Menopause

Today, more than ever, menopause is being accepted as a normal stage of a woman's life-not a disease. While it's true this change of life is marked by hormonal shifts that can cause symptoms and leave you more vulnerable to certain diseases, these symptoms can be controlled and diseases can be prevented.

By definition, menopause is the absence of menstrual periods for six to twelve months in a row and an elevated follicle-stimulating hormone (FSH) level. The cessation of menstruation indicates that there are no remaining follicles left in the ovaries. This leads to an end of ovarian estrogen production.

Most women associate menopause with the lack of menstruation, as well as the symptoms that are most prevalent roughly five years before and five years after their last period. The few years before and after your last period are known as " perimenopause" and "climacteric."

Perimenopause is heralded by the onset of irregular periods. The climacteric is a more encompassing term that defines the transitional time from the reproductive to the post-reproductive years. During perimenopause, your symptoms may include hot flashes, vaginal dryness, insomnia, and mood swings.

The good news is that more options exist than ever before for treating the symptoms of menopause and preventing the diseases associated with it. They range from behavioral modifications such as nutrition and exercise to medical treatments.

Indeed, your experience of menopause will be defined by a variety of lifestyle and genetic factors that are unique to you. Similarly, barring serious medical conditions, your approach to treatment can also be tailored to your personal choices. In short, like all changes, menopause presents a challenge-a challenge that can bring greater rewards when you are informed about it and your options.

Hormonal Changes

Menopause is a time of dramatic changes. To better understand them, a refresher course on the hormonal fluctuations that occur during your reproductive cycle may be helpful.

During your fertile years, starting at puberty, your monthly cycle begins with the release of the hormone Gonadatropin-releasing hormone (GnRH) from the hypothalamic region of the brain that is close to the pituitary gland. GnRH hormone triggers the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland. The release of FSH stimulates the development of follicles, or small structures in the ovary, which contain eggs.

Each month, FSH and LH stimulation cause the follicles to ripen and secrete estrogen and progesterone upon ovulation. These two hormones cause your uterus to thicken in preparation for pregnancy. LH triggers the release of a mature egg from the follicle. If pregnancy does not happen, progesterone and estrogen levels decline and the uterine lining (endometrium) sheds as menstrual blood. FSH levels increase in preparation for a new cycle.

As you age, the number and quality of follicles in your ovaries declines. Irregular menses are a sign that you are intermittently not ovulating. As a consequence of this, progesterone is not always produced. This erratic pattern may continue until menopause.

During this time, called the perimenopausal stage, estrogen levels also change unpredictably and dramatically. The changes in estrogen can cause different menopausal symptoms. The fluctuations in estrogen can contribute to erratic vaginal bleeding. At the times when estrogen levels are low, you may experience hot flashes. The depletion of estrogen results in vaginal and urinary changes, and higher risk of osteoporosis and heart disease.

As the reproductive stage of your life draws to a close, ovarian estrogen falls to undetectable levels. The ovary is no longer sensitive to FSH. FSH levels escalate, as do LH levels, and menstruation comes to an end.

When to Expect Menopause?

As menopause draws closer, you may experience changes in the characteristics of your periods. These may include irregular bleeding, periods that last for fewer or greater days, and heavier or lighter flow. This usually occurs when you are in your forties.

The average age of menopause (the last menstrual period) is 52. While the average age of puberty's onset has steadily declined, the average age of menopause has remained constant. There are exceptions, however.

One of which is surgical menopause, which results from the surgical removal of the ovaries (oophorectomy-with or without a removal of the uterus, know as a hysterectomy). A small percentage of women begin the physiologic journey to menopause before the age of forty, and start experiencing symptoms as early as their twenties. In contrast, a small number of women continue menstruating regularly until they are near sixty.

What accounts for this vast difference? There is some evidence that the onset of menopause follows a genetic pattern. If your mother went through menopause in her mid-fifties, for example, you are more than likely to follow her lead. Lifestyle factors also play a role in the arrival of menopause. Cigarette smoking may bring on an early menopause. Smoking hastens the body's breakdown of estrogen, resulting in lower estrogen levels than nonsmokers. It also may have a direct toxic affect on the ovary, inducing a more rapid loss of follicles.

What to Expect in Menopause

No two women will experience menopause in exactly the same way. Some women have hot flashes, for example, and about twenty percent of women have no symptoms at all. For up to ten percent of women, the symptoms are very mild, while about 20 percent of women have severe symptoms.

The way you feel during menopause or perimenopause will also be influenced by other factors that are unique to you, such as your overall health, nutrition, stress level, exercise routine, etc.


Symptom chart
Here are some of the changes that might occur with menopause. Keep in mind that most women experience only a few of these changes, and mostly in a mild form.

Symptom	Description
Irregular periods	Menstrual cycle may become longer or shorter, lighter or heavier.
Hot flashes	Dramatic sensation of heat, centering around the head, neck and chest; associated with heart palpitations, sweating, shallow breathing. May begin years before menopause.
Insomnia/hot sweats	Caused by night-time hot flashes.
Weight gain	Although many women attribute weight gain to menopause, studies have refuted this and found it to be more an age-related problem. Remember that men tend to gain weight at this time too.
Emotional effects	Irritability, anxiety, stress, depression. The exact cause is unknown but seems to be more problematic during perimenopause. Women who have a prior history of depression are more likely to have a worsening of symptoms at this time.
Bone loss (osteoporosis)	A reduced amount of bone, making the bones more fragile and thus, more susceptible to fractures.
Heart/blood vessel (cardiovascular) changes	Increased risk for hardening of the arteries. Also, blood vessels are less likely to dilate, preventing oxygen rich blood to flow to the heart, both increasing the risk of heart attacks.
Dryness and thinning of vaginal walls and bladder	Atrophy of vaginal mucosa and bladder may lead to dryness, painful intercourse, irritation, higher risk of infection, difficulty in controlling bladder. Atrophy of the urethra also increases the likelihood of bladder infections and problems with urine loss.

Hot Flashes

An estimated 85 percent of women in perimenopause experience hot flashes at some point. They vary in severity from woman to woman. Some women have just a vague feeling of being warm. For others, the hot flash comes on suddenly and quickly, starting with a rush of heat to the chest, neck, face and/or upper arms. The skin flushes with redness and beads with perspiration. The pulse steps up its pace and breathing quickens and becomes shallower.

These symptoms can last seconds or minutes, disappearing as quickly as they appear. They can occur rarely, or multiple times a day. In a woman who is still menstruating, hot flashes are usually most acute just before and after periods.

It's clear that the lack of estrogen plays a role in the occurrence of hot flashes. However, the exact cause of hot flashes remains unknown. A hot flash is actually a dysregulation of temperature control in the body. What initiates this dysregulation of temperature control is unknown.

However, we do know that a hot flash is brought on by a dilation of blood vessels on the surface of your body, which causes an increase in your body's surface temperature. In response, the body appropriately tries to compensate for this increase by sweating and decreasing the core temperature of the body.

Although hot flashes are not life threatening, they are uncomfortable enough to interrupt sleep (due to "night sweats"), work, and social activities. You c an arm yourself against the potentially disabling hot flash by dressing in layers, avoiding warm environments, avoiding hot and spicy foods, or by considering medical treatment.


Vaginal Dryness and Urinary Changes

The linings of the vagina, urethra (urinary opening), lower part of the bladder, and vulva are highly sensitive to changes in estrogen. Normally, these tissues are soft, moist, and elastic. Starved of estrogen, however, they become thinner, less flexible, and less able to produce lubrication. In medical terms, these changes are called atrophy. Unlike hot flashes, untreated vaginal and urethral atrophy persists throughout menopause and beyond, and can become more troublesome as time goes on.

In the vagina, atrophy may feel like dryness or a scratchy pain. Painful intercourse is the most common complaint. Estrogen loss also disrupts the delicate acid/alkaline balance of the vagina, possibly leading to vaginal infections, such as yeast infections and bacterial vaginosis. Using a water-based (not oil-based) vaginal lubricant can help relieve dryness but will not prevent infections.

Estrogen also has a direct affect on the urethra. A lack of estrogen leads to similar atrophic changes in the urethra as in the vagina. These changes can impair the urethra's ability to prevent involuntary loss of urine, especially while sneezing, coughing, or laughing. Atrophy may also make you more susceptible to bladder infections. Kegel exercises may be useful in maintaining bladder control by strengthening the internal muscles of your pelvis. However, they do not address the problem of atrophy of the urethra.


Weight Gain

Weight gain is a common complaint that is probably more closely related to aging than menopause. Many women find that diligent attention to their diet and increased exercise play an important role in maintaining their weight during this time. If weight gain is a continual problem, you may want to have your physician check your thyroid gland for any abnormalities. If thyroid function is normal, a referral to a nutritionist or specialized weight loss center that addresses nutrition, exercise, and behavioral changes can be quite rewarding.


Emotional Changes

Any change can bring stress. And "the change of life" can be a substantial stressor for some women. Many women report mood disturbances in the perimenopausal years. Laden with negative social connotations, menopause may be seen by some women as a negative change, causing a decline in self-image. Some women may mourn the loss of their reproductive capabilities. Women with a prior history of depression may be more susceptible to mood fluctuations of perimenopause.

As any woman who has experienced a hot flash knows, the physical symptoms alone can be a source of emotional stress. Loss of sleep due to night-time hot flashes (also known as "night sweats") can cause chronic fatigue. The good news is that most women note an improvement in their moods once menopause has occurred.

Tests for Menopause

Are your symptoms related to menopause or some other condition? The answer can have important health ramifications, and determine the course of your treatment. For example, palpitations can be caused by menopausal changes, emotional problems (e.g., panic disorder), or heart problems. The danger lies in misdiagnosis and administering incorrect treatment.

To make things more confusing, it is not always easy to know whether you are approaching menopause because the symptoms can wax and wane, vary widely from other women's, or not occur at all.

The best way to determine whether menopause is around the corner, or far down the road, is to first investigate your own menstrual patterns. If you notice a marked change in your menstrual cycle, you may have begun the perimenopausal transition.

In addition, you can have your doctor obtain a simple blood test that will measure the level of follicle stimulating hormone (FSH) in your body. FSH levels climb when estrogen levels drop. An elevated FSH level confirms that you will be approaching menopause within a year or two. However, it is important to note that both FSH and estrogen levels can fluctuate widely during your perimenopausal years.