Symptoms of menopause begin when estrogen levels start changing. A woman's body can go through several kinds of changes at the same time.

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1 Menopause Menopause is a natural part of a woman's life. Learn what to expect from menopause and how to manage your individual symptoms through our Menopause Map, fact sheets, and other resources. Overview: Menopause is a natural part of a woman's life cycle. When a woman has passed through menopause, her monthly periods end and she can no longer get pregnant naturally. While menopause is challenging both emotionally and physically, many women welcome the new life that it brings, with freedom from menstrual periods and pregnancy. In the United States, the average age of menopause is 51 in non-smokers, 49 in smokers, and ranges on average from ages 47 to 55. Women younger than age 45 are considered to have early menopause. Those under 40 have premature menopause, which can have other health concerns. The changes of menopause begin when your ovaries no longer produce eggs. The ovaries produce fewer female hormones at this time too. Two hormones made in the ovaries estrogen and progesterone help regulate a woman's monthly period. As you approach mid-life, estrogen levels start to fluctuate and then drop. Most women notice that their periods become less predictable. Periods may become shorter or longer, the flow may be lighter or heavier than usual, and the length of time between periods may change. Eventually women start to skip periods, and within a few years, their periods end. The menopausal transition usually takes about 4 or 5 years, and during that time hormone levels are likely to fluctuate widely. Some months you may have a period; other months you may not. During this time, you may still be able to get pregnant. Menopause typically occurs very gradually. However, sometimes menopause occurs more abruptly, for example, when both ovaries are removed surgically, or when a woman undergoes radiation or chemotherapy, damaging the ovaries. Symptoms: Symptoms of menopause begin when estrogen levels start changing. A woman's body can go through several kinds of changes at the same time. The first menopause symptoms most women notice are hot flashes and mood swings. The hot flashes may start while you are still getting your period usually when they start to become very irregular. Some women report mental fogginess, difficulty finding words, and sometimes a sense of sadness or depression. You also may have problems during

2 sex, either because of vaginal dryness or lack of desire. Some women may have worsening PMS (premenstrual syndrome). Eventually, as your estrogen stays at a consistently low level, hot flashes and mood symptoms usually decrease or disappear. New studies suggest that for some women, hot flashes can continue for up to a decade. Menopause can affect your body organs and systems in many ways: Blood vessels Feeling warm, quick body temperature changes, hot flashes or sweats and waking during the night Brain/nerves - Moods that change often; feelings of sadness, anger, or confusion; easy crying; and in extreme cases, depression or anxiety Genitals - Problems with dryness, itching, pain during sexual intercourse, or irritation of the tissues in and around the vagina Urinary system - Problems with sudden or frequent urinating Bones - A higher risk of bone loss, osteoporosis, and bone breaks (fractures) Heart A higher risk of heart disease after menopause due to increased cholesterol and plaque formation Treatment Options: Treatment for the symptoms of menopause can be approached in two phases: 1. Early in menopause, you and your doctor should discuss your first signs of menopause and whether to treat them as they occur. If your symptoms are really bothering you, and you are not at high risk for breast cancer and have never had a heart attack, stroke, or blood clot, you can think about taking estrogen for a few years to manage your symptoms. If, after weighing the pros and cons of estrogen, you decide it's not for you, other treatments are available. 2. Later in menopause you should focus on preventing diseases such as osteoporosis and heart disease. Your earlier hot flash or mood symptoms will probably disappear. For most women, they go away after about 4 or 5 years but for some, symptoms can last for up to 10 years or more. You and your doctor should work together to help you make the best decisions about your health. Talk to your doctor about all of the treatment choices to decide what is right for you. Pros and Cons for Treatment of Menopausal Symptoms:

3 Estrogen* Pros: Hormone therapy is the most effective treatment for relieving hot flashes; also helps prevent vaginal thinning; prevents bone loss Cons: Increased risk of breast cancer with long-term use, especially when combined with a progestin (a synthetic form of progesterone); increased risk of uterine cancer if estrogen taken without progestin; increased risk of blood clots and stroke Hot flashes Gabapentin Pros: Effective for relieving hot flashes, particularly at night Cons: Dizziness and lethargy if used during daytime SSRI drugs Pros: Shown to be effective for hot flashes and also for depression Cons: Causes mood changes; can decrease sex drive; paroxetine and sertraline hydrochloride can have adverse interactions with tamoxifen

4 Vaginal moisturizers Pros: Over-the-counter, nonhormonal solution (for vaginal dryness) Cons: Some people don't like these products because of consistency or scent; does not thicken the vaginal lining; not as effective as estrogens Dry vagina and painful intercourse Water-soluble lubricants Low dose vaginal estrogens (tablet, ring, or cream) Pros: Over-the-counter solution (for painful intercourse) Cons: Some people don't like these products because of their consistency or scent; does not thicken the vaginal lining Pros: Helps keep vaginal and urethral (opening to the bladder) tissue from thinning; vaginal estrogen has fewer risks compared to systemic (whole body) estrogen taken in higher doses Cons: Some estrogen gets absorbed into the body but this is small (of possible concern to women with a history of breast cancer) Estrogen* (systemic pills, patches, gels) Pros: Helps keep vaginal and urethral (opening to the

5 bladder) tissue from thinning; also helps prevent bone loss; very effective against hot flashes Cons: Increased risk of breast cancer if taken long-term with a progestin; increased risk of uterine cancer if estrogen taken without progestin; increased risk of blood clots and stroke Ospemifene Pros: New medication by mouth that reduces vaginal pain with intercourse. Does not require vaginal application. Cons: May be linked to increase risk of hot flashes, blood clots, possible growth of the lining of the uterus, and stroke. Bone loss Bisphosphonates Pros: Osteoporosis treatment is very effective against bone loss Cons: Common to have gastrointestinal problems when taking these drugs; can cause injury to esophagus unless taken with lots of water while sitting upright or standing; rarely, causes jaw necrosis (death of cells in the jaw) and unusual breaks of the long

6 bone of the thigh. Estrogen* Pros: Helps prevent bone loss and fracture (not usually used just for bone health), thinning vaginal tissue; very effective against hot flashes Cons: Increased risk of breast cancer if taken long-term with a progestin; increased risk of uterine cancer if estrogen taken without progestin; increased risk of blood clots and stroke Raloxifene Pros: Effective against bone loss and risk of vertebral (spine) fractures, lowers risk of breast cancer Cons: Increases risk of blood clots; hot flashes; leg cramps Tamoxifen Pros: Lowers risk of breast cancer; reduces risk of fractures Cons: Increases risk of uterine cancer, blood clots; more hot flashes; irregular vaginal bleeding Vitamin D Pros: Helps body absorb

7 calcium Cons: Very large amounts of vitamin D can cause build-up of calcium in blood, which could lead to heart and lung problems and kidney stones Counseling Pros: Can be empowering; leads to increased insight Cons: Can be expensive; may need to be combined with medications Depression and mood changes SSRI drugs Pros: Treats depression and may be effective for reducing hot flashes Cons: Can decrease sex drive; some types such as paroxetine or sertraline hydrochloride may interfere with effect of tamoxifen Estrogen* Pros: Not a treatment for depression but sometimes when combined with antidepressants for symptomatic women, can help with mood stability. Effective at preventing bone loss and fractures; very effective at preventing hot flashes; prevents vaginal tissue

8 thinning. Cons: Increased risk of breast cancer if taken long-term with a progestin; increased risk of uterine cancer if estrogen taken without progestin; increased risk of blood clots and stroke; increased risk of dementia in women 65 years and older taking hormone therapy; HT no longer recommended at this age.) *A note on estrogen The short-term goal of estrogen treatment is to relieve symptoms; If you take hormones for less than three to five years, the risks are relatively low. If you are concerned about bone loss and are thinking about taking hormone therapy for more than five years, consult with your doctor to see whether hormone therapy or an alternative treatment is best for you. You should not take estrogen if you have had breast cancer or are at high risk for breast cancer. There is an increased risk of breast cancer if taken with progestin, increased risk of uterine cancer if not taken with progestin, and increased risk of blood clots and stroke for women taking estrogen, with or without a progestin. Healthy Lifestyle: Women have many choices in the ways they can treat symptoms of menopause. All women, however, should aim for a healthy lifestyle. Eat a healthy diet, including 1,200 mg of calcium daily; lower the amount of fat in your diet; and maintain the right balance of calories to support an active lifestyle. If you are overweight, losing weight is a good idea. Here are more tips for a healthy lifestyle: Quit or try to cut down on smoking. Drink alcohol moderately, if at all. Exercise for 30 minutes at least five times a week. Maintain a healthy weight. Learn to manage stressful situations.

9 Have a yearly mammogram Other lifestyle options that may help with hot flashes are dressing in layers that you can remove, paced breathing exercises, meditation, or yoga. Hormone Treatment Options: Many women want to take estrogen because it is the most effective way to relieve many of the troubling symptoms of menopause. Estrogen increases the risk of uterine cancer if taken alone, however. For this reason, women who still have a uterus take a combination of estrogen with progesterone, which helps to protect the uterus. If you no longer have a uterus, you can take estrogen alone. If you have survived breast cancer, you should not take systemic estrogen (estrogen that has effects throughout the body). You may want to discuss vaginal estrogen therapy with your doctor. You also should not take estrogen if you have had liver disease, a history of blood clots, heart disease, a stroke, or any unusual bleeding from the vagina that has not yet been evaluated. If you have had cancer of the uterus, talk with your doctor about whether you can use estrogen. Estrogen can help to reduce hot flashes, vaginal dryness, bone loss, and possibly skin changes. Non-hormonal Treatment Options for Symptoms of Menopause: The following are some other options that may help your menopausal symptoms: Selective-serotonin reuptake inhibitor (SSRI) drugs and serotonin norephinephrine reuptake inhibitor (SNRI) drugs are useful in treating both depression and hot flashes. Gabapentin, an anti-seizure medication, can be used to treat hot flashes, particularly at night when hot flashes can disturb sleep. Clonidine is a blood-pressure-lowering drug that is sometimes used to reduce the frequency and severity of hot flashes. However, this drug is rarely used because it can have unpleasant side effects such as dizziness, dry mouth, and constipation. Individual counseling or support groups can help you handle the sad, depressed, or confusing feelings you may be having as your body changes. Although depression is more common during the menopausal transition, most women begin to feel better again once they are postmenopausal and hormones are no longer fluctuating. Vaginal moisturizers can help women with vaginal dryness. Lubricants can help with lubrication problems during intercourse.

10 Lack of desire might be helped with more open communication with your partner. Creating a pleasurable atmosphere at home and making a point to enjoy other activities with your partner may be helpful as well. Selective Estrogen Receptor Modulators (SERMs): SERMs are drugs that act like estrogen on some tissues and block the effects of estrogen on other tissues. Two such drugs are tamoxifen and raloxifene. A third drug, ospemifene, has just become available. Tamoxifen is used to prevent and treat breast cancer, and may help prevent bone loss. However, tamoxifen increases the risk of uterine cancer, and usually increases hot flashes, too. Raloxifene is used to prevent and treat osteoporosis and prevent breast cancer. Raloxifene therapy is best for women not seeking relief of hot flashes, since these can be aggravated with raloxifene therapy, as well. Ospemifene is a new medicine taken by mouth to reduce pain with intercourse. Like tamoxifen and raloxifene, it may increase hot flashes. Like these other agents, ospemifene can also increase the risk of blood clots. Disease Prevention: Preventing disease will be a major concern after you go through menopause. Your risk of bone loss and bone fractures, heart disease, and other health problems increases as you age. To prevent bone loss: Maintain a healthy diet and exercise. Other treatments for preventing bone loss and osteoporosis symptoms include calcium tablets and vitamin D (800 units daily). These can be taken separately or combined in a pill. Estrogen therapy is effective at preventing bone loss and reducing fractures, which can be an important added benefit if you are already taking estrogen to help with hot flashes. Raloxifene (Evista) is a medication that helps prevent bone loss in women. It increases bone density slightly and helps to prevent future fractures. It is taken by mouth If your doctor thinks that you are at high risk for a fracture (if you already have a diagnosis of osteoporosis, a history of fractures, or low bone density with other risk

11 factors), he/she might start you on a bone-specific medication. The most common firstline medications are the bisphosphonates. These are given by prescription. Examples include alendronate (Fosamax), risedronate (Actonel), and ibandronate sodium (Boniva). Bisphosphonates are given by mouth, or by infusions for people who cannot tolerate the oral medications or for those whose bone problem is more severe. Denosumab is another medication to reduce fractures. It is given by an under-the-skin injection every six months.another drug, parathyroid hormone (Forteo) is a medication given by daily injection for 6 to 18 months to build bone in people with severe osteoporosis. To prevent heart disease: A healthy diet and regular exercise can help to keep your heart healthy as you age. If your cholesterol is high, however, you may need cholesterol-lowering drugs. These drugs are called statins. The role of estrogen in preventing heart disease is still being debated by scientists. The American Heart Association recommends that women should not take estrogen for the sole purpose of preventing heart disease. Hormone therapy combining estrogen plus progestin does not reduce the risk of heart disease and may actually increase the risk of heart disease and stroke in older women. Newer studies are looking to see whether hormone therapy benefits the heart in recently menopausal women with symptoms (those in their 50's) compared to women who are older and have gone at least years without a period. Remember, each woman is different. You and your doctor should consider the overall benefits and risks of hormone therapy, as well as your personal health status, to come up with the best plan for you. Expect that the plan will change over time as you, your symptoms, and your health concerns also change. Editors: Kathryn Martin, MD Massachusetts General Hospital Cynthia Stuenkel, MD University of California, San Diego Last Review: May 2013