Menopause is the cessation of regular menstrual cycles, a normal physiological and biological event (unless from oophorectomy) that occurs in women at an average age of 51. Today, 50 million women in the United States have reached menopause. The experience of menopause varies enormously between individuals and among cultural groups. While up to 80% of American women experience hot flashes within a collection of symptoms, a study of Mayan Indians found that no women experienced hot flashes. Although women's life expectancy has greatly increased over time, the average age of menopause onset remains constant. Most women will spend one-third of their life postmenopausal.

• Ovarian failure
• Depletion of oocytes
• Depletion of functional gonadotropin-sensitive ovarian follicles—reduces and eventually eliminates estradiol production, resulting in cessation of menses
• Estrone—predominant postmenopausal estrogen is one-third as potent as estradiol
• Hysterectomy and certain medical treatments for endometriosis and cancer

• Premature ovarian failure—menopause before age 40; karyotypic abnormalities and autoimmune disorders need to be ruled out
• Age
• Smoking—hastens follicular depletion

• Amenorrhea—the cessation of uterine bleeding for more than one year is clinically determined to be menopause; average duration is four years from early menstrual changes to complete cessation of menses
• Vasomotor symptoms—including hot flashes (flushing of face, neck, and upper trunk; may be accompanied by palpitations, dizziness, headaches); night sweats (with subsequent depression and irritability from insomnia); cold hands and feet
• Vaginal atrophy—dryness may result in postcoital bleeding; vulvar pruritus
• Urinary tract atrophy—increased frequency, burning, nocturia, incontinence
• Mood symptoms—depression, irritability, tension; usually correlate with sleep disturbances
• Facial hirsutism (from androgens) and wrinkles (from lack of estrogen)
• Osteoporosis—bone fractures possible; risk increases with premature menopause
• Coronary heart disease (CHD)—twice as many women die from CHD than cancer. Marked increase in susceptibility after menopause.

• Pregnancy—perimenopausal women may neglect to use contraception
• Endometrial cancer
• Excessive exercise—causing cessation of menses
• Uterine leiomyoma
• Hypothalamic dysfunction
• Mood and anxiety disorders

Unless there is premature menopause or concurrent illness, the patient appears normal. The uterus may be smaller on bimanual examination.

• Follicle-stimulating hormone (FSH)—values rise in response to estrogen decline; 40 mIU/mL is diagnostic of menopause; may fluctuate daily until postmenopause; diagnoses premature ovarian failure; helps rule out differential diagnosis
• Estradiol-17 beta decreases from 120 pg/mL to below 20 pg/mL; estrone becomes the main circulating estrogen; eventually, estradiol results only from estrone conversion
• Estrone—production decreases from 80 to 300 mg/day to 40 mg/day
• Androstenedione (primary androgen)—decreases from 1,500 to 800 mg/mL; testosterone levels decline far less than estrogen
• Luteinizing hormone (LH)—maximum increase two to three years postmenopause; abnormal pulse frequency and amplitude patterns; levels drop below FSH levels

• Follicular atresia
• Thinning of vaginal epithelium
• Lack of estrogen decreases bone density and intestinal calcium absorption
• Arteriosclerosis
• Osteoporosis

May be done for osteoporosis detection

Menopause is defined as a 12-month cessation of menses, usually with history of vasomotor complications. FSH measurement is rarely used solely for diagnosis. Commonly used procedures are endometrial sampling, Pap smears, and regular pelvic exams. Endometrial biopsy for differential diagnosis.

Estrogen replacement therapy can help prevent osteoporosis and coronary artery disease. Serious side effects of hormone replacement therapy warrant careful individual evaluation and consideration of alternatives. Supplementation with calcium and other micronutrients and regular exercise help prevent these conditions.

• Estrogen—relieves hot flashes and vaginal atrophy and retards osteoporotic bone loss and fractures. Studies point toward possible CHD and Alzheimer's disease prevention. Use the lowest effective dose. Continuous administration avoids uterine bleeding. Estrogen use increases risk of breast cancer, uterine (endometrial) cancer, thromboembolism, pulmonary embolus, and gallbladder disease. Side effects include bloating, nausea, adult-onset asthma, and breast tenderness.
• Conjugated equine estrogens (e.g., Premarin 0.625 mg/day, or 1.25 mg/day with severe vasomotor symptoms)—most commonly used form; can cause metabolic changes in the liver; contraindicated with obesity, smoking, hypertension or cholesterol, varicose veins
• Estradiol—most easily metabolized delivering estrogen directly into the bloodstream; available in transdermal patch (e.g., Estraderm, 1.0 mg/day of estradiol, 0.05 mg/day of transcutaneous estrogen)
• Vaginal creams—for urogenital atrophy, four to six weeks for initial effect, then twice weekly
• Progesterone—may potentiate estrogen, allowing for lower estrogen dosage (e.g., medroxyprogesterone, 2.5 to 10 mg/day); eliminates uterine cancer caused by estrogen therapy; may slow osteoporosis but does not prevent CHD or urogenital atrophy; side effects—bloating, depression, breast tenderness
• Methyltestosterone—increases libido; may decrease osteoporosis of the spine; 1.25 to 5.0 mg/day; side effect—facial hirsutism
• Alendronate—equally effective treatment for osteoporosis prevention
• Lipid-lowering drugs and aspirin—alternative treatment for CHD
• Estriol—weaker form of estrogen; best used in combination with 10% each estrone and estradiol (e.g., Tri-estrogen 2.5 to 5 mg/day, therapeutically equivalent to 0.625 to 1.25 mg/day conjugated estrogen); add progesterone for women with intact uterus; early studies show fewer adverse effects than other estrogens
• Estrogel—rubbed on abdomen and absorbed into the body; commonly used in France

Alternative therapies may be effective alone or in conjunction with standard treatment. Alternative medicine has much to offer for improving cardiovascular health and preventing osteoporosis. Relaxation techniques, stress management, yoga, and meditation can help with perimenopausal symptoms. Weight-bearing and aerobic exercise are crucial for cardiovascular health and osteoporosis prevention. Exercise increases endorphin release, aiding pain relief and mood elevation. Walking, swimming, and biking are less stressful on the joints.

• Soy (25 to 50 mg soy/day) contains soy isoflavones (phytoestrogens); studies suggest relief of hot flashes and vaginal atrophy, and increased protection from osteoporosis and breast cancer.
• Vitamin E (400 to 1,600 IU/day) can balance vasomotor instability, decrease hot flashes, and is cardioprotective. High doses may be contraindicated in hypertension.
• Calcium/magnesium (1,000/500 mg/day for women taking estrogen and 1,500/750 mg/day for those who are not) is best absorbed with meals and sufficient gastric juices. Citrate or citramate forms may be the most absorbable forms.
• Avoiding smoking, alcohol, caffeine, and spicy foods may help decrease hot flashes.
• A combination of vitamin C (1,200 mg), hesperidin (900 mg), and hesperidin methylchalcone (900 mg) relieves hot flashes in a majority of women.
• Gamma-oryzanol (from rice bran oil) 300 mg/day gives partial or total relief of hot flashes in over 80 percent of users.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Black cohosh (Cimicifuga racemosa) relieves vasomotor symptoms and depression; Remifemin is the most tested extract of black cohosh. Toxicology studies show long-term use to be safe; side effect may be mild stomach upset; historic use in climacteric depression; 2 mg/day
• Chaste tree (Vitex agnus cactus) for irregular menstrual cycles; normalizes pituitary function; may take up to six months for full therapeutic effect
• Angelica (Angelica archangelica) relieves vasomotor symptoms
• Licorice (Glycyrrhiza glabra) is an estrogen-balancing herb, especially with chronic stress (regulates cortisol); not for use with hypertension; 250 mg tid, 30 to 60 drops tincture tid, or 1 cup of tea tid
• Ginkgo (Ginkgo biloba) improves memory and peripheral circulation, to treat depression and prevent Alzheimer's disease; may take up to 12 weeks for full effect; 120 mg bid to tid

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing, use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Mulimen—German combination remedy (chasteberry, black cohosh, St. John's wort, cuttlefish ink) shown effective for hot flashes in 1992 study
• Ferrum phosphoricum, graphites, lycopodium—for symptoms occurring during sexual intercourse
• Amyl nitrosum, Lachesis, Sulphur—for hot flashes

Kegel exercises increase pelvic muscle tone, which helps to prevent incontinence and bladder or uterine prolapse.

Acupuncture enhances endorphin release and stimulates kidney function. May also help to balance hormones and relieve vasomotor symptoms.

Massage increases circulation and promotes general relaxation. Use water-soluble nonestrogen lubricants, vegetable oil, or vitamin E oil for vaginal atrophy.

Women should have an annual Pap smear and mammography.

Menopause is not a disease but a natural process of aging. Certain symptoms may be prevented and more serious complications avoided with appropriate treatment.

Possible complications from estrogen use include the following.

• Breast cancer—no correlation with <5 years' use
• Endometrial cancer—eliminated by concurrent progesterone use
• Thromboembolism—30 in 100,000 risk
• Pulmonary embolus
• Pancreatitis—use of transdermal patch obviates most of the risk
• Gallbladder disease—twice as prevalent
• Adult-onset asthma—twice as prevalent

Complications possibly prevented from estrogen use include the following.

• Decrease in vasomotor symptoms
• Osteoporosis—slows progression, reducing fractures 30% to 50%
• CHD—observational studies indicate decreased CHD; not confirmed by randomized clinical trials
• Alzheimer's disease—effects on central nervous system may decrease risk; unproven

All symptoms of menopause will progress more slowly and risks for several diseases can be reduced if managed appropriately.

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