Menopause is the time when a woman's ovaries cease to function meaning that they stop producing the hormone called estrogen. This process happens gradually over a period of three to five years before the final menstrual period. This transition period or perimenopausal period can be thought of going through puberty in reverse. The reproductive system consisting of the ovaries, fallopian tubes, uterus, cervix, and vagina is gradually winding down.

The number of eggs in the ovaries which numbered hundreds of thousands at birth has gradually been diminishing over the years. As menopause approaches, only a few thousand eggs remain. Beginning as early as your mid to late thirties, the ovaries will produce less estrogen and progesterone even though a woman may continue to ovulate. Hormone levels fall more dramatically when the perimenopausal period is entered. Failure to menstruate in a twelve month period can be called postmenopausal.

What is Surgical Menopause?

Surgical menopause is menopause created by removal of the ovaries earlier than the pre-set natural time your ovaries were destined to cease functioning. Both ovaries must be removed to create a surgical menopause, because one ovary can produce sufficient estrogen to sustain reproductive function. A bilateral oophorectomy (removal of both ovaries) results in a sudden loss of the hormones estrogen and progesterone with rapid onset of menopause regardless of whether or not a woman has her uterus. Surgically induced menopause results in more severe symptoms, and a predilection to develop heart disease and What is Menopause? at an earlier age than women who have a natural menopause.

What different types of hysterectomies are there?

Many people confuse what exactly is meant by the term hysterectomy. A partial hysterectomy is removal of the uterus without the cervix. A total hysterectomy is removal of the uterus and the cervix. Many women undergo these procedures and still have their ovaries after surgery. Women who no longer have a uterus will not have monthly periods, but if they have their ovaries they will not go through menopause until their ovaries are pre-determined to do so. Many doctors will recommend concurrent removal of the ovaries with the uterus if a patient is 45 years or older.

The rationale behind this is that the ovaries are going to function on average 5-6 more years coupled with a 1.5% lifetime risk of ovarian cancer. Problems can also arise with benign cystic disease of the ovaries as well. However, this is a patient's choice, and she is entitled to an informed decision.

When can I expect to go through menopause?

In a large study of women, the average age of American women at the time of menopause is 51 years. The range can vary from 48-55 years. Women who smoke cigarettes may experience menopause at an earlier age. Radiation in high doses such as in those used to treat cancer will cause menopause to occur at an earlier age. One simple way to predict when one might go through menopause is to ask one's mother or older sister how old she was at the time of her climacteric.

Is there a test for menopause?

A blood test can be done called an FSH (Follicle stimulating hormone) which is released by the pituitary gland in the brain. FSH signals the ovaries to prepare for ovulation. Loss of ovarian function will cause the pituitary to produce this hormone at high levels. A high FSH level is a sign that you are approaching or have gone through menopause. Generally, menopause is diagnosed based on clinical symptoms such as hot flashes, vaginal dryness, or cessation of menses.

What are the Long Term Health Risks to a Post-menopausal Women?

Unfortunately, there significant changes in your body when the climacteric which can increase a woman's risk for serious diseases. The drop in estrogen after menopause may result in a rapid, painless loss of bone mass. What is Menopause? is a condition where bones become weak and can break easily. There are good practical steps to prevent and/or reverse this condition.

Another long-term health risk is cardiovascular disease, including heart attacks and strokes. Postmenopausal women are more than twice as likely to develop heart problems as premenopausal women. Estrogen prevents the build up of fatty deposits on the arteries by lowering LDL (bad cholesterol) and raising HDL (good cholesterol). After menopause, the risk of cardiovascular disease approaches that of men.

Certain emotional changes have been documented to occur in menopausal women. There is no uniform pattern: symptoms include being out of control, mood swings, irritability, impaired short-term memory, fatigue, headaches, insomnia, and depression. New data has shown that estrogen may delay the onset or prevent Alzheimer's disease.

What signs and symptoms can be expected?

Although some lucky women have few, if any, or the usual signs and symptoms of menopause, most women can tell something is going on with their bodies.

Hot Flashes, mood swings, increase irritability, sleep disturbances, vaginal dryness, burning upon urination, or incontinence (involuntary loss of urine).

The most common ones are:

• Hot Flashes
• Genital Atrophy (Vaginal Dryness)
• Psychologic and Psychiatric Disorders
• What is Menopause?
• Atherosclerosis

What are Hot Flashes?

A hot flush is a sudden sensation of intense warmth of the upper body that typically lasts for a few minutes. This event is accompanied by visible ascending flush of the thorax, neck, and face and is followed by profuse seating. Approximately, 75-85 percent of women will experience the phenomenon known as a hot flash.. For some, hot flashes may be little more than a fleeting sensation of warmth, whereas others may have more intense symptoms.

In the past, women were told that they were imagining things. Today we know that these events are very real. For a patient to experience a hot flash, two factors must be present. One, the patient must have been exposed to estrogen in the past. Almost all women have had exposure, but in a small subset of women who have Turner's syndrome they produce little or no estrogen. Two, a rapid decline in estrogen levels i.e. surgical removal of the ovaries/menopause will cause a hot flash..

Past research has shown that hot flashes occur when the hypothalamus, the part of the brain that helps regulate body temperature, mistakenly senses that you are too warm and attempts to cool you off. The skin may become cool, clammy, and sweaty.

Although the age of menopause may be hereditary, the severity of the hot flash is not. A woman's experience may be totally different from that of her mother or sisters. Women who have had their ovaries removed tend to have a greater severity of symptoms. At the other end of the spectrum, women may have less trouble with hot flashes if they are overweight rather than slim.

How often and how long can hot flashes occur?

In one study, 87 percent had one or more flashes per day and one-third reported more than 10 per day. 25% characterized them as severe; the rest mild to moderate. In a study of 126 women not on estrogen replacement, 64 percent had hot flashes for one to five years, 26 for six to ten, and 10 percent more than 11 years.

How to stay cool without medications

Hormone replacement therapy will be discussed below. For women not on medication,

• Exercise regularly which is only good for your bones, but active women have less of a severity of hot flashes.
• Avoid stress.
• Avoid foods which can trigger a flash, such as coffee, tea, other hot drinks, spicy foods, and alcohol.
• Keep an ice cold drink handy-especially at the bedside.

Genital Atrophy

The tissues of the genital tract which are the lower vagina, labia, urethra (were urine comes out), and area surrounding the urethra are dependent on estrogen for their function and thickness. Without estrogen, the surface of the vagina becomes thin and more prone to infection and trauma.

The normal flora (bacteria) of the vagina changes after the withdrawal of estrogen. The vaginal secretions diminish. Vaginal dryness can make intercourse painful and cause persistent itching and burning. Urinary incontinence (involuntary loss of urine) can result as a loss of strength surrounding the bladder neck which is dependent on estrogen.

Emotional Changes

Certain psychologic and psychiatric disorders have been reported in the perimenopausal period. An exacerbation of a pre-existing condition may occur as well. It is not certain whether there is a direct cause and effect to withdrawal of estrogen or declining estrogen levels. Most certainly, the physical symptoms of menopause can be a source of mental anguish. Hot flashes may be accompanied by heart palpitations that can feel an awful lot like anxiety attacks. Night sweats can disturb sleep.

Estrogen in some studies has been found to influence the production of serotonin, a brain chemical that plays a role in depression. As estrogen levels rise and fall, so do serotonin levels in the brain, possible triggering transient blue moods during the perimenopausal years. In addition, menopause may coincide with stressful life events such as grown children leaving the home. Elderly parents needing medical care and assistance. A menopausal women may be in the middle of a mid-life crisis.

What is Menopause?

What is Menopause? is a general reduction in bone mass and a tendency to break bones easily caused by minimal trauma. The bones most commonly fractured occur in the vertebrae (middle to lower thoracic and lumbar spine), the femoral neck, and the distal radius. A condition leading up to What is Menopause? is osteopenia which the bone mass is significantly lower in a women accounting for her age and race.

From birth until early adulthood, bone is constantly renewing itself as older, worn-out bone is replaced by new, strong bone. The most rapid phase of bone mass accumulation occurs from puberty to the mid-20's. Until about age 35, bone loss begins to exceed new bone production. When the body is deprived of the bone-preserving effects of estrogen, the rate of bone loss accelerates rapidly, and women can lose up to 7 percent of bone mass in a year. Typically, about 0.3-0.5% of bone is lost slowly until menopause is reached.

Certain women are at higher risk for What is Menopause?. White and Asian races, body build, diet deficient in calcium, life style (excessive alcohol use, smoking-causes early menopause, decreased exercise), and previous menstrual history. Menopausal women with hyperthyroidism (overactive thyroid) or hyperparathyroidism (overactive parathyroid gland-controls level of calcium in body) can accelerated bone loss.

A machine called a bone densitometer can measure your bone mass. Measurements can be taken from the hip, the distal radius (bone that connects the forearm to the wrist), and vertebrae (spinal column). During the test you will lie on a examining table while a machine with a moving arm scans your entire body or the parts of your skeleton most vulnerable to fractures.

Atherosclerosis

Cardiovascular disease is responsible for the deaths of more postmenopausal women than all other diseases combined. This disease can be reduced by 50% in postmenopausal women treated with estrogens. Coronary disease develops later in women compared to men, and this is thought to be due to the protective effects of estrogen. Once menopause occurs, the beneficial effects are lost.

The way estrogen protects the heart is that estrogen is responsible for lowering the low-density lipo-protein (bad cholesterol) LDL and raising the high density lipo-protein (good cholesterol) HDL. LDL is responsible for damaging the endothelium (lining of the arteries), and a damaged vessel wall can attract plaque build up. These plaques can eventually cause a clot to form in the heart vessels (coronary arteries) leading to decrease blood flow to vital heart tissue. Decrease blood flow in turn my lead to depravation of oxygen to the heart, and possibly a heart attack.

One of the most pressing issues a woman will face as she enters menopause is whether or not to take hormone replacement therapy (HRT). Many women have become confused about HRT because of conflicting reports about its benefits and risks. Most of the research has shown that hormone replacement therapy offers clear benefits to postmenopausal women. Recent conferences geared toward health care providers encourage your doctor or health care provider to prescribe these medications. However, before making a choice every woman should make an informed decision.

What is hormone replacement therapy?

Hormone replacement therapy (HRT) is replacing the estrogen your ovaries have stopped producing when menopause is reached. If a woman still has a uterus, a progesterone-like agent should be given in conjunction with estrogen to protect the uterus. Estrogen is very effective in dealing with the short term symptoms of menopause such as hot flashes and vaginal dryness. 98% of women who receive and achieve adequate blood levels of estrogen are relieved of their hot flashes. Mood swings and irritability can be reduced by HRT.

How can estrogen benefit me?

Hormone replacement therapy is beneficial for keeping an older woman's bones healthy. Estrogen prevents bone loss by decreasing calcium loss from bone, increasing calcium absorption in the gut, and stopping the kidneys from excreting calcium. Adding a progesterone can further prevent bone density loss.

There has been significant evidence that estrogen provides protection against heart disease. Many studies have shown that women who take estrogen after menopause have up to 50% fewer heart attacks than those who didn't. Estrogen increases the good cholesterol (HDL) and decreases the bad cholesterol (LDL). The most recent research has shown that HRT may prevent or delay the onset of Alzheimer's disease characterized by memory loss and confusion. Protection against colon cancer is being substantiated by ongoing multi-center trials.

What are the negative effects of HRT?

Several topics to be discussed:

1. Blood Clots Deep Venous Thrombosis

2. Cancer Endometrial and Breast

3. Abnormal Bleeding

4. Other effects

Women taking estrogen run the risk of a two to three fold increase of developing blood clots in the legs than women not on HRT. The risk of developing a blood clot is approximately one in 5000 for healthy women. People who are at increased risk are obese, have cancer, or have a previous history of or have had a family history of deep venous thrombosis (blood clots). Unless you are at risk for developing blood clots, HRT carries more benefits than risks.

One of the most common reasons for a woman not to take HRT is fear of developing cancer. Two types of cancers are pertinent to this discussion. Cancer of the endometrium (lining of the uterus that sheds off monthly) is fueled by estrogen. If one takes estrogen without a progesterone, a woman's risk doubles to a 6 percent lifetime risk of cancer. Most cancers of the endometrium caused by estrogen are of an early stage and good prognosis. A combination of estrogen and progestin, however, prevents the overstimulation of the uterine lining and reduces the risk of endometrial cancer. In fact, the combination of both hormones will lower a woman's risk of uterine cancer compared to women who aren't taking HRT.

The issue of whether or not hormone replacement will increase a woman's chance of developing breast cancer is more complicated. A meta-analysis (a group of large studies lumped into one) showed no significant increase in breast cancer in women who used estrogens. A few studies, have suggested that the risk may be higher among women with a family history of breast cancer. Long-term users of HRT may be at a slightly greater risk, too. The Nurses' Health study of 23,000 post-menopausal women identified 722 cases of breast cancer in women taking HRT and not taking HRT. These women were followed up for 10 years. The conclusion was that past estrogen use did not increase the risk of breast cancer, but use within the preceding year modestly increased the risk of breast cancer in comparison with women who never used estrogens. Until researchers draw more concrete conclusions, one can say estrogen use may slightly increase a woman's chance of getting breast cancer. Researchers point out that the risk is no greater than that posed by a naturally delayed menopause, which increases the time that women are exposed to their own estrogens.

Other side effects of estrogen use are abnormal bleeding, breast tenderness, fluid retention, and pelvic cramping. Postmenopausal bleeding (only seen in women who have a uterus) associated with HRT is seen in about 30% of women and this gradually progresses to 0% over a course of 3-5 years. Women who have bleeding should be evaluated by an ultrasound to measure the lining of the uterus or a sample of tissue can be taken from the endometrial lining. Some women who are prone to migraine headaches find HRT makes them worse, but others with a history of migraines have fewer headaches when taking HRT. Another long-term complication is a slightly increased risk of gallbladder problems.

How long will I need to take HRT?

Until we have more data, no one knows how long the optimal length of therapy is. The appropriate time of treatment may have to be individualized depending on the patient's needs and risk factors. Long term therapy can protect a woman's heart and bones, but may increase her risk of breast cancer.

For women who still have a uterus, periods, and are experiencing menopausal symptoms, a cyclic regiment is indicated. Generally, a cyclic regiment includes about 2 weeks of a progestin each month. The patient will continue to take estrogen on a daily basis. After the patient finishes the progestin, she will have a period. Women who no longer have periods are given a continuous combined regiment where an estrogen and progestin are taken on a daily basis. Bleeding may be seen in up to 30% of women, but more than 50% of women stop bleeding altogether within six months to a year. If you experience a lot of irregular bleeding, it may be a sign of a problem with the uterine lining that requires you doctor's attention. Women who have had a hysterectomy may take estrogen alone and they will not experience bleeding.

Everyone may respond differently to estrogen, and fortunately, hormone replacement therapy can be administered in a number of ways, depending on a patient's needs or personal preferences. So if you don't get relief from symptoms with one form of HRT, or if the type of HRT you're taking doesn't fit your lifestyle, work with your doctor until you find something that suits you. Estrogen pills are the most widely prescribed and are easiest in terms of cost and convenience. This is the most widely prescribed form of HRT. Estrogen Skin Patches contain micronized estradiol which are the same estrogens produced by the ovaries. Because this route bypasses the liver, lower amounts of estrogen may be administered to achieve the desired effect. Women who live in hot climates may find that sweating causes the patch to dislodge reducing the effectiveness of the patch.

Vaginal estrogen creams can be inserted with an applicator two to three times a week for women who complain of vaginal dryness. These creams are designed to be a local treatment specifically for estrogen-deprived vaginal tissues. They are not intended for treatment of hot flashes or the prevention of heart disease and What is Menopause?, although estrogen in the vagina can be absorbed into the bloodstream. The FDA approved a vaginal estrogen ring which is less messy than the cream. The ring has only been approved for treating vaginal dryness.

Progestins are generally given by the oral route. There are certain kinds of progesterones which can be tailored to suit the patients needs. A progesterone vaginal suppository has been FDA approved, but not to treat a menopausal patient.

Who should not take HRT?

Absolute contraindications to hormone replacement therapy are endometrial cancer, breast cancer, vaginal bleeding that has not been worked up by a doctor, liver disease, and someone who currently has a blood clot or has had a blood clot caused by use of estrogen.

What are some other treatment options that can be use alone or in conjunction with HRT?

Exercise is important for keeping muscles toned and joints limber so that a fall is less likely or at least less severe. Weight bearing exercise may stimulate late bone formation and help prevent further bone loss.

Exposure to the ultraviolet radiation from the sun can stimulate the body to make its own Vitamin D. Vitamin D can increase absorption of calcium from the gut and decrease renal exertion of calcium. Vitamin D is also found in milk which contains 100 international units or 25 percent of your total daily requirement. If you don't get out in the sun often or drink much milk, consider taking a vitamin supplement. Most multivitamin supplements contain a full day's supply of Vitamin D.

Most authorities recommend 1200 mg of calcium supplementation in menopausal women who are not on HRT. It is recommended that a women take 1500 mg if she is not on HRT. Calcium supplementation has been shown to reduce bone loss in pre-menopausal women.

Calcitonin, Etidronate, and Alendronate (Fosamax) all reduce bone mass by inhibiting cells called osteoclasts which absorb bone. Fosamax actually increased bone mass in the spine and hip. Fosamax which has grown in popularity can irritate the stomach and must be taken on an empty stomach the first thing in the morning. Fosamax can be given to a patient who has a contraindication to taking estrogens. It does not relieve menopausal symptoms such as hot flashes.

What is all the hoopla about "designer estrogens"?

A new class of drugs being developed are SERMS which stands for selective estrogen response modulators. Estrogen is a hormone which can affect more than one tissue site i.e. the uterus, breast, bone, vagina, etc. What if a particular estrogen was designed only to hit the sites we want. Leave the breast and uterus alone because bad things can happen if we stimulate the estrogen receptors in those sites. We would like to stimulate the bone and possibly alter the lipid profile to protect the heart. The first of the SERMS to hit the market is called Evista or raloxifene. Evista has been shown to increase bone density, but it does not relieve hot flashes. A press release from Eli Lily states that Evista is good for the heart, but most authorities say more studies over a longer period of time are needed. The drug has not been on the market long enough. Evista is in the same class of compounds as tamoxifen which has been shown to reduce a women's risk of breast cancer. A recent study has shown that Evista reduces the incidence of breast cancer without stimulating the uterus like tamoxifen does. There are more of these designer estrogens in the pipeline. Eventually, someone will develop a SERM to hit all the desired tissues and leave alone the tissues that can cause problems.

Are there alternative/non-mainstream therapies?

Other people have been turning to acupuncture, Black cohosh, Vitamin E, and soy protein as a means of managing menopause. Although less studied and regulated than standard medications, alternative therapies are garnering increased attention among patients and even some physicians. Unfortunately, for the vast majority of alternative therapies there haven't been enough studies to prove or disprove their validity.

Of particular interest are phytoestrogens or plant estrogens. These are weak versions of estrogens found in flaxseed, soybeans, dried peas, dried beans, yams, and a number of fruits and vegetables. Cross-cultural studies suggest Japanese women have fewer menopausal symptoms because their diet is high in these plant estrogens. Just because alternative therapies are considered "natural" remedies doesn't mean their totally safe. One should use these "natural" herbs and drugs with the same caution that one uses a prescription drug.

The office of Alternative Medicine at the National Institutes of Health (NIH) recommends:

1. Gather as much objective information as you can about the treatment. Talk with people who have tired the approach. Ask about the advantages, disadvantages, risk, side effects, costs, results they had, and how long it took for them to see results.

2. Ask about the training and expertise of the person administering the treatment (certification, license to practice in their field). Be sure to meet with the practitioner at least once before you begin treatment to ask questions and to make sure you feel comfortable with him or her.

3. Consider the cost of the treatment. Health insurance carriers are less likely to cover alternative medicine costs.

In summary, some people feel that menopause is a disease process and must be treated aggressively to ensure protection against heart disease and What is Menopause?. On the contrary, menopause is period of time in which the body is in transition ready to begin the next phase of life. Every women should understand the process that her body is going through is normal and be informed of the risks, benefits, and alternatives to treatment during this period of her life. A treatment plan can be devised between her and her health care provider, but the final decision should be hers.

Ryan K. Lee is a physician specializing in Obstetrics and Gynecology. He is currently in private practice in Glendale and Los Angeles, California.