Menopause and Menopausal Problems

Menopause is the time in a woman's life when menstruation stops. It is usually a gradual process. The ovaries begin to produce lower amounts of hormones. The reduced amounts of hormones cause menstrual periods to become irregular and eventually to stop completely. The hormonal changes often cause other symptoms.

Menopause can also occur when the ovaries are surgically removed.

Menopause normally occurs between ages 45 and 60. In the U.S. the average age for menstrual periods to stop completely is 51.

What are the symptoms?
You may have both physical and psychological symptoms during menopause. Symptoms may occur for a few weeks, a few months, or sometimes over several years. Your symptoms may come and go, or they may occur regularly.

Physical symptoms that are common during menopause include:

• Irregular menstrual periods
• Hot flashes
• Night sweats
• Disturbed sleep patterns
• Vaginal dryness and shrinkage of genital tissues, sometimes resulting in discomfort or pain during sexual intercourse
• Dry skin
• More frequent urination or leakage of urine (urinary incontinence)
• More frequent minor vaginal and urinary infections.

Menopause usually occurs at a time in life when other dramatic changes take place. Some of these changes may include loss of parents, adjustment to children growing up and leaving home, becoming a grandparent, retirement, or career changes. These changes, in addition to the changes in your body, may result in psychological or emotional stress. Psychological symptoms of menopause may include:

• Anxiety
• Depression
• Tearfulness, irritability
• Sleeplessness
• Less desire for sex
• Lack of concentration
• More trouble remembering things

How is it diagnosed?
Menopause can often be diagnosed through your medical history. Your health care provider will then examine you. He or she may order blood tests. A pelvic exam and Pap smear may show effects of decreased estrogen.

How is it treated?
Menopause is a natural part of a woman's life cycle. It is not a disease and does not necessarily require any treatment. However, certain health problems such as osteoporosis and increased heart disease are associated with low estrogen. To help prevent such problems, many women choose to take estrogen to replace what their body is no longer producing. This treatment is called estrogen replacement therapy (ERT), or hormone replacement therapy (HRT).

You and your health care provider should discuss the pros and cons of hormone replacement therapy for you. Factors such as your age, race, family history, and health history will be considered in the discussion. Hormone replacement therapy is the most effective treatment for preventing osteoporosis (loss of bone density). However, it is not the right treatment for every woman. Women who have had some types of breast cancer or other cancer, blood clots, or certain liver diseases should not take estrogen. There are other ways to help prevent osteoporosis. For example, you can take calcium supplements and exercise regularly.

Hormone replacement therapy may also benefit your heart and blood vessels. Discuss the potential benefits with your health care provider, especially if you have a family history of heart disease.

If you and your health care provider decide you will start taking estrogen, it may be prescribed in the form of tablets to be swallowed, patches to be applied to the skin, or a cream to be inserted into the vagina. You will probably continue the treatment for at least several months and possibly many years.

If your uterus has been removed, you may take only estrogen. Otherwise you will need to take both estrogen and progesterone. Taking estrogen alone can increase your risk of cancer of the uterus.

Ask your health care provider about any side effects or special precautions you should know about while you are taking hormones. Make sure that your provider knows about any other medications you are taking.

How long will the effects last?
Symptoms of menopause may last only a month or may continue for several years.

If you have had no menstrual periods for several months and then have bleeding from the vagina, check with your health care provider promptly. Vaginal bleeding in a woman, who has not had periods for months, or especially years, can be a symptom of cancer.

How can I take care of myself?
To help your general mental and physical well-being, you should:

Have a baseline mammogram between the age of 35 to 40 years, then every year after age 40.

Eat more foods that are high in calcium, such as dark green vegetables and nonfat (skim) milk and dairy products.

Reduce saturated fats in your diet. Check labels for product contents before you buy them.

Get regular physical exercise. Exercise will help you fight depression and maintain good circulation, mobility, bone density, and a sense of well?being.

Use birth control during sexual intercourse until your health care provider says that you may stop. It is not possible to know exactly when you will stop being able to get pregnant and it is important to avoid high?risk pregnancies.

You may also choose to:

• Wear cotton sleepwear to reduce discomfort from night sweats.
• Use a vaginal lubricating cream or jelly if intercourse is painful. This problem is usually caused by a lack of estrogen and should be discussed with your health care provider.
• Talk and share feelings with a friend or family member who understands what you are experiencing.

What is hormone replacement therapy?
Hormone replacement therapy (HRT) refers to a program of taking estrogen, usually the lowest effective dose, and progesterone to replace the natural hormones that decrease at menopause.

Menopause is the time when menstruation stops. It is often a gradual process in which menstrual periods become irregular and eventually end completely. After you are through menopause, your ovaries no longer produce eggs and your body produces less estrogen.

Menopause is part of a natural aging process and not a disease. For many women menopause is an easy transition. However, some women will have a variety of difficulties that are related to their estrogen deficiency. If you are one of these women, you may benefit from therapy to replace some of the estrogen lost from menopause. Estrogen also benefits women with easy menopausal transitions by decreasing heart disease and strengthening the bones.

Estrogen is one of two major female hormones. The other is progesterone. For women who still have their uterus, progesterone is added to the estrogen program because it reduces the risk of cancer of the uterus, a major concern with estrogen replacement therapy (ERT) in the past. Treatment with both estrogen and progesterone is called hormone replacement therapy (HRT).

These hormones are available in tablets and are also given in the form of creams, skin patches, vaginal suppositories, or shots.

When is it used?
Hormone replacement therapy can be used to treat some women during the period before, during, and after menopause. Menopause means having no menstrual periods for at least 6 months to 1 year.

There are two kinds of menopause:

• Physiologic menopause refers to menopause that occurs naturally for most women between ages 45 and 60; the average age is 50 to 52.
• Artificial menopause refers to when a woman's menstrual periods stop because the ovaries have been removed by surgery or damaged by radiation therapy.

Many physicians recommend HRT for women who go through menopause prematurely, that is, for women who stop menstruation before the age of 40, either naturally or artificially. Symptoms of estrogen withdrawal may be severe after an early surgical menopause. If the uterus is removed, uterine cancer is no longer a concern.

Estrogen replacement therapy is often recommended to relieve these symptoms associated with menopause:

• severe hot flashes
• sleeplessness
• vaginal dryness, resulting in discomfort or pain during sexual intercourse.

In addition, a doctor may prescribe estrogen therapy if you are at risk for osteoporosis or coronary heart disease.

What are the benefits of HRT?
Osteoporosis
Osteoporosis is a skeletal disorder that reduces the density of bone, thus making you prone to fractures. Bone loss begins around age 35 and accelerates rapidly at menopause. You are at greatest risk of the disease if you are Caucasian, do not participate in regular exercise, thin and fair-skinned, if you smoke, or if your mother had osteoporosis.

Estrogen therapy is the best prevention and treatment of the disorder. Low-dose estrogen therapy can stop or slow down bone loss if medication is begun soon after menopause. Calcium supplements can also help to cut down on bone loss in combination with HRT.

Coronary heart disease
The risk of heart disease dramatically increases for women who have gone through menopause. Evidence shows estrogen reduces the risk of coronary heart disease. Some doctors recommend estrogen if you are at high risk for coronary heart disease. If you have high blood pressure, diabetes, high blood-cholesterol levels, or a family history of heart disease before age 55, hormone therapy may reduce your risk of heart disease.

Menopausal symptoms
Hormone replacement therapy is also prescribed to relieve these symptoms of menopause:

• hot flushes or flashes, which may last for several months to a few years and are accompanied by profuse sweating
• Sleep disturbances
• Atrophic vaginitis, an irritation of the vagina caused by loss of estrogen; less estrogen in the body causes the tissues of the vagina to shrink and become thin and dry. This can case painful intercourse.

What are the risks of HRT ?
--Endometrial cancer if you are given only estrogen replacement therapy, without progesterone, and you still have a uterus. If you do not have a uterus, estrogen alone is fine.

Constant exposure of the endometrium, which is the lining of the uterus, to estrogen without progestin is associated with a higher risk of endometrial cancer.

-- Breast cancer
Studies are still being done to determine if being on HRT increases your risk of getting breast cancer. It is best to talk to your doctor about this possible risk. Many physicians recommend women be checked thoroughly for any tumors and be given a mammogram before beginning HRT. They also advise women taking HRT to have yearly mammograms and physical exams and to examine their own breasts monthly. If you have a family history of estrogen-dependent breast cancer, discuss this factor with your doctor.

Side effects of estrogen
The side effects of estrogen may include :

• uterine bleeding and vaginal discharge
• bloating, fluid retention, and weight gain
• breast tenderness and enlargement
• nausea
• symptoms resembling those of premenstrual tension, such as headaches and mood swings
• increased risk of gallstones if estrogen is taken orally.

Side effects of the combination therapy
Use of combination estrogen-progestin therapy after menopause has been associated with vaginal bleeding, especially for the first six months of use. When you stop estrogen and progestin combination therapy or withdraw from it during the days in the cycle when you are not taking hormones, you will usually have withdrawal bleeding. Unlike a menstrual period, the flow typically lasts only 2 or 3 days and is not usually accompanied by cramps or bloating.

When not to take HRT
If you have any of the following conditions or diseases, you should not take HRT :

• unexplained vaginal bleeding
• liver disease
• thromboembolic disease (history of blood clots, strokes) ; however, transdermal estrogen (a skin patch) may decrease thromboembolic disease
• endometrial or breast cancer

If you have any of the following diseases or conditions, you may want to discuss HRT's pros and cons with your provider:

• Uterine fibroids, or benign tumors that grow in response to estrogen ; they begin to shrink at menopause unless a woman takes estrogen. Taking progestin with estrogen does not prevent their growth.
• Endometriosis
• Fibrocystic breast disease
• Seizure disorder
• Migraine headaches
• Gallbladder disease
• Hypertension

How to take care of yourself
If you are considering HRT :

• Have your doctor check your cholesterol levels. If you find yourself in the danger zone, talk to your doctor about taking HRT.
• Get a mammogram before you begin HRT to see if you are at risk for breast cancer

If you are already on HRT :

• Ask your doctor about any special precautions or side effects to consider while taking estrogen and progestin.
• If you are taking estrogen combined with progestin, it is important to tell your doctor if bleeding occurs at any other time except the drug-free part of your therapy.
• If you are taking estrogen without progestin (and you have not had a hysterectomy), ask you doctor how to monitor for risk of endometrial cancer
• Check your cholesterol levels periodically
• If you have a history of hypertension, monitor your blood pressure closely.