Menopause

What is Menopause?

Menopause is a natural process where a woman’s menstrual cycle permanently stops due to the decrease in the hormone estrogen. The term “menopause” comes from Greek words meaning “pause” and “month”. When a woman has not had a period for twelve months, this signifies the end of her fertility or ability to bear children. Generally, this happens between the ages of 45 and 56 with the average age being 51 years in the United States.

Most women experience physical changes, like hot flashes, during menopause, but it can also have an effect on various other areas such as the urinary and mental health, and heart health. This article discusses different treatment options, both hormonal and non-hormonal, as well as potential complications that can arise during menopause.

As the average lifespan of women increases, they spend about 40% of their lives, or over 30 years for most women, in the postmenopausal stage. This makes understanding and managing menopause important for their long-term health.

What Causes Menopause?

As women age, the number of their ovarian follicles, which are small sacs in the ovaries that produce eggs, naturally decrease. This happens due to atresia, a process where the follicles naturally degenerate, and ovulation, when an egg is released from the ovary.

These changes also impact the granulosa cells in the ovaries, which are responsible for producing the hormones estradiol and inhibin B. As these cells decline, the levels of these hormones also decrease. Antimullerian hormone (AMH), another hormone produced by granulosa cells, lowers too.

With less estrogen and inhibin hormones to manage them, the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), hormones that control the menstrual cycle, increase. The decrease in estrogen also disrupts the communication between the hypothalamus, the pituitary gland, and the ovaries, which governs the reproductive system. As a result, the endometrium, or lining of the uterus, doesn’t develop properly, leading to irregular periods until periods eventually stop altogether.

In the years leading up to menopause, often known as perimenopause, there are several changes in the menstrual cycle. First, the phase of the menstrual cycle when the follicle grows and prepares to release an egg gets shorter, leading to more frequent periods. Then, the length of the whole menstrual cycle typically increases. Sometimes, cycles happen without an egg being released, and this can cause abnormal bleeding. Eventually, periods stop entirely.

Another significant change that happens during this time is the balance between the hormones testosterone and estrogen. Testosterone levels stay relatively the same during the early stages of menopause, but with the decrease in estrogen, the balance between the two hormones shifts. This can lead to symptoms associated with an excess of testosterone.

Menopause can also be brought on by surgical procedures, such as the removal of both ovaries, or treatments for certain conditions, like endometriosis or cancer. Treatments that have anti-estrogen effects can also cause menopause. This summary primarily focuses on natural menopause, which happens without medical procedures or treatments.

Risk Factors and Frequency for Menopause

In the United States, around 1.3 million women enter menopause each year. It usually starts between the ages of 45 and 56. Nevertheless, about 5% of women start menopause early, between the ages of 40 and 45. Moreover, 1% of women stop having their periods before they turn 40 due to a condition known as primary ovarian insufficiency, which is a permanent failure of the ovaries.

Menopause tends to occur earlier and more often among Black and Hispanic women compared to their white counterparts. The rate of premature menopause is 1.4% for Black and Hispanic women versus 1% for white women, while the rate of early menopause is 3.7% to 4.1% for Black and Hispanic women compared to 2.9% for white women. However, these differences may not be due to race alone when considering individual cases, but race could play a role when looking at the whole population.

Furthermore, Black women tend to experience more severe symptoms during menopause, known as vasomotor symptoms, compared to other races. About 80% of Black women endure these symptoms for an average of 10.1 years, while 65% of white women experience them for an average duration of 6.5 years.

Signs and Symptoms of Menopause

When looking at the effects of menopause, focus should be on symptoms caused by low estrogen levels.

Vasomotor symptoms, affecting blood vessels and sweat glands, are the most common and are experienced by roughly 75-80% of women. This can include:

• Hot flashes
• Night sweats
• Heart palpitations
• Migraines

Migraines may change in intensity during menopause due to fluctuating estrogen levels. These frequent types of headaches can get worse at the onset of menopause and most women report improvement after menopause, although a few may have worsening migraines.

Around 50-75% of women also experience genitourinary syndrome of menopause, relating to the urinary tract and genitals. This can cause vaginal dryness, irritation, itching, and a burning sensation. Urinary symptoms are also common, including frequency and urgency due to estrogen receptors on the bladder and urethra. A drop in estrogen can also lead to recurrent urinary tract infections.

Psychological symptoms are also common, affecting up to 70% of women. These may include irritability, depression, anxiety, loss of concentration, and self-esteem issues. Other symptoms can be sleep apnea, insomnia, and restless leg syndrome, leading to further disturbance in sleep.

A physical examination might show the following changes:

• Elevated blood pressure due to arterial constriction
• Weight gain and decrease in height
• Changes in the breasts and vagina
• Joint pain and muscle loss

Sleep problems are common during menopause, including difficulty falling asleep, waking up early, and frequent awakenings during the night. Cognitive performance may temporarily decrease before improving in the postmenopausal years. Sexual function could also decrease, and intercourse can become painful. Lastly, bone health is affected during menopause due to changes in bone remodeling leading to bone loss.

Testing for Menopause

Menopause is typically diagnosed using the patient’s age and symptoms, rather than laboratory tests. Symptoms often occur before any changes can be seen in lab results. In some cases, like women who have had certain surgical procedures or have stopped ovulating, measurements of hormone levels – namely, follicle-stimulating hormone (FSH) and estradiol – can help in diagnosing menopause.

There’s some debate over using AMH (antimullerian hormone) levels to predict the age of menopause. AMH levels might be able to show us how many functional eggs a woman has left in her ovaries. However, AMH levels drop at different rates for different women, so it’s not a perfect method. We’re still investigating how well they can predict a woman’s age at menopause, and how the levels might differ between ethnic groups.

An elevated FSH level (>30 mIU/mL) is a clear marker of menopause. However, certain pelvic surgeries can temporarily increase FSH levels, so it’s better to wait at least 3 months after surgery to test for menopause. Similarly, low estradiol levels (<20 pg/mL) are suggestive of menopause. Still, FSH levels can fluctuate greatly in women aged 40 to 50 years and will only stabilize 3 to 6 years after menopause. Inhibin B and AMH are not usually measured for diagnosing menopause.

Because hormone levels can change significantly, measuring FSH and estradiol is not regularly done to diagnose menopause. Estradiol levels during the transition to menopause (known as perimenopause) are generally found to be 20% to 30% higher than premenopausal levels. Other hormonal tests can be used to rule out causes of amenorrhea (absence of menstruation) other than menopause, like thyroid stimulating hormone and prolactin tests. It’s also important to note that certain medications, such as estrogens, androgens, and hormonal contraceptives, can affect lab results, so hormonal tests should ideally be done at least 2 weeks after stopping such medications.

Treatment Options for Menopause

The 2022 North American Menopause Society Position Statement has advised that treatment for menopause should focus on managing disruptive symptoms and preventing long-term complications. One common treatment is Hormone Replacement Therapy (HRT), which might work best if started within ten years of the last menstrual cycle and before the age of 60. However, if HRT is started more than ten years after the last period or at an age beyond 60, the balance of benefits versus risks might not be as favorable.

Hormonal therapy is usually recommended in cases of serious symptoms like hot flashes that occur during menopause. These can be given through tablets, sprays, gels, vaginal rings, or patches. It’s available in various forms such as estrogen alone, estrogen-progestin combination, estrogen-bazedoxifene, and progestin alone. It’s important for women with an intact uterus to not solely use estrogen, as it can lead to the overgrowth of the lining of the uterus (endometrial hyperplasia) and possibly increase the risk of cancer. Instead, a progestin can be added to help manage these risks, or an alternative like Bazedoxifene can be used.

Despite these benefits, the therapy should be used at the lowest effective dose and for the shortest duration possible due to potential risks. For instance, estrogen therapy increases the risk of deep vein thrombosis and stroke while combined HRT might elevate the risk of breast cancer. However, the risk is minimal in women who start HRT early into menopause.

It remains a topic of active research to understand whether systemic HRT influences the risk of coronary heart disease. Certain conditions, like a history of breast or endometrial cancer, deep vein thrombosis, pulmonary embolism, liver disease, and unexplained vaginal bleeding, are contraindications for estrogen use.

HRT’s effects on heart disease in postmenopausal women depend on when the treatment is started. Beginning HRT within 10 years of the final menstrual period can decrease cardiovascular disease and overall mortality rates, but hormone use isn’t recommended exclusively for preventing heart disease.

Using HRT through the skin (transdermal estrogen) is linked with fewer adverse effects on blood clotting and inflammation compared to oral estrogen. Transdermal estrogen might also be a beneficial treatment for mood changes associated with menopause.

Bioidentical hormones prepared in a pharmacy are not monitored for quality and aren’t evaluated for safety or effectiveness hence aren’t approved by the Food and Drug Administration (FDA).

The FDA does not recommend using HRT for the primary prevention of chronic conditions in postmenopausal women because there has been no found benefit to systemic hormonal therapy in preventing such conditions.

Systemic HRT doesn’t always decrease the risk of urinary tract infections caused due to menopause-related changes in urinary and genital health (genitourinary syndrome of menopause). So local estrogen therapy may sometimes be used in addition to systemic therapy. Local estrogen therapy through vaginal rings, creams, or tablets can help manage urogenital symptoms. This is particularly helpful for women who are unable to take systemic hormonal replacement therapy, who can then benefit from local estrogen therapy without the need for progesterone.

Selective Estrogen Receptor Modulators (SERMS) like raloxifene, tamoxifen, bazedoxifene, and ospemifene, are sometimes used in treating and preventing various conditions in menopausal women. These drugs work differently in different tissues. For example, they may act as an estrogen booster in one type of tissue and a blocker in another.

Certain antidepressants, like Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), along with a medication called gabapentin, can be used for treating menopausal symptoms like hot flashes.

Hormone Replacement Therapy can prevent osteoporosis but it isn’t approved for treating it. For menopausal women dealing with osteoporosis alone, various other medications, including bisphosphonates and denosumab, and supplements such as calcium and vitamin D can be used.

There are non-prescription remedies available as well, such as phytoestrogens, vitamin E, and omega-3 fatty acids, but these have been shown to be no better than a placebo in treating menopausal symptoms. Lifestyles practices like wearing breathable clothing, using fans, and trying to lower room temperature, have not been proven to help in clinical trials, though weight loss, hypnosis, and cognitive behavioral therapy could potentially alleviate some women’s symptoms.

What else can Menopause be?

If a woman experiences typical signs of menopause at 45 years or older, menopause can be diagnosed without any tests. However, in younger women, it’s important to rule out other health conditions that could be causing their periods to stop. Pregnancy, for instance, is a common reason and should always be checked for first.

There can also be physical issues causing periods to stop in women who are yet to reach 45. This can include:

• Asherman’s syndrome: a condition where scar tissue forms in the womb, commonly after a particular type of procedure (known as dilation and curettage)
• Chronic endometritis: an infection that causes long-lasting inflammation in the womb, which can lead to scarring inside the womb. Tuberculosis can cause this condition.

Another potential reason for periods stopping is due to problems with the system of the body that regulates menstrual cycles. This could be due to several factors such as:

• Obesity
• Eating disorders like anorexia or bulimia
• Chronic illnesses such as kidney disease or inflammatory bowel disease
• Certain medications
• Excessive exercise
• Poor nutrition
• Stress
• Cancer
• Celiac disease
• Adrenal disorders
• Exposure to chemotherapy or radiation
• Sheehan syndrome (which leads to damage of the pituitary gland)
• Growth of a benign tumour (pituitary adenoma) in the pituitary gland

Problems with the ovaries can also stop periods from occurring. This could be due to ovarian tumours, a condition called polycystic ovary syndrome, or premature ovarian insufficiency (where the ovaries stop working correctly before the age of 40).

What to expect with Menopause

Menopause is officially identified when a woman goes 12 months without a menstrual period. The phase leading up to menopause, as well as the years following menopause, can span several years. Vasomotor symptoms, a term referring to hot flashes and night sweats, often last for more than 7 years and even beyond 10 years after a woman’s final menstrual period in some cases.

Without treatment, typically, these hot flashes will disappear after about 7.4 years. However, between 10% to 20% of women experience severe hot flashes. Further information was obtained from the SWAN study started in 1996, one of the most extensive and longest studies in this area. It examined over 3,000 women across the United States as they experienced menopause, collecting surveys and conducting interviews from a diverse range of ethnic and racial groups. This gathering of data helped researchers better understand menopause and midlife aging.

For women with severe hot flashes, Hormone Replacement Therapy (HRT) can be used. Other medications might also be recommended depending on the specific symptoms that are causing discomfort. With proper treatment, most women find that the symptoms of menopause greatly improve.

Possible Complications When Diagnosed with Menopause

Decreased estrogen levels during menopause can cause long-term complications, such as heart disease and osteoporosis.

Heart Disease

During menopause, falling estrogen levels can increase a woman’s risk for heart disease. This risk is influenced by changes in blood lipid levels, poor arterial function, and the activation of the renin-angiotensin system, which controls blood pressure. Women who have gone through menopause have 2 to 3 times higher rates of heart disease compared to women of the same age who have not. That’s why it’s crucial for menopausal and postmenopausal women to follow a healthy diet and exercise regimen.

Osteoporosis

Osteoporosis, a condition that causes bones to become weak, affects more than 250,000 menopausal and postmenopausal women. This bone loss or reduced bone density is caused by a lack of estrogen. From the age of 40, women start to lose bone at a rate of 0.3% to 0.5% per year, which increases to 3% to 5% per year during menopause for 5 to 7 years. While hormone therapy can help prevent bone loss associated with menopause, it carries its own risks with long-term use. Therefore, other strategies are recommended to reduce the risk of osteoporosis and related injuries. These include quitting smoking, staying active, taking calcium supplements, and using non-hormonal treatments like bisphosphonates and denosumab.

Common Long-Term Complications:

• Heart Disease
• Osteoporosis

Preventative Measures:

• A healthy diet and exercise regimen
• Stopping smoking
• Regular physical activity
• Calcium supplementation
• Using non-hormonal treatments like bisphosphonates and denosumab

Preventing Menopause

Here are some key points you should know about menopause:

Firstly, stopping smoking is strongly advised, particularly for those considering hormone replacement therapy (HRT). HRT is a treatment that replaces hormones no longer produced after menopause.

Maintaining an active lifestyle is also important during menopause. Women should try to aim for about 150 minutes of cardio, like jogging or biking, every week, and also try to do weight-bearing exercises, like weight lifting or hiking, two to three times per week.

Maintaining a healthy diet is also beneficial for weight management during menopause.

If you experience uncomfortable symptoms like painful intercourse during menopause, don’t hesitate to talk to your doctor or healthcare provider about it.

Even during menopause, it’s recommended to continue using birth control until you reach the age of 50 to 55. That’s because we can’t pinpoint the exact age when the ability to bear children ends. Also, keep in mind that HRT isn’t a reliable method of birth control.

If you’re facing bothersome symptoms of menopause, don’t be shy about discussing it with your doctor. There are many different treatments available to help manage these symptoms.

And finally, though you might hear about it, compounded bioidentical hormone therapy isn’t recommended for use. This is because there isn’t enough scientific data about how safe and effective it is, and some of the marketing claims about it aren’t backed up by evidence.