Dealing with the symptoms of menopause
with the symptoms of menopause
(This article was first printed in the Special
Health Report from Harvard Medical School "Menopause:
Managing the Change of Life". For
more information or to order, please go to www.health.harvard.edu/MN.)
You could argue that the physical and mental
changes that occur during menopause aren’t
really “symptoms.” The term is usually
associated with a disease, which menopause is
not. Also, it is often hard to say which changes
are a direct result of a drop in hormone levels
and which are natural consequences of aging.
Some of the symptoms overlap or have a cascade
effect. For example, vaginal dryness may contribute
to a lower sex drive, and frequent nighttime
hot flashes may be a factor in insomnia.
A 2005 report from the Agency of Healthcare
Research and Quality concluded that hot flashes
and vaginal dryness are the two symptoms most
frequently linked with menopause. The report,
which included data from 48 different studies,
found that other symptoms commonly attributed
to menopause, such as sleep disturbances, urinary
complaints, sexual dysfunction, mood changes,
and quality of life, are not consistently associated
with the hormone changes seen with menopause
Also called vasomotor symptoms, hot flashes
may begin in perimenopause, or they may not start
until after the last menstrual period has occurred.
On average, they last three to five years and
are usually worse during the year following the
last menstrual period. For some women they go
Hot flashes probably begin in the hypothalamus,
a part of the brain that controls body temperature.
For reasons that remain elusive, the thermostat
in a midlife woman’s body is suddenly reset
at a temperature lower than normal. The hot flash
is the body’s way of cooling itself, like
the way a refrigerator kicks on when you open
the door on a hot day.
Hot flashes can be extremely troubling for the
15% of women who have the most severe form. Women
who have had surgical menopause or those who
are taking tamoxifen to prevent breast cancer
are often in this unfortunate group.
The outward signs of a hot flash — sweating
and pink or reddened skin — tell the world
that a woman’s estrogen production is dwindling.
Heart palpitations and feelings of anxiety, tension,
or a sense of dread also may accompany hot flashes;
some women say they feel agitated or unsettled
right before a hot flash occurs. Women experience
hot flashes differently. Some feel warm; others
complain of burning up. A lot of women feel chills
afterward. Hot flashes that occur during sleep,
called night sweats, may disrupt sleep, causing
fatigue and mood changes.
Treating hot flashes. Depending
on their severity and how much they affect your
day-to-day activities, you can take several steps
to help alleviate hot flashes. Begin with a commonsense
approach. Some possible triggers of hot flashes
are hot beverages, spicy food, warm air temperatures,
stressful situations, alcohol, caffeine, and
some medications. If you can identify your own
triggers, you may be able to avoid some hot flashes.
Keep a diary to note which of these or other
triggers were present before each hot flash.
Review it each week to pinpoint the most common
During the day, dress in layers so that you
can take off garments when needed. If possible,
regulate the air conditioning and heat in your
environment to accommodate your temperature changes.
If you wake up hot at night, sleep in a cool
room. Go to bed with a frozen cold pack under
your pillow, and turn the pillow over when you
wake up. Keep a change of nightclothes next to
your bed so that you can change easily if you
wake up soaked.
Some women find deep-breathing exercises helpful.
Research suggests that a technique called paced
respiration can cut in half the frequency of
hot flashes. To perform paced respiration, take
slow, deep, full breaths — expanding and
contracting the abdomen gently while inhaling
and exhaling — at a rate of about six to
eight breaths per minute. One of the best ways
to learn paced respiration is by taking a yoga
class. Practice this technique twice a day for
15 minutes. You can also use paced respiration
whenever you feel a hot flash coming on. Stress-relief
techniques and biofeedback may also be of some
Increasing the soy in your diet has been shown
to be helpful in some but not all studies. Over-the-counter
remedies that some women find helpful include
preparations of black cohosh, sold under the
brand name Remifemin. There are many other products
containing plant estrogens (phytoestrogens),
but many have not been scientifically evaluated
for either safety or efficacy. Some women report
that vitamin E is helpful, but compelling evidence
to support this is lacking.
It is important to remember that all of the
hot flash studies using a placebo show that at
least 25%–30% of women respond to the placebo.
That’s worth knowing before you spend money
on over-the-counter remedies. In addition, most
hot flashes wax and wane, although the summer
months can be especially difficult.
Short-term hormone therapy is quite effective
in treating hot flashes. Doctors try to prescribe
the lowest dose that effectively relieves symptoms.
If you can’t or don’t want to take
hormones, you may find that an antidepressant
such as venlafaxine (Effexor) or fluoxetine (Prozac)
helps. Certain antihypertensive medications such
as clonidine (Catapres) relieve hot flashes in
some women. An antiseizure medication, gabapentin
(Neurontin), has also shown some promise. Talk
with your clinician about which medication may
be right for you, and remember that most hot
flashes improve over time on their own.
Decreased estrogen causes the vaginal lining
to thin and vaginal secretions to diminish. The
vagina also becomes shorter and narrower. The
result often is dryness and irritation, which
can make sexual intercourse unpleasant. Inflammation
of the vaginal wall also may occur, causing a
condition called atrophic vaginitis. It isn’t
an infection, but if it is not treated, further
thinning and ulceration of the vagina may occur;
this can cause bleeding or make intercourse or
pelvic exams painful at best and impossible at
worst. It is important to keep in mind that there
are a variety of conditions other than menopause
that can cause painful intercourse, so consulting
a clinician is wise.
Treating vaginal changes. A
simple vaginal lubricant such as Astroglide or
Silk-E may help treat vaginal dryness. A vaginal
moisturizer such as Replens may also be helpful.
Estrogen treatments applied directly to the vagina
in the form of creams, rings, and tablets are
quite effective. Also, experts say regular sexual
stimulation can help keep the vagina healthy
by maintaining its elasticity.
Irregular uterine bleeding
A pear-shaped organ about the size of a fist,
your uterus is made mostly of muscle. As you
move through perimenopause, your uterus shrinks
slightly, and the inner layer of tissue, or endometrium,
no longer builds up and sheds on a predictable
monthly cycle. Changes in the menstrual cycle
are a hallmark of perimenopause, so determining
what’s normal and what isn’t can
be a challenge for women and their clinicians.
Only 10% of women stop having periods with no
irregularity in their cycles.
What’s normal, what’s not
One concern for perimenopausal and postmenopausal
women is knowing whether irregular uterine
bleeding is normal. Most women notice normal
changes in their cycle as they approach
menopause. Periods are often heavy or more
frequent, and they may stop and start.
But abnormal uterine bleeding may be a
sign of benign gynecologic problems or
even uterine cancer. Consult your physician
if any of the following situations occur:
- You have a few periods that last three
days longer than usual.
- You have a few menstrual cycles that
are shorter than 21 days.
- You bleed after intercourse.
- You have heavy monthly bleeding (soaking
a sanitary product every hour for more
than a day).
- You have spotting (bleeding between
- You have bleeding that occurs outside
the normal pattern associated with hormone
When you report abnormal vaginal bleeding,
your clinician will try to determine whether
the cause is an anatomic problem or a hormonal
issue. He or she also will investigate
other possible causes. In addition to identifying
the cause, he or she will help you manage
any excess bleeding, which sometimes leads
On rare occasions, postmenopausal women
experience uterine bleeding from a “rogue
ovulation,” which is vaginal bleeding
after a hiatus that may be preceded by
premenstrual symptoms such as breast tenderness.
Presumably, the ovaries are producing some
hormones and maybe a final egg.
Postmenopausal women who are not taking
hormones should not generally have vaginal
bleeding and should seek medical care if
they do. But it is normal for women who
take hormone therapy in continuous doses
to experience bleeding or spotting during
the first several months of taking these
medications. And women on cyclic hormone
regimens sometimes have light monthly bleeding.
Vaginal bleeding outside the usual pattern
for hormone therapy in a postmenopausal
woman is always a cause for concern.
In the early stages, your menstrual cycle may
shorten, with periods beginning sooner than you
expect. Maybe your periods used to come every
28 days, exactly at 3:15 p.m. Now, they may still
come at 3:15 p.m., but the cycle is every 24
or 26 days. But any pattern is possible. Bleeding
also may become lighter or heavier. Going for
three months without a period suggests menopause
is at hand, although more than 20% of women have
regular periods again after such a break.
These irregular patterns may be exacerbated
by other gynecologic problems common in midlife — for
example, uterine growths such as polyps or fibroids.
Declining fertility, another sign of perimenopause
that accompanies irregular periods, can become
a stressful emotional issue for women who still
want to become pregnant.
Treating troublesome periods. For
women whose periods become very irregular, prolonged,
or heavy, doctors often prescribe birth control
pills, which can make periods lighter and more
regular. Alternatively, intermittent doses of
progestogen (a version of progesterone, the hormone
that causes the uterine lining to slough) may
be helpful for women who are having intermittent
bleeding and who are not ovulating. Some women
find it helpful to take nonsteroidal anti-inflammatory
pain relievers such as ibuprofen (Advil, Motrin)
and naproxen (Aleve). An intrauterine device
(IUD) called Mirena, which secretes a low dose
of the progestogen levonorgestrel, can help control
excess or unpredictable bleeding caused by irregular
ovulation or hormonal problems. In addition,
a variety of procedures can stop excess bleeding
by destroying the endometrial lining of the uterus;
these include thermal (heat) and cryo (cold)
therapies. Talk with your doctor about your symptoms
to determine the best approach.
Other physical and mental changes at midlife
Some common midlife changes that are often attributed
to menopause are not necessarily related to the
fluctuating or decreasing hormone levels of menopause.
The four most commonly reported changes include
mood changes and depression; insomnia or other
sleep problems; cognitive or memory problems;
and decline in sexual desire, function, or both.
Other physical changes that crop up in the middle
years include weight gain, urinary incontinence,
heart palpitations, dry skin and hair, and headaches.
For these, a hormonal link is possible, but has
not been proved. Consider the fact that men,
who don’t experience a dramatic drop in
hormone levels in their early 50s, often notice
many of these same symptoms!
Mood swings and depression
Studies indicate that mood swings are more common
during perimenopause, when hormonal fluctuations
are most erratic, than during the postmenopausal
years, when ovarian hormones stabilize at a low
level. No direct link between mood and diminished
estrogen has been proved, but it is possible
that mood changes result when hormonal shifts
disrupt the established patterns of a woman’s
life. These changes can be stressful and may
bring on “the blues.” Mood swings
can mean laughing one minute and crying the next,
and feeling anxious or depressed. These changes
are transient, however, and do not usually meet
the criteria for a diagnosis of clinical depression,
a more profound dysfunctional emotional state.
Over their lifespan, women have more depression
than men. But there is no evidence that decreased
estrogen alone causes clinical depression. In
fact, a study in Psychosomatic Medicine in
2001 found that menopausal status is not associated
with symptoms of depression, such as feeling
sad, irritable, anxious, or hopeless. Although
women who have had previous episodes of depression
may be vulnerable to a recurrence during perimenopause,
menopause in and of itself does not cause clinical
depression. The incidence of depression in postmenopausal
women is not any higher than at any other time
Disrupted sleep from night sweats can cause
a woman to feel fatigued and irritable. Also,
remember that perimenopause coincides with many
of life’s stresses — children who
are teenagers or leaving home, peaking professional
responsibilities, illness or death of elderly
parents, and aging itself. These events, combined
with unpredictable hormonal changes, can leave
a woman feeling fatigued, overwhelmed, and out
Treating mood swings. Many
women choose to make lifestyle changes before
turning to medications. Taking care of yourself
by getting more sleep, exercising regularly,
and using stress-control methods can all help
even out your mood. For an herbal approach, St.
John’s wort may have some mood-elevating
effects, although studies have been conflicting.
Prescription antidepressants, particularly the
selective serotonin reuptake inhibitors (SSRIs),
effectively moderate moods.
Memory and concentration problems
During perimenopause, women often complain of
short-term memory problems and difficulty with
concentration. Some earlier observational studies
found that women ages 65 and older who had been
taking estrogen therapy had higher scores on
tests of mental functioning than did women who
had not used estrogen. But the Women’s
Health Initiative found that hormones seemed
to increase the risk of dementia and cognitive
problems. And other research suggests that stress
may be more closely linked with memory problems
than hormonal fluctuations.
Treating memory and concentration problems. Just
as it isn’t clear what causes memory and
concentration problems, there is no obvious remedy.
Brain and memory experts recommend that people
with these issues work to keep their brain functioning
at its peak by taking on new and interesting
challenges. Use your mind in many different ways.
Do crossword puzzles. Learn a new musical instrument
or sport. Play chess. Read more books. Learn
a new language or how to use the computer. The
idea is to challenge your brain in new ways.
Disrupted sleep is a common complaint during
perimenopause. Whether hot flashes during sleep
cause sleep disruption is not completely clear.
Some women report that they perspire so profusely
that they soak the bed linens and wake up. Others
sleep right through their hot flashes. At least
one study showed that hot flashes disrupt the
most restorative form of sleep, known as REM,
even if the woman doesn’t wake up. Although
some studies suggest that hot flashes are a cause
of sleep disruption, a more recent study has
Insomnia also can be a problem for women who
don’t have hot flashes. Some women may
have difficulty falling asleep, but a common
pattern is to sleep for a few hours, awaken too
early, and not be able to fall back to sleep.
Whether sleep disruptions are due primarily to
hormonal changes is currently unknown. Sleep
cycles change as people age, and insomnia is
a common age-related complaint. The problem is
a troublesome one that can leave sleep-deprived
women fatigued, tense, irritable, and moody.
Insomnia is not a trivial matter, as sleep problems
also have been associated with heart attacks
and congestive heart failure.
Treating insomnia. Medications
are available for temporary treatment of insomnia,
but you can also take some practical steps to
improve your chances of getting a good night’s
sleep. If hot flashes are keeping you awake,
trying a treatment for hot flashes may also improve
Low sexual desire
Sex drive may decline at midlife for a variety
of reasons. Diminished estrogen or age-related
changes in circulation may reduce blood flow
to the genitals and cause a decrease in sensation.
Vaginal dryness or thinning can make intercourse
painful. And women who have sleep problems may
feel too fatigued to be interested in sex. Urinary
incontinence may cause embarrassment that diminishes
the appeal of sex. Concern about changes in physical
appearance and body image can also reduce sex
A 2001 study in Fertility and Sterility showed
that during perimenopause, not only did women’s
sexual responsiveness decline, but their partners
also had a significant increase in sexual performance
problems. As a result, women in the study said
they didn’t feel quite as warmly toward
their partners as they had earlier in the relationship.
As women in the study entered the postmenopausal
years, they reported further decreases in sex
drive, sexual responsiveness, and frequency of
intercourse. They also had more pain during intercourse
and said their partners’ performance problems
Sex drive may be more closely associated with
testosterone (a type of androgen) than with estrogen,
and it’s long been assumed that low blood
testosterone levels lead to low sexual desire.
However, a 2005 study in the Journal of the
American Medical Association found no link
between blood androgen levels and sexual function.
There is much more to be known about female sexuality.
And sexual identity is highly individual. The
good news is that many women continue to enjoy
their sexuality for decades after menopause.
Treating low sexual desire. Some
women with low sexual desire appear to benefit
from estrogen. Testosterone replacement is another
option; however, in late 2004, the FDA refused
to endorse a new testosterone patch for women,
citing a lack of long-term safety data. The patch
and other drugs designed to enhance desire, sensation,
or both are still under study. But it’s
important to realize that libido isn’t
driven by hormones alone. It’s quite possible
that, as Ann Landers has said, “The most
important sex organ is the brain.” Lifelong
perceptions about sex and the quality of relationships
also have a profound impact on women’s
sexual function at midlife. Some women don’t
have a partner. Some have partners who are themselves
suffering from sexual dysfunction; this, too,
may play a role in the woman’s declining
interest in sex. Talking with your partner about
each of your needs and expectations can go a
long way toward helping solve this problem. If
talking is too difficult, counseling with a trained
sex therapist can help pave the way.
Although weight gain is a significant issue
for a lot of women in this age group, there’s
no clear evidence that it’s a direct result
of hormone changes or even age. A 2004 study
in the American Journal of Epidemiology of
more than 3,000 women found no link between menopausal
status and weight gain or an expanding waistline.
Instead, the classic middle-age spread seemed
to stem from a variety of factors, including
the fact that older women (and men) are simply
less physically active. There is also some speculation
that weight gain in midlife is due, in part,
to a slowdown in metabolism.
Treating overweight. Many strategies
are available for losing weight. For women who
have yet to gain excess weight, the best strategy
is to try to avoid gaining by exercising and
eating right. Measure your waistline regularly
and try to prevent any increase. As your waist
size grows, so does your risk of heart disease
and diabetes. Walking, swimming, or other aerobic
exercise is your best bet because it helps prevent
accumulation of fat at the waistline.
Up to 30% of American women ages 50–64
have problems with urinary incontinence, compared
with, at most, 5% of men in the same age group.
The disproportionate impact on women is from
the effects of vaginal childbirth on pelvic tissues
and basic anatomical design differences between
men and women.
Decreased estrogen may cause or contribute to
thinning in the lining of the urethra, the tube
that empties urine from the bladder. Problems
may include a more frequent need to urinate,
a sudden urge to urinate even though your bladder
is not full, pain during urination, the need
to urinate more often during the night, and urine
leakage when sneezing, coughing, or laughing.
Urinary problems persist and worsen in postmenopause
because changes in the urinary anatomy occur
with general aging as well as estrogen loss.
Some other causes of urinary incontinence include
bladder and urethral infections, muscle weakness
caused by aging or injuries during childbirth,
and some types of prescription medication.
Treating incontinence. Bladder
training may be useful for urge incontinence.
This entails holding urine for five minutes after
feeling the urge to void and increasing the holding
period by five minutes each week. Eliminating
diuretic beverages such as coffee, tea, and alcohol
as well as citrus juice and other bladder irritants
may also help. Pelvic floor exercises, known
as Kegel exercises, can be effective. They involve
repeatedly contracting and releasing the pelvic
floor muscles used ordinarily to halt urination.
Although estrogen was previously thought to help
incontinence, research suggests that this isn’t
the case. Talk with your doctor about your treatment
options, which include lifestyle habits, medications,
Some women have complained of heart palpitations
during perimenopause. Heart rate has been shown
to increase by 8–16 beats during a hot
flash, but more research is needed to determine
how heart rate may be affected by hormonal fluctuations
during perimenopause in the absence of hot flashes.
Some women do report that heart palpitations
improve with hormones or get better after menopause.
Little is known about this phenomenon, but women
are sometimes mistakenly diagnosed with heart
disease and prescribed unnecessary medication.
Treating heart palpitations. Treatment
depends on the cause of your heart symptoms.
The role of hormones in regard to heart symptoms
has not been well studied. Talk with your doctor
about your symptoms and possible treatments.
Dry skin and hair
Many women experience dry skin and hair at midlife.
While some research suggests that declining estrogen
levels may contribute to dry skin, it may also
be the result of cumulative sun exposure or smoking.
With age, the skin’s ability to retain
water and produce oil diminishes, too. But there
is little evidence that decreased estrogen is
directly involved in causing skin to dry and
Treating dry skin and hair. Because
these conditions are so common, many remedies
are available. Protect your skin from sun exposure
with sun blocks, hats, and clothing. Use moisturizers
and hair conditioners, especially in the dry
winter months. Buying a moisturizer is one case
in which the old adage “you get what you
pay for” doesn’t hold true. Inexpensive
and effective moisturizers are widely available
and often equal or superior to high-end products.
For instance, petroleum jelly is an inexpensive
and highly effective moisturizer for skin that
is extremely dry.
Hormonal changes have been linked with headaches.
It’s not uncommon to hear premenopausal
women complain of “menstrual migraines” around
the time of their periods; some women who get
migraine headaches say their migraines improve
during pregnancy. Experts believe that changes
in estrogen levels in the blood, rather than
a consistently low level, may trigger migraines.
The erratic hormonal fluctuations that precede
menopause can make some perimenopausal women
especially susceptible to migraines.
Headaches of all kinds can be triggered by a
number of things, including smoke and pollen,
alcohol, sleep deprivation, certain foods such
as chocolate and aged cheeses, or stress. These
triggers may be more likely to induce a headache
when hormone levels are fluctuating. Women who
have had frequent menstrual headaches may find
that the problem worsens during perimenopause.
However, some women say their headaches get better
or even stop in the postmenopausal years.
Treating headaches. Treatment
depends on the cause and type of headache. Identifying
headache triggers and taking steps to avoid them
is a good first step. Talk with your doctor about
what kind of medication may be best to treat
your kind of headache. Some women find other
techniques, including biofeedback or acupuncture,
to be helpful. Some experts find that timed supplemental
estrogen can be helpful with cyclic headaches.
(This article was first printed in the Special
Health Report from Harvard Medical School "Menopause:
Managing the Change of Life". For
more information or to order, please go to www.health.harvard.edu/MN.)
Menopause is no longer the obvious sign of aging it once was. Menopause:
Managing the Change of Life takes a view of the whole woman
and helps her sort through the latest medical findings and choose the
most practical strategies for making her midlife transition as easily
as possible. Read more »