Symptoms associated with the menopause transition

| May 1, 2008

In-Depth Report

Menopause: Managing the change of life

What is menopause?

Menopause and your life

Symptoms associated with the menopause transition

Hot flashes
Vaginal changes
Irregular uterine bleeding
Other physical and mental changes at midlife

Menopause and healthy living

Hormones and disease

Treating menopausal symptoms

Living with menopause

Glossary

Resources

Symptoms associated with the menopause transition

You could argue that the physical and mental changes that occur during menopause aren't really "symptoms." The term is usually associated with a disease, which menopause is not. Also, it is often hard to say which changes are a direct result of a drop in hormone levels and which are natural consequences of aging. Some of the symptoms overlap or have a cascade effect. For example, vaginal dryness may contribute to a lower sex drive as intercourse becomes painful, and frequent nighttime hot flashes may be a factor in insomnia.

A 2005 report from the Agency of Healthcare Research and Quality concluded that hot flashes and vaginal dryness are the two symptoms most frequently linked with menopause. The report, which included data from 48 different studies, found that other symptoms commonly attributed to menopause, such as urinary complaints, sexual dysfunction, mood changes, and deteriorating quality of life, are not consistently associated with the hormone changes seen with menopause transition.

Each of the symptoms listed below is followed by treatment suggestions.

Hot flashes

Also called vasomotor symptoms, hot flashes may begin in perimenopause, or they may not start until after the last menstrual period has occurred. On average, they last three to five years and are usually worse during the year following the last menstrual period. For some women they go on indefinitely.

Hot flashes probably begin in the hypothalamus, a part of the brain that controls body temperature. For reasons that remain obscure, the thermostat in a midlife woman's body is suddenly reset at a temperature lower than normal. The hot flash is the body's way of cooling itself, like the way a refrigerator kicks on when you open the door on a hot day.

What is a hot flash?

Women have endured the discomfort and embarrassment of hot flashes for centuries. Yet it wasn't until 1975 that this hallmark of menopause came under scientific scrutiny. A study that year in the Journal of Applied Physiology documented physiological changes that occurred during hot flashes — skin temperatures rose and fell, sweating occurred, and the heart rate increased by 13% at the beginning of a flash. The 1975 study finally put to rest the notion that hot flashes were more imagined than real.

A variety of studies have shown that the prevalence of hot flashes varies greatly among different cultures. The phenomenon has been studied most often in white women in Western cultures. But additional studies have examined hot flashes among women in Japanese, Filipino, Indian, Mayan, and Native American cultures, to name a few. While up to 80% of American women have hot flashes, Japanese women have a much lower prevalence. In Mexico's Yucatan peninsula, Mayan women do not report hot flashes. Researchers have speculated as to whether these variations are the result of differences in diet, exercise, perceptions of hot flashes, or other cultural factors. However, answers remain elusive.

The biggest mystery about hot flashes is the physiological mechanism that causes them in the first place. It's commonly accepted that hot flashes are associated with decreasing estrogen, but there's more to it than that. Before puberty, girls have low estrogen but no hot flashes. Conversely, women in the late stages of pregnancy may have hot flashes at a time when their estrogen levels are high

Researchers have examined the complex interactions that occur among more than a dozen hormones and other substances during hot flashes, but as yet they haven't arrived at any clear-cut conclusions about how or if they cause hot flashes. However, the secretion of many of these hormones is regulated in the brain by the hypothalamus, which houses the body's thermoregulatory center. Researchers believe that something happens in this center that causes the body's thermostat to be altered. The result is a hot flash, a feeling of excessive warmth if the body gets just a little overheated. In an attempt to cool itself, the body perspires and blood vessels dilate, sometimes causing skin to turn pink or red. After a brief time, maybe a few minutes, the heat dissipates, often leading to chills.

Source: Adapted from Freedman, RR. Seminars in Reproductive Medicine 2005; 23 (2): 117-125.

Research has at least helped explain why some women have hot flashes and others don't. Researchers found that women who have hot flashes have a lower tolerance for small increases in the body's core (innermost) temperature than women who don't have hot flashes. The body tries to maintain its core temperature within a comfortable "thermoneutral zone." When your core temperature rises above the zone's upper threshold, you sweat; when it drops below the lower threshold, you shiver. Women who don't have hot flashes have a thermoneutral zone of several tenths of a degree centigrade. But in women with hot flashes, this thermoneutral zone is extremely narrow. As a result, small variations in core body temperature that don't trouble some women trigger hot flashes (and chills) in others.

What causes the thermoneutral zone to narrow? One idea is that elevated levels of the brain chemical norepinephrine are involved. Norepinephrine has been shown to reduce the thermoneutral zone in animals. The fact that the drug clonidine, which lowers norepinephrine, widens the zone in women with hot flashes supports this notion. This is true for estrogen and certain antidepressants as well, although scientists still don't understand all the mechanisms.

Hot flashes can be extremely troubling for the 10%-15% of women who have the most severe form. Women who have had surgical menopause or those who are taking tamoxifen to prevent breast cancer are often in this unfortunate group.

Women experience hot flashes differently. The outward signs of a hot flash — sweating and turning red in the face — tell the world that a woman's estrogen production is dwindling. But these are not obvious in all women. Heart palpitations and feelings of anxiety, tension, or a sense of dread also may accompany hot flashes; some women say they feel agitated or unsettled right before a hot flash occurs. Some feel warm; others complain of burning up. A lot of women feel chills afterward. Hot flashes that occur during sleep, called night sweats, may disrupt sleep, causing fatigue and mood changes.

Treating hot flashes. Depending on their severity and how much they affect your day-to-day activities, you can take several steps to help alleviate hot flashes. Begin with a commonsense approach. Some possible triggers of hot flashes are hot beverages, spicy food, warm air temperatures, stressful situations, alcohol, caffeine, and some medications. If you can identify your own triggers, you may be able to avoid some hot flashes. Keep a diary to note which of these or other triggers were present before each hot flash. Review it each week to pinpoint the most common triggers.

During the day, dress in layers so that you can take off garments when needed. If possible, regulate the air conditioning and heat in your environment to accommodate your temperature changes. Wash your hands in cold water as soon as you notice a hot flash. If you wake up hot at night, sleep in a cool room. Go to bed with a frozen cold pack under your pillow, and turn the pillow over when you wake up. Keep a change of nightclothes next to your bed so that you can change easily if you wake up soaked.

Some women find deep-breathing exercises helpful. Research suggests that a technique called paced respiration can cut in half the frequency of hot flashes. To perform paced respiration, take slow, deep, full breaths — expanding and contracting the abdomen gently while inhaling and exhaling — at a rate of about six to eight breaths per minute. One of the best ways to learn paced respiration is by taking a yoga class. Practice this technique twice a day for 15 minutes. You can also use paced respiration whenever you feel a hot flash coming on. Stress-relief techniques and biofeedback may also be of some benefit.

Increasing the soy in your diet has been shown to be helpful in some but not all studies. Over-the-counter (OTC) remedies that some women find helpful include preparations of black cohosh. One product sold under the brand name Remifemin is manufactured in Germany and approved by its regulatory agency. However there have been recent rare reports of liver problems related to black cohosh.

There are many other OTC products containing plant estrogens (phytoestrogens), but many have not been scientifically evaluated for either safety or efficacy. Some women report that vitamin E is helpful, but compelling evidence to support this is lacking.

It is important to remember that all of the hot flash studies using a placebo show that at least 25%–30% of women respond to the placebo. That's worth knowing before you spend money on OTC remedies. In addition, most hot flashes wax and wane, although the summer months can be especially difficult.

Short-term hormone therapy is effective in treating hot flashes. Doctors now prescribe lower doses than they did previously because of health risks of these medications. If you can't or don't want to take hormones, you may find that an antidepressant such as venlafaxine (Effexor) or fluoxetine (Prozac) helps. Certain antihypertensive medications such as clonidine (Catapres) relieve hot flashes in some women. An antiseizure medication, gabapentin (Neurontin), has also shown some promise. Talk with your clinician about which medication may be right for you, and remember that most hot flashes improve over time on their own.

Vaginal changes

Decreased estrogen causes the vaginal lining to thin and vaginal secretions to diminish. The vagina becomes shorter and narrower. The result often is dryness and irritation, which can make sexual intercourse unpleasant and sometimes painful. Inflammation of the vaginal wall also may occur, a condition called atrophic vaginitis. It isn't an infection, but if it is not treated, further thinning and ulceration of the vagina may occur; this can cause bleeding or make intercourse or pelvic exams uncomfortable at best and intolerable at worst. It is important to keep in mind that there are a variety of conditions other than menopause that can cause vulvovaginal irritation and painful intercourse, so consulting a clinician is wise.

Treating vaginal changes. A simple vaginal lubricant for intercourse such as Astroglide or Silk-E may be all that is needed. A vaginal moisturizer such as Replens is another option. Estrogen treatments applied directly to the vagina in the form of creams, rings, and tablets are quite effective. Also, experts say regular sexual stimulation can help keep the vagina healthy by maintaining its elasticity and blood supply.

Irregular uterine bleeding

A pear-shaped organ about the size of a fist, your uterus is made mostly of muscle. As you move through perimenopause, your uterus shrinks slightly, and the inner layer of tissue, or endometrium, no longer builds up and sheds on a predictable monthly cycle. Changes in the menstrual cycle are a hallmark of perimenopause, so determining what's normal and what isn't can be a challenge for women and their clinicians. Only 10% of women stop having periods with no irregularity in their cycles.

Uterine bleeding: What's normal, what's not

One concern for perimenopausal and postmenopausal women is knowing whether irregular uterine bleeding is normal. Most women notice changes in their cycle as they approach menopause. Periods are often heavy or more frequent, and they may stop and start. But abnormal uterine bleeding may be a sign of benign gynecologic problems or even uterine cancer. Consult your physician if any of the following situations occur:

You have a period that last three days longer than usual.

You have a few menstrual cycles that are shorter than 21 days.

You bleed after intercourse.

You have heavy monthly bleeding (soaking a sanitary product every hour for more than a day).

You have spotting or bleeding between periods.

You have bleeding that occurs outside the normal pattern associated if you are using hormones.

When you report abnormal vaginal bleeding, your clinician will try to determine whether the cause is an anatomic problem (such as a polyp, fibroids, or other abnormal tissue growth) or a hormonal issue (lack of ovulation). He or she also will investigate the possibility of cancer, if indicated. In addition to identifying the cause, he or she will help you manage any excess bleeding, which sometimes leads to anemia.

One condition that may cause abnormal uterine bleeding is endometrial hyperplasia, a precancerous condition of the lining of the uterus (endometrium). Other possible explanations include fibroids, benign uterine tumors that may enlarge during perimenopause and decrease in size after menopause; endometrial polyps, which are benign growths in the uterine lining; and thyroid disorders, which can cause either too much or too little bleeding. Some contraceptives may also cause bleeding between periods or changes in bleeding patterns.

Postmenopausal women who are not taking hormones should not have vaginal bleeding and should seek medical care if they do. But it is normal for women who take hormone therapy in continuous doses to experience bleeding or spotting during the first several months of taking these medications. And women on cyclic hormone regimens sometimes have light monthly bleeding. Vaginal bleeding outside the usual pattern for hormone therapy in a postmenopausal woman is always a cause for concern...

On rare occasions, postmenopausal women experience uterine bleeding from a "rogue ovulation," This vaginal bleeding after a hiatus that may be preceded by premenstrual symptoms such as breast tenderness. Presumably, the ovaries are producing some hormones and maybe a final egg.

Diagnosing abnormal bleeding. Your physician may use any or all of the tests below to diagnose abnormal bleeding:

Endovaginal (transvaginal) ultrasound. This painless procedure uses a small, tampon-sized transducer, or probe, inserted in the vagina to generate ultrasound images of the uterus and measure endometrial thickness and look for fibroids or other uterine abnormalities. If the endometrium is thickened, the next step may be an endometrial biopsy, hysteroscopy, or sonohysterogram to obtain a more complete diagnosis.

Sonohysterography. The doctor performs this test like an endovaginal ultrasound, by inserting an ultrasound probe in the vagina. The probe transmits images of the uterus and uterine lining. The difference is that a saline solution is introduced through a thin tube to expand the uterus for better viewing. Your physician can measure uterine thickness and identify polyps and other abnormalities inside the uterus.

Endometrial biopsy. Usually performed in a physician's office, this procedure involves inserting a thin tube through the vagina and cervical opening to remove a sample of the endometrium with a suction device. The tissue is analyzed to rule out cancer or a precancerous condition. Even though endometrial biopsy usually is performed without anesthesia, many women find it uncomfortable or painful. Taking an over-the-counter pain reliever can help before and after the procedure. In some cases, doctors use sedation or anesthesia. (This procedure, along with those below, has all but completely replaced the outmoded dilation and curettage, or D and C, which was done in the past to evaluate abnormal uterine bleeding).

Hysteroscopy. In this procedure, the doctor uses a thin fiber-optic tube, or hysteroscope, to obtain a direct view of the uterus. After numbing the cervical area with a local anesthetic, the doctor inserts the tube through the vagina and cervix and introduces a liquid or gas to expand the uterus so it can be seen clearly through the scope. This is called a diagnostic hysteroscopy. In a more extensive procedure called operative hysteroscopy, the doctor can take tissue samples or remove polyps or fibroids, usually with a regional or general anesthetic.

Irregular periods

In the early stages, your menstrual cycle may shorten, with periods beginning sooner than you expect. Maybe your periods used to come every 28 days, exactly at 3:15 p.m. Now, they may still come at 3:15 p.m., but the cycle is every 24 or 26 days. But any pattern is possible. Bleeding also may become lighter or heavier. Skipping a period means you will probably be menopausal in two years. Going for three months without a period suggests menopause is at hand although more than 20% of women have regular periods again after such a break.

These irregular patterns may be exacerbated by other gynecologic problems common in midlife — for example, uterine growths such as polyps or fibroids. Women also should keep in mind that until they have been a year without a period they are still potentially fertile.

Pregnancy during perimenopause

Fertility rates begin dropping steeply between ages 35 and 38 and fall to less than 1% by age 50. While pregnancy isn't common in 40-something women, it does occur. In fact, unintended pregnancy rates are actually higher among women in their 40s than in any other age group, including teenagers. It's one reason some women use oral contraceptives during perimenopause.

There are women in their 40s who want to become pregnant but cannot. The success rates of medical fertility treatments (such as in vitro fertilization) decline as a woman gets older. Also, there is a higher likelihood of miscarriage and genetic abnormalities in a baby born to an older mother. Using donor eggs from a younger woman has extended the maximum age at which women can carry a pregnancy.

Treating troublesome periods. Treatment varies depending on the underlying cause of the bleeding. Your clinician may just monitor you and suggest iron if you are anemic from excess bleeding. For women whose periods become very irregular, prolonged, or heavy, doctors often prescribe birth control pills, which can make periods lighter and more regular. Alternatively, intermittent doses of progestogen (a version of progesterone, the hormone that causes the uterine lining to slough) may be helpful for women who are having intermittent bleeding and who are not ovulating. Some women find it helpful to take nonsteroidal anti-inflammatory pain relievers such as ibuprofen (Advil, Motrin) and naproxen (Aleve). An intrauterine device (IUD) called Mirena, which secretes a low dose of the progestogen levonorgestrel, can help control excess or unpredictable bleeding caused by irregular ovulation or hormonal problems. In addition, a variety of procedures can stop excess bleeding by destroying the endometrial lining of the uterus; these include thermal (heat) and cryo (cold) therapies. Operative hysteroscopy or sometimes hysterectomy is needed. Talk with your doctor about your symptoms to determine the best approach.

What about hysterectomy?

Hysterectomy is less common than it used to be, although it remains the most common non-obstetrical surgery in the United States. More than a third of these surgeries are done to treat abnormal uterine bleeding or fibroids. One in three women in the United States has a hysterectomy by age 60. Removing only the uterus in a premenopausal woman can accelerate menopause by as much as two years. When the ovaries are removed with the uterus, menopause occurs immediately.

Reasons for hysterectomy. More than 90% of hysterectomies are done for noncancerous conditions, such as uncontrollable uterine bleeding, fibroids, endometriosis (in which tissue from the uterine lining adheres outside of the uterus), chronic pelvic pain, some precancerous conditions, and uterine prolapse (in which the uterus drops from its normal position into the vagina). The remainder is done to treat cancer of the uterine lining, ovaries, or cervix. Currently, no universally accepted criteria exist for when a hysterectomy is warranted for some conditions. Unless your condition is potentially life-threatening, talk to your physician about whether a hysterectomy is really necessary. It's always a good idea to get a second opinion. The fact that hysterectomy rates are far higher in the southern United States compared with the northeastern states and other countries such as the United Kingdom suggests that factors unrelated to medical necessity may be at work.

Types of hysterectomy. In an abdominal hysterectomy, the surgeon makes an incision several inches long in the abdominal wall, just above the pubic bone, and removes the uterus through the incision. In a vaginal hysterectomy, the uterus is removed through the vagina, via an incision made in the vaginal wall. In some cases, the surgeon may use a laparoscopic technique, which involves several small incisions in the abdomen and the insertion of a thin, flexible tube called a laparoscope to view the pelvic organs. The uterus is removed through one of the small incisions or through the vagina. Because of the smaller incisions, recovery time is shorter and scars are smaller. Hospitalization can be as short as one day.

Standard hysterectomy

The hysterectomy procedure. You will usually have general anesthesia. Your airway will be kept open with a small tube, and a catheter will be placed in your bladder. You'll probably receive an antibiotic to reduce the risk of infection. During the surgery, tissues that attach the uterus to the pelvic wall are cut, and the uterus is separated from the top of the vagina. Some or all of the cervix may be removed, depending on why you are having the surgery. If cancer isn't a concern, some women feel that keeping part of the cervix helps them maintain sexual function. Be sure you know what surgery is planned for you. According to the Centers for Disease Control and Prevention, 78% of women ages 45–64 who have hysterectomies also have their ovaries removed at the same time, a procedure known as oophorectomy. The ovaries are routinely removed in women who have ovarian cancer or suspicious ovarian tumors. Women known to have rare, inherited types of breast or ovarian cancer sometimes have their ovaries removed to reduce their risk of these cancers. And women who have severe endometriosis often have oophorectomies, both because estrogen from the ovaries can promote the growth of any remaining endometriosis, and because endometriosis on the ovaries can spread to other organs. But oophorectomy can worsen menopausal symptoms and increase a woman's susceptibility to osteoporosis and heart disease. A 2005 study in Obstetrics and Gynecology found that for most women, these increased risks overshadow the small benefit of preventing ovarian cancer, which is very rare. Be sure to have a conversation with your surgeon about your ovaries.

After the surgery. You will no longer have monthly menstrual periods, and you won't be able to become pregnant. As you recuperate, give yourself time to heal physically, and emotionally. Studies show a high level of satisfaction among women who choose hysterectomy. But it is a personal decision, and one that should be made after considering all the alternatives.

Other physical and mental changes at midlife

Some common midlife changes that are often attributed to menopause are not necessarily related to the fluctuating or decreasing hormone levels of menopause. The four most commonly reported changes include mood changes and/or depression; insomnia or other sleep problems; cognitive and/or memory problems; and decline in sexual desire, function, or both. Other physical changes that crop up in the middle years include weight gain, urinary incontinence, heart palpitations, dry skin hair changes (growth or loss), and headaches. For these, a hormonal link is possible, but has not been proved. Consider the fact that men, who don't experience a dramatic drop in hormone levels in their early 50s, often notice many of these same symptoms!

Mood swings and depression

Studies indicate that mood swings are more common during perimenopause, when hormonal fluctuations are most erratic, than during the postmenopausal years, when ovarian hormones stabilize at a low level. No direct link between mood and diminished estrogen has been proved, but it is possible that mood changes result when hormonal shifts disrupt established patterns of a woman's life.

Over their lifespan, women have more depression than men. But there is no evidence that decreased estrogen alone causes clinical depression. In fact, a study in Psychosomatic Medicine in 2001 found that menopausal status is not associated with symptoms of depression, such as feeling sad, irritable, anxious, or hopeless. Although women who have had previous episodes of depression may be vulnerable to a recurrence during perimenopause, menopause in and of itself does not cause clinical depression. The incidence of depression in postmenopausal women is not any higher than at any other time in life.

Disrupted sleep from night sweats can cause a woman to feel fatigued and irritable. Also, remember that perimenopause coincides with many of life's stresses — children who are teenagers or leaving home, peaking professional responsibilities, illness or death of elderly parents, and aging itself. These events, combined with unpredictable hormonal changes, can leave a woman feeling fatigued, overwhelmed, and out of control.

Treating mood swings. Many women choose to make lifestyle changes before turning to medications. Taking care of yourself by getting more sleep, exercising regularly, and using stress-control methods can all help even out your mood. For an herbal approach, St. John's wort may have some mood-elevating effects, although studies have been conflicting. Prescription antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), effectively moderate moods.

Memory and concentration problems

During perimenopause, women often complain of short-term memory problems and difficulty with concentration. Some earlier observational studies found that women ages 65 and older who had been taking estrogen therapy had higher scores on tests of mental functioning than did women who had not used estrogen. But the Women's Health Initiative found that hormones seemed to increase the risk of dementia and cognitive problems. And other research suggests that stress may be more closely linked with memory problems than hormonal fluctuations.

Treating memory and concentration problems. Just as it isn't clear what causes memory and concentration problems, there is no obvious remedy. Regular physical exercise may be the best answer. People who engage in moderate intensity exercise most days of the week maintain higher cognitive abilities compared to people who are sedentary.

Also, brain and memory experts suggest that people with these issues work to keep their brain functioning at its peak by taking on new and interesting challenges. Use your mind in many different ways. Do crossword puzzles. Learn a new musical instrument or sport. Play chess. Read more books. Learn a new language or how to use the computer. The idea is to challenge your brain in new ways.

Insomnia

Disrupted sleep is a common complaint during perimenopause—and as we age in general. Whether hot flashes during sleep cause sleep disruption is not completely clear. Some women report that they perspire so profusely that they soak the bed linens and wake up. Others sleep right through their hot flashes. At least one study showed that hot flashes disrupt the most restorative form of sleep, known as REM, even if the woman doesn't wake up. Sleep apnea, which can interfere with sleep, has been shown to get worse after menopause.

Insomnia also can be a problem for women who don't have hot flashes. Some women may have difficulty falling asleep, but a common pattern is to sleep for a few hours, awaken too early, and not be able to fall back to sleep. Whether sleep disruptions are due primarily to hormonal changes is currently unknown. Sleep cycles change as people age, and insomnia is a common age-related complaint. The problem is a troublesome one that can leave sleep-deprived women fatigued, tense, irritable, and moody. Insomnia is not a trivial matter, as sleep problems also have been associated with heart attacks and congestive heart failure.

Treating insomnia. Medications are available for temporary treatment of insomnia, but you can also take some practical steps to improve your chances of getting a good night's sleep. If hot flashes are keeping you awake, trying a treatment for hot flashes may also improve your sleep.

Sweet dreams

With age come changes in sleep stages and reduced levels of chemicals that promote sleep, such as melatonin and growth hormone. At midlife, hot flashes seem to rob some women of much-needed sleep. Maintaining healthy sleep habits can help.

Wake up and go to sleep at about the same time every day, even on weekends.

Avoid caffeine or alcohol within three hours of bedtime.

Avoid exercise close to bedtime; it can overstimulate you.

Stop smoking.

Stay cool in the evening — don't take hot showers or baths before bed.

Use the bed only for sleep or sex.

Relieve stress, depression, or anxiety with exercise or relaxation techniques. If sleep problems persist, psychotherapy or medication may help.

Keep the bedroom quiet and at a comfortable, cool temperature when you sleep.

Use ear plugs and an eye mask to eliminate distractions.

Seek treatment for conditions such as arthritis or congestive heart failure that can disrupt sleep.

If this is an ongoing problem, ask your physician about having a sleep evaluation study.

Low sexual desire

Sex drive may decline at midlife for a variety of reasons. Diminished estrogen or age-related changes in circulation may reduce blood flow to the genitals and cause a decrease in sensation. Vaginal dryness or thinning can make intercourse painful. And women who have sleep problems may feel too fatigued to be interested in sex. Urinary incontinence may cause embarrassment that diminishes the appeal of sex. Concern about changes in physical appearance and body image can also reduce sex drive. Orgasm may be less intense and harder to achieve.

A 2001 study in Fertility and Sterility showed that during perimenopause, not only did women's sexual responsiveness decline, but their partners also had a significant increase in sexual performance problems. As a result, women in the study said they didn't feel quite as warmly toward their partners as they had earlier in the relationship. As women in the study entered the postmenopausal years, they reported further decreases in sex drive, sexual responsiveness, and frequency of intercourse. They also had more pain during intercourse and said their partners' performance problems had worsened.

Sex drive may be more closely associated with testosterone (a type of androgen) than with estrogen, and it's long been assumed that low blood testosterone levels lead to low sexual desire. However, a 2005 study in the Journal of the American Medical Association found no link between blood androgen levels and sexual function. There is much more to be known about female sexuality. And sexual identity is highly individual. The good news is that many women continue to enjoy their sexuality for decades after menopause.

Treating low sexual desire. Some women with low sexual desire appear to benefit from estrogen. Testosterone replacement is another option; however, in late 2004, the FDA refused to approve a new testosterone patch for women, citing a lack of long-term safety data. The patch and other drugs designed to enhance desire, sensation, or both are still under study. But it's important to realize that libido isn't driven by hormones alone. It's quite possible that, as Ann Landers has said, "The most important sex organ is the brain." Lifelong perceptions about sex and the quality of relationships also have a profound impact on women's sexual function at midlife. Some women don't have a partner. Relationship issues may affect a woman's interest in sexual activity (for example, a husband who is unemployed while his wife is working). Some have partners who are themselves suffering from sexual dysfunction; this, too, may play a role in the woman's declining interest in sex. Talking with your partner about each of your needs and expectations can go a long way toward helping solve this problem. If talking is too difficult, counseling with a trained sex therapist can help pave the way.

Weight gain

Although weight gain is a significant issue for a lot of women in this age group, there's no clear evidence that it's a direct result of hormone changes or even age. A 2004 study in the American Journal of Epidemiology of more than 3,000 women found no link between menopausal status and weight gain or an expanding waistline. Instead, the classic middle-age spread seemed to stem from a variety of factors, including the fact that older women (and men) are simply less physically active. There is also some speculation that weight gain in midlife is due, in part, to a slowdown in metabolism.

Treating overweight. Many strategies are available for losing weight. For women who have yet to gain excess weight, the best strategy is not a surprise—try to avoid gaining by exercising and eating right. Measure your waistline regularly and try to prevent any increase. Walking, swimming, or other aerobic exercise is your best bet because it helps prevent accumulation of fat at the waistline.

Urinary incontinence

Up to 30% of American women ages 50–64 have problems with urinary incontinence, compared with, at most, 5% of men in the same age group. The disproportionate impact on women is from the effects of vaginal childbirth on pelvic tissues and basic anatomical design differences between men and women.

Decreased estrogen may cause or contribute to thinning in the lining of the urethra, the tube that empties urine from the bladder. Problems may include a more frequent need to urinate, a sudden urge to urinate even though your bladder is not full, pain during urination, more urinary tract infections, the need to urinate more often during the night, and urine leakage when sneezing, coughing, or laughing. Urinary problems persist and worsen in postmenopause because changes in the urinary anatomy occur with general aging as well as estrogen loss. Some other causes of urinary incontinence include bladder and urethral infections, muscle weakness caused by aging or injuries during childbirth, and some types of prescription medication.

Treating incontinence. Bladder training may be useful for urge incontinence, that is, the need to go is so urgent that you can't get to the bathroom in time. This entails holding urine for five minutes after feeling the urge to void and increasing the holding period by five minutes each week. Eliminating diuretic beverages such as coffee, tea, and alcohol as well as citrus juice and other bladder irritants may also help. Pelvic floor exercises, known as Kegel exercises, can be effective. They involve repeatedly contracting and releasing the pelvic floor muscles used ordinarily to halt urination. Although estrogen was previously thought to help incontinence, research suggests that this isn't the case. Talk with your doctor about your treatment options, which include lifestyle habits, medications, and surgery. A urogynecologist is a specialist with training in woman's incontinence issues.

Heart palpitations

Some women have complained of heart palpitations during perimenopause. Heart rate has been shown to increase by 8–16 beats during a hot flash, but more research is needed to determine how heart rate may be affected by hormonal fluctuations during perimenopause in the absence of hot flashes.

Treating heart palpitations. Treatment depends on the cause of your heart symptoms. The role of hormones in regard to heart symptoms has not been well studied. Talk with your doctor about your symptoms and possible treatments.

Dry skin and hair

Many women experience dry skin and hair at midlife. While some research suggests that declining estrogen levels may contribute to dry skin, it may also be the result of cumulative sun exposure or smoking. With age, the skin's ability to retain water and produce oil diminishes, too. But there is little evidence that decreased estrogen is directly involved in causing skin to dry and wrinkle.

Treating dry skin and hair. Because these conditions are so common, many remedies are available. Protect your skin from sun exposure with sun blocks, hats, and clothing. Use moisturizers and hair conditioners, especially in the dry winter months. Buying a moisturizer is one case in which the old adage "you get what you pay for" doesn't hold true. Inexpensive and effective moisturizers are widely available and often equal or superior to high-end products. For instance, petroleum jelly is an inexpensive and highly effective moisturizer for skin that is extremely dry.

Headaches

Hormonal changes have been linked with headaches. It's not uncommon to hear premenopausal women complain of "menstrual migraines" around the time of their periods; some women who get migraine headaches say their migraines improve during pregnancy. Many women say their headaches get better or even stop in the postmenopausal years.

Headaches of all kinds can be triggered by a number of things, including smoke and pollen, alcohol, sleep deprivation, certain foods such as chocolate and aged cheeses, stress, and changing hormone levels. The erratic hormonal fluctuations that precede menopause can make some perimenopausal women especially susceptible to migraines. Women who have had frequent menstrual headaches may find that the problem worsens during perimenopause and some women get migraines for the first time.

Treating headaches. Treatment depends on the cause and type of headache. Try to identify your headache triggers and taking steps to avoid them. Talk with your doctor about what kind of medication may be best to treat your kind of headache. Other techniques, including biofeedback or acupuncture, may be helpful. Some experts find that timed supplemental estrogen can be helpful with cyclic headaches.

Two women, two choices

Just as every woman is unique, no two menopause experiences are exactly alike. Many factors can influence a woman's decisions regarding whether to try hormone therapy, at what dosage, and for how long. Severity of symptoms, family health history, lifestyle, and professional responsibilities all come into play, as the following two stories describe.

Sylvia: Stopping hormone therapy after 20 years

Sylvia, now a retired school psychologist, started taking Premarin (estrogen alone) in her late 40s and stayed on the drug for two decades. Like many women, she decided to quit after the results from the Women's Health Initiative (WHI) were released in 2002. After tapering off Premarin, she began having hot flashes every other day or so, but they gradually subsided over the next few years. This is Sylvia's story:

I decided to take hormones in part because of my mother. When she reached her mid-40s, she became very anxious and paranoid. Maybe it was a coincidence that these emotional problems surged as she approached menopause. But my father and I suspected the changes were related, at least in part, to her hormone levels. This was in the early 60s, when hormone therapy was just becoming popular. But my mother didn't like doctors or taking medication. Within four or five years, she began to return to her old self, but her difficult experience had a big effect on me.

When I reached my late 40s, I began feeling anxious. Because I'm a trained psychologist, I recognized that my symptoms were bordering on obsessive-compulsive disorder. I went to my gynecologist and told him that I needed something to help me calm down. He prescribed Premarin, and I tell you, within one month, I was back to my normal, calm self. Even stressful things didn't bother me. For example, I was vacationing in Greece and I lost my return plane ticket. Instead of panicking, I just dealt with the problem.

I remember being concerned about uterine cancer, because my maternal grandmother had died of uterine cancer at age 47. When I mentioned this to my doctor, he said, "Oh, we can take care of that if it happens. I'll just give you a hysterectomy!" Fortunately, that wasn't necessary.

I continued to take estrogen, and after I retired, I volunteered to participate in the Women's Health Initiative. Here's something I can do to help humanity, I thought. I was in the dietary-modification component of the study and was selected to follow a low-fat, high-fruit, -vegetable, and -grain diet, and I did that for another 10 years while staying on estrogen. Then, in 2002, I and all the other volunteers received a letter about the early termination of the hormone arm of the WHI because of the increased risk of heart disease and breast cancer.

I went online to find out more, and then went to see a new, younger, female gynecologist, because my other doctor had retired. She agreed that I should taper off the hormones. So that's what I did, cutting back to one pill every other day, then every third day, and then once a week. It took about six months to stop completely. Soon after, when I had my first hot flash at age 67, I wondered, did I do the right thing? I also got a little bit of the old anxiety back, but it's now gone away.

I noticed that I tended to get hot flashes when I was in a large group of people or when I was under stress. My husband didn't believe that I was really getting them until he saw the perspiration on my face!

I tried eating soy products, which are supposed to help. I was drinking two glasses of soy milk a day and eating lots of tofu salad. But it didn't really seem to make a difference. Now, after three years, I notice the hot flashes only occasionally, usually in the evenings. All in all, stopping the hormones wasn't really that difficult for me.

Nancy: Stopping and starting again

For 53-year-old Nancy, hot flashes were far more bothersome than a brief warm flush. When she entered menopause around age 49, her hot flashes became so frequent and severe they affected her professional life. As executive director of a nonprofit cancer organization, Nancy found that her daytime hot flashes made her uncomfortable and anxious. Nighttime hot flashes disrupted her sleep, leaving her exhausted and mentally foggy. After starting hormone therapy, she felt much better within weeks. She took a low-dose estrogen (.025 mg/24-hour Climara patch) plus natural progesterone (Prometrium) for a year and a half, but after she tapered off the medication, her hot flashes returned with a vengeance, and she began taking the hormones again. She plans to taper off again, sometime within the next year or so. This is Nancy's story:

For me, the decision to take hormones was a quality-of-life consideration. I understand that there's a slight increased risk, but my hot flashes were so disabling that taking hormones is absolutely worth it for me.

My work involves public appearances and occasional meetings with high-level politicians. As many women know, even a minimally stressful situation — talking to people whom you are trying to persuade, for example — can trigger a hot flash. I was totally unable to prepare for or control them. I needed to be clear-headed and responsive. But if I had a hot flash during an important meeting, I'd flush and sweat and my brain would do a little blip. It would undermine my confidence and effectiveness. But it wasn't just during the day. There was a period when I would get hot flashes every 20 minutes, like clockwork, between the hours of 2 and 4 a.m. I was exhausted all the time, which made my job even more challenging.

I started using a low-dose estrogen patch (Climara) and progesterone (Prometrium) tablets, as recommended by my gynecologist. She was extremely informative and walked through the information and statistical data on hormone therapy with me. Both are "bioidentical" hormones, the same as the ones made naturally by the body, which makes sense to me. After a while, the dose I was taking stopped working, so we upped it a little bit, which did the trick.

The results from the WHI came out after I had been taking hormones for about a year. Because of the work I do, the findings about breast cancer were not that surprising to me. I had already planned to start weaning myself off hormones at 12 months. But unfortunately, I wasn't "done" yet. My symptoms came back.

In this phase, I felt more misdirected anxiety connected to the hot flashes. For instance, I'd wake up with a hot flash and worry about something totally inconsequential. Part of this could have been connected to the fact that I was under significant personal stress at the time, as both a family member and a co-worker were dying of cancer.

I started on an antidepressant, which I had heard helped some women with hot flashes. This medication helped me get through a difficult six months, but the hot flashes did not subside. I'm a big believer in the mind-body connection and I meditate regularly, usually 20 to 30 minutes every morning. I also do yoga and deep-breathing exercises. But these habits had no effect on my symptoms — in fact, the hot flashes interrupted my practice.

I've tried some other alternatives, including Estroven, an herbal product that contains phytoestrogens. I took the recommended dosage for a full six weeks, but it had no effect. Neither did 400 mg of vitamin E, which I took twice a day for weeks. I had intended to try acupuncture and Chinese herbs, but I was at my wit's end and instead went back on hormones because I knew it would help me. We have a lot more information on the side effects of hormones than the possible side effects of many different herbs. I feel that I am making an informed decision.

My grandmother died of breast cancer when she was in her 40s. She was the inspiration for the work I do. My mother also died young, of heart disease, so I don't know whether she might have developed breast cancer. Because of my family history, and the fact that I didn't have children, I realize that I may have a higher-than-average risk of breast cancer. That plays into my decision of being cautious about using hormones. I am planning to taper off again. But if I try to quit and find that the hot flashes haven't subsided, I won't hesitate to go back on the hormones. Hormone therapy has made that big a difference in my quality of life.

Review Date: 2008-05-01

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