MENOPAUSE: Understanding the Change

I n a phenomenon some sociologists have dubbed "youth creep," the meaning of middle age in America today is different than what it was just a generation ago. Doctors now consider 55, rather than 40, as the turning point into middle age. Women reaching their 40s and 50s today can look forward to a vigorous, active, and healthy middle and old age -- particularly if they take responsibility for the preventive health care that can help keep them in good physical and mental condition.

Changes at Midlife

Women may notice the first signs of bodily changes in their menstrual patterns, skin, and shape as early as their late 30s. Menopause -- the cessation of the menstrual cycle -- is certainly the most notable sign of advancing age for women. The hormonal changes that spur the end of menstruation affect our entire bodies, from the texture of our skin to the condition of our heart and bones.

The medical definition of menopause is the end of menstruation, so menopause can only be diagnosed after the fact. But the bodily changes leading up to menopause may take place over a decade. Most women reach menopause between the ages of 45 and 55. At age 52, 80 percent will no longer be menstruating. There does not appear to be any consistent relationship between a woman's age at the onset of menopause and her age at her first menstruation, nor does marriage, childbearing, height, weight, or use of oral contraceptives appear to make a difference. However, women who smoke do tend to reach menopause a year or two earlier than nonsmokers.

Menopause Without Mystery

Until quite recently, menopause was something of a "taboo" topic, and often not discussed even between mothers and daughters or among close friends. Now that the huge "baby boom" generation (known for its openness and take-charge attitude toward medical care) is entering its middle years, discussion of menopause appears more frequently in the media and in private conversations. A recent survey indicates that menopause is now also discussed more openly among women and men at work. By taking some of the mystery out of this natural process, women and men are learning how to cope with everyday changes.

Most of today's women will live 25 to 30 years -- one-third of their lives -- after menopause. An understanding of the body's physiological changes during this phase of life can ease the transition, and equally important, better prepare you to safeguard your health during your later years.

Is Menopause a Deficiency Disease?

Within the medical community, there's a debate about whether menopause should be viewed as a natural process or as a health threat. Some physicians see menopause as a hormone deficiency syndrome associated with dysfunction of the ovaries, requiring diagnosis and treatment. Their argument is based on the fact that menopausal women are at increased risk for developing health disorders. For example, for every 2,000 postmenopausal women, 20 will develop heart disease; 11 will develop severe bone loss (osteoporosis); six will develop breast cancer; and three will develop endometrial cancer. The risk of some of these diseases can be reduced by treating menopause with hormone replacement therapy (HRT), and many physicians now strongly believe that this treatment should be used by all women who have no medical reason to avoid it.

Other professionals object to the "medicalization" of menopause, believing that it perpetuates negative cultural perceptions of aging as a time of decay that should be feared, rather than as a normal developmental stage in a woman's life. They, too, acknowledge that the risk of certain diseases rises after menopause and encourage various preventive strategies.

Premature and Induced Menopause

There are certain situations that bring about menopause earlier than usual. About one percent of women cease menstruating before age 40. This is called premature menopause or premature ovarian failure. The reasons for it are largely unknown. In some cases, severe infections or tumors in the reproductive tract damage the ovaries and precipitate menopause. Other possible causes are exposure to radiation, chemotherapy drugs, and surgery that impairs blood flow to the ovaries.

When a woman has her ovaries surgically removed or rendered nonfunctional through radiation therapy, induced or artificial menopause occurs. Because this results in an abrupt and almost total loss of estogen in the body, symptoms of induced menopause can be particularly severe. The condition is usually a side effect of treatment for abdominal disease, such as ovarian cancer. Elective removal of the ovaries is someVerdana used to prevent ovarian cancer particularly where there is a family history of the disease. The practice is highly controversial in premenopausal women, though less so in postmenopausal women. In the past, it was also common to remove the ovaries during a hysterectomy (surgical removal of the uterus), but today in premenopausal women the ovaries are left in place whenever possible.

The Menstrual Cycle

A brief overview of the menstrual cycle is essential to understanding what happens to the body during menopause. Taking a close look at how your body functions will help increase your sense of comfort and familiarity, and place the someVerdana puzzling symptoms of menopause into perspective.

Monthly Ovarian Cycle

While men manufacture sperm each day, often into advanced age, women are born with a single lifetime supply of egg cells that are released from the ovaries gradually throughout the menstrual years. The entire structure of an egg, with its surrounding flat sheet of cells, is called a follicle. The ovarian cycle begins when the follicular cells swell, absorbing a cholesterol-rich fluid that is then converted into steroid hormones -- predominantly estrogen, a woman's most important sex hormone. These hormones act as chemical messengers that orchestrate the menstrual cycle, which lasts an average of 28 days. Some of these hormones escape the follicle into the bloodstream and travel throughout the body. Not only do the sex organs need estrogen to function, but almost every part of your body is affected by the hormones produced by the ovaries.

The ovary raises many follicles each month but usually only one follicle matures to reach ovulation. Ovulation occurs when the egg is released from its follicle -- leaving the ovary, entering the fallopian tube, and journeying toward the uterus. If the egg is fertilized by a sperm, pregnancy occurs.

The cycle continues after ovulation with the reconnection and multiplication of the cells of the ruptured follicle in the ovary. The former follicle grows and takes on a yellow color, thus its name, corpus luteum ("yellow body"). As the corpus luteum grows, it secretes increasing amounts of estrogen and progesterone, raising the levels of these hormones in the blood. If the egg is not fertilized by the fourteenth day after ovulation, the cells of the corpus luteum begin to die and, simultaneously, hormone levels in the blood decline sharply.

Monthly Uterine Cycle

Along with ovarian changes, the uterus goes through a cycle of its own. When stimulated by the estrogen secreted during the ovarian cycle, the lining of the uterus (the endometrium) develops to serve as a bed for the fertilized egg. As hormone levels in the blood rise, the endometrial cells multiply, and blood vessels grow to provide nourishing oxygen, causing an increase in the thickness of the endometrial tissue.

When hormone levels drop at the end of the ovarian cycle, the blood vessels in the endometrium begin to deteriorate and deprive the cells of nourishment. The elimination of blood, mucus and the dead cells from the endometrial tissue, in the form of menstrual blood flow, generally occurs for three to five days. This signals the start of a new cycle.

The Control Center

The entire monthly cycle is controlled by certain centers in the brain. The hypothalamus, located in the base of the brain, releases several hormones directly into the bloodstream.

One of these, gonadotropin releasing hormone (GnRH), prompts the pituitary gland to secrete two hormones called the gonadotropins: follicle stimulating hormone (FSH) and luteinizing hormone (LH). These hormones control the ovaries. FSH stimulates the development of follicles in the ovaries. LH causes ovulation and changes the ruptured follicle into the corpus luteum. In turn, the progesterone produced by the corpus luteum prevents the pituitary from releasing additional FSH and LH, thus preventing the growth of new follicles until the next cycle. The ovaries' declining production of estrogen and progesterone at the end of the cycle signals the hypothalamus to produce GnRH, which begins the cycle anew.

Changes to Expect

Some women continue to menstruate normally until the onset of menopause and then simply cease to have periods. But for most women, the transition is not so orderly. You can expect to see a variety of changes. What they are and why they happen is the subject of the section that follows. In later chapters, you'll find more on the symptoms and management of the most troubling of these problems.

Changing Hormonal Patterns

A woman's egg supply, as much as 2 million in the ovaries at birth, is programmed for depletion. When the supply is almost exhausted because of the aging process, or the ovaries are surgically removed, the menstrual cycle comes to an end. In fact, the reproductive cycle begins to change several years before menopause, a period referred to as perimenopause.

During this time, typically starting in the late 40's, the ovaries' response to the various stimulating hormones produced by the brain becomes unsynchronized, until eventually the aging ovaries fail to respond at all. They start to produce less progesterone, losing their ability to ovulate and develop the subsequent corpus luteum. When ovulation stops, estrogen levels decline and menstruation ceases.

As ovulatory cycles become more irregular throughout perimenopause, the body's sensitive hormonal rhythm is thrown off and menstruation may vary more from month to month. In addition, two hormones known as androgens begin to play a bigger role. Though referred to as male sex hormones, they are in fact produced in small amounts by the female body as well. As levels of the female hormones decline, the impact of these "male" hormones can increase.

The bottom line is that fluctuating blood levels of hormones during the transitional years can create a number of physiological changes. These may be less unsettling for women who have an understanding of what their bodies are going through.

Changes in the Menstrual Cycle

Cyclical Changes occur for the vast majority of women whose periods do not just stop. The perimenopausal years may be marked by skipped menstrual periods, heavier or lighter than usual bleeding, and changes in the frequency of cycles. During some menstrual cycles, no egg may be produced; these are called anovulatory cycles.

Light, short, or skipped periods occur as the ovaries' hormonal response becomes unpredictable. Heavy and prolonged bleeding arise when a longer than normal release of estrogen overstimulates growth of the uterine lining. The lining may be irregular or thickened and may not slough off completely or evenly, causing menstruation to stop and start again. Clotting may be noticeable in menstrual bleeding.

The physical changes that accompany the menstrual cycle may also become less predictable and regular. Such signs as breast tenderness, fluid retention and headache may occur at unpredictable Verdana.

Fertility declines as a woman enters her 40s, but it does not disappear entirely until menopause is complete. To avoid unplanned pregnancies, doctors recommend using birth control until a full year has passed since the last menstrual cycle.

Muscle Tone and Elasticity

Skin and mucous membranes in various parts of the body become drier because of the decline in estrogen levels and the aging process in general. Women who once worried about oily skin may now find their skin dry and itchy and may need to apply moisturizers and hand creams.

As the body ages and the estrogen level declines, the fatty layer beneath the skin surface that makes the skin appear supple and youthful begins to shrink from a loss of elasticity and moisture. The outer skin layer is now looser than the deeper layers, and begins to fold and wrinkle. The skin may also develop a rougher texture.

During midlife, it is especially important to protect your skin from the sun. Aging skin produces less melanin, the pigment that causes your skin to tan instead of burn. This decreases your natural protection from harmful UV rays.

Thinning skin also reveals any harmful effects of previous years of sun exposure. Limiting sun exposure and using sunscreen is a prudent and effective way to delay aging of the skin.

Vaginal Changes are the first sign of approaching menopause for some women, while many do not notice changes until five to ten years after menopause. As estrogen levels drop, the vulva and vagina lose elasticity, resulting in vaginal dryness, itching and a shrinking process known as vaginal atrophy in which the vagina becomes shorter and narrower at the opening. Vaginal membranes also become thinner, hold less moisture, and lubricate more slowly. The thinner vaginal lining becomes more susceptible to tears. Reduced secretion of cervical mucus can add to the problem. The result of all these changes can be discomfort, vaginal infections, and painful intercourse.

Breast Changes are also apparent as estrogen's stimulation of the breast tissue is reduced, causing glandular tissue to shrink. Loss of elasticity causes the breasts to droop and flatten, losing their earlier fullness. Nipples become smaller and flatter and may lose their erectile properties.

Women who have been bothered by breast tenderness and cysts related to the menstrual cycle are often relieved to find that these symptoms disappear after menopause.

Abdominal wall tone may lessen gradually as we age, resulting in a protruding stomach. Regular exercise to strengthen the abdominal muscles can help maintain muscle tone.

A sudden increase in the size of the abdomen may be the first warning sign of ovarian tumors. Stomach enlargement may also be caused by inadequate nutrition or exercise, but should be seen promptly by your gynecologist.

Hair, Bones, and Teeth

Hair all over the body can change in texture and quantity during menopause. For some women, the increased effects of the body's androgens can result in darker, thicker and wiry body hair on the pubis, underarms, face, chest, lower abdomen, and back. This sprouting of excess, coarse hair, known as hirsutism, is usually related to hormonal changes. However, not all cases of hirsutism are menopause-related, so check with your physician for proper diagnosis.

The softer hair on your head also begins to change in texture as you reach your forties. A loss of luster occurs because individual hair shafts begin to thin and dry as a result of hormonal changes. The replacement process for normal daily hair loss becomes slower, and new replacement hair is generally dryer, with less shine. Many women also note a thinning of pubic and underarm hair after menopause. Female baldness, a rare problem, may begin about age forty. See a dermatologist if hair loss persists.

Changes in hair texture and thickness can be minimized by avoiding over-styling. Good nutrition can also slow the brittleness of hair that comes with normal aging.

Bone strength is critical at all ages but particularly during and after menopause. As estrogen and progesterone levels fall drastically, the bones begin to lose mass. This causes them to become progressively more fragile. Backaches, common in midlife, may indicate the beginning of bone loss as a result of declining estrogen levels. These pains are localized, beginning in the lower back. Severe loss of bone becomes a condition called osteoporosis, which strikes at least half of all women age 50 and older. In fact, by the time a woman is 80, she may have lost 40 percent of her bone mass. Osteoporosis leaves a woman vulnerable to bone fractures, especially in the hip, spine, and wrist.

Teeth and the mouth are similarly affected. Dental problems that can occur around midlife, such as receding gums or loose teeth, may be related to declining levels of estrogen and a loss of bone mass. Gingivectomy, a procedure to repair the gums after periodontal disease, is a common oral surgery procedure for women in midlife, especially for those prone to osteoporosis. Maintenance of your teeth and gums, including daily cleaning, and flossing, professional cleaning and regular checkups, will help reduce your risk of these dental problems.

"Classic" Menopausal Changes

Hot flashes, flushes, or night sweats are the most common characteristics of menopause. Some women experience a simple warming sensation throughout the body. Others feel acute flushes that begin with a sensation of pressure in the head similar to a headache, which then leads to a feeling of heat or burning in the face, neck, and chest, followed immediately by an outbreak of sweating. In most cases, hot flashes are mild and disappear after a year or two. But the frequency can vary from 1 or 2 a week to 1 or 2 per hour, and a few women experience them acutely for as long as 2 or 3 years.

The exact physiological cause of this upset in body temperature control is not yet known. Low estrogen levels alone are not responsible; it appears that estrogen must be present, and then withdrawn, for hot flashes to occur. The feeling may be precipitated by a hormonally induced imbalance in the body's temperature- control center, resulting in a drop in core body temperature and a subsequent attempt by the body to activate heat centers to re-adjust the body's "thermostat." (See the next chapter for a discussion of remedies.)

Short term memory loss has been cited as a problem by women in midlife, although this phenomenon has not been carefully documented and memory lapses have not as yet been linked to changing hormone levels during menopause. Forgetfulness may be related to stress or lack of sleep. Anecdotal reports suggest that memory problems in the perimenopausal period tend to disappear after menopause. If the problem persists, you should see your doctor.

Emotional issues loom large for many women during menopause, but contrary to previous conventional wisdom, studies now show that there is no increase in serious psychiatric disorders in women experiencing menopause. Minor emotional distress, however, may be a natural response to the changes a woman faces during this period.

Two changes in physical function that occur around the time of menopause may take a particularly heavy toll on a woman's psychological state. Hot flashes may keep you up at night, leading to chronic sleep deprivation which can reduce your mental and coping abilities. Vaginal changes that result in painful intercourse may interfere with your sexual pleasure and psychological health. There may also be other factors, currently unknown, that create coping challenges for women in the years immediately surrounding menopause.

Weight gain, while a common occurence around menopause, has not been shown to be directly related to hormonal changes. There is a natural redistribution of fat over the abdomen and hips. That may be due in part to changes in the endocrine system; but weight gain most likely results from reduced muscle tone, reduced physical activity, increased appetite and calorie intake, and other effects of the aging process. Increased physical activity and a nutritious, balanced diet, can minimize weight gain.

Heart Health

Women rarely die of heart disease before menopause because estrogen provides protection against it -- partially by helping to keep cholesterol levels in check. For reasons not completely understood, there is a relationship between hormone levels and the development of the plaque-like substances inside the blood vessels that can cause blockage and lead to heart disease.

A women's risk of cardiovascular disease rises dramatically after menopause. Surgical menopause likewise increases the risk for heart disease, even in young women. In fact, the younger a woman is when her ovaries stop functioning, the greater her risk for heart attack and although women tend to worry more about breast cancer, heart disease is considerably more lethal -- it is the number one killer of American women. One in seven women, ages 45 to 64, has some form of heart disease. This number increases to one in three over the age of 65.

Thus menopause itself is a risk factor for cardiovascular disease, along with high blood pressure, smoking, family history, poor diet, high blood cholesterol, diabetes, and obesity. Hormone replacement therapy (HRT) may help to promote cardiovascular health; but reducing the risk factors that are within your control can be equally important. Proper nutrition, regular exercise, maintaining your proper weight, and quitting smoking are key strategies for ensuring your cardiovascular health during midlife and beyond.

Bladder Control

Women in peri- and postmenopause may experience mild stress incontinence, defined as the loss of a little urine in response to sudden muscular stress, such as jogging, sneezing, coughing, laughing, or emotional distress. Many women also experience urge incontinence, the sensation that they need to urinate with great urgency, even though the bladder may be empty. These problems occur when declining estrogen levels cause cell deterioration and diminished muscle control in the urethra, bladder, and vagina.

Severe incontinence problems are rare and are not related to menopause. If incontinence goes beyond the mild form usually associated with menopause, you should see your doctor for proper diagnosis and treatment. (See the next chapter for exercises that help prevent or treat incontinence.)

Repeated urinary tract infections (UTIs), are also common in menopausal women. The deterioration of cells in the urinary tract produces an easily torn and bruised surface, creating an hospitable environment for the bacteria that cause UTI.

Mid-Life Medical Checkup

Most women will live many vital, useful, and enjoyable years after menopause. To stay healthy during this phase of life, preventive health measures and medical care are needed. When the signs of mid-life changes begin to appear, it's a good reminder to set up an appointment for a thorough medical checkup. A good relationship with a doctor who is aware of your health history and personality can give you an excellent resource to turn to when questions about menopausal signs and symptoms arise.