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Menopause Treatment

Many women pay close attention to their gynecological health during their younger years and start to ignore it after menopause. Your wellness plan after menopause should include at minimum annual visits to a health care professional. As part of those visits, the following tests should be done:

  • Annual breast examinations by a health care professional
  • Annual mammograms
  • An annual gynecologic exam and a Pap test every one to three years, depending on your personal health history; HPV testing (human papillomavirus DNA testing) may be offered if you have atypical or 'funny' cells. Recommendations regarding how frequently Pap test screening should occur after age 65 vary. The U.S. Preventive Services Task Force (USPSTF) recommends against routine Pap test screening for women older than age 65 if they "have had adequate recent screening with normal Pap smears and are not otherwise at increased risk for cervical cancer." It also recommends against routine Pap screening for women who have had a total hysterectomy for benign disease. (Note: Screening for cervical cancer should begin within three years of becoming sexually active or at age 21, whichever comes first, according to USPSTF.) The American Cancer Society (ACS) recommends that beginning at age 30, women who have had three normal test results in a row get screened every two to three years. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, or a weakened immune system due to organ transplant, chemotherapy or chronic steroid use should continue to be screened annually. Women who are age 70 or older, and who have had three or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having cervical cancer screening, according to ACS.
  • Annual fecal occult blood test, which checks for blood in your stool (a symptom of colon cancer); this test is recommended beginning at age 50
  • Colon cancer screening with either flexible sigmoidoscopy or colonoscopy beginning at age 50 unless you or someone in your family has had benign colon polyps or colorectal cancer or an inflammatory bowel disease, such as ulcerative colitis, irritable bowel syndrome or Crohn's disease.
  • Annual blood pressure and blood cholesterol screening every five years; ask your health care professional for guidance
  • Bone density screenings, such as a DEXA-scan (dual-energy x-ray absorptiometry) if you are over age 65 or at a younger age if you are at risk for developing osteoporosis; ask your health care professional about how often you should have this test ; in some parts of the country, peripheral screening for bone density is available using PIXA ( peripheral DEXA) or ultrasound of calcaneus (heel).
  • Annual screenings for diabetes (again, your health care professional may tell you this test is needed less frequently, depending on your risk factors)
  • Thyroid function testing every five years

Discuss any unusual or uncomfortable symptoms with your health professional. Keep track of medications that you take and ask your health care professional or pharmacist about potential drug interactions, if you are told to take a new medication. Be sure to discuss with your health care professional any alternative medical treatments or herbal products you use or may wish to use.

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The Menopause Transition

As your body transitions into menopause (a process that typically lasts about five years) you may notice some physical and emotional changes. The most common include:

  • irregular menstrual periods
  • hot flashes
  • vaginal dryness
  • urinary tract infections or painful urination
  • stress incontinence
  • night sweats
  • insomnia
  • headaches
  • heart palpitations
  • forgetfulness
  • mood changes
  • anxiety and irritability
  • diminished concentration

There are a variety of options available to relieve these symptoms, if you find they interfere with your lifestyle. Discuss your symptoms and your concerns with your health care professional to determine which options make the most sense for you.

The following tips may be recommended to relieve the most common menopausal symptoms:

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1. Hot flashes: This experience is caused by your body's attempt to stimulate your ovaries with less and less success. The pituitary gland in your brain increases the amount of follicle stimulating hormone (FSH) and luteinizing hormone (LH) aimed at the ovaries. Falling estrogen levels and the increase in FSH and LH levels disturb your body's internal temperature. The result: a hot flash.

According to the U.S. Food and Drug Administration, about 85 out of every 100 women approaching or going through menopause have hot flashes, which may start intermittently in your late 30s or early 40s. Hot flashes may get more intense and more frequent around your last menstrual period and then taper off, usually stopping altogether after two to five years. Approximately one in 10 women still have hot flashes 10 years after their last period.

During a hot flash, you may experience a sudden sensation of heat in your face, neck and chest. You may sweat profusely and your pulse may become more rapid. Some women get dizzy or nauseous. A hot flash typically lasts about three to six minutes — which can seem like an eternity. For some women hot flashes are intolerable, occurring at inconvenient moments or at night, disrupting sleep.

There are a variety of strategies for coping with hot flashes, ranging from short-term hormone replacement therapy (estrogen alone or estrogen plus progesterone for no more than three to five years) and other medical options to herbal remedies (see further down in this article), but lifestyle strategies may be the easiest and quickest changes to try first:

  • dressing in layers that may be removed if you find you're getting too warm
  • sleeping in a cool room
  • drinking plenty of water
  • avoiding hot foods, like soups, spicy foods, caffeinated foods and beverages, and alcohol, which can trigger hot flashes
  • trying to decrease stress
  • exercising
  • breathing deeply and slowly, if you feel a hot flash starting; rhythmic breathing may help to "turn down" the heat of a hot flash or prevent it from starting altogether

2. Insomnia: Sleep often is a casualty of menopause, whether it is interrupted by hot flashes (called night sweats when they occur at night) or difficulty falling asleep. Hormonal ups and downs are partly responsible. As you age, your sleep patterns may change. Older people may sleep less, awaken earlier and go to sleep sooner or later than they did at younger ages.

Lifestyle changes for coping with insomnia:

  • sleep in a cool room to help relieve hot flashes that may be disturbing your sleep
  • exercise regularly
  • set and keep a regular routine and hour for going to sleep
  • a glass of warm milk but no other food right before bedtime
  • no alcoholic beverages or smoking before going to sleep
  • don't watch TV in bed
  • practice relaxation techniques like deep breathing
  • review any medications you are taking to see if they may cause sleeplessness

3. Mood swings: For reasons still not well understood, declining and fluctuating estrogen levels during the transition to menopause, can cause emotional highs and lows and irritability. Lack of sleep due to night sweats may also contribute to feeling irritable and depressed. Though your periods are coming to an end, you may continue to experience the symptoms of premenstrual syndrome (PMS). In fact, emotional symptoms may become worse for a time for some women as they approach menopause. You may also notice that you've lost interest in sex. Declining estrogen and testosterone levels in women at this time may lower your sex drive.

 

Lifestyle strategies for coping with mood swings:

  • try relaxation exercises such as meditation or massage which can be calming and reduce irritability
  • discuss your symptoms with your partner and what may be causing them; try new and different approaches to intimacy
  • make physical activity part of your schedule; exercise can improve mood and make you feel better about yourself

4. Vaginal dryness and frequent urinary tract infections: Estrogen, a natural hormone produced by the body, helps to keep the vagina lubricated and supple. Following menopause, as estrogen levels decline, the vagina becomes drier and the vaginal wall becomes thinner. Sex may become painful. The wall of the urethra becomes thinner, too, as estrogen levels fall, and increases the chance of more frequent urinary tract infections. Urine leakage may become a problem as muscle support for the bladder and urethra weakens.

Strategies for coping with vaginal dryness and frequent urinary infections:

  • consider using vaginal creams or gels (prescription or nonprescription) to help with vaginal dryness during different times of your cycle or regularly vaginal estrogen is available as creams, rings, or tablets if moisturizers and lubricants are not enough. These are prescription medications.
  • drink plenty of water to help your body stay hydrated
  • use moisturizing lotions
  • exercise to maintain muscle tone

practice Kegel techniques to strengthen the pelvic floor muscles that support your bladder and urethra to help limit urine leakage. Kegel exercises help firm up the vaginal canal, control urine flow, and enhance orgasm. The exercise is a matter of tightening and relaxing the muscles you use to stop urination. Do at least five Kegels in a row several times a day:

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Tighten a little — count to five.

Tighten a little more — count to five.

As hard as possible — count to five.

  • Relax in reverse steps, counting to five at each step.

5. Heart palpitations: Some women in their late 40s are frightened by their hearts pounding in their chests for no apparent reason. This symptom, called a heart palpitation, is caused by the heart beating irregularly or by missing one or two beats. Though this symptom can be associated with several types of serious heart-related conditions, it is also common during the transition to menopause, and typically is not related to heart disease. For example, a woman's heart rate can increase eight to 16 beats during a hot flash, according to the North American Menopause Society.

If you think you are experiencing heart palpitations:

  • consult with a health care professional immediately if you have any of these symptoms that could indicate a heart-related problem: shortness of breath; pounding or irregular heartbeat; dizziness; nausea; pain in the neck, jaw, arm or chest that comes and goes; or tightness in the chest
  • ask your health care professional to rule out conditions that may cause heart palpitations, such as thyroid disorders
  • ask your health care professional what options are appropriate for relieving heart palpitations such as decreasing caffeine and whether medications are needed

6. Forgetfulness and/or difficulty concentrating: During early menopause, many women are troubled to find they have difficulty remembering things, experience mental blocks or have trouble concentrating. Not getting enough sleep or having sleep disrupted can contribute to memory and concentration problems. Stress associated with major life changes — such as children leaving home and caring for aging parents — can also interfere with sleep. More research is needed, experts say, to determine the cause of these symptoms during the transition to menopause. However, though they can be upsetting, memory-related issues at this time in your life rarely are associated with serious medical conditions such as Alzheimer's disease.

Strategies for coping with memory problems and lack of concentration:

  • recognize that these symptoms may be caused by menopausal changes in your body and don't put pressure on yourself to rely on past strategies for remembering things; develop daily reminder lists or messages to help get you through periods of forgetfulness
  • practice stress-reduction techniques, such as deep breathing exercises, yoga and meditation and try to be physically active on a regular basis

Some women go through menopause with little to no discomfort. If you find you need relief for uncomfortable symptoms and the strategies you've tried don't help, ask your health care professional about medical options. There are a variety of medical strategies used to relieve different symptoms. A few are described below:

Oral contraceptives: Oral contraceptives can help ease symptoms associated with early menopause, including irregular periods and mood swings, among others. Typically, oral contraceptives are recommended to women who are still having periods. For many women in their 40s, oral contraceptives provide the added benefit of preventing pregnancy. Still, taking oral contraceptives close to menopause can make it difficult to determine when you have stopped menstruating. Women who smoke, have high blood pressure, diabetes, a history of gall bladder disease or blood clotting disorders should not use oral contraceptives. Discuss your health history with your health care professional and ask for guidance on this treatment option.

A recent study published in the New England Journal of Medicine found no increased risk of breast cancer with oral contraceptives in women 40 and older. New types of contraceptives are now available including lower doses, shorter placebo weeks, and both a contraceptive patch and a contraceptive vaginal ring.

If you're considering taking hormones to manage menopausal symptoms, be aware that the doses of estrogen and progestogen typically taken to manage menopausal symptoms are not adequate to provide protection against an unwanted pregnancy. A woman who is still fertile must use contraceptives containing higher levels of hormones or use additional birth control methods in addition to hormone replacement.

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Antidepressant medication: Lower doses of several medications used to treat depression and anxiety have been found effective in relieving hot flashes in as many as 70 percent of women. These drugs include venlafaxine (Effexor), fluoxetine (Prozac) and paroxetine (Paxil) and are available in tablet form.

Cardiovascular medication: The blood pressure drugs Catapres and Aldomet taken in lower doses than are used to treat high blood pressure may also relieve hot flashes in some women. They are typically prescribed in tablet form or as skin patches.

Side effects are possible with these medications. Ask your health care professional for more information, if you consider using one of these medical strategies for hot flashes.

Hormone Therapy (HRT)

Once thought safe for the long-term prevention of osteoporosis and heart disease as well as for the short-term relief of menopausal symptoms such as hot flashes, the safety of HRT for both short-term and long-term use is now under intense study by the federal government.

Hormone therapy comes in two forms: estrogen and a synthetic form of the hormone progesterone (progestin) combined, or HRT, and estrogen replacement therapy, or ERT, when estrogen alone is prescribed. Hormone therapy is typically given to women who have not had hysterectomies because estrogen is known to increase the risk of uterine cancer. Postmenopausal hormone therapy is available in a variety of applications: pills, creams, skin patches, vaginal ring and injections.

In January 2003, the U.S. Food and Drug Administration (FDA) announced that it would require a new, highlighted (boxed) warning on all estrogen products for use by postmenopausal women. The so-called "black box" is the strongest step the FDA can take to warn consumers of the potential risks of a medication. The warning highlights the increased risk for heart disease, heart attacks, stroke and breast cancer from supplemental estrogen. This warning came on the heels of three major studies published in July 2002 which showed significant health risks in connection with the long-term use of both forms of hormone therapy, estrogen-progestin therapy and estrogen alone.

Experts offer these guidelines to help understand these recent findings on hormone therapy:

  • Women who take hormone therapy to prevent osteoporosis should discuss their personal risks for heart disease and breast cancer with their health care professional. Alternative treatments and preventive medications for osteoporosis are available.
  • If you are currently using hormone therapy, talk with your health care professional first before stopping your medication; if you are using hormone therapy to relieve menopausal symptoms, stopping the medication abrupting could make your symptoms worse. How you taper off your medication will depend on what type of therapy you are using. Conditions such as elevated cholesterol and low bone density may return to pre-HRT levels and require intervention.
  • Ask your health care professional about alternatives to HRT for specific medical conditions and overall health. In the summer of 2003, a new lower dose version of a combination estrogen and progestin drug for postmenopausal women (medroxyprogesterone, sold as Prempro) is expected to become available. Bear in mind, too, that a recent major federal clinical trial, part of the Women's Health Initiative, recently concluded that, contrary to popular belief, estrogen and progestin, are effective for short-term relief from hot flashes and night sweats, but nothing else. They have no significant impact on general health, or quality of life factors, such as energy, mental health, symptoms of depression, or sexual satisfaction.
  • If you are considering "natural" supplements as an alternative, it is also important to keep in mind that studies related to their effectiveness are sparse and that the FDA doesn't oversee the production of supplements, nor does it require manufacturers to prove their products are effective, as it does with prescription or over-the-counter medications.

Alternatives to hormone therapy for cardiovascular health

Lifestyle strategies for cardiovascular health may include exercise, not smoking, avoiding excess weight and limiting salt and alcohol. For example, a balanced diet rich in antioxidant vitamins with fish two to three times a week may also be prescribed. Several different classes of safe, effective medications designed to lower elevated blood cholesterol and low stroke risk are also available. Drug treatment may be recommended together with lifestyle changes such as a diet low in saturated fat to lower cholesterol levels.

Twenty-five percent of all American women have blood cholesterol levels high enough to pose a serious risk for coronary heart disease, according to the American Heart Association. When to begin drug therapy typically depends on your risk factors for high cholesterol.

Testosterone: This hormone, an androgen, appears to play an important role in women's bodies. Often thought of incorrectly as exclusively a male sex hormone, testosterone is secreted by the ovaries and is therefore natural to the female body. Surgical menopause (removal of the ovaries) may have a negative effect on sex drive. Testosterone therapy is sometimes prescribed to help. Taking the correct dose is very important. Too much testosterone may not provide the desired improvement in sex drive, and can make the woman feel agitated, overly aggressive, and/or depressed. Higher doses can cause masculinizing side effects (that may not go away after stopping therapy) such as facial and body hair growth, acne, an enlarged clitoris, a lowered voice and muscle weight gain. Testosterone may also be associated with adverse heart-related conditions, such as increased risk for atherosclerosis.

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Since the safety of taking testosterone for extended periods of time has not been established, women should be very cautious when considering this type of hormone treatment.

Alternatives to Hormone Therapy for Osteoporosis Prevention

Among the lifestyle changes that have been shown to improve bone density in young women and prevent fractures in older women are dietary calcium, avoiding smoking and excessive alcohol consumption. Prescription drugs used to treat and/or prevent osteoporosis include:

  • Alendronate (Fosamax): approved by the FDA to treat and prevent osteoporosis, Fosamax (from the bisphosphonate class of drugs) has been shown to increase bone mass and reduce the risk of spine, hip, wrist, and other fractures in women with osteoporosis.
  • Risedronate (Actonel): approved by the FDA to prevent and treat osteoporosis, Actonel (another type of bisphosphonate drug) has been shown to increase bone mass and decrease the risk of spine, hip and other fractures.
  • Calcitonin (Miacalcin): approved by the FDA to treat women who are five years postmenopausal and cannot tolerate estrogen therapy, calcitonin helps maintain bone mass.
  • Selective Estrogen-Receptor Modulators (SERMS). This class of drugs, including raloxifene (Evista) appears to prevent bone loss at the spine, hip and total body. One of the drugs in this class, raloxifene (Evista) has been shown to reduce the chance of spinal fracture by half in women with osteoporosis.
  • Teriparatide (Forteo). This new drug, approved by the FDA in November 2002, is the first medication to actually stimulate bone formation instead of just slowing the breakdown of bone. You take it as a once-a-day shot.

Not all women should take these drugs and each medication has side effects. Ask your health care professional for more information.

Herbal Remedies

Some women report that vitamin and herbal supplements are helpful in managing menopausal symptoms. For instance, phytoestrogens — naturally occurring compounds in certain plants, herbs and seeds — are similar in chemical structure to estrogen and/produce estrogen-like effects.

Soy products like tofu, tempeh, soy milk, soy burgers and roasted soy nuts contain phytoestrogen. These are healthy foods that are excellent sources of protein and calcium that can be added to your diet. Good scientific research is limited on the effects of soy on menopausal symptoms and ideal doses for specific symptoms have not been established. Research on effectiveness of soy products on hot flashes is mixed. Some research suggests that a serving of soy foods eaten daily may help relieve hot flashes.

Black cohosh supplements may also help relieve hot flashes, according to some research, but may take several weeks before effects from the supplement are felt. Extracts from the root of this herb — a relative of the buttercup family — were considered an important medicinal herb in Native American cultures for a variety of conditions. A federally funded study investigating the use of black cohosh for menopausal symptoms is currently underway at the Center for Complementary and Alternative Medicine Research in Aging and Women's Health at Columbia University College of Physicians and Surgeons.

Some women report vitamin E helpful in reducing hot flashes. However, there is limited scientific evidence to support its use. There is also no scientific evidence to support the effectiveness of evening primrose oil, flaxseed oil and dong quai root although some women report improvements n reducing menopausal symptoms.

Discuss any herbal or vitamin supplements you are considering taking with your health care professional. Bear in mind that studies related to their effectiveness are sparse and that the FDA doesn't oversee the production of supplements, nor does it require manufacturers to prove their products are safe. Also be aware that high doses of certain vitamins and herbal supplements can be dangerous. For example ephedra used in some weight loss products has potential serious side effects.

Copyright 2003 National Women's Health Resource Center Inc. (NWHRC)

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