By menopause we mean the definitive interruption of menstruation and, therefore, of fertility.
- Even for several years before and shortly after menopause, estrogen levels fluctuate greatly, cycles become irregular, and symptoms (such as hot flashes) may arise.
- After menopause, bone density decreases.
- Menopause is diagnosed when a woman hasn’t had a period for 1 year, but blood tests can be done to confirm it.
- Some measures, including hormone therapy and other medications, can reduce symptoms.
During the fertility years, menstruation usually occurs in cycles of about one month, with an egg releasing from the ovary (ovulation) about two weeks after the first day of a cycle.
For the cycle to be regular, the ovaries must produce a sufficient amount of the hormones estrogen and progesterone.
Menopause occurs because as a woman ages, the ovaries stop producing progesterone and estrogen. In the years preceding the menopause, the production of progesterone and estrogen begins to decrease and ovulation and menstruation are less frequent, and then finally stop; at that point the pregnancy can no longer occur naturally.
A woman’s last period can only be identified later, after the absence of menstruation (amenorrhea) for at least one year (women who do not wish to become pregnant must continue to use contraceptive methods for one year after the last menstrual period).
For perimenopausal it means the period of several years before and the year after the last menstrual cycle. The number of years of perimenopause prior to the last menstruation varies greatly.
During this phase, estrogen and progestin levels fluctuate greatly and this phenomenon is thought to be responsible for the symptoms of menopause experienced by many women after the age of 40 years.
The menopausal transition is the phase of perimenopause leading to the last menstrual cycle and is characterized by changes in the course of menstrual cycles. Usually menopausal transition lasts 4 to 8 years. It lasts longer in smokers and in women where it starts at a younger age.
With post-menopause refers to the period after the last menstrual cycle.
In the United States, the average age at the time of menopause is approximately 52 years. However, it can also normally occur in women aged 45 (or even 40) to 55 or older. Menopause can begin at a lower age in women than
- They smoke
- They live at high altitudes
- They are malnourished
We talk about premature menopause if it occurs before the age of 40. The early menopause is also known as premature ovarian failure or primary ovarian failure.
Symptoms of menopause
During perimenopause, symptoms may be absent, modest, moderate, or severe. Symptoms can last anywhere from six months to about ten years, sometimes longer.
The first symptom is represented by menstrual irregularity. The cycles can be more or less frequent, but without a precise pattern and can be more or less long and more or less abundant. They can disappear for months and then reappear regularly. In some women, regular periods last until menopause.
The hot flashes affect 75 to 85% of women and usually appear before the interruption of the cycles. They last on average about 7.5 years, but also more than 10 years. Typically, the intensity and frequency of hot flashes decrease over time.
The cause of hot flashes is not known. but it affects a reset of the brain’s thermostat (the hypothalamus), which controls body temperature. As a result, even small rises in temperature can make you feel hot. These can be related to fluctuations in hormone levels. There is no evidence that spicy foods or alcohol trigger hot flashes.
During hot flashes, the blood vessels located near the skin surface widen (dilate). As a result, blood flow increases, resulting in redness and warming (flushing) of the skin, especially the head and neck.
Women feel heat or and sweating increases. Hot flashes sometimes get this name because the face can turn red.
They last from 30 seconds to five minutes and can be followed by chills.
Other symptoms may appear around the time of menopause. Changes in hormone levels that occur during this time can contribute to:
- Breast sensitivity
- Mood variability
- Worsening of migraines that appear just before, during or after menstrual periods (menstrual migraines)
Depression, irritability, anxiety, nervousness, sleep disturbances (including insomnia), loss of concentration, headache and fatigue may also occur. Many women experience these symptoms during perimenopause and assume that they are caused by menopause.
Night sweats can disrupt sleep, causing fatigue, irritability, loss of concentration, and mood swings. In these cases, the symptoms may be indirectly associated with menopause (through night sweats). However, sleep disturbances are common during menopause even among women who do not have hot flashes.
The stresses of middle age (problems with teenagers, worries about aging, aging parental care, and changes in the marital relationship) can promote sleep disturbances. Therefore, the relationship between fatigue, irritability, loss of concentration and mood swings appears less clear.
Symptoms after menopause
Many symptoms of perimenopause, while bothersome, subsequently decrease in frequency and intensity after menopause.
However, the decrease in estrogen levels causes changes that can continue to negatively affect health (for example, by increasing the risk of osteoporosis) and can worsen if measures are not taken to prevent them. They may be interested:
- Reproductive system: The vagina’s mucous membrane thins, becomes less elastic and drier (a condition called vaginal atrophy or sometimes, with an inappropriate term, atrophic vaginitis).
These changes can make sexual intercourse painful. Other sexual organs (labia minora, clitoris, uterus and ovaries) shrink. Sexual arousal (libido) typically decreases with age; most women can still orgasm, but some may take longer.
- Urinary tract: The lining of the urethra thins and the organ shortens. These transformations facilitate the introduction of microorganisms and the development of urinary tract infections. Urinary tract infection can cause a burning sensation during urination.
After menopause, the urge to urinate can suddenly become very urgent (called urge urgency), sometimes leading to urinary incontinence , which is an involuntary leakage of urine. Urinary incontinence becomes more common and severe with age.
- Skin: The decrease in the level of estrogen and the aging itself cause a decrease in the amount of collagen (a protein that strengthens the skin) and elastin (a protein that gives the skin elasticity).
Therefore, the skin can become thinner, drier, inelastic and more prone to injury.
- Bone: The reduction of estrogen , which is important in maintaining bone structure, often causes a decrease in bone density and, sometimes, osteoporosis. The bone becomes less dense and more fragile, and the likelihood of fractures increases.
During the first 5 years time period of after menopause, bone density decreases rapidly. It subsequently decreases at about the same rate as men (about 1-3% annually).
- Lipid (Fat) Levels: After menopause, low-density lipoprotein (LDL, bad cholesterol) cholesterol levels rise, while high-density lipoprotein (HDL, good cholesterol) cholesterol levels remain roughly unchanged. These changes in LDL levels may partly explain the increased frequency of atherosclerosis and therefore of coronary heart disease after menopause.
However, it is unclear whether these changes result from aging or from decreased estrogen levels after menopause. Until menopause, the high levels of estrogen serve as protection against coronary heart disease.
Menopausal genitourinary syndrome
Menopausal genitourinary syndrome is a new, more accurate term used to describe symptoms caused by menopause affecting the vagina and urinary tract.
These symptoms include vaginal dryness, pain during intercourse, urinary urgency, and urinary tract infections.
Diagnosis of menopause
- Medical evaluation
- Rarely, blood tests to measure hormone levels
In about three quarters of women, menopause is evident; therefore, there is no need for laboratory tests.
If menopause begins a long time before the age of 50 or if symptoms are not well defined, the disorders that interrupt menstrual cycles can be identified with tests. Rarely, if the diagnosis of menopause or perimenopause needs confirmation, blood tests are done to measure the levels of follicle-stimulating hormone (which stimulates the ovaries to produce estrogen and progesterone).
Before starting any therapy, the doctor:
- He asks the woman about their personal and family medical history
- He does a physical examination, including a pelvic and breast exam , and a blood pressure measurement
During the pelvic exam the doctor checks for typical vaginal changes, which confirm the diagnosis of menopause. It also checks for abnormalities of the reproductive organs.
The woman’s personal and family history help the doctor determine the risk of developing certain diseases after menopause.
If it hasn’t been done recently, a mammogram is also done as part of routine care. Blood tests may be done.
Bone density is measured in women:
- at high risk of osteoporosis or who have sustained a fracture due to relatively low effort or a fall, which would not fracture healthy bone (a so-called fragility fracture)
- who have had an eating disorder or have had gastric bypass surgery
- who have used corticosteroids for a long time
- who have a low body mass index (BMI), Crohn’s disease or malabsorption syndrome
- all women from 65 years of age
Treatment of menopause
- General measures
- Certain drugs
- Alternative and complementary medicine
- Hormone therapy
Understanding what happens in perimenopause helps manage symptoms. Talking to other women who have gone through menopause or to your doctor can also help.
Treatment of menopause focuses on relieving symptoms such as vaginal dryness and hot flashes. General measures can be helpful, however if additional therapy is needed, the more effective it is
- The hormone therapy (estrogen, a progestin or both)
Progesterone refers to both synthetic and natural forms of progesterone (a female hormone). Another term, progestin, refers only to the synthetic forms.
Effective measures that do not involve hormones can include
- Hypnosis by a qualified health care practitioner to help relieve hot flashes
- Cognitive-behavioral therapy
- Other drugs such as two types of antidepressants (selective serotonin reuptake inhibitors or serotonin reuptake inhibitors – norepinephrine ) or the anticonvulsant drug gabapentin
Cognitive-behavioral therapy has been adapted for use during the menopausal transition and post-menopause. It can help women manage night sweats and hot flashes.
To relieve hot flashes, the following may help:
- Dress like an onion, with layers of clothing to gradually take off when you feel hot and put on when you feel cold.
- Further benefit can come from clothing that ensures good breathability (such as cotton underwear) or that can protect against moisture (such as certain types of underwear or sports clothing).
- Avoiding symptoms that trigger symptoms (such as hot environments, spicy foods, and bright lights) may also be helpful.
- Using fans or turning down the thermostat can help.
- Getting regular exercise and losing weight can help control hot flashes as well as have other benefits.
Although self-awareness (mindfulness; the practice of being aware of the present), relaxation techniques, and / or yoga can have general benefits for women, it is unclear whether they relieve hot flashes.
To manage sleep disorders , women can follow a routine to calm down before bed and when night sweats cause awakening. Developing good sleep habits and exercising can also help improve sleep.
The bladder control can be improved with Kegel exercises . In these exercises, the woman contracts her pelvic muscles as if she were blocking urination. Women can be taught to use biofeedback to help them learn to control their pelvic muscles.
The biofeedback is a method of bringing biological processes unconscious under the conscious control. It involves the use of electronic devices to measure information about these processes and report it to the conscious mind.
If vaginal dryness is causing painful intercourse, an over-the-counter vaginal lubricant can be used. Some women benefit from applying vaginal moisturizers every 1-3 days. Staying sexually active or masturbating also helps, by stimulating the circulation of the vagina and surrounding tissues and maintaining the elasticity of the tissues.
Many medications can prove to be helpful in relieving some menopausal symptoms.
Paroxetine (an antidepressant) can help relieve hot flashes. Gabapentin, an anticonvulsant, and other antidepressants (such as desvenlafaxine, fluoxetine, sertraline, or venlafaxine) are quite effective in relieving hot flashes. the antidepressants may also help relieve depression, anxiety and irritability.
However, none of these drugs are as effective as hormone therapy in relieving menopausal symptoms.
For insomnia problems, a sleeping pill is recommended.
Alternative and complementary medicine
Some women rely on pesticides and other supplements to relieve hot flashes, irritability, mood swings, and memory loss.
However, black cohosh, other pesticides (such as dong quai, evening primrose, ginseng, and St. John’s wort), and over-the-counter medications do not appear to be more effective than placebo , which works in 50% of cases. Furthermore, these remedies are not regulated like drugs.
This means that their manufacturers are under no obligation to demonstrate their safety or efficacy and furthermore that the nature and quantity of their ingredients are not standardized.
Studies conducted on soy protein have yielded mixed results. A soy product, called S-equol, has been shown to help relieve hot flashes in some women.
Some supplements (such as kava) can be harmful.
Additionally, some supplements can interact with other medications to aggravate some ailments.
Concerns about the use of standard hormone therapy have fostered interest in the use of plant-derived hormones such as sloth and soy, which have nearly the same molecular structure as hormones produced by the body and are therefore said to be bioidentical.
Many hormones used in normal hormone therapy are also so-called bioidentical of plant origin.
However, the hormones used in normal hormone therapy have been tested and approved and their use is closely monitored.
Pharmacists sometimes personalize (make up) bioidentical hormones for a client based on the doctor’s prescriptions. In this case we are talking about compound bioidentical hormones and their production is not adequately regulated.
Therefore, many doses, combinations and forms are possible; furthermore, purity, consistency and charge may also vary. Compound bioidentical hormones are often marketed as substitutes for regular hormone therapy and sometimes proposed as a better and safer treatment than standard therapy.
However, there is no evidence that compound products are safer and more effective, or even as effective as regular hormone therapy. Sometimes women are not told that bioidentical compound hormone products carry the same risks as standard hormones.
Patients considering taking such supplements are advised to consult a physician.
Hormone therapy for menopause
Hormone therapy can relieve moderate to severe symptoms of menopause such as night sweats, hot flashes and vaginal dryness. However, it may increase the risk of developing some serious disorders.
Hormone therapy improves the quality of life of many women by relieving their symptoms, but it does not improve the quality of life in the absence of symptoms. Therefore, it is not normally given to postmenopausal women.
The decision to undertake hormone therapy must be made by the woman and the doctor based on the specific condition of the woman.
For many women, the risks outweigh the potential benefits, so this type of therapy is not recommended. However, for some women, depending on their medical conditions and risk factors, the benefits may outweigh the risks.
For example, hormone therapy may be recommended for women who have a high risk of bone loss or fractures plus one of the following:
- Age under 60.
- In menopause for less than 10 years.
- They cannot take other medications (such as bisphosphonates) to prevent bone loss and fractures.
Hormone therapy reduces bone loss and fracture risk in these women.
Doctors do not usually recommend starting hormone therapy
- In women over 60.
- In menopause for more than 10-20 years.
In these women, the risk of coronary artery disease , stroke , thrombi in the legs , thrombi in the lungs and dementia is greater.
When hormone therapy is used, doctors prescribe the lowest hormone dosage needed to control symptoms, for the shortest time needed.
Hormone therapy can include
- A progestin (for example progesterone or medroxyprogesterone acetate)
- Both of these causes
All the hormones used for therapeutic purposes are produced in the laboratory; they may be identical or different from those produced by the body, but act in a similar way. Progestogens resemble progesterone , a female hormone produced by the body.
Estrogens and progestogens come in various forms . Estradiol and conjugated estrogens (a mixture of estrogen) are commonly used forms of estrogen).
Estrogen associated with a progestogen (combination hormone therapy) is usually given to women who have a preserved uterus, as estrogen alone increases the risk of cancer of the uterine epithelium (endometrial cancer).
The progestogen is a protection against this type of cancer. Women whose uterus has been removed can only take estrogen.
Benefits and risks of hormone therapy depend on the administration of the hormones individually or in combination.
Estrogen with or without progestin: Potential risks and benefits
Estrogen has significant advantages:
- Hot flashes and other symptoms: Estrogenic treatment is the most effective for hot flashes.
- Dryness and thinning of vaginal tissues and urinary tract: Estrogen can prevent dryness and thinning of these tissues, thus reducing pain during intercourse. If the only problem is dryness and thinning of these tissues, the doctor may recommend a form of estrogen that is introduced into the vagina.
These forms include tablets estrogen low dose, a ring of estrogen low dose, a cream based on estrogen at low doses and suppositories. If low-dose estrogen is used, women who still have a womb are not required to take a progestogen.
- Urgent need to urinate and recurrent urinary tract infections: Forms of estrogen that are placed in the vagina (creams, tablets or rings) can help relieve these problems.
- Osteoporosis : Estrogen , whether or not with a progestin, helps prevent or slow the progression of osteoporosis. However, taking hormone therapy aimed only at preventing osteoporosis is usually not recommended. Most women can take a bisphosphonate or other drug to help prevent osteoporosis (although these drugs have their own risks).
Bisphosphonates increase bone mass by reducing the amount of bone that the body destroys in the process of bone regeneration. The body continually destroys and regenerates bones, thus helping them to adapt to different bodily needs. With aging, the amount of bone destroyed is greater than that regenerated.
Taking estrogen without a progestin increases the risk of endometrial cancer in women who have retained the uterus and is higher with higher doses and longer use. Combining a progestogen with estrogen almost completely eliminates the risk of endometrial cancer, reducing it to a lower level than that seen in women not taking hormone therapy.
Nonetheless, doctors evaluate vaginal bleeding in women taking hormone therapy to rule out endometrial cancer.
Estrogen, taken in combination with a progestogen or alone, increases the risk of:
- Breast cancer: The risk of breast cancer begins to increase by a small amount after taking estrogen associated with a progestogen for about 3-5 years. However, if estrogen is taken on its own at the onset of menopause, the risk may begin to increase as early as 10 or even 15 years.
- Blood clots in the legs (deep vein thrombosis) or blood clots in the lungs ( pulmonary embolism)
- Disorders of the gallbladder (such as stones)
- Urinary incontinence : taking estrogen increases the risk of developing incontinence and worsening it if already present.
For certain disorders, it is difficult to determine whether the risk is increased by taking estrogen alone or by combining estrogen with a progestogen (combination therapy).
Although hormone therapy increases the risk of all the ailments listed above, it always remains the safest for healthy women who take it for a short time or soon after perimenopause.
The risk of most of these disorders increases with age, particularly 10 or more years after menopause, regardless of whether hormone therapy is used. In older women, taking estrogen with a progestogen can also increase the risk of coronary heart disease.
The risks associated with hormone therapy are believed to be lower if lower doses of estrogen are used . Estrogen- based formulations that are introduced into the vagina (for example, creams, tablets, or rings containing estrogen) often contain less amounts than tablets taken by mouth.
Estrogen administered via a skin patch (transdermal form) appears to have a lower risk of blood clots, stroke, and gallbladder disorders (such as stones) than oral forms.
Generally, women who have breast cancer, coronary artery disease or blood clots (thrombi) in the legs, who have had a stroke or have risk factors for these disorders should not take therapy with estrogen.
Combined hormone therapy reduces the risk of the following conditions:
- Colorectal cancer
Progestogens: benefits and harms
Progestogens have some advantages:
- Endometrial cancer: The association of a progestogen with estrogen almost completely eliminates the risk of endometrial cancer in women who have retained the uterus.
- Hot flashes: High doses of progestins can relieve hot flashes, but they are not as effective as estrogen.
Progestogens can increase the risk of:
- Increase in LDL (bad) cholesterol levels: Progestogens may have this effect. However, micronized progesterone (a natural rather than synthetic type of progesterone) appears to have a less negative effect on HDL levels than synthetic ones.
- Blood clots in the legs and lungs.
The effect of a progestogen alone on the risk of other disorders is unclear.
Side effects of estrogen and progesterone
Side effects of estrogen and progestin, especially at high doses, can include nausea, breast sensitivity, headache, fluid retention, and mood changes.
Forms of hormone therapy
The combination of estrogen and / or a progestin can be taken in several ways:
- estrogen tablets or a progestin by mouth (oral form)
- estrogen- based creams, tablets, rings, or suppositories inserted into the vagina (vaginal form)
- estrogen- based lotions, sprays, or gels applied externally to the skin (topical form)
- skin patches of estrogen or an estrogen-progestogen combination (transdermal form)
In oral tablet form, estrogen and a progestin can exist in two separate tablets or one that combines both. Usually, estrogen along with a progestogen is taken daily. This pattern can cause irregular vaginal bleeding during the first or first few years of treatment.
(However, if bleeding continues for more than a year, you should consult your doctor) Alternatively, estrogen can be taken daily, with a progestogen for 12-14 days a month. Following this pattern, most women have monthly vaginal bleeding in the days after taking the progestogen.
Some vaginal forms of estrogen hormone are inserted into the vagina. They include
- A cream inserted using a plastic applicator
- A tablet inserted using a plastic applicator
- An estrogen- containing ring (similar to a diaphragm )
- A suppository containing estrogen
The products available are different and packaged in different doses containing various types of estrogen. Creams and rings may contain a low or high dose of estrogen.
If a high dosage of estrogen is used vaginal is used, a progestin is also given to reduce the risk of endometrial cancer. Typically, a low dosage is sufficient for vaginal symptoms.
Using a vaginal formulation of estrogen may be more effective than taking estrogen by mouth for vaginal symptoms (such as dryness or thinning). This treatment helps prevent pain during sexual intercourse, reduces urinary urgency and reduces the risk of bladder infections.
The estrogen may be applied to the skin as a lotion, spray or gel.
In addition, a patch containing estrogen or a combination of estrogen plus a progestin can also be applied to the skin.
Selective Estrogen Receptor Modulators (SERMs)
SERMs (such as raloxifene and tamoxifen) act like the estrogen in some cases, while in others they have opposite effects.Raloxifene is used to treat osteoporosis and prevent breast cancer. Tamoxifen is used to treat breast cancer. The doctor may recommend the use of ospemifene to relieve vaginal dryness.
When women take a SERM, hot flashes may temporarily get worse.
Bazedoxifene is a SERM that is given in combination with estrogen in a single tablet. It can relieve hot flashes and vaginal atrophy symptoms, reduce breast sensitivity, improve sleep, and prevent bone loss. Like estrogen, this drug increases the risk of blood clots in the legs and lungs, but may reduce the risk of endometrial cancer and affect the breasts less.
Dehydroepiandrosterone (DHEA) is a steroid that is produced by the adrenal glands and is converted into sex hormones (estrogen and androgen). It is available as a vaginal suppository. DHEA is used to relieve vaginal dryness and other symptoms of vaginal atrophy. It is used to reduce pain during sexual intercourse due to vaginal atrophy.