Talking About Menopause
Today more than ever, menopause is accepted as a normal stage of a woman’s life — not a disease. True, this change of life is marked by hormonal shifts that can cause symptoms and leave women more vulnerable to certain diseases. However, with the growing array of options available today, often these symptoms can be controlled and the diseases prevented.
By definition, menopause is the absence of menstrual periods for 6 - 12 months in a row and an elevated FSH (follicle-stimulating hormone) level. The cessation of menstruation indicates that there are no remaining follicles left in the ovaries. This leads to an end of ovarian estrogen production.
Most women associate menopause with the lack of menstruation, as well as the symptoms that are most prevalent roughly five years before and five years after their last period. The few years before and after the last period are known as “perimenopause” and “climacteric”. Perimenopause is heralded by the onset of irregular periods. The climacteric is a more encompassing term that defines the transition from the reproductive to the post-reproductive years. During perimenopause, symptoms may include hot flashes, vaginal dryness, insomnia and mood swings.
The good news is that more options exist than ever before for treating the symptoms of menopause and preventing the diseases associated with it. They range from behavioral modifications such as nutrition and exercise to medical treatments, one of which is hormone replacement therapy.
Indeed, your experience of menopause will be defined by a variety of lifestyle and genetic factors that are unique to you. Similarly, barring serious medical conditions, your approach to treatment can also be tailored to your personal choices. In short, like all changes, menopause presents a challenge — a challenge that can bring greater rewards when you are informed about it and your options.
Anatomy Of Menopause
Menopause is a time of dramatic changes. To better understand them, a refresher course on the hormonal fluctuations that occur during a woman’s reproductive cycle may be helpful.
During her fertile years, starting at puberty, a woman’s monthly cycle begins with the release of the onadatropin-releasing hormone (GnRH) from the hypothalamic region of the brain that is close to the pituitary gland. GnRH hormone triggers the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland. The release of FSH stimulates the development of follicles, or small structures in the ovary, which contain eggs. Each month, FSH and LH stimulation cause the follicles to ripen and secrete estrogen and progesterone upon ovulation. These two hormones cause the uterus to thicken in preparation for pregnancy. LH triggers the release of a mature egg from the follicle. If pregnancy does not happen, progesterone and estrogen levels decline and the uterine lining (endometrium) sheds as menstrual blood. FSH levels increase in preparation for a new cycle.
As a woman ages, the number and quality of follicles in the ovaries decline. Irregular menses are a sign that she is intermittently not ovulating. As a consequence, progesterone is not always produced. This erratic pattern may continue until menopause. During this time, called the perimenopausal stage, estrogen levels also change unpredictably and dramatically. The changes in estrogen can cause different menopausal symptoms. The depletion of estrogen results in vaginal and urinary changes and higher risk of osteoporosis and heart disease.
As the reproductive stage of a woman’s life draws to a close, ovarian estrogen falls to undetectable levels. The ovary is no longer sensitive to FSH. FSH levels escalate, as do LH levels, and menstruation comes to an end. These may include irregular bleeding, periods that last for fewer or greater days, and heavier or lighter flow. This usually occurs when a woman is in her 40’s. The average age of menopause (the last menstrual period) is 52. While the average age of puberty’s onset has steadily declined, the average age of menopause has remained constant.
There are exceptions, however. One of these is surgical menopause, which results from the surgical removal of the ovaries (oophorectomy — with or without a removal of the uterus, know as a hysterectomy). A small percentage of women begin the physiologic journey to menopause before the age of forty, after having started experiencing symptoms as early as their 20’s. In contrast, a small number of women continue menstruating regularly until they are near 60.
What accounts for this vast difference? There is some evidence that the onset of menopause follows a genetic pattern. If your mother went through menopause in her mid-50’s, for example, you are more likely to follow her lead. Lifestyle factors also play a role in the arrival of menopause. Cigarette smoking may bring on an early menopause. Smoking hastens the body’s breakdown of estrogen, resulting in lower estrogen levels than in nonsmokers. It also may have a direct toxic affect on the ovaries, inducing a more rapid loss of follicles.
No two women will experience menopause in exactly the same way. Some have hot flashes, for example, and about 20 percent have no symptoms at all. For up to 10 percent of women, the symptoms are very mild, while about 20 percent have severe symptoms.
The way you feel during menopause or perimenopause will be influenced by other factors that are unique to you, such as your overall health, nutrition, stress level, exercise routine, and so forth.
More Serious Health Risks
The common symptoms of menopause, such as hot flashes and vaginal atrophy, may be uncomfortable, but they are not life-threatening. Some long-term consequences of estrogen depletion, however, can pose serious health risks such as osteoporosis and heart disease.
Men and women reach their peak bone mass in their 20s. Age-related bone loss for both men and women begins sometime in their 30s. However, osteoporosis is a much larger problem for women than men for three reasons: Women start out with lower bone density than men, women suffer menopausal bone loss, and women live longer than men allowing for a greater degree of age-related bone loss.
Bone loss leads to osteoporosis. Bones become brittle, making them more susceptible to fractures. Most osteoporotic fractures happen in the vertebral column, wrist, or hip. The lifetime risk of incurring an osteoporotic fracture 60%, although this number will vary greatly depending on the site of bone, the ethnic background, lifestyle, and health of the woman. Vertebral fractures can cause very little or very severe pain. They can result in the classic curvature of the spine (Dowager’s Hump), loss of height, and chronic back pain. Hip fractures are the most devastating. At best they are uncomfortable, and at worst, lethal: 12 to 20 percent of elderly people with hip fractures die within a year. The debilitating nature of hip fractures leads to immobility, loss of muscle tone, and decreased body strength. This can result in an inability to care for oneself and complete dependence on others.
Osteoporosis cannot be cured. Luckily, it can be prevented. Furthermore, in women who are already suffering from osteoporosis, treatment can diminish additional bone loss and fractures.
These figures are overall numbers. Many variables can cause these numbers to differ, such as ethnicity and diet.
- In 1990, there were 1.7 million hip fractures worldwide, 50% of which were in North America and Europe.
- By the year 2050, there are expected to be 6.3 million hip fractures. (This is due, in part, to the increasing number of elderly.)
- The age at which bones begin to thin is 30.
- In women, the overall lifetime risk of incurring a hip fracture is 17%.
- The risk of incurring an osteoporotic fracture is two to four times greater in women than men.
- At age 65, the risk for hip fractures in women is 1 - 2 per 1,000.
- At age 85, the risk for hip fractures in women increases to 25 per 1,000.
- Up to 60% of women over the age of 70 will have evidence of a vertebral fracture.
- 10 - 20% of people who sustain a hip fracture will die within a year.
Osteoporosis is a “silent” disease. Most often, there are no symptoms until a bone breaks. This is why it is important to take early measures to prevent osteoporosis.
What is Your Risk?
Some people are at greater risk of osteoporosis and breaking a bone than others. You are at greater risk if someone in your family had osteoporosis or a Dowager’s Hump. Other risk factors include cigarette smoking, a low calcium diet, premature menopause, inactivity, being fair-haired and fair-skinned, a slender build, alcohol abuse and some medications such as Synthroid, prednisone, and seizure medications. To determine your risk level, you can start by taking this test below — and discussing the results with your doctor.
- Are you Caucasian or Asian?
- Are you thin?
- Are there people in your family who broke bones at an old age, or who had a very stooped posture?
- Have you gone through menopause?
- Did you go through menopause at an early age (younger than 40)?
- Have you had surgery to remove your ovaries (oophorectomy)?
- Do you take medicine for thyroids?
- Do you take high doses of cortisone-like drugs for asthma, arthritis, cancer or other ailments?
- Do you eat very little dairy (cheese, milk, yogurt), dark-green leafy vegetables (like spinach), or broccoli?
- Do you exercise less than twice a week?
- Do you smoke cigarettes?
- Do you drink alcohol regularly?
The more “yes” answers you have, the greater your risk of getting osteoporosis. Call your doctor for an appointment and bring this quiz with you.
Tests for osteoporosis
The best time to check your bone mass is before you experience symptoms. You can have a greater impact on your bone density if you initiate therapy earlier rather than later. Unfortunately, routine office tests cannot detect osteoporosis. Regular X-rays are not sensitive enough to pick up on osteoporosis until 30% or more of bone has been lost. Blood tests for calcium are not helpful in making the diagnosis of osteoporosis.
The best way to assess your current bone status is by having a Bone Mineral Densitometry (BMD) test. This test will determine how much bone mass you have at the time, while future tests will define your rate of bone loss. Currently, most BMD tests are conducted on DEXA machines. The DEXA machine is considered the best method of measuring bone mass. It involves very little radiation exposure and has good precision and accuracy. It can measure bone mass levels at all three important sites: the hip, vertebrae and the lower arm.
There are also new urine tests available on the market that can help better characterize the state of bone metabolism. Bone is actively remodeling in a continual process of breakdown and reformation. These new urine tests, called cross-links, can better determine whether the problem is due to excessive breakdown of bone or an impaired reformation.
It is much easier, and safer, to prevent osteoporosis than it is to reverse it. The two keys to preventing osteoporosis are to achieve the highest possible peak bone mass and to prevent bone loss. Achieving peak bone mass occurs in your teens and early 20’s and is greatly controlled by genetic make-up. However, the contributions of adequate calcium, Vitamin D and weight-bearing exercise cannot be minimized. Excellent sources of calcium are dairy products, leafy-green vegetables, beans and fish. Some specific foods that are especially high in calcium include:
Green, leafy vegetables
Sardines and canned salmon (with bones)
It is always preferable to get the necessary calcium from food. However, this is often difficult to achieve. Calcium supplements might then be advisable. Not all calcium supplements are created equal. Calcium citrate or calcium carbonate are absorbed well by the body. In addition, Vitamin D enhances the absorption of calcium from the intestines.
How much calcium do you need to prevent osteoporosis? Recently, the National Institute of Health reached a consensus at a Development Conference on Optimal Calcium Intake:
- From birth to 6 months — 400mg./day
- 6 - 12 months — 600 mg./day
- 1 - 5 yrs. — 800 mg./day
- 6 - 10 yrs. — 800-1200 mg./day
- 11 - 24 yrs. — 1200-1500 mg./day
- 25 - 50 yrs. — 1000 mg./day
- Pregnant or lactating women — 1200-1500 mg./day
- Post-menopausal women on estrogen replacement therapy — 1200-1500 mg./day
- Post-menopausal women not taking estrogen — 1500 mg./day
- All women over 65, regardless of their supplemental estrogen therapy — 1500 mg./day
Furthermore, adequate Vitamin D is essential for calcium absorption in the intestines (400 mg./day is the recommended dose of Vitamin D). Exercise, but not just any exercise, can help prevent osteoporosis. It is important that the exercise be weight-bearing. This includes walking, jogging, dancing, and aerobics. Swimming, while good exercise, is not helpful in preventing osteoporosis.
Treatment is available for osteoporosis. The standard treatment is hormone replacement therapy (HRT) with estrogen. Studies have shown that HRT can halt bone loss in osteoporosis, and in some cases, can restore some lost bone. In fact, HRT is not only a treatment but also preventive medicine.
The best time to start HRT is before you’ve lost a lot of bone. This is soon after you begin menopause. The most commonly prescribed dose of estrogen is 0.625 mg of conjugated estrogens. This dose has been shown to prevent bone loss in most women, however lower doses may be adequate in select circumstances. Consult your health care provider for the dose that is right for you. If your baseline DEXA revealed low bone mass, it is advised that you repeat the scan in one to two years to evaluate the effects of HRT.
There exists other non-estrogen medications that can be used to treat osteoporosis for those women who cannot or will not take HRT. These include Calcitonin and Alendronate. These medications should be discussed with a physician or perhaps a specialist in metabolic bone diseases.
It is well-known that the risk of heart attack and cardiovascular illness increases with age. Estrogen appears to have a natural “cardio-protective” effect on women. Their heart attack “years” seem to lag behind those of men, coinciding with menopause and estrogen loss.
At menopause, estrogen levels drop precipitously. Estrogen depletion affects the blood vessels and the heart. Estrogen levels can affect cardiac risks by modifying the different cholesterol levels. LDL (the “bad” cholesterol) increase as estrogen decreases and HDL (the “good” cholesterol) decreases with declines in estrogen. Thirty percent of the cardiac risks attributable to estrogen loss is felt to be caused by these changes of the cholesterol profile. A lack of estrogen also lessens the ability of the blood vessels to dilate and allow healthy, oxygenated blood to flow to the heart. Finally, estrogen may have a direct affect on the muscle of the heart by increasing its pumping capabilities.
There is growing and compelling evidence, including that listed above, that HRT can reduce the risk of heart attacks by as much as 50%. Although the women with established heart disease may derive the most benefit, even healthy women will receive protection from HRT. Since heart disease is the number one killer of menopausal women (40-45 percent of women die of heart disease, while 20 percent die of all cancers combined). HRT should at least be considered by most women. However, hormone replacement therapy is just one measure for reducing the risk of heart disease. Other means of preventing heart problems include: stopping smoking, aggressively monitoring for and treating diabetes and hypertension, targeting your ideal body weight, reducing fat in your diet, performing regular aerobic exercise, and reducing stress