June 16, 2021
Hot flashes, night sweats, belly fat, vaginal dryness. The M-word is dreaded by many women as they approach middle age, but gynecologists say that menopause doesn't have to be a negative experience. It is all about understanding treatment options and keeping a positive mindset.
Most women experience menopause — when a woman no longer has menstrual periods — between ages 40 to 58, with the average age being 51.
Some women might not realize that the physical changes start years before they have their last menstrual period. Perimenopause — the precursor to menopause — can take anywhere from two to eight years.
During perimenopause, a woman will start to experience irregular periods, which may be lighter or heavier than usual or of varying duration. She may even have months where there is no menstrual bleeding at all.
All this upheaval to a woman's menstrual cycle is caused by changing hormone levels. The ovaries are no longer consistently producing the same levels of the hormones estrogen and progesterone.
A woman is considered to be in menopause when she hasn't had a menstrual period in a year.
The symptoms associated with menopause often begin during perimenopause. The most common are irregular periods, hot flashes, trouble sleeping, night sweats, mood changes, weight gain, dry skin, thinning hair and vaginal dryness, which can make sex painful.
Once a woman completes the transition into menopause, some of her symptoms, like hot flashes, may become less severe, but others may need to be carefully managed for the rest of her life.
Menopause is a natural part of aging for women, so there is no cure, but gynecologists say there are a variety of treatments that can help lessen the symptoms, including lifestyle changes, natural remedies, hormone therapy and non-hormonal prescription medications.
Because menopause can cause such a variety of symptoms, it's sometimes difficult to sort out what is menopause and what might be a separate medical condition, said Dr. Marisa Rose, an obstetrics, gynecology and reproductive sciences professor at Temple University's Lewis Katz School of Medicine.
Each woman's experience with menopause is different, Rose said. For some women, menopause can be debilitating, but others experience very little symptoms.
For example, women with endometriosis, a condition in which the lining inside the uterus grows onto the ovaries and fallopian tubes, typically have very painful menstrual cycles. So they actually find relief during menopause, Rose explained.
The connection between these rarer, and surprising, symptoms are still not really understood, Rose said. It is all still very theoretical at this point.
"There is not a lot of data on them, but estrogen is an important hormone for women," added Dr. Rachel Kramer, medical director of women's services at Virtua Medical Group. "Many organs have estrogen-receptors."
Some research has suggested vasomotor symptoms can alter a woman's cognitive function during perimenopause, leading to decreased memory performance.
Kramer warned, however, that women and their doctors shouldn't exclude other conditions, such as thyroid disorder or mood disorders, when trying to understand new symptoms.
"Be careful to not blame perimenopause and menopause on all your symptoms," she said. "It is a diagnosis of exclusion."
Leukemia can cause hot flashes and night sweats just like menopause and heart palpitations also could mean heart disease, she said.
"Get a checkup regularly," she said. It is important to take care of your bones and your heart, and when you do, you end up treating many of the symptoms of menopause."
One condition that has similar symptoms to menopause is hypothyroidism, which occurs when the thyroid no longer produces enough hormones to regulate metabolism and the body's sensitivity to heat and cold.
Low levels of these hormones — T4 (thyroxine) and T3 (triiodothyronine) — can lead to fatigue, depression, unexplained weight gain and bouts of forgetfulness. People with hypothyroidism also may feel cold all the time, and their hair and skin may become dry and coarse. These symptoms are very similar to menopause.
Middle-aged women also often experience mood swings, short-term memory loss and cognitive difficulties for reasons beyond menopause. It could be life stresses, like divorce, widowhood or caring for children and aging parents. Or it could be related to another medical condition.
Rose and Kramer each recommended menopause.org, a website created by The North American Menopause Society, as a good resource on the different symptoms of menopause and the most up-to-date research.
Lifestyle changes can make a big difference, they said. Eating a healthy diet, exercising daily and using relaxation techniques, like massages or deep-breathing exercises, can help with mood changes and other symptoms. Some women also find relief with non-prescription treatments, like St. John's wort or vitamin B6.
There is no one size fits all. Treatment is very individual. Talk to your doctor about what symptoms you would like to treat. You might not want to treat some of them. — Dr. Rachel Kramer, Virtua Medical Group
Depression is an important health issue for postmenopausal women. Gynecologists emphasize that women who are experiencing mood changes that don't respond to lifestyle changes should get evaluated for depression. Treatment with antidepressant medication, therapy or counseling may be needed.
Women experiencing urinary incontinence, another possible menopause symptom, can make lifestyle changes too. Drinking enough water, and avoiding food and drinks with a high acid or caffeine content, like grapefruit, oranges, tomatoes and coffee, can reduce irritation to the bladder. Doing Kegel exercises can strengthen the pelvic floor muscles.
To make night sweats more bearable, menopause.org recommends women try these simple tips: sleep in layers, keep an electric fan in the bedroom and place a cold pack under the pillow to keep their heads cool at night.
For sexual discomfort, experts recommend using vaginal lubricants, like Astroglide or Silk-E, or vaginal moisturizers, like Replens and L-Y long-lasting vaginal moisturizer. They are available without a prescription. Experts emphasize that only water-soluble products should be applied. Oil-based lubricants, like vaseline, may make the irritation worse.
Regular sexual stimulation is necessary to prevent vagina atrophy. The vagina is a muscle — use it or lose it, Kramer said.
Hormone replacement therapy also is a treatment option, but the risks and benefits need to be weighed carefully, experts say.
"Hormone replacement therapy is only recommended to treat symptoms like hot flashes, night sweats, vaginal atrophy, bladder and urinary problems," Rose said. "It can also be used to treat osteoporosis if other options are contradicted. HRT should only be taken for a short duration. Go over risks and benefits with your doctor."
Risks include blood clots in the legs or lungs and a higher risk of stroke. There also is an increased risk for breast cancer from long-term use of estrogen/progesterone therapy. Use of estrogen by itself for seven years was not found to increase breast cancer risk in the Women's Health Initiative trial, a study examining the effects of hormone therapy.
"HRT gets a bad rap, but in the right person it can be beneficial," Kramer said. "It's an individual choice a woman should make with her doctor."
Hormone replacement therapy is only recommended to treat symptoms like hot flashes, night sweats, vaginal atrophy, bladder and urinary problems, Dr. Marisa Rose, Temple Health.
Women who just experience vaginal dryness or discomfort with intercourse are recommended to take low doses of vaginal estrogen instead. Vaginal estrogen is safe for women with breast and ovarian cancer, unlike hormone replacement, Kramer added.
A recent study also found resveratrol, a phytoestrogen with circulatory benefits, to be a safe alternative to hormone replacement therapy, especially for treating chronic pain, which many postmenopausal women experience.
"Take care of your body and your heart. Eat right, exercise, and have regular sex. It helps with everything," Kramer said.
"Estrogen is cardio protective. That is why women are less likely to have an early heart attack. In perimenopause, however, their risk of heart disease increases. Eat healthy, consume the correct amount of daily calories, get 30 minutes of exercise almost every day to protect your health. Exercise can even jumpstart a sluggish libido by increasing blood flow."
Bone health becomes an issue about seven years post menopause, Kramer added. Women may develop osteoporosis from bone loss. There is a 10% mortality rate for osteoporosis.
She emphasized that women should make sure they are getting enough calcium and vitamin D in their diets. Anchovies, sardines, shiitake mushrooms and wild salmon are good choices.
A woman's mindset during the transition to menopause also can effect their symptoms, experts say. Studies show that negative attitudes about symptoms may make them worse.
Women are encouraged to watch their thoughts and be more present, rather than worrying about their symptoms. Laughter, staying connected with loved ones and making time for self-care all can change the menopause experience.
Rose said that one of the biggest surprises for women going through perimenopause is that their menstrual cycle actually gets shorter before it gets longer. It is completely normal for women to get their periods twice in one month when their cycles are 21 days, she said.
Women also become frustrated because exercising will no longer cause weight loss on its own. Watching what they eat becomes even more important because weight management is now more related to the kitchen, not the gym, she explained.
"Weight gain doesn't have to happen in menopause," Kramer added. "If you are at a normal weight in the beginning, you can maintain it. If you do gain weight though, it will go right to the belly, which is bad for the heart."
"Rarer symptoms, like brain fog, are generally not as upsetting as changes in cycle and weight," Rose said. "Feel free to discuss all symptoms with your gynecologist. That is what we are here for. We will go through the pros and cons of treatment for your particular symptoms."
Kramer urged women to have this conversation with their doctors often and early.
"There is no one size fits all. Treatment is very individual," she said. "Talk to your doctor about what symptoms you would like to treat. You might not want to treat some of them.
"Top concerns for women during this stage — weight gain, vaginal dryness — happens to a large percent of people. They want to know how will their sex life will be affected? How will their body change?"
Kramer is in perimenopause herself. She was surprised that, for her, the hot flashes weren't as bad as the night sweats. Triggers for night sweats include a hot shower or hot bath, a glass of wine, and stress.
Kramer and Rose each stressed that there is still more research that needs to be done on this stage in a woman's life.
"Women are surprised that we don't have a lot of answers," Kramer said. "It is really important to see your primary care doctor every year to make sure your symptoms aren't something else."