Menopause

Natural menopause is diagnosed after after a consecutive 12 month absence of menstrual periods with no obvious pathologic cause. Induced menopause is defined as menopause that occurs after surgical removal of both ovaries or after ablation of ovarian function (for example, by chemotherapy, radiation, severe infection, or procedures that impair ovarian blood supply).  Premature menopause is menopause that occurs at or before age 40 and can be natural or induced.  Laboratory findings consistent with menopause are a low level of estrogen in the blood and a high level of FSH, or follicle stimulating hormone, which is the pituitary hormone that stimulates the ovary to produce hormones.

The years leading up to menopause, also known as perimenopause or the menopausal transition, are characterized by fluctuations in estrogen production by the ovaries. These fluctuations are the cause of of the many signs and symptoms that develop during this time.  Perhaps the most revealing sign of the menopausal transition is the change in the menstrual period. Early on during the perimenopause, the interval between menstrual cycles begins to change; the interval can lengthen by 7 or more days. The duration of bleeding also changes—typically becoming shorter, but it may become longer. These changes can linger for 4-7 years before actual menopause occurs. During this time, pregnancy is unlikely but still possible. Therefore, it is recommended to protect against unwanted pregnancy until a full year without periods.

As changes occur in their menstrual period, women experience symptoms during the menopausal transition that are uncomfortable, disruptive, and often disheartening for many. These include: hot flashes, cold spells, mood swings (irritability, depression), sleep disruption, fatigue, night sweats, sexual dysfunction, altered urinary habits, and “foggy brain.” Other unwelcome changes are physical: changes in weight, body shape, in the breasts, and the female organs. However, not all changes after menopause are negative: menstrual bleeding stops, premenstrual syndrome ends, sex can be enjoyed without fear of pregnancy, hormonal headaches improve or stop altogether, and uterine fibroids shrink. For many, these positive changes can be emotionally and socially energizing and liberating.

Abnormal menstrual bleeding occurs during the perimenopause in more than half of women. The most common cause is the cessation of the release of an egg from the ovary (a state known as anovulation). Anovulation during the perimenopause stems from the paucity of the ovaries’ remaining eggs and the decrease in estrogen and progesterone production by the ovaries. Progesterone is produced even less than estrogen, which creates an imbalance resulting in a relative estrogen dominance. The result is an unopposed estrogenic stimulation of the endometrium (the uterine lining) to grow and thicken. This causes irregular episodes of vaginal bleeding when the thickened, unstable endometrium breaks down. While this bleeding is disconcerting, the process is physiologic. However, estrogenic dominance can become pathologic and cause abrupt growth in existing uterine fibroids, development of endometrial polyps, abnormal thickening of the endometrium (known as hyperplasia), and even endometrial cancer: all of which can be causes of abnormal bleeding during the perimenopause. Estrogenic dominance and its consequences may also stem from: obesity (because body fat produces a weak estrogen), rare estrogen-producing tumors in the ovary, taking estrogen orally or by patch without also taking progesterone, and taking the estrogen-like medication tamoxifen to prevent breast cancer.

Given that any of these causes of perimenopausal irregular vaginal bleeding—both physiologic and pathologic—may be at play, a thorough clinical evaluation is necessary. Clinical evaluation typically consists of sonographic imaging of the uterus (with special attention to the endometrium) and office endometrial sampling, or biopsy. Sonographic imaging is done by a transvaginal and transdabdominal sonogram of the pelvis, and it allows the determination of the appearance and thickness of the endometrium. If abnormal endometrial appearance or thickness is seen on a pelvic sonogram, a biopsy is done to determine its cause. The endometrial biopsy specimen is then analyzed under the microscope in a laboratory for evidence of estrogen/progesterone hormonal imbalance or signs of pathology.

Postmenopausal bleeding is vaginal bleeding that occurs after menopause, or at 12 months or more after a woman’s last menstrual period. Postmenopausal bleeding is not normal. It can be secondary to a non-uterine cause, such as vaginal atrophy or, much less commonly, cervical cancer. If from the uterus, postmenopausal bleeding can be secondary to endometrial atrophy; however, in contrast to irregular perimenopausal bleeding, postmenopausal bleeding from the uterus cannot be attributed to a hormonal imbalance. This is because neither estrogen nor progesterone is being produced enough during the postmenopause for an imbalance to occur. Therefore, the endometrium in a postmenopausal woman is not expected to be thickened; in fact, it should be thin (atrophic). When postmenopausal bleeding is associated with an abnormally thickened or appearing endometrium on pelvic sonography, pathology must be considered and an endometrial biopsy should be done.

In many instances, in cases of either peri- or postmenopasal bleeding, there may be a need—when certain pathology is suspected on pelvic sonography, endometrial biopsy, or both—to evaluate the endometrium more accurately by means of direct visualization. Office hysteroscopy (using the Endosee Advance system) can be performed, whereby a narrow scope with an attached camera is entered into the uterine cavity and the endometrium is easily seen. Any pathology discovered on office hysteroscopy may have to be further managed by dilatation and curettage (D&C) and diagnostic/operative hysteroscopy in the operating room.

During the perimenopause and after, there are progressive changes in the appearance and functionality of all the female reproductive organs: the vulva, cervix, vagina, uterus, tubes, and ovaries. There are also changes in the pelvic support structures, the urinary tract, and breasts. These changes occur secondary to waning estrogen levels.

The vulva gradually diminishes in size as the fatty tissue in the labia is lost. This leads to shrinkage, fusion, and narrowing of the vaginal opening. There is also decreased sebaceous gland secretions, which causes dryness.

The cervix usually decreases in size and the cervical canal becomes narrowed. There is diminished secretion of cervical mucus. The vagina’s lining becomes thin, or atrophic. The anatomic wrinkles of the vagina progressively flatten as they lose collagen and fatty tissue, and they lose their ability to retain water.  These changes may cause vaginal dryness, itching, irritation, and painful intercourse. The thinner vaginal lining is easily traumatized and becomes prone to bleeding—not just from intercourse but even from simply walking or running. Also, the vaginal canal itself progressively narrows.

Atrophy of the uterus, with both thinning of the endometrium and shrinkage of the myometrium, or muscle of the uterus, occurs.  This myometrial shrinkage can be beneficial to women who have fibroids: smaller fibroids and the elimination of fibroid-related symptoms can often prevent the need for surgical management of the fibroids.  The same applies to endometriosis, which becomes asymptomatic after menopause.

The ovaries and fallopian tubes decrease in size after menopause.  This makes the ovaries difficult to feel on pelvic exam.  An ovary that can be felt on pelvic exam in a postmenopausal woman must be viewed with suspicion: it might bear a cyst or mass. Ovaries can also be difficult to see on pelvic sonography if they are very small.

Pelvic support changes

The pelvic floor muscles and ligaments that anatomically and functionally support the reproductive organs, bladder, and rectum suffer loss of tone as estrogen levels fall.  This can result in progressive pelvic relaxation and eventual prolapse of the uterus, vagina, bladder, and/or rectum. Prolapse of the uterus and vagina may result in the sensation of a bulge in the vagina, the feeling pressure in the pelvis or vagina, or pain in the lower back accompanied by a bulging in the vagina. If pelvic relaxation is severe, urogynecologic evaluation would be recommended to consider the potential benefit from corrective surgery.

Changes in the urinary tract

Changes in the bladder and urethra are common. Their lining becomes thin, making them more vulnerable to infection. This can lead to an increased frequency and chronicity of urinary tract infections (UTIs). Another reason for increased UTI frequency and chronicity is the loss of the ability to fully empty the bladder.

Urinary incontinence has been associated with the perimenopause and postmenopause. This association is somewhat controversial as urinary incontinence is also associated with hysterectomy, worsening anxiety symptoms, weight gain, and new-onset diabetes.  However, pelvic relaxation does have a direct relationship with urinary incontinence. Normally, the pelvic floor muscles tighten as a closure mechanism for the urethra, and their loss of tone can cause leaking and dribbling.

Weight gain and body fat deposition

Weight gain is a very common complaint among women going through menopause.  With aging, a woman’s metabolism slows, which reduces her caloric requirements. So even if eating and physical activity remain the same, weight can be gained over time.  Lack of physical activity is strongly related to weight gain; women who are more physically active during the perimenopause report gaining less weight.

Weight gain during this period is associated with fat deposition in the abdominal wall, increased amounts of fat around the abdominal organs, and body fat redistribution.  These raise the likelihood of developing insulin resistance and subsequent diabetes and heart disease.   While many women believe menopausal hormone therapy itself causes weight gain, results of epidemiologic studies and clinical trials have indicated that it actually slightly blunts the rate of age-related weight gain. Realistic lifestyle interventions such as regular exercise and healthful nutrition can help minimize gains in fat mass and changes in fat distribution.

Breast changes

The breasts undergo changes mainly because of hormonal diminution.  In premenopausal women, estrogen and progesterone exert proliferative effects on the breasts.  At menopause, low levels of these hormones lead to a relative reduction in this proliferation.  A significant reduction in the volume and density of the breast tissue is seen on mammography as it becomes replaced with fatty tissue.   Some women are distressed by the decrease in breast size. However, for those bothered by cyclic symptoms of breast pain and cyst formation, the disappearance of these symptoms offers great relief.

Screening mammography is recommended for women starting at age 40.

The symptomatic changes during the menopausal transition are just as compelling as the troubling physical changes described above. The symptoms of the menopausal transition are what impacts womens’ quality of life the most. They include symptoms that stem directly from some of the physical changes and those resulting from physiologic mechanisms that become altered because of diminished estrogen levels.

Atrophic vaginitis

Atrophic vaginitis—vaginal dryness, itching, irritation, and painful intercourse—is very common and initially treated with topical options. These include water-soluble vaginal lubricants and moisturizers which add moisture and loosen the vagina. Some women use olive or coconut oil as moisturizers and lubricants, but they may cause an allergic irritation in the vagina. While these topicals can provide some vaginal relief, they do not completely restore the health of the vagina. Topical estrogen creams or tablets work better by restoring the vaginal lining. Topical estrogen options work locally, so they help avoid high hormone levels in the rest of the body. However, women who are also having multiple other menopausal symptoms may chose to use systemic hormone therapy to concurrently treat all their symptoms. If systemic hormone therapy is contraindicated, declined, or not effective, there remains the option of office vaginal laser therapy (the MonaLisa Touch system^R ) which can give effective symptomatic relief.

Vasomotor symptoms (hot flashes)

Of the many menopausal symptoms that can affect quality of life, vasomotor symptoms, or hot flashes, are the most common. They can be countered by episodes of feeling cold and result from a dysfunction of body temperature regulation that has yet to be well understood.  Most women experience a sudden wave of heat that starts in the face, neck, and chest, followed by an outbreak of sweating that affects the entire body, but is particularly prominent over the head, neck, upper chest, and back.  The hot flash can be accompanied by palpitations, anxiety, irritability, and even panic.  Less common associated symptoms include weakness, fatigue, faintness, and dizziness. The episode may last for only moments or up to 10 minutes; on average, it lasts for four minutes.  Frequency varies from 1-2 per hour to 1-2 per week. Hot flashes endure, on average, for seven years during the menopausal transition.

Treatment of hot flashes includes: behavioral modifications, such as turning down the thermostat, dressing in layers, avoiding alcohol and spicy foods, and reducing obesity and stress; systemic hormone therapy, which, again, should be individualized; bio-identical hormone replacement therapy, using hormones derived from plant estrogens that are identical to those produced by the human body; and non-hormonal and complementary/alternative therapies, which should be used with caution.

Sleep dysfunction and fatigue

Sleep quality can decline with age, but in women, the menopausal transition may contribute to this decline.  Women may awaken several times during the night; they may also have night sweats. Disturbed sleep can lead to fatigue, irritability, symptoms of depression, and impaired thought processing (“foggy brain”) and daily functioning.  Improvement in these symptoms may result from commonsense changes in lifestyle that can improve sleep, such as regular exercise to reduce stress, avoiding long work hours and maintaining a personal schedule, limiting alcohol, drugs, and nicotine, eating a healthful and balanced diet, and drinking plenty of water.  Ruling out underlying medical causes of fatigue, such as thyroid disease and anemia among other causes, should be considered.

Dyspareunia and sexual dysfunction

Menopausal women often develop painful intercourse, or dyspareunia, and other forms of sexual dysfunction during the menopausal transition.  Dyspareunia is correlated with other sexual problems, including lack of libido, arousal disorder, and anorgasmia.  Although largely attributed to vaginal atrophy, dyspareunia also occurs because of other vaginal changes that develop secondary to low estrogen levels: a decrease in blood flow, vaginal vein congestion, and lubrication that normally occur during sexual arousal. These changes are coupled with, and compounded by, the perimenopausal physical changes in the vagina.

Finally, urogenital conditions that stem from pelvic relaxation and prolapse and from urinary incontinence can significantly contribute to sexual dysfunction.

There are many ways to manage the different types of sexual dysfunction experienced by women going through the menopausal transition, and therapies can overlap.  It often takes a team approach with involvement of professionals with different types of expertise. It should be kept in mind that most sexual problems warrant treatment only if they are bothersome to the woman and her partner.  If they’re not, taking no action may be the most appropriate action.

Psychosocial symptoms

Mental health symptoms experienced during the menopause are well known, and managing them can be challenging. Women have long been known to carry a higher lifetime risk of developing depression than men.  A prior depression episode, particularly if related to a reproductive event, remains the strongest predictor of altered mood or depression during the menopausal transition.  Hot flashes, anxiety, and health-related issues during this time also affect risk of depression.

Contemporary findings have dispelled the myth that natural menopause itself is associated with depressed mood.  However, studies have repeatedly revealed an increased risk of depressive mood observed during the menopausal transition.  Moreover, it is known that women with no history of depression are two and half times more likely to report depressed mood during the menopausal transition than before menopause, and the depressive mood episodes can be recurrent.

It has been suggested that the drop in estrogen levels during early menopausal transition are responsible, in part, for this instability in a woman’s psychological wellbeing.  However, to be sure, the menopausal transition is a complex sociocultural as well as hormonal event, and psychological factors may contribute to mood and cognitive changes. For example, a woman entering menopausal transition may face emotional stress from the onset of a major illness, or the caring for a teenager or an aging parent, or from divorce or widowhood, or a career change or retirement.   Because western culture emphasizes beauty and youth, when women grow older, some suffer from a perceived loss of status, function, and control.   For others, the approach of menopause is perceived as a significant loss, both to women who have had children and can have no more and those who never did, whether by choice or not.

One can reduce mood swings by making proactive lifestyle changes, some of which are mentioned above.  Doing aerobic exercise, or any enjoyable physical activity, helps release endorphins and other feel-good chemicals in the brain.   Eating healthy food, getting enough sleep, and reducing stress (by reading, meditating, taking walks) can also be helpful in stabilizing mood.  However, seeing a doctor is indicated if mood swings become extreme, or they add to existing anxiety, or make it difficult to participate fully in life.  The doctor would determine if lifestyle changes are enough, or if medication or other treatment would be necessary.