Menopause is the time in a woman’s life when she stops menstruating. Natural menopause is genetically pre-determined and typically occurs between the ages of 48 and 52. However, some women will go through menopause at an earlier or later age. Menopause is a normal biological event that all women experience. Once a woman reaches menopause, she can no longer bear children.

Main Menu:

• Overview
• The Female Reproductive System
• Menopause Terminology
• Menopausal Symptoms
• Diagnosing Menopause
• Coping with Short Term Effects of Menopause
• Menopause and Osteoporosis
• Menopause and Heart Disease
• Regular Physical Exams After Menopause
• News: Physical Abuse May Alter Ovary Function, Could Lead to Premature Menopause
• Additional Resources and References

Overview

According to the North American Menopause Society, approximately 41.75 million American women were over age 50 in 2000, and approximately 31.2 million of those women were over 55 years (compared with 28.7 million in 1990). By 2020, an estimated 45.9 million women in the United States will be over age 55. Because of the increased life expectancy over the last several decades, it is estimated that most women go on to live one-third to one-half of their lives after they reach menopause.

Menopause is considered premature if it occurs before age 35. Premature menopause may occur for several reasons, including premature ovarian failure (POF), or from secondary changes, such as the surgical removal of both ovaries (oophorectomy), certain types of cancer treatment (such as chemotherapy or pelvic radiation), mumps, and certain autoimmune disorders such as lupus or rheumatoid arthritis. Also, women who smoke tend to go through menopause at an earlier-than-average age.

Before menstruation stops completely at menopause, most women will go through pre-menopause and peri-menopause. During pre-menopause, menstrual periods (menses) begin to become irregular. During peri-menopause, menstrual periods often become highly irregular and women may experience symptoms of menopause, such as hot flashes, vaginal dryness, or sleep disturbances. Peri-menopause occurs a few years before a woman reaches menopause. Once a woman reaches menopause, menstruation will stop forever unless she takes hormone replacement therapy.

In addition to short-term effects such as hot flashes, the decrease in levels of hormones that occur during menopause can increase the risk of osteoporosis and heart disease. Therefore, it is important that women maintain a healthy lifestyle and talk to their physicians about ways to protect themselves from future health problems.

The Female Reproductive System

The female reproductive system is made up of both external and internal organs.

Vulva: The term vulva refers to the external parts of the female genitalia. The upper portion of the vulva is covered with pubic hair in mature females. The lower portion of the vulva consists of the labia majora (outer lips), which are two folds of fatty tissue covered with skin. Inside the labia majora are the labia minora (inner lips), another two folds of tissue. The labia minora protect the opening of the urethra (urine canal) and the entrance to the vagina. Above the urethra, the labia minora join to form the tip of the clitoris. The clitoris plays a key role in female sexual arousal.

Vagina: The vagina is the canal that leads from the uterus to the outside of the body. It serves as a passageway for menstrual discharge and as the birth canal. In young girls, the opening of the vagina is covered by a thin membrane called the hymen. As a woman begins to increase physical activity, use tampons, or engage in sexual intercourse, the hymen is gradually stretched. The vagina tends to be dry in girls before puberty and in women after menopause.

Cervix: The cervix is the lower portion of the uterus that connects the uterus to the vagina. The opening of the cervix remains small except during labor when it expands to allow the baby to pass from the uterus to the vagina. Click here to learn more about cervical cancer.

Uterus: The uterus is a pear-shaped muscular sac that houses the fetus during pregnancy. During each menstrual cycle, the lining of the uterus (endometrium) thickens to prepare for possible pregnancy. If a woman does not become pregnant during this time, the endometrium is shed and exits the body through the vagina each month during menstruation. Menstruation ends at menopause.

Fallopian tubes: The Fallopian tubes are attached to the uterus and extend toward the ovaries. At the ends of each tube are fringe-like structures called fimbriae that wrap around each ovary. These fimbriae help guide the reproductive eggs (ova) that are released by the ovaries each month into the Fallopian tubes in pre-menopausal women. When an egg enter one of the Fallopian tubes, a series of contractions force the egg down toward the uterus. While an egg is traveling from the ovaries to the uterus through one of the Fallopian tubes, it may be fertilized by sperm released during sexual intercourse.

Ovaries: The ovaries are located on both sides of uterus. In addition to producing the hormones estrogen and progesterone, the ovaries also produce mature reproductive eggs (ova) that are released each month during ovulation in pre-menopausal women. If an egg becomes fertilized by sperm while it travels from the ovaries to the uterus through one of the Fallopian tubes, then it implants itself in the uterus where it will grow and evolve into a mature baby over the next nine months. If the egg is not fertilized by sperm, then it breaks down along with the uterine lining and is discarded during menstruation. Near menopause, the follicles in the ovaries become less responsive to the follicle-stimulating hormone (FSH), which is responsible for preparing the egg for fertilization. When a woman reaches menopause, her ovaries reduce their production of estrogen and progesterone which usually results in irregular periods and other symptoms such as hot flashes, vaginal changes, sleep disturbances, etc.

Menopause Terminology

Menopausal Symptoms

The symptoms of menopause vary significantly from woman to woman. Some women only experience mild menopausal symptoms while others have severe discomfort. The most common symptoms that signal that a woman is beginning the transition to menopause are irregular menstrual periods, hot flashes, and vaginal dryness.

Most women experience changes in their menstrual periods before they reach menopause. These changes may include longer or shorter menstrual cycles or the absence of menstruation (amenorrhea) for periods of time. On average, women experience changes in menstrual periods approximately two years before they reach menopause, although the time may be longer or shorter depending on the individual. It is important for women to report these changes to their physicians since, at times, irregular menstrual cycles can signal other health problems.

Hot flashes are a common symptom of menopause. Hot flashes may be accompanied by sweating, flushing, or heart palpitations. Hot flashes occur when estrogen is blocked in the hypothalamus, the part of the brain that controls the body’s thermostat. It is estimated that nearly 80% of menopausal women experience hot flashes. Hot flashes typically last up to two years after the final menstrual period.

During peri-menopause (the time period immediately before a woman reaches menopause), changes also occur in the vagina and urinary tract. Vaginal tissue becomes thinner, dryer, and less elastic, which may cause discomfort or pain during sexual intercourse. Urinary tract tissue also becomes less elastic, which may cause a release of urine during laughter, coughing, sneezing, or exercise. Many women also find that urinary tract infections occur more frequently during this time. Other menopausal symptoms may include mood changes, insomnia (sleep deprivation), depression, or anxiety. Hormone replacement therapy (HRT) can relieve many of these symptoms.

Diagnosing Menopause

Before menopause, the female body produces the hormones estrogen and progesterone in the ovaries. Estrogen works to regulate a woman’s monthly menstrual cycle and secondary sexual characteristics (such as breast development and function), and also prepares the body for fertilization and reproduction. Progesterone is released each month during menstruation to prepare the uterus for possible pregnancy and to prepare the breasts for lactation (milk production). As a woman reaches menopause, typically around 50 years old, her body produces less and less estrogen and progesterone.

This loss of estrogen and progesterone usually results in irregular periods and other symptoms such as hot flashes, vaginal changes, sleep disturbances, etc. At this time, a woman’s physician will usually test her follicle stimulating hormone (FSH) level. FSH is a hormone that is secreted by the body’s pituitary gland to stimulate growth of ova (female reproductive eggs). As the ovaries produce less estrogen, the pituitary gland increases production of FSH to try to stimulate the ovaries into producing more estrogen.

While FSH levels can help determine a woman’s stage of menopause, FSH levels do tend to fluctuate from month-to-month during peri-menopause. Women who take oral contraceptive pills will have to temporarily stop taking them so that their FSH levels can be measured accurately. In addition, as a woman nears menopause, the walls of her vagina will become thinner and dryer. At this time, the physician may take a sample of the vaginal wall when performing a Pap smear. However, it is also important for a woman to keep track of her menstrual periods when they begin to become irregular to help her physician know when she is in the pre-menopausal and peri-menopausal stages.

Coping With Short Term Effects of Menopause

While menopausal symptoms (hot flashes, vaginal dryness, sleep disturbances, etc.) are temporary, they are usually bothersome to most women. There are a variety of ways to treat these symptoms, from natural remedies (such as dressing in layers to reduce the effects of hot flashes) to taking hormone replacement therapy.

Hormone replacement therapy (HRT) is synthetic estrogen and/or progesterone (called progestin). It is designed to "replace" a menopausal woman’s depleting hormone levels. HRT helps to relieve hot flashes and other menopausal symptoms. Research has also shown that HRT may also help prevent osteoporosis, heart disease, short-term memory loss, depression and other diseases or conditions in post-menopausal women.

While HRT can greatly reduce menopausal symptoms and may provide protection against other diseases and conditions, there is also conflicting evidence that supports a link between HRT and an increased risk for breast cancer. However, current research shows the risk to be small and that it appears to be related to the duration of treatment and the general breast cancer risk of the patient. Further research will provide more information on the risks of HRT. Because HRT can provide many benefits, patients and physicians should make the decision about HRT together, based on a woman’s individual medical situation and circumstances.

For women who choose not to take HRT, there are a variety of over-the-counter products available. Some of these products contain phytoestrogens, natural chemicals that act like a weak form of estrogen. Some research suggests that products containing phytoestrogens (such as soy) may help alleviate menopausal symptoms, although further research is still needed to confirm this association. Women should discuss the use of these products with their physicians, as they may not be appropriate for all women.

Some women find that regular exercise can improve hot flashes. Calcium is also thought to reduce the occurrence of hot flashes. The National Institute on Aging provides the following suggestions to help improve hot flashes:

In 2001, the American College of Obstetricians and Gynecologists (ACOG) issued new practice guidelines to physicians regarding the use of over-the-counter botanical products as alternatives to HRT in relieving menopausal symptoms. The chart below summarizes their findings.

Source: American College of Obstetricians and Gynecologists. Click here for more information.

• Dress in easily removable layers
• Drink a glass of cold water or juice at the onset of a flash
• Keep a thermos of ice water by the bed to drink when needed
• Keep an ice pack by the bed at night to use on the skin when a hot flash occurs
• Use cotton sheets, lingerie and clothing which lets the skin "breathe"

Women who experience vaginal dryness, irritation, or discharge are encouraged to ask their physicians about using vaginal lubricants to help relieve these symptoms. In some cases, vaginal discharge can be an indication of a more serious condition, such as endometrial cancer (cancer of the uterine lining), and may require further investigation.

Menopause and Osteoporosis

The loss of estrogen at menopause is associated with a significantly increased risk of osteoporosis. Osteoporosis is a decrease in normal bone mineral density. A loss of bone density causes bones to become brittle, and in turn, may lead to more frequent fractures and other serious effects. It is estimated that one in two women over 50 will have an osteoporosis-related fracture.

Before a woman reaches her mid-30s, her body gains more bone than it loses. Around age 35, this process balances out. However, the onset of menopause (and a decrease in estrogen) around 50 years of age may speed up the rate of bone loss. Bone loss, known as osteopenia, may eventually become more severe and result in osteoporosis. When this occurs, a woman is at greater risk for bone injury and fracture, even with relatively minor trauma.

The key to avoiding severe effects from osteoporosis and bone fractures associated with the condition is prevention. Women may protect themselves from severe bone loss by:

• Maintaining a balanced diet rich in calcium
• Performing regular weight-bearing exercise (such as walking or aerobics)
• Limiting alcohol intake
• Not smoking
• Considering hormone replacement therapy or other treatments

 Click here for more information on osteoporosis.

Menopause and Heart Disease

When a woman reaches menopause, her risk of heart disease increases due to a loss of estrogen. An estimated 9,000 American women under age 45 have heart attacks each year versus 250,000 women over age 65. Researchers believe that estrogen helps protect women against heart disease in their reproductive years and appears to help maintain lower cholesterol levels and improve artery flexibility and expandability. Pre-menopausal women are still at risk of heart disease, but the risk is significantly lower than for post-menopausal women, according to researchers. When a woman’s estrogen production ceases at menopause, her arteries tend to lose their flexibility and her risk of heart disease increases significantly since no collateral (back-up) blood supply is developed.

Because many of the other risk factors for heart disease are controllable, women can minimize their risk of heart disease by focusing on these controllable risk factors. Many of these risk factors can be changed with modifications to diet, exercise, or drug therapy. Women should talk to their physicians about their risk of heart disease and how best to minimize this risk.

Controllable risk factors for heart disease include:

• High cholesterol
• High blood pressure
• Smoking
• Obesity
• Lack of physical activity
• Stress

  Click here to learn more about heart disease.

Regular Physical Exams After Menopause

Because menopause and advancing age increase the risk for several diseases and conditions, it is very important that women continue to receive annual physical exams once they reach menopause.

Women 40 years of age and older should have the following specific exams every year in addition to an overall physical exam:

• Pelvic exam
• Pap smear
• Rectal exam
• Stool blood test
• Mammogram

Beginning at age 50, women should also have a sigmoidoscopy every three to five years to screen for colon cancer. A sigmoidoscopy involves examining the rectum and lower portion of the colon. Women who have a family history of cancer or other illnesses should talk to their physicians about beginning screening exams at an earlier age. With continued focus on their health, women can continue to lead long, productive lives for decades after menopause.

Additional Resources and References

• The North American Menopause Society provides information on menopause at http://www.menopause.org/
• The National Institute of Aging provides information on menopause at http://www.nih.gov/nia/
• Power-Surge is a website created by Alice Lotto Stamm, better known by her online persona, "Dearest." The site offers a warm and caring support community for women at midlife and in menopause. Features include an ask-the-expert section and message boards, http://www.power-surge.com/
• To learn more about hormone replacement therapy, please visit http://www.imaginis.com/breasthealth/hrt.asp
• To learn more about osteoporosis, please visit http://www.imaginis.com/osteoporosis/
• To learn more about heart disease, please visit http://www.imaginis.com/heart-disease/

Updated: January 15, 2008