Introduction

photo of woman (PantherMedia / Markus Nicolini)The balance of hormones in a woman’s body changes during menopause. A lot of processes in the body are regulated by hormones, and it can take some time to adapt to the changes. The hormonal changes are sometimes, but not always, associated with menopause symptoms. This varies greatly from woman to woman.

Around their mid-forties, women’s bodies gradually start making less of the female sex hormone estrogen (also spelt “oestrogen”). Their monthly periods become less regular and eventually stop completely. A woman has reached menopause when she has had her last period. The word “menopause” might be misleading because it is not a “pause,” but an ending. Women can no longer get pregnant after menopause. The average age of menopause is 51. But it is also normal at a much younger or older age.

The end of fertility often happens around the same time as other important changes in a woman’s life: children move out, couples might have to redefine their relationship, some women try a fresh career start, others start working less. Women might find they have less energy than before. But only a few of the problems that are often considered to be menopause-related are actually caused by hormonal changes. And only a small proportion of women have very severe symptoms. Typical symptoms like hot flashes come and go, and can be relieved in various ways.

Symptoms

About half to two-thirds of women will have hot flashes (also called “hot flushes”) and sweats during menopause. These are the most common symptoms. If you have them at night, they can disturb your sleep. In some women hot flashes and sweats are hardly noticeable and do not cause any problems. In others they are sometimes so severe and frequent that it really affects their daily life. Hot flashes last about three minutes on average. How often women have hot flashes, how severe they are and how long they last can also vary from day to day.

In most women hot flashes stop on their own after a year or two. But about a third of women have hot flashes for about five years. A few women have them for even longer.

The lining of the vagina changes around menopause. It usually becomes thinner and drier.

As women get older, their risk of bone fracture increases. Many women also gain a bit of weight around the time of menopause. But most of the physical and emotional changes that happen around this time are not due to, or at least not only due to, hormonal changes. Things like mood swings, sexual problems, a weak bladder or back ache are not directly caused by menopause. They can also affect women before or after menopause, and can have various other causes. Many men are affected by these problems too.

Causes

Throughout their reproductive years, women’s ovaries produce the female sex hormones estrogen and progesterone. These hormones not only prepare the womb (uterus) for a possible pregnancy, but they also affect things like the skin and mucous membranes.

Every month a new egg matures inside a follicle in an ovary. The follicle produces hormones itself. If the mature egg is not fertilized after it is released from the ovary (ovulation), the woman has a menstrual period. During the time leading up to menopause the ovaries gradually make less and less hormones. A woman has reached menopause when her ovaries stop releasing eggs.

All of the egg cells a woman will ever have are already inside her ovaries when she is born. It is thought that there is a link between the time when a woman reaches menopause and the time when her supply of egg cells is used up. Before the age of about 40, the number of follicles that mature decreases gradually. After that, the number decreases quite quickly, until no more follicles mature.

Women might go through menopause at a younger age as a side effect of a treatment, such as the removal or radiation of both ovaries in the treatment of cancer. This is known as induced or artificial menopause. Although induced menopause usually causes similar symptoms to natural menopause, the issues surrounding induced menopause are often very different.

Outlook

The start of the menopausal transition can be so subtle that some women do not notice any changes at all. But others have very noticeable physical symptoms. Their periods might sometimes be lighter or heavier, or the gaps between periods might become irregular.

Most women have their last menstrual period at around the age of 51. You can only know that it was your last period in hindsight. As a rule of thumb, if you have not had a period for twelve months in a row, you probably reached menopause when you had your last period. If a woman goes through menopause before the age of 40, it is called premature menopause.

The one or two years leading up to a woman’s last menstrual period is referred to as perimenopause or pre-menopause, and the time afterwards is referred to as post-menopause. The body gets used to the new balance of hormones during this time. The length of the menopausal transition varies from woman to woman. It usually lasts a few years. Another word that is sometimes used to describe this phase of life is “climacteric.” This comes from the Latin word for the step of a ladder, which is an ancient symbol for “a critical point in life.”

There is some evidence that the age of menopause might be genetically determined. This means that mothers and daughters might experience menopause at about the same age. It is thought that other factors might affect the age of menopause too. These include the number of times women have given birth. Women in some developing countries go through menopause earlier, and this might be because they generally have more children.

It is also believed that women who smoke a lot go through menopause earlier. Being underweight or overweight and the length of a woman’s menstrual cycle might influence the age of menopause too. But there is no clear evidence supporting any of these theories.

Effects

It is often thought that the menopause increases the risk of a number of diseases, including cardiovascular disease and osteoporosis. While it is true that women have a higher risk of cardiovascular disease after menopause, the only reason for this is because they are older than before. Menopause itself does not influence the risk. And bone stability does not only depend on hormones in the body: bones become more brittle with age, in both men and women.

The changes in the lining of the vagina make it more susceptible to infection. Sex can be uncomfortable if the vagina is not lubricated well enough through arousal. But sexual changes around this time of life are not only due to menopause and symptoms such as vaginal dryness. The situation in a relationship will play a big role too. There is no evidence that menopause itself has a negative effect on sexual pleasure or desire.

Menopause can also have positive effects, although these are not often mentioned: Having no menstrual periods makes contraception and menstrual problems a thing of the past. This can mean a great improvement in quality of life for women who have heavy periods, very painful periods or endometriosis.

Diagnosis

If a woman would like to know for sure whether she has entered menopause, a doctor can measure the levels of various hormones in her blood. But the levels of hormones in her blood will not tell her anything about whether she could still get pregnant, or whether it is worth considering treatment if she has menopause-related problems.

The overall level of estrogen gradually decreases during menopause. This changes the balance between estrogens and other hormones. The body also reacts to the reduction in estrogen by producing more of another type of hormone called follicle-stimulating hormone (FSH).

These changes are typical during menopause. But measuring hormone levels is usually not a reliable way to determine whether a woman’s menopause is already over. This is because hormone levels can fluctuate a lot around the time of her last menstrual period. Looking at ovarian activity cannot provide any definite answers either. Even if a woman's periods are already very irregular, she might still get pregnant.

Treatment

Menopause symptoms can be relieved in various ways. In most women, though, hot flashes and sweats lessen over time and then go away completely without any treatment. Menopause is not an illness. It is normal for hormone levels to fall in middle age. These hormones do not need to be replaced.

There are a lot of complementary medicine products for the relief of menopause symptoms. These are often available in the form of dietary supplements. They have not been proven to work. The best-researched products are those containing plant-based estrogens, known as phytoestrogens. These include soy-based products. But it is not clear whether they actually help relieve menopause symptoms. This is true of products containing red clover and black cohosh (Cimicifuga racemosa) too. There is also no proof that certain foods can make menopause symptoms better or worse.

The currently most effective treatment for hot flashes and sweats is hormone therapy with a combination of estrogen and progestin, or with estrogen alone (for women who have had a hysterectomy). But the symptoms often come back when women stop taking the hormones. Women might have spotting, breast tenderness and/or nausea in the first few months of hormone therapy. Hormone therapy can increase the risk of a number of serious diseases such as cardiovascular disease and breast cancer, particularly if a woman takes hormones for many years.

Hormones are available in the form of tablets, patches, nasal sprays and injections. The hormones that are used to relieve menopause symptoms do not prevent women from getting pregnant.

Problems affecting the lining of the vagina can be treated locally with hormones in the form of creams, suppositories or vaginal rings. Hormone-free alternatives include plant oils, lubricants and creams that help relieve vaginal dryness.

Antidepressants and the hormones testosterone and DHEA are sometimes used to relieve menopause symptoms too. It is not clear how effective they are. But they can have considerable side effects. Most of them have not been licensed for the treatment of menopause symptoms in Germany.

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Everyday life

Many women try out things like relaxation techniques, breathing exercises, meditation, yoga and tai chi to help them get through this sometimes difficult time of life. Although these activities will probably not relieve symptoms such as hot flashes, they might improve women’s overall wellbeing and help them sleep better. The same is true for sports and exercise: physical activity has a positive effect on the cardiovascular system and bones, improves overall fitness, muscle strength and mobility. Exercise can also help you maintain a healthy body weight, or lose weight if you are overweight.

Even though the generally negative perception is gradually changing, menopause is still mainly associated with growing older and the related problems. But women often see menopause as the start of a new phase of life. Not all women have menopause symptoms or other problems during menopause. Many also discover a new sense of freedom and start living their life more consciously.

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