Menopause and Hormone Therapy

Menopause, like puberty, is a natural event experienced by virtually every woman who lives long [Page 359]enough. The termmenopause officially refers to the final menstrual period and can be identified only in retrospect in the absence of menstrual cycles for 12 months. The average age of menopause is 51 years; menopause is considered to be premature when it occurs in women under 40 years of age. The cardinal symptom of the menopausal transition, the years leading up to the last menstrual period, is a change in the menstrual cycle. For some women, the cycle length shortens; for other women, bleeding becomes heavier and periods are longer; and for yet other women, bleeding becomes irregular and unpredictable. Vasomotor symptoms (“hot flashes”) also occur, but for the uninitiated they are not always recognized immediately. Most women describe episodes of intense warmth (enough to throw off the covers in bed) often starting in the chest, neck, and face, accompanied by perspiration (sometimes enough to require a change of nightgown), and subsequently a chill (enough to put covers back on). Some women have no symptoms, most women will notice some hot flashes, and a few women will experience hot flashes so severe that they must stop whatever they are doing or will experience bleeding so heavy that they are confined to home. When the menopausal transition is abrupt because of surgical removal of the ovaries or compromise of ovarian function by chemotherapy for breast or other cancers, hot flashes are often more frequent and more severe than during the natural transition.

For women who have had their uteri removed at younger ages and cannot monitor their menstrual cycles, a simple office blood test can be helpful to determine whether or not they are menopausal. Follicle-stimulating hormone (FSH) is secreted by the pituitary gland in response to a decline in ovarian hormones, so that an elevated FSH confirms the menopausal transition. Measurement of estrogen and progesterone concentrations are usually not necessary, and because ovarian hormone secretion is often erratic during the menopausal transition, results can be difficult to interpret.

In addition to the anticipated “low” levels of estrogen characteristic of postmenopausal women, estrogen concentrations intermittently surge to very high levels during the menopause transition. Over time, higher estrogen levels contribute to heavy bleeding, growth of uterine fibroid tumors, and increased risk of uterine cancer. Any departure from a woman's characteristic menstrual pattern, then, should be reviewed with her physician.

Irregular cycles and anticipation of menopause render some women less vigilant about contraception. Paradoxically, although fertility is substantially reduced at this age, unexpected pregnancies do occur. Protection against sexually transmitted diseases remains an important practice for women engaging in new sexual partners at this time of life.

The menopausal transition usually lasts several years, but for some women the process takes as long as a decade. After the menopausal transition is complete and menstruation ceases, persistent low levels of estrogen contribute to increasing symptoms of hot flashes, vaginal dryness, and painful intercourse. For the vast majority of women, hot flashes are self-limited and gradually diminish over a period of 3 to 5 years. Vaginal symptoms might respond to over-the-counter lubricants and moisturizers. Bone loss in susceptible women, if unchecked by appropriate therapy, can lead to osteoporosis and increased risk of fracture—most commonly of the wrist, spine, and hip—during the decades ahead.

...