Menopause, sometimes referred to as “the change” or “change of life,” occurs when a woman’s body no longer releases eggs, and her ovaries substantially reduce production of the hormones estrogen and progesterone.

A woman is considered to have entered menopause when she does not have a menstrual cycle (also known as a period) for 12 consecutive months. In most cases, this occurs when a woman is between 45 to 55 years old, although for various reasons it can happen much earlier or later in life.

Traditionally, menopause has been viewed as the end of a woman’s childbearing years. However, the exact date of menopause can be hard to pinpoint, and it is possible for women considered to be postmenopausal to still conceive a child. In addition, recent advances in medical technology are allowing more menopausal and postmenopausal women to become pregnant (e.g., through use of a donor egg).

There are about 37.5 million women in the United States reaching or currently at menopause (ages 40 to 59 years), according to data collected as part of the census in 2000. Menopause may trigger symptoms that cause women varying levels of discomfort. These can include hot flashes, changes in vaginal tissue, weight gain and mood swings. Menopause also raises the risk of various health disorders, including weakened bones (osteoporosis) and various heart conditions.

For many women who are menopausal or postmenopausal, hormone replacement therapy (HRT) may be recommended. However, there are both positive and negative factors with this form of treatment. HRT is believed to increase the risk of certain cancers, such as breast cancer, but also may decrease the risk of other conditions, including heart disease. For this reason, women and their physicians must consider the use of HRT as treatment based on their individual health issues.

Women can reduce the risk of experiencing some of the symptoms and conditions with various lifestyle habits, such as exercising regularly and eating a healthy diet. Because of increased life expectancy, women today may live as much as one-third to one-half of their lives after menopause. For this reason, women should be careful to make lifestyle choices that can help them live healthy, productive lives during these years.

Menopause is a change that occurs when a woman’s body no longer releases eggs, and her ovaries produce significantly lower amounts of the hormones estrogen and progesterone. It typically occurs between the ages of 45 and 55 years, although it can occur earlier or later in a woman’s life. The average age of menopause in the United States is 51 years. Menopause is officially said to have occurred when a woman does not have a menstrual cycle (also known as a period) for 12 consecutive months and there are no other causes for this change.

During a woman’s reproductive years, a gland in the brain produces hormones (substances sometimes called the body’s “chemical messengers”) that cause a new egg produced by the ovaries to be released from its follicle (sac). This occurs at approximately the same time each month. As the follicle develops, it produces estrogen and progesterone, which help prepare the body to receive and nourish a fertilized egg (zygote). When fertilization does not occur, estrogen and progesterone levels drop. This causes the lining of the uterus to break down, and the result is menstruation.

During menopause – sometimes referred to as “the change” or “change of life” – a woman’s body no longer releases eggs, and her ovaries substantially reduce production of the hormones estrogen and progesterone. This can cause many side effects, including hot flashes, vaginal dryness and thinning of the bones (osteoporosis). In addition, women report a lower sex drive and feelings of depression. To relieve these symptoms, many women choose to take medications known as hormone replacement therapy (HRT). This can involve taking synthetic estrogen, which is often combined with synthetic progesterone, known as progestin. HRT has become controversial over the past years due to its association with an increased risk for breast cancer. However, HRT may help prevent bone loss and heart disease, especially if started before age 60. A woman and her physicians can best determine if HRT is a viable treatment in menopausal and postmenopausal years.

Although menopause usually occurs because of the natural aging process, other factors can also trigger the event at younger ages. Surgery to remove both ovaries (bilateral oophorectomy) will cause premature ovarian failure. Genetic factors and cancer treatments such as chemotherapy or radiation therapy to the pelvic area also can cause early menopause.

In addition, a new study that analyzed data from the renowned Framingham Heart Disease Epidemiology Study found that certain risk factors for heart disease (e.g., high cholesterol levels, excess weight, high blood pressure) can lower the age at which women reach menopause.

Traditionally, menopause has been viewed as the end of a woman’s ability to conceive. However, many women have erratic menstrual cycles in the period leading up to menopause, known as perimenopause. This can make the exact date of menopause difficult to pinpoint, and it is possible for women considered to be postmenopausal to conceive a child. In addition, recent advances in medical technology are allowing more menopausal and postmenopausal women to become pregnant (e.g., through use of a donor egg).

There are about 37.5 million women reaching or currently at menopause (ages 40 to 59 years) in the United States, according to data collected as part of the census in 2000. Because of increased life expectancy, women today may live as much as one-third to one-half of their lives after menopause. For this reason, women must be careful to take steps that can help them live healthy, productive lives during these years.

Aging is the chief cause of menopause. Natural menopause is preceded by a period of transition known as perimenopause. This can begin as early as a woman’s early 30s or – in rare cases – as late as a woman’s late 60s. Perimenopause may end in the course of several months, or may unfold over many years. It is important to note that women can still get pregnant during this time period.

This process that leads to menopause usually begins in a woman’s middle to late 30s, when the ovaries’ production of estrogen and progesterone begins to fluctuate. The hormone levels vary even more during a woman’s 40s and may cause irregular menstrual cycles. By a woman’s mid-50s, menstruation cycles typically cease altogether. When this occurs, it is known as menopause. Most women experience menopause between ages 45 and 55, with the average age being between 50 and 51 years.  

Though most women experience menopause naturally as they age, other factors can trigger premature menopause in women. These include:

• Surgical menopause. Also known as induced menopause, it involves an operation to remove the uterus (hysterectomy) and ovaries (oophorectomy). Such surgery is often necessary to treat conditions like gynecologic cancers or endometriosis. The symptoms are likely to appear immediately after surgery, rather than occurring gradually as they do in natural menopause. In addition, symptoms are often more severe after surgical menopause.
  
  In some cases, women will have their uterus removed, but their ovaries will be left in place. Although these women are no longer able to bear children and do not menstruate, they will not experience premature menopause, as their ovaries will continue to produce hormones. Some of these women will experience hot flashes, as the surgery may disrupt the blood supply to the ovaries. In addition, women who have their uterus removed may experience menopause a year or two earlier than expected, and are at higher risk for osteoporosis.
  
  
• Other forms of early menopause, or premature ovarian failure (POF). In addition to surgery, there are several other potential triggers of premature menopause. This is defined as any menopause that occurs before age 40, whether natural or induced. POF may occur because of several factors, including:
  
  
• • Genetics. The age at which a woman enters menopause often corresponds closely with that of her mother. In addition, twin sisters appear to be at higher risk of experiencing early menopause than women who do not have a twin, according to new research.
    
    
  • Cancer treatments. Chemotherapy or radiation to the pelvic area can damage the ovaries, triggering POF. Female survivors of childhood cancer are more likely to experience early menopause than other women.
    
    
  • Smoking. Tobacco use may cause menopause to occur up to two years earlier than normal.
    
    
  • Chromosome defects. For example, women born without a second X chromosome, or born without part of the chromosome have a condition known as Turner syndrome. In this disorder, the ovaries do not form normally, which leads to early menopause.
    
    
  • Autoimmune diseases. The body’s immune system sometimes mistakenly attacks part of the reproductive system, damaging ovaries and preventing them from producing female hormones. Examples of diseases that can cause these symptoms include thyroid disease and rheumatoid arthritis.
    
    
  In addition, a new study that analyzed data from the renowned Framingham Heart Disease Epidemiology Study found that women with certain risk factors for heart disease (e.g., high cholesterol levels, excess weight, high blood pressure) can experience menopause earlier than women without such risk factors. Premature menopause increases the risk for osteoporosis later in life. Some women may also experience emotional trauma, as POF severely restricts a woman’s ability to have children. Women who still desire to become pregnant should talk to their physician about donor egg programs.

For many women, the first sign of oncoming menopause is a fluctuation in menstrual cycles. This period of transition is known as perimenopause. Menopause occurs when a woman has not had a menstrual period for 12 consecutive months and no other biological or physiological cause for this phenomenon can be identified.

As women enter menopause, they may begin to experience several symptoms typically associated with the changes that are taking place in their bodies. These symptoms include:

• Hot flashes. This is a feeling of warmth in the face, neck or chest that ranges from mild to severe. According to the Food and Drug Administration (FDA), about 85 percent of women approaching or going through menopause have hot flashes.
  
  
• Night sweats (evening versions of “hot flashes”) and difficulty sleeping. Lack of sleep can contribute to women feeling tired, stressed or tense.
  
  
• Changes in vaginal tissue, including thinning, dryness, itchiness or burning. In some cases, sex may become painful (dyspareunia) due to decreased vaginal secretions.
  
  
• Thinning of bones. Known as osteoporosis, this condition can lead to a reduction of bone mass that reaches 20 percent in some women. As a result, menopausal and postmenopausal women are susceptible to fractures of the hip, spine, wrist and other bones. In some cases, osteoporosis can lead to loss of height.
  
  
• Abnormal vaginal bleeding or “spotting.” This is a common sign of menopause. However, women who have not had a period for 12 consecutive months should see a physician if they experience spotting, as this can sometimes be a sign of other conditions, such as:
  
• • Cancer
    
  • Side effects of using birth control pills or hormone replacement therapy
    
  • Hormonal imbalance
    
  • Noncancerous growths in the lining of the uterus, such as fibroids
    
    
• Mood changes. These changes can include mood swings, depression and irritability. Some researchers believe these emotions are a result of changes in the brain caused by a decrease in estrogen. Others think menopausal symptoms such as sleep problems, hot flashes and fatigue cause the feelings. Still others maintain that a combination of these factors is probably responsible.
  
  
• Urinary problems. These may include leaking, burning or pain when urinating (dysuria) or urgency. Leakages may also occur during sneezing, coughing or laughing. An increase in urinary tract infections (UTIs) is also associated with menopause as a result of a thinning of the urethra that happens at this time.
  
  
• Increased risk of heart problems. Estrogen helps raise HDL cholesterol (“good cholesterol”). This in turn helps remove LDL-cholesterol (“bad cholesterol”), which can contribute to plaque buildup in the arteries. As estrogen levels drop, there is increased risk of this buildup, which can lead to coronary artery disease, in which the veins and arteries to the heart become narrowed or blocked.
  
  
• Heart palpitations. A sudden pounding in the chest sometimes occurs in women during menopause. While heart palpitations can be harmless, they can also be a sign of a major health disorder. For this reason, women who experience palpitations should seek medical care.
  
  
• Memory or concentration problems. The source of these symptoms is not clearly understood, though they may be related to factors such as stress or lack of sleep.
  
  
• Lack of interest in sex or changes in sexual response due to decreased hormone production.
  
  
• Changes in physical appearance. After menopause, weight that previously was settled in the hips and thighs may shift to the waist. The breasts may lose their fullness, wrinkles may form and hair may thin on the woman’s head. As estrogen levels drop, the small amount of testosterone that women produce may have more pronounced effects on the body. This may include development of coarse hair on the chin, upper lip, chest and abdomen.

The severity of these symptoms varies from woman to woman, with some experiencing few or no symptoms. In many women, the symptoms may fade over time, with or without treatment.

The typical way to determine whether menopause has occurred is to record when a woman has not had a menstrual period for 12 consecutive months and no other biological or physiological cause for this phenomenon can be identified.

To determine whether the absence of menstrual periods is caused by menopause or another illness, a physician will perform a physical examination and compile a medical history of the patient. Some women may be referred to an endocrinologist, a physician who specializes in the diagnosis and treatment of disorders related to glands and hormones. Physicians may perform a number of tests that may help reveal whether menopause has occurred.

For example, a blood test that reveals the level of follicle stimulating hormone (FSH) is frequently used to determine if menopause has occurred. FSH is made in the pituitary gland in the brain and circulates in the blood to stimulate the ovaries to make estrogen and progesterone during a woman’s reproductive years. Once the ovaries stop making estrogen and progesterone, the pituitary gland compensates by making more FSH. FSH levels greater than 25 to 40 mIU/ml (milli-international units per millimeter) are a sign of menopause.

The Food and Drug Administration (FDA) has approved a home urine test kit that measures FSH in a woman’s urine. This may help women determine if they are in menopause or the period leading up to menopause known as  perimenopause.

A physician may also test for levels of estradiol. This is a type of estrogen, and its levels fall in the body once the ovaries fail. A test for luteinizing hormone (LH) – the hormone that triggers ovulation  – also may indicate menopause has occurred if higher levels are detected.  

Once a woman has entered menopause, it becomes even more important to monitor aspects of her health that may be affected by the hormonal changes associated with menopause. Tests that can help a physician monitor a woman’s postmenopausal health include:

• Pap smear. A scraping of the surface of the cervix to obtain cells that can be analyzed for signs of cancer or other disorders of the cervix, uterus or other pelvic organs. 
  
  
• Mammography. An annual x-ray of the breast that can reveal signs of breast cancer.
  
  
• Bone density screening. This can be used to help detect signs of osteoporosis, thinning of the bones that can be accelerated by low levels of estrogen. Women with osteoporosis are at greater risk for fractures of the wrist, hip and spine.
  
  
• Blood tests. Tests may be conducted to monitor a woman’s cholesterol levels due to the higher risk of heart disease. Blood sugar also may be checked with blood tests.

Although a woman cannot prevent menopause, she can take steps to reduce the severity of symptoms associated with this time of life. The most common form of treatment for menopause is hormone replacement therapy (HRT). This involves taking synthetic estrogen or a combination of estrogen and synthetic progesterone, known as progestin. Benefits of HRT include:

• Reducing hot flashes
• Relieving vaginal dryness
• Slowing bone loss
• Alleviating mood swings and depression

Although HRT is often effective at controlling symptoms, recent studies have revealed major health risks associated with the treatment. These include:

• Blood clots
• Breast cancer
• Gallbladder disease
• Heart attacks
• Strokes

However, a new study that analyzed various trials concluded that HRT can reduce heart disease risk in menopausal women who begin treatment early, especially before age 60. The same study showed mixed results for older women. For this reason, women should consult with their physician about the pros and cons of HRT. Some women with various health conditions will not be candidates for HRT. These include:

• Pregnancy
• Cancers of the breast and uterus
• History of stroke or heart attack
• History of blood clots
• Liver disease

In some cases, medications can be taken to help strengthen bones and to treat other side effects. In addition, some women may find relief from various forms of complementary and alternative medicine.

Women may also reduce common symptoms associated with menopause by following these general guidelines:

• Exercise regularly. Try to get at least 30 minutes of exercise on most days of the week. Weight-bearing exercises such as walking, running or dancing can help strengthen bones and reduce the risk of osteoporosis. In addition, exercise may help control weight and it has benefits for the heart.
  
  
• Quit smoking. Smoking increases bone loss, probably because it decreases a woman’s production of estrogen and reduces the body’s ability to absorb calcium.
  
  
• Eat a healthy diet. Women should eat plenty of whole-grain products, vegetables and fruits. They should choose foods low in fat and cholesterol and get enough calcium and vitamin D to keep their bones strong. Menopausal and postmenopausal women need about 1,500 milligrams of calcium a day to keep bones strong.
  
  
• Drink in moderation. Women should not have more than one alcoholic drink a day.
  
  
• Maintain a healthy weight. Women should maintain a weight deemed healthy by their physician.
  
  
• Continue to have regular physical and gynecological examinations. Physical exams should include checks of bone density, blood pressure, cholesterol and blood sugar. Gynecological exams should include an annual breast exam, including a mammogram, and an annual pelvic examination, with a Pap smear every one to three years (depending on health history).

Although good health and sound lifestyle choices can reduce the likelihood of symptoms, most women will experience at least some ill effects associated with menopause. If and when these symptoms occur, steps can be taken to reduce their severity. These include:

• Hot flashes. Women should avoid triggers such as warm environments, eating or drinking hot or spicy foods, drinking alcohol or caffeine and stress. Dressing in layers, exercising regularly and using a fan in the home or workplace can also help women reduce or prevent hot flashes. Non-hormonal therapies, such as alternative remedies like herbs (e.g., black cohosh, soy) or acupuncture have little effect on alleviating hot flashes, according to new findings.
  
  
• Memory problems. A physician can recommend mental exercises to improve memory during menopause. Adequate sleep and regular physical activity may also help prevent memory problems in menopausal women.
  
  
• Mood swings. Sufficient sleep and regular physical activity can often help women combat mood swings during menopause. In addition, physicians can recommend relaxation exercises or prescribe antidepressant medication if necessary. Support groups are often valuable for many menopausal women.  
  
  
• Sleeping problems. Regular exercise may help women achieve a better night’s sleep. Avoiding alcohol, caffeine, sugar, large meals and work right before bedtime can also help prevent sleep problems. Some women find they are better able to sleep after drinking a warm, non-caffeinated beverage before bedtime. Women who are having trouble sleeping should avoid napping. In addition, they should try to go to bed and get up at the same times every day, and should keep their bedroom at a comfortable temperature. Women should discuss the use of over-the-counter (OTC) and prescription medicine for sleep with their physician if they continue to experience difficulties.
  
  
• Vaginal dryness. Various OTC vaginal lubricant products are available for women experiencing vaginal dryness. Prescription estrogen replacement creams might also offer relief for some women.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about menopause:

1. How will I know when I’m entering menopause?
   
   
2. What is the difference between perimenopause and menopause?
   
   
3. What tests will I receive to determine if I’m experiencing menopause?
   
   
4. Am I a candidate for hormone replacement therapy (HRT)?
   
   
5. What are the benefits and risks of HRT?
   
   
6. If I cannot use HRT, what are my other options?
   
   
7. Can any complementary or alternative medicines help me with my menopausal symptoms? What are the benefits and risks of such therapies?
   
   
8. Which tests will I need to monitor my health after menopause?
   
   
9. Is there anything I can do to improve my sex drive or response?
   
   
10. What are my options for conceiving a child if I’m in menopause?
    
    
11. How will I know if I’m postmenopausal?
    
    
12. Can you recommend some books or informational materials on menopause for me?