Menopause is the end of a woman’s reproductive phase, which usually occurs around their 50th year. It is characterized by the absence of menstruation, ovulation, and release of sex hormones (estrogen and progesterone) by the ovaries.
From a medical point of view, a woman is known to enter menopause if she has not had a menstrual period for 12 consecutive months.
*Some people use the term post-menopause to describe the period of time after menopause, which is not entirely appropriate since menopause is a permanent condition.
The intensity of symptoms varies for every woman. Some women have no symptoms except for the absence of menstruation, while others have moderate to severe symptoms (20-30% of women).
What triggers menopause?
Each female begins her life with a certain number of eggs, the female gametes. However, menopause is not triggered when all the eggs are exhausted. A female has about 30,000 eggs. Only 500 of them will pass through the ovulation cycle. The age of menopause is mainly determined by genes. It can also be influenced by health status.
More or less long-term effects
Reducing estrogen levels increases women’s risk of a variety of health problems, including osteoporosis, urinary incontinence, and cardiovascular disease.
The symptoms are usually more pronounced during perimenopause. These symptoms are related to the hormonal changes that occur during this transition phase, but also to aging. They are unpredictable and vary greatly from month to month.
Here are the symptoms:
Irregular menstruation: These are a common manifestation of hormonal instability that occurs during perimenopause.
Hot flashes and night sweats: Hot flashes are usually felt for the first time in the abdomen or chest wherein heat rises to the neck and face in seconds. Its duration varies from a few seconds to a few minutes. Its frequency and intensity vary greatly from woman to woman. They are sometimes accompanied by palpitations and sweats. 50% to 80% of women experience them. Hot flashes are the main reason why menopausal women seek professional medical help.
Night Sweats: These are characterized by intense sweating throughout the body. It occurs during the night and may interrupt a woman’s sleep. The important question is whether hot flashes and night sweats affect the quality of life to such an extent that treatment is necessary.
Sleep disorders: Sleep problems are a very common complaint during this transition period. In general, nights are shorter with increasing age and the quality of sleep tends to be poorer. Hormonal changes can also disturb sleep.
For example, problems with falling asleep and waking up frequently during the night are usually associated with hot flashes and night sweats. These sleep disorders can lead to considerable fatigue, irritability, mood swings, and concentration problems.
Mood disorders: Although still controversial, the time around menopause seems to be a time of greater emotional vulnerability. Irritability, tendency to cry more often, mood swings, anxiety, and lack of motivation or energy are the most frequently reported complaints during this phase of life. Even women who suffered from depression before menopause sometimes have a worsening of the condition.
Decreased libido: Sexual desire is a complex human phenomenon that, on a hormonal level, depends mainly on both a woman’s sex hormones, estrogens, and androgens (testosterone and dehydroepiandrosterone or DHEA). According to the results of a large study on menopausal women, libido and sexual arousal tend to decrease over the years.
Vaginal dryness: Stopping estrogen secretion from the ovaries reduces mucus production in the vagina. This decrease in production leads to dryness and thinning of mucous membranes.
In addition, vaginal secretions change as they become more aqueous and alkaline (less acidic). More than half of postmenopausal women suffer from symptoms associated with vaginal dryness. These complaints include itching, a burning sensation in the vagina and vulva, and pain during intercourse. This dryness of the mucous membranes does not pose a health risk. Also, there are solutions to relieve the discomfort it causes.
Aging of the skin and dry hair: The skin tends to get drier and wrinkles become more pronounced. The hair, too, becomes drier and more brittle. The reduction in estrogen levels leads to a reduction in the production of collagen and elastin, which are two substances that play an important role in skin elasticity and resilience.
However, the main causes of wrinkles are still time (aging) and cumulative exposure to the sun. In addition, other factors can alter the appearance of the skin and hair, such as a slowing down of thyroid activity (hypothyroidism). Therefore, the overall situation should be evaluated.
Women at risk for more severe symptoms:
The differences in risk between western women and Asian women can be explained by the following:
- Abundant consumption of soy (soybeans), which is a food with a high phytoestrogen content
- A change in status leading to an appreciation of the role of older women for their experience and wisdom.
Studies on immigrant populations have shown that genetic factors do not seem to be involved.
- Psychological factors: Menopause occurs at a time in life when other changes frequently occur, such as the departure of children, early retirement, etc., affecting a woman’s life. Moreover, the end of the possibility of having children (although most women at this age have renounced the possibility of having children) is a psychological factor that confronts women with aging and therefore death. The state of mind in the face of these changes influences the intensity of the symptoms.
- Other factors: Lack of exercise, physical inactivity, and poor diet.
Menopause is a natural evolutionary process. However, studies from around the world show that differences in lifestyle, diet, and physical activity can influence the intensity and type of symptoms women experience during menopause.
In general, the following preventive measures taken before the age of 50, especially during the forties, help reduce the likelihood of menopausal symptoms.
- Eating foods rich in phytoestrogens (soy, flaxseed, chickpeas, onions, etc.).
- If necessary, take calcium and vitamin D supplements.
- Regular physical activity that puts a strain on the heart and joints, as well as mobility and balance exercises.
- Cultivating a positive attitude towards life.
- Staying sexually active.
- Practice Kegel exercises, both to combat urinary incontinence and to improve sex life by increasing vaginal muscle tone.
- Avoid smoking since tobacco not only damages the bones and heart but also destroys the estrogens.
In addition, as explained above, women have a higher risk of osteoporosis, cardiovascular disease, endometrial cancer, and breast cancer as they are going through menopause, which is truer if they are aging. Therefore, it is important to apply the preventive measures associated with these diseases.
Medical treatments for menopause symptoms
A healthy lifestyle helps reduce the intensity of menopause symptoms, improves cardiovascular and bone health, and provides some protection against many health problems.
To reduce hot flashes, you should incorporate the following:
- Instead of 3 main meals, you should reduce portions and take healthy snacks between meals
- Drink plenty of water
- Avoid or greatly reduce the consumption of stimulants, such as hot drinks, coffee, alcohol, and spicy foods.
- Reduce consumption of concentrated sugar.
- Regularly eat foods that are rich in phytoestrogens.
Any form of physical activity is preferable to no physical activity at all. For all women, especially those entering this transitional phase, daily exercise offers several important benefits, such as:
- Maintain or achieve a healthy weight
- Keep the cardiovascular system in good shape
- Reduce bone loss and the risk of falling
- Reduce the risk of breast cancer
- Stimulates sexual desire.
Studies also suggest that sedentary women are more likely to experience moderate to severe hot flashes than women who exercise regularly.
It is recommended that women be moderately active for at least 30 minutes per day and integrate flexibility exercises, such as stretching, tai chi, or yoga into their daily routine.
Deep breathing, massage, yoga, visualization, meditation, etc. can help with sleep problems if necessary. Also, relaxation can help relieve other menopause symptoms.
To combat various problems associated with menopause, doctors use 3 types of pharmacological approaches:
- General hormonal treatment
- Local hormonal treatment
- Non-hormonal treatments
General hormonal treatment
Hormone therapy complements hormones that are no longer being secreted by the ovaries. It allows most women to have their symptoms (hot flashes, sleep disturbances, and mood swings) decrease or even disappear during the period of hormone therapy.
It is important to know that most women who start a general hormone treatment will see their symptoms return when they stop because the body is going through a hormonal transition again. Some women, for example, choose to undergo hormone therapy for a few years until they retire because they know that it is easier to manage their symptoms at that time.
General hormone therapy usually involves a combination of estrogen and progestin. Only estrogen is reserved for women who have had their uterus removed, (hysterectomy) because ingestion over a long period of time increases the risk of uterine cancer. Although the addition of a progestin reduces this risk.
Currently, hormone therapy is reserved for women with pronounced menopausal symptoms whose quality of life is sufficiently impaired to justify it. It is recommended that doctors prescribe the lowest effective dose for the shortest time possible. The maximum recommended duration is 5 years.
Hormone therapy can help slow the loss of bone mass, reducing the risk of fracture. However, it should not be prescribed only for this purpose.
Hormone replacement therapy can sometimes have side effects that are not dangerous but unpleasant. Contact your doctor for more information.
Some women take the hormones continuously, that is, they take estrogen and progesterone daily. Doing so will stop menstruation.
The risks of conventional hormone therapy
The Women’s Health Initiative Study (WHI), which is a large study conducted in the United States from 1991 to 2006 involving more than 160,000 menopausal women, had a major impact on the treatment of menopause symptoms. Participants took either Premarin® and Provera®, Premarin® alone (for women without a uterus), or a placebo. The first results were published in 2002.
This hormonal intake was associated with an increased long-term risk of the following health problems:
- Formation of a blood clot, which can lead to various vascular complications, such as phlebitis, pulmonary embolism, or stroke, regardless of the age of postmenopausal women
- There is also an increased risk of coronary heart disease or heart attack in women who have been postmenopausal for 10 years or more (plus 6 women per 10,000 per year) and in the case of breast cancer, which is more likely to be fatal. This may be partly because breast cancer is more difficult to detect in women under hormone therapy because their breasts are denser.
Dementia in women over 65
These risks increase with the duration of use and depend on individual risk factors, such as age, genetics, and other factors.
Although the WHI study did not include hormone therapy with Estrace®, Ogen®, and C.E.S.®, it can be assumed that these types of hormones expose women to cardiovascular risks similar to those of Premarin® because they are taken orally.
Bioidentical Hormone Therapy
Bioidentical hormones have the same molecular structure as ovarian secreted hormones: oestradiol-17ß (the main estrogen produced by the female body) and progesterone. They are from plants such as soy or wild yams, which is then synthesized in the laboratory.
The bioidentical oestradiol-17ß is administered through the skin, which distinguishes it from conventional hormone therapy. It is available as a patch (Estraderm®, Oesclim®, Estradot®, Sandoz-Estradiol Derm® or Climara®) or as a gel (Estrogel®).
In addition to Estradiol-17ß, doctors who use bioidentical therapy generally prescribe micronized progesterone. The micronization technique converts progesterone into small particles that are well absorbed by the body. It is also available orally (Prometrium®).
Do note that OTC preparations of Bioidentical estrogens are also available in the form of a cream containing a compound of the three natural estrogenic molecules of women: estriol, estradiol, and estrone.
Extemporaneous formulations of progesterone in its cream form are also available in pharmacies. These are not recommended since the absorption of progesterone through the skin is not very effective, varies a lot from woman to woman, and does not provide enough concentration to protect the uterus. Remember that taking estrogen alone increases the risk of uterine cancer, and adding progesterone helps reduce this risk.
Is bioidentical hormone therapy safer?
No study has been done to prove this. Also, we may never have an answer to this question because a comparative study (as large as the Women’s Health Initiative Study) would be too expensive. Therefore, women have to make a decision in a context of uncertainty.
However, the dermal administration of estrogen could reduce the cardiovascular risks of conventional oral hormone therapy. This is because estrogen forms metabolites as it passes through the digestive system, particularly the liver, which is not the case with bioidentical hormones taken via the dermal route. This is why some doctors prefer it in women at risk of heart problems, for example.
Local hormone treatment
Small doses of estrogen are administered vaginally to relieve the symptoms of vaginal dryness and thinning of mucous membranes. However, this has no therapeutic effect on hot flashes, sleep disorders, or mood swings. Local hormone therapy does not cause the side effects and risks associated with systemic hormone therapy.
Estrogen can be administered in the vagina with a cream, a ring, or in the form of tablets, and they are also effective. The vaginal cream and pills are inserted into the vagina with an applicator. The estrogen-vaginal ring is made of flexible plastic. It is inserted at the bottom of the vagina and must be changed every 3 months. Most women tolerate it well, but some women find it uncomfortable or, sometimes, tend to get in and out of the vagina.
At the beginning of the treatment, when the vaginal mucosa is very thin, the estrogen applied locally to the vagina can leak into the body. However, no long-term adverse health effects have been reported with the recommended doses.
Non-hormonal drugs can help relieve some of the symptoms of menopause.
For hot flashes
Antidepressants: Studies suggest that some antidepressants can reduce hot flashes, but the effect is less than that of hormone therapy, whether or not there is an underlying depression. This can be an interesting option for a woman who has depressive symptoms and hot flashes but does not want to take hormones.
Antihypertensive medication: Clonidine, a drug to lower blood pressure, has been shown to be slightly more effective than a placebo in relieving hot flashes. However, this drug is not widely used because it causes a number of side effects, such as dry mouth, drowsiness, and constipation.
For vaginal dryness
Replens® Moisturizing Gel has proven to be an effective vaginal moisturizer for the relief of itching, irritation, and pain during intercourse. It should be applied every 2 to 3 days.
Against mood swings
Taking antidepressants, anxiolytics, and sleeping pills should not be part of basic menopause care. They should be prescribed according to the same criteria and with the same rigor as for any other phase of life.
Several non-hormonal drugs are used to increase bone density and reduce the risk of fracture.
For sleeping problems
Here are some ideas to make sleeping easier: Do regular exercise, use different ways of relaxing (deep breathing, massage, etc.), avoid caffeine and alcohol, and drink chamomile or valerian tea before going to bed.
Studies tend to show that women with an active sex life during menopause have fewer symptoms than women with little or no active sex life. However, it is not known if there is a causal relationship or if it is simply a coincidence between the two.
In any case, it is clear that menopause, with its many symptoms, can disturb sex life. However, active and satisfying sex life can still be maintained through vaginal hormone therapy, vaginal moisturizers, and lubricants.
Remember that exercise can also awaken the desire in women. To maintain an active libido, it is also important to maintain good communication with your spouse and manage stress in general (work, etc.).
The prescription of testosterone to women in their postmenopausal stage is still a controversial phenomenon in North America. However, more doctors do it to restore and stimulate libido, especially in women who have had both ovaries surgically removed. The potential side effects of testosterone use on women are still poorly understood. Therefore, this treatment should be considered experimental.
The only official recommendation concerns the use of calcium and vitamin D supplements to combat osteoporosis.
Tips to avoid hot flashes
Take time to determine what causes your hot flashes and then avoid them better. For example:
- Certain foods or beverages (see above)
- High temperatures outside or inside your home
- Long-term exposure to the sun
- Very hot showers or baths
- Sudden changes in temperature, such as when moving from an air-conditioned room to a place where there is excessive heat
- Clothing made of synthetic fibers
I like to use the backpack analogy: 50-year-old women carry a very heavy and unbalanced load today, in which work and family life leave little room for personal life. When you walk on hormonally stable ground (your ovaries are working like a clock), you can support the load, even if it is heavy. However, when this hormonal terrain becomes rough, irregular, with ups and downs (the perimenopausal hormonal waltz), the load becomes much more difficult to carry.
As doctors, we can suggest stabilizing the hormonal terrain (with hormone therapy, for example), but this is still the ideal time to take a “break,” by decreasing the load and replacing it with moderation and balance. This can mean reviewing our priorities and taking time for ourselves.
In the end, there is no right or wrong decision, nor a final decision, about whether or not to take hormone therapy. Rather, it is an informed and personal decision.