Menopause and the Menstrual Cycle

During childbearing years, one of the ovaries releases an egg each month. This is called ovulation. The ovaries produce hormones each month that prepare the uterus to nourish this egg, if it is fertilized. Estrogen is produced in the ovaries during the entire menstrual cycle. It prompts the lining of the uterus, the endometrium, to grow a thick layer of tissue each month.

Progesterone is produced in the ovaries during the second half of the menstrual cycle. It further thickens the lining of the uterus. If the egg is not fertilized, it moves from the fallopian tube to the uterus and is absorbed. The levels of both of these hormones then drop. This signals the uterus to shed its lining. This shedding is your monthly period.

Estrogen and Menstrual Changes
As menopause nears, the ovaries produce less estrogen. A year or two before menopause, you may notice changes in your menstrual cycle. They may be caused by low estrogen levels. One of the earliest signs of approaching menopause is irregular periods. You may skip one or two periods. Your menstrual flow may change. It may become lighter or heavier. Bleeding may last a shorter or longer time than is usual for you.

Abnormal bleeding can sometimes be a sign of a problem in the uterus or its lining. Even though periods tend to be irregular around the time of menopause, it is important to be aware of bleeding that is not normal for you.

Call your doctor if you:

• Have a change in your monthly cycle
• Have very heavy bleeding
• Have bleeding that lasts longer than normal (usually less than 7 days)
• Bleed more than often than every 3 weeks
• Bleed after intercourse

Early Menopause
Early menopause sometimes occurs in women less than 40 years of age whose ovaries stop functioning or are removed by surgery. With surgery, there is a sudden loss of estrogen. This sudden loss may trigger severe symptoms. Women who have early menopause may need to take hormones to replace those made by the ovaries.

While the removal of the uterus alone (hysterectomy) ends periods, it will not cause early menopause. If any part of one or both ovaries remains after surgery, most women will go through menopause around the normal age.

Body Changes During Menopause
Menopause is a natural part of aging. Its changes occur slowly, over time. For some women, the decrease in estrogen causes symptoms, many of which can be treated. Long and short-term treatments are available.

A woman is not completely without estrogen even after menopause. It continues to be made by glands or body fat. In fact, women who are overweight sometimes don't have symptoms of menopause because their extra body fat allows them to make estrogen after the ovaries stop functioning.

Hot Flashes
Hot Flashes, also called hot flushes, are the most frequent symptoms of menopause. A hot flash is a sudden feeling of heat that spreads over part or all of the upper body. The skin may blush red or break out in a sweat. Flashes can come on at any time, day or night, but they don't last long. At night, they may disrupt sleep. Some women will have hot flashes for a few months, some for a few years, and some not at all.

Changes in the Vaginal Area
The loss of estrogen in menopause may cause changes in the vagina. Its lining may become thinner and less flexible. The vagina is drier, which can cause pain during sex. Some women have vaginal burning and itching. Others feel discomfort in the clitoris, part of the female genitals involved in sexual stimulation. The urethra-the tube that carries urine from the bladder- can become inflamed or irritated. Some women may need to urinate more often. memopause may make a woman more prone to urinary incontinence. Painful urination, however, may be a sign of urinary tract infection.

Bone Changes and Other Body Changes
Bone loss is a normal part of aging. At menopause, the rate of bone loss increases. Such bone thinning, called osteoporosis, increases the risk of broken bones in older women. This is a major health problem. The hip, wrist, and spinal bones are most often affected. The most serious impact of hip fractures is the marked increase in death rates that can occur. Up to one in five patients dies within 6 months of hip fracture from problems caused by lack of activity, such as blood clots, stroke, heart attack, and pneumonia.

The estrogen that women produce before menopause gives them a natural protection from heart attacks. When less estrogen is made at menopause, women lose much of this protection. The risk of heart attack and stroke goes up after menopause.

Other changes are related to a decrease in hormones, but are hard to separate from the normal aging process. Skin becomes wrinkled. Hair thins and its texture changes. Some pubic hair is lost, and some facial hair may be gained. The breasts lose some of their fullness, and the nipples become less erect. There is less body fat in some places and more in others.

Emotional Changes
Some women go through menopause without any emotional changes. Some even feel a sense of freedom from unwanted pregnancy and monthly periods. Others may find themselves nervous, irritable, very tired, or mildly depressed. These feelings may be linked to changes in hormones; to other symptoms of menopause, such as lack of sleep from hot flashes; or to other factors, such as stress. If you find it hard to cope, don't deny your feelings. Talk them over with your partner, a close friend, a relative, or your doctor. Some women may want to seek professional counseling.

Heart Disease
The risk of heart disease is much greater than other health risks for postmenopausal women. Estrogen replacement therapy has a "heart-protective" effect that makes it a wise choice for many women. The estrogen replacement reduces a woman's risk of heart disease by increasing high-density lipoprotein (HDL or "good" cholesterol).

Sexuality
Sexual relations often become more enjoyable at this stage of life. An older woman and her partner may be more experienced sexually and know how to please each other. Also, couples who have more privacy and time for each other often have a deeper, more satisfying relationship.

Menopause need not affect a woman's ability to enjoy sex. Although the hormonal changes that cause vaginal dryness can make intercourse uncomfortable, this can be treated with estrogen creams or lubricating jellies. Regular intercourse helps the vagina keep its natural elasticity and lubrication. Longer foreplay will stimulate lubrication. If you have not been sexually active for a while, you may want to talk with your doctor about ways to make sex more comfortable.

Source: Patient education material from the American College of Obstetrics and Gynecology was used as a source of information to develop the content for this topic.