Menopause represents the end of menstruation. Between 1995 and 2010, the number of women over age 50 entering menopause in the United States will grow from 37 million to 52 million.Although it refers to the final period, it is notan abrupt event, but a gradual process. Menopause is not a disease that needsto be cured, but a natural life-stage transition. However, many women are faced with important decisions about treatment of menopause symptoms, includingthe use of hormone replacement therapy (HRT).

Many women have irregular periods and other problems of "perimenopause" for years, and it's not easy to predict the onset of menopause, although doctors agree it is complete when a woman has not had a period for a year. Eight out of every 100 women stop menstruating before age 40, and five out of every 100continue to have periods until they are almost 60. The average age of menopause is 51.

There is no mathematical formula to predict when menopause will begin, but awoman can get a general idea based on her family history, body type, and lifestyle. Women who began menstruating early will not necessarily stop having periods early as well; instead, most women will likely enter menopause at aboutthe same age as their mothers.

A woman's menopause may be earlier than average (that is, age 51) if she:

  • is thin and small boned
  • has never had children
  • doesn't smoke
  • lives at a high altitude
  • has eaten poorly throughout yourlife
  • has a higher standard of living
  • has had a hysterectomyor tubal ligation (even if the ovaries aren't removed, a woman whose uterus has been removed enters menopause a few years earlier than otherwise)
  • has shorter-than-average cycles (less than 25 days)
  • has had several abortions

Menopause may be later than average if women:

  • are heavy or big-boned
  • have had several children (each child you've had will delay the onsetof menopause by about five months)
  • smoke
  • live at sea level
  • have had diabetes, cancer of the breast or uterus, uterine fibroid tumors
  • have a lower standard of living
  • had your first child afterage 40
  • have taken birth control pills for many years

How It Occurs

Once a woman enters puberty, each month her body releases one of the more than 400,000 eggs that are stored in her ovaries, and the lining of the womb (uterus) thickens in anticipation of receiving a fertilized egg. If the egg is not fertilized, progesterone hormone levels drop and the uterine lining shedsand bleeds. By the time a woman reaches her late 30s or 40s, her ovaries begin to shut down, producing less of the hormones estrogen and progesterone andreleasing eggs less often. As your store of eggs gradually diminishes, the estrogen-secreting layer of cells becomes less responsive to the signals from the brain. Some months a woman won't ovulate at all, which means she won't produce any estrogen or progesterone. The result: she skips a period. Some womenin this situation have longer periods with heavy flow; others find they haveshorter cycles and hardly any bleeding. Some have a combination of the two,and others will begin to miss periods completely. During this time, a woman also will experience a decrease in the ability to become pregnant.

The gradual decline of estrogen causes a wide variety of changes in tissues that respond to estrogen--including the vagina, vulva, uterus, bladder, urethra, breasts, bones, heart, blood vessels, brain, skin, hair, and mucous membranes. Over the long run, the lack of estrogen can make a woman more vulnerableto osteoporosis (which can begin in the 40s) and heart disease. Indeed, hormones influence almost every body structure and can be associated with a widerange of other disorders including many cancers, Alzheimer's disease and evenskin changes.

As hormone levels fluctuate, the menstrual cycle begins to change. Some womenmay have longer periods with heavy flow followed by shorter cycles and hardly any bleeding. Others will begin to miss periods completely. During this time, a woman also becomes less able to get pregnant.


The most common symptom of menopause is a change in the menstrual cycle, butthere are a variety of other symptoms as well, including:

  • Breast changes
  • Depression
  • Fatigue
  • Hair changes
  • Headaches
  • Heart palpitations
  • Hot flashes
  • Insomnia
  • Memory or concentration problems
  • Mood swings/irritability
  • Night sweats
  • Sexual disinterest
  • Urinary changes
  • Vaginal bleeding (heavy)
  • Vaginal dryness
  • Weight gain

Menstrual Problems

Although there is a wide variation in the length of menstrual cycles from woman to woman, in general a woman entering perimenopause will become more irregular; periods may come closer together or farther apart, heavier or lighter.Some women notice their periods change month to month. Missed periods aren'tuncommon, because there are some months when a woman doesn't ovulate, which means she won't produce progesterone and won't shed the uterine lining.

Almost a fourth of all hysterectomies in the United States are performed in an effort to control prolonged abnormal bleeding. If the only reason a woman is having problems with bleeding is due to menopause, hormone replacement therapy may make a hysterectomy unnecessary. This abnormal bleeding will stop once menopause is complete.

Hot Flashes

The second most common symptom of menopause is hot flashes. According to a 1991 Gallup survey, 87% of menopausal women report they have experienced hot flashes, and more than half say they also experience night sweats. About half of women, according to another study, experience hot flashes while they are still menstruating regularly. Hot flashes range from an occasional brief flushto a sheet-soaking feeling of heat. The sensations of searing heat may last anywhere from a few seconds to an hour, between once a day and several times an hour.

While hot flashes usually only occur for about a year, some women struggle with them for up to five years on an intermittent basis. The precise cause of hot flashes isn't completely understood, but experts think they are related tochanges in the hypothalamus as hormone levels decline. The more abruptly ormore often a woman's estrogen levels fluctuate, the stronger and more frequent the hot flashes become. This is why women who have had their ovaries removed experience much more severe hot flashes than those whose ovaries are intact. This is also why thin women have stronger hot flashes (fat cells produce estrogen even after menopause is complete). Scientists suspect that other hormones and brain chemicals may also be involved.


About two in 10 women experience menopause insomnia, the inability to fall asleep during menopause. Experts believe the sleep problems are due to fallinglevels of estrogen. Hot flashes at night can cause a chronic sleep deprivation, which can make a woman more irritable, moody, depressed or forgetful.

Irritability and Mood Swings

At least three out of every five women report they have experienced anxiety,irritability or nervousness during menopause, and nearly 58% say they have experienced mood swings or some depression. As hormones fluctuate, it's perfectly normal to feel tense and irritable and cry easily. Estrogen and progesterone affect chemicals in the brain that control a wide variety of emotions.

Thinking and Memory Problems

Some of the most disturbing symptoms of menopause are mental, including disorientation, concentration problems and memory loss. Researchers believe thesemental acuity glitches may be linked to the dropping estrogen level. The brain, like the uterus and breasts, contains sites where estrogen hormones can affect cells. The more abruptly the estrogen levels drop, the more pronounced the symptoms. This is why women recovering from surgery or chemotherapy may experience particular memory problems. In one study at Rockefeller University,researchers found that lower estrogen levels in lab animals may reduce the number of connections between brain cells, leading to problems of concentrationand memory. Related studies found that lower estrogen levels may lead to a drop in the brain chemical serotonin, a neurotransmitter related to mood and depression.

Vaginal Dryness

Vaginal dryness is a common complaint during menopause, which can be severe enough to make intercourse uncomfortable. As estrogen levels fall, the vaginalwalls become drier and thinner; eventually, the vagina itself may become shorter and narrower. If untreated, the vagina can actually atrophy.This lack oflubrication can make sex painful. In severe cases, the vaginal walls can actually tear and bleed.

Breast Changes

The breasts may become more full or tender during menopause, since breast tissue is very sensitive to estrogen and progesterone, even in amounts producedduring a normal cycle. Women undergoing hormone replacement therapy may alsoexperience breast tenderness.


Fluctuating levels of estrogen can cause headaches, especially if the woman was prone to premenstrual migraines before menopause. In addition, women on hormone replacement therapy may experience intense headaches in response to theinitial boost in hormones. Women taking hormone replacement therapy can choose the patch instead of a pill to lessen the risk of headaches.

Heart Palpitations

Heart palpitations are a fairly common symptom of menopause, caused by the brain's response to changing hormone levels. However, palpitations also can becaused by other other factors, including too much caffeine or nicotine, or aheart condition.

Loss of Sexual Interest

Declining levels of estrogen can have a direct effect on a woman's sex drive;lower estrogen levels also can make the genitals less sensitive, and make sex painful due to dry vaginal tissues.

Urinary Changes

Many women report changes in urination beginning with menopause, becoming unable to hold in urine during moments of stress (sneezing, laughing or running). Others feel as if they must go to the bathroom all the time, or that the urge to urinate is too strong. Losing control during times of stress ("stress incontinence") is caused by loosening muscles around the bladder and urethra.As the vaginal wall weakens due to estrogen depletion, it can no longer support the bladder, which can drop out of place. Without the support of the vaginal wall and other muscles, even the tiniest pressure of a sneeze or a cough can lead to a small loss of urine. The urethra itself has estrogen receptors and without the hormone, it can atrophy in the same way as the vagina.

Facial Hair

The beginning of menopause may trigger the appearance of darker hair on the face as the level of estrogen drops and male hormones are no longer balanced by estrogen. In this case, hair usually appears in a typically masculine pattern -- on upper lip, chin and cheeks.


Many women become mildly depressed during menopause, but experts no longer believe that depression is directly caused by the onset of menopausal symptoms.In fact, studies have failed to find any link between depression and menopause; women who do become depressed during this time don't appear to have symptoms any different from younger depressed women. However, menopause can disturb healthy sleep patterns and cause other annoying symptoms which can make a woman feel depressed, but there is a difference between symptom-related feelings of depression and emotional illness.

Symptoms are tied to hormonal levels; however, as a woman first enters menopause, her hormones often fluctuate wildly from day to day. For example, if a woman's estrogen levels are high and progesterone is low, she may have mood swings, irritability, and other symptoms similar to premenstrual syndrome (PMS). As hormone levels shift and estrogen level falls, hot flashes occur. Because of these fluctuations, a normal hormone level when the blood is tested maynot necessarily mean the levels were normal the day before or will be the dayafter.

If it has been at least three months since a woman's last period, a test of the follicle-stimulating hormone (FSH), which rise steadily as a woman ages, might help determine whether menopause has occurred. Most doctors believe thatthe FSH test alone can't be used as proof that a woman has entered early menopause, especially because FSH tends to fluctuate wildly during perimenopause. A better measure of menopause is a test that checks the levels of estrogen,progesterone, testosterone and other hormones at mid-cycle, in addition to FSH. If the reading is between 10-12, it's a sign of the beginning of ovarianfailure. FSH above 40 is a sign that menopause is complete.

Hormone Replacement Therapy

As a woman enters perimenopause, her estrogen levels drop and annoying symptoms (such as hot flashes and vaginal dryness) begin. he goal of HRT is to replace estrogen that's lost at menopause, easing symptoms like hot flashes and safeguarding women against health risks linked to low hormone levels: heart disease and osteoporosis. But it's also true that HRT causes breakthrough bleeding and sore breasts, and it may trigger other diseases, such as breast cancer.

When a woman reaches menopause and still has a uterus, her doctor will prescribe hormone replacement with both estrogena and progesterone, which protectsthe uterus from the cancer-causing effects of estrogen alone.

Hormone replacement therapy treats the symptoms of menopause by boosting hormone levels enough to suppress symptoms while also providing protection against heart disease and osteoporosis. Experts disagree on whether HRT increases or decreases the risk of developing breast cancer. One Harvard study concludedthat short-term use of hormones carries little risk, while HRT used for morethan five years among women 55 and over seems to increase the risk of breastcancer.

Some of the newest types of HRT are called selective estrogen receptor modulators (SERMS) that seem to offer some of the protection against heart diseaseand bone loss as estrogen, but without the increased risk of breast cancer. Two of the best-known as raloxifene and its cousin, tamoxifen. SERMS block estrogens, and prevent cells from over-reproducing -- a key source of cancer. They mimic the effects of estrogen in the bones and blood, but block some of its bad effects elsewhere. However, it's not clear if SERMS will be as effective and versatile as estrogen replacement itself. Still, experts are hoping that the new generation of SERMS may offer many of the benefits of HRT with fewer risks or side effects. A new seven-year study called "STAR" (Study of Tamoxifen and Raloxifene) is the first large direct comparison of both drugs' ability to prevent breast cancer.

Alternative Treatments

Many women find that yoga (the ancient meditation/exercise developed in India5,000 years ago) can ease menopausal symptoms. Because yoga has been shown to balance the endocrine system, some experts believe it may affect hormone-related problems. Studies have found that yoga can reduce stress, improve mood,boost a sluggish metabolism, and slow the heart rate. Specific yoga positions deal with particular problems, such as hot flashes, mood swings, vaginal and urinary problems, and other pains.

Exercise helps ease hot flashes by lowering the amount of circulating FSH andLH and by raising endorphin levels (which drop while you're having a hot flash). Even exercising 20 minutes three times a week can significantly reduce hot flashes.

Acupuncture is an ancient Asian art that involves placing very thin needles into different parts of the body to stimulate the system and unblock energy. It is has also been used for many menopausal symptoms, including insomnia, hotflashes, and irregular periods. Therapeutic massage involving acupressure can bring relief from a wide range of menopause symptoms by placing finger pressure at the same meridian points on the body that are used in acupuncture. Some women have been able to control hot flashes through biofeedback, a painless technique that helps a person train the mind to control the body.

User Contributions:

charles hopkins
My wife has been menopausal for more than 10 years. Now at 60 she is having her period again. I am a little concerned. Can you offer an explanation? Thank you

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