Discuss all medical advice, diagnosis, and treatment with your healthcare provider.

Introduction

While menopause used to mean withdrawal from active life for many women, this is not true today. Yet, women still worry about what will happen and what they should do when menopause arrives. Women may experience a wide range of feelings, from anxiety and discomfort, to release and relief. Most adapt to the changes and continue to live well and remain healthy through these transitions.

Most of today’s women will live 25 to 30 years—one third of their lives—after menopause. An understanding of the body’s changes during this phase of life can ease the transition, and equally important, better prepare you to safeguard your health during the later years. There are many different considerations a woman needs to take into account as she approaches menopause. Specific treatment for menopausal symptoms will be determined by your healthcare provider based on your age, overall health, and medical history; current symptoms; your tolerance for specific medication, procedures, or therapies; and your opinion or preference.

The Basics

Menopause is only one of several stages in the reproductive life of a woman. The entire menopause transition is divided into distinct stages known as premature menopause, premenopause, perimenopause, menopause, and postmenopause.

The stages of menopause

1. Premature menopause

Premature menopause is menopause that occurs before the age of 40, whether it is natural or induced by medical or surgical means. Women who enter menopause early have symptoms similar to those of natural menopause, like hot flashes, emotional problems, vaginal dryness, and decreased sex drive. However, for some women with premature menopause, these symptoms are severe. Also, women who have premature menopause tend to get weaker bones faster than women who enter menopause later in life. This raises their chances of developing osteoporosis, putting them at risk of fractures of their bones.

Premature menopause can happen for the following reasons:

Chromosome defects: Defects in certain chromosomes can cause premature menopause. For example, women with Turner’s syndrome are born without a second X chromosome or born without part of the X chromosome. In this case the ovaries don’t form normally, and premature menopause results.

Genetics: Women with a family history of premature menopause are more likely to have premature menopause themselves.

Autoimmune diseases: The body’s immune system, which normally fights off diseases, mistakenly attacks a part of its own reproductive system, causing the ovaries to shut down and stop producing female hormones. Thyroid gland disease and rheumatoid arthritis are two diseases in which this can happen.

Surgery to remove the ovaries: Surgical removal of both ovaries, also called a bilateral oophorectomy, puts a woman into premature menopause. She may have immediate menopausal symptoms, like hot flashes and diminished sexual desire or libido. Women who have a hysterectomy, but have their ovaries left in place, will not have induced menopause because their ovaries will continue to make hormones. However, because their uterus is removed, they no longer have their periods and cannot get pregnant. They might have hot flashes since the surgery can sometimes disturb the blood supply to the ovaries. Later on, they will most likely have natural menopause a year or two earlier than expected.

Chemotherapy or pelvic radiation treatments for cancer: Chemotherapy or pelvic radiation therapy for reproductive system cancers can cause ovarian damage. Women may stop getting their periods, have fertility problems, or lose their fertility completely. This can happen immediately or take several months. With cancer treatment, the chances of menopause depend on the type of chemotherapy used, how much was used, and the age of the woman when she gets treatment. The younger a woman is, the less likely she will go into menopause.

How to find out whether you have premature menopause
Your healthcare professional will ask you if you’ve had changes typical of menopause, like hot flashes, irregular periods, sleep problems, and vaginal dryness. Normally, menopause is confirmed when a woman hasn’t had her period for 12 months consecutively.

However, in certain cases of premature menopause, these signs may not be enough for a diagnosis. A blood test that measures follicle-stimulating hormone (FSH) can be done. Your ovaries use this hormone to make estrogen. FSH levels rise when the ovaries stop making estrogen. When FSH levels are higher than normal, you've reached menopause. However, your estrogen levels vary daily, so you may need this test more than once to know for sure.

You may also have a test for levels of estradiol (a type of estrogen) and luteinizing hormone (LH). Estradiol levels fall when the ovaries fail. Levels lower than normal may be a sign of menopause. LH is a hormone that triggers ovulation. If you test above normal levels, you’ve gone through menopause.

2. Perimenopause

Perimenopause marks the time when your body begins its move into menopause. It includes the years leading up to menopause—anywhere from 2 to 8 years—plus the first year after your final period. There is no way to predict how long preimenopause will last or how long it will take you to go through it. It's a natural part of a womans’s life that signals the ending of her reproductive years.

Signs and symptoms

Perimenopause causes some changes in your body that may not be noticeable. For most women, the discomforts associated with perimenopause are minimal and manageable. Other discomforts you might experience include:

• Changes in your menstrual cycle (longer or shorter periods, heavier or lighter periods, or missed periods)
• Hot flashes (sudden rush of heat from your chest to your head). In some months they may occur and in other months they may not.
• Night sweats (hot flashes that happen while you sleep)
• Vaginal dryness
• Sleep problems
• Mood changes (mood swings, depression, irritability)
• Pain during sex
• More urinary infections
• Urinary incontinence
• Less interest in sex
• Increase in body fat around your waist
• Problems with concentration and memory

By monitoring your menstrual cycle and recording your signs and symptoms for several months, you’ll gain a better understanding of the changes occurring during this time. You will also have valuable information to discuss with your doctor.

Oral contraceptives (birth control pills) are often the treatment of choice to relieve perimenopausal symptoms—even if you don’t need them for birth control. Today’s low-dose pills regulate periods and eliminate or reduce hot flashes, vaginal dryness, and premenstrual syndrome.

Making lifestyle changes may help ease the discomfort of your symptoms and keep you healthy in the long run.

Good nutrition. Because your risk of osteoporosis and heart disease increases at this time, a healthful diet is more important than ever. Adopt a low-fat, high-fiber diet rich in fruits, vegetables, and whole grains. Add calcium-rich foods or take a calcium supplement. Avoid alcohol or caffeine, which can trigger hot flashes. If you smoke, try to quit.

Regular exercise. Regular physical activity helps keep your weight down, improve your sleep, strengthen your bones, and elevate your mood. Try to exercise at a moderate intensity for 30 minutes or more on most days of the week.

Stress reduction. Practiced regularly, stress reduction techniques, such as meditation or yoga, can help you relax and cope with your symptoms more easily in this period of transition.

Pregnancy and perimenopause

If you’re still having periods, even if they are not regular, you can get pregnant. Talk to your clinician about birth control options. Keep in mind that methods of birth control, such as birth control pills, injections, implants, or diaphragms will not protect you from sexually transmitted diseases (STDs) or HIV. If you use one of these methods, be sure to also use a latex condom or dental dam (used for oral sex) correctly every time you have sexual contact. Be aware that condoms don’t provide complete protection against STDs and HIV—the only sure protection is abstinence (not having sex of any kind). But appropriate and consistent use of latex condoms and other barrier methods of contraception can help protect you from STDs.

Wellbeing

Engage in regular physical activity and reduce sedentary activities to promote health, psychological wellbeing, and a healthy body weight.

• To lower the risk of chronic disease, get at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week.
• To help manage body weight and prevent gradual, unhealthy body weight gain, get about 60 minutes of moderate-to-vigorous-intensity activity on most days of the week, while not exceeding caloric intake requirements.
• To keep weight off, get at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult their healthcare provider before participating in this level of activity.

Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.

3. Menopause

Menopause is a normal change in a woman’s life when her period stops. It is often called the “change of life.” During menopause, which usually occurs between the ages of 45 and 55, a woman’s body slowly makes less of the hormones estrogen and progesterone. A woman has reached menopause when she has not had a period for 12 months in a row, and there are no other causes for this change. As you near menopause, you may have symptoms from the changes ocurring in your body. Many women wonder if these changes are normal, and many are confused about how to treat their symptoms. You can feel better by learning all you can about menopause and talking with your doctor about your health and symptoms. If you want to treat your symptoms, your healthcare provider can discuss treatment options with you.

Symptoms of menopause

Every woman’s period will stop at menopause. Some women may not have any other symptoms. But as you near menopause or as you are going through menopause, you may also have one or more of these symptoms:

Hot flashes (“hot flushes”). A feeling of sudden warmth in the face, neck, and chest.

Night sweats and sleeping problems. These may lead to feeling tired, stressed, or tense.

Vaginal changes. The vagina may become dry and thin, and sex and vaginal exams may be painful. You also might get more vaginal infections.

Weakening of your bones. This may lead to osteoporosis and an increased risk of fracture.

Mood changes. May include mood swings, depression, and irritability. Some researchers believe that the decrease in estrogen triggers changes in your brain, causing depression.

Urinary problems. You may have leaking (urinary incontinence), burning, or pain when urinating, or you may have leaking when sneezing, coughing, or laughing (stress incontinence).

Lack of concentration. You may become forgetful.

Decreased libido. You may have less interest in sex and changes in sexual response.

Weight fluctuation. Weight gain or increase in body fat around your waist.

Hair loss or thinning. Hair thinning or loss is a problem for some women.

Symptom relief

Here are some ways to relieve menopausal symptoms.

• Hot flashes. A hot environment, eating or drinking hot or spicy foods, alcohol or caffeine, and stress can bring on hot flashes. Try to avoid these triggers. Dress in layers and keep a fan in your home or workplace. Regular exercise might also bring relief from hot flashes and other symptoms. Ask your healthcare provider about taking medication such as antidepressants, or hormone therapy, both of which can be helpful for some women.
• Vaginal dryness. You could try an over-the-counter vaginal lubricant. There are also prescription estrogen-replacement creams that your doctor may prescribe to use topically in the vagina. If you have spotting or bleeding while using estrogen creams, you should see your doctor.
• Problems sleeping. One of the best ways to get a good night’s sleep is to get at least 30 minutes of physical activity on most days of the week. But avoid exercising vigorously close to bedtime. Also avoid alcohol, caffeine, large meals, and working right before bedtime. You might want to drink something warm, such as herb tea or warm milk, before bedtime. Try to keep your bedroom at a comfortable temperature. Avoid napping during the day and try to go to bed and get up at the same times every day. Try relaxation exercise like meditation before bedtime.
• Memory problems. Try to get enough sleep and be physically active.
• Mood swings. Try to get enough sleep and be physically active. Ask your clinician about relaxation exercises you can do. Ask him or her about taking an antidepressant medicine. There is proof that medication can be helpful for people who develop clinical depression. Think about going to a support group for women who are experiencing the same symptoms or getting counseling to talk through your problems and fears.

Two other common health problems can start at menopause, which you might not even notice.

• Osteoporosis. Day in and day out your body is breaking down old bone and replacing it with new healthy bone. Estrogen helps control bone loss. So losing estrogen around the time of menopause causes women to begin to lose more bone than is replaced. In time, bones can become weak and fracture easily. This condition is called osteoporosis.
• Heart disease. After menopause, women are more likely to develop heart disease and other forms of cardiovascular disease. Changes in estrogen levels may be part of the cause, but so is getting older. As you age, you may develop other problems, like high blood pressure or weight gain, putting you at greater risk for heart and cardiovascular disease.

4. Postmenopause

Postmenopause refers to a women’s time of life after menopause has occurred. It is generally believed that the postmenopausal phase begins when 12 full months have passed since the last menstrual period. At that point, a woman will be postmenopausal for the rest of her life, and should never have a menstrual period again. If a postmenopousal woman experiences any vaginal bleeding, no matter how minor, she should consult her healthcare professional.

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Understanding estrogen and progesterone

Estrogen is known as a “female hormone” because it plays a key role in shaping the female body and preparing it for uniquely female functions such as pregnancy. For example, estrogen is vital for the development of breasts and hips. In addition, the vagina, uterus, and other female organs depend on the presence of estrogen in the body to mature.

Together with progesterone, another female hormone made by the ovaries, estrogen regulates the changes that occur with each monthly period and prepares the uterus for pregnancy. Prior to menopause, more than 90% of the estrogen in a woman’s body is made by the ovaries. Other organs (including the adrenal glands, liver, and kidneys) also make small amounts of estrogen. That’s why women continue to have low levels of estrogen after menopause. Because fat cells can also make small amounts of estrogen, women who are overweight when they are going through menopause may have fewer problems with hot flashes and osteoporosis (both of which are related to lack of estrogen).

Some of the other important benefits of estrogen become apparent when estrogen levels decline after menopause. For instance, estrogen stimulates skeletal growth and helps maintain healthy bones. It also helps protect the heart and veins by increasing “good cholesterol“ (HDL or high-density lipoprotein) and lowering “bad cholesterol” (LDL or low-density lipoprotein). Estrogen may also affect a woman’s sexual desire.

Progesterone is the second most important female hormone. Like estrogen, most progesterone is made by the ovaries, with a smaller amount made by the adrenal glands. Progesterone stimulates the growth of a cushiony lining in the uterus where the fertilized egg can grow and develop into a baby, it helps the breast make milk, and it generally supports pregnancy.

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Health changes after menopause

Osteoporosis

Osteoporosis is the medical term for reduced strength of the bones. Thin bones become weaker and fracture easily, with the bones of the spine, wrists, and hips most prone to fracture. Although bones naturally weaken with age in both men and women starting at about age 40, women lose bone more rapidly after menopause.

Using hormone therapy after menopause can slow the rate of bone thinning and may prevent bones from fractures. As well as being beneficial for strengthening bone, estrogen use has some known side effects and you should talk to your healthcare professional about these. He or she can help you to evaluate your risk for developing these side effects and to decide whether estrogen therapy is right for you.

Increase the calcium in your diet in order to keep your bones strong. Calcium is naturally found in many foods, including dairy products, and may also be added to a food (for instance, some orange juices and cereals now have calcium added). Calcium tablets are another good way to add to calcium to your diet. The goal should be to reach a total daily intake of 1000 milligrams per day before menopause or 1500 milligrams per day after menopause. Regular weightbearing exercise, like walking, running, or strength training may also help prevent osteoporosis, as well as getting enough vitamin D through sunlight exposure and food sources.

Heart disease

The risk of heart disease rises considerably in women after menopause. Many people think of heart disease as a “man’s problem,” so it may be surprising to note that heart disease is the leading cause of death among women.

Risk factors for heart disease in women (as well as men) include:

• Being overweight (obesity)
• High blood pressure
• Diabetes
• Cigarette smoking
• High cholesterol
• A low level of physical activity (sedentary lifestyle)
• Family history of heart disease
• Age

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Sex, pregnancy, HIV/AIDS, and sexually transmitted diseases (STDs)

Sex

Both men and women may find themselves taking longer to become sexually aroused as they age. However, medications such as antidepressants, tranquilizers, and high blood pressure drugs can alter your sexual desire. Health problems such as heart disease, diabetes, or arthritis, concern about your appearance, and stress in your daily life can also inhibit your sexual response. Some postmenopausal women will experience either a reduced sex drive.

In 2000, scientists at the New England Research Institute and the University of Massachusetts Medical School found that women experience changes in libido with menopause due to changing attitudes, general health, and marital status rather than because of lower levels of estrogen. Estrogen loss, however, is definitely the main reason for painful intercourse.

If you are one of the women who lose interest in sex at the time of menopause, talk to your healthcare professional. He or she will consider all possible causes. Women’s bodies also produce some of the male hormone testosterone, which some scientists think lead to a drop in libido. Although there is evidence suggesting that some women may benefit from a small amount of testosterone supplement, the effectiveness of this treatment needs further study. Side effects of testosterone in women include skin problems, extra hair on the face and body, and voice changes.

Talk to your sexual partner also. Let him or her know that you both may need to spend extra time kissing and touching before you become fully aroused. If your intimacies have become routine, try new ways or a different place—be creative.

Pregnancy

If you do not wish to become pregnant at this age, continue using contraception until your doctor determines that you are indeed past menopause. Since estrogen and other reproductive hormones are still produced by the body during perimenopause, an egg may be released and pregnancy is possible. Irregular menstrual cycles make it more difficult to predict the time of ovulation, when sexual intercourse is mo re likely to result in pregnancy. If you are currently using a birth control pill as contraception, your periods will continue to be regular even after you have passed menopause. An oral contraceptive, even one with a low does of estrogen, may also help control symptoms such as hot flashes.

HIV/AIDS and sexually transmitted diseases (STDs)

The possibility of pregnancy will disappear once you are a year past your last period. The chance of becoming infected by HIV (human immunodeficiency virus) and developing AIDS (acquired immunodeficiency syndrome) is a possibility you must consider as long as you are sexually active. In fact, about 10% to 15% of all people diagnosed with AIDS in the US are age 50 and older—more than 75,000 Americans.

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Menopause and mental health

Midlife is often considered a period of increased risk for depression in women. The drop in estrogen levels during perimenopause and menopause can lead to depression, and is treated in much the same way as depression that strikes at any other time. Symptoms of depression include low mood, loss of interest and/or pleasure, feelings of worthlessness and guilt, reduced appetite, and problems sleeping.

If you experience symptoms of depression, and they are interfering with your quality of life, it is important to discuss them with your healthcare provider. Talk openly with him or her about the other issues in your life that might be adding to your depressive feelings. Other problems that could be contributing to depression and/or anxiety during menopause include:

• Having a history of depression before menopause
• Feeling worried and negative about menopause and getting older
• Increased stress in your life in general
• Having severe menopausal symptoms
• Not having adequate physical activity
• Relationship problems
• Being unemployed
• Having financial problems
• Suffering low self-esteem
• Lacking adequate social support

If you need treatment for these symptoms, you and your healthcare professional can work together to find a treatment that is best for you. If you have mood swings often, here are a few things you can do:

• Try to get enough sleep and be physically active, ask your healthcare professional about relaxation exercises you can do.
• Ask your doctor about psychotherapy or taking an antidepressant.
• Talk to your friends who are perimenopausal or menopausal, or go to a support group for women who are experiencing the same problem as you are.

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Diagnosis and Treatment

Diagnosis

Menopause is a natural biological process or a normal part of a woman's life; therefore, when we talk about treatment for menopause, it is different than discussing treatment for other conditions like diseases or illnesses. Treatment for menopause means finding ways that can help reduce menopausal symptoms like hot flashes and urinary symptoms and ways to help prevent and reduce risk of diseases that are associated with the menopause like osteoporosis, heart disease, and depression.

Of course it advisable that all women take steps towards reducing their risk of diseases associated with the menopause, but as for reducing symptoms, not all women will see this as part of their menopause treatment goals. Women will have different treatment goals depending on the following factors:

• What menopausal symptoms they have


• How severe those menopausal symptoms


• How they are able to cope with their symptoms and the menopausal transition


• What their perspectives are on different treatments, including medications


• Side effects and other experiences with different treatments


• Other medical conditions they may have, which influence treatment options and choices


• Insurance and cost issues

Your healthcare professional will work together with you to design individual treatment goals, that may change over time. As we are always learning more about menopause treatment options and hormone therapy, managing menopausal symptoms can be confusing. It is important to have a healthcare professional whom you can trust, so you can talk openly about your concerns and your treatment options. You can then confidently make an informed decision about your choices. If you feel that you have talked openly with your healthcare provider and still do not feel satisfied, you should consider a second opinion.

Knowing how to communicate with your healthcare professional or other members of your healthcare team can help you obtain the information you need regarding menopause. Your healthcare professional will tell you, as you near menopause, that you may have symptoms from changes in your body as you age. For some women, menopausal symptoms will decline or disappear over time without treatment. Other women will choose treatment for their symptoms.

Make sure your healthcare professional knows your medical history and that of your family, which will reveal whether you are at risk for heart disease, osteoporosis, and breast cancer. Remember you can always alter your decision regarding treatment as well as different treatment choices. You can, and should, review your medical history with your healthcare professional during yearly checkups. Your needs may change, and so might what we know about menopause.

Prevention

There are several aspects of menopause that are difficult to predict and prevent. It is not possible to know exactly when you will start menopause or to predict what symptoms you will have and how long they will last.

Menopause occurs at a different age in every woman's life, usually over the age of 45 at a time when her period stops. Research describes that women who smoke, who have never had children, or who have regular cycles may experience menopause at an earlier age than other women. A woman reaches menopause when she has not had a period for one year, however, she can have symptoms several years earlier.

• One of the most common symptoms in menopause are hot flashes and most women will have them for at least a year or they may last up to a few years. It is difficult to say for how long you will experience hot flashes and how severe they will be. They can't be prevented, but they can be reduced with treatments such as hormone therapy.

Preventing diseases associated with menopause

There are certain diseases that occur with a higher risk during menopause and there are particular steps to prevent or to reduce your risk. These conditions include osteoporosis, cardiovascular disease, and depression.

Osteoporosis

Osteoporosis is a condition of reduced strength in the bones and risk of this condition rises when estrogen levels fall with the onset of menopause. With osteoporosis you are at an increased risk of sustaining fractures of the wrist, hips, and spine due to weak and brittle bones. Your healthcare professional may recommend the following for osteoporosis prevention.

Bone mineral density (BMD) testing

Experts recommend that you have a special scan called dual-energy X-ray absorptiometry or a BMD test which measures bone mineral density. This is very important to have if you are over the age of 65 or if you have risk factors for osteoporosis and you are not yet 65 years of age. If you are being treated for osteoporosis, you should have your bone density measured every 2 years to monitor your progress.

Calcium

All postmenopausal women should aim for 1500 mg of calcium each day. This can be in the form of three servings of dairy foods per day or calcium supplementation in the form of calcium carbonate or calcium citrate, for example.

Vitamin D

Helps the body absorb calcium and incorporate calcium into bone. Postmenopausal women under the age of 70 years should get at least 400 IU of vitamin D each day either through diet or with a vitamin supplement. Women over 70 years should take 800 IU of vitamin D.

Exercise

Bones remain stronger when they are used in day-to-day activities, and inactivity increases the rate of postmenopausal bone loss. Weight-bearing exercises are best for building strong bones and slowing bone loss; these include activities such as walking, jogging, skipping rope, skiing, and tennis, but does not include bicycling or swimming.

Other tips for preventing bone loss

• Add soy to your diet
• Do not smoke
• Avoid excessive alcohol intake
• Limit caffeine

Medications

Several medications may be prescribed to prevent osteoporosis and reduce the risk of fractures. These include

• Alendronate (Fosamax^®)
• Risedronate (Actonel^®)
• Ibandronate (Boniva^®)
• Raloxifene (Evista^®)
• Estrogen therapy (see next section for details)

The following medications may be prescribed for treatment of osteoporosis and to reduce the risk of further fractures

• Raloxifene (Evista^®)
• Alendronate (Fosamax^®)
• Risedronate (Actonel^®
• Ibandronate (Boniva^®)
• Teriparatide (Forteo^®)
• Calcitonin (Miacalcin^®)
• Zoledronic acid (Reclast^®)

Estrogen therapy

Estrogen or hormone therapy has been shown to prevent bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spine fractures in postmenopausal women. However, it is important that you discuss this in detail with your healthcare professional as hormone therapy, like all medications, has side effects and you need to consider these as well as the benefits when choosing this treatment. More about hormone therapy will be described in other sections of this module.

Cardiovascular disease

Cardiovascular disease means disease of the heart and the blood vessels or the arteries and the veins in the body. The risk of cardiovascular disease is considerably higher in women after menopause and heart disease is the leading cause of death in women. There has been much research regarding hormone therapy and the prevention of cardiovascular disease after menopause. So far the research has not been conclusive and for women over the age of 60 some research suggests that use of certain hormone therapy may actually increase the risk. More about this is described later in this module.

There are steps you can take towards reducing your risk of cardiovascular disease which are very important to follow:

• Maintain a normal weight
• For high blood pressure get regular checkups with your healthcare professional and talk to him/her about treatment
• For diabetes: Diet and exercise can help prevent it. If you have diabetes keep your blood sugar levels under tight control and see your healthcare provider for regular checkups
• Avoid cigarette smoking as well as second hand smoke exposure. If you smoke, talk to your healthcare professional about ways to stop.
• Stick to a low fat diet and talk to your healthcare professional about other things that can prevent or lower your cholesterol level
• Get plenty of exercise, at least 30 minutes on most days of the week. You may need to do extra exercise if you are trying to lose weight.

Sexual problems

As a result of aging, both men and women can experience difficulty becoming sexually aroused. For women it may be a physical problem such as having low estrogen levels due to menopause. Estrogen deficiency can cause vaginal atrophy and decreased vaginal lubrication, which can lead to vaginal dryness and painful sexual intercourse. There is also some research describing low testosterone levels in postmenopausal women as a reason for low libido.

If you are going through menopause and experiencing sexual problems talk to your partner as well as your healthcare professional. Your healthcare professional will be able to assess what may be contributing to your problem and suggest treatment options such as vaginal estrogen treatments (like creams, tablets, or rings) or testosterone.

Depression

When going through the transition period of menopause you may be at an increased risk of developing depression. Menopause can be a stressful time in a woman's life, not only because of physical changes, but it it is often the time when children are leaving home; parents are aging, becoming unwell, frail or dependant; and you may experience the onset of chronic illnesses for the first time in life.

If you are experiencing mood swings, irritability, or periods of sadness or hopelessness, see your healthcare professional as you might be suffering from depression. Talk openly with him or her about the other issues in your life that might be adding to your depressive feelings.

The following suggestions could help improve your feeling of wellbeing:

• Try to get enough sleep and be physically active
• Ask your healthcare professional about relaxation exercises or other techniques to reduce stress
• Schedule pleasant events into your day.
• Keep a diary of your thoughts and feelings
• Talk to your friends or attend a support group for women who are experiencing similar problems
• Ask your doctor about psychotherapy or taking an antidepressant

Cancer prevention

Certain cancers such as breast, colorectal, endometrial, and ovarian are more common for women after the age of 40 or 50, which usually correlates with the onset of menopause in many women. Talk to your healthcare professional about when and how often to be screened for these conditions. There is some research about hormone therapy that says that taking hormone therapy may reduce the risk of developing colorectal cancer in some women. Hormone therapy of course has risks as well as benefits, so always discuss this with your healthcare professional before deciding to use it.

Menopause and dementia

Dementia is a disorder that affects a person's memory as well as language, speech, coordination, behavior, learning and retaining new information, sense of direction, and reasoning ability. The risk of dementia increases with age and women are slightly more likely than men to develop dementia due to a longer life expectancy.

Numerous studies have been conducted on estrogen, hormone therapy, and the development of dementia. Some research has described estrogen as a protective hormone for the brain and beneficial for preserving cognitive functioning and preventing the onset of dementia.

However, recently a large study in postmenopausal women (Women's Health Initiative memory study) demonstrated that hormone therapy with estrogen alone or combined estrogen-progestin therapy does not prevent dementia in older, postmenopausal women who had no signs of dementia at the time. This study suggested that estrogen or estrogen-progestin may actually increase the risk of dementia. It should be emphasized that this study did not look at dementia in younger women or women with preexisting cognitive function and if it did results may have been different.

There is still controversy and much research needed concerning hormone therapy and dementia. Therefore, if you are considering hormone therapy you should talk to your healthcare provider about the benefits and the risks.

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Accepted Treatments

For the treatment of menopausal symptoms your healthcare professional will discuss with you the various options available, including either hormonal or nonhormonal therapies described below.

Nonhormonal therapies are available to treat menopausal symptoms in women who cannot or prefer not to take hormones. Most of these products are not FDA approved and do not have scientific evidence backing up the benefits for treatment. However, many people choose to take them as they are often available over the counter (without a prescription) and are often marketed as being natural and/or without serious side effects.

You should always talk to your clinician about treatment options and which is right for you.

Understanding the hormone debate

Currently, hormone therapy is prescribed mainly for the relief of symptoms, such as hot flashes, night sweats, vaginal dryness and urinary symptoms in perimenopausal and postmenopausal women. The FDA has also approved hormone therapy for the treatment and prevention of osteoporosis although often there are other therapies that your healthcare professional also will prescribe or recommend. Perimenopausal and postmenopausal women should not take hormone therapy to prevent problems like heart disease.

The use of hormone therapy has been debated a great deal since the Women's Health Initiative findings were first released in 2002. This research study commenced in 1991 and involved over 160,000 women, the majority of whom were over the age of 60 (most women who take hormone therapy are 50-59 years old), Caucasian, and overweight or obese. Apart from being overweight this was a relatively healthy group of women. The research determined the risks and benefits of hormone therapy in postmenopausal women with regard to effectiveness in treating menopausal symptoms and risk or benefit on breast cancer, colorectal cancer, heart disease, blood clots, stroke, and osteoporosis.

In the study, some women were given estrogen alone and others used combined estrogen and progestin because they had an intact uterus. Women using estrogen alone did so because they previously had a hysterectomy (progesterone protects against endometrial cancer and women with an intact uterus should never use estrogen therapy alone). Part of the study was stopped prematurely in 2002 after it was noted that the risks of hormone therapy were far greater then the benefit and these results reached the media and popular press causing a wave of concern among users and prescribers of hormone therapy.

Before this study, it was thought that hormone therapy could treat hot flashes, prevent heart disease, and treat osteoporosis, while improving a women's quality of life. Findings emerged in the last 5 years that although hormone therapy can be beneficial for the treatment of osteoporosis, its use may increase the risk of heart disease in certain women and increase slightly the risk of breast cancer.

More recently, new information about hormone therapy and the risk of heart disease has been published in scientific journals. In the Women's Health Initiative follow-up study published in April 2007 women who used hormone therapy and were 50 to 59 years old had a lower risk of stroke, heart attacks, and breast cancer and women who used hormone therapy within 10 years of menopause had no increased risk of heart attacks.

Your healthcare professional is the best person to talk with about understanding the results and implications of the results and follow-up study of the Women's Health Initiative study as well as the Women's Health Initiative memory study. Research results can be confusing because they usually involve a set of individuals that may not be representative of the public and study findings are described in terms of statistics, which can be misleading if you are not familiar with what all the different numbers mean.

We will summarize here for you the main results of these studies which will include both the risks and benefits of hormone therapy. When reading this please keep in mind the following:

• The diseases and conditions that were studied in terms of how they are affected by hormone therapy are all common conditions that postmenopausal women can suffer regardless of the use of hormone therapy
• There are many different factors that can influence your risk of these diseases, thus hormone therapy is only part of the overall picture
• The research involved certain characteristics of women who were taking specific doses of hormones for specific periods of time and, therefore, the results relate to these specific situations and not to every woman
• The study results are factual and do not take into account a subjective viewpoint, therefore, whether you decide to take hormone therapy may depend on other factors such as your personal views or your previous experiences with hormone therapy—it is an individual choice

To understand these results imagine a group of 10,000 women taking hormone therapy (either estrogen alone or in combination with progestin) for about 5 to 7 years. These are the risks and benefits of hormone therapy for these women (per the Women's Health Initiative study)

Women Taking Combined Estrogen and Progestin for About 5 years

	Breast cancer	Stroke	Heart attack	Blood clots	Colorectal cancer	Fractures	Dementia
Risk	8 more cases	8 more cases	7 more cases	18 more cases			23 more cases
Benefit					6 fewer cases	5 fewer cases

Women Taking Only Estrogen for About 7 years

	Breast cancer	Stroke	Heart attack	Blood clots	Colorectal cancer	Fractures	Dementia
Risk		12 more cases		6 more cases			Result no available yet
Benefit						6 fewer cases	Result no available yet
No difference	No difference		No difference		No difference		Result not available yet

Approaches to Hormone Therapy

Despite the many risks and published warnings, hormone therapy remains the most widely accepted treatment for menopausal symptoms. Hormone therapy is considered by experts to be a reasonable short-term treatment option for 6 months to about 5 years. However, due to the potential risks of hormone therapy, it should be used at the lowest dose and for the shortest duration of time to relieve symptoms.

Hormone therapy can be taken in various forms

• Different routes: oral (by mouth), transdermal (through the skin), vaginal (inserted into the vagina)
• Different dosages: some women need higher doses than other women to get relief of their menopausal symptoms
• Different ways of taking it: estrogen alone or combined estrogen and progestin in a cyclic or continuous manner

If you are considering hormone therapy your healthcare professional may recommend a specific type of hormone depending on your stage of menopause as well as your symptoms and your response to the different treatments.

Here is a description of the type of hormone therapy that may be recommended for you at different stages of menopause. Continuous combined hormone therapy means estrogen and progestin (synthetic progesterone) that is used in one regime. For women who have a uterus (who haven't had a hysterectomy) always use combined hormone therapy (estrogen + progestin), as estrogen therapy alone puts you at risk of endometrial cancer (cancer of the womb). Cyclical therapy means that women take different amounts of both hormones through the month as opposed to a standard daily dose.

Stage	Hormone therapy approach	Benefit
Perimenopause	Low dose oral contraceptive (birth control pills)	Helps with irregular bleeding and provides contraception (birth control) as well as relief from menopausal symptoms
Perimenopause and early menopause	Cyclic combined hormone therapy (estrogen + progestin)	For women with a uterus For women without a uterus
	Cyclical estrogen Vaginal estrogen	For painful intercourse and urinary symptoms
Later menopause	Continuous combined hormone therapy (estrogen + progestin) Continuous estrogen Vaginal estrogen	For women with a uterus. Provides consistent symptom relief and less chance of irregular bleeding For women without a uterus For painful intercourse and urinary symptoms

Hormone therapy can also cause troublesome side effects that some women may not be able to tolerate or may require them to try different doses and types of hormone therapies. Here are some of the common side effects of hormone therapy

• Vaginal bleeding
• Abdominal or pelvic bloating
• Breast tenderness or enlargement
• Headaches
• Mood changes
• Nausea
• Abrupt withdrawal of hormone therapy may result in the return of hot flashes and other menopausal symptoms

Certain women may not be able to take hormone therapy to treat their menopausal symptoms and their healthcare professionals can help if they are one of these women. You may be one of these women if you have:

• problems with vaginal bleeding
• liver disease
• had certain kinds of cancers (such as breast and uterine)
• had a stroke or heart attack
• had blood clots

Women with a previous history of breast cancer, cardiovascular disease, and/or blood clots should discuss their treatment carefully with their healthcare professional, who may recommend alternative treatments.

In summary, menopausal symptoms particularly hot flashes are the main reason that women are prescribed and chose to take hormone therapy. Women with mild hot flashes do not usually require any treatment, however, for women with moderate or severe hot flashes, you may need hormone treatment. Women need to talk with their healthcare professionals about the risks and benefits of hormone therapy and have regular checkups for other health concerns related to the menopause including osteoporosis, cancers, and cardiovascular disease. Most women stop having hot flashes after 1 to 2 years, thus treatment time is relatively short.

Many women have recurrent hot flashes when they stop hormone therapy, especially if they stop suddenly. One option is to slowly taper the treatment. Another option is to restart hormone therapy and remain on it for a longer period of time under the guidance of your healthcare professional.

Hormone Therapy Preparations

Here is a summary of the different types of hormone therapy preparations available. If the medication is absorbed into the blood stream it is useful for relieving hot flashes. If it is topical, the medication is used to treat symptoms in a specific location, such as the vagina, and is not significantly absorbed into the blood stream.

• Estrogen or progestin (progesterone)
  
  Oral estrogen
  
  • Enjuvia^®
  • Premarin^®
  • Estrace^®
  • Estratab^®
  • Menest^®
  • Ogen^®
  • Cenestin^®
  • Ortho-Est^®
  
  Transdermal (through the skin) estrogen
  
  Patches
  
  • Alora^®
  • Climara^®
  • Estraderm®
  • Vivelle^®
  • Vivelle-Dot
  
  Lotion, gel, or sprays
  
  
  • Estrasorb®: Lotion that is applied to the thighs or calves of each leg
  • Evamist^®: A spray that is applied to the forearm
  • Divigel^® and Estrasorb^®: Comes in a foil pouch that is spread over the upper thigh
  • Elestrin^® and EstraGel^®: Gel in a pump that is spread over the upper arm and shoulder
  
  There is some research describing a low risk of blood clots with transdermal estrogen as opposed to oral estrogen. However, there is still much to be learned about this issue. Transdermal estrogen is preferred for women with gallbladder or liver disease.
  
  Vaginal estrogen
  
  
  • Premarin vaginal cream (Premarin^®)
  • Vaginal estrogen tablets (Vagifem^®)
  • Estrogen vaginal rings:
    • (Estring^®)
    • (Femring^®) [higher dose]
    
    
  Vaginal estrogen creams and tablets are usually given every day for 2 to 3 weeks, and then once or twice a week for maintenance. They are used for the treatment of vaginal dryness and painful sexual intercourse.
  
  The estrogen vaginal ring is inserted into the vagina. Small amounts of estrogen hormone are released into the vagina over a 3-month period, and very little, if any, is absorbed into the blood stream. As with vaginal creams or tablets, it can be used to treat the same symptoms.
  
  Oral progestin
  
  
  • Aygestin^®
  • Prometrium^®
  • Provera^®
  • Cycrin^®
  • Norlutate^®


• Combined estrogen and progestin (progesterone)
  
  Oral Preparations
  
  
  • Angeliq^®
  • femhrt^®
  • Prefest^®
  • Prempro^®
  • Premphase^®
  
  Transdermal combined estrogen and progestin
  
  
  • Climara Pro^®
  • Combipatch^®


• Bioidentical hormone therapy
  
  Bioidentical hormones are custom-mixed formulas containing various hormones that are supposed to be chemically identical to those naturally occurring in your body. They are not FDA approved. There is inadequate research to substantiate the safety and benefit of these preparations, however, they are popular with women as they have been marketed as natural and tailored to the individual's needs. They are available in different forms including oral and sublinqual tablets as well as gels.

Nonhormonal Therapies

Apart from hormones there are other medications as well as "natural" options that people have used for the treatment of menopausal symptoms. Many of these have not been FDA-approved for the treatment of menopausal symptoms. Natural substances such as black cohosh and phytoestrogens may relieve symptoms of hot flashes. However, there is no conclusive scientific data to support their effectiveness. If you are considering using any of these nonhormonal options, you should talk to your healthcare professional about their benefits and risks.

Here is a summary of the different nonhormonal therapies that your healthcare professional may prescribe for you. Please note that these therapies are not FDA approved for the treatment of postmenopausal symptoms.

1. Antidepressants
   
   Venlafaxine (Effexor^®)
   
   paroxetine (Paxil^®)
   
   Fluoxetine (Prozac^®)
   
   Antidepressants are typically used to treat depression and anxiety but they may also be beneficial in treating hot flashes. One of their side effects is nausea and abdominal discomfort. They are not addictive. They can be used by women who cannot take estrogen and who suffer from hot flashes.



2. Clonidine
   
   transdermal skin patch (Duraclon^®)
   
   oral medication (Catapres^®)
   
   This drug is typically used to treat high blood pressure but it can also may be useful in reducing hot flashes, although its not FDA approved for this indication. Side effects include dry mouth and constipation.



3. Gabapentin
   
   Gabapentin (Neurontin^®)
   
   This drug is typically used in the treatment of epilepsy, however, it may also be useful for the treatment of hot flashes, although its not FDA approved for this indication. Side effects include drowsiness, therefore it is best taken at nighttime



4. Topical vaginal treatments
   
   Nonhormonal vaginal lubricants can be used for vaginal dryness or for the pain associated with sexual intercourse.



5. Dietary supplementation and other alternative approaches
   
   Plant-derived estrogens are also called phytoestrogens. In some individuals they may help relieve hot flashes, however, research does not support these claims. Phytoestrogens can be derived from eating plenty of soy products (for example, soy beans) or by taking dietary supplements such as black cohosh. The benefit of these supplements is not proven with research and, furthermore, they may have harmful side effects such as an adverse effect on breast tissue increasing the risk for breast cancer.
   
   Using vitamin E, ginseng, Chinese herbs, and evening primrose oil also has not been proven in research to be of benefit in treating menopausal symptoms, but may help some women.
   
   If you are considering treating your menopause symptoms with dietary supplementation talk to your healthcare professional about the benefits and risks.

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Emerging Treatments

There is a lot of research underway into new ways of treating menopausal symptoms and new ways of preventing diseases associated with the menopause. Here we will discuss some emerging treatment approaches.

1. Treatment for hot flushes
   
   Tibolone
   Tibolone is a drug used in Europe and other countries for the past 20 years, though it is not yet available in the USA. Tibolone is a synthetic steroid drug that has some effects similar to estrogens, progestins, and androgens. It may be helpful in treating hot flushes and preventing osteoporosis, and, unlike hormone therapy, it may not have the same risks regarding breast cancer.
   
   Treatment in breast cancer survivors
   The use of hormone therapy in women who have survived breast cancer is problematic as hormones can actually encourage breast cancer growth. There is a lot of research into suitable alternatives for these women, particularly nonhormonal alternatives such as venlafaxine, paroxetine, and gabapentin which are considered to be the most promising.



2. Treatment for decreased libido
   
   As both men and women get older they can experience a reduced libido or sexual desire. It is unclear whether there is a relationship between menopause and decreased libido in women and whether hormone therapy with testosterone can improve the symptoms. Research is underway into the treatment of reduced libido with hormone therapy.



3. Prevention of disease
   Osteoporosis
   There are several new and emerging therapies to prevent osteoporosis, such as with denosumab, a drug that can alter the immune system.
   
   Dementia and cognitive decline
   Research is underway into the effect of hormone therapies on dementia and cognitive decline associated with aging and menopause in women. The results in this area are mixed and experts are not sure whether taking hormone therapy increases or decreases the risk of these problems. We have yet to know whether hormone therapy can be recommended as a dementia prevention treatment.

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Empower Yourself

Eating right and physical activity

You can feel better by having a healthy lifestyle. Don't smoke, and eat a variety of foods low in saturated fat, trans fat, and cholesterol. Include grains, especially whole grains, and a variety of dark green leafy vegetables, and deeply colored fruit in your eating plan. Also, maintain a healthy weight and be physically active for at least 30 minutes most days.

• To lower the risk of chronic disease, get at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week.
• To help manage body weight and prevent gradual, unhealthy body weight gain, get about 60 minutes of moderate-to vigorous-intensity activity on most days of the week, while not exceeding caloric intake requirements.
• To keep weight off, get at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with their doctor before participating in this level of activity.

Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises increasing muscle strength.

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Frequently asked questions

Will these symptoms last for the rest of my life?

For most women, the symptoms of menopause last for a relatively short time, for others they can last a few years. However, a woman's level of estrogen naturally remains low after menopause, which can affect many parts of her body, including her sexual and urinary organs, heart, and bones. Therefore, the bodily changes of menopause will be lifelong, even if the symptoms stop being a problem. But eating healthful foods, exercising, and making other positive lifestyle changes can help a woman feel great and live a long, healthy life after menopause.

Is a change in sexual desire normal after menopause?

Many women say that their sexual desire lessens during menopause. In many cases, the cause is physical. For instance, because lower estrogen levels sometimes cause vaginal dryness, having sex may become uncomfortable or painful. For some women, taking hormones called androgens can help restore sexual desire.

Some women find that sexual desire changes because of how they feel about themselves during menopause. Counseling and support groups can help women learn strategies for coping with the physical and emotional changes that occur during menopause.

What can be done to relieve pain during sex?

Remedies include taking a warm bath before intercourse or using lubricants. Short-acting, water-based lubricants, such as K-Y Jelly, supply moisture and are used immediately before intercourse. These products are readily available in grocery stores and pharmacies, usually at a low cost.

Long-acting vaginal moisturizers are also available and can provide extended relief. Vaginal creams containing estrogen are very helpful in relieving the symptoms of vaginal dryness in menopause.

Since I began menopause, I've had an embarrassing problem—urine leaks when I laugh or cough. What can be done to prevent this?

Some women have problems with bladder control after menopause begins. This happens because the muscles that surround the bladder and hold the urine inside become weaker when estrogen levels are low. Fortunately, simple exercises, known as Kegel or pelvic floor exercises, can strengthen these muscles. To perform the exercise, contract the pelvic muscles as if trying to tighten or close the vaginal or anal opening. Hold the contraction for a count of three and then relax. Wait a couple of seconds and repeat. Performing several of these exercises a day (try for a total of 50 per day) can markedly improve bladder control.

My doctor has recommended hormone replacement therapy, but I've heard that I'll have menstrual periods again if I take it. Is that true?

Estrogen therapy may cause vaginal bleeding in some women. This depends on the hormone that is selected and the dose taken each day, as well as each woman's own unique response to therapy. Often, estrogen is taken in a cyclic regimen, that is, estrogen is taken for 21 to 25 days of the month followed by several days without estrogen. After menopause, low estrogen levels result in a thinning of the uterine lining, which in turn stops the monthly period. Taking estrogen after menopause thickens the uterine lining. This lining is shed on the days when estrogen is not being taken, resulting in vaginal bleeding similar to a period. About two thirds of women who still have a uterus will have a period on the days when they are not taking estrogen. Similarly, most women who take continuous estrogen (that is, estrogen daily) plus progestin pills on some days of the month will have a period.

If I have a period on estrogen therapy, will I also have PMS again?

Some women do experience PMS-like symptoms, including swollen or tender breasts, bloating, nausea, and sometimes even a blue mood. Although these are PMS-like symptoms they are not truly related to menstruation. Some of these symptoms are linked to mild water retention and may be relieved by a mild diuretic. Other remedies that can help include:

• Reducing salt intake
• Increasing exercise and activity
• Avoiding caffeine and chocolate
• Taking vitamin B6 or B complex
• Wearing a support bra
• Eating ginger

Even though my eating habits have not changed, I've gained weight recently. Is that linked to menopause?

It may be. The body's metabolism changes during and after menopause. Everyone's metabolism begins to slow during the early-to mid-30s. This change occurs slowly, so it may take a while for the impact of eating habits to affect weight. It is important to make a sensible, nutritious diet and healthy behaviors, such as getting enough exercise, goals for life.

I seem to be very forgetful lately and I'm worried. What's happening?

Many menopausal women have problems with short-term memory, like forgetting the location of car keys or eyeglasses, skipping appointments they didn't remember, or losing the end of a thought when speaking or writing. These lapses may be due to a busy lifestyle and/or stress at home or work. Notably, several medical studies have shown distinct differences in memory in women who have active ovaries producing estrogen or are taking estrogen replacement therapy, compared with women with low estrogen levels due to menopause.

How will menopause affect my daily activities and lifestyle?

That all depends on you. Menopause is a natural part of life, not a disease or a health crisis. However, menopause may occur when many other changes are happening in your life. For instance, your children may be marrying or leaving home, your parents may be ill or dying, or you may be wondering what you'll do when you retire from work. That's why it is probably more helpful to think of how your daily activities and lifestyle will affect menopause. For instance, making sure that you exercise and eat nutritious foods can make a real difference in how you feel and can even help prevent some of the long-term effects that are linked to estrogen deficiency, like heart disease or osteoporosis.

Physical changes do occur with menopause and with aging. But the changes that happen during this period can be minimized by healthy living and a sense of purpose in life.

What should I do if I am still getting hot flashes despite being on hormone therapy?

If you have been taking hormone therapy and are still experiencing troublesome hot flashes, you should talk to your healthcare professional about them and what options you have. One of the reasons could be that you are not absorbing your hormone tablets properly and using a hormone skin patch may suit you better. Also sometimes taking a short break from your hormone therapy and then restarting it can be helpful. Otherwise, you may simply require a higher dose of the hormones, as not every women finds benefit from the same dose. There may be other reasons you are getting hot flashes also and your healthcare professional can help to eliminate other causes.

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Glossary of menopause terms

Adrenal gland: The triangular-shaped endocrine glands that sit on top of the kidneys. They are chiefly responsible for regulating the stress response through the synthesis of corticosteroids.

Antidepressant: Medication that can be used to treat depression

Autoimmune: An immune response by the body against one of its own tissues, cells, or molecules.

Autoimmune disease: Disease caused by an immune response against foreign substances in the tissues of one’s own body.

Black cohosh: A plant based component of many dietary supplements that have been marketed for use in the treatment of menopausal and menstrual symptoms. Research studies do not provide evidence that it is effective.

Bloating: Any abnormal swelling of the abdominal area that can make a person feel uncomfortable, full, and tight in that region. It can be caused by several factors including gas build up in the intestines, fat, and fluid in the abdomen.

Bone mineral density: Measures the density or mass of minerals and vitamins such as calcium in your bones, which is related to your risk of developing osteoporosis and fractures.

Blood clot: Is a focus of coagulated blood in a blood vessel, also known as a thrombosis. Blood clots that develop in the main arteries of the heart, brain, and lungs can have serious consequences on health.

Bisphosphonates: A class of drugs that inhibits the resorption of bone. Its uses include the prevention and treatment of osteoporosis, multiple myeloma and other conditions of bone fragility.

Cervix: The lower, narrow part of the uterus (womb). The cervix forms a canal that opens into the vagina, which leads to the outside of the body.

Chemotherapy: Use of chemical substances to heat diseases such as cancer.

Chromosome defect: Chromosomes are the part of every single living cell that contains the genes inherited from each parent. Each cell contains 46 chromosomes. Sometimes people are born with abnormalities in their chromosomes, including extra chromosomes, missing parts to chromosomes, missing whole chromosomes, etc.

Cognitive function: Brain functioning like memory, thinking, and problem solving

Colorectal cancer: Cancer of the colon or large intestines

Condom: A barrier method of birth control. There are both male and female condoms. The male condom is a sheath placed over an erect penis before sex that prevents? pregnancy by blocking the passage of sperm. A female condom also is a sheath, but is inserted into the vagina to block the passage of sperm.

Constipation: A condition of the digestive system where stool becomes hard and difficult to pass causing irregularity in a person's bowel routine.

Continuous combined hormone therapy: This is another method of taking hormone therapy whereby a woman takes daily estrogen and progestin every day of the month.

Cyclic combined hormone therapy: A method of taking estrogen and progestin hormone therapy whereby a person takes daily estrogen and then a daily progestin only on 1 to 14 days of each month. Most women on this regimen experience monthly bleeding related to withdrawal.

Dementia: A brain condition where there is progressive deterioration in cognitive function due to a disease process in the brain that is unrelated to normal aging. One of the most common causes of dementia is Alzheimer's disease.

Depression: A condition of low mood associated with feelings of hopelessness, guilt, lack of energy, loss of interest or pleasure, loss of appetite and poor sleep, persisting for more than 2 weeks.

Dual-energy X-ray absorptiometry: A test that measures bone mineral density via X-ray beams. Postmenopausal women should be having this test done to screen for osteoporosis.

Diabetes: An illness where people have high circulating blood sugars because either their insulin is lacking or is not working. It can lead to various complications such as heart disease, kidney, and eye disease.

Endometrial cancer: Cancer of the womb.

Estradiol: A sex hormone representing estrogen, which is essential to reproductive and sexual function.

Estrogen: A group of female hormones that are responsible for the development of breasts and other secondary sex characteristics in women. Estrogen is produced by the ovaries and other body tissues. Estrogen, along with progesterone, is important in preparing a woman's body for pregnancy.

Follicle-stimulating hormone (FSH): A hormone produced by the pituitary gland. In women, it helps control the menstrual cycle and the production of eggs by the ovaries, by stimulating the ovaries to produce female hormones.

Fractures: Broken bones

HIV/AIDS infection: HIV is the virus that causes AIDS or acquired immunodeficiency syndrome. HIV infection can produce no symptoms for many years. When certain symptoms develop, a person has AIDS. AIDS is a syndrome, or group of diseases, that can be fatal. HIV/AIDS infection is lifelong; there is no cure.

High blood pressure: High blood pressure is a condition otherwise known as hypertension, meaning that there is increased pressure in the flow of blood through the circulation. Typically, high blood pressure refers to arterial pressure. Having high blood pressure puts someone at risk of diseases of the heart, kidney, and eye, as well as the risk of stroke.

High-density lipoprotein (HDL): A class of lipoproteins that carry cholesterol from the body's tissues to the liver.

Hormone: A substance produced by one tissue and conveyed by the bloodstream to another tissue to affect a function of the body, such as growth or metabolism.

Hormone therapy (HT): Replaces the hormones that a woman’s ovaries stop making at the time of menopause, easing symptoms like hot flashes and vaginal dryness. HT combines the female hormones estrogen and progestrogen and is usually given in pill form. A recent study has found that HT can cause more harm than good in healthy women, and can increase a woman’s risk for breast cancer, heart disease, stroke, and pulmonary embolism (blood clot in the lung). Talk with your healthcare provider to find out if HT is best for you and about other ways to control menopausal symptoms.

Hot flashes: Sometimes referred to as a hot flush or night sweat, these are symptoms of changing hormone levels often considered characteristic of menopause. Hot flashes are typically experienced at night as a feeling of intense heat with sweating and rapid heartbeat and may typically last from 2 to 30 minutes on each occasion for older women. The event may be repeated a few times each week or up to a dozen times a day, with the frequency reducing over time.

Hysterectomy: An operation to remove a woman's uterus (womb).

Immune system: A complex system in the body that recognizes and responds to potentially harmful substances, like infections, in order to protect the body.

Libido: Sexual drive.

Low-density lipoprotein (LDL): LDL transports cholesterol and triglycerides from the liver.

Luteinizing hormone (LH): Necessary for proper reproductive function.

Menopause: The transition in a woman's life when production of the hormone estrogen in her body falls permanently to very low levels, the ovaries stop producing eggs, and menstrual periods completely stop.

Menstruating: The blood flow from the uterus that happens about every 4 weeks in a woman.

Osteoporosis: A bone disease that is characterized by progressive loss of bone density and thinning of bone tissue, causing bones to break easily.

Ovaries: Part of a woman’s reproductive system, the ovaries produce her eggs. Each month, through the process called ovulation, the ovaries release eggs into the fallopian tubes, where they travel to the uterus, or womb. If an egg is fertilized by a man's sperm, a woman becomes pregnant and the egg grows and develops inside the uterus. If the egg is not fertilized, the egg and the lining of the uterus is shed during a woman’s monthly menstrual period.

Ovarian cancer: Cancer of the ovaries

Ovulation: The release of a single egg from a follicle that developed in the ovary. It usually occurs regularly, around day 14 of a 28-day menstrual cycle.

Perimenopause: The time preceding menopause during which the production of hormones, such as estrogen and progesterone, diminishes and becomes more irregular. Symptoms of perimenopause can begin as early as age 35, although most women become aware of them much later. It can last for a few months or for several years. The duration of perimenopause cannot be predicted in advance.

Phytoestrogens: Chemicals produced by plants that act like estrogens in animal cells and bodies; trace substances can also be found in food. In a comparatively recent discovery, these chemicals mimic and supplement the action of the body’s own estrogen hormones and researchers are still exploring the nutritional role of these substances in such diverse metabolic functions such as the regulation of cholesterol and maintaining proper bone density in postmenopause. Also, phytoestrogens may play a role in some types of cancers, although it is not clear if the relationship is due to the phytoestrogens or overall eating habits.

Postmenopause: Postmenopause refers to a women’s time of life after menopause has occurred. It is generally believed that the postmenopausal phase begins when 12 full months have passed since the last menstrual period. The postmenopausal phase will continue for the rest of a woman’s life.

Premature menopause: Menopause occurring before the age of 40, which affects 1% of women. Causes of premature menopause include autoimmune disorders, thyroid disease, and diabetes mellitus. Premature menopause is diagnosed by measuring the levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH), which will be higher if menopause has occurred.

Progesterone: A female hormone produced by the ovaries. Progesterone, along with estrogen, prepares the uterus (womb) for a possible pregnancy each month and supports the fertilized egg if conception occurs. Progesterone also helps prepare the breasts for milk production and breastfeeding.

Progestin: A hormone that works by causing changes in the uterus. When taken with the hormone estrogen, progestin works to prevent thickening of the lining of the uterus. This is helpful for women who are in menopause and are taking estrogen for their symptoms. Progestins also are prescribed to regulate the menstrual cycle help a pregnancy occur or to maintain a pregnancy, or to treat unusual or heavy bleeding of the uterus. Progestins also can be used to prevent pregnancy, to treat cancer of the breast, kidney, or uterus, and to treat loss of appetite and severe weight or muscle loss.

Psychotherapy: A type of psychological treatment

Radiation treatment: May be used for curative or adjuvant cancer treatment to control malignant cells or tumors.

Rheumatoid arthritis: A chronic, inflammatory autoimmune disorder that causes the immune system to attack the joints.

Scientific evidence:

Sexually transmitted disease (STD): Caused by an infectious pathogen possibly transmitted by means of sexual contact. There are at least 25 different STDs that are cause by viruses, bacteria, and parasites.

Soy: Food products made from soybean, which is a type of legume. Examples are tofu and soy milk.

Stroke: Stroke is also known as cerebrovascular accident and is a condition whereby a person develops loss of brain function, such as paralysis or loss of vision as a result of a disruption in the blood supply to the brain. This disruption of the blood supply is usually caused by a blood clot on the main circulation to the brain.

Steroid: A type of drug that has properties related to sex hormones and glucocorticoids which are hormones that have a role in the body's immune system and metabolism. Steroids used in treatment usually have an anti-inflammatory effect, however, they can also have many side effects if used for a prolonged period of time.

Testosterone: A steroid hormone from the androgen group. Testosterone is primarily secreted in the testes of males and the ovaries of females, although small amounts are secreted by the adrenal glands. It is the principal male sex hormone and an anabolic steroid. In both males and females, it plays key roles in health and wellbeing. Examples include enhanced libido, energy, immune function, and protection against osteoporosis.

Thyroid disease: A small gland located below the skin and muscles at the front of the neck. When the thyroid doesn't supply the proper amount of hormones needed by the body, the gland enlarges, resulting in either an underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism).

Transdermal: Delivery via the skin. For example in the case of hormone therapy, it implies that a drug is absorbed through the skin and then into the blood, rather than being taken as a pill through the mouth.

Turner's syndrome: Encompasses several chromosonal abnormalities, in which monosomy X is the most common, resulting in underdeveloped female sexual characteristics.

Urinary incontinence: Loss of bladder control.

Uterus: A woman’s womb, or the hollow, pear-shaped organ located in a woman's lower abdomen between the bladder and the rectum.

Vagina: The muscular canal that extends from the cervix to the outside of the body. Its walls are lined with mucus membranes and tiny glands that make vaginal secretions.

Vaginal atrophy: An abnormal inflammation of the vagina due to thinning and shrinking tissues and decreased lubrication of the vaginal walls, caused by a lack of estrogen. The most common cause is the decrease in estrogen after the menopause, although it can be caused by other conditions. Symptoms include vaginal soreness and itching, as well as painful intercourse, and bleeding after sexual intercourse.

Vaginal bleeding: Bleeding coming out of the vagina that originates anywhere in the reproductive system such as from the vagina itself or the uterus. Vaginal bleeding can be normal such as in menstruation or abnormal such as caused by a disease in the uterus like fibroids.

Vulva: Opening to the vagina.

Women's Health Initiative (WHI): A research initiative launched by the National Institutes of Health (NIH) in 1991. The objective of the initiative was to conduct medical research into some of the major health problems of older women. In particular, clinical trials were designed and funded that address cardiovascular disease, cancer, and osteoporosis.

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Menopause resources and tools

Government Agencies

*Accepts Spanish Calls

*National Women’s Health Information Center, OWH, HHS
8270 Willow Oaks Corporate Drive
Fairfax, VA 22031
Phone: (800) 994-9662
TDD: (888) 220-5446
Fax: (703) 663-6942
www.womenshealth.gov/Menopause

Administration on Aging, HHS
1 Massachusets Avenue
Washington, DC 20201
Phone: (202) 619-0724
http://www.aoa.dhhs.gov/prof/notes/notes_hrt.asp

*Agency for Healthcare Research and Quality (AHRQ)
540 Gaither Road, Suite 2000
Rockville, MD 20850
Phone: (800) 358-9295
TDD: (888) 586-6340
http://www.ahrq.gov/downloads/pub/evidence/pdf/menopause/menopaus.pdf

*National Cancer Institute, NIH, HHS
Building 31, Room 10A31
31 Center Drive, MSC 2580
Bethesda, MD 20892-2580
Phone: (800) 422-6237
TTY: (800) 332-8615
http://www.cancer.gov/cancertopics/menopausal-hormone-use

*National Center for Complementary and Alternative Medicine, NIH, HHS
PO Box 7923
Gaithersburg, MD 20898
Phone: (888) 644-6226
TTY: (866) 464-3615
Fax: (866) 464-3616
http://nccam.nih.gov/health/menopause.htm

*National Institute on Aging, NIH, HHS
Public Information Office
Building 31, Room 5C27
31 Center Drive, MSC 2292
Bethesda, MD 20892
Phone: (800) 222-2225
TTY: (800) 222-4225
Fax: (301) 496-1072
http://www.niapublications.org/agepages/menopause.asp

*Osteoporosis and Related Bone Diseases National Resource Center, NIH, HHS
2 AMS Circle
Bethesda, MD 20892-3676
Phone: (800) 624-2663
TTY: (202) 466-4315
Fax: (202) 293-2356
http://www.osteo.org

Private Organizations

American Association of Clinical Endocrinologists (AACE)
1000 Riverside Avenue Suite 205
Jacksonville, FL 32204
Phone: (904) 353-7878
http://www.aace.com/pub/pdf/guidelines/menopause.pdf

American College of Obstetricians and Gynecologists (ACOG) (Offers Publications in Spanish)
PO Box 96920
Washington, DC 20090-6920
Phone: (202) 638-5577
http://www.acog.org/from_home/publications/press_releases/pauseAwards.cfm

American Menopause Foundation, Inc. (Offers publications in Spanish)
350 5th Avenue, Suite 2822
New York, NY 10118
Phone: (212) 714-2398
http://www.americanmenopause.org

Boston Women's Health Book Collective (Offers publications in Spanish)
34 Plympton Street
Boston, MA 02118
Phone: (617) 451-3666
Fax: (617) 451-3664
http://www.ourbodiesourselves.org

*Hormone Foundation
8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815-5817
Phone: (800) 467-6663
http://www.hormone.org

*National Osteoporosis Foundation (NOF)
1232 22nd Street, NW
Washington, DC 20037-1292
Phone: (800) 223- 9994 (English), (800) 624-2663 (Spanish)
http://www.nof.org

National Women’s Health Network
514 10th Street, NW, Suite 400
Washington, DC 20004
Phone: (202) 628-7814
http://www.nwhn.org/menopause

North American Menopause Society (NAMS) (Offers publications in Spanish)
PO Box 94527
Cleveland, OH 44101
Phone: (440) 442-7550
http://www.menopause.org

*Planned Parenthood Federation of America
434 West 33rd Street
New York, NY 10001
Phone: (800) 230-7526
http://www.plannedparenthood.org/sexual-health/women-health/menopause-4807.htm

Newsletters, Magazines, and Reports

Healthy Women Today
The National Women’s Health Information Center
http://www.womenshealth.gov/newsletter/

Bone Health Updates
The National Osteoporosis Foundation
http://www.nof.org/list_server/

Menopause Flashes
The North American Menopause Society
http://www.menopause.org/newsletter.htm

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