hot flashes can be treated with either oral (by mouth) or transdermal (patch) forms of estrogen. Both oral and transdermal estrogen therapies are available either as estrogen alone, or estrogen combined with progesterone. For more, please read the Hormone Therapy article. All available prescription estrogen therapies, whether oral or transdermal, are effective in reducing hot flash frequency and severity. Generally, available treatments decrease hot flash frequency by about 80 to 90%.
Mood Symptoms
Even though moodiness, irritability, and tearfulness are commonly attributed to menopause, studies are underway to determine which of these symptoms are actually due to menopause versus other conditions such as medical depression. Even though many women experience improvement in irritability with oral hormone therapy, hormone therapy alone will not be adequate treatment for a woman suffering from true medical depression (a true depression may require antidepressant medications that are different from medications for menopause). Accordingly, women who are experiencing significant mood symptoms should be evaluated by their doctors to exclude depression and other medical illnesses.
Treatment of Late Onset Symptoms
Vaginal Symptoms
Prior to being treated for vaginal irritation, burning, and itching, women should first undergo an evaluation by a doctor, including a pelvic exam, to verify that the symptoms are due to estrogen deficiency.
There are local (meaning vaginal) and oral treatments for the symptoms of vaginal estrogen deficiency. Local treatments include the vaginal estrogen ring, vaginal estrogen cream, or vaginal estrogen tablets. Oral treatments include multiple types of estrogen either alone, or estrogen given with progesterone (read the Hormone Therapy article). Local and oral estrogen treatments are both effective in relieving vaginal symptoms and are sometimes combined for this purpose. In women for whom oral or vaginal estrogens are deemed inappropriate, such as breast cancer survivors, or women who do not wish to take oral or vaginal estrogen, there are a variety of over-the-counter vaginal lubricants. However, they are probably not as effective in relieving vaginal symptoms as replacing the estrogen deficiency with oral or local estrogen.
Osteoporosis
The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, the prevention of osteoporosis is as important as treatment. Osteoporosis treatment and prevention measures are: - Lifestyle changes including quitting cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D.
- Estrogen therapy for postmenopausal women and those with other low estrogen conditions. Women using HT for the short-term (less than 5 years) control of hot flashes will probably derive protection against osteoporosis during the time they are using HT. Other safe and effective non-hormonal prescription medications can be used to address osteoporosis in women who stop taking HT when hot flashes cease, and in women not taking HT.
- Medications that stop bone loss and increase bone strength, such as alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), and calcitonin (Calcimar).
For an extensive review of osteoporosis, its treatment and prevention, please read the Osteoporosis article, and for more on supplements, read the Vitamins and Calcium Supplements article.
Heart Disease
Although it was previously felt that oral estrogen decreases the risk of heart disease in postmenopausal women, research with a large enough number of women in well-designed research (specifically, the Women's Health Initiative ) has only just become available. The research suggests that estrogen does not protect against heart disease in women who do not yet have heart disease, nor is it protective in women who are already known to have heart disease. In fact, women with heart disease who begin HT may be at increased risk of a heart attack in the first year of starting oral HT. In the near future, we will have more research studies regarding this issue so we can know if the Women's Health Initiative results can be extended to other HT brands and preparations, and whether the results apply to patches as well as oral HT. In summary, oral HT is not appropriate for heart disease protection, but is clearly appropriate for women with hot flashes who intend short-term (less than 5 years) use and have no other contraindications. - Menopause is the time in a woman's life when the function of the ovaries ceases. The ovary, or female gonad, is one of a pair of reproductive glands in women.
- The process of menopause does not occur overnight, but rather is a gradual process. This so-called perimenopausal transition period is a different experience for each woman.
- The average age of menopause onset is 51 years old. There is no reliable lab test to predict when a woman will experience menopause.
- The age at which a woman starts having menstrual periods is not related to the age of menopause onset.
- A women is in menopause when she has had no menstrual periods (menses) for 12 months and has no other medical reason for her menses to stop.
- Symptoms of menopause can be divided into early and late onset symptoms. Early symptoms include abnormal vaginal bleeding, hot flashes, and mood changes. Late symptoms include vaginal dryness and irritation, osteoporosis, and heart disease.
- Treatments for menopause are directed toward alleviating the symptoms present in the particular woman affected.
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