Menopause Essentials: What You Need To Know

By Rhoda H. Cobin, MD, MACE, ECNU

For most females, it’s an inevitable, and sometimes unwelcome, rite of passage.

Menopause is strictly defined as having no periods for one year. In fact, a woman’s ovaries often lose function gradually for many months to years before they stop producing estrogen altogether. This “peri-menopausal” interval may be a time when periods become less regular or different than usual. Hot flashes may occur. And the loss of estrogen may already be having effects on a woman’s bones and other tissues.

Menopause occurs because a woman’s ovaries reach a time in life when they no longer produce enough estrogen to cause periods and no longer release eggs (ovulation) in order to become pregnant. Menopause may be “spontaneous,” which is a normal occurrence in one’s life cycle or “induced,” occurring when the ovaries are removed surgically or are damaged by radiation, chemotherapy or other medications which cause them to stop working. The loss of hormones is the same in both types of menopause.

Considered a normal stage of life especially with today’s longer lifespans, it is estimated that the average woman spends about one third of her life in menopause, i.e., without estrogen being produced by the ovaries.

At what age does menopause typically occur?

There is no way to predict exactly when a woman will undergo menopause or begin having symptoms that signal menopause has begun. It is considered to be normal if it occurs any time after the age of 35, although some suggest the age cutoff should be 40. Prior to that age, menopause is called primary ovarian insufficiency (POI). This condition used to be called “premature ovarian failure” or “premature menopause,” but these terms are misleading, because women with POI do not always stop menstruating (having periods), and their ovaries do not always completely shut down.

Are there other conditions that seem the same as menopause?

There are many medical conditions which directly or indirectly affect the ovaries’ ability to work. Since these are conditions which often carry other risks and which are usually treatable, it is very important that a woman consult her doctor to find out whether she is truly “in menopause” or perhaps has another condition affecting the ovaries. When a woman stops having periods at a younger age, doctors will look for other reasons for the lack of periods, especially when a woman stops having periods at a very young age.

It’s important to note that doctors distinguish between conditions that are clearly known to be caused by a lack of estrogen, those that are really common during the aging process, and conditions which may occur randomly at that time in a woman’s life.

Estrogen treatment

Many conditions that occur with menopause can improve with estrogen replacement treatment, which comes in several forms—transdermal such as patches, sprays, creams or gels administered through the skin, oral tablets, or a soft, flexible vaginal ring that is inserted directly into the vagina. Depending upon a woman’s age and other medical conditions, she and her physician should consider the benefits of treatment versus risks of this therapy, as well as how long treatment should continue if it’s successful.

If there is an important medical reason that estrogen should not be used, other measures, including non-hormonal medication, should be discussed. Recent studies suggest that SSRI medications (selective serotonin reuptake inhibitors), a class of medication also used to treat anxiety and depression, can be helpful in reducing hot flashes and improving sleep and quality of life.

Estrogen treatment should always be accompanied by progesterone in women who have not had a hysterectomy (removal of the uterus), as there is an increase in the risk of cancer of the uterus when estrogen is used without progesterone.

There may be differences in the type of progesterone hormone in various hormone preparations. These so-called “bio-identical” hormones are not approved by the FDA and are not recommended by the American Association of Clinical Endocrinologists (AACE) as treatment for menopause.

The Effects of Estrogen Loss

Hot flashes are one of the hallmarks of estrogen loss. They present as a rapid-onset feeling of warmth that spreads over the body, but tends to be concentrated around the head and neck area. Hot flashes are often accompanied by a red, flushed face and sweating, which can be followed by chills. The severity of these hot flashes can be mild to intense. Mild hot flashes do not require any treatment, while severe hot flashes may disturb sleep and affect the quality of a menopausal woman’s life.

Another common symptom of menopause is vaginal dryness, which may cause discomfort and difficulty with intimacy. On occasion, it is severe enough to cause bleeding. Normally, estrogen helps maintain a thin layer of fluid that keeps the vaginal walls lubricated. However, during menopause, the drop in estrogen levels reduces the amount of moisture available and also makes the vagina thinner and less elastic. Dry tissue in the lower part of the urinary tract (urethra) may cause urinary burning and increased frequency in urinating.

Osteoporosis, or weakening of the bones, may be caused by lack of estrogen (in addition to being part of the aging process). Estrogen treatment can improve osteoporosis and reduce the risk of broken bones (fractures). There is a risk with estrogen treatment in some women (see below), so unless there are other reasons to use estrogen, drugs targeted directly to the bones are preferred.

Lack of interest in sex (libido) is a complicated condition. For some women, vaginal dryness, severe hot flashes and sleep deprivation may reduce their interest in intimacy. But there are so many other factors which contribute to a woman’s desire for intimacy, so lack of estrogen is often not the answer to this problem.

Depression is a common disorder, and many women in the menopausal age group suffer from depression. Estrogen is not a treatment for depression. But hot flashes and loss of sleep may make matters worse.

Each woman should have a discussion with her physician regarding these problems.

What are the risks of hormone treatment?

Hormone replacement therapy (HRT) increases the risk of stroke and of blood clots in the legs which may travel to the lungs. Although the increase in risk is extremely small, there are some women who are already at greater risk because of clotting disorders which are inherited. Recent studies suggest that estrogen delivered through the skin (transdermal) may be less likely to cause problems with the blood clotting system.

Also, there is a small increase in risk of breast cancer with the use of estrogen, which may be slightly greater when progesterone is added.

The risk of heart attack in younger post-menopausal women is low, and estrogen may even reduce the risk of heart attack in this population. However, as a woman ages, the risk of heart disease increases and the chances that estrogen adds to this risk may increase. Some women who already have a high risk of heart disease may also not be good candidates for estrogen therapy.

Although menopause is the point in a woman’s life when she can no longer produce children, it can also be seen as a positive beginning to a new stage of life...and an opportunity to make improvements that will help prevent major health issues.

If you want to know more about menopause and its treatment, discuss your own particular condition with your doctor. For additional patient information about menopause and women’s health conditions, visit http://empoweryourhealth.org/womens-health-conditions.

AACE clinical guidelines offer healthcare professionals the most current information about menopause and can be found at: https://www.aace.com/files/menopause.pdf

Dr. Rhoda Cobin, MACE, ECNU, is a Clinical Professor of Medicine at the Mount Sinai School of Medicine, where she is Chief of the Endocrine/Thyroid Clinic. A practicing endocrinologist for over 40 years in Ridgewood, NJ, she has special interests in thyroid cancer, reproductive endocrinology, polcystic ovary syndrome (PCOS), pituitary disease and general endocrinology and diabetes. A former president of the American Association of Clinical Endocrinologists (AACE), Dr. Cobin has published in the fields of thyroid, reproductive endocrinology and insulin resistance.