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Menopause

Overview

Menopause is a natural part of a woman's life cycle. When a woman has passed through menopause, her monthly periods end and she no longer can get pregnant naturally. While menopause is challenging both emotionally and physically, many women welcome the new kind of life that menopause brings, with freedom from pregnancy and additional child-raising responsibilities. In the UK, the average age of menopause is around 50, although there is a great range.
The changes of menopause begin when your ovaries, the organs that form eggs, no longer produce eggs. Their production of female hormones decreases at this time too. Hormones are chemicals secreted by endocrine system glands, or organs, that travel through the blood to another organ, where they produce a specific effect on some bodily process. Two hormones made in the ovaries - estrogen and progesterone - help to regulate a woman's monthly period.
As you approach mid-life, estrogen begins to drop to low levels. The reproductive organs gradually shut down, just as they gradually became active during puberty. Most women notice that their periods become lighter, farther apart and then eventually, they end.
The menopausal transition may take from one to 10 years, and during that time hormone levels are likely to fluctuate widely. Some months you may have a period; other months you may not. During this time, you may still be able to get pregnant.
Menopause typically happens gradually, over time. The onset of menopause may occur suddenly for reasons such as the removal of both ovaries, radiation or chemotherapy, gland disorders, or a sudden, severe illness.

Menopause Symptoms

Symptoms of menopause begin when estrogen levels start changing. A woman's body can go through several kinds of changes at the same time.

Early in menopause, estrogen levels can rise sharply and then drop, which means you may skip periods or even have more frequent and heavier flow than usual during some months. Your period is likely to become increasingly irregular, and then eventually stop altogether.

The first menopause symptoms most women notice are hot flashes and mood swings. Some report mental confusion and sometimes a sense of sadness or depression. You also may have problems during sex, either because of vaginal dryness or lack of desire. Eventually, as your estrogen stays consistently at a low level, symptoms of menopause including the hot flashes, changing moods, and mental confusion usually disappear.

Menopause can affect your body organs and systems in many different ways:

Blood Vessels - Quick body temperature changes, or hot flashes, and waking during the night
Brain/ nerves - Moods that change frequently or a tendency toward sadness, anger, or confusion, and in extreme cases, depression or anxiety
Genitals - Problems with dryness, itching, pain during sexual intercourse, or irritation of the tissues in and around the vagina
Urinary system - Problems with sudden or frequent urinating
Bones - A higher risk of weaker bones, osteoporosis, and bone breaks

Heart - Acceleration of risk factors associated with heart attacks and other heart problems

Menopause Treatment Options

Treatment for the symptoms of menopause can be approached in two phases:

Early in menopause, you and your doctor should discuss your first signs of menopause and whether to treat them as they occur. You should be evaluated for your risk of getting breast cancer or heart disease, as well as osteoporosis, which is severe bone loss that puts you at increased risk for broken bones. If you are not at high risk for breast cancer, you may wish to consider taking estrogen for a limited time. By using the lowest effective dose, you may be able to manage several menopause symptoms at once. If, after weighing the pros and cons of estrogen, you decide it's not for you, other treatments are available.
Later in menopause you should focus on effectively preventing diseases such as osteoporosis and heart disease. Your earlier menopause symptoms will probably disappear.

You and your doctor should form a partnership and share information that will help you make the best decisions about your health. There are many things to keep in mind, because menopause and the years that follow it usually cover the second half of a woman's life. Talk to your doctor about all of the treatment choices to decide what is right for you.

Please also see the below table - Treating Your Menopausal Symptoms: The Quick Pros and Cons.

Hormone Treatment Options

Many women want to address the hormone imbalance and keep estrogen levels by taking estrogen, because it is often the most effective way to relieve many of the troubling symptoms of menopause. Estrogen increases the risk of uterine cancer, if taken alone, however. For this reason, women who still have a uterus usually take a combination of estrogen with a form of progesterone, called progestin, which helps to protect the uterus. The combination of estrogen and progesterone is called hormone therapy.

If a woman no longer has a uterus, she can take estrogen alone, which is called estrogen therapy.

If you have a family history of breast cancer or have survived breast cancer, you probably should not take either estrogen or hormone therapy. You also should not take estrogen if you have had cancer of the uterus, liver disease, a history of blood clots, heart disease or any unusual bleeding from the vagina.

Estrogen can help to reduce hot flashes, vaginal dryness, and possibly skin changes. It is also an effective way to protect your bones from rapid weakening as you age.

Treating the symptoms of early menopause:

The following are some other ways to treat your symptoms of the hormone imbalance that occurs during menopause without choosing hormones:

Selective-Serotonin Reuptake Inhibitor (SSRI) drugs and Serotonin Norephinephrine Reuptake Inhibitor (SNRI) drugs are useful both in treating depression and in treating hot flashes.
Gabapentin may be used to treat hot flashes, particularly for those occurring at night and disturbing sleep.
Medroxyprogesterone acetate and megestrol acetate, progesterone-type drugs, may be used to treat hot flashes.
Clonidine is a blood-pressure-lowering drug that is also used to reduce the frequency and severity of hot flashes.
Individual counselling or support groups can also help you to handle sad, depressed, or confusing feelings you may be having as your body changes.
Vaginal moisturizers such as Vagisil or Replens, can help women with thinning vaginal tissue or dryness. Lubricants, such as K-Y Jelly or Astroglide, can help with lubrication difficulties that may be present during intercourse.
Low-dose vaginal estrogen is generally a safe way to take estrogen to solve vaginal thinning and dryness problems while only minimally increasing the levels of estrogen in the blood.
Lack of desire may be helped with more open communication with your partner. Creating a pleasurable atmosphere at home and making a point to enjoy other activities with your partner may be helpful as well. Counseling can empower you with long lasting benefits if your lack of desire is related to the mood swings and depression that sometimes accompany menopause.

"Designer Estrogens"

Tamoxifen, which is used to prevent breast cancer, and raloxifene, which is used to prevent osteoporosis, are drugs known as "designer estrogens." These medications have been developed to act as beneficially as estrogen on some tissues and to act as estrogen-blockers on other tissues. These drugs also are known by their more technical name - Selective Estrogen Receptor Modulators (SERMs).

Tamoxifen, however, acts like an estrogen on the uterus, increasing the risk of uterine cancer. Raloxifene blocks harmful effects of estrogen on the breast and does not stimulate the lining of the uterus, so women who still have a uterus may want to try this drug. Unfortunately, neither of the "designer estrogens" addresses all the symptoms of menopause in all women, and some women experience hot flashes with raloxifene or tamoxifen.

Menopause Lifestyle and Prevention

Women have many choices in the ways they can treat symptoms of menopause. All women, however, should aim for a healthy lifestyle. Eat a healthy diet, including 1,500 mg of calcium daily, lower the amount of fat in your diet, and maintain the right balance of calories to support an active lifestyle. If you are overweight, losing weight is encouraged.

Quit or try to cut down on smoking.
Drink alcohol moderately, if at all.
Exercise for 30 minutes at least three times a week.
Avoid stressful situations.
Have a yearly mammogram and breast examination by a health professional.

Preventing disease will be a major concern after you go through menopause. Your risk of bone loss and bone fractures (both of which are osteoporosis symptoms), heart disease, and other conditions increases as you age.

To prevent bone loss:
Maintain a healthy diet and exercise. Other treatments for preventing bone loss and osteoporosis symptoms include calcium tablets and Vitamin D. These can be taken separately or combined in a pill.
Other bone treatments require a prescription:

The hormone calcitonin is used to block bone breakdown.
The bisphosphonate family of drugs blocks the breakdown of bone and results in an increased amount of bone. Commonly prescribed bisphosphonates include risedronate and alendronate.
Hormone therapy is effective at preventing bone loss and fractures, but you should weigh the risks against the potential benefits.
The "designer estrogens," tamoxifen and raloxifene also help to prevent bone loss.
Parathyroid hormone is used to add bone in severe cases of bone loss.

To prevent heart disease:
A healthy diet and regular exercise can help to keep your heart healthy as you age. If your cholesterol is high, however, you may need cholesterol-lowering drugs. These drugs are called the "statin" drugs, such as, rosuvastatin, atorvastatin, simvastatin, lovastatin, pravastatin, and fluvastatin.

The role of estrogen in preventing heart disease is being debated by scientists. Recently, the American Heart Association announced that no woman should take estrogen for the sole purpose of preventing heart disease. Right now more studies are being conducted to learn whether estrogen prevents heart disease and stroke. Hormone therapy combining estrogen plus progestin does not reduce the risk of heart disease in women with or without previous heart disease, and may actually increase the risk of heart disease and stroke in some cases. Newer studies are looking at the ways hormone therapy affects the heart in recently menopausal women with symptoms (those in their 50's) compared to women who have gone at least 15-20 years without a period. While hormone therapy may have some heart benefits in the younger group of postmenopausal women, there is currently not enough medical evidence to warrant its use solely for this purpose, although ongoing studies seek to provide more information.

Preventing other diseases:
Some studies have shown other preventive roles for estrogen. More studies are needed to learn how effective estrogen might be in preventing these diseases. For example:

Estrogen loss may be linked with Alzheimer's disease, a fact that led to the notion that taking estrogen after menopause might help to prevent this disease. However, the Women's Health Initiative data suggest that women who initiate hormone therapy at age 65 or older have worsening dementia than women who take no hormones. Whether there is an optimal age to initiate estrogen treatment, or whether the results would have been different if estrogen had been started at the time of the menopause is unclear. Until more is known, hormone therapy cannot be recommended for prevention of Alzheimer's disease.
Taking estrogen plus progestin lowers the risk of developing colon cancer.
Taking estrogen lowers the risk of developing age-related macular degeneration, a degeneration of the retina of the eye.
Taking estrogen lowers the risk of bone fractures, one of the leading symptoms of osteoporosis.

It should be remembered that each woman is different, and the benefits of hormone therapy need to balanced against its risks as well as the complete health status of each and every woman to come up with the best plan.

Pros and Cons for Treatment of Menopause Symptoms

Symptoms of Menopause	Treatment	Pros and Cons of Treatment
Hot flashes	Vitamin E	Pros: May reduce number and severity of hot flushes Cons: No toxicity of vitamin E; some people get headaches; scientific support for its effectiveness is very weak
	Megestrol acetate/ Medroxyprogesterone acetate	Pros: Effective progestin treatment for hot flushes Cons: Weight gain; not studied well in women who have had breast cancer
	SSRI drugs	Pros: Shown to be effective for hot flushes and also for depression Cons: Causes mood changes; can affect sex drive; paroxetine and sertraline hydrochloride have adverse interactions with tamoxifen
	Estrogen*	Pros: Hormone therapy is very effective at relieving hot flushes; also helps prevent vaginal thinning; prevents bone loss Cons: Increased risk of breast cancer when combined with a progestin; increased risk of uterine cancer if estrogen is taken without progesterone; increased risk of blood clots
Dry vagina and painful intercourse	Vaginal moisturizers	Pros: Over-the-counter solution Cons: Some people don't like these products, because of consistency or smell; does not thicken the vaginal lining; not as effective as estrogens
	Water-soluble lubricants	Pros: Over-the-counter solution (Note: There is a difference between lubricant and moisturizer) Cons: Some people don't like these products because of their consistency or smell; does not thicken the vaginal lining
	Low dose vaginal estrogen ring	Pros: Helps keep vaginal tissue from thinning; local estrogen believed to have fewer risks compared to systemic estrogen pills taken in higher doses Cons: Some absorption of estrogen into the body occurs but this is small.
	Estrogen* (by mouth)	Pros: Helps keep vaginal tissue from thinning; also helps prevent bone loss; very effective against hot flushes Cons: Increased risk of breast cancer if taken with a progestin; increased risk of uterine cancer if estrogen is taken without progesterone; increased risk of blood clots

Bone loss	Bisphosphonates	Pros: Osteoporosis treatment is very effective against bone loss Cons: Common to have gastrointestinal problems when taking these drugs; can cause injury to esophagus unless taken with lots of water while sitting upright or standing; rarely causes jaw necrosis (death cells in the jaw)
	Raloxifene	Pros: Very effective against bone loss, lowers risk of breast cancer Cons: Increases risk of blood clots; hot flushes; leg cramps
	Calcitonin	Pros: Slows bone breakdown Cons: Headaches, dizziness, diarrhea, lack of desire for eating, nose bleeds (with nasal form); much less effective than bisphosphonates
	Vitamin D	Pros: Helps body absorb calcium Cons: Very large amounts of vitamin D can cause build-up of calcium in blood, which could lead to heart and lung problems and kidney stones
	Estrogen*	Pros: Helps prevent vaginal tissue from thinning; also helps prevent bone loss; very effective against hot flushes Cons: Increased risk of breast cancer if taken with a progestin; increased risk of uterine cancer if estrogen is taken without progesterone; increased risk of blood clots
	Tamoxifen	Pros: Lowers risk of breast cancer; reduces risk of fractures Cons: Increases risk of uterine cancer, blood clots; more hot flushes; irregular vaginal bleeding

Depression and mood changes	Counseling	Pros: Can be empowering; leads to increased insight Cons: Can be expensive; may not work as well as medications
	SSRI drugs	Pros: Shown to be effective for hot flushes and also for depression Cons: Can affect sex drive; some types such as paroxetine or sertraline hydrochloride may interfere with effect of tamoxifen
	Estrogen*	Pros: Very effective at preventing symptoms of osteoporosis such as bone loss and preventing fractures; very effective at preventing hot flushes; prevents vaginal tissue thinning; may reduce the risk of dementia (in younger menopausal women taking HT for 10 years or more) Cons: Increased risk of breast cancer if taken with a progestin; increased risk of uterine cancer if estrogen is taken without progesterone; increased risk of blood clots; increased risk of dementia (in women 65 years and older taking hormone therapy for five years or less)

*A note on estrogen
Short-term goals of estrogen treatment are different from the long-term goals. Short-term hormone therapy is designed to relieve symptoms; long-term therapy helps to prevent bone loss. If you take hormones for less than three to five years, the risks are relatively low. If you are concerned about bone loss and are thinking about taking hormone therapy for more than five years, consult with your doctor to see whether hormone therapy or an alternative treatment is best for you.
You should not take estrogen if you have had breast cancer or are at risk for breast cancer. There is an increased risk of breast cancer if taken with progestin, increased risk of uterine cancer if not taken with progesterone and increased risk of blood clots for women taking estrogen.