Menopause

Overview

Menopause is when periods stop for good. It's diagnosed after 12 months without a menstrual period, vaginal bleeding or spotting. Menopause can happen in the 40s or 50s. But the average age is 51 in the United States.

Menopause is natural. But the physical symptoms, such as hot flashes, and emotional symptoms of menopause may disrupt sleep, lower energy or affect mood. There are many treatments, from lifestyle changes to hormone therapy.

Symptoms

Most often, menopause happens over time. The months or years leading up to menopause are called perimenopause or the menopausal transition.

During the transition, the amount of hormones your ovaries make varies. Perimenopause can last 2 to 8 years. The average is about four years.

The hormone changes can cause symptoms such as:

• Irregular periods.
• Vaginal dryness.
• Hot flashes.
• Night sweats.
• Sleep problems.
• Mood changes.
• Trouble finding words and remembering, often called brain fog.

Different people have different menopause symptoms. Most often, periods are not regular before they end.

Skipped periods during perimenopause are common and expected. Often, menstrual periods skip a month and return. Or they skip a few months and then start monthly cycles again for a few months.

Period cycles tend to get shorter in early perimenopause, so periods are closer together. As menopause gets closer, periods get farther apart for months before they end.

You can still get pregnant during this time. If you've skipped a period but aren't sure it's due to menopause, think about taking a pregnancy test.

When to see a doctor

Keep seeing your healthcare professional for wellness visits and medical concerns before, during and after menopause. See your healthcare professional as soon as you can if you bleed from your vagina after menopause.

Causes

Menopause can result from:

• Natural decline of hormones. As you enter your late 30s, your ovaries start making less of the hormones that control your period. These are called estrogen and progesterone. With lower levels of them, it's harder to get pregnant.

  In your 40s, your menstrual periods may get longer or shorter, heavier or lighter, and happen more often or less often. In time, your ovaries stop releasing eggs. Then you have no more periods. This happens on average around age 51.

• Surgery that removes the ovaries, called oophorectomy. Ovaries make hormones, including estrogen and progesterone, that control the menstrual cycle. Surgery to remove the ovaries causes instant menopause.

  Your periods stop. You're likely to have hot flashes and other menopausal symptoms. Symptoms can be severe because the surgery causes hormones to drop all at once rather than slowly over several years.

  Surgery that removes the uterus but not the ovaries, called hysterectomy, most often doesn't cause instant menopause. You no longer have periods. But your ovaries still release eggs and make estrogen and progesterone for a time.

• Chemotherapy and radiation therapy. These cancer therapies can cause menopause. They can cause symptoms such as hot flashes during or shortly after treatment. Periods sometimes return after chemotherapy. Then you can still get pregnant. So you might want to keep using birth control.

  Radiation therapy aimed at the pelvis, belly and lower spine can cause menopause. Radiation to the whole body for stem cell transplant also can cause menopause. Radiation therapy to other parts of the body, such as breast tissue or the head and neck, likely won't affect menopause.

• Primary ovarian insufficiency. About 1% of people who have menopause get it before age 40. This is called premature menopause. Premature menopause may result from the ovaries not making the usual levels of hormones. This is called primary ovarian insufficiency. It can happen from gene changes or an autoimmune disease.

  Often no cause of premature menopause can be found. Then healthcare professionals most often suggest hormone therapy. Taken at least until the typical age of menopause, hormone therapy can protect the brain, heart and bones.

Risk factors

People assigned female at birth go through menopause. The main risk factor is reaching the age of menopause.

Other risk factors include:

• Surgery to remove the ovaries.
• Certain cancer treatments.

Complications

After menopause, your risk of certain medical conditions increases. Examples include:

• Heart and blood vessel disease. This also is called cardiovascular disease. When your estrogen levels fall, your risk of cardiovascular disease increases. Heart disease is the leading cause of death in both women and men.
• Weakened bones, called osteoporosis. This condition causes bones to become brittle and weak, leading to a greater risk of breaking bones. During the first few years after menopause, you may lose bone density quickly. This ups your risk of osteoporosis. Bones often broken after menopause include the spine, hips and wrists.
• Loss of bladder control, called urinary incontinence. As the tissues of your vagina and urethra change, you may have sudden, strong urges to urinate often. Then you might lose urine, called urge incontinence. Or you might lose urine with coughing, laughing or lifting, called stress incontinence. You may have urinary tract infections more often.
• Sex problems. Menopause causes the vagina to get drier and lose its stretch. This can cause discomfort and slight bleeding during sexual intercourse. Also, less feeling in the area may lessen your desire for sex, called libido.
• Weight gain. Many women gain weight during and after menopause because calorie burning, called metabolism, slows.

Diagnosis

Most people can tell by the symptoms that they've started menopause. If you have worries about irregular periods or hot flashes, talk with your healthcare professional.

Tests most often aren't needed to diagnose menopause. But sometimes, your healthcare professional may suggest blood tests to check your levels of:

• Follicle-stimulating hormone (FSH) and estrogen (estradiol). FSH goes up and estrogen goes down during menopause. Because hormones go up and down during perimenopause, it can be hard to tell from these tests whether you're in menopause.
• Thyroid-stimulating hormone (TSH). Overactive thyroid, called hyperthyroidism, can cause symptoms like those of menopause.

You can get home tests to check FSH levels in your urine without a prescription. The tests show whether you have higher FSH levels. This might mean that you're in perimenopause or menopause.

But FSH levels rise and fall during your menstrual cycle. So home FSH tests can't really tell you whether you're in menopause.

Treatment

Menopause needs no treatment. Treatments aim to ease symptoms and prevent or manage ongoing conditions that may happen with aging. Treatments may include:

• Hormone therapy. Estrogen therapy works best for easing menopausal hot flashes. It also eases other menopause symptoms and slows bone loss.

  Your healthcare professional may suggest estrogen in the lowest dose and for the time needed to relieve your symptoms. It's best used by people who are younger than 60 and within 10 years of the onset of menopause.

  If you still have your uterus, you'll need progestin with estrogen. Estrogen also helps prevent bone loss.

  Long-term use of hormone therapy may have some heart disease and breast cancer risks. But starting hormones around the time of menopause has shown benefits for some people. Talk with your healthcare professional about whether hormone therapy may be safe for you.

• Vaginal estrogen. To relieve vaginal dryness, you can apply estrogen to the vagina using a vaginal cream, tablet or ring. This treatment gives you a small amount of estrogen, which the vaginal tissues take in. It can help ease vaginal dryness, pain with intercourse and some urinary symptoms.
• Prasterone (Intrarosa). You put this human-made hormone dehydroepiandrosterone (DHEA) into the vagina. It helps ease vaginal dryness and pain with intercourse.
• Low-dose medicines to treat depression, called antidepressants. Some antidepressants may ease menopausal hot flashes. These are called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRI). A low-dose antidepressant may help manage hot flashes in people who can't take estrogen for health reasons or for those who need an antidepressant for a mood disorder.
• Gabapentin (Gralise, Neurontin). Gabapentin is approved to treat seizures, but it also has been shown to help reduce hot flashes. This medicine is useful for people who can't use estrogen therapy and for those who also have nighttime hot flashes.
• Clonidine (Catapres-TTS-1, Nexiclon XR). This pill or patch most often treats high blood pressure. It might give some relief from hot flashes. It's not often prescribed for hot flashes because of the possible side effects, such as low blood pressure, headache, sleepiness and constipation.
• Fezolinetant (Veozah). This medicine is free of hormones. It treats menopause hot flashes by blocking a pathway in the brain that helps manage body temperature. It's FDA approved for managing menopause symptoms. It can cause abdominal pain, liver problems and make sleep problems worse.
• Oxybutynin (Oxytrol). This medicine treats overactive bladder and urinary urge incontinence. It's also been shown to relieve menopause symptoms. But in older adults, it may be linked to cognitive decline.
• Medicines to prevent or treat the bone-thinning condition called osteoporosis. Your healthcare professional might suggest medicine to prevent or treat osteoporosis. Several medicines can help reduce bone loss and risk of fractures. Your healthcare professional also might prescribe vitamin D supplements to help strengthen bones.
• Ospemifene (Osphena). Taken by mouth, this selective estrogen receptor modulator (SERM) medicine treats painful intercourse linked to the thinning of vaginal tissue. This medicine isn't for people who have had breast cancer or who are at high risk of breast cancer.

Before deciding on any form of treatment, talk with your healthcare professional about your choices and the risks and benefits of each. Review your choices yearly. Your needs and the treatment choices may change.

Lifestyle and home remedies

Many of the symptoms menopause causes go away on their own in time. In the meantime, the following might help:

• Cool hot flashes. Dress in layers, wear sleeveless tops and wear fabrics that breathe, such as cotton. Lower room temperatures and use hand or room fans. Put cold packs under your pillow and turn the pillow often so your head is on the cool side.

  It might also help to avoid triggers such as caffeine, alcohol and spicy foods.

• Ease vaginal pain. Try a water-based vaginal lubricant (Astroglide, Sliquid, others) or a silicone-based lubricant or moisturizer (Replens, K-Y Liquibeads, others). You can get these without a prescription.

  Stay sexually active by yourself or with a partner. This also can ease vaginal discomfort by increasing blood flow to the vagina.

• Get enough sleep. Skip caffeine and alcohol, which can make it harder to sleep. Exercise during the day, but not right before bedtime. If hot flashes disturb your sleep, find a way to help manage them so you can get better rest.
• Find ways to relax. There's little proof that deep breathing, guided imagery, massage and muscle relaxation can ease menopausal symptoms. But finding ways to relax is good for overall health and may help you cope with menopausal symptoms. You can learn how through books and websites.
• Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.
• Eat a balanced diet. Include a variety of fruits, vegetables and whole grains. Limit saturated fats, oils and sugars. Ask your healthcare professional if you need calcium or vitamin D supplements.
• Manage weight. Studies show that being obese is linked to having more and worse hot flashes. Losing weight and keeping it off may help ease them. Talk with your healthcare professional if you need help losing weight.
• Don't smoke. Smoking increases your risk of heart disease, stroke, osteoporosis, cancer and a range of other health problems. It also may increase hot flashes and bring on earlier menopause.
• Exercise regularly. Get regular physical activity or exercise on most days to help protect against heart disease, diabetes, osteoporosis and other conditions associated with aging.

Alternative medicine

There are many alternative medicines that claim to help ease the symptoms of menopause. But few of them have been proved in studies. Some complementary and alternative treatments that have been or are being studied include:

• Plant estrogens, also called phytoestrogens. There are natural estrogens in certain foods. There are two main types of phytoestrogens, called isoflavones and lignans. Soybeans, lentils, chickpeas and other legumes have isoflavones. Flaxseed, whole grains and some fruits and vegetables have lignans.

  It hasn't been proved that the estrogens in these foods can ease hot flashes and other menopausal symptoms. Isoflavones have some weak estrogen-like effects. So if you've had breast cancer, talk with your healthcare provider before taking isoflavone pills.

• Bioidentical hormones. These hormones come from plant sources. The term "bioidentical" implies the hormones in the product are chemically the same as those the body makes.

  The Food and Drug Administration (FDA) has approved some bioidentical hormones. But many are mixed in a pharmacy from a healthcare professional's prescription, called compounded. But the FDA doesn't regulate them, so quality and risks could vary.

  Bioidentical hormones have not been shown to work better or be safer than other hormone therapy.

• Cognitive behavior therapy. This type of therapy can help you change thoughts, feelings and behaviors that aren't healthy. It's been shown to reduce how much menopause symptoms bother you.
• Black cohosh. Black cohosh has been popular among many people with menopause symptoms. But there's little proof that black cohosh works. And it can harm the liver and not be safe for people with a history of breast cancer.
• Yoga. Yoga might ease menopause symptoms at least as well as other forms of exercise. And balance exercises such as yoga or tai chi can improve strength and help you move better. That may help prevent falls that could lead to broken bones.
• Acupuncture. Acupuncture may help to reduce hot flashes in the short term. But research hasn't shown that it helps a lot. More research is needed.
• Hypnosis. This mind-body therapy involves a deeply relaxed state and mental images. Hypnotherapy may lower the number of hot flashes and how bad they are for some menopausal people.

You may have heard of or tried other dietary supplements, such as red clover, kava, dong quai, DHEA, evening primrose oil and wild yam, a natural progesterone cream. There's no scientific proof that they work. Some of these products may be harmful.

Talk with your healthcare professional before taking any herbal or dietary supplements for menopause symptoms. The FDA does not oversee herbal products. Some can be harmful or affect other medicines you take, putting your health at risk.

Preparing for an appointment

Your first appointment will likely be with your primary healthcare professional or a gynecologist.

What you can do

Before your appointment:

• Keep track of your symptoms. For instance, make a list of how many hot flashes you have in a day or week. Note how bad they are.
• Make a list of all medicines, herbs and vitamin supplements you take. Include the doses and how often you take them.
• Ask a family member or friend to go with you, if possible. Someone with you can help you remember what your healthcare team tells you.
• Write down questions to ask your healthcare team. List your most important questions first.

Some basic questions to ask include:

• What tests do I need, if any?
• What treatments are there to ease my symptoms?
• What else can I do to ease my symptoms?
• Are there alternative therapies I might try?
• Are there any printed materials or brochures I can have?
• What websites do you suggest?

Be sure to ask all the questions you have.

What to expect from your doctor

Some questions your healthcare team might ask include:

• Are you still having periods?
• When was your last period?
• How often do you have symptoms that bother you?
• How bad are your symptoms?
• Does anything seem to make your symptoms better?
• Does anything make your symptoms worse?