Menopause

Definition

Menopause represents the end of menstruation. While technically it refers to the final period, it is not an abrupt event, but a gradual process. Menopause is not a disease that needs to be cured, but a natural life-stage transition. However, women have to make important decisions about "treatment," including the use of hormone replacement therapy (HRT).

Description

Many women have irregular periods and other problems of "pre-menopause" for years. It is not easy to predict when menopause begins, although doctors agree it is complete when a woman has not had a period for a year. Eight out of every 100 women stop menstruating before age 40. At the other end of the spectrum, five out of every 100 continue to have periods until they are almost 60. The average age of menopause is 51.

There is no mathematical formula to figure out when the ovaries will begin to scale back either, but a woman can get a general idea based on her family history, body type, and lifestyle. Women who began menstruating early will not necessarily stop having periods early as well. It is true that a woman will likely enter menopause at about the same age as her mother. Menopause may occur later than average among smokers.

Causes and symptoms

Once a woman enters puberty, each month her body releases one of the more than 400,000 eggs that are stored in her ovaries, and the lining of the womb (uterus) thickens in anticipation of receiving a fertilized egg. If the egg is not fertilized, progesterone levels drop and the uterine lining sheds and bleeds.

By the time a woman reaches her late 30s or 40s, her ovaries begin to shut down, producing less estrogen and progesterone and releasing eggs less often. The gradual decline of estrogen causes a wide variety of changes in tissues that respond to estrogen—including the vagina, vulva, uterus, bladder, urethra, breasts, bones, heart, blood vessels, brain, skin, hair, and mucous membranes. Over the long run, the lack of estrogen can make a woman more vulnerable to osteoporosis (which can begin in the 40s) and heart disease.

As the levels of hormones fluctuate, the menstrual cycle begins to change. Some women may have longer periods with heavy flow followed by shorter cycles and hardly any bleeding. Others will begin to miss periods completely. During this time, a woman also becomes less able to get pregnant.

The most common symptom of menopause is a change in the menstrual cycle, but there are a variety of other symptoms as well, including:

• hot flashes
• night sweats
• insomnia
• mood swings/irritability
• memory or concentration problems
• vaginal dryness
• heavy bleeding
• fatigue
• depression
• hair changes
• headaches
• heart palpitations
• sexual disinterest
• urinary changes
• weight gain

Diagnosis

The clearest indication of menopause is the absence of a period for one year. It is also possible to diagnose menopause by testing hormone levels. One important test measures the levels of follicle-stimulating hormone (FSH), which steadily increases as a woman ages.

However, as a woman first enters menopause, her hormones often fluctuate wildly from day to day. For example, if a woman's estrogen levels are high and progesterone is low, she may have mood swings, irritability, and other symptoms similar to premenstrual syndrome (PMS). As hormone levels shift and estrogen level falls, hot flashes occur. Because of these fluctuations, a normal hormone level when the blood is tested may not necessarily mean the levels were normal the day before or will be the day after.

If it has been at least three months since a woman's last period, an FSH test might be more helpful in determining whether menopause has occurred. Most doctors believe that the FSH test alone cannot be used as proof that a woman has entered early menopause. A better measure of menopause is a test that checks the levels of estrogen, progesterone, testosterone and other hormones at mid-cycle, in addition to FSH.

Treatment

When a woman enters menopause, her levels of estrogen drop and symptoms (such as hot flashes and vaginal dryness) begin. Hormone replacement therapy can treat these symptoms by boosting the estrogen levels enough to suppress symptoms while also providing protection against heart disease and osteoporosis, which causes the bones to weaken. Experts disagree on whether HRT increases or decreases the risk of developing breast cancer. A Harvard study concluded that short-term use of hormones carries little risk, while HRT used for more than five years among women 55 and over seems to increase the risk of breast cancer.

There are two types of hormone treatments: hormone replacement therapy (HRT) and estrogen replacement therapy (ERT). HRT is the administration of estrogen and progesterone; ERT is the administration of estrogen alone. Only women who have had a hysterectomy (removal of the uterus) can take estrogen alone, since taking this "unopposed" estrogen can cause uterine cancer. The combination of progesterone and estrogen in HRT eliminates the risk of uterine cancer.

Most physicians do not recommend HRT until a woman's periods have stopped completely for one year. This is because women in early menopause who still have an occasional period are still producing estrogen; HRT would then provide far too much estrogen.

Most doctors believe that every woman (except those with certain cancers) should take hormones as they approach menopause because of the protection against heart disease, osteoporosis, and uterine cancer and the relatively low risk of breast cancer. Heart disease and osteoporosis are two of the leading causes of disability and death among post-menopausal women.

Critics say the benefit of taking hormonal drugs to ease symptoms is not worth the risk of breast cancer. Since menopause is not a disease, many argue that women should not take hormones to cure what is actually a natural process of aging. Advocates of HRT contend that the purpose of taking hormones is not to "treat" menopause but to prevent the development of other diseases.

There are risks with HRT and there are risks without it. In order to decide whether to take HRT, a woman should balance her risk of getting breast cancer against her risk of getting heart disease, and decide how bad her menopause symptoms are. Most doctors agree that short-term use of estrogen for those women with symptoms of hot flashes or night sweats is a sensible choice as long as they do not have a history of breast cancer.

For a woman who has no family history of cancer and a high risk of dying from heart disease, for example, the low risk of cancer might be worth the protective benefit of avoiding heart disease. Certainly, for Caucasian women aged 50 to 94, the risk of dying from heart disease is far greater than the risk of dying of breast cancer.

Women are poor candidates for hormone replacement therapy if they have:

• had breast or endometrial cancer
• a close relative (mother, sister, grandmother) who died of breast cancer or have two relatives who developed breast cancer before age 40
• had endometrial cancer
• had gallbladder or liver disease
• blood clots or phlebitis

Some women with liver or gallbladder disease, or who have clotting problems, may be able to go on HRT if they use a patch to administer the hormones through the skin, bypassing the liver.

Women would make a good candidate for HRT if they:

• need to prevent osteoporosis
• have had their ovaries removed

• need to prevent heart disease
• have significant symptoms.

Taking hormones can almost immediately eliminate hot flashes, vaginal dryness, urinary incontinence (depending on the cause), insomnia, moodiness, memory problems, heavy irregular periods, and concentration problems. Side effects of treatment include bloating, breakthrough bleeding, headaches, vaginal discharge, fluid retention, swollen breasts, or nausea. Up to 20% of women who try hormone replacement stop within nine months because of these side effects. However, some side effects can be lessened or prevented by changing the HRT regimen.

The decision should be made by a woman and her doctor after taking into consideration her medical history and situation. Women who choose to take hormones should have an annual mammogram, breast exam, and pelvic exam and should report any unusual vaginal bleeding or spotting (a sign of possible uterine cancer).

Anti-estrogens

A new type of hormone therapy offers some of the same protection against heart disease and bone loss as estrogen, but without the increased risk of breast cancer. This new class of drugs are known as antiestrogens. The best known of these anti-estrogens is raloxifene, which mimics the effects of estrogen in the bones and blood, but blocks some of its negative effects elsewhere. It is called an anti-estrogen because for a long time these drugs had been used to counter the harmful effects of estrogen that caused breast cancer. Oddly enough, in other parts of the body these drugs mimic estrogen, protecting against heart disease and osteoporosis without putting a woman at risk for breast cancer.

Like estrogen, raloxifene works by attaching to an estrogen "receptor," much like a key fits into a lock. When raloxifene clicks into the estrogen receptors in the breast and uterus, it blocks estrogen at these sites. This is the secret of its cancer-fighting property. Many tumors in the breast are fueled by estrogen; if the estrogen cannot get in the cell, then the cancer stops growing.

Women may prefer to take raloxifene instead of hormone replacement because the new drug does not boost the breast cancer risk and does not have side effects like uterine bleeding, bloating, or breast soreness. Unfortunately, the drug may worsen hot flashes. Raloxifene is basically a treatment to prevent osteoporosis. It does not help with common symptoms and it is unclear if it has the same protective effect against heart disease as estrogen does.

Testosterone replacement

The ovaries also produce a small amount of male hormones, which decreases slightly as a woman enters menopause. The vast majority of women never need testosterone replacement, but it can be important if a woman has declining interest in sex. Testosterone can improve the libido, and decrease anxiety and depression; adding testosterone especially helps women who have had hysterectomies. Testosterone also eases breast tenderness and helps prevent bone loss. However, testosterone does have side effects. Some women experience mild acne and some facial hair growth, but because only small amounts of testosterone are prescribed, most women do not appear to have extreme masculine changes.

Birth control pills

Women who are still having periods but who have annoying menopausal symptoms may take low-dose birth control pills to ease the problems; this treatment has been approved by the FDA for perimenopausal symptoms in women under age 55. HRT is the preferred treatment for menopause, however, because it uses lower doses of estrogen.

Alternative treatment

Some women also report success in using natural remedies to treat the unpleasant symptoms of menopause. Not all women need estrogen and some women cannot take it. Many doctors don't want to give hormones to women who are still having their periods, however erratically. Indeed, only a third of menopausal women in the United States try HRT and of those who do, eventually half of them drop the therapy. Some are worried about breast cancer, some cannot tolerate the side effects, some do not want to medicate what they consider to be a natural occurrence.

Herbs

Herbs have been used to relieve menopausal symptoms for centuries. In general, most herbs are considered safe, and there is no substantial evidence that herbal products are a major source of toxic reactions. But because herbal products are not regulated in the United States, contamination or accidental overdose is possible. Herbs should be bought from a recognized company or through a qualified herbal practitioner.

Women who choose to take herbs for menopausal symptoms should learn as much as possible about herbs and work with a qualified practitioner (an herbalist, a traditional Chinese doctor, or a naturopathic physician). Pregnant women should avoid herbs because of unknown effects on a developing fetus.

The following list of herbs include those that herbalists most often prescribe to treat menstrual complaints:

• Black cohosh (Cimicifuga racemosa ): hot flashes and other menstrual complaints
• Black currant: breast tenderness
• Chaste tree/chasteberry (Vitex agnus-castus ): hot flashes, excessive menstrual bleeding, fibroids, and moodiness
• Evening primrose oil (Oenothera biennis ): mood swings, irritability, and breast tenderness
• Fennel (Foeniculum vulgare ): hot flashes, digestive gas, and bloating
• Flaxseed (linseed): excessive menstrual bleeding, breast tenderness, and other symptoms, including dry skin and vaginal dryness
• Gingko (Gingko biloba ): memory problems
• Ginseng (Panax ginseng ): hot flashes, fatigue and vaginal thinning.
• Hawthorn (Crataegus laevigata ): memory problems, fuzzy thinking
• Lady's mantle: excessive menstrual bleeding
• Mexican wild yam (Dioscorea villosa ) root: vaginal dryness, hot flashes and general menopause symptoms
• Motherwort (Leonurus cardiaca ): night sweats, hot flashes
• Oat (Avena sativa ) straw: mood swings, anxiety
• Red clover (Trifolium pratense ): hot flashes
• Sage (Salvia officinalis ): mood swings, headaches, night sweats
• Valerian (Valeriana officinalis ): insomnia.

Natural estrogens (phytoestrogens)

Proponents of plant estrogens (including soy products) believe that plant estrogens are better than synthetic estrogen, but science has not yet proven this. The results of smaller preliminary trials suggest that the estrogen compounds in soy products can indeed relieve the severity of hot flashes and lower cholesterol. But no one yet has proven that soy can provide all the benefits of synthetic estrogen without its negative effects.

It is true that people in other countries who eat foods high in plant estrogens (especially soy products) have lower rates of breast cancer and report fewer "symptoms" of menopause. While up to 80% of menopausal women in the United States complain of hot flashes, night sweats, and vaginal dryness, only 15% of Japanese women have similar complaints. When all other things are equal, a soy-based diet may make a difference (and soy is very high in plant estrogens).

The study of phytoestrogens is so new that there are not very many recommendations on how much a woman can consume. Herbal practitioners recommend a dose based on a woman's history, body size, lifestyle, diet, and reported symptoms. Research has indicated that some women were able to ease their symptoms by eating a large amount of fruits, vegetables, and whole grains, together with four ounces of tofu four times a week.

What concerns some critics of other alternative remedies is that many women think that "natural" or "plant-based" means "harmless." In large doses, phytoestrogens can promote the abnormal growth of cells in the uterine lining. Unopposed estrogen of any type can lead to endometrial cancer, which is why women on conventional estrogen-replacement therapy usually take progesterone (progestin) along with their estrogen. However, a plant-based progesterone product can sometimes be effective alone, without estrogen, in assisting the menopausal woman in rebalancing her hormonal action throughout this transition time.

Yoga

Many women find that yoga (the ancient meditation/exercise developed in India 5,000 years ago) can ease menopausal symptoms. Yoga focuses on helping women unite the mind, body, and spirit to create balance. Because yoga has been shown to balance the endocrine system, some experts believe it may affect hormone-related problems. Studies have found that yoga can reduce stress, improve mood, boost a sluggish metabolism, and slow the heart rate. Specific yoga positions deal with particular problems, such as hot flashes, mood swings, vaginal and urinary problems, and other pains.

Exercise

Exercise helps ease hot flashes by lowering the amount of circulating FSH and LH and by raising endorphin levels that drop while having a hot flash. Even exercising 20 minutes three times a week can significantly reduce hot flashes.

Elimination

Regular, daily bowel movements to eliminate waste products from the body can be crucial in maintaining balance through menopause. The bowels are where circulating hormones are gathered and eliminated, keeping the body from recycling them and causing an imbalance.

Acupuncture

This ancient Asian art involves placing very thin needles into different parts of the body to stimulate the system and unblock energy. It is usually painless and has been used for many menopausal symptoms, including insomnia, hot flashes, and irregular periods. Practitioners believe that acupuncture can facilitate the opening of blocked energy channels, allowing the life force energy (chi) to flow freely. This allows the menopausal woman to keep her energy moving. Blocked energy usually increases the symptoms of menopause.

Acupressure and massage

Therapeutic massage involving acupressure can bring relief from a wide range of menopause symptoms by placing finger pressure at the same meridian points on the body that are used in acupuncture. There are more than 80 different types of massage, including foot reflexology, Shiatsu massage, or Swedish massage, but they are all based on the idea that boosting the circulation of blood and lymph benefits health.

KEY TERMS

Endometrium— The lining of the uterus that is shed with each menstrual period.

Estrogen— Female hormone produced by the ovaries and released by the follicles as they mature. Responsible for female sexual characteristics, estrogen stimulates and triggers a response from at least 300 tissues, and may help some types of breast cancer to grow. After menopause, the production of the hormone gradually stops.

Estrogen replacement therapy (ERT)— A treatment for menopause in which estrogen is given in pill, patch, or cream form.

Follicle-stimulating hormone (FSH)— The pituitary hormone that stimulates the ovary to mature egg capsules (follicles). It is linked with rising estrogen production throughout the cycle. An elevated FSH (above 40) indicates menopause.

Hormone— A chemical messenger secreted by a gland that is released into the blood, and that travels to distant cells where it exerts an effect.

Hormone replacement therapy (HRT)— The use of estrogen and progesterone to replace hormones that the ovary no longer supplies.

Hot flash— A wave of heat that is one of the most common perimenopausal symptoms, triggered by the hypothalamus' response to estrogen withdrawal.

Hysterectomy— Surgical removal of the uterus.

Ovary— One of the two almond-shaped glands in the female reproductive system responsible for producing eggs and the hormones estrogen and progesterone.

Ovulation— The monthly release of an egg from the ovary.

Pituitary gland— The "master gland" at the base of the brain that secretes a number of hormones responsible for growth, reproduction, and other activities. Pituitary hormones stimulate the ovaries to release estrogen and progesterone.

Progesterone— The hormone that is produced by the ovary after ovulation to prepare the uterine lining for a fertilized egg.

Testosterone— Male hormone produced by the testes and (in small amounts) in the ovaries. Testosterone is responsible for some masculine secondary sex characteristics such as growth of body hair and deepening voice.

Uterus— The female reproductive organ that contains and nourishes a fetus from implantation until birth. Also known as the womb.

Vagina— The tube-like passage from the vulva (a woman's external genital structures) to the cervix (the portion of the uterus that projects into the vagina).

Biofeedback

Some women have been able to control hot flashes through biofeedback, a painless technique that helps a person train her mind to control her body. A biofeedback machine provides information about body processes (such as heart rate) as the woman relaxes her body. Using this technique, it is possible to control the body's temperature, heart rate, and breathing.

Prognosis

Menopause is a natural condition of aging. Some women have no problems at all with menopause, while others notice significant unpleasant symptoms. A wide array of treatments, from natural to hormone replacement, mean that no woman needs to suffer through this time of her life.

Prevention

Menopause is a natural part of the aging process and not a disease that needs to be prevented. Most doctors recommend HRT for almost all post-menopausal women, usually for a few years. When HRT is then stopped, symptoms should be mild or non existent. But HRT is not only useful in lessening the symptoms of menopause; it also protects against heart disease and osteoporosis.

Resources

BOOKS

Goldman, Lee, et al., editors. Cecil Textbook of Medicine. 21st ed. W. B. Saunders, 2000.

Goroll, Allan H., et al. Primary Care Medicine. 4th ed. Lippincott Williams & Wilkins, 2000.

OTHER

Menopause Online Page. 〈http://www.menopause-online.com/links.htm〉.

Menopause Page. 〈http://www.howdyneighbor.com/menopaus〉.

Meno Times Online. 〈http://www.aimnet.com/hyperion/meno/menotimes.index.html〉.

Menopause

Definition

Menopause represents the end of menstruation . While technically it refers to the final menstrual period, it is not an abrupt event, but a gradual process. Menopause is not a disease that needs to be cured, but a natural life-stage transition. However, women have to make important decisions about managing its symptoms, including the use of hormone replacement therapy (HRT).

Description

Many women have irregular periods and other problems of perimenopause for years. It is not easy to predict when menopause begins, although doctors agree it is complete when a woman has not had a period for a full year. Eight out of every 100 women stop menstruating before age 40. At the other end of the spectrum, five out of every 100 continue to have periods until they are almost 60. The average age of menopause is 51.

There is no method to determine when the ovaries will begin to scale back but a woman can get a general idea based on her family history, body type, and lifestyle. Women who began menstruating early will not necessarily stop having periods early. A woman will likely enter menopause at about the same age as her mother.

Causes & symptoms

Once a woman enters puberty, each month her body releases one of the more than 400,000 eggs that are stored in her ovaries, and the lining of the womb (uterus) thickens in anticipation of receiving a fertilized egg. If the egg is not fertilized, progesterone levels drop and the uterine lining sheds and bleeds.

By the time a woman reaches her late 30s or 40s, her ovaries begin to produce less estrogen and progesterone and release eggs less often. The gradual decline of estrogen causes a wide variety of changes in tissues that respond to estrogen—including the vagina, vulva, uterus, bladder, urethra, breasts, bones, heart, blood vessels, brain, skin, hair, and mucous membranes. Over the long term, the lack of estrogen can make a woman more vulnerable to osteoporosis (which can begin in the 40s) and heart disease .

As the levels of hormones fluctuate, the menstrual cycle begins to change. Some women may have longer periods with heavy flow followed by shorter cycles and very little bleeding. Others will begin to miss periods completely. During this time, a woman also becomes less able to get pregnant.

The most common symptom of menopause is a change in the menstrual cycle, but there are various other symptoms as well, including:

• hot flashes
• night sweats
• insomnia
• mood swings/irritability
• memory or concentration problems
• vaginal dryness
• heavy bleeding
• fatigue
• depression
• hair changes
• hadaches
• heart palpitations
• sexual disinterest
• urinary changes
• weight gain

Diagnosis

The clearest indication of menopause is the absence of a period for one full year. It is also possible to diagnose menopause by testing hormone levels. If it has been at least three months since a woman's last period, a follicle-stimulating hormone (FSH) test might be helpful in determining whether menopause has occurred. FSH levels rise steadily as a woman ages. The FSH test alone cannot be used as proof that a woman has entered early menopause. A better measure of menopause is to determine the levels of FSH, estrogen, progesterone, testosterone, and other hormones.

Treatment

Some women also report success in using natural remedies to treat the unpleasant symptoms of menopause. Not all women need estrogen and some women cannot take it due to adverse side effects. Many doctors do not want to give hormones to women who are still having their periods, however erratically. Only a third of menopausal women in the United States try HRT and of those who do, eventually half of them drop the therapy. As for alternative therapies, most have only received attention in the United States in the past decade or so. Debate continues until scientific studies can prove these treatments' effectiveness on menopausal symptoms. As interest in alternative therapies for menopause continues, so will research. In the meantime, women should consult their physicians when adding alternative therapies to treatment of menopause symptoms.

General dietary recommendations include raw foods, fruits, fresh vegetables, whole grains, nuts, seeds, and fresh vegetable juices. Some foods are recommended because they contain phytoestrogens. Intake of dairy products and meats should be reduced. Pork and lunch meats should be avoided.

Herbs

Herbs have been used to relieve menopausal symptoms for centuries. Women who choose to take herbs for menopausal symptoms should learn as much as possible about herbs and work with a qualified practitioner (an herbalist, a traditional Chinese doctor, or a naturopathic physician).

The following list of herbs include those that herbalists recommend to treat menopausal symptoms:

• black cohosh (Cimicifuga racemosa ): shown to reduce hot flashes, other menstrual complaints at a recommended dose of 20 mg twice daily
• black currant: breast tenderness
• chaste tree/chasteberry (Vitex agnus-castus ): hot flashes, excessive menstrual bleeding, moodiness
• chickweed (Stellaria media ): hot flashes
• evening primrose oil (Oenothera biennis ): mood swings, irritability, breast tenderness
• fennel (Foeniculum vulgare ): hot flashes, digestive gas , bloating
• flaxseed (linseed): excessive menstrual bleeding, breast tenderness, and other symptoms, including dry skin and vaginal dryness
• ginkgo (Ginkgo biloba ): memory problems
• ginseng (Panax ginseng ): hot flashes, fatigue, vaginal thinning
• hawthorn (Crataegus laevigata ): memory problems, fuzzy thinking
• horsetail (Equisetum arvense ): osteoporosis
• lady's mantle: excessive menstrual bleeding
• Licorice (Glycyrrhiza glabra ) root: general menopausal symptoms
• Mexican wild yam (Dioscorea villosa ) root: vaginal dryness, hot flashes, general menopause symptoms
• motherwort (Leonurus cardiaca ): night sweats, hot flashes
• oat (Avena sativa ) straw: mood swings, anxiety
• passionflower (Passiflora incarnata ): insomnia, pain
• raspberry leaf: normalizes hormonal system
• sage (Salvia officinalis ): mood swings, headaches, night sweats
• skullcap (Scutellaria lateriflora ): insomnia
• sesame oil: vaginal dryness (applied topically)
• valerian (Valeriana officinalis ): insomnia
• violet (Viola odorata ): hot flashes.

Phytoestrogens

Proponents of plant estrogens (including soy products) believe that phytoestrogens are better than synthetic estrogen, but this has not been proven. The results of small preliminary trials suggest that the estrogen compounds in soy products can relieve the severity of hot flashes and lower cholesterol . It has not been proven that soy can provide all the benefits of synthetic estrogen without its negative effects.

Women in other countries who eat foods high in plant estrogens (especially soy products) have lower rates of breast cancer and report fewer symptoms of menopause. While up to 80% of menopausal women in the United States complain of hot flashes, night sweats, and vaginal dryness, only 15% of Japanese women have similar complaints. When all other things are equal, a soy-based diet may make a difference (and soy is very high in plant estrogens). One study showed positive effects from soy, but they only lasted about six weeks.

Several studies have shown that a black cohosh extract (Remifemin) relieved menopausal symptoms as well as or better than estrogen and that it showed the greatest promise among alternative treatments. Side effects were rare. Flaxseeds also are a good source of phytoestrogens. Other sources include red clover leaf, licorice, wild yam, chick peas, pinto beans, french beans, lima beans, and pomegranates. In 2003, red clover leaf was thought to offer relief for hot flashes, but in two short clinical trials, it failed to demonstrate hot flash relief.

Herbal practitioners recommend a dose based on a woman's history, body size, lifestyle, diet, and reported symptoms. In one study at Bowman-Gray Medical School in North Carolina, women were able to ease their symptoms by eating a large amount of fruits, vegetables, and whole grains, together with 4 oz of tofu four times a week.

Many women think that natural or plant-based means harmless. In large doses, phytoestrogens can promote the abnormal growth of cells in the uterine lining. Unopposed estrogen of any type can lead to endometrial cancer . However, a plant-based progesterone product sometimes can be effective alone, without estrogen, in assisting the menopausal woman in rebalancing her hormonal action throughout this transition time.

Homeopathy

Homeopathic remedies for menopausal symptoms have been clinically successful. For best results, the patient should consult a homeopathic physician. However, the following remedies can be tried to alleviate specific groups of symptoms:

• lachesis: hot flashes, irritability, talkativeness, tightness around abdomen, dizziness , fainting
• sepia: bleeding between periods, chilliness, tearfulness, withdrawal from loved ones, sinking feeling in stomach
• pulsatilla: tearfulness, thirstless, feels better with others, avoids heat, hot flashes, varicose veins , hemorrhoids
• sulfur: philosophical personality, feeling hot, itching and burning of vagina and rectum
• lycopodium: low self esteem, bloated after eating, infrequent menstruation, low blood sugar, weak digestion, belching
• Argentum nitricum: gas, indigestion , craving for sweets and chocolate, panic attacks, fear of crossing bridges
• Magnesium phosphoricum: severe cramping
• transitional formula: hot flashes, night sweats, insomnia, skin-crawling sensation
• women's formula: perimenopause, PMS, irregular cycles, infertility , absent or excessive bleeding, menopausal discomfort
• vital formula: anxiety, headaches, palpitations, PMS, mood swings

Yoga

Many women find that yoga can ease menopausal symptoms. Yoga focuses on helping women unite the mind, body, and spirit to create balance. Because yoga has been shown to balance the endocrine system, some experts believe it may affect hormone-related problems. Studies have found that yoga can reduce stress , improve mood, boost a sluggish metabolism, and slow the heart rate. Specific yoga positions deal with particular problems, such as hot flashes, mood swings, vaginal and urinary problems, and other pains.

Exercise

Exercise helps ease hot flashes by lowering the amount of circulating FSH and LH and by raising endorphin levels (which drop during a hot flash). Even exercising 20 minutes three times a week can significantly reduce hot flashes. Weight bearing exercises help to prevent osteoporosis.

Elimination

Regular, daily bowel movements to eliminate waste products from the body can be crucial in maintaining balance through menopause. The bowels are where circulating hormones are gathered and eliminated, keeping the body from recycling them and causing an imbalance.

Acupuncture

This ancient Asian art involves placing very thin needles into different meridian points on the body to stimulate the system and unblock energy. It usually is painless and has been used for many menopausal symptoms, including insomnia, hot flashes, and irregular periods.

Acupressure and massage

Therapeutic massage involving acupressure can bring relief from a wide range of menopause symptoms by placing finger pressure at the same meridian points on the body that are used in acupuncture . There are more than 80 different types of massage, including foot reflexology, Shiatsu massage, and Swedish massage , but they all are based on the idea that boosting the circulation of blood and lymph benefits health. Breast massage (rubbing castor oil or olive oil on the breasts for five minutes thrice weekly) balances hormone levels, helps the uterus contract during menstruation, and prevents cramping pains.

Biofeedback

Some women have been able to control hot flashes through biofeedback , a painless technique that helps a person train her mind to control her body. A biofeedback machine provides information about body processes (such as heart rate) as the woman relaxes her body. Using this technique, it is possible to control the body's temperature, heart rate, and breathing.

Other treatments

Therapeutic touch , an energy-based practice, may relieve menopausal symptoms. Cold compresses on the face and neck can ease hot flashes. Sound or music therapy may relieve stress and other menopausal symptoms. Prayer or meditation can help improve coping ability.

Supplementation with magnesium, calcium, vitamin D, vitamin K, boron, manganese , and phosphorous is used to prevent osteoporosis. Vitamin E supplementation may reduce hot flashes and risk of heart disease.

Allopathic treatment

When a woman enters menopause, her levels of estrogen drop and troublesome symptoms begin. Hormone replacement therapy (HRT) can suppress symptoms by boosting the estrogen levels while also providing protection against heart disease and osteoporosis (bone weakening). There are two types of hormone treatments: hormone replacement therapy (HRT) and estrogen replacement therapy (ERT). HRT is the administration of estrogen and progesterone; ERT is the administration of estrogen alone. Only women who have had a hysterectomy (removal of the uterus) can take estrogen alone, since taking this "unopposed" estrogen can cause uterine cancer . The combination of progesterone and estrogen in HRT eliminates the risk of uterine cancer.

Experts once disagreed on whether HRT increases or decreases the risk of developing breast cancer. A Harvard study concluded that short-term use of hormones carried little risk, while HRT used for more than five years among women 55 and over seemed to increase the risk of breast cancer. In 2002, the Women's Health Initiative (WHI) quieted much of the disagreement, particularly concerning long-term use of HRT. Use of combined estrogen and progestin therapy was stopped in the large trial when invasive breast cancer risk hit a threshold among participants. The risks of HRT were determined to outweigh the benefits. Use of combined HRT also increased risk of coronary heart disease, stroke and even dementia .

Following the WHI, many physicians have cautioned women to discuss the benefits and risks of HRT with their doctors on an individual basis. In some cases, the benefits of short-term use of HRT still may outweigh the risks.

Women remain poor candidates for hormone replacement therapy if they:

• have ever had breast or endometrial cancer
• already have heart disease
• have a close relative (mother, sister, grandmother) who died of breast cancer or have two relatives who got breast cancer before age 40
• have had endometrial cancer
• have had gallbladder or liver disease
• have blood clots or phlebitis

Women would make a good candidate for HRT if they:

• need to prevent osteoporosis
• have had their ovaries removed
• have significant symptoms
• need short-term symptom relief

Aside from the findings of the WHI concerning risks of HRT, side effects of treatment include bloating, breakthrough bleeding, headaches, vaginal discharge, fluid retention, swollen breasts, or nausea . A 2001 study reported that HRT might worsen asthma in post-menopausal women who had asthma prior to menopause. Some side effects can be lessened or prevented by changing the HRT regimen.

The decision should be made by a woman and her doctor after taking into consideration her medical history and situation. Women who choose to take hormones should have an annual mammogram, breast exam, and pelvic exam and should report any unusual vaginal bleeding or spotting (a sign of possible uterine cancer).

Anti-estrogens

This new type of hormone therapy offers some of the same protection against heart disease and bone loss as estrogen, but without the increased risk of breast cancer.

The best known of these anti-estrogens is raloxifene (Evista), which mimics the effects of estrogen in the bones and blood, but blocks some of its negative effects elsewhere. It is called an anti-estrogen because for a long time these drugs had been used to counter the harmful effects of estrogen that caused breast cancer. Oddly enough, in other parts of the body these drugs mimic estrogen, protecting against heart disease and osteoporosis without putting a woman at risk for breast cancer.

Testosterone replacement

The ovaries also produce a small amount of male hormones (about 300 micrograms), which decrease slightly as a woman enters menopause. Most women never need testosterone replacement. Testosterone can improve the libido, and decrease anxiety and depression; adding testosterone is especially beneficial to women who have had hysterectomies. Testosterone also eases breast tenderness and helps prevent bone loss. Side effects include mild acne and some facial hair growth.

Birth control pills

Women who are still having periods but who have annoying menopausal symptoms may take low-dose birth control pills to ease the problems; this treatment has been approved by the FDA for perimenopausal symptoms in women under age 55. HRT uses lower doses of estrogen, however.

Expected results

Menopause is a natural condition of aging . Some women have no problems with menopause, while others notice significant unpleasant symptoms. Results of allopathic and alternative treatments vary from one woman to another.

Prevention

Menopause can't be prevented, though some of the symptoms can be relieved by the treatments listed above.

Resources

BOOKS

Carlson, Karen J., Stephanie Eisenstat, and Terra Ziporyn. The Harvard Guide to Women's Health. Cambridge, MA: Harvard University Press, 1996.

Kronenberg, Fredi, Patricia Aikins Murphy, and Christine Wade. "Complementary/Alternative Therapies in Select Populations: Women." In Complementary/Alternative Medicine: An Evidence Based Approach. Edited by John W. Spencer and Joseph J. Jacobs. St. Louis: Mosby, 1999.

Laux, Marcus, and Christine Conrad. Natural Woman. Natural Menopause. New York: HarperCollins Publishers, 1997

Teaff, Nancy Lee, and Kim Wright Wiley. Perimenopause: Preparing for the Change. Prima Publishing, 1996.

PERIODICALS

"Alternative Medicine: Natural Approaches to Menopause." Harvard Women's Health Watch 9, no. 2 (October 2001).

Doering, Paul L. "Treatment of Menopause Post-WHI: What Now?" Drug Topics (April 21, 2003):85.

Elliott, William T. "HRT, Estrogen, and Postmenopausal Women: Year-old WHI Study Continues to Raise Questions." Critical Care Alert (July 2003):1.

Gardner, Cindee. "Ease Through Menopause with Homeopathic and Herbal Medicine." Journal of PeriAnesthesia Nursing 14 (June 1999): 139–143.

"In Brief — Most Alternative Therapies Not so Hot for Hot Flashes." Harvard Women's Health Watch (February 2003).

Kirchner, Jeffrey. "Testosterone Replacement for Menopausal Women." American Family Physician 63, no. 6 (March 15, 2001): 1199.

Lieberman, Shari. "A Review of the Effectiveness of Cimicifuga racemosa (Black Cohosh) for the Symptoms of Menopause." Journal of Women's Health 7 (1998): 525–529.

Moon, Mary Ann. "Herbal Menopause Aids Lack Evidence." Internal Medicine News 34, no. 21 (November 1, 2001): 13.

Murkies, Alice L., Gisela Wilcox, and Susan R. Davis. "Phytoestrogens." Journal of Clinical Endocrinology and Metabolism 83 (1998): 297–303.

Sadovsky, Richard. "Alternative Medicines for Menopausal Symptoms." American Family Physician (April 1, 2003):1586.

Shute, Nancy. "Menopause is No Disease." U.S. News & World Report 122 (March 24, 1997): 71.

Wallis, Claudia. "The Estrogen Dilemma." Time 145 (June 26, 1995).

Wright, Karen. "Hormone Replacement may Exacerbate Asthma." Internal Medicine News 34, no. 24 (December 15, 2001): 12.

Zoler, Michael L. "Menopause, Naturally." Health (January/February 1996): 75–79.

ORGANIZATIONS

American Menopause Foundation, Inc. Empire State Bldg., 350 Fifth Ave., Ste. 2822, New York, NY 10118. (212) 714-2398.

Federation of Feminist Women's Health Centers. 633 East 11th Ave., Eugene, OR 97401. (503) 344-0966.

National Women's Health Network. 1325 G St. NW, Washington, DC 20005. (202) 347-1140.

North American Menopause Society. PO Box 94527, Cleveland, OH 44101. (216) 844-8748. <http:www.menopause.org>.

OTHER

Menopause Online. [cited December 2002]. <http://www.menopause-online.com>.

Belinda Rowland

Teresa G. Odle

MENOPAUSE

Menopause is defined as a mature woman not having a period for one year. The average age of women entering menopause in North America is 51.2 years. Most women will spend more than a third of their lives in menopause. For many, this is a fulfilling time in their lives, as they are relieved from dealing with menstruation and fears of pregnancy; while for some it means dealing with a new set of symptoms.

Menopause occurs at a time of transition in women's lives. Children are usually grown and living independently. However, there is often an increased level of responsibility and stress related to caring for aging parents. It is a time of change that can redefine partners' intimate roles in what has become an empty nest. This provides both opportunities for personal growth due to the freeing up of child-care responsibilities, but may also unmask previously avoided tensions in the relationship. These psychosocial variables profoundly affect a woman's perception of her passage through menopause.

Seventy percent of women have only a few, time-limited symptoms going through menopause. The remainder suffer to varying degrees from hot flushes, sweats, mood swings, fatigue, weight gain, vaginal dryness, pain with intercourse, and loss of sexual desire. Menopausal loss of estrogen increases the future risk of osteoporosis and coronary artery disease.

The physiological basis for menopause

The effects of menopause are due to the loss of hormone production by the ovaries. Besides producing eggs over a woman's reproductive life span, the ovaries are also responsible for producing most of a woman's estrogen ("female" hormones) as well as half of her androgens, including testosterone ("male" hormones). Most symptoms of menopause are due to the loss of estrogen, though increasing attention is being paid to the effects of the loss of androgen production.

Menopause is not one moment in time, but rather a process called perimenopause that evolves over three to five years before the cessation of menses. During this time a woman's ovaries gradually become less responsive to stimulation from the central control of the pituitary gland at the base of the brain. Over this time, menstrual periods become gradually more irregular, both in timing and in flow. The pituitary gland at the base of the brain responds to circulating estrogen levels and the brain's hypothalamic stimulation by increasing secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH). Elevated levels of FSH are the cause of hot flushes.

Premenopausal women who have both ovaries removed, usually as part of a hysterectomy and bilateral oophorectomy, have a precipitous decline in their hormones and are suddenly thrust into the symptoms of menopause. The loss of ovarian function causes an 80 percent decrease in estrogen levels. The low levels remaining are produced by the adrenal glands, as well as by peripheral conversion of cholesterol to estrogen in the skin.

Estrogen has effects on many tissues in the body, especially the mucosal lining of the vagina. As estrogen levels drop, this lining thins, produces less lubrication, and becomes more vulnerable to trauma. The urethra is also affected by this increasing the chances of bladder infection and incontinence.

Ovarian testosterone production drops by half, starting as much as three years before a woman's final period. This decline can adversely affect overall mood and energy, as well contribute to decreased sexual desire. The ratio of androgens to estrogen can flip to androgen excess for some women, contributing to increases in hair growth in such "male" areas as the upper lip and chin.

Sexuality during menopause

Menopause frees a woman's sexuality from fear of pregnancy. Up to 70 percent of women note no effects of menopause on their sexuality. These women are more likely to be in mature relationships and have worked through relationship issues that can otherwise confound sexual intimacy. Women who have previously had an active, comfortable sex life tend to have fewer problems with post-menopausal sexuality. The stimulation of intercourse helps keeps the vaginal mucosa thickened and more youthful, supporting the old adage of "Use it or lose it." Cultural values may also play a role in how menopause affects sexuality. In societies where the elderly are more likely to be respected for their wisdom, such as in Japan, most women make the transition through menopause with far fewer symptoms than women in the West.

The most common change in sexual function in menopause is decreased vaginal lubrication in response to sexual stimulation. This loss of arousal can lead to sexual pain, reduced orgasmic intensity, and, ultimately, in decreased desire. Much of this can be helped by taking replacement estrogen. Desire and orgasmic capacity can drop on their own as a result of menopause, independent of any pain or discomfort. Many women loose the sense of sexual passion. These changes can be due to decreased testosterone.

The menopausal woman is not the only one going through changes at this point in her life. Married women's husbands are dealing with their own physical changes. The slowing of the sexual response allows many couples to savour their sexual interaction, in contrast to the mad rush of youth. While it takes longer for both men and women to get aroused, lovemaking can last longer due to the aging male's decreased pressure for orgasm. Indeed, many older men do not need to ejaculate in order to enjoy the sexual experience. For most, this is an enjoyable experience. For some couples, however, not understanding the physical changes that go with aging creates concerns. Some women, having been used to a stronger sexual response from their partner, personalize these changes and wonder if they are no longer seen as attractive by their mate, or if he is having an affair. This often increases the pressure to perform that is already worrying the man, who may be wondering if he is developing impotence.

When women have sexual dysfunction, about half of their partners will also have sexual difficulties of their own. Women who have no sexual difficulties may still have to deal with their partner's loss of potency. Male erectile dysfunction increases with age, with complete loss of erection occurring in 5 percent of men at forty, and increasing to 15 percent by age seventy. More than half of older men have some partial degree of erectile dysfunction that interferes with sexual intercourse. Most erectile dysfunction in men is not due to hormonal changes, but rather to aging of blood vessels and the mechanisms that increase the blood flow to the penis. The revolution brought about by Viagra™ and other therapies can often help men and women dealing with these difficulties.

Men also appear to go through a male menopause. In contrast to women, men have a more gradual decline in their own testosterone, starting in the late forties and continuing over the next two to three decades. This results in similar changes seen in women, including decreased desire and orgasmic drive, and ultimately in the loss of erections.

Many women become single, either through widowhood or divorce, in the years following menopause. For many this leaves them to deal with their sexual needs alone. Women who reenter the world of dating and becoming sexual with a new partner face a number of concerns. The vaginal changes of menopause leading to atrophy and loss of elasticity progress more quickly if a women is not sexually active. If a woman has not had a partner for a long time, she is at increased risk of having discomfort. This can usually be treated with local estrogen. Many physicians desexualize their older female patients and do not think to counsel them about safe sex. Many older women are not conscious of the risks of sexually transmitted disease in this population. The thinner vaginal walls are more vulnerable to infection with intercourse. While numbers are still small, the greatest rate of increase in HIV/AIDS is in women over fifty.

Women in menopause are aging and may have other medical illnesses that can affect sexual function. Hypertension, diabetes, depression, and heart disease are but a few examples that can have profound effects on sexual function. The drugs used to treat these conditions frequently have sexual side-effects as well. Antidepressants commonly cause sexual difficulties, decreasing desire, arousal, and orgasm for both women and men.

Many sexual concerns during menopause are not related to hormonal changes at all. Sexual behavior involves an interaction between two people. Women are generally more sensitive to the context and connection they feel within the relationship than men are, and sexual dysfunctions are often symptomatic of other stresses, either on an individual or a couple. Sex can deteriorate due to psychological problems for either partner, or due to relationship strains. Effective treatment of sexual concerns needs to take into account the physical and psychological health of both partners, as well as the state of their relationship both inside and outside of the bedroom.

Estrogen replacement/hormonereplacement therapy (HRT) and androgen replacement

The loss of estrogen affects more than the reproductive organs. Decreased estrogen leads to increased bone loss and the risk of osteoporosis, with concerns about hip and vertebral fractures. The protection that estrogen provides premenopausal women against heart attack (relative to men) is also lost in menopause. Skin, in general, becomes thinner and more susceptible to trauma, and thinning of the vaginal mucosa leads to decreased lubrication and potentially painful intercourse. A woman's mood can become more unstable around menopause, with greater mood swings and an increased risk of depression.

The use of hormone replacement therapy (HRT) with estrogen (and progesterone to protect against uterine cancer if the woman still has a uterus), helps prevent and treat vaginal atrophy, as well as providing proven benefits such as osteoporosis prevention. The use of HRT to treat post-menopausal mood problems may help some women previously labeled depressed as much as antidepressants do.

Clinical trials currently underway with estrogen replacement may show benefit in reducing the rate of bowel cancer. Further studies are needed to see if estrogen can prevent the risk of heart attack and coronary heart disease. At this point estrogen does not seem to reduce future heart attacks in women who have already had one.

Women who receive estrogen replacement need to also take progesterone if they still have their uterus. Progesterone is produced along with estrogen in the pre-menopausal woman. It is more active in the second half of the menstrual cycle and maintains the lining of the uterus until levels drop to trigger the next period. Progesterone serves a protective function for the endometrial lining, balancing the stimulating effects of estrogen. Post-menopausal women taking estrogen alone are at increased risk of developing endometrial or uterine cancer. This increased risk is eliminated with the combination use of progesterone with estrogen.

Many women have decreased sexual desire and responsiveness in spite of HRT. This is due to a reduction in testosterone and other androgenic hormones. When women enter menopause, they lose half of their testosterone production when the ovaries stop functioning. While traditionally thought of as a "male" hormone; in reality, men and women have both estrogen and testosterone, just in different ratios. More than half of women with post-menopausal decreased desire will respond positively to testosterone replacement. The potential risks of androgen replacement can include possible virilization, with skin changes such as acne, increased and coarser body hair, deepening of the voice, and enlargement of the clitoris.

Adding replacement testosterone increases women's sexual desire, arousal, and ability to orgasm; as well as nonsexual energy and mood levels. Within a few years, triple hormone therapy with estrogen, testosterone, and progesterone may well become the standard of care.

Effect of HRT on sexual problems

All three stages of the human sexual response cycle (desire, arousal, and orgasm) can be affected by the hormonal changes of menopause.

Sexual desire is mainly modulated by testosterone. Women with decreased desire due to low testosterone respond with increased sexual frequency and improved sexual pleasure. Estrogen contributes in a limited way to desire, primarily by reducing the negative effects of vaginal atrophy. Otherwise, the effects of estrogen on desire are limited. Testosterone replacement for women is a rapidly advancing field, with oral and injectable forms, topical creams, patches, and implantable pellets all being available.

The loss of natural estrogen can lead to vaginal dryness and lack of lubrication, which HRT can help. Estrogen can be given in a number of ways as well, with vaginal cream, oral pills, patches, and injectable medications being available. All have similar effectiveness, although the intravaginal cream provides the most rapid healing for vaginal atrophy.

When given over an extended time, estrogen must be given in combination with progesterone to reduce the risk of uterine cancer. Most women notice little change on their sexuality from progesterone therapy. Those women who have had a hysterectomy do not need to take additional progesterone.

For some women, the use of HRT is generally contraindicated (such as those with advanced breast cancer.) For those women not responding to alternative therapies, local vaginal symptoms can be treated using a soft plastic pessary (Estring™) that is impregnated with estrogen. It is only locally absorbed and is believed to not increase the risk of cancer recurrence.

Many women who loose the intensity, or even the capacity, to orgasm after menopause will benefit from replacement testosterone. This is especially noticeable after surgical menopause (the operative removal of both ovaries, which causes a sudden loss of estrogen). Sexual satisfaction, as well as overall psychological well-being is generally improved by testosterone replacement.

Some women may not be able to take HRT for medical or personal reasons. Nearly half of adults have used alternative therapies in the last year. There is great clinical demand to have more products available to help these women. While there has been an increase in sexual health research, especially for men, there are still many more questions than answers that await study to demonstrate effective therapies for women. Many alternative products exist to try to help women with menopausal, including sexual, concerns. Some of these include phytoestrogens, dong quai, evening primrose oil, black cohosh, and ginkgo biloba. Few of these have been evaluated using placebo-controlled studies, and some have negative side-effects and interactions with other medications. Given the strong psychological effect on sexual function of taking a placebo, these therapies need to be viewed with caution.

Specific products for post-menopausal vaginal dryness include Replens™, which is a longeracting vaginal moisturizer that is inserted into the vagina every few days as needed. This is helpful for nonsexual sensations of vaginal dryness.

Other nonhormonal options that are effective include vaginal artificial lubricants to help with intercourse, such as Astroglide™, Just Silk™ and K-Y™ personal lubricant. All of these are safe to use with condoms. Oil-based products, however, can cause condoms to leak. The use of unscented oils, such as peanut oil and Alpha-Keri Bath Oil™, is also more acceptable than petroleum jelly, which is too sticky.

There are no other aphrodisiacs better than a placebo available to help women have more sexual desire or better orgasms.

Conclusion

Menopause has historically been a time when women were considered to be in the twilight of their lives, and when they were often disregarded in society. Today, however, women are entering menopause healthier and more active than ever before. Recognition that they have many roles to play allows them to have productive lives longer than their mothers and grandmothers. Much of this is due to social change and new perceptions of aging women, especially with respect to how menopausal women look at their sexuality. Medical treatments have been expanding to help reduce the effects of changes in hormonal status, helping maintain energy, well-being and sexual function.

Stephen Holzapfel

See also Andropause; Breast; Depression; Endocrine System; Hair; Osteoporosis; Sexuality; Urinary Incontinence; Urinary Tract Infection.

BIBLIOGRAPHY

Braunstein, G. D.; Burki, R. E.; Buster, J. E.; Caramelli, K. E.; Casson, P. R.; Ginsburg, E. S.; Leiblum, S. R.; Mazer, N. A.; Redmon, G. P.; Rosen, R. C.; Shiffren, J. L.; and Simon, J. A. "Transdermal Testosterone Treatment in Women with Impaired Sexual Function after Oophorectomy." New England Journal of Medicine 343 (2000): 682–688.

Bush, T.; Grady, D.; Hulley, S.; et al. "Randomized Trial of Estrogen, Plus Progestin for Secondary Prevention of Coronary Heart Disease in Postmenopausal Women." Journal of the American Medical Association 280 (1998): 605–618.

Danaceau, M. A.; Nueman, L.;Schmidt, P. F.; et al. "Estrogen Replacement in Perimenopausal-Related Depression—a Preliminary Report." American Journal of Obstetrics and Gynecology 183 (2000): 414–420.

Eisenberg, D. M.; Davis, R. B.; Ettner, S. L.; et al. "Trends in Alternative Medicine Use in the United States, 1990–1997: Results of a Follow-Up National Survey." Journal of the American Medical Association 280 (1998): 1569–1575.

Feldmann, H. A.; Goldstein, I.; Hatzichristou, D. G.; et al. "Impotence and Its Medical and Psychological Correlates: Results of the Massachusetts Male Aging Study." Journal of Urology 151, no. 1 (1994): 54–61.

Laumann, E. O.; Paik, A.; and Rosen, R. C. "Sexual Dysfunction in the United States: Prevalence and Predictors." Journal of the American Medical Association 291 (1999): 537–544.

National Institute on Aging (NIA). "Menopause." World Wide Web document. www.nih.gov/nia

North American Menopause Society (NAMS). "Scientific News About Menopause." World Wide Web document. www.menopuase.org

Speroff, L. "Alternative Therapies for Post-menopausal Women." ACOG, 29 April 2001.

Menopause

Menopause refers to the cessation of menses. However, sociocultural definitions beyond the biological facts reflect differences between cultures. The feelings that a woman holds about herself and her social relationships, as well as the symptoms she experiences, can be defined by the culture in which she lives. It is the cultural definition that is the source of meaning women use to assess their expectations. Examples of such variance are described among women in the United States, Europe, the Middle Eastern, China, and Japan and among South African Indian women and rural Mayan Indians.

Cultural and Social Meanings

Women's specific concerns about menopause vary by culture (Datan 1987). Once thought of as a deficiency disease, menopause has been feared as well as welcomed (Lewis and Bernstein 1996). The sociocultural values about aging account for part of the diversity in meaning. In Asian cultures, for instance, age is regarded with respect. Women in menopause, therefore, may be accorded a higher status (Lock 1993). This may change, however, as Western values influence other parts of the world, and women may feel less satisfied as they enter this period of life (Berger 1999). In the United States and European countries, age is often associated with loss of attractiveness and value. In Western culture, the menopausal years are regarded as the enemy of youth, and they result in disqualification of the woman's feminine beauty (Scarf 1980). In other cultures, however, the biological processes are themselves qualifications for entry into the man's world. The end of menses is associated with a new freedom to participate in rituals previously closed to women (duToit 1990). In some Indian cultures, for example, women who have ceased menstruation are given more opportunity to move around the house in an unrestricted manner and to participate in prayers and funeral preparations (du Toit 1990).

In a study of women from different cultures residing in Israel, Nancy Datan (1987) found significant differences among her subjects. Some Moslem Arabs feared a decline in marital relations with the loss of fertility, while some European women were concerned about going crazy during menopause (Datan 1987).

Menopausal Symptoms

Women vary in their subjective experiences of symptoms. Not all of women's perceived changes in the body are reflected in the mirror; some are derived from a woman's perception of herself, based on the accounts of others. Expectations vary and are adjusted to actual experiences.

In the United States and Europe, symptoms of hot flashes and irritability are most commonly presented. Japanese women seem more worried about stiff shoulders, eyesight problems, fatigue, and irritability (Lock 1993). Indian women report hot flashes, weight gain, bloating of the stomach, headaches, lack of sexual interest, dizzy spells, loss of energy, and constipation (duToit 1993).

The differential report of symptoms supports the view that menopause is both a biological and subjective event defined by culture. Some Arab women report that they are not aware when they reach menopause. Many have been pregnant or nursing since the onset of menses to menopause (Beyene 1986). Rural Mayan Indian women do not report any symptoms and in fact welcome menopause as a positive transition from childbearing and a time when they may pass many household chores to daughters-in-law (Martin et al. 1993). Lock (1993) reports that some Japanese women separate the experience of cessation of menses and the "change," which is known as konenki. Many believe the way in which a woman lives her life can control the symptoms. Interestingly, the view that menopause can be controlled was a belief previously accepted in Western thought before it arose in Japan (Lewis and Bernstein 1996). Some women do make a connection between the end of menstruation and konenki. Among Japanese women, neither educational level nor occupation seems to account for the differences. The women who associate the symptoms of konenki with the end of menstruation hold beliefs that are more closely related to those of North American women (Lock 1993).

Preparation for Menopause

Preparation for menopause evolves from stories a woman hears or reads about the experience (McAdams 1993). In cultures with taboos against intergenerational communication, communication between the sexes, and open discussions about physical functions, women have only limited opportunities for learning about menopause. Women among Indian South Africans are seldom prepared for menopause (du Toit 1993). There is little discussion or preparation for this women's issue, and consequently women become aware of many myths (duToit 1993). These include the idea that women with no children will have delayed menopause or none at all. Similarly, another myth is that women with many children will experience menopause at a younger age because the uterus is "exhausted" (p. 266). Gabriella Berger (1993) reported that Filipino women may feel less satisfied with themselves as they adopt the Western values of youth and beauty that have been imported from Australia. In many cultures, sometimes women may feel a lack of purpose in society when they are no longer able to reproduce (Spira and Berger 1999).

Women have the opportunity to experience several versions of menopause through relationships with mothers, aunts, grandmothers, and friends, as well as encounters with the culture, media, and health professionals (Spira and Berger 2000). They tend to make the explanations internally consistent with their self-understanding. They may focus on their lost capacity to bear children, the aging process and loss of memory, and the impact these have on their work and social life. Because of the stresses created by these events, some women may become more sensitive to their own adaptive abilities and self-esteem (Kaufert 1982).

Kathryn Hunter (1991) describes how difficult it is for doctors to diagnose menopause based solely on objective measurements of medical symptoms, without the woman's subjective account. Both are important in assessing the need for care. Health professionals must help women to communicate the symptoms in order to anticipate these natural changes. Those who suffer a loss in self-esteem and fear the end of their personal worth need to recognize the biological facts and the cultural influences on their responses. Most of the women report that freedom from childbearing responsibility and the discomfort of monthly periods are welcome aspects of menopause.

Medical Treatment

Most women experience perimenopausal symptoms between the ages of forty-five and fifty-five, with the actual cessation of menstruation as the final chapter. The slowdown of estrogen is thought to contribute to menopausal symptoms. However, culture clearly has a place in the construction of meaning of symptoms. Hot flashes are not prevalent enough in Japan to indicate konenki, whereas in the United States and Europe, this is the defining symptom of menopause.

In the United States, endocrine transitions are emphasized in the analysis of menopause, while in Japan, physicians understand the symptoms as functions of the autonomic nervous system. In Japan, medication may be prescribed to improve the hormone system, but treatments are given to improve circulation, which is seen as faulty (Lock 1993).

Medical treatment remains controversial because of the side effects of hormone replacement therapy (Spira and Berger 1999). Many women may be ashamed of their symptoms as an indication of advancing age (and implied loss of role and status). As women assume new roles, unaffected by biological change, they may perceive the symptoms of menopause as less important (Spira and Berger 2001).

Conclusion

Menopause, viewed as part of aging, intricately relates the biological, cultural, and social aspects of a woman's life. Women in the cultures described all experience irregular periods and cessation of menses in midlife. However, women relate to the psychological and social aspects of menopause in less universal ways.

Symptomatic relief through medical interventions remains an important aspect of treatment. However, the focus on biomedical concerns does not outweigh the social and psychological expression of internalized cultural attitudes toward aging. The culture is a source of both language and images about aging from which individuals learn to describe their experience. Their concerns extend to the interpersonal realm of relationships between husbands and wives and mothers and daughters, as well as their status in the culture and social system. One aspect is clear: Despite the tangible marker of aging and the impact on identity, many women welcome the end of reproduction as a relief to their bodies and an opportunity for new experiences.

See also:Adulthood; Elders; Fertility; Self-Esteem; Sexuality in Adulthood

Bibliography

beyene, y. (1986). "the cultural significance and physiological manifestation of menopause: a biocultural analysis." culture, medicine & psychiatry 10:47–71.

bowles, c. (1990). "the menopausal experience: socio-cultural influences and theoretical models." in the meanings of menopause, ed. r. formanek. hillsdale, nj: analytic press.

daton, n. (1990). "aging into transitions: cross-cultural perspective on women at midlife." in the meanings of menopause, ed. r. formanek. new jersey: analytic press.

dutoit, b. (1990). aging and menopause among indiansouth african women. albany, ny: state university of new york press.

formanek, r. (1990). "continuity and change and the 'change of life'; premodern views of the menopause." in the meanings of menopause, ed. r. formanek. new jersey: analytic press.

hunter, k. (1991). doctors' stories. princeton, nj: princeton university press.

kaufert, p. a. (1982). "myth and menopause." sociology ofhealth and illness 4:141–166.

lewis, j., and bernstein, j. (1996). women's health: a relational perspective across the life cycle. sudbury, ma: jones and barlett.

lock, m. (1993). encounters with aging: mythologies ofmenopause in japan and north america. berkeley: university of california press.

martin, m.; block, j.; sanchez, s.; arnaud, c.; and beyene, y. (1993). "menopause without symptoms among rural mayan indians." american journal of obstetrics and gynecology 168(6 part 1):1839–1845.

mcadams, d. (1993). the stories we live by. new york: guilford press.

scarf, m. (1980). unfinished business: pressure points in the lives of women. garden city, ny: doubleday.

spira, m., and berger, b. (1999). "the evolution of understanding menopause in clinical treatment." clinical social work journal 27(3):259–272.

spira, m., and berger, b. (2001). "the penultimate: understanding adult women beyond menopause." psychoanalytic social work 8(1):23–37.

Other Resource

berger, g. (1999) "study finds culture and menopause linked." abc online news. available from http://abc.net.au/science/news/stories/s31980.htm.

MARCIA K. SPIRA

Menopause

Young girls start menstruating between the ages of eleven and thirteen, when their reproductive systems reach maturity. Women have regular menstrual cycles every twenty-eight days until about the age of fifty, at which time menstruation becomes irregular. This irregularity signals the start of menopause . The natural cessation of menstruation occurs due to reduced production of the female hormones estrogen and progesterone, which generally occurs between the ages of forty and fifty-five. The age at which a woman enters menopause is affected by genetics , race, and environmental factors. Women can also go into premature menopause, either naturally or due to oophorectomy (the surgical removal of the ovaries).

Stages of Menopause

Women go through different phases of menopause, including perimenopausal, menopausal , and postmenopausal periods. During the perimenopausal period, the regular cyclical occurrence of menstruation is disrupted and menstruation becomes irregular. This phase may last anywhere from six months to a year. During the perimenopausal period, production of estrogen is reduced, and eventually stops. Menopause is defined as the cessation of the menstrual period. Women are described as postmenopausal when they have gone one year without a menstrual period.

Physiological Changes

The lack of estrogen and progesterone causes many changes in women's physiology that affect their health and well-being. These changes include:

• Elevated levels of total cholesterol and LDL-cholesterol, which increases the risk of coronary heart disease (CHD) in women. During the reproductive years, estrogen prevents increased levels of blood cholesterol and maintains the activity of estrogen receptors in women, thus preventing the risk of CHD.
• Calcium loss from the bones is increased in the first five years after the onset of menopause, resulting in a loss of bone density. This bone loss then tapers off until about the age of seventy-five, when calcium loss accelerates again. This predisposes women to the risk of osteoporosis and bone fractures.
• The body composition of menopausal women also changes, with the percentage of body fat increasing and muscle mass decreasing. The increase in body-fat percentage is believed to be partly due to decreased physical activity.
• Decreased muscle mass reduces the rate of basal metabolism , which may be responsible for weight gain at this period of a woman's life.
• The abdominal-fat storage that occurs in women at this stage increases the risk for cardiovascular disease.
• The tissues in the urinary tract and reproductive organs atrophy.

Some other transient but unpleasant symptoms of menopause include hot flashes, fatigue , anxiety , sleep disturbance, and memory loss.

Treatments and Remedies: Benefits and Disadvantages of Each

Menopausal women are faced with many choices in terms of treatment or remedies for these problems. Some of the treatment choices are experimentally proven to be effective and relatively harmless, while other options such as herbs, teas, and dietary supplements have not been subjected to scientific experimentation and have not been proven to be without harm.

Estrogen replacement therapy (ERT) is the often-used medically prescribed treatment for menopausal and postmenopausal women. Although some studies have indicated a decreased risk of CHD and osteoporosis with ERT use, others have indicated it may increase the risk of breast cancer . The Women's Health Initiative, which was designed to study the effects of ERT on the health of elderly women, stopped the ERT part of the research in July 2002. The preliminary result of that study showed the risk of CHD was, in fact, increased in women on ERT.

Scientific investigations have shown that physical activity, including aerobic and muscular strengthening exercises, not only prevent bone mineral loss, they also help alleviate many menopausal symptoms, including the increased percentage of body fat, abdominal-fat storage, hot flashes, fatigue, and sleep disturbances.

Phytoestrogens , which are present in foods such as soy, red clover, flaxseed, and other beans and legumes , are natural plant estrogen-type chemicals that can help replace human estrogen without some of the risk factors of ERT. Epidemiological observations indicate that in some cultures where soy is a staple food, women do not suffer from hot flashes during and after menopause. The results of human experiments designed to study the effect of soy products on alleviating symptoms during menopause are new and inconsistent, but promising. In addition, the isoflavones in soy products are strong antioxidants and may be effective in reducing the risk of CHD in women of menopausal age.

Herbal supplements promoted by the supplement industry to prevent hot flashes, anxiety, sleep disturbances, and other symptoms of menopause have not been scientifically studied, and since the chemical composition of these supplements is not always known, they may contain harmful substances. Thus, these kinds of supplements are not generally recommended for menopausal women.

Dietary and Lifestyle Changes

Recommendations for dietary and lifestyle changes for women during menopause are a little different from that for women in general. Menopausal women need to eat less of foods that are high in iron . Because they are not menstruating, their requirement for iron is reduced, and is thus the same as for men, about 10 milligrams per day. This means that they need to cut down on red meat, organ meats such as liver and kidney, and other foods high in iron. If they are taking multivitamin and mineral supplements, ones with a low iron content are recommended.

Water intake is emphasized in older women and men, since the thirst sensation becomes dulled as people age. Six to eight glasses of fluid per day are recommended for this age group. Water, fruit juices, other nonalcoholic beverages, and fresh fruits can help provide variety in fluid intake. In addition, an increased consumption of legumes (e.g., dried chick peas, varieties of beans, lentils, soy and soy products) is recommended to provide phytoestrogens and isoflavones. There are other alternatives that are used by people around the world to reduce hot flashes and other symptoms of menopause, including herbs such as ginseng, black cohash, kava, and wild yam. However, there has been little scientific data to determine the effectiveness and safety of these supplements.

Menopausal women need to decrease their intake of total fat, saturated fat , and total calories to balance their energy expenditure and prevent weight gain, which is sometimes associated with this period in a women's life. It is believed that, on average, women gain about 1.2 pounds a year, with most of the weight gain in the form of abdominal fat. A study done in the 1990s found that a modest weight reduction program in premenopausal women, including diet and exercise, produced modest weight loss and favorable blood lipid changes that lasted five years through the women's menopausal period. This study (Simkin-Silverman et al.) proved that weight gain during menopause is not only related to hormonal changes, but also to decreased level of physical activity.

A woman's intake of dietary fiber must be increased during menopause to prevent constipation . This objective can be accomplished by following the Dietary Guidelines for Americans, which recommend consuming six servings of whole grains and cereals, three to five servings of vegetables, and two to four servings of fruit per day. Exercise is also very important for all older individuals. Thirty minutes of moderate daily exercise, such as speed walking, is recommended. Other exercises, such as flexibility and strength training to maintain lean muscle mass and bone density, can be very helpful if done two to three times a week.

see also Women'S Nutritional Issues.

Simin Vaghefi

Bibliography

Nelson, M. E.; Fiatrone, M. A.; Morganti, C. N. M.; et al. (1994). "Effects of High-Intensity Strength Training on Multiple Risk Factors for Osteoporotic Fractures." Journal of the American Medical Association 272:1909–1914.

Simkin-Silverman, L.; Wing, R. R.; Hansen, D. H.; et al. (1995). "Prevention of Cardiovascular Risk Factor Elevations in Healthy Premenopausal Women." Preventive Medicine 24:509–517.

Internet Resources

Women's Health Initiative. "Findings from the Women's Health Initiative." Available from <http://www.nhlbi.nih.gov/whi>

menopause This is defined as the cessation of menstruation that occurs at the end of a woman's reproductive life. However, since menstrual periods can become very irregular towards the menopause, it is difficult to know which menstruation will actually be the last. Women around the age of 50 are usually considered to be past their menopause if menstruation has not occurred for a year. A variety of terms are associated with that of the menopause: pre-menopausal, peri-menopausal, post-menopausal. The ‘climacteric’ or more popularly ‘the change of life’ refer to the physical and psychological symptoms which occur in the peri-menopausal years. The menopause normally occurs between the ages of 45 and 55, although occasionally women may undergo a premature menopause much earlier in their reproductive lives. An ‘artificial menopause’ may be brought about by hysterectomy. When only the uterus is removed in a pre-menopausal woman, the cyclical changes continue in the ovaries and the subsequent decline of ovarian hormone secretion takes its natural course. However, if the ovaries are removed at the same time, which is often advised in the late forties, the full menopausal condition is precipitated, and hormone replacement therapy is likely to be required.

The natural menopause occurs because all the egg-containing follicles left in the ovary ultimately degenerate and so there are no follicles which, under the influence of gonadotrophins, will develop and begin secreting oestrogen. Ovulation will not occur and there will be no formation of a corpus luteum to secrete progesterone and oestrogen. Thus the body becomes deprived of the female sex hormones normally produced by the ovaries. Since these have previously had a negative feedback effect on gonadotrophin secretion by the pituitary, this secretion increases dramatically. There remains only a limited source of female sex hormones after the menopause, by conversion of androgens secreted by the adrenal cortex. This does not compensate for the ‘oestrogen deficient’ state of the post-menopausal woman whose ovaries have ceased to function. If a woman lives to 90 she will spend nearly half of her life in an oestrogen-deficient state.

The loss of oestrogen secretions has several profound effects, not only physically but also psychologically. Some of these symptoms are limited to the peri-menopausal period when a woman is adjusting to the loss of her hormones. Others may become manifest at the menopause but can have serious consequences in the long term. Common symptoms associated with the peri-menopausal period are hot flushes and night sweats, vaginal dryness, and depressive episodes. There is evidence that oestrogens can affect dilatation of arterioles, and thus symptoms, like flushes, linked with altered control of blood flow during oestrogen withdrawal are not surprising. Loss of oestrogen also leads to the thinning of the vaginal walls and loss of vaginal secretions. This causes vaginal dryness, and sexual intercourse can become painful.

Psychological symptoms are often linked with the menopausal years, particularly in those women who have a history of depression. However, it is difficult to determine to what extent these are due to social changes (such as children leaving home, marriage becoming dull) and negative cultural influences (ageing and loss of reproductive status and sexuality). Nevertheless some women do suffer from tiredness, lack of concentration, anxiety, tearfulness, and loss of interest in sex.

After the menopause there is an increased loss of bone mass (osteoporosis). In both men and women peak bone mass is usually achieved between the ages of 30 and 40 years and thereafter there is a gradual age-related loss in both sexes. In women, after the withdrawal of oestrogens at the menopause this bone loss is accelerated for several years, thereafter continuing at a similar rate to men. The result is that the age at which bones become so brittle that they are likely to fracture without any major trauma is, on average, much earlier in women than men. Thus women are far more likely than men to suffer from fractures related to osteoporosis. Common fractures are those of the wrist, hip, and spine (vertebrae). Indeed, fractures of the vertebrae can occur without trauma, and the resulting compression can cause the loss of several inches in height. Hormone replacement therapy (HRT) can stop the acceleration of bone loss, but when the therapy is withdrawn the usual rate of bone loss will recur. There is, however, considerable individual variation in bone loss, which may well be affected by lifestyle: exercise, especially if it involves ‘impact’, has been shown to decrease the rate of bone loss.

The other major long-term adverse effect of the menopause is on the cardiovascular system. The loss of sex steroids changes metabolism so that there is an increase in the amount of fats in the blood. This can increase the risk of arteriosclerosis (narrowing of the arteries by fatty deposits), which can lead to coronary artery disease and stroke. Thus pre-menopausal women are to some extent protected against cardiovascular disease by their sex hormones, as are women taking HRT. After the menopause, or after withdrawal of HRT, their risk of developing cardiovascular disease becomes the same as that of men.

There is no doubt that the loss of female sex hormones, notably oestrogens, can have profound effects on physiological functions in women. There is also little doubt that cultural influences can affect the way in which women experience and cope with menopausal symptoms. Western women live in a society in which social influences on the menopause are largely negative and there is a tendency for women to feel that they are left with the choice of being ‘saved’ by HRT or becoming old, sexless, and useless members of society. In contrast, in cultures where menopausal women achieve status and social advantages the reported incidence of menopausal symptoms is often negligible or even absent. For example amongst the Rajput of Northern India, women who are past their menopause are no longer in purdah and are able to move freely within their community. This has a positive effect on their outlook. Similarly the New Zealand Mayans view their post-menopausal years as a relief from child-bearing, and thus the menopause is an attribute. Japanese women report a lower frequency of menopausal symptoms compared with American and Canadian women, and the same is true for the Navajo Indians.

But all is not gloom and doom, even in Western society. The increasing presence of women in responsible posts in political, business, and professional life, and the acceptance in general of their employment outside the home enhances the prospect of rewarding and indeed more energetic activity without the inconveniences of the menstrual cycle and of potential pregnancy; employment of mothers also enhances the scope of the traditional role of the grandmother in the extended family. Thus, while the menopause can be considered as the beginning of an oestrogen-deficient state which may become an increasing health problem as longevity increases, there are clearly large cultural influences which can affect the way women experience this change of life.

Saffron Whitehead

Bibliography

Greer, G. (1991). The change: women, ageing and the menopause. Fawcett Books, Greenwich, CT.
Mackenzie R. (1984). Menopause. Sheldon Press, SPCK, London.

menopause or climacteric , transitional phase in a woman's life when the ovaries stop releasing eggs, ovarian production of estrogen and other hormones tapers off, and menstruation ceases. It results from declining ovarian function due to aging of the ovaries and is usually a gradual process. In the United States, natural menopause occurs at age 51 on average. Premature menopause (due to premature aging of the ovaries, debilitating disease, or infection) and artificial menopause (due to destruction of the ovaries by surgery, irradiation, or purposeful hormone therapy, as in severe premenstrual syndrome ) may occur much earlier.

Menopause may pass with no signs other than cessation of menstruation, or it may be accompanied by menstrual changes (heavy or erratic periods), night sweats, hot flashes, and vaginal dryness. There is some debate as to whether emotional symptoms and "mood swings" are any more common during menopause than at any other age. Lower levels of estrogen following menopause may be accompanied by a variety of physical changes. For example, the risk of osteoporosis , in which the bones lose elasticity and become brittle, increases. In addition, levels of high-density lipoproteins (HDLs) decrease as low-density lipoproteins (LDLs) increase, arteries lose elasticity, and more body weight is redistributed to the waist area—all heightening the risk of heart disease . Other possible estrogen-related changes include stress incontinence due to loss of muscle tone in the pelvis, loss of elasticity in the skin, and hair thinning.

Estrogen replacement therapy (ERT) is a controversial treatment introduced in the 1970s for bodily changes that occur in menopause; beginning in the 1980s progestins were added to reduce the risk of uterine cancer. Although ERT eases hot flashes and other physical changes and appears to decrease the risk of osteoporosis, it has been linked to increases in breast cancer , heart disease, and stroke.

Other approaches to dealing with the physical changes include exercise to help circulation, increase bone density and HDL levels, and lower stress; lubricants for vaginal dryness; avoidance of smoking and excess alcohol; and dietary changes limiting protein and fat and increasing fiber and calcium . Natural remedies such as vitamins E and B ₆ or ginseng and other foods that contain or mimic estrogen are sometimes recommended, but research as to their efficacy has been limited.

See also uterus .

Bibliography: See publications of the National Institute of Child Health and Human Development; J. E. Huston and L. D. Lanka, Perimenopause: Changes in a Woman's Health after 35 (1997); Boston Women's Health Book Collective, Our Bodies, Ourselves for the New Century (1998).

menopause The time in a woman's life when ovulation and menstruation cease (see menstrual cycle). It normally occurs between the ages of 45 and 55. The effects of the gonadotrophic hormones, follicle-stimulating hormone and luteinizing hormone, in the ovaries decrease so that the follicles do not develop properly. There is a change in the balance of the hormones oestrogen and progesterone, secreted by the ovaries, which may be associated with certain physical symptoms, such as weight gain and `hot flushes', and there may also be mood changes. These symptoms can be treated by long-term hormone replacement therapy with oestrogens and progestogens.

menopause (climacteric) (men-ŏ-pawz) n. the time in a woman's life when ovulation and menstruation cease and the woman is no longer able to bear children. The menopause can occur at any age between the middle thirties and the middle fifties, but occurs most commonly between 45 and 55; it can only be established in retrospect after 12 consecutive months of amenorrhoea. It is associated with a change in the balance of sex hormones in the body, which sometimes leads to hot flushes and other vasomotor symptoms, palpitations, and emotional disturbances.
—menopausal adj.

menopause Stage in a woman's life marking the end of her reproductive years, when the menstrual cycle becomes irregular and finally ceases, generally around the age of 50. It may be accompanied by side-effects such as hot flushes, excessive bleeding, and emotional upset. Hormone replacement therapy (HRT) is designed to relieve menopausal symptoms.

men·o·pause / ˈmenəˌpôz/ • n. the ceasing of menstruation. ∎  the period in a woman's life (typically between 45 and 50 years of age) when this occurs. DERIVATIVES: men·o·pau·sal / ˌmenəˈpôzəl/ adj.

menopause •applause, Azores, cause, clause, Dors, drawers, gauze, hawse, indoors, Laws, outdoors, pause, plus-fours, quatorze, Santa Claus, taws, tawse, yaws, yours •menopause