The stages of menopause

1. Premature menopause

Premature menopause is menopause that occurs before the age of 40, whether it is natural or induced by medical or surgical means. Women who enter menopause early have symptoms similar to those of natural menopause, like hot flashes, emotional problems, vaginal dryness, and decreased sex drive. However, for some women with premature menopause, these symptoms are severe. Also, women who have premature menopause tend to get weaker bones faster than women who enter menopause later in life. This raises their chances of developing osteoporosis, putting them at risk of fractures of their bones.

Premature menopause can happen for the following reasons:

Chromosome defects: Defects in certain chromosomes can cause premature menopause. For example, women with Turner’s syndrome are born without a second X chromosome or born without part of the X chromosome. In this case the ovaries don’t form normally, and premature menopause results.

Genetics: Women with a family history of premature menopause are more likely to have premature menopause themselves.

Autoimmune diseases: The body’s immune system, which normally fights off diseases, mistakenly attacks a part of its own reproductive system, causing the ovaries to shut down and stop producing female hormones. Thyroid gland disease and rheumatoid arthritis are two diseases in which this can happen.

Surgery to remove the ovaries: Surgical removal of both ovaries, also called a bilateral oophorectomy, puts a woman into premature menopause. She may have immediate menopausal symptoms, like hot flashes and diminished sexual desire or libido. Women who have a hysterectomy, but have their ovaries left in place, will not have induced menopause because their ovaries will continue to make hormones. However, because their uterus is removed, they no longer have their periods and cannot get pregnant. They might have hot flashes since the surgery can sometimes disturb the blood supply to the ovaries. Later on, they will most likely have natural menopause a year or two earlier than expected.

Chemotherapy or pelvic radiation treatments for cancer: Chemotherapy or pelvic radiation therapy for reproductive system cancers can cause ovarian damage. Women may stop getting their periods, have fertility problems, or lose their fertility completely. This can happen immediately or take several months. With cancer treatment, the chances of menopause depend on the type of chemotherapy used, how much was used, and the age of the woman when she gets treatment. The younger a woman is, the less likely she will go into menopause.

How to find out whether you have premature menopause
Your healthcare professional will ask you if you’ve had changes typical of menopause, like hot flashes, irregular periods, sleep problems, and vaginal dryness. Normally, menopause is confirmed when a woman hasn’t had her period for 12 months consecutively.

However, in certain cases of premature menopause, these signs may not be enough for a diagnosis. A blood test that measures follicle-stimulating hormone (FSH) can be done. Your ovaries use this hormone to make estrogen. FSH levels rise when the ovaries stop making estrogen. When FSH levels are higher than normal, you've reached menopause. However, your estrogen levels vary daily, so you may need this test more than once to know for sure.

You may also have a test for levels of estradiol (a type of estrogen) and luteinizing hormone (LH). Estradiol levels fall when the ovaries fail. Levels lower than normal may be a sign of menopause. LH is a hormone that triggers ovulation. If you test above normal levels, you’ve gone through menopause.

2. Perimenopause

Perimenopause marks the time when your body begins its move into menopause. It includes the years leading up to menopause—anywhere from 2 to 8 years—plus the first year after your final period. There is no way to predict how long preimenopause will last or how long it will take you to go through it. It's a natural part of a womans’s life that signals the ending of her reproductive years.

Signs and symptoms

Perimenopause causes some changes in your body that may not be noticeable. For most women, the discomforts associated with perimenopause are minimal and manageable. Other discomforts you might experience include:

• Changes in your menstrual cycle (longer or shorter periods, heavier or lighter periods, or missed periods)
• Hot flashes (sudden rush of heat from your chest to your head). In some months they may occur and in other months they may not.
• Night sweats (hot flashes that happen while you sleep)
• Vaginal dryness
• Sleep problems
• Mood changes (mood swings, depression, irritability)
• Pain during sex
• More urinary infections
• Urinary incontinence
• Less interest in sex
• Increase in body fat around your waist
• Problems with concentration and memory

By monitoring your menstrual cycle and recording your signs and symptoms for several months, you’ll gain a better understanding of the changes occurring during this time. You will also have valuable information to discuss with your doctor.

Oral contraceptives (birth control pills) are often the treatment of choice to relieve perimenopausal symptoms—even if you don’t need them for birth control. Today’s low-dose pills regulate periods and eliminate or reduce hot flashes, vaginal dryness, and premenstrual syndrome.

Making lifestyle changes may help ease the discomfort of your symptoms and keep you healthy in the long run.

Good nutrition. Because your risk of osteoporosis and heart disease increases at this time, a healthful diet is more important than ever. Adopt a low-fat, high-fiber diet rich in fruits, vegetables, and whole grains. Add calcium-rich foods or take a calcium supplement. Avoid alcohol or caffeine, which can trigger hot flashes. If you smoke, try to quit.

Regular exercise. Regular physical activity helps keep your weight down, improve your sleep, strengthen your bones, and elevate your mood. Try to exercise at a moderate intensity for 30 minutes or more on most days of the week.

Stress reduction. Practiced regularly, stress reduction techniques, such as meditation or yoga, can help you relax and cope with your symptoms more easily in this period of transition.

Pregnancy and perimenopause

If you’re still having periods, even if they are not regular, you can get pregnant. Talk to your clinician about birth control options. Keep in mind that methods of birth control, such as birth control pills, injections, implants, or diaphragms will not protect you from sexually transmitted diseases (STDs) or HIV. If you use one of these methods, be sure to also use a latex condom or dental dam (used for oral sex) correctly every time you have sexual contact. Be aware that condoms don’t provide complete protection against STDs and HIV—the only sure protection is abstinence (not having sex of any kind). But appropriate and consistent use of latex condoms and other barrier methods of contraception can help protect you from STDs.

Wellbeing

Engage in regular physical activity and reduce sedentary activities to promote health, psychological wellbeing, and a healthy body weight.

• To lower the risk of chronic disease, get at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week.
• To help manage body weight and prevent gradual, unhealthy body weight gain, get about 60 minutes of moderate-to-vigorous-intensity activity on most days of the week, while not exceeding caloric intake requirements.
• To keep weight off, get at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult their healthcare provider before participating in this level of activity.

Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.

3. Menopause

Menopause is a normal change in a woman’s life when her period stops. It is often called the “change of life.” During menopause, which usually occurs between the ages of 45 and 55, a woman’s body slowly makes less of the hormones estrogen and progesterone. A woman has reached menopause when she has not had a period for 12 months in a row, and there are no other causes for this change. As you near menopause, you may have symptoms from the changes ocurring in your body. Many women wonder if these changes are normal, and many are confused about how to treat their symptoms. You can feel better by learning all you can about menopause and talking with your doctor about your health and symptoms. If you want to treat your symptoms, your healthcare provider can discuss treatment options with you.

Symptoms of menopause

Every woman’s period will stop at menopause. Some women may not have any other symptoms. But as you near menopause or as you are going through menopause, you may also have one or more of these symptoms:

Hot flashes (“hot flushes”). A feeling of sudden warmth in the face, neck, and chest.

Night sweats and sleeping problems. These may lead to feeling tired, stressed, or tense.

Vaginal changes. The vagina may become dry and thin, and sex and vaginal exams may be painful. You also might get more vaginal infections.

Weakening of your bones. This may lead to osteoporosis and an increased risk of fracture.

Mood changes. May include mood swings, depression, and irritability. Some researchers believe that the decrease in estrogen triggers changes in your brain, causing depression.

Urinary problems. You may have leaking (urinary incontinence), burning, or pain when urinating, or you may have leaking when sneezing, coughing, or laughing (stress incontinence).

Lack of concentration. You may become forgetful.

Decreased libido. You may have less interest in sex and changes in sexual response.

Weight fluctuation. Weight gain or increase in body fat around your waist.

Hair loss or thinning. Hair thinning or loss is a problem for some women.

Symptom relief

Here are some ways to relieve menopausal symptoms.

• Hot flashes. A hot environment, eating or drinking hot or spicy foods, alcohol or caffeine, and stress can bring on hot flashes. Try to avoid these triggers. Dress in layers and keep a fan in your home or workplace. Regular exercise might also bring relief from hot flashes and other symptoms. Ask your healthcare provider about taking medication such as antidepressants, or hormone therapy, both of which can be helpful for some women.
• Vaginal dryness. You could try an over-the-counter vaginal lubricant. There are also prescription estrogen-replacement creams that your doctor may prescribe to use topically in the vagina. If you have spotting or bleeding while using estrogen creams, you should see your doctor.
• Problems sleeping. One of the best ways to get a good night’s sleep is to get at least 30 minutes of physical activity on most days of the week. But avoid exercising vigorously close to bedtime. Also avoid alcohol, caffeine, large meals, and working right before bedtime. You might want to drink something warm, such as herb tea or warm milk, before bedtime. Try to keep your bedroom at a comfortable temperature. Avoid napping during the day and try to go to bed and get up at the same times every day. Try relaxation exercise like meditation before bedtime.
• Memory problems. Try to get enough sleep and be physically active.
• Mood swings. Try to get enough sleep and be physically active. Ask your clinician about relaxation exercises you can do. Ask him or her about taking an antidepressant medicine. There is proof that medication can be helpful for people who develop clinical depression. Think about going to a support group for women who are experiencing the same symptoms or getting counseling to talk through your problems and fears.

Two other common health problems can start at menopause, which you might not even notice.

• Osteoporosis. Day in and day out your body is breaking down old bone and replacing it with new healthy bone. Estrogen helps control bone loss. So losing estrogen around the time of menopause causes women to begin to lose more bone than is replaced. In time, bones can become weak and fracture easily. This condition is called osteoporosis.
• Heart disease. After menopause, women are more likely to develop heart disease and other forms of cardiovascular disease. Changes in estrogen levels may be part of the cause, but so is getting older. As you age, you may develop other problems, like high blood pressure or weight gain, putting you at greater risk for heart and cardiovascular disease.

4. Postmenopause

Postmenopause refers to a women’s time of life after menopause has occurred. It is generally believed that the postmenopausal phase begins when 12 full months have passed since the last menstrual period. At that point, a woman will be postmenopausal for the rest of her life, and should never have a menstrual period again. If a postmenopousal woman experiences any vaginal bleeding, no matter how minor, she should consult her healthcare professional.

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Understanding estrogen and progesterone

Estrogen is known as a “female hormone” because it plays a key role in shaping the female body and preparing it for uniquely female functions such as pregnancy. For example, estrogen is vital for the development of breasts and hips. In addition, the vagina, uterus, and other female organs depend on the presence of estrogen in the body to mature.

Together with progesterone, another female hormone made by the ovaries, estrogen regulates the changes that occur with each monthly period and prepares the uterus for pregnancy. Prior to menopause, more than 90% of the estrogen in a woman’s body is made by the ovaries. Other organs (including the adrenal glands, liver, and kidneys) also make small amounts of estrogen. That’s why women continue to have low levels of estrogen after menopause. Because fat cells can also make small amounts of estrogen, women who are overweight when they are going through menopause may have fewer problems with hot flashes and osteoporosis (both of which are related to lack of estrogen).

Some of the other important benefits of estrogen become apparent when estrogen levels decline after menopause. For instance, estrogen stimulates skeletal growth and helps maintain healthy bones. It also helps protect the heart and veins by increasing “good cholesterol“ (HDL or high-density lipoprotein) and lowering “bad cholesterol” (LDL or low-density lipoprotein). Estrogen may also affect a woman’s sexual desire.

Progesterone is the second most important female hormone. Like estrogen, most progesterone is made by the ovaries, with a smaller amount made by the adrenal glands. Progesterone stimulates the growth of a cushiony lining in the uterus where the fertilized egg can grow and develop into a baby, it helps the breast make milk, and it generally supports pregnancy.

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Health changes after menopause

Osteoporosis

Osteoporosis is the medical term for reduced strength of the bones. Thin bones become weaker and fracture easily, with the bones of the spine, wrists, and hips most prone to fracture. Although bones naturally weaken with age in both men and women starting at about age 40, women lose bone more rapidly after menopause.

Using hormone therapy after menopause can slow the rate of bone thinning and may prevent bones from fractures. As well as being beneficial for strengthening bone, estrogen use has some known side effects and you should talk to your healthcare professional about these. He or she can help you to evaluate your risk for developing these side effects and to decide whether estrogen therapy is right for you.

Increase the calcium in your diet in order to keep your bones strong. Calcium is naturally found in many foods, including dairy products, and may also be added to a food (for instance, some orange juices and cereals now have calcium added). Calcium tablets are another good way to add to calcium to your diet. The goal should be to reach a total daily intake of 1000 milligrams per day before menopause or 1500 milligrams per day after menopause. Regular weightbearing exercise, like walking, running, or strength training may also help prevent osteoporosis, as well as getting enough vitamin D through sunlight exposure and food sources.

Heart disease

The risk of heart disease rises considerably in women after menopause. Many people think of heart disease as a “man’s problem,” so it may be surprising to note that heart disease is the leading cause of death among women.

Risk factors for heart disease in women (as well as men) include:

• Being overweight (obesity)
• High blood pressure
• Diabetes
• Cigarette smoking
• High cholesterol
• A low level of physical activity (sedentary lifestyle)
• Family history of heart disease
• Age

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Sex, pregnancy, HIV/AIDS, and sexually transmitted diseases (STDs)

Sex

Both men and women may find themselves taking longer to become sexually aroused as they age. However, medications such as antidepressants, tranquilizers, and high blood pressure drugs can alter your sexual desire. Health problems such as heart disease, diabetes, or arthritis, concern about your appearance, and stress in your daily life can also inhibit your sexual response. Some postmenopausal women will experience either a reduced sex drive.

In 2000, scientists at the New England Research Institute and the University of Massachusetts Medical School found that women experience changes in libido with menopause due to changing attitudes, general health, and marital status rather than because of lower levels of estrogen. Estrogen loss, however, is definitely the main reason for painful intercourse.

If you are one of the women who lose interest in sex at the time of menopause, talk to your healthcare professional. He or she will consider all possible causes. Women’s bodies also produce some of the male hormone testosterone, which some scientists think lead to a drop in libido. Although there is evidence suggesting that some women may benefit from a small amount of testosterone supplement, the effectiveness of this treatment needs further study. Side effects of testosterone in women include skin problems, extra hair on the face and body, and voice changes.

Talk to your sexual partner also. Let him or her know that you both may need to spend extra time kissing and touching before you become fully aroused. If your intimacies have become routine, try new ways or a different place—be creative.

Pregnancy

If you do not wish to become pregnant at this age, continue using contraception until your doctor determines that you are indeed past menopause. Since estrogen and other reproductive hormones are still produced by the body during perimenopause, an egg may be released and pregnancy is possible. Irregular menstrual cycles make it more difficult to predict the time of ovulation, when sexual intercourse is mo re likely to result in pregnancy. If you are currently using a birth control pill as contraception, your periods will continue to be regular even after you have passed menopause. An oral contraceptive, even one with a low does of estrogen, may also help control symptoms such as hot flashes.

HIV/AIDS and sexually transmitted diseases (STDs)

The possibility of pregnancy will disappear once you are a year past your last period. The chance of becoming infected by HIV (human immunodeficiency virus) and developing AIDS (acquired immunodeficiency syndrome) is a possibility you must consider as long as you are sexually active. In fact, about 10% to 15% of all people diagnosed with AIDS in the US are age 50 and older—more than 75,000 Americans.

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Menopause and mental health

Midlife is often considered a period of increased risk for depression in women. The drop in estrogen levels during perimenopause and menopause can lead to depression, and is treated in much the same way as depression that strikes at any other time. Symptoms of depression include low mood, loss of interest and/or pleasure, feelings of worthlessness and guilt, reduced appetite, and problems sleeping.

If you experience symptoms of depression, and they are interfering with your quality of life, it is important to discuss them with your healthcare provider. Talk openly with him or her about the other issues in your life that might be adding to your depressive feelings. Other problems that could be contributing to depression and/or anxiety during menopause include:

• Having a history of depression before menopause
• Feeling worried and negative about menopause and getting older
• Increased stress in your life in general
• Having severe menopausal symptoms
• Not having adequate physical activity
• Relationship problems
• Being unemployed
• Having financial problems
• Suffering low self-esteem
• Lacking adequate social support

If you need treatment for these symptoms, you and your healthcare professional can work together to find a treatment that is best for you. If you have mood swings often, here are a few things you can do:

• Try to get enough sleep and be physically active, ask your healthcare professional about relaxation exercises you can do.
• Ask your doctor about psychotherapy or taking an antidepressant.
• Talk to your friends who are perimenopausal or menopausal, or go to a support group for women who are experiencing the same problem as you are.

Diagnosis and Treatment

Diagnosis

Menopause is a natural biological process or a normal part of a woman's life; therefore, when we talk about treatment for menopause, it is different than discussing treatment for other conditions like diseases or illnesses. Treatment for menopause means finding ways that can help reduce menopausal symptoms like hot flashes and urinary symptoms and ways to help prevent and reduce risk of diseases that are associated with the menopause like osteoporosis, heart disease, and depression.

Of course it advisable that all women take steps towards reducing their risk of diseases associated with the menopause, but as for reducing symptoms, not all women will see this as part of their menopause treatment goals. Women will have different treatment goals depending on the following factors:

• What menopausal symptoms they have


• How severe those menopausal symptoms


• How they are able to cope with their symptoms and the menopausal transition


• What their perspectives are on different treatments, including medications


• Side effects and other experiences with different treatments


• Other medical conditions they may have, which influence treatment options and choices


• Insurance and cost issues

Your healthcare professional will work together with you to design individual treatment goals, that may change over time. As we are always learning more about menopause treatment options and hormone therapy, managing menopausal symptoms can be confusing. It is important to have a healthcare professional whom you can trust, so you can talk openly about your concerns and your treatment options. You can then confidently make an informed decision about your choices. If you feel that you have talked openly with your healthcare provider and still do not feel satisfied, you should consider a second opinion.

Knowing how to communicate with your healthcare professional or other members of your healthcare team can help you obtain the information you need regarding menopause. Your healthcare professional will tell you, as you near menopause, that you may have symptoms from changes in your body as you age. For some women, menopausal symptoms will decline or disappear over time without treatment. Other women will choose treatment for their symptoms.

Make sure your healthcare professional knows your medical history and that of your family, which will reveal whether you are at risk for heart disease, osteoporosis, and breast cancer. Remember you can always alter your decision regarding treatment as well as different treatment choices. You can, and should, review your medical history with your healthcare professional during yearly checkups. Your needs may change, and so might what we know about menopause.

Prevention

There are several aspects of menopause that are difficult to predict and prevent. It is not possible to know exactly when you will start menopause or to predict what symptoms you will have and how long they will last.

Menopause occurs at a different age in every woman's life, usually over the age of 45 at a time when her period stops. Research describes that women who smoke, who have never had children, or who have regular cycles may experience menopause at an earlier age than other women. A woman reaches menopause when she has not had a period for one year, however, she can have symptoms several years earlier.

• One of the most common symptoms in menopause are hot flashes and most women will have them for at least a year or they may last up to a few years. It is difficult to say for how long you will experience hot flashes and how severe they will be. They can't be prevented, but they can be reduced with treatments such as hormone therapy.

Preventing diseases associated with menopause

There are certain diseases that occur with a higher risk during menopause and there are particular steps to prevent or to reduce your risk. These conditions include osteoporosis, cardiovascular disease, and depression.

Osteoporosis

Osteoporosis is a condition of reduced strength in the bones and risk of this condition rises when estrogen levels fall with the onset of menopause. With osteoporosis you are at an increased risk of sustaining fractures of the wrist, hips, and spine due to weak and brittle bones. Your healthcare professional may recommend the following for osteoporosis prevention.

Bone mineral density (BMD) testing

Experts recommend that you have a special scan called dual-energy X-ray absorptiometry or a BMD test which measures bone mineral density. This is very important to have if you are over the age of 65 or if you have risk factors for osteoporosis and you are not yet 65 years of age. If you are being treated for osteoporosis, you should have your bone density measured every 2 years to monitor your progress.

Calcium

All postmenopausal women should aim for 1500 mg of calcium each day. This can be in the form of three servings of dairy foods per day or calcium supplementation in the form of calcium carbonate or calcium citrate, for example.

Vitamin D

Helps the body absorb calcium and incorporate calcium into bone. Postmenopausal women under the age of 70 years should get at least 400 IU of vitamin D each day either through diet or with a vitamin supplement. Women over 70 years should take 800 IU of vitamin D.

Exercise

Bones remain stronger when they are used in day-to-day activities, and inactivity increases the rate of postmenopausal bone loss. Weight-bearing exercises are best for building strong bones and slowing bone loss; these include activities such as walking, jogging, skipping rope, skiing, and tennis, but does not include bicycling or swimming.

Other tips for preventing bone loss

• Add soy to your diet
• Do not smoke
• Avoid excessive alcohol intake
• Limit caffeine

Medications

Several medications may be prescribed to prevent osteoporosis and reduce the risk of fractures. These include

• Alendronate (Fosamax^®)
• Risedronate (Actonel^®)
• Ibandronate (Boniva^®)
• Raloxifene (Evista^®)
• Estrogen therapy (see next section for details)

The following medications may be prescribed for treatment of osteoporosis and to reduce the risk of further fractures

• Raloxifene (Evista^®)
• Alendronate (Fosamax^®)
• Risedronate (Actonel^®
• Ibandronate (Boniva^®)
• Teriparatide (Forteo^®)
• Calcitonin (Miacalcin^®)
• Zoledronic acid (Reclast^®)

Estrogen therapy

Estrogen or hormone therapy has been shown to prevent bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spine fractures in postmenopausal women. However, it is important that you discuss this in detail with your healthcare professional as hormone therapy, like all medications, has side effects and you need to consider these as well as the benefits when choosing this treatment. More about hormone therapy will be described in other sections of this module.

Cardiovascular disease

Cardiovascular disease means disease of the heart and the blood vessels or the arteries and the veins in the body. The risk of cardiovascular disease is considerably higher in women after menopause and heart disease is the leading cause of death in women. There has been much research regarding hormone therapy and the prevention of cardiovascular disease after menopause. So far the research has not been conclusive and for women over the age of 60 some research suggests that use of certain hormone therapy may actually increase the risk. More about this is described later in this module.

There are steps you can take towards reducing your risk of cardiovascular disease which are very important to follow:

• Maintain a normal weight
• For high blood pressure get regular checkups with your healthcare professional and talk to him/her about treatment
• For diabetes: Diet and exercise can help prevent it. If you have diabetes keep your blood sugar levels under tight control and see your healthcare provider for regular checkups
• Avoid cigarette smoking as well as second hand smoke exposure. If you smoke, talk to your healthcare professional about ways to stop.
• Stick to a low fat diet and talk to your healthcare professional about other things that can prevent or lower your cholesterol level
• Get plenty of exercise, at least 30 minutes on most days of the week. You may need to do extra exercise if you are trying to lose weight.

Sexual problems

As a result of aging, both men and women can experience difficulty becoming sexually aroused. For women it may be a physical problem such as having low estrogen levels due to menopause. Estrogen deficiency can cause vaginal atrophy and decreased vaginal lubrication, which can lead to vaginal dryness and painful sexual intercourse. There is also some research describing low testosterone levels in postmenopausal women as a reason for low libido.

If you are going through menopause and experiencing sexual problems talk to your partner as well as your healthcare professional. Your healthcare professional will be able to assess what may be contributing to your problem and suggest treatment options such as vaginal estrogen treatments (like creams, tablets, or rings) or testosterone.

Depression

When going through the transition period of menopause you may be at an increased risk of developing depression. Menopause can be a stressful time in a woman's life, not only because of physical changes, but it it is often the time when children are leaving home; parents are aging, becoming unwell, frail or dependant; and you may experience the onset of chronic illnesses for the first time in life.

If you are experiencing mood swings, irritability, or periods of sadness or hopelessness, see your healthcare professional as you might be suffering from depression. Talk openly with him or her about the other issues in your life that might be adding to your depressive feelings.

The following suggestions could help improve your feeling of wellbeing:

• Try to get enough sleep and be physically active
• Ask your healthcare professional about relaxation exercises or other techniques to reduce stress
• Schedule pleasant events into your day.
• Keep a diary of your thoughts and feelings
• Talk to your friends or attend a support group for women who are experiencing similar problems
• Ask your doctor about psychotherapy or taking an antidepressant

Cancer prevention

Certain cancers such as breast, colorectal, endometrial, and ovarian are more common for women after the age of 40 or 50, which usually correlates with the onset of menopause in many women. Talk to your healthcare professional about when and how often to be screened for these conditions. There is some research about hormone therapy that says that taking hormone therapy may reduce the risk of developing colorectal cancer in some women. Hormone therapy of course has risks as well as benefits, so always discuss this with your healthcare professional before deciding to use it.

Menopause and dementia

Dementia is a disorder that affects a person's memory as well as language, speech, coordination, behavior, learning and retaining new information, sense of direction, and reasoning ability. The risk of dementia increases with age and women are slightly more likely than men to develop dementia due to a longer life expectancy.

Numerous studies have been conducted on estrogen, hormone therapy, and the development of dementia. Some research has described estrogen as a protective hormone for the brain and beneficial for preserving cognitive functioning and preventing the onset of dementia.

However, recently a large study in postmenopausal women (Women's Health Initiative memory study) demonstrated that hormone therapy with estrogen alone or combined estrogen-progestin therapy does not prevent dementia in older, postmenopausal women who had no signs of dementia at the time. This study suggested that estrogen or estrogen-progestin may actually increase the risk of dementia. It should be emphasized that this study did not look at dementia in younger women or women with preexisting cognitive function and if it did results may have been different.

There is still controversy and much research needed concerning hormone therapy and dementia. Therefore, if you are considering hormone therapy you should talk to your healthcare provider about the benefits and the risks.

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Accepted Treatments

For the treatment of menopausal symptoms your healthcare professional will discuss with you the various options available, including either hormonal or nonhormonal therapies described below.

Nonhormonal therapies are available to treat menopausal symptoms in women who cannot or prefer not to take hormones. Most of these products are not FDA approved and do not have scientific evidence backing up the benefits for treatment. However, many people choose to take them as they are often available over the counter (without a prescription) and are often marketed as being natural and/or without serious side effects.

You should always talk to your clinician about treatment options and which is right for you.

Understanding the hormone debate

Currently, hormone therapy is prescribed mainly for the relief of symptoms, such as hot flashes, night sweats, vaginal dryness and urinary symptoms in perimenopausal and postmenopausal women. The FDA has also approved hormone therapy for the treatment and prevention of osteoporosis although often there are other therapies that your healthcare professional also will prescribe or recommend. Perimenopausal and postmenopausal women should not take hormone therapy to prevent problems like heart disease.

The use of hormone therapy has been debated a great deal since the Women's Health Initiative findings were first released in 2002. This research study commenced in 1991 and involved over 160,000 women, the majority of whom were over the age of 60 (most women who take hormone therapy are 50-59 years old), Caucasian, and overweight or obese. Apart from being overweight this was a relatively healthy group of women. The research determined the risks and benefits of hormone therapy in postmenopausal women with regard to effectiveness in treating menopausal symptoms and risk or benefit on breast cancer, colorectal cancer, heart disease, blood clots, stroke, and osteoporosis.

In the study, some women were given estrogen alone and others used combined estrogen and progestin because they had an intact uterus. Women using estrogen alone did so because they previously had a hysterectomy (progesterone protects against endometrial cancer and women with an intact uterus should never use estrogen therapy alone). Part of the study was stopped prematurely in 2002 after it was noted that the risks of hormone therapy were far greater then the benefit and these results reached the media and popular press causing a wave of concern among users and prescribers of hormone therapy.

Before this study, it was thought that hormone therapy could treat hot flashes, prevent heart disease, and treat osteoporosis, while improving a women's quality of life. Findings emerged in the last 5 years that although hormone therapy can be beneficial for the treatment of osteoporosis, its use may increase the risk of heart disease in certain women and increase slightly the risk of breast cancer.

More recently, new information about hormone therapy and the risk of heart disease has been published in scientific journals. In the Women's Health Initiative follow-up study published in April 2007 women who used hormone therapy and were 50 to 59 years old had a lower risk of stroke, heart attacks, and breast cancer and women who used hormone therapy within 10 years of menopause had no increased risk of heart attacks.

Your healthcare professional is the best person to talk with about understanding the results and implications of the results and follow-up study of the Women's Health Initiative study as well as the Women's Health Initiative memory study. Research results can be confusing because they usually involve a set of individuals that may not be representative of the public and study findings are described in terms of statistics, which can be misleading if you are not familiar with what all the different numbers mean.

We will summarize here for you the main results of these studies which will include both the risks and benefits of hormone therapy. When reading this please keep in mind the following:

• The diseases and conditions that were studied in terms of how they are affected by hormone therapy are all common conditions that postmenopausal women can suffer regardless of the use of hormone therapy
• There are many different factors that can influence your risk of these diseases, thus hormone therapy is only part of the overall picture
• The research involved certain characteristics of women who were taking specific doses of hormones for specific periods of time and, therefore, the results relate to these specific situations and not to every woman
• The study results are factual and do not take into account a subjective viewpoint, therefore, whether you decide to take hormone therapy may depend on other factors such as your personal views or your previous experiences with hormone therapy—it is an individual choice

To understand these results imagine a group of 10,000 women taking hormone therapy (either estrogen alone or in combination with progestin) for about 5 to 7 years. These are the risks and benefits of hormone therapy for these women (per the Women's Health Initiative study)