Patient education: Menopause (Beyond the Basics)

INTRODUCTION — Menopause is defined as the time in a woman's life, usually between age 45 and 55 years, when the ovaries stop producing eggs (ovulating) and menstrual periods end. After menopause, a woman can no longer get pregnant.

Menopause does not happen suddenly; most women experience several years of changes in their menstrual periods before they stop completely. During this time, many women also start to have menopausal symptoms. These result from declining levels of estrogen in the body and can include hot flashes, night sweats, mood changes, sleep problems, and vaginal dryness. A woman is said to have completed menopause once she has gone a full year without having a period. The average age for a woman to stop having periods is 51 years.

Menopause is a normal part of a woman's life and does not always need to be treated. However, the changes that happen before and after menopause can be disruptive. If you have bothersome symptoms, effective treatments are available.

More detailed information about menopause is available by subscription. (See "Clinical manifestations and diagnosis of menopause".)

AM I GOING THROUGH MENOPAUSE? — Several different terms are used to describe the time before and after you stop having menstrual periods.

●The menopausal transition (also called "perimenopause") is the time when your periods start to change (usually becoming less frequent). This phase lasts an average of four years and ends when you have your final period.

●Menopause is complete when it has been 12 months since your last menstrual period.

●"Postmenopause" is the time after menopause (a woman who has been through menopause can be described as "postmenopausal").

The average age of menopause is 51 years, although the age range can vary between approximately 45 and 55 years. Women who go through menopause before age 40 years are considered to have an abnormally early menopause (called premature ovarian failure or primary ovarian insufficiency). (See "Patient education: Primary ovarian insufficiency (Beyond the Basics)".)

If you are 45 years or older and you have not had a menstrual period in 12 months, there is a good chance that you have gone through menopause. Most women in this group do not need any laboratory testing to confirm this, especially if they are having menopausal symptoms such as hot flashes or vaginal dryness.

If you are under 45 and you stop having periods or think you may be having symptoms of menopause, talk to your doctor or nurse. You may need testing (to measure certain hormone levels) to see if menopause, or another problem, is the cause of your symptoms.

After hysterectomy — If you do not have a uterus (eg, if you have had a hysterectomy) but you still have ovaries, you will still go through menopause when your ovaries stop producing eggs. However, it can be hard to know when this happens because you don't have menstrual periods. You may develop menopausal symptoms as your ovaries stop working and your blood levels of estrogen begin to fall. If you are having bothersome symptoms of menopause after hysterectomy, talk to your doctor or nurse.

MENSTRUAL CYCLE CHANGES — Many women begin to notice changes in their menstrual periods during the menopausal transition (perimenopause). This happens as a result of the changes to hormone levels in the body. You might:

●Have menstrual periods more or less often than usual (eg, every five to six weeks instead of every four)

●Have bleeding that lasts for fewer days than before

●Skip one or more menstrual periods

●Start noticing symptoms of menopause, such as hot flashes (see 'Menopause symptoms' below)

Abnormal bleeding — It can be hard to know if vaginal bleeding is abnormal when you are near menopause. In general, you should see your doctor or nurse if you have the following symptoms:

●Vaginal bleeding more often than every three weeks

●Excessive, heavy menstrual bleeding

●Spotting between your periods

●Vaginal bleeding after menopause (even if it's just a spot of blood)

Irregular vaginal bleeding may be a normal part of menopause, or it may be a sign of a problem. (See "Patient education: Absent or irregular periods (Beyond the Basics)".)

Menopause and birth control — Fertility naturally declines with age, and most women are less likely to become pregnant (without infertility treatment) after age 45 years. However, it is possible. It is important to continue to use birth control if you do not want to get pregnant, particularly if you are still having monthly periods and are sexually active. You should continue to use some form of birth control until you are sure that you have gone through menopause (ie, it has been 12 months or longer since your last period). Once you become menopausal, you cannot get pregnant.

If you are using a hormonal method of birth control, like pills, an injection, a vaginal ring, or a skin patch, talk to your doctor or nurse to find out when you should stop. Many types of hormonal birth control are generally safe to continue during perimenopause; for women who want to use the pill during perimenopause, most experts recommend a low-dose version. However, if you smoke, you should not take birth control pills during perimenopause. Because hormonal methods of birth control affect the menstrual cycle, they can make it hard to tell when menopause has occurred. Your doctor may suggest stopping birth control once you are close to the average age for menopause (51 years) and seeing whether your period continues and if you experience any symptoms of menopause. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

If you want to stop taking hormonal birth control during perimenopause, you can switch to a nonhormonal method (such as condoms and/or spermicide) sooner. If you are over 45 years, are using a nonhormonal method of birth control, and have not had a menstrual period for 12 months, you can stop using birth control altogether.

If you have an intrauterine device (IUD), you should leave it in at least until you are past the average age for menopause (51 years). This is particularly important if you have a levonorgestrel IUD (sample brand name: Mirena) because this type of IUD causes some women to stop having periods while using it, which can make it difficult to tell if you have been through menopause. If you prefer, you can wait and get your IUD removed when it expires (after 10 years for most copper IUDs, after three to eight years for levonorgestrel IUDs).

MENOPAUSE SYMPTOMS — As the ovaries stop working, levels of the hormone estrogen fall. This is what leads to the typical symptoms of menopause. Some women have few or no menopausal symptoms, while other women have bothersome symptoms that interfere with their life. These symptoms often begin during the menopausal transition, before you stop having periods completely. However, there are treatments that can help. (See 'Menopause treatment' below.)

Common symptoms of menopause include:

●Hot flashes – Hot flashes are the most common symptom of menopause, affecting up to 60 to 80 percent of women. They typically begin as a sudden feeling of heat in the upper chest and face; the hot feeling then spreads throughout the body and lasts for two to four minutes. Some women sweat during the hot flash and then feel chills and shiver when the hot flash ends. Some women have a feeling of anxiety or heart palpitations during the hot flash. Hot flashes can occur once or twice each day or as often as once per hour during the day and night.

Hot flashes usually begin well before your last menstrual period. It is not clear what causes hot flashes. Most women who have hot flashes will continue to have them for about four years (on average). (See "Menopausal hot flashes".)

●Night sweats – Hot flashes are more common at night then during the day. When they occur during sleep, they are called "night sweats." Night sweats may cause you to sweat through your clothes and wake you from sleep because you are hot or cold. This can happen one or more times per night. Waking frequently can make it hard to get a good night's sleep. As a result of interrupted sleep, many women develop other problems, such as fatigue, irritability, trouble concentrating, and mood swings.

●Sleep problems – During the transition to menopause, some women begin to have trouble falling asleep or staying asleep, even if they don't have night sweats. Sleep problems can cause you to feel tired and irritable the next day. Effective treatments for sleep problems are available. (See "Patient education: Insomnia treatments (Beyond the Basics)".)

●Vaginal dryness – As the levels of estrogen in the body decrease before and during menopause, the tissues inside the vagina and urethra (the tube that carries urine from the bladder to outside the body) can become thin and dry. This can cause discomfort, itching, or pain during sex. (See "Patient education: Vaginal dryness (Beyond the Basics)".)

●Depression – During the menopausal transition, many women develop new problems with mood, such as sadness, difficulty concentrating, feeling uninterested in normal activities, and sleeping too much or having trouble staying asleep. Women with a past history of depression may notice a recurrence during the menopause transition. If you have any symptoms of depression or blues that will not go away, talk to your doctor or nurse. There are a number of effective treatments available. (See "Patient education: Depression treatment options for adults (Beyond the Basics)".)

MENOPAUSE TREATMENT — Not all women need treatment for menopausal symptoms. If your symptoms are mild, there are things you can try on your own that might help (table 1). But for more severe or bothersome symptoms, there are effective treatment options available.

Menopausal hormone therapy — Estrogen is the most effective treatment for hot flashes. While there have been concerns in the past about the safety of hormone therapy, for most healthy women who are seeking help with symptoms of menopause, it is safe, low risk, and effective. It should be started before the age of 60 years and is generally given for up to five years. It is not recommended for women with a history of (or at high risk for) certain medical problems, including breast cancer, heart disease, and stroke. (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)

Hormone therapy usually involves a combination of estrogen and progestin (a progesterone-like medication), although women who do not have a uterus (eg, after a hysterectomy) need only estrogen. Hormone therapy is available in a pill that you take by mouth, a skin patch, a vaginal ring, and a skin gel, cream, or spray. In addition to relieving hot flashes, hormone therapy may help with other symptoms of menopause as well, including vaginal dryness, depression, and other mood problems. However, some women struggling with depression may also need treatment with an antidepressant medication. (See "Patient education: Depression treatment options for adults (Beyond the Basics)".)

If you don't need hormone therapy for hot flashes but you have problems with vaginal dryness, vaginal estrogen can help. This is different from the estrogen preparations used to treat hot flashes; it comes in a much lower dose and does not need to be taken with progestin. It is available as a cream, tablet, or flexible plastic ring that you insert into the vagina. (See "Patient education: Vaginal dryness (Beyond the Basics)".)

Nonhormonal treatment options — If you are bothered by hot flashes but you cannot take or would prefer to avoid hormone therapy, there are alternatives. Although hormone therapy is the most effective treatment for hot flashes, nonhormonal alternatives are a good option for many women. (See "Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Menopause (The Basics)
Patient education: Vaginal dryness (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Primary ovarian insufficiency (Beyond the Basics)
Patient education: Absent or irregular periods (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Insomnia treatments (Beyond the Basics)
Patient education: Vaginal dryness (Beyond the Basics)
Patient education: Depression treatment options for adults (Beyond the Basics)
Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)
Patient education: Menopausal hormone therapy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations and diagnosis of menopause
Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis
Menopausal hot flashes
Ovarian development and failure (menopause) in normal women
Menopausal hormone therapy and the risk of breast cancer
Menopausal hormone therapy: Benefits and risks
Treatment of menopausal symptoms with hormone therapy
Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/menopause.html)

●The Menopause Society

(www.menopause.org)