Menopausal Changes

Menopausal Changes

Signs of a New Beginning

You protect your skin by staying out of the sun, control your cholesterol by sticking to a low-fat diet and keep your bones strong by exercising regularly and getting enough calcium.

But among the physical changes life can bring, there's one you can't prevent. And that's menopause.

Okay, so you don't want to hear about it. You don't even want to think about it. You figure you're too young for menopause. And besides, you've heard about its discomforts--hot flashes, mood swings and vaginal dryness, to name a few.

But menopause doesn't have to be terrible. In fact, when women share their experiences they often find that some of the myths about it just don't hold water. They find that it doesn't have to be the beginning of old age. Instead, it can mark the start of a new phase in life, one that is vital, productive and fulfilling.

What May Happen

An estimated 40 to 50 million women--more than ever before--will enter menopause in the next two decades. Most American women hit menopause around age 51. Some women go through it earlier, and an estimated 1 percent do so before age 40.

Menopause begins after a woman's last period. A woman is considered to be in menopause after she hasn't menstruated for a full year. But before that happens, women go through a phase known as the climacteric, or perimenopause. At this time, the ovaries get smaller and produce less estrogen. This drop is what causes the hot flashes, night sweats, vaginal dryness, skin changes, sleep difficulties, mood swings, depression and weight gain experienced by some women. The drop in estrogen often alters a woman's period, which may become heavier or lighter, longer or shorter or irregular. And symptoms of premenstrual syndrome (PMS) can worsen.

It's often difficult for women to tell whether menopause has started because the onset of physical changes can be gradual. Doctors can do a follicle-stimulating hormone (FSH) test to see if menopause has started. This test measures the amount of FSH a woman is producing; at menopause the amount increases because more FSH is necessary to stimulate the ovaries to release an egg. An FSH level of about 40 indicates that you may be in menopause.

Menopause can bring physical and emotional changes, which may be both uncomfortable and troublesome. Because of hormonal shifts, women sometimes can feel out of control. "It can be a real up-and-down time," says Joan Borton, a licensed mental health counselor in Rockport, Massachusetts, who runs workshops for menopausal women and is the author of Drawing from the Women's Well: Reflections on the Life Passage of Menopause. "That is very disconcerting for women, particularly those who have been able to feel like they are on top of things."

But the changes women fear do not always occur, experts say. Studies indicate that between 16 and 38 percent of menopausal women are symptom-free--no hot flashes, no dryness, no nothing.

And even if women do have symptoms, they don't happen overnight, and they don't turn women into wrinkled old ladies. On the contrary, women often feel sexy, productive, bright and relieved that they no longer need to worry about getting pregnant, says Ellen Klutznick, Psy.D., a psychotherapist in San Francisco who counsels menopausal women.

At this time, some women truly branch out. "A lot of women are starting new businesses or new careers," says Dr. Klutznick. During menopause many women evaluate what they have done, what they are doing and where they are going, says Borton. "There is a sense of excitement among many women at this time, as well as a real sense of urgency," she says. Women commonly tell her, "For this last third of my life I really want to be giving my energy to things that are real core concerns to me. I am not going to give my energy to peripheral stuff anymore," she says.

How the Body Responds

But even if a woman approaches menopause with positive feelings, there are changes going on inside her body that put her at risk for certain diseases.

When estrogen drops, for instance, a woman's risk of heart disease increases: Before age 65, one in nine women develops heart disease, compared to one in three after age 65. Estrogen exerts a protective effect on the heart by keeping levels of "good" cholesterol, or HDL, high, and levels of "bad" cholesterol, or LDL, low.

Declining levels of estrogen also place women at increased risk for osteoporosis and the debilitating fractures that can result from it. This is because estrogen plays a key role in stimulating bone growth and promoting the absorption of calcium. When estrogen levels drop, these effects do, too. After menopause, between 25 and 44 percent of women experience hip fractures due to osteoporosis. And women are nearly twice as likely to fracture their hips as men when they reach their nineties.

Hormone Replacement: Yes or No?

These disease risks and the physical changes that some women go through are why some women consider hormone replacement therapy (HRT)--formulations designed to replenish a woman's diminishing hormones.

While there are different types of HRT, most doctors recommend ones that include estrogen and a synthetic form of progesterone called progestin. Estrogen is used for its beneficial effect on the heart and bones, among other things. But when given alone, estrogen can stimulate cancer growth in the uterus and breast. Progestin cuts that risk.

Whether to take HRT is one of the biggest questions women confront about menopause, says Borton. It is a difficult personal decision, she says, because there are pros and cons.

Among the benefits of HRT is relief from hot flashes and vaginal dryness--the two symptoms that drive most women to ask about the therapy, says Brian Walsh, M.D., director of the Menopause Clinic at Brigham and Women's Hospital in Boston.

Between 75 and 85 percent of menopausal women who have symptoms get hot flashes. Of those who do, 80 percent have them for more than a year, while 25 to 50 percent have them for more than five years. Frequency and intensity vary, Dr. Walsh says. For some women they can be mild and last a couple of minutes, while for others they can be more intense, cause flushing and sweating and last as long as 12 minutes. When hot flashes come at night--what's commonly called night sweats--they can disrupt sleep, leaving women exhausted and irritable the next day.

Without estrogen, the vagina can become dry and less elastic. HRT replenishes estrogen, so moisture is restored.

Regarding the Risks

From a health standpoint, a big plus for HRT is the protection from heart disease it provides, experts say. In studies of women who took just estrogen, doctors found that it appeared to lower women's risk of heart disease by 50 percent compared to women who didn't take it. Thorough studies on HRT--which provides both estrogen and progestin--have yet to be done, but initial research shows that HRT may also offer substantial protection against heart disease.

Hormone replacement therapy can also prevent women from developing osteoporosis. Research suggests that women who take HRT reduce their risk of osteoporosis-related fractures by 50 percent.

And women who have the disease may be able to increase their bone density by 5 percent through HRT.

But HRT is not without its risks, cautions Dr. Walsh. The greatest concern is whether taking HRT will increase the risk of uterine or breast cancer.

Of postmenopausal women not taking HRT, 1 in 1,000 will develop uterine cancer, according to studies. For women who take estrogen alone, that risk increases between two and ten times, depending on how much estrogen is in the formulation they take and how long they take it.

Studies indicate, however, that when progestin is taken with estrogen, the risk of uterine cancer is lower than when estrogen is taken by itself. In a ten-year study of 398 women taking both hormones, none of the women who took progestin for at least 10 days out of 25 developed uterine cancer. Whether women who take HRT are at lower risk for uterine cancer than women who don't take any hormones has not been conclusively proven, but based on preliminary studies, doctors suspect that the risk may be lower by an estimated 30 to 40 percent.

If a woman decides to take only estrogen, she can be monitored for uterine cancer by her doctor.

Breast cancer is a concern for women on HRT. Estrogen promotes cancer growth in lab animals, so there's reason to suspect that giving women estrogen might stimulate breast cancer. While research on breast cancer risk from HRT has yielded no definite conclusion, a study conducted at the Centers for Disease Control and Prevention in Atlanta determined that a woman's risk may be relative to how long she's on the therapy. Women in the study who took hormones the longest--for more than 15 years--had the greatest risk, and it was 30 percent higher than for women who did not take HRT or took it for less than 5 years.

Women who take HRT are also at risk for gallstones, particularly during the first year of therapy, says Dr. Walsh.

If you've had cancer of the breast or uterus, have active liver disease or have had major problems with blood clots, HRT is not usually recommended.

Looking Ahead to Menopause

Menopause may bring some physical changes, but there are some steps you can take now to help you get through it. Here are some suggestions.

Get in the exercise habit. Do some form of weight-bearing, aerobic exercise for 30 minutes at least three times a week, and more if possible. Weight-bearing activities--such as walking or running--help increase or maintain bone density. Aerobic exercise, the kind that gets your heart rate up continuously for at least 20 to 30 minutes, will also help keep your cholesterol levels down and boost your feelings of well-being, Dr. Walsh says.

Watch your fat intake. Each day, 25 percent or less of the calories you eat should come from fat, experts say. Eating a diet low in saturated fats will help bring your cholesterol level down.

Give up those cigarettes. Smoking can worsen any menopausal symptoms you have, Dr. Walsh says. Smoking not only brings on menopause sooner, it also reduces the small amount of estrogen women do have after menopause. In addition to making you feel better at menopause, giving up smoking will also be better for your bone health--you'll have more estrogen available to maintain bone strength.

Bone up now. Get enough calcium to keep your bones strong and healthy. After age 35, women begin to lose about 1 percent of their bone mass per year. The Daily Value for calcium for premenopausal women is 1,000 milligrams, but some doctors recommend getting between 1,000 and 1,200 milligrams. An eight-ounce glass of 1 percent low-fat milk and one cup of low-fat yogurt with fruit contain about 300 milligrams each. Three ounces of canned sockeye salmon, with bones, contains about 203 milligrams, and a half-cup of tofu contains about 258 milligrams.

Calcium supplements are another option. When deciding how many supplements to take, read the label to see how much "elemental" or "bioavailable" calcium each tablet contains; that's the number of milligrams your body will actually absorb. Take the supplements with food and a glass of water to help your body absorb them easily and efficiently, says Kendra Kaye, M.D., clinical assistant professor of medicine at the University of Pennsylvania School of Medicine and attending physician at Graduate Hospital, both in Philadelphia.

Have your cholesterol checked. Ask your doctor to check your cholesterol levels to make sure you are in the healthy range, says Dr. Walsh. She should measure the ratio of your total cholesterol to your good cholesterol, or HDL. A total cholesterol/HDL cholesterol below 3.5 indicates that you are at low risk for a heart attack. A ratio between 3.5 and 6.9 means you are at moderate risk, and a ratio over 7.0 means you are at high risk. Menopause can cause your ratio to go up, because levels of LDL (bad cholesterol) go up and levels of HDL go down.

See your doctor about PMS. If you've got PMS and your symptoms are getting worse, see your doctor; you may have begun menopause, says Dr. Klutznick. Your doctor can perform an FSH test to determine whether that is the case.

Ask Mom. If the uncertainty of menopause weighs on your mind, talk to your mother about it. It's not uncommon for women to follow the same pattern as their mothers, says Dr. Walsh, especially if they have a similar health history.

Bring your husband into the picture. Share information you learn about menopause with your husband, says Dr. Klutznick. One way to do that is to ask him to read a book or two on menopause, she says. Some books have chapters just for men.

Savor the moment. It can make the menopausal transition easier if you appreciate where you are in your life and enjoy it, says Borton.

When Menopause Arrives

Don't just sit back and worry, or try to ignore it. Here are tips to help you cope.

Talk about it. "Talk to other women," says Dr. Klutznick. Find out what symptoms they're having, what causes them difficulty and what they do to cope. A lot of women are doing their own research and information-gathering, and they can be a tremendous resource for you, she says.

Find someone to look up to. Some older women who have been through menopause can serve as wonderful mentors, says Borton. Find a woman 10 to 15 years older who's living a lifestyle you admire and respect and talk to her about what has meaning in her life. Make her a role model.

Consider HRT. Talk to your doctor about your symptoms and options for dealing with them. Deciding to take hormones is a very individual decision, experts say. Talk to several doctors if you need to, Dr. Klutznick says, until you find one you are comfortable with and who is willing to respect what you want to do to manage your menopause.

Create a sense of community. "Women need to have a community of other women," says Dr. Klutznick. This can help you feel connected and productive during this transitional time, she says. So join a book club or take art lessons or a course that stimulates your intellect, she says.

Expect sexual changes. For some, sex will change during menopause, says Dr. Klutznick. Some women find that sex is not as passionate but becomes more affectionate. And this can be fine, since their mate's testosterone levels may be dropping as well, lowering his sex drive. Some women also find that certain places on the body that used to be highly sensitive are less so, and that other places that were not sensitive now are, she says.

Stay sexually active. Sex may feel different, but try to stay active, doctors say. Women who do so undergo fewer vaginal changes than those who slow down, studies show. Not having sex can cause your vagina to change in size and elasticity, which can make sex painful. Communicate to your partner the changes you are feeling and explore new and different ways to have sex that may be more comfortable. You may take longer to lubricate than you used to--it may take one to three minutes for your vaginal area to become aroused, compared to the 6 to 20 seconds it used to take.

Besides allowing yourself more time, you can also use water-based vaginal lubricants. Try K-Y Lubricating Jelly or Replens, which are available in drugstores.

If you do not have a partner, masturbation helps promote circulation and moistness in the vagina, helping it to maintain its size and elasticity, says Dr. Klutznick.

Try herbs. Black cohosh, blue cohosh, sarsaparilla, wild yam root and dong quai are among some of the herbs doctors often recommend to alleviate menopausal symptoms. These herbs contain phytoestrogens, plant sources of estrogen similar to that produced in the body.

The levels of phytoestrogens found in these herbs are lower than the doses of estrogen in HRT and are believed by some doctors to relieve menopausal symptoms without causing harmful side effects. Consult with your doctor before using these remedies.