By Vicki Erwin-Wilson, MD

Menopause is a natural occurrence with its hallmark being a “pause in the menses.” The process usually occurs in the 40s and 50s, though this is variable(in general, when periods stop without surgery before age 40, this is termed “premature menopause”). When a hysterectomy is performed before natural menopause, this produces an immediate cessation of menstruation. But if the ovaries are left in, the hormones associated with the menstrual cycle continue to be produced cyclically, and many of the menstrual symptoms persist. A total hysterectomy with oophrectomy produces immediate surgical menopause, and may be associated with acute onset of menopause symptoms, like hot flashes and mood swings, unless hormone replacement takes place. In general, menopause is a gradual process that occurs over several years, with onset of noticeable symptoms as many as 10 years before ovaries stop producing estrogen and progesterone. Symptoms are extremely variable from woman to woman, and may include hot flashes or night sweats, mood swings, decreased sex drive, irregular heart beats or “palpitations,” vaginal dryness, menstrual irregularity until periods cease, skin and hair changes. Loss of bone mass, which can lead to osteoporosis and fractures, is a common occurrence after menses stop, and the greatest loss usually occurs in the year or two after the ovaries stop their hormone production. Usually, the mood swings and hot flashes, when present, will eventually subside, but may take two to five years after the ovaries cease their hormone production and periods stop.

In recent years past, it was felt that benefits of estrogen and progesterone supplementation outweighed potential risks, by keeping bones strong, and making the cardiovascular system more like that of a young, menstruating woman. However, a large study released in the summer of 2002 indicated a greater risk of hormone supplementation than was previously thought to exist, and less cardiovascular benefit. The biggest benefits of hormone supplementation include maintenance of bone density and amelioration of many of the menopause symptoms. Risks include blood clotting, lipid abnormalities, and possibly increased risk of some types of cancer. Uterine cancer risk is increased if estrogen is taken without progesterone by a woman with a uterus. The risk of hormone replacement causing breast cancer is unclear, though many forms of breast cancer are clearly estrogen or progesterone sensitive, and rate of progression may be increased by taking hormones after menopause. Symptoms of menopause may be controlled without drugs by eating a diet high in fruits and vegetables, exercising regularly, drinking plenty of water, and dressing comfortably, with layered clothing. There are also supplements that may be helpful, including soy, evening primrose oil, black cohash, and others. If hormone replacement is chosen, there are many forms, including creams, patches, pills, and shots. Regimens may be cyclic, with estrogen continuously and progesterone for part of the month, or continuous, with both hormones taken daily. Testosterone may also be useful in some cases to help with hot flashes and sex drive. Which of these is appropriate for each individual should be addressed with her personal health care provider.

Regardless of symptoms and treatments, it is helpful for peri- and post-menopausal women to eat a healthy diet, with adequate calcium from food or supplements, and to get regular exercise. Bone density may be monitored periodically by a bone density scan. If declines in bone density occur, there are medications that can help, and sometimes these are used for prevention of bone loss before it occurs. Breast health should be monitored by monthly breast self-exams, yearly exams by a trained health care provider, and routine mammograms. Keep in mind that menopause is a natural process, and not an illness. Many women experience a great deal of freedom after their periods cease, and can be extremely happy and productive in the post-menopausal years. A positive attitude may be the most important ingredient for easing into this new stage of life.