MENOPAUSE: Common Problems and Their Remedies

T he effects of hormonal gyrations during the years surrounding menopause can be extremely powerful and disconcerting. This is especially true if a woman interprets the changes as signaling the "end of life" rather than a "change of life." Three or four generations ago menopause did signal the beginning of the end. In 1900, the average age of menopause was 46, and the life expectancy of women was 51. But today, most women can expect to live one-third of their lives after menopause. According to medical expert Dr. Leon Speroff, "the menopause should and can mark the beginning of a new and promising period of life, relatively free from previous obligations, ready for new career choices, more education, and new ventures."

Many of the upsets of the menopausal period can be regarded as temporary inconveniences that most women find they can manage quite well on their own. A good understanding of what is happening to your body and how other women cope with these changes can help with the adjustment. So can an understanding doctor who can make recommendations tailored to your particular problems, health history, and life-style.

There is no totally "normal" menopause; each woman experiences this transition somewhat differently. A woman's final menstrual period commonly occurs between ages 45 and 55, but the process that leads up to menopause occurs gradually, easing the body's adjustment to shifting hormonal patterns. Women are affected in varying degrees by the uncomfortable symptoms that can accompany menopause, such as irregular menstrual cycles, hot flashes, disturbed sleep patterns, vaginal discomfort, and the emotional difficulties these problems can cause.

Some women barely notice the changes and experience no interruption in their daily routines, but about 60 percent of women approaching the age of menopause experience some symptoms due to biochemical changes taking place within. Symptoms often subside naturally as the menopausal years progress. Other women experience symptoms suddenly or very intensely, and seek medical relief for their debilitating effect.

This chapter focuses on the most common symptoms of the menopausal period and the non-pharmaceutical strategies that can relieve them. A discussion of pharmaceutical remedies can be found in the chapter on hormone replacement therapy.

Irregular Menstrual Cycles

A change in your menstrual pattern is usually the first sign of menopause. During the time referred to as perimenopause, which for some women can last as long as 5 or even 10 years, the menstrual cycle is likely to become less predictable. Some women notice changes as early as their late 30s.

Because the decline of ovarian function occurs gradually, only 10 to 15 percent of women experience an abrupt cessation of menstruation. During this time, women whose periods do stop abruptly are apt to get a pregnancy test. It's important to note that pregnancy can occur, even amidst irregular cycles, so to ensure greatest accuracy, a blood test is recommended over standard urine tests.

For most women the change is more gradual, with a steady decrease in both the amount and duration of menstrual flow, until it eventually ceases to occur. Typically, the transition takes about four years. During this time, it may become difficult to keep track of your menstrual cycles, with periods occurring late or early, cycles being skipped, and the flow becoming heavier or lighter than previously experienced. This unpredictability is usually the biggest inconvenience of irregular cycles.

Irregular and longer cycles occur as hormonal regulators become less reliable. As menopause nears, the periods become further apart and the flow becomes lighter. If menstruation doesn't occur for 6 months to a year, menopause probably has occurred. If you have vaginal bleeding after a prolonged lack of menses you should see your doctor; it could be a sign of disease.

More frequent or heavier bleeding may also be experienced during the menopausal years. This occurs when estrogen continues to stimulate the uterine lining, while production of the progesterone needed to counteract its growth declines. Thus, when the lining is shed, the flow is much heavier than usual. Cigarette smoking and excessive alcohol intake can make a woman more susceptible to heavy irregular bleeding.

Declining ovulation may also shorten the menstrual cycle, so that periods come so close together that you bleed throughout the month. A 7 to 10 day menstrual period is not uncommon and bleeding between periods may also occur. Any unusual menstrual patterns should be evaluated by your doctor, to make sure they are truly due to changing hormone levels, rather than such conditions as fibroid tumors, polyps, uterine cancer, or cervical cancer.

To Stay In Control

Once medical problems are ruled out, the challenge for a woman with unpredictable menstrual patterns is to find ways of decreasing the inconvenience.

One method is to keep track of your cycles with an ongoing written record. This allows you to notice overall patterns in a system that seems to have gone completely awry. It also provides you with a record to bring to your doctor for evaluation. Making quick notes on your calendar may make the process less tedious.

To keep a log, note the beginning and end of your cycle, the type of flow, and when any accompanying symptoms, such as cramps, sore breasts, or bloating, occur. Also note bleeding that occurs at any time other than the end of your monthly cycle.

Even women who keep a chart, however, may still be taken by surprise by unexpected menstruation. Many women in this predicament find it helpful to continue to keep some form of sanitary protection handy at home, and in their purse.

If heavy bleeding becomes an ongoing problem, discuss the condition with your doctor. Depending on your individual case and where you are in the menopausal process, possible medical remedies include low dose birth control pills to regularize the menstrual cycle and reduce bleeding; progesterone therapy to cause regular monthly shedding of the uterine lining; and hormone replacement therapy. If the bleeding is associated with uterine fibroids (benign tumors), your doctor may recommend surgical removal of either the fibroids or the entire uterus (hysterectomy).

Body Temperature: Hot Flashes, Hot Flushes

The most common symptom of the perimenopausal period is an upset in the body's thermostat that results in episodes of warmth and flushing. Although the hot flash or flush can cause discomfort, it does not in and of itself, present a health hazard and does not indicate disease.

Your first hot flash can be a startling experience. It may begin like a headache, with a pressure in the head, or as a sudden sensation of intense warmth. The "flash" increases in intensity until a feeling of heat or burning occurs in the face, neck, and chest. Your skin may redden and increase in temperature by as much as seven degrees. You may feel an urgent need to remove a sweater, jacket, or nightgown, and cool yourself by grabbing for a fan, throwing off covers, or standing by an open window. An outbreak of sweating, particularly affecting the upper body, may immediately follow the hot flash. Sweating cools down the skin temperature, causing the shivers. Less common symptoms which may accompany a hot flash include palpitations, weakness, fatigue, faintness and vertigo.

Hot flashes vary in frequency, intensity and duration. The average length of a hot flash is 4 minutes, though it can last from a moment to as long as 10 minutes. Frequency varies from 1 to 2 an hour to 1 to 2 a week.

Hot flashes trouble three-fourths of women experiencing natural or surgical menopause. However, only 10 to 15 percent of women find them debilitating. Eight out of 10 women who experience hot flashes get them for more than a year, but only 25 percent get them for more than 5 years. Hot flashes can occur as early as age 42. Heavier women tend to experience hot flashes less often, perhaps due to the estrogen produced in fatty tissue.

For some women, a hot flash is not unbearable and they easily go on with their daily routine. For others, it can be an intolerable disruption to their lives. The greatest problem the hot flash brings about is disturbed sleep patterns. A women experiencing regular hot flashes may wake several times, or even hourly, during the night. Some women wake up sweating profusely, in a phenomenon known as night sweats, and need to change the sheets or their night clothes.

Sleep deprivation affects people differently. A profound sleep disturbance may cause memory disorders or make concentration difficult. Some women feel anxiety, or suffer from fatigue or muscle aches. Lack of sleep can also cause a woman to cry easily and feel mentally and physically exhausted.

Coping with Hot Flashes

For the majority of women, hot-flash symptoms begin to subside within four to six years after their last menstrual period. Studies have shown that women who exercise are less likely to experience hot flashes. Among smokers, however, the incidence rises, probably due to the effect smoking has on the hormonal output of the ovaries.

Though there is no way to eliminate hot flashes short of drug therapy, many women develop ways to cope that help them get through the experience gracefully. For example, they learn not to wear turtlenecks or they switch from wool to cotton sweaters. Dressing in layers that can be quickly removed when feeling warm is also a good idea.

Embarrassment and concerns about what others are thinking is a common reaction. To allay your worries, you might ask a friend, or your spouse, to give you an accurate picture of how you look when experiencing a hot flash. As intense as it feels to you, close observers may not even realize that you appear slightly flushed and moist. If this is the case, ignoring the experience during a business meeting or other public event may be the best course.

On the other hand, if you perspire so profusely that it is obvious to others, you may want to plan what you will do if a hot flash strikes at an inconvenient time. It may be best to excuse yourself and head for the ladies' room, or to be prepared with a brief joke or explanation to ease yourself through the moment. With over 40 million American women set to experience menopause in the next 2 decades, public understanding of hot flashes is likely to expand. Though you may not be able to predict when the next one will occur, you can be prepared to react. Confidence, patience, self-assurance and a sense of humor will help ease the frustration.

Hot flashes lead more women to seek professional medical assistance than any other symptom of menopause. Estrogen therapy is the principal treatment eliminating hot flashes quickly and completely. Beneficial results include an end to the symptoms and thus relief from the constant awakening that can end in chronic sleep deprivation. Restored sleep patterns bring measurable improvements to memory, as well as decreased anxiety and irritability.

Other medications, such as clonidine (Catapres TTS) also have been studied for effectiveness against hot flashes. If you cannot or do not wish to take hormone replacement therapy, ask your doctor about alternative medications. But be aware, that like all drugs, these can cause side-effects about which you should be informed.

Mood Swings

There is no increase in severe psychiatric illness in women during or after menopause. Indeed, depression is less -- not more -- common among middle-aged women.

Some psychological symptoms, however, do tend to occur around menopause. Emotional problems may arise in the period just preceding menopause, and decline one to two years into the postmenopausal period. It is unlikely that these symptoms are indeed related to changing hormonal levels. Fatigue, nervousness, headaches, insomnia, depression, irritability, joint and muscle pain, dizziness, and heart palpitations are among the symptoms women frequently report to their doctors.

Some emotional disturbances can be associated with the sleep deprivation that occurs as a result of hot flashes. Changing sexual patterns due to untreated vaginal atrophy can also be psychologically distressing for some women. Other changes at this point in life, such as children leaving home, career disappointments, or fear of aging, can also induce bouts of emotional turmoil.

The value of estrogen therapy for psychological complaints is not established, but a woman's outlook can often be improved simply by relief from hot flashes, insomnia, and vaginal atrophy.

Coping with Emotional Changes

Anticipating the physical and emotional changes likely to occur during menopause can help you get through this time with a minimum of friction and despair. Many women find that simply identifying the fact that they are in a bad mood or feeling irritable helps them and those around them adjust to a temporarily difficult situation. It also helps to distinguish trivial annoyances that get blown out of proportion because of moodiness from the real sources of anger and frustration. Some women call a "time out" when they are feeling out of sorts and delay any discussion of serious issues for another time. A chance to discuss emotional and physical symptoms with other women also undergoing menopause can provide support and comfort. Reading books and magazine articles about other women's menopausal reactions can also help.

After menopause, many women report what anthropologist Margaret Mead identified as "postmenopausal zest." This sense of well-being, hard-won individuality, and positive attitude toward life propels women into an especially rewarding period of their lives. So it can be comforting for women undergoing unpredictable mood swings to realize that there's something to look forward to a little further down the road.

Vaginal Discomfort

Because estrogen plays such a significant role in a woman's reproductive system, the decline in estrogen that accompanies menopause brings significant changes in all the reproductive organs. Some women begin to experience vaginal problems during perimenopause, but for most, it does not become a problem until five to ten years after menopause.

As a woman ages, lubrication of the vagina in response to sexual arousal, occurs more slowly. With the drop in estrogen the vaginal lining becomes thinner, drier and less elastic, and over time, the vagina shrinks. Burning and itching sensations may signal vaginal dryness which can be aggravated by reduced secretion of cervical mucus. All of these factors can cause pain or bleeding during intercourse, known medically as dyspareunia.

In addition, these changes make the vagina more vulnerable to injury because the tissues are more easily traumatized. This, in turn can increase the likelihood of local bacterial infection.

These difficulties can lead to a steep decline in sexual desire because of discomfort, embarrassment, or misinformation. However, for couples who adjust to the situation by using slower, gentler sexual techniques and vaginal lubricants, it need not be a problem. In fact, an active sexual life can help maintain vaginal health, as well as having a positive impact on a couple's self-esteem.

Coping with Vaginal Changes

The best way to combat vaginal dryness is to remain sexually active throughout life. Regular sex increases blood flow to the vagina, stimulating the mucous membrane and exercising the surrounding muscle. A study of postmenopausal women found that women who achieved orgasm by any means 3 or more times a month were less likely to suffer vaginal atrophy than those who had intercourse less then 10 times a year.

Using over-the-counter vaginal lubricants can make intercourse more comfortable. Water soluble lubricants such as K-Y Lubricating Jelly, or vaginal moisturizers such as Replens are recommended. Avoid oil-based lubricants, such as petroleum jelly or baby oil; because they are not easily cleaned away, they are a breeding ground for bacterial infection.

Hormone replacement therapy is also an effective cure for vaginal dryness. Estrogen cream applied locally also restores the lubricating capacity of the vagina. However, estrogen cream carries the same risks as oral or transdermal estrogen. (See chapter 31, "Hormone Replacement Therapy: Weighing the Pros and Cons.")

Treating vaginal dryness can keep it from devastating a woman's sex life. Sexual responsiveness reaches a peak for women in the late 30s and remains on a high plateau into the 60s. Some women even discover an increase in desire after menopause. They find sex more enjoyable without the fear of unwanted pregnancy and the interruptions caused by contraception and menstruation.

Preventing Bladder Problems

Lower estrogen levels also cause a loss of muscle tone and control in the bladder and urethra. When stress is put on the bladder -- due to sneezing, coughing, laughing or jogging -- a momentary loss of control can occur resulting in a small amount of leakage. Called urinary stress incontinence, this problem is more likely to occur in women who have had one or more children.

Urge incontinence can also be a problem for some women. It takes the form of a sudden overwhelming feeling of having to go to the bathroom even when the bladder contains very little urine. Whichever the type, urinary incontinence usually does not go beyond the mild condition associated with perimenopause. Nevertheless, it's important to see your doctor for an accurate diagnosis.

Kegel Exercises

Mild urinary stress incontinence is a temporary problem that can be controlled. Kegel exercises, named after the doctor who invented them, help to strengthen the pelvic floor, and are usually effective for those who do them diligently. This easy-to-do exercise can be done anywhere, without anyone being aware of it.

Locate your pelvic muscles by contracting the vaginal opening as if trying to stop the flow of urine. Hold the contraction for a count of ten, relax and repeat. You may not be able to maintain this squeeze, but with practice the muscles will get much stronger. Another method is to alternately contract and relax the muscles quickly. Repeat a series of 10 muscle contractions several times each day, for a total of 50 to 100 contractions.

Making these exercises part of your daily routine is probably all you need to restore bladder control. To help alleviate urge incontinence, delay trips to the bathroom as much as possible. This will aid in restraining reflex responses. Urge incontinence and mild stress incontinence are frequently eliminated by hormone replacement therapy.

Other Menopausal Symptoms

More than 50 symptoms have been blamed on the hormonal changes of the menopause. Because a proven link between these symptoms and declining estrogen levels has not been established, some believe that they have other origins. Symptoms that are thought to be clearly not a result of menopause are: weakness, anorexia, nausea, vomiting, gas, constipation, and diarrhea.

Unexplained symptoms are often attributed to anxiety or other emotional imbalances, but much research is yet to be done. What follows summarizes the current thinking on symptoms women commonly ask about.

Weight Gain

Women do tend to gain weight during menopause, but this has not been linked to hormonal changes nor to hormone replacement therapy. The cause is more likely a combination of reduced physical activity, declining muscle tone, possibly increased caloric intake, and other effects of aging. Increased physical activity and a nutritious, balanced diet can minimize weight gain.

Breast Changes

If your breasts are sore throughout your cycle, it may be due to hormonal changes not unlike those in pregnancy, when breast tenderness is also a problem. Women who have experienced breast tenderness related to their menstrual cycle are often relieved to find that symptom disappears after menopause.

Itchy Skin

Some women experience a prickling, itching sensation on the skin, known as formication. It has been called "crawling skin" because it feels as though tiny insects are marching along your body. One study shows that the greatest incidence of formication occurs 12 to 24 months after the last menstrual period. Though the cause is unknown, it has been linked with menopause. Eventually this symptom disappears on its own.

Memory Loss

There does not appear to be a direct relationship between memory loss and menopause. However, the problem has been linked with the sleep deprivation that often accompanies "night sweats." Some reports suggest that memory problems in the perimenopausal period tend to disappear after menopause. If problems persist, you should see your doctor.

Problem Vision

Visual capacity, such as the ability to read road signs at night, has been reported to decline by a sample of menopausal women. This change has not been systematically studied, and can not as yet be directly linked to hormonal changes during menopause.