The Change: a Q & A about menopause
In simplest terms, menopause means the end of menstruation, but real life is naturally more complicated. Menopause dramatically divides the lives of women into two parts – pre- and post-menopausal. Each is signified by a host of distinctly different physiological and psychological challenges.
As a result, menopause is the subject of intense study, with new findings regularly reported, but even so, the process remains imperfectly understood and almost always daunting.
We asked Kathryn Macaulay, MD, coordinator of UC San Diego Health System’s Menopause Health Program, to explain some of the life-changing fundamentals.
Q: How does a woman know she’s in menopause?
A: One of the first signs of the start of the menopause transition is a change in menstrual cycle length. Some clinicians refer to this transition as the “peri-menopause.” It can start in the mid- to late-40s and last for a few to several years. Typically, menstrual cycle length increases (time between menstrual periods is longer) so a woman may notice that she is skipping periods. As production of estrogen from the ovary fluctuates and eventually declines, symptoms such as hot flashes, night sweats, insomnia, mood changes and vaginal dryness may be experienced.
In clinical terms, menopause is defined as a cessation of menses for 12 months. So, if a woman has not menstruated for 12 months, then she has reached menopause and should not expect to bleed again. The average age for menopause in the US is 51-52 years.
Q: How does a woman know whether her symptoms are typical of menopause or signal something more worrisome? Is it a matter of degree?
A: Hot flashes and night sweats are the most common symptoms that women experience and, together with a change in menstrual cycle length, are part of a typical menopausal transition for a woman in her late 40s or early 50s. While 75 percent of women experience hot flashes during menopause, there is variability in how they rate the severity. Some women experience mild hot flashes, maybe a few during the day (and not necessarily every day) and they may occasionally wake up at night feeling warm or sweaty.
At the other end of the spectrum, women having more severe symptoms describe hot flashes that are frequent throughout the day and night, causing distraction and discomfort during the day, and night sweats that cause them to wake up feeling “drenched,” with a need to change bedding and bedclothes. These symptoms, while concerning for women if severe, are recognized as part of the menopause syndrome and are treatable with hormone therapy.
One symptom that can be concerning is excessive menstrual bleeding during the menopause transition or any bleeding after menopause has been reached (postmenopausal bleeding). Excessive menstrual bleeding during peri-menopause can signal problems such as uterine fibroids, polyps and precancerous changes in the uterine lining. Postmenopausal bleeding is concerning as it can be an early symptom of endometrial cancer, so women should be evaluated by their provider with either a pelvic ultrasound or endometrial biopsy.
Q: Are there aspects of health that menopausal women need to pay more attention to?
A: Yes, the decline in hormone production from the ovaries, mainly estradiol (estrogen) can have long term effects on the body, including bone, vaginal tissues, and metabolism. Long term effects of low estrogen in a woman’s body include: osteoporosis, which is associated with increase in risk of fractures; vaginal atrophy, which can cause thinning and decrease in lubrication of vaginal tissues, leading to painful sexual intercourse; and weight gain.
Reaching and maintaining a healthy body weight (BMI 18-24.9) before menopause is important as many women feel they gain some weight with the menopause transition. Studies have shown that regular daily cardiovascular exercise, during and after the menopause transition, can offset this weight gain. However, attention to diet and caloric intake is key as well as monitoring the extra calories from alcohol.
Menopause is a good time to review preventive health guidelines with a provider, including making sure one is up-to-date on cancer screening, particularly breast and colon cancer screening which, for a patient with average risk for these particular cancers, start at regular intervals at age 50. (Though several national medical organizations recommend starting breast cancer screening with mammography at age 40).
Q: What are the benefits and risks of hormone therapy? Who should consider it?
A: The benefits of taking hormone therapy for bothersome menopausal symptoms include reduction in frequency and severity of hot flashes and night sweats, which can improve sleep, mood and quality of life. Treatment of symptoms of vaginal atrophy (dryness, pain) can improve sexual function and reduce incidence of vaginal and urinary tract infections.
Long term use of hormone therapy reduces the risk of developing osteoporosis and osteoporotic fractures.
Current research is underway to examine whether starting hormone therapy, at or around the time of the menopause transition, is associated with reduction in cardiovascular disease. At this time, however, it is not recommended to take hormone therapy to reduce risk of cardiovascular disease.
Using hormone therapy after menopause does have risks including increased risk of blood clots, breast cancer, and stroke.
Taking hormone therapy earlier in the menopause transition and at a younger age (< age 60yrs) seems to be associated with fewer risks. Risks can also be minimized by limiting use of hormone therapy to a short duration, for a few years after menopause.
Women who are very bothered by hot flashes and night sweats, are within 10 years of menopause and at a younger age (under age 60) and are healthy (with no excess risk factors for blood clots, breast cancer, and stroke) are the best candidates for hormone therapy as efficacy should be high with fewer risks.