Menopause is an important health issue. This health feature offers information about menopause: how to tell if you’re entering it, the role of estrogen replacement therapy, and tips on making yourself more comfortable – and staying healthy – as your body adjusts to this new phase.

Menopause – a change of life

All women eventually enter menopause, also known as “the change” or climacteric, which marks the end of a woman’s reproductive life. The stage you go through before actual menopause is called perimenopause, which takes place over about two to eight years (the average is four years) as the body undergoes its hormone-driven changes. This is the time when levels of estrogen, progesterone, and androgen start to decrease. The ovaries gradually stop releasing follicles (eggs), eventually ending your reproductive stage of life. As the body adjusts to this new stage, certain signs and symptoms can occur.

Perimenopause

During perimenopause, you might start to experience some of the symptoms of menopause but still have menstrual periods. However, menstrual periods tend to become more and more irregular during this time. You’ve officially entered menopause when your doctor has confirmed that you’re no longer ovulating (there’s a special blood test to check this), or when you haven’t had a single period in a whole year. Keep in mind that, unless your doctor tells you for sure, or until the full year is up, there’s still a chance you can get pregnant.

Women are most likely to be between ages 40 and 60 years when they experience natural menopause – the average age is about 51. If you begin to go through menopause before the age of 40, it’s called premature or early menopause. Menopause occurring after the age of 55 is considered a late menopause.

Induced menopause

Some women experience induced menopause, which can happen for one of three reasons:

• Surgical menopause is triggered by having both ovaries removed during an operation. Women who have hysterectomies (removal of the uterus, therefore no menstrual periods) may or may not have their ovaries taken out, depending on how extensive the surgery was and why it was done.
• Chemotherapy-induced menopause is brought on by chemotherapy, usually in the course of being treated for cancer. These drugs can affect the ovaries enough to begin the process but, depending on different factors, chemotherapy-induced menopause isn’t always complete or permanent.
• Radiation-induced menopause can happen while undergoing radiotherapy for cancer. If the ovaries are exposed to enough radiation, they’ll begin to shut down.

Signs and symptoms of menopause

The signs and symptoms of menopause – and how severe they are – vary so much from woman to woman that it’s hard to know fully what to expect. Some women go through menopause with only a few hot flushes. Others feel most symptoms to the hilt. Some doctors say that the best guide to knowing how you’ll be affected is to get your closest female relatives – mothers, aunts and grandmothers – to tell you about their experiences.

How can you tell if you’re entering menopause? Some signs include:

• less frequent or erratic periods, which last for fewer days or have a lighter flow (although some women temporarily experience much heavier flows than usual during perimenopause)
• hot flushes (or flashes) – bursts of feeling extremely hot, accompanied by sweating – which can range from being mildly annoying to intensely uncomfortable (some women are awakened by night sweats that literally drench their sheets)
• insomnia or difficulty staying asleep
• mood changes
• vaginal dryness and itching
• decreased libido
• headaches
• difficulty concentrating
• urinary incontinence (leakage)

You should know that irregular bleeding, along with some of these symptoms, might be due to another cause. See your doctor to rule out other possible conditions.

Menopause is a very personal life event. Knowing what to expect can go a long way to easing any concerns or anxieties you may have about going through “the change.” There’s an upside, too: many women after menopause say that they’ve never felt better!

The estrogen question

Is taking estrogen right for you? Is it safe? You’ve probably heard a lot about hormone replacement therapy (HRT), which may be used to treat the symptoms of menopause and, in some cases, to protect against osteoporosis and colorectal cancer. HRT is a controversial topic, especially now that the results of a major U.S. study (the Women’s Health Initiative [WHI] study) have become available. To help sort out the issues, here are some key points that can help you decide what’s right for you.

First, you need to speak with your doctor. You may be interested in taking hormone replacement but it’s not advised for women with certain health issues. This type of therapy isn’t recommended if you have a history of:

• endometrial or breast cancer
• blood clots
• stroke
• unexplained vaginal bleeding
• active liver disease

Some women ask why they should take hormones for a perfectly natural stage of life. After all, it’s not a medical condition, is it? True, menopause is a normal state and doesn’t pose any serious health problems on its own. On the other hand, hormone replacement may help certain women in a few ways:

• by helping to get through the worst of their symptoms, including irregular bleeding, hot flashes, night sweats, difficulty sleeping, mood disturbances, and vaginal dryness
• by protecting against osteoporosis: the WHI study found that taking a combination of estrogen plus progestin decreased overall fracture risk by 24% (the risk was reduced from 11.1% in women who did not take active medication to 8.6% in women taking estrogen plus progestin) and hip fracture risk by 33%. Estrogen and progestin also increased bone density in the hip by 3.7% (compared with 0.14% in women who did not take active medication). However, because of the risks of HRT, it is not recommended for preventing osteoporosis. It is not routinely recommended for treating osteoporosis except for cases where the benefits outweigh the risks.
• by reducing the risk of colorectal cancer: the WHI study found that taking a combination of estrogen plus progestin decreased the risk of colorectal cancer by 44%. This translates to six fewer colorectal cancers for every 10,000 women over one year.
• by reducing the risk of diabetes: in the WHI study, women taking a combination of estrogen plus progestin had a 21% lower risk of diabetes. This translates to 15 fewer cases of diabetes for every 10,000 women over one year. However, HRT is not recommended for the sole purpose of preventing diabetes because of its risks.

HRT also has some risks. Some of the side effects can include:

• tender breasts
• nausea
• abdominal bloating
• vaginal bleeding
• uterine cramps
• weight gain
• headaches
• mood swings
• irritability

Estrogen replacement therapy can increase the risk of endometrial (uterine lining) cancer in women with an intact uterus. This is why women who have a uterus are also prescribed a progestin (such as medroxyprogesterone acetate) to protect them from endometrial cancer. Taking a progestin with estrogen replacement therapy reduces the risk of endometrial cancer to a similar (same or lower) level compared with women who are not taking estrogen replacement therapy.

The Women’s Health Initiative (WHI) study recently found that the use of a certain combination of estrogen and progestin taken in pill form (a combination of conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5 mg) significantly increases the risk of breast cancer, heart disease, and stroke. It is important to note that not all forms of HRT have been linked to an increased risk and that these risks occurred with long-term versus short-term usage. It is also important to note that the group of women studied in the trial had an average age of 63 years (with a range of 50 to 79 years), and none had severe menopause symptoms (many had no symptoms at all). Therefore, it is not known to what extent the results will apply to postmenopausal women who have different characteristics than the study group.

Specifically, initial study findings showed that the hormones increased a healthy woman’s risk of:

• heart disease by 29%
• stroke by 41%
• breast cancer by 26%

Although these increases seem high, the actual number of cancers, heart attacks, strokes, and blood clots among the women in the study was small. The study authors say that given the increased risks they found, a group of 10,000 women who took the hormone combination for one year would experience:

• seven additional heart attacks
• eight more breast cancers
• eight additional strokes
• eight more blood clots in the lungs

The Women’s Health Initiative (WHI) also studied women taking estrogen alone (women who had had a hysterectomy). For every 10,000 women taking estrogen alone, the risks and benefits for these women were (per year):

• an increased risk of stroke: 12 more cases of stroke
• possibly, an increased risk of blood clots: six more women with blood clots
• a decreased risk of hip fractures: six fewer women with hip fractures
• possibly, a decreased risk of breast cancer: seven fewer breast cancers

As a result of the WHI study, the Society of Obstetricians and Gynecologists of Canada (SOGC) does not recommend that hormone replacement therapy be started or continued for the sole purpose of preventing heart disease, since estrogen plus progestin can actually increase the risk, and estrogen alone does not have any significant effect on the risk. Hormone replacement therapy may be used to treat menopausal symptoms (such as hot flashes), or to protect against osteoporosis and colorectal cancer. However, it is not recommended for women who do not have any menopausal symptoms. The current thought is that the risk of developing breast cancer increases after five years of taking HRT. Because some symptoms of menopause subside after two to three years, a woman should re-evaluate her need for HRT each year. The SOGC recommends that the lowest effective dose of HRT should be used for the shortest period of time needed.

Since each woman’s health history is different, it’s important that you openly discuss your concerns and needs with a doctor. Together, you can weigh the pros and cons of hormone replacement. If you decide not to take hormone replacement therapy, there are other treatment options for menopausal symptoms and osteoporosis. If you decide to go ahead with hormone replacement, you’ll be prescribed a treatment plan that’s tailored for you. Hormone replacements come in many forms and dosages, including pills, patches, gels, vaginal preparations, and injections.

The first time hormone therapy is suggested might be while you’re still in perimenopause. Some doctors recommend low-dose contraceptive pills to help regulate the menstrual cycle as it becomes more irregular. It’s convenient, but the drawback is that you can’t tell if your period has stopped completely or not.

It’s only natural

Whether or not you choose hormone replacement, other methods may help ease some of the discomforts of perimenopause and menopause. Because not all women are affected the same way, finding the right solution is sometimes a matter of trial and error.

For hot flashes:

• stop smoking
• avoid caffeine and alcohol
• get regular exercise
• decrease body mass index (BMI) if your doctor says it’s too high
• reduce stress either by relaxation, biofeedback, meditation, or some other method you find soothing
• lower your room temperature
• dress in layers to reduce body temperature as needed

For insomnia:

• don’t eat a heavy snack before bed
• avoid caffeine and alcohol
• make your bedroom as inviting and “sleepy” as possible; don’t use your bedroom for anything other than sleeping or sexual intimacy
• develop a calming bedtime routine every night
• avoid taking daytime naps

For problems with urinating too often or having episodes of urinary incontinence (leakage):

• avoid hard alcohol or any liquid that triggers the need to urinate such as coffee, tea, or beer
• practice Kegel (pelvic) exercises daily
• wear a pad if you’re afraid of being caught in an embarrassing situation

Don’t limit your fluid intake to keep from urinating unless you’re advised to do so by your doctor. Dehydrating yourself will make menopausal symptoms worse.

For decreased sexual desire:

• if you don’t have enough vaginal lubrication, try using a water-soluble gel
• set a sexy mood by wearing that special gown, lighting candles, or playing romantic music

It also helps to let your partner know how you’re feeling, so that you can both take the time to get in the mood.

You can also speak to your doctor about highly effective non-hormonal medications to treat your menopausal symptoms. For example, venlafaxine or clonidine may reduce the frequency of your hot flashes, and medications called selective serotonin reuptake inhibitors (SSRIs) may help control mood swings.

If you’d like to try herbal remedies for some of your symptoms, check with your doctor or pharmacist to be sure that these don’t interact with any medications you are taking and that you don’t have any medical conditions where these herbal remedies should be avoided.

Staying healthy after menopause

It used to be that the average lifespan of a woman in North America only extended into the early 60s. Now that women are living into their 70s, 80s and beyond, this brings a whole new dimension to women’s health.

The main health concerns after menopause are osteoporosis, heart disease and breast cancer. We’ve been told that hormone replacement can help lessen the risk of osteoporosis, but if you’re one of the women who can’t take the drugs or have decided not to, there are other ways to help protect yourself. These measures benefit all women – whether they’re on hormone replacement or not.

To protect against osteoporosis

• Osteoporosis Canada recommends taking 1,200 mg of calcium per day, along with 800 to 2,000 IU of vitamin D daily if you are over 50 years old. Be sure to mention if you’re taking any kind of supplement to your doctor.
• Stay active. If you haven’t already and can do so, begin a weight-bearing exercise program. Studies have shown that weight-bearing exercises encourage healthy bones and prevent bone mass loss. If you can’t participate in a regular program, simple walking routines or gardening also help. If you’re one of the many women with joint pain, perhaps swimming would be a good option for you.
• Stop smoking, avoid caffeine and eat a well-balanced diet with plenty of calcium and vitamins.

There are also medications specifically designed to treat bone loss, so you may want to discuss this with your doctor if needed. As well, you may want to go for a bone-density measurement test to get a baseline measurement. This way, you and your doctor will know where you stand and if you’ll need regular monitoring.

In the past, hormone replacement therapy was also used to protect against heart disease. However, a major clinical study, the Women’s Health Institute (WHI) study, has found that instead of preventing heart disease, long-term use of hormone replacement therapy actually increases the risk. For this reason, it is no longer recommended that women take hormone replacement therapy for the sole purpose of preventing heart disease. Therefore, it’s more important than ever for women to find other ways to reduce their risk of heart disease.

To protect against heart disease

• Stop smoking. Yes, you’ve heard it before, but here’s yet another good reason to quit. Cigarettes increase your risk of stroke and heart disease.
• Eat a healthy, balanced diet that is low in saturated fats.
• Watch your blood pressure. Have it checked regularly and follow your doctor’s recommendations for lowering it, including medication if needed.
• Watch your weight. Obesity contributes to heart disease.
• Get physical. Move around to keep your heart healthy.
• Try to limit your stress levels.

If you’re in perimenopause, or have already entered menopause, it’s important to take stock of your health status, especially if you’re aware of conditions for which you may be at high risk. Talk to your doctor about the options available to keep you healthy. Information about taking preventive steps can help you fully enjoy the many years to come after menopause.

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