Menopause is defined as the natural absence of menstrual periods for 12 months. This condition is experienced by all women as they get older as reproductive hormone levels decrease. Once menopause is complete and periods have ceased for one full year, women are no longer able to become pregnant.
At birth, a woman’s ovaries contain all the eggs she will ever have. The eggs are stored in the ovaries and one is released each month. If not fertilized by a man’s sperm, the menstrual period follows. Menstruation and ovulation are controlled by estrogen and progesterone, the reproductive hormones produced by the ovaries. As a woman ages, the production of estrogen by the ovaries slowly declines until periods stop. The average age of natural menopause is 51 years in the US but can be considered normal when it occurs any time after the age of 40.
Some women experience menopause at younger ages. When this occurs before age 40, it is considered premature menopause. Surgical causes include removal of the ovaries as may happen during hysterectomy. Other causes may include exposure to toxins such as chemotherapy which damages the ovaries or certain medical conditions such as premature ovarian failure.
Natural menopause occurs gradually over several years and has three phases:
Perimenopause. Perimenopause usually begins several years before menopause as the ovaries start to produce less estrogen. This phase lasts up until menopause when the ovaries stop releasing eggs. A woman may have menopausal symptoms during this phase as estrogen levels drop. The reduction of estrogen levels speeds up during the last one to two years of perimenopause and menopausal symptoms may be more pronounced during this time.
Menopause. When a woman has not had a period for one full year, she is in menopause. The ovaries have stopped releasing eggs and producing estrogen.
Post menopause. After experiencing menopause, a woman enters the post menopause phase. Hot flashes and other menopausal symptoms stop, and she can no longer become pregnant. Her risk for other health conditions increase due to increasing age.
What is Premature Menopause?
Some women experience menopause at younger ages. When this occurs before age 40, it is considered premature menopause. This can be caused by genetics, medical conditions affecting the ovaries, surgery or exposure to toxic substances.
Genetics. The age that women go through menopause is associated with genetics. Within a family, a woman’s age at menopause may be like that of her mother’s or sister’s age at menopause.
Surgery. Surgical causes include removal of the ovaries as may happen during hysterectomy for uterine cancer or ovarian cancer. Not all hysterectomies remove the ovaries however, so younger women who have hysterectomies should discuss the extent of the surgery with their health care provider. If both ovaries are removed for any reason in a younger woman, supplemental hormone therapy is usually prescribed.
Damage to the ovaries. Exposure to toxins may have a negative effect on the ovaries. Some medications used for cancer chemotherapy can damage the ovaries and hormone production stops. Similarly, radiation therapy to the pelvis can cause damage to the ovaries.
Premature ovarian failure. Certain medical conditions can cause the ovaries to stop producing reproductive hormones or stop releasing eggs. When this happens before a woman is age 40, it is known as premature ovarian failure. This can be caused by some autoimmune conditions such as hypothyroidism, Grave’s disease or lupus. If a woman has been unable to become pregnant for one year, she should see her health care provider to determine the reason.
How is Menopause or Premature Menopause Diagnosed?
Women are advised to keep track of their periods and chart them as they become irregular as the menstrual pattern can help determine if a woman is premenopausal. When a woman’s periods stop, she should have a medical evaluation to determine the reason. Pregnancy or other medical conditions, such as thyroid disease, must be eliminated as the cause. A physical examination will be performed, and blood tests ordered to determine the levels of hormones in the body.
Estradiol level. This is a blood test to measure the amount of estradiol in the body. Low levels of estradiol, a form of estrogen, can indicate that the ovaries are starting to fail. When estradiol levels are below 30, it may signal that the woman is in menopause.
Follicle stimulating hormone level. Follicle stimulating hormone (FSH) stimulates the ovaries to produce estrogen. When the ovaries slow down estrogen production, levels of FSH go up as the body tries to boost estrogen levels. FSH levels higher than 40 most often mean a woman is in menopause.
Once it is determined that premature menopause has occurred, the condition is irreversible and permanent.
What are symptoms of Menopause?
Menopausal symptoms vary, but the most common are hot flashes (or flushes), night sweats, sleep disturbance, vaginal dryness, incontinence (loss of bladder control), mood changes, and weight gain (especially around the abdomen). You can find out more about symptoms here.
When do the symptoms of menopause (e.g., hot flashes, night sweats, mood swings, etc.) begin and end?
Some women experience no (or very few) symptoms of menopause or they come and go quickly. Generally, women begin to experience symptoms several years before reaching menopause and symptoms begin to subside after menopause. A small number of women experience symptoms throughout their postmenopausal years. Each woman’s menopausal experience is unique even though studies have demonstrated some commonalities or averages in length and frequency of certain symptoms. It’s important to listen to and understand your body and discuss your concerns and symptoms with your healthcare provider to determine the best way to provide relief for your symptoms.
Can you still become pregnant during menopause?
During perimenopause, when a woman’s ovaries are still producing eggs, she can become pregnant, even if she’s experiencing menopausal symptoms. Speak with your healthcare provider about your needs for family planning or pregnancy prevention before you reach menopause. Once you reach menopause and have not had your period (including spot bleeding) for one-full year, pregnancy is no longer possible naturally.
Everything you need to know about the journey to and through menopause.
During this time, you may lose muscle and gain fat mainly in the belly area. That weight gain can raise your risk for high blood pressure, cholesterol, diabetes, heart attack and stroke.
Make every calorie count. To get the nutrients you need, eat vegetables, fruits, whole grains, low-fat dairy products and lean protein foods including beans and lentils to make up the majority of your meals and snacks. In other words, eat right.
Keep in mind, alcohol has calories that do count. Try to limit your intake.
Drink plenty of water. Water helps move fiber through your body, keeps you hydrated and may lighten hot flashes.
Hot flashes?For some, both caffeine and spicy foods may trigger hot flashes. Try cutting back.
Be physically active. You’ll be more successful if you find an activity that you enjoy. Exercise should be fun. Physical activity can help your bones, heart and mood.
Try to include at least 30 minutes of exercise most days, aiming for strength-building exercises at least twice per week. The latter will replace your lost muscle mass and help slow mineral loss in your bones that can lead to osteoporosis.
Exercise doesn’t have to mean a trip to the gym. Take the stairs, garden, dance and/or park further away from your destination and walk. Find something you enjoy.
If you are unable to be active, everything you eat should be nutrient-dense, meaning high in nutrients but relatively low in calories. Nutrient-dense foods contain lean proteins, complex carbohydrates, vitamins, minerals and healthy fats.
Calcium and Vitamin D. To maintain bone health, your calcium needs go up after menopause. Vitamin D is also important to bone health.
It is recommended that menopausal women get 1,200 milligrams of calcium each day and 600 international units (IU) of vitamin D. After 70, increase the vitamin D to 800 IU. Be sure to check with your physician about the appropriate amount of calcium and vitamin D to meet your specific needs.
Eating right is even more important during menopause.
As you enter menopause, it often becomes harder to keep extra pounds off due to both lowering hormone levels and the natural process of aging.
Did you know that our bones are living tissues that grow and rebuild over time? Up until about the age of 30, people build more bone than they lose. After this age though, the rebuilding process slows and there is more bone loss than bone building. When the loss of bone becomes significant, a person has osteoporosis. Osteoporosis means “porous bone”. If you think of the interior of our bones as a honeycomb, those with low bone mass or osteoporosis have a lot more holes in the honeycomb than those with healthy bone.
According to the National Osteoporosis Foundation, 10 million Americans have osteoporosis and another 44 million have low bone mass, which means they have a greater chance of breaking bones. More women than men suffer from osteoporosis because estrogen plays a role in protecting our bone mass. It’s estimated that women can lose up to 20 percent of their bone density in the first five-to-seven years after menopause. Men get osteoporosis too, but it tends to happen later in life for the majority of them.
Why should you be concerned about osteoporosis?
If you want be active, mobile and independent as you age, you need to take care of your bones. If you don’t take care of your bone health, you won’t have the physical support you need to do the things you want and love to do. Some people think weakening bones is just a normal part of aging, but it isn’t. You should be able to lose a little bone mass without breaking bones. If you break a bone over the age of 50, it can have a tremendous impact on your quality of life. And it means you are at greater risk for breaking more bones, so it’s important to act now.
How do you know if you’re at risk for osteoporosis?
There are many risk factors for osteoporosis, some we have control over and others we don’t.
Age. After reaching peak bone density and strength (approximately between age 25-30), bone mass begins to naturally drop with age.
Gender. Women over the age of 50 have the greatest risk of developing osteoporosis. In fact, women are four times more likely than men to develop osteoporosis.
Family history. Heredity is one of the most important risk factors for osteoporosis. If your parents or grandparents have been diagnosed with osteoporosis or fractured a hip, you may be at greater risk of developing the disease.
Race. Osteoporosis effects all races, but research has shown that Caucasian and Asian women are more likely to develop osteoporosis. Additionally, hip fractures are twice as likely to occur in Caucasian women as in black women. However, women of color are more likely to die after a hip fracture.
Body frame. Petite and thin women have a greater risk of developing osteoporosis because they have less bone to lose than women with more body weight and larger frames.
Other diseases and certain medications. Unfortunately, other diseases and the medications used to treat them can also lead to osteoporosis. Celiac disease, bowel disease, rheumatoid arthritis, eating disorders, cancer, kidney or liver disease – all increase your risk of developing osteoporosis. Extended steroid use has been shown to cause osteoporosis and medications used to treat seizures, gastric reflux, and cancer increase your risk of developing osteoporosis as well.
There are things you can control to decrease your risk of osteoporosis, including:
Be active. Exercise strengthens the bone the same way it strengthens muscles.
Eat healthy. Your bones need calcium and vitamin D and other nutrients found in a healthy diet to keep the bone structure strong.
Don’t smoke. Smoking increases your chance of developing osteoporosis…in addition to all the other horrible diseases it can lead to. Smoking messes with the body’s cell functioning and can prevent proper absorption of calcium.
Don’t drink too much. What’s too much, you say? Well, studies show that more than 2 drinks per day can have a negative impact on your body’s calcium supply. Everything in moderation!
What can you do to protect your bone health at menopause?
Many of the things you can do to protect your overall health also help protect your bones. Eating a healthy diet, exercising, avoiding too much alcohol and not smoking are all things that will help keep your bones strong as you age. Some of the key areas to focus on include:
Calcium and Vitamin D – think of these nutrients as the building blocks of strong bones. If your body doesn’t get enough of these nutrients from food, sunlight, or supplements, the body takes the nutrients from where it’s stored – mainly your bones. It’s important to try to get all of the nutrients you need from the food you eat. Yes, taking a supplement is easier, but there are more benefits to getting key nutrients from food. So…eat a well-balanced diet with plenty of fruits, vegetables, lean protein, dairy, fortified foods, and healthy fats. Only supplement when you believe you aren’t getting the recommended daily amount of nutrients from the food you eat.
The National Osteoporosis Foundation recommends the following daily amounts of calcium and vitamin D for women at midlife:
Calcium for Women Age 50 and younger: 1,000 mg per day
Calcium for Women Age 51 and older: 1,200 mg per day
Weight-bearing and muscle-strengthening exercises – For bone building, you need to be on your feet and creating some “impact.” While swimming and cycling are great for cardiovascular health, they don’t do much for your bone health. Try walking, running, jumping rope, aerobics, dancing, hiking, etc., to get the weight-bearing exercise in. For muscle strengthening, try lifting small weights, yoga, Pilates, tai-chi, or other activities that help to keep your muscles strong and support your balance. One caveat – if you have osteoporosis or osteopenia (low bone mass), check with your healthcare provider about the types of exercises that are safe for you. Many of the activities that build and strengthen bones in people with healthy bones can actually break bones in people with osteoporosis and osteopenia (low bone mass).
How can you find out if you’ve got osteoporosis or low bone mass?
There is a simple, non-invasive test called a bone density test, also called a dual energy x-ray absorptiometry (DXA for short), that can determine if you have osteoporosis or low bone mass. This is the only test that can diagnose osteoporosis. If you are over age 50 and have broken a bone from a fall from a standing height, you should get a bone density test. If you have more than one of the risk factors noted earlier, you should also talk with your healthcare provider about getting a baseline bone density test. Otherwise, when women reach age 65, the Medicare program includes a bone density test as part of its “welcome to Medicare” package. It’s really important to ask your healthcare provider if you’re at risk and whether or not you should have a bone density test, regardless of your age.
Can osteoporosis be treated? If so, how?
The good news is that osteoporosis is treatable. There are many effective medications available that can stop the bone loss process and/or stimulate rebuilding of bone. As with all medications, there are side effects to be concerned about. However, it’s really important for you and your healthcare provider to determine if your risk of a major debilitating or deadly fracture is higher than your risk of getting a rare side effect. Keep in mind, even aspirin has side effects. Only you and your healthcare provider can decide what the best option is for your treatment.
In addition to medical treatment, it’s really important to get enough calcium and vitamin D and to be active. If your body doesn’t have enough calcium and vitamin D, even medical therapies won’t work as well. And weight-bearing and muscle-strengthening exercise will help you to maintain the bone strength and density you have.
Heart Disease and Stroke
Heart disease is the number one killer of American women. Often women don’t know they are at risk for heart disease and/or don’t recognize when they are having a heart attack. You need to know the uncontrollable and controllable risk factor for heart disease and take steps to improve your heart health.
Uncontrollable Risk Factors for Heart Disease:
Family history. If your father or brother had heart disease before 55, you are at higher risk of getting heart disease yourself. If your mother or sister had heart disease before 65, you are also at higher risk. If heart disease runs in your family, it may be because your family carries genes that raise your risk. Talk to your doctor about your family health history.
Age and menopause. Estrogen may help protect against heart disease by keeping blood vessels open and helping to maintain healthy cholesterol levels. When estrogen is lost, cholesterol can start to build up on artery walls. There is also a natural stiffening and thickening of arteries that happen with age.
Race and ethnicity.African-American, American Indian and Alaska Native women are more likely to have heart disease than white, Hispanic, and Asian-American women.1 But heart disease is still the number one killer of white and African-American women.
Pregnancy history. Women who experience gestational high blood pressure, preeclampsia, and/or gestational diabetes all raise your risk for high blood pressure and heart disease later in life.
Controllable Risk Factors for Heart Disease
High blood pressure. High blood pressure, also called hypertension, raises your risk for heart disease. Blood pressure is the force your blood makes against your artery walls when your heart beats. If this force (pressure) is too high, it can damage your heart over time. Your risk for high blood pressure goes up as you age. High blood pressure does not usually have symptoms. The only way to know you have it is to get your blood pressure measured.
High cholesterol and triglycerides. In women, high triglycerides combined with low HDL cholesterol can mean a very high risk of heart disease. There are no symptoms of high cholesterol or triglycerides. The only way to know whether you have high LDL or “bad” cholesterol or triglyceride levels is to see your doctor for a blood test.
Overweight and obesity. The more overweight you are, the higher your risk for heart disease. The larger your body is the harder the heart has to work to pump blood throughout it. Being overweight also increases your chances of developing high blood pressure and diabetes.
Depression. Research has found that women 55 and younger who are depressed are twice as likely to have a heart attack or to die of heart disease as women who are not depressed. Depression also increases your risk for another heart attack if you’ve already had one. Depression can hurt your heart’s ability to beat correctly. It also can speed up the buildup of plaque in your arteries.
Sleep apnea. Loud snoring is often a sign of sleep apnea, a common sleep disorder in which you have one or more pauses in breathing or shallow breaths while you sleep. Sleep apnea is linked to atrial fibrillation (irregular heartbeat). Sleep apnea also may affect more than half of people with heart disease.
Diabetes. Diabetes greatly increases your risk for heart disease and makes it harder to survive a heart attack. Postmenopausal women who have an increase in body fat around the belly region tend to have a greater risk for diabetes and heart disease.
Metabolic syndrome.Metabolic syndrome is the name for a group of risk factors that happen together and are related to your metabolism. Metabolism is the process your body uses to convert food into energy. Having metabolic syndrome doubles your risk of heart disease. You have metabolic syndrome if you have any three of these five risk factors:
1. Waist measurement of more than 35 inches
2. Triglyceride level greater than 150 mg/dL (milligrams per deciliter)
3. HDL cholesterol less than 50 mg/dL
4. Blood pressure of 130/85 mmHg (millimeters of mercury) or higher
5. Blood glucose greater than 110 mg/dL after fasting for at least eight hours
Excessive blood clotting. Excessive, or extra, blood clotting is when blood clots form too easily or break apart too slowly. Blood clots can narrow arteries and veins or block blood flow completely. This can lead to heart attack, stroke, or damage to the kidneys, lungs, or other parts of the body. Medicines with the hormone estrogen, such as hormonal birth control or menopausal hormone therapy, can raise your risk for blood clots.
Behaviors that impact heart health:
In addition to the risk factors noted above, changes to lifestyle habits can impact your risk of heart disease.
Don’t smoke. Smoking leads to heart disease. If you smoke, stop. If you don’t smoke, don’t start. The long-term effects of vaping and e-cigarettes on heart health are not known, so better to be safe than sorry and don’t do it.
Eat healthy. Choose a variety of foods from all food groups. Consume sweets, fats and sodium in moderation.
Exercise. The heart is like all of our muscles, the more you work it, the stronger it gets. You need at least 30 minutes of physical activity five times a week to stay healthy.
Avoid alcohol. More than three drinks a day can raise blood pressure and triglyceridelevels and can damage your heart muscle.
Try not to stress. Long-term stress raises your risk of heart disease. If you have heart disease, long-term stress also makes you more likely to have a heart attack.
How do you know if you’re having a heart attack?
The most common symptom of a heart attack is pain or discomfort in the center of the chest. But only half of women who have heart attacks have chest pain. Women are also more likely to have silent heart attacks. Women experience different symptoms than men. These symptoms include:
– Pain in the back, neck, jaw, or throat
– Nausea (feeling sick to the stomach)
– Extreme fatigue (tiredness)
– Problems breathing (shortness of breath)
Women are also more likely than men to have heart attacks that do not show obvious symptoms. These are called silent heart attacks. Your doctor may discover that you had a silent heart attack days, weeks, or months later on an electrocardiogram. Women with diabetes are more likely to have silent heart attacks because diabetes can change how you sense pain.
What should you do if you think you’re having a heart attack?
If you think you’re having a heart attack, dial 911 and get emergency help right away. It’s better to call an ambulance than to try to get to a hospital yourself. The paramedics will be able to assist you with immediate help, which can be life-saving.
Don’t worry about overreacting or if it turns out you did not have a heart attack. It is far better to respond to the potential symptoms of a heart attack and be wrong then to die from ignoring them.
What is a stroke?
Stroke happens fast and you need to get help quickly. Stroke occurs when blood flow to a part of the brain stops or is blocked by a blood clot or plaque, and brain cells begin to die. High blood pressure and high cholesterol are two big risk factors for stroke.
The symptoms of a stroke come on suddenly and include:
– Numbness or weakness of face, arm, or leg, especially on only one side of the body
– Confusion or trouble speaking or understanding
– Trouble seeing in one or both eyes
– Trouble walking, dizziness, or loss of balance or coordination
– Severe headache with no known cause
Even if the symptoms go away, you should seek medical attention immediately. Sometimes you can have a “mini-stroke” and it could be a sign that you are about to have a full stroke. The sooner you get treatment for a stroke the better your chances for a full recovery. As we age, the risk of stroke increases, so the best option is to know the symptoms and be prepared to seek medical help as quickly as possible.
Unfortunately, women tend to gain weight at midlife, even if they keep the same eating habits and exercise routine they did before menopause. It’s also harder to lose weight when you’re menopausal. The loss of estrogen at menopause can cause the shift of fat from the hips to the mid-section, which increases your risk for diabetes and heart disease.
Many of the other symptoms of menopause like night sweats, insomnia and mood swings can also interfere with your ability and desire to eat healthfully and exercise more.
How can I prevent weight gain during and after menopause?
Cutting calories and watching portion size is important. Just to maintain your current weight in your 50s, you might need to eat 200 fewer calories a day than you did in your 30s and 40s. Try not to snack too much and eat your biggest meals earlier in the day. Focus on a variety of foods from every food group – https://www.choosemyplate.gov/.
Exercise more and vary your workout. High intensity interval training – a combination of high intensity bursts of activity with lower intensity activities – can be a good option for staying fit at midlife. Research suggests that adults need at least 150 minutes of moderate-intensity aerobic activity every week, and two or more days a week of muscle-strengthening activities that work all of the major muscle groups, like the legs, hips, back, abdomen, chest, shoulders, and arms. If you want to lose weight, you may need to exercise more.
Get enough quality sleep. How much sleep a person needs to function at their optimal level depends entirely on the person. Do you thrive on five good, solid hours? Do you need eight hours of restful sleep to feel your best? Knowing how much sleep your body needs is important. As we age, we may need more sleep to help our bodies achieve the maximum benefit. It also may be harder for women to get a good night sleep due to menopausal symptoms like night sweats and incontinence. Addressing some of those symptoms may help bring on better sleep habits. Too little sleep can bring on higher levels of the body’s hunger hormone, ghrelin, and lead to weight gain.
Reducing stress can also help with managing your weight at midlife. Stress elevates cortisol levels, which are associated with increased abdominal fat. Reducing stress has a lot of other health benefits too, so it’s worth pursuing!
As we journey toward and through menopause, it’s important to take time to evaluate and review our overall health.
Changes in a woman’s hormone levels bring about some important risks that all women should be aware of. If we want to age healthfully, we need to know what to look out for and how to protect our health.
The links below connect to other resources that may be of interest if you’d like more detailed information about Hormone Replacement Therapy (HRT) and the medical management of symptoms related to menopause.
There is a lot of information – both clinical and opinion – about menopause available online.
We will continue to update our Education Section with the help of our growing Medical Advisory Committee. In this section, we will highlight resources that provide more information about topics important to women during and after menopause.
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Information to help navigate the most common symptoms of menopause.