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Menopause

Menopause is the time in a woman’s life when she stops having her period. The previous years leading to that moment are called pre-menopause, or “around menopause”.

In average, women go through menopause at 51 years of age. The majority of women enjoy a healthy lifestyle from that time on. The brochure will explain:

  • ¿What should be expected around menopause?
  • ¿How to relief the symptoms caused by menopause?
  • ¿How to stay healthy during this time?

¿What is menopause?
The ovaries, two glands located on both sides of the uterus, produce estrogen since puberty until menopause. Estrogen is produced throughout the entire duration of the menstrual cycle. This hormone causes an increase in thickness in the lining of the uterus (the endometrium) each month.

Approximately on the 14 th day of the menstrual cycle, one ovule is released from the ovaries. This is called ovulation. After ovulation, the levels of progesterone increase. If the ovule is not fertilized, pregnancy does not occur. This causes a decrease in the levels of estrogen and progesterone. When this happens, the uterus receives a signal that it must release its lining. This release is the monthly menstrual period.

As menopause gets closer, the ovaries produce more estrogen. One of the first and most common signs that menopause is close is when changes in the menstrual period occur. Maybe you will not have one or more periods. The menstrual flow might be lighter or intense. Maybe the bleeding lasts for less or more time than the usual for you.

Even though periods tend to be irregular around the time menopause begins, you must be aware of any bleeding that is not normal for you. This might be a sign that a problem exists. Talk to your physician if:
Your menstrual cycle changes.

  • Bleeding is more intense and has clots.
  • You bleed more than the usual.
  • You bleed more often than 3 weeks.
  • You bleed after having sexual relations or between periods.

At some point, the ovaries stop producing enough estrogen to increase the thickness in the lining of the uterus. This is the moment when the menstrual periods stop.

Menopause can also occur when the woman´s ovaries are extracted by means of surgical procedures. This process can result in serious symptoms because the levels of hormones are completely and abruptly reduced.

Even though the extraction of the uterus (a hysterectomy) causes the menstrual periods to stop, this procedure does not cause the beginning of menopause unless the ovaries are also extracted. If the ovaries are not extracted with the surgery, the majority of women will go through menopause at the normal age.
 
¿What should be expected?
Menopause is a natural part of the aging process. The reduced quantities of estrogen that are produced during menopause cause changes in the body. These changes occur gradually. Menopause is a different experience for each person. Some women notice very little difference in their bodies. Others may find it more difficult to go through the symptoms that affect them.
 
Hot Flushes:
Menopause´s most common symptom is the hot flushes (or heat). Up to 75% of menopausal women in the United States will have them. A hot flash is a sudden heat sensation which irradiates to the upper part of the body and face. The skin might turn reddish as if flushing. You may also start to suddenly sweat. Hot flushes can last from a few seconds to several minutes or even more time.

They may also happen in any time of the day or night, and they may vary from mild to intense. Hot flushes may take place only a few times in one month, or several times a day, depending on each woman. Some women have hot flushes for a few months, others for years and others may never have them. Even though hot flushes are uncomfortable, they may cause a woman to feel embarrassed and affect her daily life, but they are not harmful.
 
Sleeping Problems:
Hot flushes may cause sleeping problems by waking up the woman frequently during deep sleep. Lack of sleep may be one of the greatest problems that she faces as she gets closer to menopause. Not having enough sleep may affect her mood, health and ability to perform daily activities. Some women have less out of phase sleep, or REM. During this state, the person dreams. 20% of the normal sleep cycle for an adult is within the REM period of sleep. Without this period, the person may wake up and feel she has not rested. Some women getting closer to menopause may also find it takes more time for them to fall asleep.
 
Changes in the vagina and urinary track:
The loss of estrogen causes changes in the vagina. Its lining may get thinner and dry. These changes may produce pain during sexual relations. They may also cause the vagina to be more susceptible to infections, causing a burning sensation and itching.

The urinary tract also changes with age. The urethra (the duct which transports urine from the bladder), may dry out, swell or irritate. Some women need to urinate more frequently. Furthermore, women are more at risk of bladder infections after menopause.
 
Changes in the bones and other parts of the body:
The loss of bone mass is a normal part of the aging process. During menopause, there is an increase in the rhythm of bone mass loss. Osteoporosis, which may occur as a result of this loss of bone mass, increases the risk of bone fractures among older women. The hip bones, wrists and the spine are more frequently affected.

The estrogen produced in the woman´s ovaries before menopause protects her against heart attacks and strokes. When less estrogen is produced after menopause, women lose a lot of this protection. Reason why, the risk of heart attacks and strokes increase.
 
Mood changes:
Menopause does not cause depression. Nevertheless, changes in the levels of hormones may make her feel nervous, irritable or very tired. These sensations may be linked to other symptoms of menopause, such as lack of sleep.

If the woman is under a lot of pressure, it may be more difficult for her to control the changes from menopause. Many middle-aged women go through important changes in her life anyway.

There may be tensions related to money or work. Some women may be going through children leaving home or learning to live with the “empty nest”. Some may feel sad for not being able to have children. Very often, women find out they are a part of the “sandwich generation”, because they become the ones in charge of their children´s care, grandchildren or old parents. If you find it hard to face these situations, talk about your feelings with your spouse, a close friend, counselor or your physician.
 
Sexuality:
Menopause does not affect your ability to enjoy sexual relations. Even though the lack of estrogen may dry out the vagina, vaginal lubricants may help in moisturizing the vagina allowing the sexual relations to be more comfortable.

Some women find their interest for sexual relations to be lower during and after menopause. The reduced levels of hormones may reduce sexual desire. They may also affect your ability to have an orgasm or it might take longer to reach an orgasm.

Furthermore, the risk of getting pregnant is present until 1 year goes by after the last period. Until that moment, if you do not wish to get pregnant, it is important for you to use a contraceptive method. Take into account that at all times you need to prevent acquiring a venereal disease, so use a latex condom.

Men can also become aware that the sexual desire decreases with age. It is possible that for an older man it may take more time to have an erection and ejaculate, or may have impotence problems.

Impotence generally is produced by physical or medical problems, or as a result of certain medications. In many cases, it is possible to satisfactorily treat impotence.
 
The gynecological visit:
Having routine medical care, even if you are not ill, may help to detect problems in advance. Go to your physician once a year to undergo the regular tests and exams. There are certain exams that must be taken regularly for all women of your age (review Table 1). During a regular checkup exam, the physician will measure your height and blood pressure and maybe examine your skin and body in general to make sure that everything is normal. During a routinely gynecological exam, the physician examines your breasts in order to detect if there are any lumps or masses and secretions, examines the abdomen to determine if there are problems with the ovaries or uterus, inspects the vulva and the vagina and may also examine the rectum. The doctor may also perform a Papanicolaou exam in order to detect changes in cells that may cause cervical cancer. Between these visits, it is always a good idea to self-examine your breasts once a month. Furthermore, depending on your age, the doctor could recommend a Mammogram. You will also be asked about your health in general and medical background, for example:

  • Your health background
  • Your diet
  • Your exercise habits
  • If you smoke, drink alcohol or use drugs
  • If you are taking any medications

If you have any problem at any given time, contact your physician. Do not wait until the next evaluation appointment.
 
Hormonal Therapy:
Hormonal therapy might help to alleviate the symptoms of menopause. This treatment may replace the feminine hormones that the ovaries do not produce anymore. In some cases, you may begin to receive hormonal therapy before menopause. If you are taking birth control pills, you will need to stop taking them when initiating the treatment.

On women with uterus, estrogen is generally administered together with progestin, a synthetic version of the progesterone hormone. This is done to reduce the risk of cancer in the uterus lining which occurs with only administering estrogen. Progestin may be taken daily with estrogen, or take estrogen on some days and add progestin on other days.

Hormonal treatment is prescribed more frequently in the form of pills, vaginal rings or patches that adhere to the skin. Creams and estrogen tablets, administered in the vagina, may treat dryness, but they are not very successful in alleviating other symptoms.
 
Benefits:
Estrogen is used to treat the main symptoms of menopause, meaning hot flushes. It also alleviates vaginal dryness and may help to alleviate some changes that can cause problems in the urinary tract. Estrogen protects against the loss of bone mass. Hormonal therapy delays the rhythm of bone mass loss after menopause and helps in preventing the development of osteoporosis. Estrogen can help in reducing the risk of colon cancer.
 
Risk:
Just as with any other treatment, hormonal therapy is not risk-free. In women with a uterus, the use of estrogen can only increase the risk of endometrial cancer because estrogen promotes the development of the lining in the uterus. Administering progestin together with estrogen helps in reducing the risk of problems in the uterus. The disadvantage of using progestin is that it seems to increase the risk of breast cancer. Furthermore, menopausal women can begin to bleed again. Even though this can happen within a brief period of time, for many women this bleeding becomes uncomfortable.

The initiative for Women´s Health, a study from the Health National Institutes, indicated concerns about the risks of hormones in menopausal women. Due to these findings, The United States’ Food and Drugs Administration (FDA) announced that all products with estrogen for use in menopausal women must contain a label warning that an extended use of hormones can increase the risk of heart attacks, strokes, blood clots and breast cancer in some women. Results of the study suggest that the increased risk in health problems caused by hormonal therapy may vary according to each woman depending on the time that has passed by since menopause. For example, a woman that has had her menopause 15 years ago may have a greater risk that one who has had her menopause 2 years ago. Therefore, you must take the lower dose of hormonal therapy that is effective for you, for the briefest time possible. You and your physician must decide if the treatment is appropriate in your case. Women who have been diagnosed with these medications to treat vaginal dryness must consider the use of a local product in the form of cream or gel.
 
Other therapies:
For women who are not receiving any hormonal therapy, there are other options in the market to prevent the loss of bone mass, such as the use of bisphosphonate or Selective Estrogen Receptor Modulator (SERM). Calcitonin delays the speed of bone decomposition. This medicine is administered by injection or nasal spray. Bisphosphonates are used to increase bone density and reduce the risk of fractures. Parathyroid hormone is also used for these purposes.

Women can take SERM in order to help prevent or treat some bone problems that may take place during menopause. These medicines strengthen the bone tissues. SERM´s can be a good option for women with osteoporosis, but cannot or do not want to receive hormonal therapy.
 

Stay healthy:

Importance of nutrition:
Keeping a balanced diet will help you stay in good health before, during and after menopause. It is important to eat a variety of foods in order to make sure you are receiving all essential nutrients. Choose a diet low in fats and cholesterol. Furthermore, make sure to incorporate enough calcium in your diet to keep the bones strong. Women over 51 years of age need 1.200 mg of calcium per day. The National Health Institutes recommend 1.500 mg of calcium per day for post-menopausal who are not receiving hormonal therapy and for all women above 65 years of age. You must be aware, though, that the body can only absorb 500 mg of calcium at the same time. If you receive more than that, try to divide the amount into two doses. It is difficult to receive enough calcium from dairy products or certain vegetables; therefore, consider the use of supplements that will delay the pace in loss of bone mass.

Calcium cannot be absorbed without vitamins D. Enriched milk with vitamin D is one of the best sources. Another source is sun light. You can also take vitamin D supplements. Women should take the daily recommended amount of vitamin D, which consists in 10 micrograms for women between 51 and 70 years of age.
 
El calcio no se puede absorber sin vitaminas D. La leche enriquecida con vitamina D es una de las mejores fuentes. Otra fuente es la luz solar. También puede tomar suplementos de vitamina D.  Las mujeres deben tomar la cantidad diaria recomendada de vitamina D, que consiste de 10 microgramos para los mujeres entre 51 y 70 años de edad.
 
Exercises:
Exercise is very important, especially as you get older. Exercising regularly delays the speed of bone mass loss and improves the person´s general physical state. Practice a regular program with exercises that include high intensity of body movement, like walking and aerobic exercises.
 
Last…
Menopause is a natural event. Nowadays, women can expect to live a third of their lives after menopause. The physical changes that take place around menopause should not prevent you from enjoying this moment of your life. In order to function in the best way possible:

  • Exercise regularly.
  • Have a balanced diet which contains enough calcium.
  • Go to your physician for routine check-ups.

Table 1: Tests and vaccines for women between 40 and 64 years of age.