The Truth About Menopause

The Change, as menopause was often discretely referred to, has only recently become a topic for open discussion. Menopause is an inevitable and natural part of every woman’s life, so it’s important to dispel the myriad myths and half-truths that surround this stage of life and understand what it really means to you.

Baby boomers–once the vanguard of the youth movement–are getting older. There are now over 30 million women in the United States who are postmenopausal (they’ve stopped menstruating), and that total will rise to about 50 million in the next two decades. The sheer number of women facing menopause has helped the subject come out of the closet. And it’s about time. Menopause is nothing to be embarrassed about: It is as natural as puberty or childbirth.

Despite the fact that menopause is now openly discussed, many myths still abound about this time of life. Some doctors suspect much of the negative associations women have with menopause are linked to our cultural attitudes. Experts point to countries like Japan where aging is thought to enhance a woman’s status. Japanese women report fewer hot flashes and lower levels of discontent perhaps because they view menopause as an achievement.

In this article we offer the facts. Yes, it’s true that some menopausal women experience symptoms which cause them discomfort. But that doesn’t mean every woman, or even most women for that matter, do.

What Changes in My Body Trigger Menopause?

During childbearing years, the ovaries release one egg each month. They also produce the hormones estrogen and progesterone, which prepare the uterus to nourish this egg in case it is fertilized. Estrogen makes the lining of the uterus grow a thick layer of tissue each month. And progesterone, which is produced in the ovaries during the second half of menstrual cycle, further thickens the lining of the uterus. If an egg is not fertilized, it moves from the fallopian tube to the uterus and is absorbed. The levels of both these hormones then drop. This signals the uterus to shed its lining, resulting in the monthly period.

As menopause nears, the ovaries begin to produce less estrogen. A year or two before menopause, you will probably notice changes in your menstrual cycle. One of the earliest sign of approaching menopause is irregular periods. Your menstrual flow may skip one or two months. It may become lighter or heavier than in the past. Bleeding may last a longer or shorter time than usual for you. Keep in mind, however, that abnormal bleeding can sometimes be a sign of a medical problem in the uterus or its lining. So even though periods tend to be irregular around the time of menopause, it is important to call your doctor if you experience vaginal bleeding that is not normal for you.

What is Early Menopause?

The average age American women enter menopause is 51, but menopause sometimes occurs in women less than 40 years of age. Such early menopause can happen because the ovaries stop functioning or are removed by surgery. Removing the ovaries causes a sudden loss of estrogen which may trigger severe symptoms. Women who have early menopause may need to take hormones to replace those made by the ovaries. On the other hand, while removal of the uterus alone (Hysterectomy) ends periods, it will not cause menopause.

How Does Menopause Affect the Body?

Like most natural events in life, menopause occurs gradually. However, a woman is not completely without estrogen even after menopause. Some continues to be made by glands and body fat. The decrease in estrogen may cause symptoms such as hot flashes, vaginal dryness and emotional changes. Below is a description of what you may experience during and after menopause.

• Hot Flashes. This sudden feeling of heat that spreads over part or all of the upper body is the most common symptom of menopause, affecting an estimated 75-85 percent of menopausal women. Hot flashes may cause you to blush red or break out in a sweat. According to the American College of Obstetricians and Gynecologists (ACOG), women going through menopause may experience hot flashes for a few months, a few years or not at all. Flashes can come on at any time, day or night but they vary greatly in frequency and severity. Some estimates say 10-15 percent of women are awakened by them hourly throughout the night and many experts now believe that the resulting lack of sleep may account for much of the irritability and emotional ups and downs usually blamed on hormonal changes.
• Vaginal changes. Lower levels of estrogen make the lining of the vagina thinner, less flexible and drier, which can cause pain during sex. Some women also have vaginal burning and itching, and others may feel discomfort in the clitoris (part of the female genitals involved in sexual stimulation). In some cases, the urethra (the tube that carries urine from the bladder) becomes irritated, and, as a result, a woman may need to urinate more frequently. Note though, that painful urination may be a sign of a urinary tract infection, and a simple urine test can determine if this is the problem.
• Emotional swings. The most common perception of menopausal women is that they’re depressed, irritable and sometimes irrational. Yet a study of 2,500 middle-aged women by the Women’s Research Institute in Massachusetts found that more than 70 percent of women experiencing menopause were either relieved that their monthly periods were coming to an end, or they felt neutral about the issue.

In truth, population surveys consistently show that women are most likely to suffer from depression in their twenties and thirties, not at mid-life. Furthermore, neither suicides nor psychiatric hospitalizations increase among women in their late forties or early fifties.

If nervousness, irritability or depression do occur, they may result from changing hormone levels, stress, or sleep deprivation due to hot flashes. Women may also get depressed if they believe that the end of their reproductive years equates the end of their usefulness or of their “womanhood.”

• Bone loss. Dwindling bone mass is a normal part of aging, but at menopause this bone loss increases, making bones fragile and increasing the risk of broken bones and Osteoporosis (thinning bone disease). As bones become fragile, they pose a major health hazard. The hip, wrist, and spinal bones are most often affected. Up to one in five patients dies within 6 months of hip fracture from complications, such as blood clots, stroke, heart attack, and pneumonia.
• Heart disease. The estrogen that women produce before menopause gives them a natural protection from heart attacks. Consequently, the risk of heart attack and stroke goes up after menopause when estrogen levels decrease (see “Women and Heart Disease” in our Special Report “In Tune with the Beat of Your Heart”).
• Sex. Many menopausal women complain that they enjoy sex less. However, this is more likely due to discomfort resulting from vaginal soreness or dryness than a loss of interest in sex. This irritation can be treated with topical lubricants available in any drug store.
• Other. According to ACOG, there are other changes related to a decline in hormone levels, but they are hard to distinguish from the normal aging process: Skin becomes wrinkled; hair thins and its texture changes; some pubic hair is lost and some facial hair may be gained; the breasts lose some of their fullness, and the nipples become less erect; there is more body fat in some places and less in others.

Hormone Replacement Therapy

Women whose ovaries are not producing estrogen may consider taking hormones to replace those that used to be produced by her body. Known as hormone replacement therapy (HRT), this treatment can help ease the symptoms of menopause and protect against bone loss and heart disease. But like all medications, hormone replacement carries some risks which have made it controversial. The question seems to be whether menopause is a disease that should be treated or a natural process that should be left to run its course.

What Are the Risks of HRT?

Hormone replacement therapy (HRT) is not new. In the mid-60’s, women were encouraged to take estrogen to relieve the temporary discomforts of menopause. But in the 70’s it was discovered that women on estrogen had eight times the risk of uterine cancer and might have an increased risk of breast cancer.

The early 80’s added another chapter to this story: The addition of progestin to HRT, which is similar to the progesterone the body produces before menopause, practically eliminates the added risk of uterine cancer–although it does cause menstruation and, possibly, symptoms like those of pre-menstrual syndrome. (Women who have had a hysterectomy do not need to take progestin along with estrogen.)

What’s more, preliminary studies suggest that estrogen alone may significantly cut a woman’s risk of heart disease and osteoporosis. And many experts not only believe that these potential benefits are true of the combination therapy of estrogen and progestin as well, but that the benefits outweigh the possible increased risk of breast cancer.

The problem is that most of this is educated speculation. The kinds of studies that could positively identify the risks and benefits of hormone replacement therapy simply have never been done. The National Institutes of Health recently began the first reliable study to evaluate the effect of hormones on a woman’s risk of heart disease as well as a 10-year comparison of hormone replacement therapy versus a low-fat diet, calcium supplements and exercise in the prevention of cancer, heart disease and osteoporosis.

However, there is some question about whether progestins block some of the effect of the estrogen. Women who choose not to take progestin should be monitored carefully for changes in the uterus.

Making the Choice

Should you take hormones? This is a decision all women will have to face at some point in their lives. Until there is more concrete evidence, it is up to you and your doctor to carefully consider your medical history, the severity of your symptoms, and your risk of bone loss and cardiovascular disease.

Reasons for Taking Hormones:

• Menopausal symptoms are making your life miserable.
• You have heart disease or are at high risk for it because you smoke, have high blood pressure, an HDL level below 35, diabetes or a family history of heart disease.
• You are at increased risk of osteoporosis because you are slender, Caucasian, smoke or drink heavily, or have a family history of it.

Reasons For Forgoing Hormones:

• You have, or have a history of, cancer of the breast or endometrium, liver disease, blood clots, or unexplained vaginal bleeding.
• You have large uterine fibroids or endometriosis.
• You have already had a stroke or a heart attack.
• You have pancreatic, gallbladder or fibrocystic breast disease.
• You have hypertension or migraines aggravated by estrogen.

What If I Don’t Take Hormones?

If you choose not to take HRT, you should discuss other ways to treat the symptoms of menopause with your doctor. Also, to lower your risks of heart disease and osteoporosis without hormones, you should follow recommended preventive measures:

• Stop smoking
• Maintain a normal body weight
• Keep your cholesterol levels within the normal range through a low-fat, low-cholesterol diet (or with medication if necessary)
• Control high blood pressure and diabetes
• Get regular aerobic exercise

For osteoporosis:

• Consume 1,500 mg of calcium and 400 IU of vitamin D each day
• Get 45-60 minutes of weight-bearing exercise four times a week.

Our thanks to Jill Maura Rabin, M.D., Head of Urogynecology and Ambulatory Care, Long Island Jewish Medical Center, New Hyde Park, NY, for reviewing this article.

What Can I Expect?

Unfortunately, there are no hard and fast answers to this question. While many of the dire predictions of the past were exaggerated, menopause affects every woman differently. No sweeping generalization can tell you what to expect, but here are some guidelines that may help you:

• Your expectations. Studies at the New England Research Institute and the University of Pittsburgh found that women who anticipate having a hard time during menopause do suffer more negative emotional and physical symptoms than women who expect it to be easier. However, it has not been determined whether these women know their bodies are especially sensitive to hormonal changes or they are creating a self-fulfilling prophecy. Either way, women who believe their symptoms inevitably will be bad are less likely to seek relief, thus making their experience more difficult.
• Cultural differences. Greek women who have hot flashes consider them trivial. And while a small percentage of Japanese women report hot flashes, they more frequently complain of head-aches and stiff shoulders. Why? Anthropologists who have compared menopause in different cultures find that the society’s view of a woman during and after menopause can dramatically influence how she experiences this stage of life.

Mayan women, for example, say they do not have hot flashes. In Mayan culture, women who have gone through menopause become respected elders and many of their household duties are then done by their daughters-in-law. Many American women, on the other hand, are convinced that menopause marks the end of their best years, adding to or creating stress that can aggravate symptoms.

• Surgically induced menopause. In the New England Research Institute study, women whose ovaries were removed were more likely to be depressed than those who underwent natural menopause. They were more negative about menopause in general and more likely to regret the loss of their periods. They also reported more hot flashes and more sleep disturbances, probably because their estrogen supply was cut abruptly rather than gradually diminished. This may also explain the decline in sexual interest and ability to climax reported by some women whose menopause resulted from surgery.
• A history of depression. Women who seem especially vulnerable to mood disturbances at menopause include those who suffered from postpartum depression after giving birth, had bouts of depression at some point in their life, or have a family history of depression.

For More Information

The American Association of Retired Persons offers a free booklet called Hormone Replacement Therapy: Facts to Help You Decide.
1-888-687-2277

The Complete Book of Menopause: Every Woman’s Guide to Good Health, by Carol Landau, Michelle G. Cyr and Anne W. Moulton, Perigee, 1995.