Menopause is the permanent end of menstrual periods and thus of fertility.

• For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular, and symptoms (such as hot flashes) may occur.
• After menopause, bone density decreases.
• Menopause is usually obvious, but blood tests may be done to confirm it.
• Certain measures, including drugs, can lessen symptoms.

During the reproductive years, menstrual periods usually occur in approximately monthly cycles, with an egg released from the ovary (ovulation) about 2 weeks after the first day of a period. For this cycle to occur regularly, the ovaries must produce enough estrogen and progesterone (see Biology of the Female Reproductive System: Menstrual Cycle). Menopause occurs because, as women age, the ovaries stop producing estrogen and progesterone. During the years before menopause, production of estrogen and progesterone begins to decrease, and menstrual periods and ovulation occur less often. Eventually, menstrual periods and ovulation end permanently, and pregnancy is no longer possible. A woman's last period can be identified only later, after she has had no periods for at least 1 year. (Women who do not wish to become pregnant should use birth control until 1 year has passed since their last menstrual period.)

A distinctive transitional period called perimenopause occurs during the years before and the 1 year after the last menstrual period. How many years of perimenopause precede the last menstrual period varies greatly. During perimenopause, estrogen and progesterone levels fluctuate widely. These fluctuations are thought to cause the menopausal symptoms experienced by many women in their 40s.

In the United States, the average age for menopause is about 51. However, menopause may occur normally in women as young as 40. Menopause is considered premature when it occurs before age 40 (see Menopause: Premature Menopause). Premature menopause is also called premature ovarian failure.

Did You Know... Symptoms of menopause can start years before menstrual periods end. The average age for menopause is about 51. Many symptoms thought to be related to menopause—mood changes, depression, irritability, anxiety, nervousness, insomnia, loss of concentration, headache, and fatigue—probably are not.

Symptoms

Perimenopause: During perimenopause, symptoms may be nonexistent, mild, moderate, or severe. Symptoms may last from 6 months to about 10 years.

Irregular menstrual periods may be the first symptom of perimenopause. Typically, periods occur more often, then less often, but any pattern is possible. Periods may be shorter or longer, lighter or heavier. They may not occur for months, then become regular again. In some women, periods occur regularly until menopause.

Hot flashes affect about three fourths of women and usually begin before periods stop. Most women have hot flashes for more than 1 year, and up to one half of women have them for more than 5 years. What causes hot flashes in unknown. They may be related to fluctuations in hormone levels and may be triggered by cigarette smoking, hot beverages, certain foods, alcohol, and possibly caffeine. During a hot flash, blood vessels near the skin surface widen (dilate). As a result, blood flow increases, causing the skin, especially on the head and neck, to become red and warm (flushed). Women feel warm or hot, and perspiration may be profuse. Hot flashes are sometimes called hot flushes because of this warming effect. A hot flash lasts from 30 seconds to 5 minutes and may be followed by chills. Night sweats are hot flashes that occur at night.

Other symptoms that may occur around the time of menopause include mood changes, depression, irritability, anxiety, nervousness, sleep disturbances (including insomnia), loss of concentration, headache, and fatigue. Many women experience these symptoms during perimenopause and assume that menopause is the cause. However, evidence supporting a connection between menopause and these symptoms is lacking. These symptoms are not directly related to the decreases in estrogen levels that occur with menopause. And many other factors (such as aging itself or a disorder) could explain the symptoms.

Night sweats may disturb sleep, contributing to fatigue, irritability, loss of concentration, and mood changes. In such cases, these symptoms may be indirectly (through night sweats) related to menopause. However, during menopause, sleep disturbances are common even among women who do not have hot flashes. Midlife stresses (such as struggles with adolescents, concerns about aging, caring for aging parents, and changes in marital relationship) may contribute to sleep disturbances. Thus, the relationship between fatigue, irritability, loss of concentration, and mood changes seems less clear.

After Menopause: Many of the symptoms that occur during perimenopause, although disturbing, become less frequent and less intense after menopause. However, the decrease in estrogen levels causes changes that can continue to negatively affect health (for example, increasing the risk of osteoporosis). These changes may worsen, unless measures to prevent them are taken.

• Reproductive tract: The lining of the vagina becomes thinner, drier, and less elastic (a condition called vaginal atrophy). These changes may make sexual intercourse painful and may increase the risk of inflammation (vaginitis). Other genital organs—the labia minora, clitoris, uterus, and ovaries—decrease in size. Sex drive (libido) commonly decreases with aging. The effect of menopause on the ability to have an orgasm varies from woman to woman. In many women, the ability is unaffected. It improves in some women but is lost in others.
• Urinary tract: The lining of the urethra becomes thinner, and the urethra becomes shorter. Because of these changes, microorganisms can enter the body more easily, and some women develop urinary tract infections more easily. A woman with a urinary tract infection may feel a burning sensation when she urinates. The muscles that control the flow of urine out of the bladder become weaker. Many postmenopausal women have stress incontinence, in which small amounts of urine escape from the bladder during laughing, coughing, or other activities that put pressure on the bladder (see Urinary Incontinence: Stress Incontinence). Some women develop urge incontinence, which is an abrupt, intense urge to urinate that cannot be suppressed. However, how much menopause contributes to incontinence is unclear. Many other factors, such as the effects of childbirth and the use of hormone therapy, contribute to incontinence.
• Skin: As estrogen decreases, the amount of collagen (a protein that makes skin strong) and elastin (a protein that makes skin elastic) also decrease. Thus, the skin may become thinner, dryer, less elastic, and more vulnerable to injury.
• Bone: The decrease in estrogen often leads to a decrease in bone density and sometimes to osteoporosis (see Osteoporosis) because estrogen helps maintain bone. Bone becomes less dense and weaker, making fractures more likely. During the first 2 years after menopause, bone density decreases by about 3 to 5% each year. After that, it decreases by about 1 to 2% each year.
• Fat (lipid) levels: After menopause, levels of lipids, particularly low-density lipoprotein (LDL—the bad) cholesterol, increase in women. Levels of high-density lipoprotein (HDL—the good) cholesterol decrease. These changes in lipid levels may partly explain why atherosclerosis and thus coronary artery disease become more common among women after menopause. However, whether these changes result from aging or from the decrease in estrogen levels after menopause is unclear. Until menopause, the high estrogen levels may protect against coronary artery disease.

Diagnosis

In about three fourths of women, menopause is obvious. Thus, laboratory tests are usually not needed. If menopause begins several years before age 50 or if symptoms are not clear-cut, tests may be done to check for disorders that can disrupt menstrual periods. Rarely, if menopause or perimenopause needs to be confirmed, blood tests are done to measure levels of estrogen and follicle-stimulating hormone (which stimulates the ovaries to produce estrogen and progesterone).

Before any treatment is started, doctors ask women about their medical and family history and perform a physical examination, including breast and pelvic examinations and measurement of blood pressure. Mammography is also done. Blood tests may be done, and bone density may be measured, particularly in women with risk factors for osteoporosis (see Osteoporosis). The information obtained helps doctors determine the woman's risk of developing certain disorders after menopause.

Treatment

Understanding what happens during perimenopause can help women cope with the symptoms. Talking with other women who have gone through menopause or with their doctor may also help.

General Measures: Noting which foods and beverages (such as coffee, tea, spicy foods) seem to trigger hot flashes and not consuming them may help prevent this symptom. Not smoking and avoiding stress may help relieve hot flashes and improve sleep.

Wearing layers of clothing, which can be taken off when a woman feels hot and put on when she feels cold, can help her cope with hot flashes. Wearing clothing that breathes, such as cotton underwear and sleepwear, may enhance comfort.

Exercising regularly (particularly aerobic exercise) may help prevent or relieve hot flashes and improve sleep. Relaxation techniques, meditation, massage, and yoga may help prevent or relieve hot flashes and relieve depression, irritability, and fatigue. A technique called paced respiration, a type of slow, deep breathing exercise, may also help hot flashes. Weight-bearing exercise (such as walking, jogging, and weight lifting) and taking calcium and vitamin D supplements slow the loss of bone density. Regular exercise, particularly when combined with a diet lower in calories, fat, and cholesterol, also helps women lose weight, lower cholesterol levels, and reduce the risk of atherosclerosis, including coronary artery disease.

If vaginal dryness makes sexual intercourse painful, an over-the-counter vaginal lubricant may help. Staying sexually active also helps by stimulating blood flow to the vagina and surrounding tissues and by keeping tissues flexible. Kegel exercises may help with bladder control (see Sexual Dysfunction: Kegel Exercises: Squeeze and Relax). For these exercises, a woman tightens the pelvic muscles as if stopping urine flow.

Hormone Therapy: Hormone therapy can relieve moderate to severe symptoms such as hot flashes, night sweats, and vaginal dryness. However, hormone therapy may increase the risk of developing certain serious disorders. Whether to take hormone therapy is a difficult decision that must be made by a woman and her doctor based on the woman's individual situation. For many women, risks outweigh benefits, so this therapy is not recommended. However, for some women, depending on their medical conditions and risk factors, benefits may outweigh risks.

Hormone therapy can include estrogen and progestins, such as medroxyprogesterone acetate. The hormones used in hormone therapy are synthetic hormones, made in laboratories. They may or may not be identical to those made in the body, but the way they act in the body is very similar. Estradiol is the form of estrogen usually used. Progestins resemble progesterone, which is made by the body.

Women who have a uterus are usually given estrogen plus a progestin (combination hormone therapy) because taking estrogen alone increases the risk of cancer of the uterine lining (endometrial cancer). The progestin helps protect against this cancer. Women who no longer have a uterus may take estrogen alone.The benefits and risks depend on whether the hormones are taken alone or together.

Estrogen has several benefits:

• Hot flashes and other symptoms: Estrogen is the most effective treatment for hot flashes. It also can prevent vaginal and urinary tract tissues from drying and thinning. Thus, it can reduce pain with sexual intercourse. However, topical therapy (for example, estrogen cream) would be recommended in this circumstance.
• Osteoporosis: Estrogen, with or without a progestin, helps prevent or slow the progression of osteoporosis. However, taking hormone therapy for the sole purpose of preventing osteoporosis is no longer recommended. Most women can take a bisphosphonate or raloxifene instead. These drugs increase bone mass by reducing the amount of bone the body breaks down as it reforms bones (the amount broken down increases with aging).

Estrogen taken alone increases the risk of the following:

• Endometrial cancer: The risk increases from about 1 to about 4 in 1,000 women each year. The risk increases with higher doses and longer use of estrogen. Taking a progestin with estrogen almost eliminates the risk of endometrial cancer, reducing the risk below that for women who do not take hormone therapy. A woman whose uterus has been removed has no risk of developing this cancer and thus does not need to take a progestin. Usually, estrogen, with or without a progestin, is not prescribed for women who have had advanced endometrial cancer or who have vaginal bleeding (which can be a symptom of endometrial cancer) unless endometrial cancer has been ruled out. A progestin without estrogen may be prescribed for certain women who have endometrial cancer or breast cancer.
• Stroke
• Blood clots in the legs and lungs
• Blood clots in the eye
• Gallstones
• Urinary incontinence: Estrogen increases this risk and worsens preexisting incontinence.

Combination hormone therapy reduces the risk of the following:

• Osteoporosis
• Colorectal cancer

Combination hormone therapy increases the risk of the following:

• Breast cancer: The breast cancers that develop in women taking combination hormone therapy are larger and more likely to spread. Also, mammograms can be more difficult to interpret because hormone therapy increases breast density, making tumors harder to differentiate from breast tissue.
• Coronary artery disease: The risk of coronary artery disease almost doubles during the first year of therapy, even among women being treated with aspirin and statins.
• Stroke
• Blood clots in the legs or lungs
• Dementia
• Urinary incontinence: Combination therapy increases this risk and worsens preexisting incontinence.
• Ovarian cancer (possible increased risk)

Progestins have some benefits:

• Endometrial cancer: Taking a progestin with estrogen almost eliminates the risk of endometrial cancer in women who have a uterus.

Progestins may increase the risk of the following:

• Atherosclerosis and thus coronary artery disease: Progestins may increase this risk because they increase the LDL (the bad) cholesterol level and decrease the HDL (the good) cholesterol level. However, micronized progesterone appears to have fewer side effects and may not adversely affect cholesterol levels.

Estrogen taken alone does not increase or decrease the risk of coronary artery disease. Dementia risk may be increased with estrogen-alone therapy. The effect of estrogen alone or a progestin alone on the risk of breast cancer and blood clots in the lungs is also not clear. Estrogen and progestins, especially at high doses, may have side effects, including nausea, breast tenderness, headache, fluid retention, and mood changes.

Estrogen and a progestin can be taken in several ways:

• Tablets taken by mouth
• Estrogen skin patches (transdermal estrogen)
• Combination estrogen-progestin patches
• Estrogen creams, lotions, or gels
• Estrogen tablets inserted in the vagina
• Injections

As tablets taken by mouth, estrogen and a progestin may be taken as two tablets or as a combination tablet. Commonly, estrogen and a progestin are taken every day. This schedule typically causes irregular vaginal bleeding for the first year or more of therapy. Alternatively, estrogen may be taken daily, with a progestin taken for 12 to 14 days each month. With this schedule, most women have monthly vaginal bleeding.

Using an estrogen cream is as effective as taking estrogen by mouth for preventing or relieving drying or thinning of the vagina. The cream may be applied to the vagina, or an estrogen tablet or a ring containing estrogen (similar to a diaphragm) may be inserted into the vagina. Such treatment helps prevent intercourse from being painful. Some of the estrogen cream is absorbed into the bloodstream, particularly as the vaginal lining becomes healthier. The amount of estrogen absorbed into the bloodstream from the vagina depends on the type and dose of estrogen used. The amount of estrogen absorbed with creams is much higher than with vaginal tablets or rings. Theoretically, estrogen absorbed through the vagina can increase the risk of endometrial cancer. Therefore, if women who have a uterus use estrogen creams, they should also take a progestin. Occasionally, women who have breast cancer or who have risk factors for it are offered a vaginal tablet or ring, but only after they have been evaluated by an oncologist.

Doctors prescribe the lowest hormone dose that controls symptoms. If women have symptoms while taking a high dose, the hormone level in the blood is measured to determine whether the hormone is being absorbed.

Selective Estrogen Receptor Modulators (SERMs): These drugs function like estrogen in some parts of the body. The only SERM currently used to prevent bone loss related to menopause is raloxifene. Like estrogen, raloxifene helps prevent bone density from decreasing in postmenopausal women and increases the risk of developing blood clots (from 1 to 10 in 10,000 women). Raloxifene also prevents fractures of the bones in the spine (vertebrae). However, raloxifene may have effects opposite to those of estrogen in other parts of the body. It does not relieve menopausal symptoms. Hot flashes worsen mildly and temporarily in about 1 in 10 women. Also, raloxifene does not appear to increase the risk of endometrial cancer. It inhibits the growth of breast tissue and reduces the risk of breast cancer.

Other Drugs: Several other types of drugs can help relieve some of the symptoms associated with menopause. Clonidine, which is used to treat high blood pressure, can reduce the intensity of hot flashes. It can be applied in a skin patch. Gabapentin, an antiseizure drug, may lessen hot flash frequency. An antidepressant, such as fluoxetine, paroxetine, sertraline, or venlafaxine, may relieve hot flashes. Antidepressants may also help relieve depression, anxiety, and irritability (see Depression and Mania: Drug Therapy). A sleep aid can often relieve insomnia (see Sleep Disorders: Treatment).

Lipid-lowering drugs (see Lipid-Lowering Drugs) may be taken to lower cholesterol levels, reducing the risk of atherosclerosis and coronary artery disease. Women with risk factors for osteoporosis can take bisphosphonates to reduce that risk (see Osteoporosis: Drugs). These drugs increase bone density and reduce the risk of some fractures.

Testosterone, the main male sex hormone, taken with estrogen is sometimes used to relieve some symptoms of menopause. This treatment is controversial because whether taking estrogen with testosterone is more effective than taking estrogen alone is unclear. Also, taking testosterone has risks and side effects, such as an increased risk of liver disorders and masculinizing effects.

Some Drugs Used to Treat Symptoms and Effects of Menopause Drug Advantages Disadvantages Female hormones Estrogen Relieves hot flashes, night sweats, and vaginal dryness Helps prevent osteoporosis In women with a uterus, increases the risk of endometrial cancer if not taken with a progestin Increases the risk of stroke, urinary incontinence, and gallstones Has less clear effects on the risk of breast cancer, ovarian cancer, blood clots in the lungs, and colorectal cancer May increase the risk of blood clots in the eye, which can impair vision Possibly increases the risk of dementia A progestin, such as medroxyprogesterone acetate Reduces the risk of endometrial cancer associated with taking estrogen alone Does not relieve vaginal dryness May have negative effects on cholesterol levels and thus may increase the risk of coronary artery disease Has less clear effects on the risk of breast cancer, blood clots in the legs or lungs, dementia, and stroke Increases the risk of blood clots in the legs Combination therapy (estrogen plus a progestin) Helps relieve hot flashes Reduces the risk of osteoporosis and colorectal cancer Increases the risk of coronary artery disease, stroke, breast cancer, blood clots in the legs or lungs, urinary incontinence, and dementia May increase the risk of ovarian cancer Selective estrogen receptor modulators (SERMs) Raloxifene Prevents and treats osteoporosis Does not appear to increase the risk of endometrial cancer In postmenopausal women with a high risk of breast cancer, reduces that risk Increases the risk of blood clots in the legs or lungs May mildly worsen hot flashes May cause leg cramps Bisphosphonates Alendronate (taken by mouth) Ibandronate (taken by mouth or given intravenously) Risedronate (taken by mouth) Zoledronic acid (given intravenously) Prevent and treat osteoporosis If taken by mouth, must be taken with 6 to 8 ounces of water after awakening, followed by 30 to 60 minutes without consuming any food, liquid, or drug and without lying down If taken incorrectly, can irritate the lining of the esophagus Antidepressants Selective serotonin reuptake inhibitors (such as fluoxetine, sertraline, and sustained-release paroxetine) Serotonin-norepinephrine reuptake inhibitors (such as venlafaxine) Relieve depression, anxiety, irritability, and insomnia May relieve hot flashes Depending on the drug, can have side effects, such as sexual dysfunction, nausea, diarrhea, weight loss (in the short term), weight gain (in the long term), sedation, dry mouth, confusion, and increased or decreased blood pressure Lipid-lowering drugs Statins (such as atorvastatin, lovastatin, pravastatin, and simvastatin) Bile acid binders (such as cholestyramine and colestipol) Fibric acid derivatives (such as fenofibrate and gemfibrozil) Niacin Prevent atherosclerosis (including coronary artery disease) Depending on the drug, can have side effects, such as constipation, loose stools, abdominal pain, nausea, bloating, rash, muscle inflammation, increased levels of liver enzymes, and fatigue Antihypertensive drug (only one type) Clonidine May lessen hot flashes Can have side effects, such as drowsiness, dry mouth, fatigue, an abnormally slow heart rate, rebound high blood pressure when the drug is stopped, and sexual dysfunction Antiseizure drug (only one type) Gabapentin May lessen hot flash frequency Can have side effects, such as drowsiness, dizziness, rash, and leg swelling Male hormone Testosterone, taken with estrogen Lessens hot flashes Decreases the HDL (the good) cholesterol level In high doses, may have some masculinizing effects, such as facial hair growth, acne, and weight gain. May cause liver disorders Has not been studied extensively, so risks are unknown HDL = high-density cholesterol.

Alternative Medicine: Some women take medicinal herbs and other supplements to relieve hot flashes, irritability, mood changes, and memory loss. Examples are black cohosh, DHEA (dehydroepiandrosterone), dong quai, evening primrose, ginseng, and St. John's wort. However, such remedies are not regulated as drugs are. That is, their manufacturers are not required to show that they are safe or effective, and what their ingredients are and how much of each ingredient a product contains are not standardized (see Medicinal Herbs and Nutraceuticals: Safety and Effectiveness). Also, none of these treatments has been shown to be effective, and some, such as black cohosh, vitamin E, and increased dietary soy protein, have been shown to be ineffective. Some (for example, kava) are harmful. Furthermore, some supplements can interact with other drugs and can worsen some disorders. Women who are considering taking such supplements are advised to discuss them with a doctor.

Last full review/revision June 2007 by Susan L. Hendrix, DO