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Menopause
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Menopause



Related terms
Background
Treatment
Author information
Bibliography
Prevention and self-management

Related Terms
  • Alzheimer's disease, amenorrhea, anti-androgen, anti-estrogen, atrophic vaginitis, bacterial vaginosis, breast cancer-related hot flashes, calcium, Candida, cervicitis, cervix, chronic pelvic pain, climacteric syndrome, contraceptive, corpus luteum deficiency, cramps, cytokines, dysmenorrheal, ectopic pregnancy, emmenagogue, endometriosis, estrogen, fibrocystic breast disease, follicle-stimulating hormone, FSH, GABA, gardnerella, gonorrhea, gynecologist, hirsutism, hormonal disorders, hormone replacement therapy, hormone-related vaginitis, hot flashes, HRT, hypermenorrhea, hypothalamus, hypothyroidism, hysterectomy, incontinence, interleukins, irritant vaginitis, leukorrhea, LH, luteal phase deficiency, luteinizing hormone, menopausal disorders, menopausal hot flashes, menopausal symptoms, menopause, menorrhagia, menstrual, menstrual pain, menstruation, neurochemicals, oophrectomy, osteoporosis, ovaries, ovariotomy, ovulation, peri-menopause, pituitary gland, postmenopause, postmenopausal vaginal dryness, progesterone, progestin, serotonin, uterine fibroids, uterus, vaginal dryness, vaginal inflammation, vaginal yeast infection, vaginitis, vitamin D, xenoestrogens, yeast infection, yeast vaginitis.

Background
  • Menopause is when a woman's menstrual periods stop completely. It signals the end of the ovaries releasing eggs for fertilization. A woman is said to have gone through menopause when her menses have stopped for an entire year. Menopause generally occurs between the ages of 45-55, although it can occur as early as the 30s or as late as the 60s. It can also result from the surgical removal of both ovaries. A woman can still get pregnant during menopause until she has gone at least 12 months without menstruating (a period).
  • Changes and symptoms include: a change in menstruation (periods may be shorter or longer, lighter or heavier, with more or less time in between); hot flashes and/or night sweats; trouble sleeping; vaginal dryness; mood swings; trouble focusing; and, less commonly, hair loss on the head but increased hair on the face. About 85% of women experiencing menopause will have hot flashes.
  • All women will experience menopause. Menopause is not considered a disorder and most women do not need treatment for it. However, if symptoms are severe, medications may be used to help alleviate symptoms.
  • Researchers have estimated that more than 1.3 million women in the United States and 25 million women worldwide experience menopause annually. There are about 470 million postmenopausal women worldwide, a number that is expected to increase to 1.2 billion by the year 2030.
  • Some women take hormone replacement therapy (HRT) to relieve the symptoms associated with menopause. HRT is medication containing one or more female hormones, commonly estrogen plus progestin (synthetic progesterone). HRT may also protect against osteoporosis. However, HRT also has risks. It can increase the risk of breast cancer, heart disease, and stroke. Certain types of HRT have a higher risk, and each woman's own risks can vary depending upon her health history and lifestyle.
  • Perimenopause: During perimenopause, the woman may begin to experience menopausal physical and emotional signs and symptoms, such as hot flashes and depression, even though they still menstruate. The average length of perimenopause is four years, but for some women this stage may last only a few months or continue for 10 years. Perimenopause ends the first year after menopause, when a woman has gone 12 months without having her period. Periods (menstruation) tend to be irregular during this time and may be shorter or longer or even absent.
  • Despite a decline in fertility during the perimenopause stage, individuals can still become pregnant. If the individual does not want to become pregnant, they should continue to use some form of birth control until menopause is reached.
  • Postmenopause: Postmenopause is a time when most of the distress of the menopausal changes have faded. Hot flashes may seem milder or less frequent and energy, emotional, and hormonal levels may seem to have stabilized. During postmenopause, women are at a higher risk for developing osteoporosis (bone loss) and heart disease, due to the decrease in circulating estrogen. The postmenopausal phase begins when 12 full months have passed since the last menstrual period.

Treatment
  • Calcium management: Adequate calcium intake is important to prevent osteoporosis and bone fractures. Daily elemental calcium intake for postmenopausal women should be around 1,200 milligrams. Women should eat foods rich in calcium (such as dairy products, leafy green vegetables, tofu, calcium-fortified foods), as well as foods that promote calcium absorption. A glass of milk provides about 300 milligrams of calcium. Intake of foods that rob the bones of calcium, such as animal protein and salt, should be limited. Vitamin D helps the body absorb calcium. Fifteen minutes of sun exposure every day provides sufficient vitamin D. Foods such as fortified milk, liver, and tuna contain vitamin D. Women should ask their healthcare provider or nutritionist if they should take a vitamin D supplement.
  • Calcium supplements are available in several forms: amino acid chelate, calcium carbonate, calcium chloride, calcium lactate, calcium gluconate, bone meal, dolomite, hydroxyappetite, and calcium citrate. To maximize absorption, supplements containing amino acid chelate, calcium citrate, gluconate, or hydroxyappetite should be taken. Make sure to look for elemental calcium amounts on the label.
  • Exercise: Exercise is an important part of preventative healthcare for postmenopausal women. By increasing cardiovascular fitness and strengthening the bones, exercise helps prevent heart disease and osteoporosis. Low impact, weight-bearing exercises, such as walking, jogging, tennis, racquetball, and dancing, are helpful. Women diagnosed with osteoporosis or cardiovascular disease should consult with their healthcare provider before initiating an exercise program.
  • Hormone replacement therapy: Hormone replacement therapy (HRT) uses estrogens and progestin (synthetic progesterone) to ease the symptoms of menopause. The hormones are available in a variety of forms: pills, vaginal creams, vaginal ring inserts, implants, injections, and patches worn on the skin.
  • HRT has many short-term and long-term side effects. It is important to weigh all of the potential benefits and risks, preferences, and needs before beginning HRT. The benefits and side effects vary considerably from woman to woman. Women who take HRT should be closely monitored by a healthcare professional to ensure that they benefit as much as possible from the hormone therapy. Sometimes, changing the dosage or the way it is administered can help to control side effects.
  • Minor side effects include bloating, breast tenderness, cramping, irritability, depression, and menstrual bleeding for months or years following menopause. More serious risks include: breast cancer - women who have not had a hysterectomy and use estrogen supplements are at increased risk for invasive breast cancer and cardiovascular disease - HRT causes an increased risk for stroke (neurological damage caused by a lack of oxygen to the brain), heart attack, and cardiovascular disease.
  • Endometrial cancer has been linked to high-dose estrogen supplements. Women who have not had their uterus removed are prescribed low doses of estrogen with progestin (progestin protects against endometrial cancer).
  • Women who take HRT are at increased risk for deep vein thrombosis (DVT or blood clots).
  • HRT may help to prevent or delay the development of many diseases, including: osteoporosis; Alzheimer's disease; colon cancer; macular degeneration - the leading cause of visual impairment in persons over age 50; urinary incontinence; and skin aging.
  • Various types and dosages of estrogen and progestin are available and the type of HRT often depends on particular symptoms. For example, women who experience vaginal dryness may opt for a vaginal cream or vaginal ring insert, both of which alleviate dryness. The vaginal ring insert can also help urinary tract problems. For women who suffer from hot flashes, pills or patches may be helpful.
  • Due to the potential health risks involved with taking HRT, doctors will prescribe the lowest possible dosage for the shortest period of time when treating symptoms of menopause. Topical application of progesterone is commonly used as an alternative to HRT, especially if vaginal dryness is present.
  • Hormonal medications:
  • Estrogen therapy remains, by far, the most effective treatment option for relieving menopausal hot flashes. Depending on the individual's personal and family medical history, a doctor may recommend estrogen in the lowest dose needed to provide symptom relief for the individual.
  • Conjugated estrogens: Conjugated estrogens are a mixture of estrogens prescribed to treat menopausal symptoms. The conjugated estrogens in Premarin® and Premarin Vaginal Cream® are obtained from pregnant mare urine. The conjugated estrogens in Cenestin® are synthetic.
  • Dienestrol: Dienestrol (Ortho-Dienestrol®) is a synthetic, nonsteroidal, estrogen vaginal cream used to treat atrophic vaginitis. Side effects include vaginal discharge, increased vaginal discomfort, uterine bleeding, vaginal burning sensation, breast tenderness, and peripheral edema.
  • Esterified estrogens: Esterified estrogens (Estratab®, Menest®) are estrogenic substances consisting of 75-85% natural estrogens and 15-25% equine (mare urine) estrogens. They are supplied in tablet form and are used to treat hot flashes and atrophic vaginitis and urethritis (infections due to thinning and drying of vaginal tissues).
  • Estradiol: Estradiol is one of the three major estrogens made by the human body and is the major estrogen secreted during the menstrual years. It is available as an oral pill (Estrace®), transdermal skin patch (Climara®, Estraderm®, Vivelle®), vaginal tablet (Vagifem®), and vaginal cream (Estrace Vaginal Cream®).
  • Estropipate (estrone): Estropipate is an estrogenic substance derived from estrone, one of the three major estrogens produced by the body. Estrone is produced from estradiol and is a less potent estrogen. It is available in pill form (Ogen®, Ortho-Est®) and prescribed to treat hot flashes and vaginal atrophy and to help prevent osteoporosis.
  • Ethinyl estradiol: Ethinyl estradiol (Estinyl®) is a synthetic nonsteroidal estrogen available as a tablet that is prescribed to treat hot flashes (vasomotor symptom). It is administered on a cyclical basis (such as three weeks on and one week off) with attempts to discontinue or taper at three to six month intervals.
  • Testosterone: Testosterone is one of the androgens or male hormones and is also produced by women. Testosterone contributes to muscle strength, appetite, well-being, and sex drive (libido). The level of testosterone falls rapidly after menopause, and some women take testosterone supplements in addition to estrogen and progestin as part of HRT. However, supplemental testosterone can produce side effects and has potentially serious risks. Common side effects include weight gain, acne, facial hair, and liver disease. Testosterone can exacerbate estrogen's carcinogenic effect on breast and uterine tissue.
  • Other medications:
  • Low-dose antidepressants: Venlafaxine (Effexor®) is an antidepressant in a group of drugs called selective serotonin and norepinephrine reuptake inhibitors (SSNRIs). Effexor® has been reported to decrease menopausal hot flashes. SSRIs may be helpful, including fluoxetine (Prozac®, Sarafem®), paroxetine (Paxil®), citalopram (Celexa®), and sertraline (Zoloft®). Side effects include drowsiness and fatigue.
  • Gabapentin (Neurontin®): Gabapentin (Neurontin®) is commonly used to treat seizures and for neuropathy (nerve pain), but it also has been reported to significantly reduce hot flashes. Side effects include drowsiness, sedation, blurred vision, nausea, vomiting, or tremor.
  • Clonidine (Catapres®): Clonidine (Catapres®) is typically used to treat high blood pressure. However clonidine may significantly reduce the frequency of hot flashes. Side effects include slow heart rate, low blood pressure, fatigue, dizziness, headache, constipation, nausea, vomiting, diarrhea, insomnia, or a dry mouth.
  • Bisphosphonates: Alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), and zoledronate (Zometa®) are approved by the U.S. Food and Drug Administration (FDA) for the prevention and treatment of osteoporosis in postmenopausal women. Alendronate is also approved for management of osteoporosis in men. Both alendronate and risedronate are approved for the prevention and treatment of steroid-induced osteoporosis in men and women. Bisphosphonates help slow down bone loss and have been shown to decrease the risk of fractures. All are taken on an empty stomach with water. Because bisphosphonates have the potential for irritating the esophagus, remaining upright for at least an hour after taking these medications is recommended by healthcare professionals. Alendronate and risedronate can be taken once a week, while ibandronate can be taken once a month. An IV form of ibandronate, given through the vein every three months, also has been FDA-approved for the management of osteoporosis. Another IV bisphosphonate being studied for osteoporosis is zoledronic acid or zoledronate (Zometa®). This form is injected once yearly.
  • Side effects, which can be severe, include nausea, abdominal pain, and the risk of an inflamed esophagus or esophageal ulcers, especially if the individual has had acid reflux or ulcers in the past. If individuals cannot tolerate oral bisphosphonates, the doctor may recommend the periodic intravenous infusions of a bisphosphonate.
  • Use of bisphosphonates in women who are pregnant or breastfeeding is not well studied. Blood calcium levels in women who take bisphosphonates during pregnancy are usually monitored. Individuals using ibandronate injection will have blood levels of creatinine measured prior to each dose to determine kidney function. Creatinine is measured using blood tests.
  • Selective estrogen receptor modulators (SERMs): Selective estrogen receptor modulators (SERMS) mimic the positive effects of estrogen on bones without some of the serious side effects such as breast cancer and stroke. Raloxifene (Evista®) decreases spine fractures in women, and is approved for use only in women at this time. Hot flashes are a common side effect of raloxifene, and individuals with a history of blood clots should not use this drug.
  • Vaginal estrogen: To relieve vaginal dryness, estrogen can be administered locally in the vagina using a vaginal tablet (Vagifem®), ring (Nuvaring®), or cream (Premarin® vaginal cream). This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse, and some urinary symptoms.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American College of Obstetricians and Gynecologists. .
  2. Bruno D, Feeney KJ. Management of postmenopausal symptoms in breast cancer survivors. Semin Oncol. 2006;33(6):696-707.
  3. Centers for Disease Control and Prevention. .
  4. Douglas S. Premenstrual syndrome. Evidence-based treatment in family practice. Can Fam Physician. 2002 Nov;48:1789-97.
  5. Harman SM. Estrogen replacement in menopausal women: recent and current prospective studies, the WHI and the KEEPS. Gend Med. 2006;3(4):254-69.
  6. Lata PF, Elliott ME. Patient assessment in the diagnosis, prevention, and treatment of osteoporosis. Nutr Clin Pract. 2007;22(3):261-75.
  7. Middleton ET, Steel SA. The effects of short-term hormone replacement therapy on long-term bone mineral density. Climacteric. 2007;10(3):257-63.
  8. National Women's Health Center. .
  9. Natural Standard: The Authority on Integrative Medicine. .
  10. North American Menopause Society. .
  11. Rosano GM, Vitale C, Marazzi G, et al. Menopause and cardiovascular disease: the evidence. Climacteric. 2007;10 Suppl 1:19-24.
  12. Women's Health America. .

Prevention and self-management
  • Fortunately, many of the signs and symptoms associated with women's hormonal imbalances are temporary. Take these steps to help reduce or prevent the unwanted symptoms of menopause.
  • Decreasing hot flashes: Hot Flashes are caused by rapid decreases in estrogen levels. Unfortunately hot flashes cannot be prevented. However, they can be helped and made less uncomfortable. Techniques that can help individuals deal with hot flashes include: wearing loose clothing and dressing in layers so the layers of clothing can be peeled off during a hot flash; wearing fabrics that absorb moisture and dry quickly; avoiding foods that may trigger hot flashes, such as hot drinks and spicy foods; splashing the face with cool water at the start of a flash; and avoiding stress.
  • Decreasing vaginal discomfort: Using over-the-counter (OTC) water-based vaginal lubricants (Astroglide®, K-Y®) or moisturizers (Replens®, Vagisil®) can help relieve vaginal dryness associated with low estrogen levels such as in menopause. Staying sexually active also helps with dryness.
  • Optimizing sleep: Healthcare professionals recommend avoiding caffeine, especially in the evening and at night. Exercise (during the day) can also help improve sleep. Relaxation techniques, such as deep breathing, guided imagery, and progressive muscle relaxation, can be very helpful.
  • Strengthening pelvic muscles: Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence. The exercises consist of the regular clenching and unclenching of the sex muscles that form part of the pelvic floor (sometimes called the "Kegel muscles").
  • Eating well: Eating a balanced diet that includes a variety of fruits, vegetables, and whole grains and that limits saturated fats, oils, and sugars is recommended by healthcare professionals. It is also recommended to consume 1,200-1,500 milligrams of elemental calcium and 800 I.U. (international units) of vitamin D a day. Eating smaller, more frequent meals each day may reduce bloating and the sensation of fullness.
  • A high protein diet or high coffee consumption increases calcium excretion and may increase the calcium needs for the body. Fiber, oxalates (in rhubarb, spinach, beets, celery, greens, berries, nuts, tea, cocoa), and high zinc foods (such as oysters and red meats) decrease absorption, requiring more calcium as a dietary supplement. The plant estrogens found in soy help maintain bone density and may reduce the risk of fractures, particularly in the first 10 years after menopause.
  • It is recommended to limit salt and salty foods to reduce bloating and fluid retention, choose foods high in complex carbohydrates, such as fruits, vegetables, and whole grains, and choose foods rich in calcium. If the woman cannot tolerate dairy products or is not getting adequate calcium in the diet, a daily calcium supplement may be needed.
  • Excessive alcohol has been associated with osteoporosis due to the degenerative metabolic effects of alcohol. Alcohol excess may inhibit calcium absorption and bone formation.
  • Weight control: Being underweight is a risk factor for osteoporosis. Staying within a healthy weight is important for individuals experiencing menopause.
  • Smoking cessation: Smoking increases the risk of heart disease, stroke, osteoporosis, cancer, and a range of other health problems. It may also increase hot flashes and bring on earlier menopause. It is never too late to benefit from stopping smoking. Smokers lose bone more rapidly than nonsmokers. Among 80 year olds, smokers have up to 10% lower bone mineral density, which translates into twice the risk of spinal fractures and a 50% increase in risk of hip fracture. Fractures heal slower in smokers, and are more apt to heal improperly.
  • Regular exercise: It is recommended by healthcare professionals to get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis, and other conditions associated with aging in women. More vigorous exercise for longer periods may provide further benefit and is particularly important if the individual is trying to lose weight. Exercise can also help reduce stress.
  • Regular checkups: A doctor can advise the individual about mammograms, Pap tests, lipid level (cholesterol and triglyceride) testing, and other screening tests.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.



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