Most women don’t realize how important estrogen is until they are living without it and experiencing “side effects” of menopause.

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The word “menopause” often is used inappropriately. A woman doesn’t “go through menopause.” She ends up in menopause. Menopause is the state a woman enters once she has gone 12 months without a period, at which point her ovaries are no longer producing the hormone estrogen. What she experiences leading up to menopause is called “perimenopause,” a challenging time when the ovaries start to release fluctuating but dwindling amounts of estrogen.

Those slowly decreasing estrogen levels cause noticeable changes in the menstrual cycle and, eventually, in a woman’s entire body. Most women begin perimenopause in their 40s. Very important note: A woman can still become pregnant while she is in perimenopause, even if she goes a few months in a row without a period.

The American College of Gynecologists and Obstetricians (ACOG) lists the average age for menopause as 51. Every woman is different, but there may well be a genetic link to when it will occur. If a woman’s mother became menopausal at age 54, chances are good she will experience it around the same time in her life.

If you suspect you’re entering perimenopause, get a gynecological exam, even if you’ve skipped them in the past. Most insurances companies still completely cover a well-woman/preventative annual physical, so it’s a low-cost opportunity to discuss your perimenopausal state and learn about ways to help you through the irritating signs of menopause. Even more importantly, your gynecological cancer risk increases as you age.

“The most important reason for an annual gynecologic exam is maintaining awareness of changes in one’s body, and a reason to seek regular gynecologic medical care is cancer,” explains Mark D. Adelson, M.D., who is board-certified in both gynecology and oncology, and the director of Comprehensive Gynecology in Syracuse, N.Y. “Female cancers are more common as a woman ages, and so are more common in menopause. This includes ovarian cancer, which most often presents in an advanced stage, with few specific symptoms. This cancer accounts for half the deaths from gynecologic cancer,” he says.

“Endometrial (uterine) cancer also becomes more common with advancing age, and although most cancers present in early stages, it is the most common gynecologic cancer. Any symptom that persists for more than two weeks, or is severe, should be reported. Symptoms include abdominal discomfort, change in bowel and bladder function, abdominal swelling, and uterine bleeding,” explains Dr. Adelson.

For more information, check out “6 Ways to Reduce Your Risk of Gynecologic Cancers.”

Signs That Menopause Is Looming

During the years leading up to menopause, a woman will experience menstrual-cycle abnormalities—long periods, frequent periods, missed periods, light bleeding, heavy bleeding—all due to the ovaries’ varying estrogen-production levels. If a woman’s ovaries are surgically removed (called an oophorectomy)—whether due to pain, cysts, or as part of a hysterectomy (surgical removal of the uterus)—she will be hit hard by menopause. No ovaries means no estrogen, so a bilateral oophorectomy results in immediate menopause with sometimes severe symptoms. (The ovaries do not have to be removed during a hysterectomy; discuss the pros and cons with your gynecologist.)

Premature ovarian failure—defined as when the ovaries stop producing estrogen before the age of 40—will also bring on menopause. According to Office on Women’s Health (U.S. Department of Health and Human Services), 5 percent of women experience premature ovarian failure.

The signs of menopause are called “vasomotor” symptoms, so named because the vasomotor part of the brain controls blood pressure (some studies have shown hot flashes result in an increase in blood pressure). Signs and symptoms that a woman is in perimenopause include:

• Anxiety
• Changes in periods
• Dry skin and scalp
• Facial hair increase
• Fatigue
• Hot flashes
• Irritability
• Lack of focus
• Loss of libido
• Mood swings
• Night sweats
• Painful sexual intercourse
• Sleep problems
• Thinning hair
• Vaginal atrophy
• Vaginal dryness

Once you’ve reached menopause, some of these symptoms will remain and some will fade away, however, any vaginal bleeding should be immediately reported to your gynecologist, as it could be a sign of cancer.

Hot flashes, which is probably a woman’s least-favorite curse, or symptom, was long believed to last only six to 24 months, but a study published in 2015 in JAMA Internal Medicine found hot flashes can continue for 11 years. Sadly, most women who have achieved menopause would likely agree with that finding.

Side Effects of Menopause

Although there aren’t “side effects” of menopause, per se, changes do occur in your body as a result of menopause. Estrogen is a powerful hormone that has more jobs than just reproduction. Most women don’t realize how important estrogen is until they are living without it and experiencing “side effects” of this change of life.

Women in menopause may find themselves facing challenges they didn’t anticipate during their reproductive years. “Menopause isn’t a disease. It’s a natural phase of a woman’s life cycle,” said Dr. Nieca Goldberg, a cardiologist and an American Heart Association (AHA) volunteer. “It’s important for women, as they approach menopause, to really take stock of their health.”

• Cardiovascular disease: According to the AHA, “an overall increase in heart attacks among women is seen about 10 years after menopause.” Part of the reason may be due to the cholesterol changes that occur once a woman is no longer producing estrogen. The lack of estrogen causes the bad cholesterol (LDL) to rise and the good cholesterol (HDL) to decrease. (For more on how menopause can affect your cholesterol levels, check out “Cholesterol Levels for Women Increase After Menopause.”) Triglycerides also increase. In addition, estrogen is believed to help the walls of blood vessels remain flexible, so they easily accommodate changes in blood flow. And, yes, menopause may result in high blood pressure as well.
• Osteoporosis: Estrogen poked the osteoblasts—cells that produce bone—to keep functioning. Without it, the osteoblasts become lazy and bones begin to thin, which can result in osteopenia or osteoporosis. Bone-density screening once every two years is important to monitor bone loss. One of the therapies for bone loss is estrogen-replacement therapy, which is also a treatment for menopausal symptoms (see below, hormone-replacement therapy). Weight-bearing exercises, like walking, are also good to combat osteoporosis.
• Urinary incontinence: The lack of estrogen is also implicated in muscle weakening, which includes the muscles of the pelvic floor. (The pelvic floor is a layer of muscles on the bottom of the pelvis that supports the organs in the pelvis and keeps them in place.) When these muscles weaken, pelvic prolapse (an organ dropping from its normal position, such as the uterus or bladder) and/or urinary incontinence can result. Incontinence can come in the form of stress incontinence, which means a woman loses some urine when she laughs, coughs, sneezes, or lifts something heavy. It may also be due to urge incontinence, which is leakage that occurs as soon as a woman feels the need to urinate. More often than not, it’s a mix of the two.
• Body shape: Yup, as if all the rest of this isn’t enough, menopause will redistribute weight, resulting in “visceral” fat, which is fat that accumulates in the abdomen (the dreaded “muffin top”). Many a woman has ended up on a clothes-shopping spree because, although the scale says the same thing, their clothes become uncomfortable. Unfortunately, too, diabetes is a possible complication of a high level of visceral fat.  An actual gain in weight results from a slowing metabolism, however, and is believed to be due to plain old aging.

Diagnosis of Menopause

It’s not difficult for your doctor to make a diagnosis of menopause. It’s a natural change of life that is based on your age and symptoms. However, your physician can run tests to confirm the diagnosis and decide about treatment, if necessary. Tests include:

• Estrogen blood test: Obviously, this will be low.
• Follicle-stimulating hormone (FHS) blood test: This hormone will be high. FHS continues to stimulate the ovaries to release an egg, but without estrogen, the ovaries aren’t listening, and FSH refuses to give up.
• Urine pregnancy test: If you’re sexually active, it’s be sure pregnancy isn’t the cause of a change in periods.
• Thyroid-stimulating hormone (TSH) blood test: Thyroid problems can cause irregular periods and symptoms similar to those during perimenopause, so they need to be ruled out as well.

Treatments for Menopause

The arsenal for combating menopause distress is astounding, but there is no reason to choose one unless perimenopause/menopause disrupts your quality of life. It’s always wise to get physician advice when choosing, and some treatments do require a prescription.

In the beginning, while you’re still having periods, low-dose birth-control pills can help with some of the symptoms, like hot flashes. Most birth-control pills contain estrogen and a form of progesterone (another hormone produced by the ovaries and important to reproductive health).

Hormone replacement therapy (HRT) replaces lost hormones and improves damage done by its loss, such as bone thinning, and combats the annoying symptoms of menopause, such as vaginal dryness and hot flashes. HRT can be just estrogen (called ERT), estrogen with progesterone, or estrogen and progestin (a synthetic progesterone). It is available as pills, patches, sprays, gels, and even a vaginal ring or vaginal ointment.

HRT/ERT is not without risk, however, making it a major decision. The main risks are blood clots, heart attack, strokes, cancer, and spotting. It’s not for everyone, and you may find your physician requires more frequent exams if you choose hormone therapy.

“Menopause impacts the quality of life to different degrees in each woman,” says Dr. Adelson. “So, hormone replacement could be more important to a woman with more severe symptoms and changes, and less important to others. A common reason many women don’t take hormone replacement is fear of cancer, specifically breast cancer. Many studies show that combined hormones (estrogen and progesterone) can be taken for up to 10 years after menopause, in the case of a woman with a uterus in place, before any risk increase occurs,” he says.

“The progesterone is added to prevent uterine bleeding and to reduce the risk for uterine cancer. A 16-year follow-up study from Denmark showed what many smaller studies have shown for estrogen replacement only. That is, that this therapy actually reduces the risk for breast cancer,” says Dr. Adelson. “Estrogen therapy alone would be used in a woman without a uterus.”

There are alternatives to HRT, of course. Some patients have experienced an improvement in hot flashes and sleeping disorders by using an antidepressant or a selective serotonin reuptake inhibitor (SSRI), like FDA-approved Briselle.

“Two common medical reasons hormone replacement might not be given are a personal history of breast cancer and blood clots (deep vein thrombosis or DVT). As with any medical treatment decision, whether this be surgery, medication, or hormones, an analysis of risk versus benefit should be done to arrive at the best decision. This should be done in partnership with a knowledgeable medical professional,” advises Dr. Adelson.

For vaginal dryness, a simple over-the-counter lubricator might do the trick. Or, in November 2016, the FDA approved Intrarosa (prasterone) to treat pain during sexual intercourse (dyspareunia). Osphena is an FDA-approved oral treatment for dyspareunia.

Natural Choices

It’s important to be aware that the FDA doesn’t oversee supplements the way it does drugs. WomensHealth.gov cautions women to talk with a doctor before reaching for a supplement to treat hot flashes and other menopause symptoms. Although scientific studies vary in their results, supplements that may help include black cohosh, red clover, and soy.

A more effective natural approach may be to practice yoga or tai chi. You may also find relief through with acupuncture. These approaches, says womenshealth.gov, “may help reduce menopause symptoms, including sleep and mood problems, stress, and muscle and joint pain. One study also found that hypnosis (a trance-like state during which your mind is relaxed) helped decrease hot flashes by 74 percent.”

Finally, it may help to lose weight and get more fit. In May 2017, the North American Menopause Society (NAMS) released a study that showed hot flashes are associated with a higher body mass index (BMI). “This study supports earlier studies that found that women who are heavier tend to have more hot flashes, particularly close to menopause,” says Dr. JoAnn Pinkerton, NAMS executive director. “In some studies, but not all, weight loss and exercise have both been shown to reduce hot flashes in women who are obese, thus giving women even more reason to create a healthier lifestyle for themselves.”

For related reading, please visit these posts:
Managing Menopause Gracefully
3 Excellent Natural Therapies for Perimenopause Treatment
Pycnogenol Benefits Include Easing the Transition to Menopause