Anatomy of Menopause
Hormonal Changes
When to Expect Menopause
What to Expect in Menopause
Tests for Menopause
Hormonal
Changes
Menopause is a time of dramatic changes. To better understand
them, a refresher course on the hormonal fluctuations that occur
during a woman's reproductive cycle may be helpful.
During her fertile years, starting at puberty, a woman's monthly
cycle begins with the release of the hormone
Gonadatropin-releasing hormone (GnRH) from the hypothalamic
region of the brain that is close to the pituitary gland. GnRH
hormone triggers the release of follicle-stimulating hormone
(FSH) and luteinizing hormone (LH) from the pituitary gland. The
release of FSH stimulates the development of follicles, or small
structures in the ovary, which contain eggs. Each month, FSH and
LH stimulation cause the follicles to ripen and secrete estrogen
and progesterone upon ovulation. These two hormones cause the
uterus to thicken in preparation for pregnancy. LH triggers the
release of a mature egg from the follicle. If pregnancy does not
happen, progesterone and estrogen levels decline and the uterine
lining (endometrium) sheds as menstrual blood. FSH levels
increase in preparation for a new cycle.
As a woman ages, the number and quality of follicles in the
ovaries decline. Irregular menses are a sign that she is
intermittently not ovulating. As a consequence of this,
progesterone is not always produced. This erratic pattern may
continue until menopause. During this time, called the
perimenopausal stage, estrogen levels also change unpredictably
and dramatically. The changes in estrogen can cause different
menopausal symptoms. The fluctuations in estrogen can contribute
to erratic vaginal bleeding. At the times when estrogen levels
are low, a woman may experience hot flashes. The depletion of
estrogen results in vaginal and urinary changes, and higher risk
of osteoporosis and heart disease.
As the reproductive stage of a woman's life draws to a close,
ovarian estrogen falls to undetectable levels. The ovary is no
longer sensitive to FSH. FSH levels escalate, as do LH levels,
and menstruation comes to an end.
When to
Expect Menopause
As menopause draws closer, many women experience changes in the
characteristics of their periods. These may include irregular
bleeding, periods that last for fewer or greater days, and
heavier or lighter flow. This usually occurs when a woman is in
her forties. The average age of menopause (the last menstrual
period) is 52. While the average age of puberty's onset has
steadily declined, the average age of menopause has remained
constant.
There are exceptions, however. One of which is surgical
menopause, which results from the surgical removal of the ovaries
(oophorectomy -- with or without a removal of the uterus, know as
a hysterectomy). A small percentage of women begin the
physiologic journey to menopause before the age of forty, and
start experiencing symptoms as early as their twenties. In
contrast, a small number of women continue menstruating regularly
until they are near sixty.
What accounts for this vast difference? There is some evidence
that the onset of menopause follows a genetic pattern. If your
mother went through menopause in her mid-fifties, for example,
you are more than likely to follow her lead. Lifestyle factors
also play a role in the arrival of menopause. Cigarette smoking
may bring on an early menopause. Smoking hastens the body's
breakdown of estrogen, resulting in lower estrogen levels than
nonsmokers. It also may have a direct toxic affect on the ovary,
inducing a more rapid loss of follicles.
What to Expect in Menopause
No two women will experience menopause in exactly the same way.
Some women have hot flashes, for example, and about twenty
percent of women have no symptoms at all. For up to 10 percent of
women, the symptoms are very mild, while about 20 percent of
women have severe symptoms.
The way you feel during menopause or perimenopause will also be
influenced by other factors that are unique to you, such as your
overall health, nutrition, stress level, exercise routine, etc.
Here are
some of the changes that might occur with menopause. Keep in mind that most women
experience only a few of these changes, and mostly in a mild
form.
Symptom
Description
Irregular periodsMenstrual cycle may become longer or shorter, lighter or heavier. Hot flashesDramatic sensation of heat, centering around the head, neck and chest; associated with heart palpitations, sweating, shallow breathing. May begin years before menopause.
Insomnia/hot sweats
Caused by night-time hot flashes.
Weight gain
Although many women attribute weight gain to menopause, studies have refuted this and found it to be more an age-related problem. Remember that men tend to gain weight at this time too.
Emotional effects
Irritability, anxiety, stress, depression. The exact cause is unknown but seems to be more problematic during perimenopause. Women who have a prior history of depression are more likely to have a worsening of symptoms at this time.
Bone loss (osteoporosis)
A reduced amount of bone, making the bones more fragile and thus, more susceptible to fractures.
Heart/blood vessel (cardiovascular) changes
Increased risk for hardening of the arteries. Also, blood vessels are less likely to dilate, preventing oxygen rich blood to flow to the heart, both increasing the risk of heart attacks.
Dryness and thinning of vaginal walls
and bladderAtrophy
of vaginal
mucosa and bladder may lead to dryness, painful intercourse,
irritation, higher risk of infection, difficulty in controlling
bladder. Atrophy of the urethra also increases the likelihood of
bladder infections and problems with urine loss.
Hot
Flashes
An estimated 85 percent of women in perimenopause experience hot
flashes at some point. They vary in severity from woman to woman.
Some women have just a vague feeling of being warm. For others,
the hot flash comes on suddenly and quickly, starting with a rush
of heat to the chest, neck, face and/or upper arms. The skin
flushes with redness and beads with perspiration. The pulse steps
up its pace and breathing quickens and becomes shallower.
These symptoms can last seconds or minutes, disappearing as
quickly as they appear. They can occur rarely, or multiple times
a day. In a woman who is still menstruating, hot flashes are
usually most acute just before and after periods.
It's clear that the lack of estrogen plays a role in the
occurrence of hot flashes. However, the exact cause of hot
flashes remains unknown. A hot flash is actually a dysregulation
of temperature control in the body. What initiates this
dysregulation of temperature control is unknown. However, we do
know that a hot flash is brought on by a dilation of blood
vessels on the surface of the body, which causes an increase in
the body's surface temperature. In response, the body
appropriately tries to compensate for this increase by sweating
and decreasing the core temperature of the body.
Although hot flashes are not life threatening, they are
uncomfortable enough to interrupt sleep (due to "night
sweats"), work and social activities. You can arm yourself
against the potentially disabling hot flash by dressing in
layers, avoiding warm environments, avoiding hot and spicy foods,
or by considering hormone replacement therapy.
Vaginal
Dryness and Urinary Changes
The linings of the vagina, urethra (urinary opening), lower part
of the bladder, and vulva are highly sensitive to changes in
estrogen. Normally, these tissues are soft, moist and elastic.
Starved of estrogen, however, they become thinner, less flexible,
and less able to produce lubrication. In medical terms, these
changes are called atrophy. Unlike hot flashes, untreated vaginal
and urethral atrophy persists throughout menopause and beyond,
and can become more troublesome as time goes on.
In the vagina, atrophy may feel like dryness or a scratchy pain.
Painful intercourse is the most common complaint. Estrogen loss
also disrupts the delicate acid/alkaline balance of the vagina,
possibly leading to vaginal infections, such as yeast infections
and bacterial vaginosis. Using a water-based (not oil-based)
vaginal lubricant can help relieve dryness but will not prevent
infections.
Estrogen also has a direct affect on the urethra. A lack of
estrogen leads to similar atrophic changes in the urethra as in
the vagina. These changes can impair the urethra's ability to
prevent involuntary loss of urine, especially while sneezing,
coughing or laughing. Atrophy may also make women more
susceptible to bladder infections. Kegel exercises may be useful
in maintaining bladder control by strengthening the internal
muscles of the pelvis. However, they do not address the problem
of atrophy of the urethra.
Weight
Gain
Weight gain is a common complaint that is probably more closely
related to aging than menopause. Many women find that diligent
attention to their diet and increased exercise play an important
role in maintaining their weight during this time. If weight gain
is a continual problem, a woman may want to have her physician
check her thyroid gland for any abnormalities. If thyroid
function is normal, a referral to a nutritionist or specialized
weight loss center that addresses nutrition, exercise and
behavioral changes can be quite rewarding.
Emotional
Changes
Any change can bring stress. And "the change of life"
can be a substantial stressor for some women. Many women report
mood disturbances in the perimenopausal years. Laden with
negative social connotations, menopause may be seen by some women
as a negative change, causing a decline in self-image. Some women
may mourn the loss of their reproductive capabilities. Women with
a prior history of depression may be more susceptible to mood
fluctuations of perimenopause. As any woman who has experienced a
hot flash knows, the physical symptoms alone can be a source of
emotional stress. Loss of sleep due to night-time hot flashes
(also known as "night sweats") can cause chronic
fatigue. The good news is that most women note an improvement in
their moods once menopause has occurred.
Tests for
Menopause:
Are your symptoms related to menopause—or some other
condition? The answer can have important health ramifications,
and determine the course of your treatment. For example,
palpitations can be caused by menopausal changes, emotional
problems (e.g., panic disorder) or heart problems. The danger
lies in misdiagnosis, and administering incorrect treatment.
To make things more confusing, it is not always easy to know
whether you are approaching menopause because the symptoms can
wax and wane, vary widely from other women's, or not occur at
all.
The best way to determine whether menopause is around the corner,
or far down the road, is to first investigate your own menstrual
patterns. If you notice a marked change in your menstrual cycle,
you may have begun the perimenopausal transition. In addition,
you can have your doctor obtain a simple blood test that will
measure the level of follicle stimulating hormone (FSH) in your
body. FSH levels climb when estrogen levels drop. An elevated FSH
level confirms that you will be approaching menopause within a
year or two. However, it is important to note that both FSH and
estrogen levels can fluctuate widely during the perimenopausal
years.
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The contents of this Web site are for informational purposes only and are not intended to be used for medical advice. You should consult your physician or health care provider on a regular basis. You should consult your physician immediately with any problem about which you are concerned.