(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 transition.
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 on indefinitely.
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 triggers.
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 benefit.
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.
Uterine bleeding: 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:
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 to anemia.
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 in life.
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 of control.
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 disputed this.
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 your sleep.
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 drive.
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 had worsened.
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, and surgery.
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 wrinkle.
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.