Menopause and Perimenopause

Topic Overview

What is menopause?

Menopause is the point in your life when you permanently stop having menstrual periods. After 1 year of having no periods, you've reached menopause.

In most cases, menopause happens around age 50. But everyone's body has its own time line. You may stop having periods in your mid-40s. Or you might have them well into your 50s.

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.

What is perimenopause?

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.

What causes menopause?

Normal changes in your body cause menopause. You start to ovulate less often. Your hormone levels fluctuate, causing changes in your periods. Over time, you stop ovulating and the levels of the hormone estrogen drop. This causes your menstrual cycle to stop. Some medical treatments can trigger early menopause.

What are the symptoms?

Menopause symptoms include hot flashes, trouble sleeping, and vaginal dryness. You may have only a few mild symptoms. Or you might have severe symptoms. Symptoms tend to get worse the first year after menopause. But then many of them improve or go away.

How is it diagnosed?

Your age, your history of menstrual periods, and your symptoms will tell your doctor if you are near or at menopause. You likely won't need to be tested to see if you have started perimenopause or reached menopause. But if your doctor suspects another medical condition, you may have some tests.

How is menopause treated?

If your symptoms are bothering you, there are treatments that can help. Medicines may include hormonal birth control, hormone therapy, antidepressants, clonidine, or gabapentin. Other treatments that may help include cognitive behavioral therapy, hypnosis, and an over-the-counter vaginal lubricant.

How can you care for yourself?

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. Quitting smoking can reduce hot flashes and long-term health risks.
• Get regular exercise. It can help you manage your weight, keep your heart and bones strong, and lift your mood.
• Limit caffeine and alcohol. This may help manage menopause symptoms.
• Eat a heart-healthy diet. Choose foods like vegetables, fruits, nuts, beans, fish, or whole grains. Limit foods that have a lot of salt, fat, and sugar.
• Be sure you are getting enough calcium and vitamin D to help your bones stay strong. Eat foods that are rich in calcium. Ask your doctor if taking a supplement with calcium and vitamin D is right for you.
• Try to manage stress. Breathing exercises, mediation, or yoga may help.

Cause

Normal changes in your reproductive and hormone systems cause menopause. Your body starts to ovulate less often. During this time, your hormone levels go up and down unevenly (fluctuate). This causes changes in your periods and may cause other symptoms. Over time, you stop ovulating, and estrogen and progesterone levels drop. This causes your menstrual cycle to stop.

Certain lifestyle choices and medical treatments are linked to an earlier menopause. They include:

• Smoking.
• Radiation therapy to or removal of the pituitary gland.
• Chemotherapy.
• Radiation therapy or other treatment to the belly or pelvis that damages the ovaries so that they no longer function.
• Genetic and autoimmune diseases.
• Removal of both ovaries (oophorectomy). This causes sudden menopause.
• Low body fat.

Symptoms

Symptoms may include:

• Hot flashes.
• Trouble sleeping.
• Vaginal dryness and sexual problems.

Symptoms related to mood and thinking may also happen around the time of menopause. These include:

• Mood swings, or feeling depressed or worried.
• Problems with remembering or thinking clearly.

You may have only a few mild symptoms. Or you might have severe symptoms that disrupt your sleep and daily life.

Symptoms tend to last or get worse the first year or more after menopause. Over time, hormones even out at low levels. Many symptoms improve or go away. But sometimes symptoms don't go away.

What Happens

In your late 30s, your egg supply starts to decline and hormone production changes. You may notice a shorter menstrual cycle and new PMS symptoms.

Starting sometime between your late 30s and your early 50s, your periods become irregular. This lasts for 2 to 8 years.

During this time, your ovaries sometimes produce higher and sometimes lower amounts of hormones. This can lead to heavy menstrual bleeding.

About 6 to 12 months before your periods stop, your ovaries stop releasing eggs. Estrogen levels drop. This causes your periods to stop. After a year of no periods, you have reached menopause.

During the next year or so, estrogen levels keep going down. This creates some health concerns, including:

• Higher risk of osteoporosis.
• Skin changes, including thinner, drier skin; thinner, weaker vaginal lining and urinary tract; and higher risk of vaginal and urinary tract infections.
• Higher risk of tooth loss and gum disease.

When To Call

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.

Exams and Tests

Your age, your history of menstrual periods, and your symptoms will tell your doctor if you are near or at menopause. If you can, bring a calendar or journal of your periods and symptoms.

You likely won't need to be tested to see if you have started perimenopause or reached menopause. But if your doctor suspects another medical condition, you may have some tests. Tests may include a pregnancy test or hormone tests.

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.

Treatment Overview

If your symptoms are bothering you, there are treatments that can help.

Medicines may include:

• Hormonal birth control before menopause.
• Hormone therapy (HT).
• Antidepressants.
• Clonidine.
• Gabapentin.

Other treatments that may help include cognitive behavioral therapy, hypnosis, and an over-the-counter vaginal lubricant.

Self-Care

A healthy lifestyle may 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. Quitting smoking can reduce hot flashes and long-term health risks.
• Exercise regularly. It can help you manage your weight, keep your heart and bones strong, and lift your mood.
• Limit alcohol and caffeine. This may help manage menopause symptoms and reduce long-term health risks.
• Eat a heart-healthy diet. Choose foods like vegetables, fruits, nuts, beans, fish, or whole grains. Limit foods that have a lot of salt, fat, and sugar.
• If you are overweight, try to lose a little weight. In addition to overall health benefits, weight loss may reduce hot flashes.
• 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. This can help lower your risk of osteoporosis. Ask your doctor if taking a supplement with calcium and vitamin D is right for you. The amount of calcium and vitamin D that you need to take depends on your age, your health, and how much calcium you get from the foods you eat.
• Improve bladder control with regular Kegel exercises.
• To manage hot flashes, keep your environment cool, dress in layers, and manage stress.
• If you're having problems with vaginal dryness, try these things:
  • Use an over-the-counter lubricant before intercourse. Lubricants can be water-, silicone-, or oil-based. Ask your doctor about what kind may be a better option for you.
  • Use a vaginal moisturizer, such as Replens. It can be used on a regular basis to help reduce vaginal dryness.
  • Ask your doctor about using vaginal estrogen (cream, tablet, or ring).
• Try to manage stress. Breathing exercises, meditation, or yoga may help.

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Medicines

If your symptoms bother you, you may want to ask your doctor about prescription medicines.

All medicines for menopause symptoms have possible risks or side effects. Talk with your doctor about the risks and benefits of treatment options for you.

Hormone medicines include:

• Low-dose vaginal estrogen (cream, tablet, or ring). These forms are mainly used to treat vaginal dryness and other tissue changes in and around the vagina. They may also help prevent urinary tract infections (UTIs) and other urinary symptoms.
• Estrogen and progestin therapy. This form of hormone therapy (HT) sends hormones throughout the body. It can come in the form of a pill, patch, vaginal ring, gel, spray, or cream. It can be used to treat menopause symptoms such as hot flashes and vaginal dryness.
• Estrogen therapy (ET). This is the use of estrogen without progestin. This form of HT also sends hormones throughout the body. It's most often used in people who have had surgery to remove their uterus (hysterectomy).
• Testosterone with estrogen. This is sometimes used for menopause symptoms that don't improve with estrogen therapy.

You may have heard of a form of HT called compounded bioidentical hormones. Treatment with this type of HT is not approved or regulated by the FDA and may have more risk. This type of HT can vary in quality and may be more costly. And studies show that compounded bioidentical hormones are not more effective than FDA-approved HT.^{footnote 1}

Non-hormone medicines include:

• Antidepressants. These can reduce how many hot flashes you have. They can also make them less severe. And they may help with irritability, depression, and moodiness.
• Clonidine. It can reduce the number of hot flashes and how severe they are. It may cause side effects related to low blood pressure.
• Gabapentin (Neurontin). It can reduce the number of hot flashes and how severe they are. Possible side effects include sleepiness, dizziness, and swelling.
• Ospemifene (Osphena). This is used to reduce vaginal changes that can make sex painful.

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Other Treatment

There are many non-medicine treatments to relieve menopause symptoms.

• Cognitive-behavioral therapy is a type of counseling. It focuses on changing certain thoughts and behavior patterns. It may help you feel less bothered by hot flashes.
• Hypnosis is a state of focused concentration. With it, you become less aware of what is around you. It may reduce the number of hot flashes and make them less severe.
• Mind and body relaxation, such as breathing exercises. This may help with hot flashes and mood symptoms.
• Yoga and biofeedback can help you reduce stress.
• Black cohosh (such as Remifemin) may help relieve symptoms. But the research on black cohosh has had mixed results.
• Soy may improve symptoms. But studies have shown mixed results.

Remember that dietary supplements aren't regulated like medicines, and they may have risks. If you choose to take them, tell your doctor what you take.