Menopause and Perimenopause

Topic Overview

What is menopause? What is perimenopause?

Menopause is the point in a woman's life when she has not had her period for 1 year. It marks the end of the childbearing years. It's sometimes called "the change of life."

For most women, menopause happens around age 50. But every woman's body has its own time line. Some women stop having periods in their mid-40s. Others continue well into their 50s.

Perimenopause is the process of change that leads up to menopause. It can start as early as your late 30s or as late as your early 50s. How long perimenopause lasts varies, but it usually lasts from 2 to 8 years. You may have irregular periods or other symptoms during this time.

Menopause is a natural part of growing older. You don't need treatment for it unless your symptoms bother you. But it's a good idea to learn all you can about menopause. Knowing what to expect can help you stay as healthy as possible during this new phase of your life.

What causes menopause?

Normal changes in your reproductive and hormone systems cause menopause. As your egg supply ages, your body begins to ovulate less often. During this time, your hormone levels go up and down unevenly (fluctuate), causing changes in your periods and other symptoms. In time, estrogen and progesterone levels drop enough that the menstrual cycle stops.

Some medical treatments can cause your periods to stop before age 40. Having your ovaries removed, having radiation therapy, or having chemotherapy can trigger early menopause.

What are the symptoms?

Common symptoms include:

• Irregular periods. Some women have light periods. Others have heavy bleeding. Your menstrual cycle may be longer or shorter, or you may skip periods.
• Hot flashes.
• Trouble sleeping (insomnia).
• Emotional changes. Some women have mood swings or feel grouchy, depressed, or worried.
• Headaches.
• Feeling that your heart is beating too fast or unevenly (palpitations).
• Problems with remembering or thinking clearly.
• Vaginal dryness.

Some women have only a few mild symptoms. Others have severe symptoms that disrupt their sleep and daily lives.

Symptoms tend to last or get worse the first year or more after menopause. Over time, hormones even out at low levels, and many symptoms improve or go away.

Do you need tests to diagnose menopause?

You don't need to be tested to see if you have started perimenopause or reached menopause. You and your doctor will most likely be able to tell based on irregular periods and other symptoms.

If you have heavy, irregular periods, your doctor may want to do tests to rule out a serious cause of the bleeding. Heavy bleeding may be a normal sign of perimenopause. But it can also be caused by infection, disease, or a pregnancy problem.

You may not need to see your doctor about menopause symptoms. But it is important to keep up your annual physical exams. Your risks for heart disease, cancer, and bone thinning (osteoporosis) increase after menopause. At your yearly visits, your doctor can check your overall health and recommend testing as needed.

Do you need treatment?

Menopause is a natural part of growing older. You don't need treatment for it unless your symptoms bother you. But if your symptoms are upsetting or uncomfortable, you don't have to suffer through them. There are treatments that can help.

The first step is to have a healthy lifestyle. This can help reduce symptoms and also lower your risk of heart disease and other long-term problems related to aging.

• Make a special effort to eat well. Choose a heart-healthy diet that is low in saturated fat. It should include plenty of fish, fruits, vegetables, beans, and high-fiber grains and breads.
• Eat a nutritious diet and be sure you are getting adequate amounts of calcium and vitamin D to help your bones stay strong. Low-fat or nonfat dairy products are a great source of calcium.
• Get regular exercise. Exercise can help you manage your weight, keep your heart and bones strong, and lift your mood.
• Limit caffeine, alcohol, and stress. These things can make symptoms worse. Limiting them may help you sleep better.
• If you smoke, stop. Quitting smoking can reduce hot flashes and long-term health risks.

If lifestyle changes aren't enough to relieve your symptoms, you can try other measures, such as breathing exercises and yoga.

If you have severe symptoms, you may want to ask your doctor about prescription medicines. Choices include:

• Low-dose birth control pills before menopause.
• Low-dose hormone therapy (HT) after menopause.
• Antidepressants.
• A medicine called clonidine (Catapres) that is usually used to treat high blood pressure.

All medicines for menopause symptoms have possible risks or side effects. A very small number of women develop serious health problems when taking hormone therapy. Be sure to talk to your doctor about your possible health risks before you start a treatment for menopause symptoms.

Remember, it is still possible to become pregnant until you reach menopause. To prevent an unwanted pregnancy, keep using birth control until you have not had a period for 1 full year.

Frequently Asked Questions

Cause

Menopause is a natural part of aging. As you age, the number and quality of your eggs decline, hormone levels fluctuate, and your menstrual cycle becomes less predictable until it finally stops completely.

Causes of early menopause

Certain lifestyle choices and medical treatments can cause or are linked to an earlier menopause, including:

• Smoking. On average, women who smoke reach menopause 1½ years earlier than those who don't. The longer you have smoked and the more you smoke, the stronger this effect is likely to be.^{footnote 1}
• Radiation therapy to or removal of the pituitary gland.
• Chemotherapy.
• Radiation therapy or other treatment to the abdomen or pelvis that damages the ovaries so that they no longer function.
• Genetic and autoimmune diseases.
• Removal of both ovaries (oophorectomy), which causes sudden menopause.
• Low body fat.

Symptoms

The first sign that you are nearing menopause is a change in your menstrual periods. They may become less frequent. And they may be lighter or heavier than you're used to.

Menopause symptoms range from mild (or none) to severe. They include:

• Hot flashes.
• Sleep disturbances (insomnia).
• Emotional changes, such as mood swings or irritability.
• A change in sexual interest or response.
• Problems with concentration and memory that are linked to sleep loss and fluctuating hormones (not a permanent sign of aging).
• Headaches.
• Rapid, irregular heartbeats (heart palpitations).

These symptoms usually go away after 1 or 2 years. But some women have them for several years longer.

Other conditions can cause similar symptoms. Examples include pregnancy; a significant change in weight; depression; anxiety; or uterine, thyroid, or pituitary problems.

Menopause caused by surgery, chemotherapy, or radiation therapy can cause more severe symptoms than usual. Preexisting conditions such as depression, anxiety, sleep problems, or irritability can also make symptoms worse.

Later symptoms

After you stop having menstrual periods, you may get other symptoms, including:

• Drying and thinning of the skin, caused by lower collagen production.
• Vaginal and urinary tract changes, such as:
  • Vaginal dryness, irritation, and itching.
  • An increased risk of vaginal and urinary tract infections (UTIs).
  • Pain with sexual activity.

What Happens

In your late 30s, your egg supply begins to decline in number and quality. As a result, your hormone production changes. You may notice a shortened menstrual cycle and some premenstrual syndrome (PMS) symptoms that you didn't have before.

Gradually, your periods become irregular. This can start as early as your late 30s or as late as your early 50s. It continues for 2 to 8 years before menstrual cycles end.

During this time, your ovaries are sometimes producing too much estrogen and/or progesterone and at other times too little. Your progesterone is likely to fluctuate more than before. This can lead to heavy menstrual bleeding. (If you have heavy or unexpected vaginal bleeding, see your doctor to be sure it isn't caused by a more serious condition.)

About 6 months to a year before your periods stop, your estrogen starts to drop. When it drops past a certain point, your menstrual cycles stop. After a year of no menstrual periods, you are said to have "reached menopause."

During the next year or so, estrogen levels keep going down. This lowers your risk for certain types of cancers (estrogen is linked to some types of cancerous cell growth). But low estrogen also creates some health concerns, such as:

• Bone loss. Low estrogen levels after menopause speed bone loss, increasing your risk of osteoporosis.
• Skin changes. Low estrogen leads to low collagen, which is a building block of skin and connective tissue. It's normal to have thinner, dryer, wrinkled skin after menopause. The vaginal lining and the lower urinary tract also thin and weaken. This condition can make sexual activity difficult. It can also increase the risk of vaginal and urinary tract infections.
• Tooth and gum changes. Low estrogen affects connective tissue, which increases your risk of tooth loss and possibly gum disease.

Although the reasons aren't well understood, a woman's risk of heart disease increases after menopause. Because heart disease is the number one killer of women, consider your heart risk factors when making lifestyle and treatment decisions.

When to Call a Doctor

Call your doctor if you have:

• Menstrual periods that are unusually heavy, irregular, or prolonged (1½ to 2 times longer than normal).
• Bleeding between menstrual periods, when periods have been regular.
• Renewed bleeding after having no periods for 6 months or more.
• Unexplained bleeding while you are taking hormones.
• Symptoms, such as insomnia, hot flashes, or mood swings, that aren't responding to home treatment and are interfering with your sleep or daily life.
• Vaginal pain or dryness that doesn't improve with home treatment, or you have signs of a urinary tract infection, such as pain or burning during urination or cloudy urine.

Who to see

The following health professionals can help you manage menopause symptoms and evaluate menstrual period changes:

• Family medicine doctor
• Gynecologist
• Internist
• Nurse practitioner
• Physician assistant

Exams and Tests

Your age, your history of menstrual periods, your symptoms, and the results of your pelvic exam will tell your doctor whether you are near or at menopause. If possible, bring a calendar or journal of your periods and symptoms.

If you have severe symptoms, if your doctor suspects another medical condition, or if you have a medical condition that makes a diagnosis difficult, your doctor may do one or more of the following blood tests:

• A pregnancy test is done if there is a chance that you are pregnant. (This can also be a urine test.)
• A follicle-stimulating hormone (FSH) test can be used to confirm whether you have reached menopause. FSH levels increase during perimenopause and are high after menopause.
• An estrogen test is sometimes done to see how low estrogen has dropped after menopause.
• A thyroid-stimulating hormone test is used to see whether irregular menstrual periods or perimenopause-like symptoms are being caused by a thyroid problem.

If you have had no menstrual periods for 1 year, this is a good time to have a full physical exam, with particular focus on your heart health and risk factors for osteoporosis.

Treatment Overview

Menopause is a natural part of aging. But symptoms can be difficult for some women.

If you have trouble sleeping, mood swings, hot flashes, cloudy thinking, heavy menstrual periods, or other symptoms, treatment can help you get through this time more comfortably.

Treatment for menopause symptoms may include:

• Healthy lifestyle habits, including exercise, healthy eating, and quitting smoking. To learn more, see Home Treatment.
• Hormones and other medicines, such as antidepressants. To learn more, see Medications.
• Treatments such as black cohosh and soy. To learn more, see Other Treatment.

Home Treatment

A healthy lifestyle can help you manage menopause symptoms. It can also help lower your risk for heart disease, osteoporosis, and other long-term health problems.

• If you smoke, stop smoking to reduce hot flashes and long-term health risks.
• Exercise regularly to promote both physical and emotional health.
• Limit alcohol intake to reduce menopause symptoms and long-term health risks.
• Make healthy eating a priority. Cut back on simple sugars and caffeine, which can make menopause symptoms worse. You'll not only feel better but may also prevent long-term health problems.
• Pay attention to how the emotional side of menopause is affecting you. Have a support network, and seek help as needed.
• Make sure you get enough calcium and vitamin D. Eat foods that are rich in calcium, and take calcium and vitamin D supplements. This can help lower your risk of osteoporosis.
• Improve bladder control with regular Kegel exercises.

To manage hot flashes, try keeping your environment cool, dressing in layers, and managing stress.

Menopause: Managing Hot Flashes

Stress Management: Relaxing Your Mind and Body

To improve vaginal dryness and muscle tone, try using a vaginal lubricant and doing Kegel exercises regularly.

Medications

Medicines can help you cope with bothersome menopause symptoms. Some medicines contain hormones, and some don't.

Hormone therapy is sometimes used to treat menopause symptoms. But women who use it may have a higher risk of other health problems.

Menopause: Should I Use Hormone Therapy (HT)?

If your symptoms are the result of early menopause brought on by having your ovaries removed along with your uterus, you may consider estrogen therapy (ET). But ET may increase the risk of health problems in a small number of women.

Hysterectomy and Oophorectomy: Should I Use Estrogen Therapy (ET)?

Medicine choices

Hormone medicines

• Birth control pills regulate menstrual bleeding and can relieve symptoms until menopause. They aren't used after menopause.
• Progestin pills and the levonorgestrel IUD release a form of progesterone into the uterus. This reduces heavy, irregular menstrual periods. Some women have side effects.
• Low-dose vaginal estrogen (cream, tablet, or ring) reduces dryness and other tissue changes in and around the vagina.
• Hormone therapy (HT) in pill, patch, vaginal ring, gel, spray, or cream form can be used to treat menopause symptoms. Experts recommend that HT only be used at the lowest effective dose for the shortest possible period of time.^{footnote 2, footnote 3}
• Bioidentical hormones are made in a lab to be similar to human-produced hormones. Some bioidentical hormones are prepared in a compounding pharmacy based on a woman's individual hormone levels. But unlike those made by pharmaceutical companies, these aren't regulated by the FDA. They may carry the same health risks that traditional HT does.^{footnote 4} Any form of hormone therapy is best taken for as short a time as possible.
• Estrogen therapy (ET) is used to prevent weakening bones and the severe symptoms that come with sudden, early menopause.
• Testosterone with estrogen is sometimes used for menopausal symptoms that don't improve with estrogen therapy. But it isn't FDA-approved, because its risks aren't yet fully known. Testosterone with estrogen carries the same risks as estrogen treatment (blood clots, stroke, breast cancer) as well as testosterone risks and side effects.

Short-term, low-dose HT or ET can be taken for up to 4 to 5 years, with regular checkups. This may work well for many women, who will find that their menopause symptoms have subsided within this period of time.

Non-hormone medicines

• Antidepressants can lower the number and severity of hot flashes. They may also help with irritability, depression, and moodiness.
• Clonidine, a high blood pressure medicine, can reduce the number and severity of hot flashes.^{footnote 5} Some women have side effects related to low blood pressure.
• Gabapentin (Neurontin) is an antiseizure medicine. It can reduce the number and severity of hot flashes.^{footnote 6} Possible side effects include sleepiness, dizziness, and swelling.
• Ospemifene (Osphena) is used to reduce vaginal changes that can make sex painful.

Other Treatment

Many women have turned to alternative medicine for menopause symptom relief. Before you try prescription medicines or hormones, you can think about using one or more of the following options for preventing or treating symptoms.

• Mind and body relaxation using breathing exercises. It may reduce hot flashes and emotional symptoms.
• Black cohosh (such as Remifemin) may prevent or relieve menopause symptoms. But the research on black cohosh has had mixed results.
• Soy may improve menopause symptoms. But studies have shown mixed results.
• Yoga (which often includes meditative breathing) and/or biofeedback gives you tools you can use to reduce stress. High stress is likely to make your symptoms worse.

Remember that dietary supplements aren't regulated the way medicines are. It's important to be careful when taking supplements. Tell your doctor what you are taking.

Treatments to avoid

Based on the latest research, some treatments aren't recommended, either because they don't work or because they can cause dangerous effects.^{footnote 7} These include:

• Angelica.
• DHEA (dehydroepiandrosterone).
• Dong quai.
• Evening primrose.
• Kava.
• Wild yam or natural progesterone creams.