Menopause and Perimenopause

Overview

What is menopause? What is perimenopause?

Menopause is the point in a woman's life when she has not had a menstrual period for 1 year. Menopause marks the end of the childbearing years. It is sometimes called 'the change of life.'

For most women, menopause happens around age 50, but every woman's body has its own timeline. Some women stop having periods in their mid-40s. Others continue well into their 50s.

Perimenopause is the process of change that leads up to menopause. It can start as early as your late 30s or as late as your early 50s. How long perimenopause lasts varies, but it usually lasts from 2 to 8 years. You may have irregular periods or other symptoms during this time.

Menopause is a natural part of growing older. You don't need treatment for it unless your symptoms bother you. But it's a good idea to learn all you can about menopause. Knowing what to expect can help you stay as healthy as possible during this new phase of your life.

What causes menopause?

Normal changes in your reproductive and hormone systems cause menopause. As your egg supply ages, your body begins to ovulate less often. During this time, your hormone levels go up and down unevenly (fluctuate), causing changes in your periods and other symptoms. In time, estrogen and progesterone levels drop enough that the menstrual cycle stops.

Some medical treatments can cause your periods to stop before age 40. Having your ovaries removed, radiation therapy, or chemotherapy can trigger early menopause.

What are the symptoms?

Common symptoms include:

• Irregular periods. Some women have light periods. Others have heavy bleeding. Your menstrual cycle may be longer or shorter, or you may skip periods.
• Hot flashes.
• Trouble sleeping (insomnia).
• Emotional changes. Some women have mood swings or feel grouchy, depressed, or worried.
• Headaches.
• Feeling that your heart is beating too fast or unevenly (palpitations).
• Problems with remembering or thinking clearly.
• Vaginal dryness.

Some women have only a few mild symptoms. Others have severe symptoms that disrupt their sleep and daily lives.

Symptoms tend to last or get worse the first year or more after menopause. Over time, hormones even out at low levels, and many symptoms improve or go away. Then you can enjoy being free from periods and birth control concerns.

Do you need tests to diagnose menopause?

You don't need to be tested to see if you have started perimenopause or reached menopause. You and your doctor will most likely be able to tell based on irregular periods and other symptoms.

If you have heavy, irregular periods, your doctor may want to do tests to rule out a serious cause of the bleeding. Heavy bleeding may be a normal sign of perimenopause. But it can also be caused by infection, disease, or a pregnancy problem.

You may not need to see your doctor about menopause symptoms. But it is important to keep up your annual physical exams. Your risks for heart disease, cancer, and bone thinning (osteoporosis) increase after menopause. At your yearly visits, your doctor can check your overall health and recommend testing as needed.

Do you need treatment?

Menopause is a natural part of growing older. You don't need treatment for it unless your symptoms bother you. But if your symptoms are upsetting or uncomfortable, you don't have to suffer through them. There are treatments that can help.

The first step is to have a healthy lifestyle. This can help reduce symptoms and also lower your risk of heart disease and other long-term problems related to aging.

• Make a special effort to eat well. Choose a heart-healthy diet that is low in saturated fat and includes plenty of fish, fruits, vegetables, beans, and high-fiber grains and breads.
• Include plenty of calcium in your diet to help your bones stay strong. Get 1,200 mg a day after age 50 (plus at least 400 IU of vitamin D to help your body use the calcium). Low-fat or nonfat dairy products are a great source of calcium.
• Get regular exercise. Exercise can help you manage your weight, keep your heart and bones strong, and lift your mood.
• Limit caffeine, alcohol, and stress. These things can make symptoms worse. Limiting them may help you sleep better.
• If you smoke, stop. Quitting smoking can reduce hot flashes and long-term health risks.

If lifestyle changes are not enough to relieve your symptoms, you can try other measures, such as:

• Meditative breathing exercise (called paced respiration). Breathing exercises may help reduce hot flashes and emotional symptoms.
• Black cohosh. This herb may prevent or relieve symptoms. But experts don't know about its long-term safety. You should not take it if there is a chance you could be pregnant. If you plan to try black cohosh, talk to your doctor about how to take it safely.
• Soy (isoflavones). Some women feel that eating lots of soy helps even out their menopause symptoms. It may also help keep your bones strong after menopause.¹
• Yoga or biofeedback to help reduce stress. High stress is likely to make your symptoms worse.

If you have severe symptoms, you may want to ask your doctor about prescription medicines. Choices include:

• Low-dose birth control pills before menopause.
• Low-dose hormone replacement therapy (HRT) after menopause.
• Antidepressants.
• A medicine called clonidine (Catapres) that is usually used to treat high blood pressure.

All medicines for menopause symptoms have possible risks or side effects. A very small number of women develop serious health problems when taking hormone therapy. Be sure to talk to your doctor about your possible health risks before you start a treatment for menopause symptoms.

Remember, it is still possible to become pregnant until you reach menopause. To prevent an unwanted pregnancy, keep using birth control until you have not had a period for 1 full year.

Health Tools

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I use estrogen replacement therapy (ERT) after a hysterectomy and oophorectomy?
	Should I use hormone replacement therapy (HRT)?
	Actionsets are designed to help people take an active role in managing a health condition.
	Menopause: Managing hot flashes

Frequently Asked Questions

Cause

Natural and expected hormone changes cause perimenopause, menopause, and postmenopause.

Perimenopause

As you age, your body begins the natural sequence of changes that eventually bring an end to your menstrual cycle (menopause). The number and quality of your eggs decline, hormone levels fluctuate, and your menstrual cycle becomes less predictable. This time of unpredictable change is called perimenopause.

Menopause and postmenopause

After a few years of fluctuating hormones, your estrogen and progesterone levels begin to decline. When your estrogen drops past a certain point, your menstrual cycle and your ability to become pregnant end. After 1 year with no menstrual bleeding, you reach menopause and begin postmenopause.

A year or more into postmenopause, estrogen levels typically even out at a low level. Since estrogen also plays a role in other functions of your body, its decline has far-reaching effects, including faster bone loss and drying and thinning of the skin and the vaginal and urinary tracts.

Menopause can be caused suddenly and prematurely by surgical removal of the ovaries (oophorectomy), by chemotherapy, or by radiation therapy to the abdomen or pelvis.

Causes of early menopause

Your body has its own timeline for when menopause will start and how long it will last. In fact, it's likely that your timeline will be much like your mother's was. But certain lifestyle choices and medical treatments can cause or are linked to an earlier menopause, including:

• Smoking. On average, women who smoke reach menopause 1½ years earlier than those who don't. The longer you have smoked and the more you smoke, the stronger this effect is likely to be.²
• Radiation therapy to or removal of the pituitary gland.
• Chemotherapy.
• Radiation therapy or other treatment to the abdomen or pelvis that damages the ovaries so that they no longer function.
• Genetic and autoimmune diseases.
• Removal of both ovaries (oophorectomy), which causes sudden menopause.
• Living at high altitudes.²
• A vegetarian diet.²
• Low body fat (body mass index of 25 or less).

Symptoms

Although some women have few or no menopause symptoms, most women do. Similarly, while some women have mild symptoms, others find that their sleep, daily life, and sense of well-being are severely affected. Menopause symptoms eventually subside when hormone levels even out. Postmenopause changes are normal signs of low estrogen and typically continue over time.

Signs and symptoms of perimenopause

Signs that you are in perimenopause include:

• Irregular menstrual periods.
• Less frequent, light menstrual periods.
• Heavier menstrual periods than you are used to having.

Symptoms of menopause

Symptoms related to menopause are caused by changing or dropping hormone levels and usually end 1 or 2 years after menopause. Some women continue to have symptoms for 5 or more years afterward. Menopause symptoms include:

• Hot flashes.
• Sleep disturbances (insomnia).
• Emotional changes, such as mood swings or irritability.
• A change in sexual interest or response.
• Problems with concentration and memory that are linked to sleep loss and fluctuating hormones (not a permanent sign of aging).³
• Headaches.
• Rapid, irregular heartbeats (heart palpitations).
• Generalized itching.

These symptoms are not only caused by menopause. They can be caused by other medical problems. If your symptoms are troubling you, talk with your doctor.

Menopause caused by surgery, chemotherapy, or radiation therapy can cause more severe symptoms than usual. Preexisting conditions such as depression, anxiety, sleep problems, or irritability can get worse during perimenopause.

Signs of postmenopause

Signs that you have reached menopause and are in postmenopause include:

• No menstrual periods (and no need for birth control measures).
• Drying and thinning of the skin, caused by lower collagen production.
• Vaginal and urinary tract changes, such as:
  • Vaginal dryness, irritation, and itching.
  • An increased risk of vaginal and urinary tract infections (UTIs).
  • Pain during sexual intercourse (dyspareunia).

Other conditions can cause changes in the menstrual cycle or symptoms resembling perimenopause and postmenopause. Examples include pregnancy, a significant change in weight, depression, anxiety, disease, or uterine, thyroid, or pituitary problems.

What Happens

In your late 30s, your egg supply begins to decline in number and quality. As a result, your hormone production changes-you may notice a shortened menstrual cycle and some premenstrual syndrome (PMS) symptoms that you didn't have before.

Perimenopause

As your egg supply continues to decline, your ovulation and menstruation become irregular. This can start as early as your late 30s or as late as your early 50s. It continues for 2 to 8 years before menstrual cycles end. During this time, your ovaries are sometimes producing too much estrogen and/or progesterone and at other times too little. Your progesterone is likely to fluctuate more than before, which can lead to heavy menstrual bleeding. (If you have heavy or unexpected vaginal bleeding, see your doctor to be sure it is not caused by a more serious condition.)

Menopause

About 6 months to a year before your periods stop, your estrogen starts to drop. When it drops past a certain point, your menstrual cycles stop. After a year of no menstrual periods, you are said to have "reached menopause."

Postmenopause

During the first year or so after menopause, estrogen levels continue to decline. It's normal to continue having symptoms, such as hot flashes or insomnia, during the first year or two after menopause. After your hormone levels reach a stable low point, these symptoms are likely to subside. But some women continue to have symptoms for years, perhaps because their estrogen levels are particularly low. (After menopause, body fat tissue continues to produce estrogen. Women with low body fat tend to have lower estrogen levels.)

Low estrogen is part of the healthy, natural state of postmenopause. Low estrogen reduces your cancer risk (estrogen is linked to some types of cancerous cell growth). But because it also plays an important role in skin and bone health, low estrogen creates some health concerns for the postmenopausal woman.

• Bone loss. Low estrogen levels after menopause speed bone loss, increasing your risk of osteoporosis.
• Skin changes. Low estrogen leads to low collagen, which is a building block of skin and connective tissue. It's normal to have thinner, dryer, wrinkled skin after menopause. The vaginal lining and the lower urinary tract also thin and weaken. This condition can make sexual activity difficult and can increase the risk of vaginal and urinary tract infections.
• Tooth and gum changes. Low estrogen affects connective tissue, which increases your risk of tooth loss and possibly gum disease.⁴

Although the reasons are not well understood, a woman's risk of heart disease increases after menopause. Because heart disease is the number one killer of women, consider your heart risk factors when making lifestyle and treatment decisions.

When to Call a Doctor

During perimenopause or postmenopause, call your doctor about:

• Menstrual periods that are unusually heavy, irregular, or prolonged (1½ to 2 times longer than normal).
• Bleeding between menstrual periods, when periods have been regular.
• Renewed bleeding after having no periods for 6 months or more.
• Unexplained bleeding while you are taking hormones.
• Perimenopause symptoms, such as insomnia, hot flashes, or mood swings, that aren't responding to home treatment and are interfering with your sleep or daily life.
• Vaginal pain or dryness that does not improve with home treatment, or you have signs of a urinary tract infection.

If you have concerns about osteoporosis risk and prevention, talk to your doctor during your next office visit.

For more information, see the topics Abnormal Vaginal Bleeding, Dysfunctional Uterine Bleeding, and Osteoporosis.

Watchful Waiting

Menopause is a normal process of hormone change and doesn't require treatment. If your menopause symptoms are mild, try home treatment for relief. Discuss your symptoms with your doctor at your next regular exam.

Who to See

The following health professionals can help you manage menopause symptoms and evaluate menstrual period changes:

• Family medicine doctor
• Gynecologist
• Internist
• Nurse practitioner
• Physician assistant

Exams and Tests

You and your doctor can tell whether you are in perimenopause based on your age, your history of menstrual periods, your symptoms, and the results of your pelvic exam. If possible, bring a calendar or journal of your menstrual period and symptoms.

If you have severe symptoms before or after menopause, if your doctor suspects another medical condition, or if you have a medical condition that makes a diagnosis difficult, your doctor may do one or more of the following tests:

• A pregnancy test is done if there is a chance that you are pregnant.
• A follicle-stimulating hormone (FSH) test can be used to confirm whether you have reached menopause. FSH levels increase during perimenopause and are high after menopause.
• An estrogen test is sometimes done to see how low estrogen has dropped after menopause.
• A thyroid-stimulating hormone test is used to see whether irregular menstrual periods or perimenopause-like symptoms are being caused by a thyroid problem.

If you have had no menstrual periods for 1 year, you have reached menopause and are in postmenopause. This is a good time to have a full physical exam, with particular focus on your heart health and risk factors for osteoporosis. Be sure to report to your doctor any unexpected vaginal bleeding.

Unexpected vaginal or menstrual bleeding

If you have irregular bleeding during perimenopause or you are taking continuous hormone therapy and have vaginal bleeding after 6 to 12 months of treatment, your doctor may use one or more additional tests to rule out serious causes of the bleeding. These tests may include:

• Transvaginal ultrasound to look for growths or structural abnormalities of the uterus.
• Endometrial biopsy to see whether the uterine lining (endometrium) is acting normally during the menstrual cycle and to check for signs of cancer.

For more information, see the topics Abnormal Vaginal Bleeding and Dysfunctional Uterine Bleeding.

Bone mineral density screening for osteoporosis

All women age 65 and older should have a routine bone mineral density test to screen for osteoporosis. If you are at increased risk for osteoporosis, your routine screening should begin earlier, at age 60. If you have stopped hormone therapy, it is very important to discuss osteoporosis screening with your doctor. This is because you no longer have the extra bone protection from extra estrogen.

Most experts say that the decision to screen women age 60 and younger should be made on an individual basis. This decision depends on your risk for developing osteoporosis and whether the test results could help with treatment decisions. For more information, see the topic Osteoporosis.

Treatment Overview

Menopause is a natural change that doesn't require treatment. But symptoms of hormonal change can be difficult. If you have insomnia, mood swings, hot flashes, cloudy thinking, heavy menstrual periods, or other menopause symptoms, treatment can help you manage this transition more comfortably. As you review your options, consider the following:

• Healthy lifestyle habits will help you reduce menopause symptoms. These habits include eating a balanced diet; reducing stress; getting regular exercise; and avoiding smoking, heavy caffeine, and heavy alcohol use. An unhealthy lifestyle can make symptoms worse.
• Low-dose hormone therapy (HT) or low-dose birth control pills may be an option if you are still having periods and have multiple or severe symptoms. Birth control pills aren't used after menopause because they contain higher levels of hormones than women need.
• After menopause, hormone therapy can be used as a short-term treatment for severe symptoms when taken in as low a dose as possible.
• You may only need a specific treatment for certain symptoms, such as hot flashes or vaginal dryness.
• Meditative breathing or supplements such as black cohosh or soy may help relieve symptoms.

Research has led to a big change in how doctors use hormone therapy after menopause. For a long time, estrogen-progestin, or hormone replacement therapy (HRT), was thought to protect against heart disease or dementia. But studies now show that HRT use can cause serious health problems in a small number of women. These health problems include dangerous blood clots, stroke, heart disease, breast cancer, ovarian cancer, and dementia.^{5, 6, 7} The heart disease risk does not seem to affect women during their first 10 years after menopause.⁸

Average HRT- and ERT-related risks are low among the general population of women. But your personal risk that hormone therapy may stimulate breast cancer, ovarian cancer, cardiovascular problems, blood clots, or neurological changes may be lower or higher, depending on your risk factors for those health problems.

Treatment options for menopause symptoms

Hot flashes. Meditative breathing exercises (paced respiration) have been shown to reduce hot flashes.⁹ Medicines that can improve hot flashes include short-term, low-dose hormone therapy, antidepressants, the high blood pressure medicine clonidine, and the antiseizure medicine gabapentin (Neurontin).^{10, 11}

Heavy periods. The hormone progestin can help relieve heavy menstrual bleeding caused by very low or very high progesterone levels (after you have an exam to rule out other possible causes). Other options include nonsteroidal anti-inflammatory drugs (NSAIDs), the levonorgestrel (LNg) IUD, or birth control pills. For severe blood loss, some women choose permanent surgical treatment. These options include removing the uterus (hysterectomy) or using heat energy to damage and scar the wall of the uterus (endometrial ablation). For more information, see the topic Dysfunctional Uterine Bleeding.

Vaginal dryness and irritation. A vaginal lubricant can help with dryness. Low-dose vaginal estrogen can help if your symptoms are thin skin, dryness, and/or irritation. Less estrogen is absorbed into your system with vaginal use, so the risks associated with ERT are less likely.

Multiple or severe symptoms. Hormone therapy can relieve multiple or difficult menopause symptoms. For symptom relief before menopause, low-dose estrogen-progestin birth control pills or low-dose HRT (estrogen-progestin) can reduce heavy menstrual bleeding and other symptoms. After menopause, low-dose HRT is an option. Also, for severe symptoms that don't improve with estrogen-progestin, there is an estrogen-testosterone therapy. But testosterone is not FDA-approved for women, because it is not yet well studied. Talk to your doctor about short-term HRT along with checkups every 6 months.

Bioidentical hormone replacement therapy (BHRT) is an alternative to HRT. But it has not been well studied. The hormones are made in a laboratory from wild yams or soy. BHRT is thought to be more similar to human-produced hormones than synthetic HRT is. (Well-designed studies have not yet proved this theory.¹²) But bioidentical HRT may carry the same heart, stroke, blood clot, breast cancer, ovarian cancer, and dementia risks that are linked to traditional HRT. Any form of hormone therapy, including BHRT, is best taken for as short a period as possible after menopause.

Should I use hormone replacement therapy (HRT)?

Testosterone is sometimes used to increase sexual desire in postmenopausal women who have low testosterone. But the U.S. Food and Drug Administration (FDA) has not approved testosterone treatment for this purpose. There is no testosterone product that comes in doses that are right for women. Studies of testosterone in women have not lasted longer than 6 months.¹³ FDA experts want to know more about long-term risks before they approve testosterone for use by females.

If you have a problem with low sexual desire, consider that most sexual problems in women relate to such things as relationship troubles, depression, or medicine side effects. For more information, see the topic Sexual Problems in Women.

Other treatment options

Women may also try alternative medicine to relieve menopause symptoms. These alternatives may include black cohosh (Remifemin) or dietary soy. For more information about alternative treatments, see the Other Treatment section.

Hormone Therapy: A Shift in Thinking

Changes in hormone replacement therapy (HRT)

Over the past decades, hormone replacement therapy (HRT) was thought to offer health- and youth-preserving benefits to postmenopausal women. But recent studies have led to a dramatic shift from this way of thinking.

One large study done by the Women's Health Initiative (WHI) has shown that HRT does not protect against heart disease. In fact, in a small number of women who are 10 or more years past menopause, it causes heart disease, including heart attacks.⁸ In the WHI study, short-term use of HRT was also linked to an increase in the numbers of strokes and blood clots. Using HRT for several years was linked to increased cases of breast cancer and dementia. Overall, most women using HRT in the WHI study had no serious side effects, but they also had no long-term benefits.

Among all women, average hormone therapy risks are very low. Your personal risks may be lower or higher than the average. This depends on your risk factors for breast cancer, ovarian cancer, cardiovascular problems, blood clots, or dementia.

Based on the WHI study, the U.S. Food and Drug Administration (FDA) has updated its HRT recommendations. Estrogen-progestin HRT is approved for:

• Short-term treatment of menopause symptoms. HRT effectively relieves menopause symptoms for most women. Women who decide that HRT benefits outweigh their risks are advised to use the lowest effective dose for as short a time as possible.⁹ For most women, menopause symptoms naturally improve within a few years' time, making long-term symptom treatment unnecessary.
• Osteoporosis prevention and treatment, in select cases. Most experts recommend that long-term HRT only be considered for women with a high osteoporosis risk. In this case, estrogen's bone-protecting benefit may outweigh the risks of taking HRT. Women are now encouraged to consider all possible osteoporosis treatments and to compare their risks and benefits.¹⁴

Changes in estrogen replacement therapy (ERT)

Women who have early, sudden menopause after a hysterectomy with both ovaries removed are usually advised to use estrogen replacement therapy (ERT) to protect against bone loss. The low estrogen levels of menopause cause bone thinning. Compared to women who are not taking hormone therapy, women taking ERT have fewer hip fractures (a sign of estrogen's bone-protecting effect).¹⁵

ERT also helps with menopausal symptoms. Known ERT risks come from studies of women older than 50. It may be that the benefits outweigh the risks for younger women who take ERT until the age of natural menopause.¹⁶ This question needs further research.

The Women's Health Initiative (WHI) studied estrogen-only therapy in older women and found that it increases the risks of blood clots in the legs (deep vein thrombosis) and lungs (pulmonary embolism) and the risk of stroke during the first year of use.¹⁵ ERT may increase the risk of dementia in women who are older than 65.¹⁷ ERT offered no protection against heart disease. In fact, it was linked to heart disease and ovarian cancer in a small number of women.^{8, 18}

Some studies have found a possible link between ERT and breast cancer.¹⁹ In the WHI trial, women using ERT had no increase in breast cancer risk during the study's nearly 7 years of ERT treatment.¹⁵ But the Million Women Study of British women ages 50 to 64 suggests that after 10 years of taking ERT, a small number of women develop breast cancer that is related to ERT.^{6, 20} (Many women in this age group also develop breast cancer without taking hormone therapy.)

If you have had breast cancer or ovarian cancer, do not take ERT or HRT.¹⁹

Should I take estrogen replacement therapy (ERT) after a hysterectomy or oophorectomy?

What are my hormone options now?

• Short-term HRT or ERT effectively relieves hot flashes and vaginal dryness for most women, though side effects are common. Side effects that lead women to stop HRT include unpredictable menstrual-like bleeding, breast tenderness, and depression.²¹
• Short-term, low-dose HRT or ERT is hoped to offer a balance between HRT benefits and risks. It can be taken for 4 to 5 years, with regular checkups. This may work well for many women, who will find that their menopause symptoms have subsided within this period of time. As more healthy postmenopausal women use low-dose hormones for shorter periods of time, researchers will be able to evaluate the actual benefits and risks.

If you are taking long-term HRT or ERT, talk to your doctor about whether its benefits outweigh its risks, considering your own needs, age, and health history. For you, the increased risks of breast cancer, heart attack, stroke, blood clots, and dementia may be small. Or, if you have a personal or family history of breast cancer or heart disease, HRT risks may outweigh HRT benefits.

Stopping HRT or ERT. Talk to your doctor before you stop hormone therapy. There is no way of knowing in advance whether you will have menopause symptoms when you stop using estrogen. About 70% of women who stop HRT have tolerable symptoms or no symptoms at all. The remaining 30% have symptoms that are less tolerable or more long-lasting.²²

Home Treatment

The years just before and after menopause (perimenopause and postmenopause) are an especially important time of your life to treat your body well. If you haven't been, now is the time to start.

• If you smoke, stop smoking to reduce hot flashes and long-term health risks.
• Exercise regularly to promote both physical and emotional health.
• Practice daily meditative breathing exercises. These exercises may reduce hot flashes and emotional symptoms.
• Limit alcohol intake to reduce menopause symptoms and long-term health risks.
• Make healthy eating a priority. Reduce your consumption of simple sugars and caffeine, which can make menopause symptoms worse. You'll not only feel better but may also prevent long-term health problems.
• Pay attention to how the emotional side of menopause is affecting you. Have a support network, and seek help as needed.

If you have symptoms of perimenopause, you may be able to handle them with self-care measures. Practical ways to manage hot flashes include keeping your environment cool, dressing in layers, and managing stress, especially with slow, rhythmic breathing (paced respiration) or relaxation exercises. Measures to improve vaginal dryness and muscle tone include using a vaginal lubricant and doing Kegel exercises regularly.

Menopause: Managing hot flashes

As the body ages, the risks of developing heart disease, osteoporosis, and other long-term health problems naturally increase. Your most powerful preventive and antiaging medicine is a healthy lifestyle.

• Reduce your risk of osteoporosis. Keep up your calcium and vitamin D intake by eating foods that are rich in calcium and by taking supplements.
• Improve bladder control with regular Kegel exercises. For more information, see the topic Urinary Incontinence in Women.
• Use birth control measures to prevent unexpected pregnancy during perimenopause.

Medications

Research has changed how doctors use hormone therapy after menopause. For a long time, hormone replacement therapy (HRT) was thought to protect against heart disease and dementia. But studies now show that HRT use can cause serious health problems. One large study done by the Women's Health Initiative (WHI) has shown that HRT does not protect against heart disease. In fact, in a small number of women who are 10 or more years past menopause, it causes heart disease, including heart attacks.⁸ In the WHI study, short-term use of HRT was also linked to an increase in the numbers of strokes and blood clots. Using HRT for several years was linked to increased cases of breast cancer and dementia. Overall, most women using HRT in the WHI study had no serious side effects, but they also had no long-term benefits.

ERT may also cause breast cancer in a small number of women.⁶

Experts do not yet know whether hormone therapy risks are the same for older and younger postmenopausal women. Researchers are now exploring HRT use by women who use short-term, low-dose hormone therapy starting at menopause.

Average HRT- and ERT-related risks are low among the general population of women. Your personal risks that hormone therapy may stimulate breast cancer, cardiovascular problems, blood clots, or neurological changes may be lower or higher, depending on your risk factors.

Many doctors now suggest trying nonhormonal treatment for bothersome menopause symptoms before considering hormone therapy (birth control pills, estrogen alone [ERT], or estrogen-progestin [HRT]). There are several nonhormonal prescription treatments that can relieve or reduce hot flashes and other menopause symptoms. You can also try using black cohosh or dietary soy.

Medication Choices

Prescription medication without hormones

• Antidepressant medicines can lower the number and severity of hot flashes. Some women have side effects.¹⁰ The safety of very long-term use has yet to be studied.
• Clonidine, a high blood pressure medicine, can reduce the number and severity of hot flashes.¹¹ Some women have side effects related to low blood pressure.
• Gabapentin (Neurontin), an antiseizure medicine, can reduce the number and severity of hot flashes.²³ Possible side effects include sleepiness, dizziness, and swelling.

Prescription medication with hormones

• Birth control pills (estrogen and progestin) regulate menstrual bleeding and can relieve symptoms until menopause. Birth control pills are not used after menopause. You should not use birth control pills if you smoke or have diabetes, untreated high blood pressure, cardiovascular disease, or a history of breast cancer. Low-dose formulations are recommended for women older than 35. Some women have side effects.
• Progestin pills or the levonorgestrel IUD, which releases a form of progesterone into the uterus, reduce heavy, irregular menstrual periods during perimenopause. Some women have side effects.
• Low-dose vaginal estrogen (cream, tablet, or ring) reduces vaginal and urethral dryness and weakening without introducing high levels of estrogen into the body.
• Hormone replacement therapy (estrogen and progestin), in pill, patch, vaginal ring, gel, or cream form, can be used to treat menopause symptoms. Because studies have found that HRT increases some health risks for some women, doctors have changed the way HRT is used. For menopause symptom relief, experts now recommend that HRT only be used at the lowest effective dose for the shortest possible period of time.⁹
• Bioidentical hormone replacement therapy is made from plants and is thought to be more similar to human-produced hormones than synthetic HRT. But bioidentical HRT is not well researched and may carry the same health risks that traditional HRT does.⁹ Any form of hormone therapy is best taken for as short a period as possible.

Should I use hormone replacement therapy (HRT)?

Estrogen replacement therapy (ERT) is used to prevent weakening bones and the severe symptoms that come with sudden, early menopause. Early menopause usually happens after surgery to remove the uterus and ovaries (hysterectomy and oophorectomy) or from ovary failure after cancer treatment. But ERT is known to slightly increase the risks of stroke and blood clots during the first year of use.²⁰ Long-term ERT may slightly increase breast and ovarian cancer risks.^{6, 18}

Taking estrogen by itself (ERT) can lead to uterine (endometrial) cancer. Taking progestin with estrogen protects against uterine cancer. This is why ERT is only recommended if you have no uterus. If you have not had your uterus removed and want hormone therapy, you take progestin with the estrogen (HRT).

Should I take estrogen replacement therapy (ERT) after a hysterectomy or oophorectomy?

Short-term, low-dose HRT or ERT is hoped to offer a balance between HRT benefits and risks. It can be taken for up to 4 to 5 years, with regular checkups. This may work well for many women, who will find that their menopause symptoms have subsided within this period of time. As more women use low-dose hormones for shorter periods of time after menopause, researchers will be able to learn about the actual benefits and risks.

Progesterone creams. "Natural" progesterone creams (available in health food stores or through mail order) or prescription progestin creams, which are made by a compounding pharmacist, are marketed to correct low progesterone levels. While some women report finding relief with progesterone cream, there is mixed evidence about whether these products increase the body's progesterone levels.^{24, 25, 26} This raises the following concerns about over-the-counter progesterone cream use.

• If it is absorbing well. Progesterone treatment has risks. It has been linked to breast cancer, headaches, and dangerous blood clots in a small number of women.²⁶ This is why progesterone is usually a prescription hormone and is not safe for women with certain health risks.
• If it is not absorbing well. If you are taking estrogen (and have an intact uterus), you also need to have enough progesterone to prevent the estrogen from causing uterine (endometrial) cancer. Using a poorly absorbed progesterone cream while taking estrogen does not protect you from uterine cancer.²⁵

Talk to your doctor before using an over-the-counter progesterone cream.

Testosterone. Testosterone-estrogen is sometimes used for menopausal symptoms that don't improve with estrogen therapy. But it is not FDA-approved because its risks are not yet fully known. Testosterone-estrogen carries the same risks as estrogen treatment (blood clots, stroke, breast cancer) as well as testosterone risks and side effects. Experts have not studied long-term risks of testosterone-estrogen use, but it is known that testosterone treatment can cause hair loss, acne, deepening of the voice, and facial hair growth.⁹

Testosterone is sometimes used to increase sexual desire in postmenopausal women who have low testosterone. But, no form of testosterone is approved for women. Studies have not shown a benefit for longer than 12 weeks of use, and long-term testosterone risks for women are not yet known.¹³ If you have a problem with decreased sexual desire, consider that most sexual troubles in women relate to such things as relationship problems, depression, or medicine side effects. For more information, see the topic Sexual Problems in Women.

What to Think About

HRT and osteoporosis. Researchers are studying the effects of low-dose estrogen therapy. A small early study has shown that a low estrogen dose-0.25 mg a day-may keep the bones as strong as the higher dose.²⁷ But the long-term risks of taking low-dose estrogen are not yet known.

Other Treatment

Because of concern about hormone replacement therapy (HRT) health risks, many women have turned to alternative medicine for menopause symptom relief. As part of a stepwise treatment approach, you can consider using one or more of the following options for preventing or treating symptoms before trying prescription medicines or hormones.

• The meditative breathing exercise called paced respiration may reduce hot flashes and emotional symptoms. This approach has no known side effects, risks, or costs and can be safely combined with additional treatment, if needed.
• Black cohosh (Remifemin, 20 mg) may prevent or relieve menopause symptoms. But the research on black cohosh has had mixed results. Some studies have shown that black cohosh can relieve hot flashes.²⁴ But other studies have shown that black cohosh does not relieve hot flashes.²⁸ Also, the long-term safety is not yet known. (Risks similar to estrogen risks are a possibility.) Have regular checkups if you are using black cohosh, and make sure your doctor knows what you are taking.
• Soy phytoestrogens (isoflavones) are in more complete form when you eat them as food, rather than in a pill or powder. A high-soy diet has been linked to stronger bones, especially in the first 10 years after menopause, when estrogen levels drop and rapid bone loss happens.¹ Regularly eating and drinking soy may also help even out menopause symptoms. But studies have shown mixed results. They have not always shown that soy is effective for treating hot flashes.²⁹
• Yoga (which often includes meditative breathing) and/or biofeedback give you tools you can use to reduce stress. High stress is likely to make your symptoms worse.

Alternative treatments to avoid

Based on the latest research, some therapies are not recommended for menopause symptoms, either because they are not effective or because they can cause dangerous effects. These include:

• Kava, evening primrose, dong quai, valerian, dehydroepiandrosterone (DHEA), and angelica.
• Wild yam or natural progesterone creams.

Using alternative treatments

These types of medicinals are not required to have the same testing or purity standards as prescription and other nonprescription medicines. The amount of a drug in herbal preparations varies widely. It is also possible for nonregulated products to be contaminated with metals or other dangerous substances. Before trying any treatment, look for scientific studies that support its beneficial claims as well as information on risks. When buying herbs or supplements:

• Find a reputable brand or supplier.
• Look for the U.S. Pharmacopeia (USP)-verified mark on product labels. This is one way of finding a product that has been tested for safety and quality. For more information, see www.usp.org/USPVerified/dietarySupplements.

If you are using an alternative medicine or herbal remedy, make sure your doctor knows. Tell him or her the type and amount you are taking, how long you have been taking it, and why.

Other Places To Get Help

Organizations

Related Information

• Abnormal Vaginal Bleeding
• Birth Control
• Breast Cancer
• Deep Vein Thrombosis
• Dysfunctional Uterine Bleeding
• Endometrial (Uterine) Cancer
• Fibrocystic Breasts
• Heart Attack and Unstable Angina
• Hysterectomy
• Osteoporosis
• Sexuality and Physical Changes With Aging

References

Citations

1. Zhang X, et al. (2005). Prospective cohort study of soy food consumption and risk of bone fracture among postmenopausal women. Archives of Internal Medicine, 165(16): 1890-1895.

2. Speroff L, Fritz MA (2005). Menopause and the perimenopausal transition. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 621-688. Philadelphia: Lippincott Williams and Wilkins.

3. Joffe H, et al (2003). Assessment and treatment of hot flushes and menopausal mood disturbance. Psychiatric Clinics of North America, 26(3): 563-580.

4. Taguchi A, et al. (2004). Effect of estrogen use on tooth retention, oral bone height, and oral bone porosity in Japanese postmenopausal women. Menopause, 11(5): 556-562.

5. Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3): 321-333.

6. Million Women Study Collaborators (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet, 362(9382): 419-427.

7. Shumaker SA, et al. (2003). Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. The Women's Health Initiative memory study: A randomized controlled trial. JAMA, 289(20): 2651-2662.

8. Rossouw JE, et al. (2007). Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA, 297(13): 1465-1477.

9. North American Menopause Society (2004). Treatment of menopause-associated vasomotor symptoms: Position statement of the North American Menopause Society. Menopause, 11(1): 11-33.

10. Stearns V, et al. (2003). Paroxetine controlled release in the treatment of menopausal hot flashes: A randomized controlled trial. JAMA, 289(21): 2827-2834.

11. Pandya KJ, et al. (2000). Oral clonidine in postmenopausal patients with breast cancer experiencing tamoxifen-induced hot flashes: A University of Rochester Cancer Center Community Clinical Oncology Program study. Annals of Internal Medicine, 132(10): 788-793.

12. Watt PJ, et al. (2003). A holistic programmatic approach to natural hormone replacement. Family and Community Health, 26(1): 53-63.

13. North American Menopause Society (2005). The role of testosterone therapy in postmenopausal women: Position statement of the North American Menopause Society. Menopause, 12(5): 497-511.

14. American College of Obstetricians and Gynecologists (2003). Statement of the American College of Obstetricians and Gynecologists on hormone therapy for the prevention and treatment of postmenopausal osteoporosis. ACOG News Release. Available online: http://www.acog.com/from_home/publications/press_releases/nr10-07-03.cfm.

15. Women's Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA, 291(14): 1701-1712.

16. North American Menopause Society (2007). Position statement: Estrogen and progestogen use in peri- and postmenopausal women: March 2007 position statement of the North American Menopause Society. Menopause, 14(2): 168-182.

17. Espeland MA, et al. (2004). Conjugated equine estrogens and global cognitive function in postmenopausal women: Women's Health Initiative Memory Study. JAMA, 291(24): 2959-2968.

18. Beral V, et al. (2007). Ovarian cancer and hormone replacement therapy in the Million Women Study. Lancet, 369(9574): 1703-1710.

19. American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Breast cancer. Obstetrics and Gynecology, 104(4, Suppl): 11S-16S.

20. American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Stroke. Obstetrics and Gynecology, 104(4, Suppl): 97S-105S.

21. Speroff L, Fritz MA (2005). Postmenopausal hormone therapy. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 689-777. Philadelphia: Lippincott Williams and Wilkins.

22. Grady D, et al. (2003). Predictors of difficulty when discontinuing postmenopausal hormone therapy. Obstetrics and Gynecology, 102(6): 1233-1239.

23. Guttuso T Jr, et al. (2003). Gabapentin's effects on hot flashes in postmenopausal women: A randomized controlled trial. Obstetrics and Gynecology, 101(2): 337-345.

24. American College of Obstetricians and Gynecologists (2001, reaffirmed 2006). Use of botanicals for management of menopausal symptoms. ACOG Practice Bulletin No. 28. Obstetrics and Gynecology, 97(6, Suppl): 1-11.

25. Cooper A, et al. (1998). Systemic absorption of progesterone from Progest cream in post-menopausal women. Lancet, 351(9111): 1255-1256.

26. Hermann AC, et al. (2005). Over-the-counter progesterone cream produces significant drug exposure compared to a Food and Drug Administration-approved oral progesterone product. Journal of Clinical Pharmacology, 45(6): 614-619.

27. Prestwood KM, et al. (2003). Ultralow-dose micronized 17 B-estradiol and bone density and bone metabolism in older women. JAMA, 290(8): 1042-1048.

28. Newton KM, et al. (2006). Treatment of vasomotor symptoms of menopause with black cohosh, multibotanicals, soy, hormone therapy, or placebo. Annals of Internal Medicine, 145(12): 869-879.

29. Grady D (2006). Management of menopausal symptoms. New England Journal of Medicine, 355(22): 2338-2347.

Other Works Consulted

• American Association of Clinical Endocrinologists Menopause Guidelines Revision Task Force (2006). American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocrine Practice, 12(3): 315-337.

• Grady D, Barrett-Connor E (2008). Menopause. In L Goldman, D Ausiello, eds., Cecil Medicine, 23rd ed., pp. 1857-1868. Philadelphia: Saunders Elsevier.

• Shifren JL, Schiff I (2007). Menopause. In JS Berek, ed., Berek and Novak's Gynecology, 14th ed., pp. 1323-1340. Philadelphia: Lippincott Williams and Wilkins.

• U.S. Preventive Services Task Force (2005). Hormone therapy for the prevention of chronic conditions in postmenopausal women: Recommendations from the U.S. Preventive Services Task Force. Annals of Internal Medicine, 142(10): 855-860.

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