Menopause is a natural part of the aging process; it marks the end of fertility in a woman’s life. Menopause may occur naturally anytime between the ages of 40 to 65, but here in the US the average age of menopause is 52 years old. There are some occasions when menopause may occur before the age of 40 years old, if this occurs, it is considered a premature or early menopause and is outside medical norms. Medical conditions, genetic disorders, surgery or medical treatments are all things that may lead to or cause early menopause.

The term menopause is sometimes used to refer to the entire process leading up to the end of fertility, but this is actually incorrect. Menopause is the exact date a woman is no longer fertile, it is the date a woman has her final day of menstruation. Obviously because a lot of women don’t keep exact records of their bleeding, this date is not always 100% known. To stray on the side of caution, waiting until one full year has passed without bleeding is usually recommended to fully confirm menopause. This is important because during this phase, bleeding becomes irregular and it’s not uncommon to skip periods, so until one full year without bleeding has passed, it’s best to assume that pregnancy is still possible.

Perimenopause

Perimenopause is the phase leading up menopause, it may last anywhere from a few months to ten years. The symptoms associated with perimenopause are the same as menopause signs. Perimenopause ends when menopause is reached and then after menopause a woman is said to be postmenopausal. Once menopause is reached, menopause signs will diminish and eventually disappear altogether; this may take a few years or happen suddenly.  

Symptoms

• Irregular bleeding – periods will sometimes be skipped, bleeding may be lighter or heavier
• Irregular ovulation – during months when ovulation doesn’t occur, mature eggs don’t drop, this makes it hard to conceive if you’re trying to get pregnant
• Hot flashes
• Night sweats
• Insomnia – maybe a result of night sweats
• Vaginal dryness – this may cause pain during intercourse
• Loss of sex drive
• Hair thinning
• Facial hair
• Ear ringing
• Mood swings
• Difficulty concentrating
• Memory loss
• Depression
• Anxiety
• Dry skin
• A skin crawling or tingling sensation in limbs (formication)
• Incontinence – this is usually urine leakage during a cough or while laughing
• Headaches
• Muscle aches
• Osteoporosis

When approaching menopause the changing levels of hormones such as estrogen and progesterone can result in a wide range of symptoms and conditions. Some women will experience serious symptoms, while others will go through this transitional period easily, experiencing only very mild symptoms and in some instances absolutely no symptoms at all. Perimenopause symptoms are very similar to the symptoms of menopause so the following symptoms apply to perimenopause as well. Let’s examine the most common signs of menopause.

A change in period bleeding and menstrual cycle is quite common.
Periods may become irregular with more or less bleeding. Some women may have very heavy bleeding for a few days and then very light bleeding for a couple more days, sometimes periods are less than 22 days apart and you may have spotting between periods.

Hot flashes are one of the very frequent signs of menopause; the vast majority of menopausal women experience them. Hot flashes demonstrate with sudden heat strokes in the upper part of the body and redness in the face and neck. Night sweating is also associated with these flashes and it can be mild or quite severe, they usually disappear a few years after menopause.

Vaginal dryness is quite commonly observed as one of the signs of menopause. The tissues of the genitalia become thin and less elastic and some women have problems with regular sexual intercourse due to pain and discomfort and they become more prone to vaginal infections. The signs of menopause include changes in sex drive with some women experiencing a sudden loss of libido or trouble getting aroused. In some cases though, women feel freer since pregnancy is no longer an issue and they become more sexually active. However, women are still advised to use condoms because menopause doesn’t offer any immunity to sexually transmitted diseases.

Many women experience urinary problems, infections, incontinence and a more frequent need to use the bathroom. In some cases, it causes small leaks of urine when sneezing, coughing, or during any sudden move.

Women may also begin to experience mood swings which can vary in intensity. For some women, the symptoms can include anxiety and clinical depression which may require prescription medication in order to overcome it. Fortunately, for most women, the symptoms aren’t that serious and are very similar in nature to the mood swings during menstruation. Exhaustion is quite common and because of night sweats and interrupted sleep, it becomes increasing difficult to feel truly rested. And, of course, less sleep leads to more stress and more mood swings so it becomes a bit a vicious cycle.

The signs of menopause also include weight gain, most often around the mid section. Lean muscle mass decreases and it becomes increasingly difficult to maintain or gain lean muscle. The skin becomes less flexible and loses its elasticity.

Heart problems might also appear, although they’re usually not serious and they’re usually short term; palpitations and tachycardia are among them and they are quite regular and common in women between the ages of 45 and 55. In some cases though these signs could mimic symptoms of other diseases and conditions, therefore it’s important to consult with a doctor to avoid complications and other potential health problems.

The signs of menopause are many and varied and each woman’s experience will be different. In the case of anxiety and depression, it’s important to see a doctor and explore possible medications in order to control the symptoms. Unfortunately for the rest of the annoying symptoms there is not a lot that can be done. The best thing you can do is to try to get plenty of sleep, reduce your stress level, invest in some vaginal lubricant, do weight bearing exercises and just generally try to be good to yourself while you ride out this challenging time. If you think you’re having unusual or severe problems with menopause then it’s always in your best interest to make an appointment with your doctor. If possible, keep a sense humor about the whole thing and try to keep in mind that this a natural phase of life that women have been enduring since the dawn of time.

1. Hot flashes/Night Sweats
2. Vaginal Dryness
3. Weight Gain
4. Moodiness/Irritability

5. Loss of Sex Drive
6. Incontinence
7. Muscle Soreness
8. Irregular periods
9. Exhaustion
10. Random Hair Growth (like on the chin)

 
6 Less Common Additional Symptoms

1. Ringing in Ears (called Tinnitus)
2. Depression/Anxiety
3. Memory Problems
4. Bowel Problems
5. Osteoporosis
6. Sleep Problems

Well, a healthy lifestyle is the most obvious choice. Eat more natural foods with high fiber. Choose fruits and vegetables with lots of variety in color to get all your different vitamins and mineral. Take a multivitamin and calcium to supplement your diet if needed.

Quit smoking. Enough said.

Reduce caffeine intake. Caffeine has been linked to hot flashes and makes getting to sleep more difficult.

Limit alcohol use.

Do regular weight bearing exercises such as weight lifting, walking, aerobics, and dancing. Weight bearing exercise just means that you’re on your feet and your bones are supporting your weight, so activities like biking and swimming aren’t included. Make sure to choose an activity you like and mix it up a bit so you don’t get bored. A work out partner not only gives you motivation but will increase you odds of staying with a work out program. 

Try Soy Foods. Soy is high in phytoestrogens which is a plant chemical that acts like estrogen which is produced naturally in the body.  “These plant estrogens are thousands of times weaker than natural estrogen,” says nutritionist Mindy Kurzer of the University of Minnesota. “But they also circulate in the blood at levels thousands of times higher than natural estrogen.” That’s why researchers want to know if plant estrogens work like natural estrogen. Limited studies have produced limited evidence that soy is a good remedy but soy would have virtually no side effects and it’s generally good for you overall. 

Herbs that might help include black cohosh, dong quai, St. John’s Wort, ginseng, and evening primrose oil, red clover and chasteberry. These herbal remedies have little clinical proof that they help with the signs of menopause, but many women still use them.

As with all medical treatments, you should discuss your options with a doctor. If you choose to take a homeopathic route, make sure to discuss your plans with your doctor as herbal medicines can interact with prescription medications and be harmful if taken at inappropriate levels.

It’s unfortunate in some ways that the medical community, and women themselves, have taken the view that menopause is a medical condition that needs treatment. While some of the symptoms of menopause do impact the quality of your life such as sleeplessness, hot flashes and depression, it’s also a fact that it’s a necessary part of the aging process. True some of the potentially more dangerous conditions of menopause, such as depression and osteoporosis, may need to be dealt with medically, but as with all medical treatments comes the fact that the cure may be worse than the “disease”. And this has proved true in the case of hormone replacement therapy (HRT).

For years, the best medical treatment recommended for menopause
was the use of HRT, but in 2002 all of this began to be questioned when the US government stopped a drug trial of the Women’s Health Initiative (WHI) to test the uses of hormone replacement therapy. Evidence began to emerge that HRT caused an increase in breast cancer, heart disease, blood clots, strokes, and endometrial cancer. Even though this study also showed HRT use decreased osteoporosis risk and maybe also colon cancer, in 2002, the cons began to outweigh the pros and women began to reject HRT.

More information is available for women today due to new studies and tests, but there are still questions and concerns regarding HRT. A study conducted by WISDOM (Women’s International Study of Long Duration Estrogen after Menopause) started in the early 1990’s was closed early due in part to the problems found in the WHI study but WISDOM was breaking down HRT use by the age and was getting some more promising data on the use of HRT. The Women’s Health Initiative studied women aged 50 – 79 years old and the study reflected the long term effects of HRT use but not short term use by women just starting menopause. Unfortunately both of these studies left questions. Two questions listed in the WISDOM study as specifically not addressed are: 1) What is the long term effect of HRT if started at the onset of menopause? 2) Are there differences among the various types of HRT available?.

HRT is still in use today, but it is generally only recommended for short term use, usually one to two years for women who are under going natural menopause. Young women having surgical menopause brought on my hysterectomy or other procedures stay on hormone replacement therapy longer, sometimes until the onset of natural menopause.

HRT has many different forms and many different delivery systems. It usually includes a low dose estrogen with progesterone, or sometimes a synthetic progesterone, called progestin may be used. Testosterone is sometimes included in the treatment and this is used to help treat loss of sexual desire. Various combinations of these hormones may be given depending on what your doctors feels is the best way to proceed. Delivery systems include pills, creams, patches, IUDs, vaginal rings and sometimes shots.

 HRT Risks:

• Breast cancer
• Ovarian cancer
• Gallbladder disease
• Moodiness
• Water retention
• Nausea
• Blood Clots
• Heart Attacks
• Strokes
• Breast sensitivity

Some of these side effects depend on the type of dosage and delivery system used. For example, creams and gels might upset your stomach. Also, these risks depend on the type of estrogen or progesterone taken. Conjugated equine estrogens (CEE) have been the most prescribed HRT so most of the current testing has been done on them and because most of the studies conducted have been done on equine estrogens, only the side effects and risks attributed to these estrogens are known. These same risks are not applicable to bioidentical human estrogen and more studies still need to be conducted as these treatments are gaining in popularity.

Only a discussion with your doctor can help you decide if HRT is the choice for you. If you do have a family medical history of cancer or any of the other HRT risks listed above, be sure to discuss this with your doctor.

Traditional hormone replacement therapy is made from animal products, specifically the urine of pregnant horses while BHRT is made from plant products, which produces hormones that are an exact chemical match to the ones produced naturally in the body.

The Case For BHRT

In 2002, the Women’s Health Initiative halted a groundbreaking 15 year study on the use of traditional HRT, both estrogen therapy alone and estrogen plus progestin. This study revealed significant risk associated with extended HRT use, in fact, the risks were considered so great that the study was halted prematurely. This except is taken directly from their website and indicates the risks of both types of traditional HRT:

Compared with the placebo, estrogen plus progestin resulted in:

•  Increased risk of heart attack
   Increased risk of stroke
   Increased risk of blood clots
   Increased risk of breast cancer
   Reduced risk of colorectal cancer
   Fewer fractures
   No protection against mild cognitive impairment and increased risk of dementia (study included only women 65 and older)

Compared with the placebo, estrogen alone resulted in:

•  No difference in risk for heart attack
   Increased risk of stroke
   Increased risk of blood clots
   Uncertain effect for breast cancer
   No difference in risk for colorectal cancer
   Reduced risk of fracture

(Findings about memory and cognitive function are not yet available.)

Once the results of this study were revealed the use of traditional HRT dropped dramatically and women were left with little to no treatment options, this is where BHRT enters the picture.

A lot of women report significant improvement in their quality of life and a lessening of menopause symptoms after starting BHRT, but most of these cases are considered antidotal and not scientific in nature. Two of the more famous proponents of BHRT are Suzanne Somers who has been touting the benefits of BHRT since the publication of her 2006 book while recent convert Oprah Winfrey probably caused the biggest stir when she reported that she achieved excellent results with BHRT.

The Case Against BHRT

There are two main controversies surrounding BHRT: compounding and the use of the term “bioidentical” combined with false or misleading advertising claims.

Compounding

Compounding is the process by which a pharmacist “compounds” or mixes up a specific plant based hormone blend made according to each woman’s specific hormone needs which are determined by a blood or saliva test conducted by a doctor.

Controversy

There are a few problems associated with compounding; the main ones are as follows:

• Saliva testing for hormone levels may not be reliable – this simply has not been studied enough.
• Compounded hormones are outside of FDA approval. Each woman’s hormone blend is made specifically for her needs, so each blend is unique; this makes the type of standardized testing that is necessary for FDA approval impossible.
• There is not currently enough scientific testing to confirm or deny that compounded bioidentical hormone replacement therapy (CHRT) is any safer than traditional HRT.
• The FDA considers the term “bioidentical hormone replacement therapy” to be simply a marketing term.
• A lot of false claims, have been made about the safety and/or superiority of CHRT over HRT, but at this time, it is unknown if CHRT is actually safer or more effective than HRT. The FDA has begun cracking down on people and businesses making these false claims. 

FHA Approved BHRT Drugs

Compounding isn’t the only option when it comes to BHRT, there are several FDA approved medications available on the market, some are estrogen only, some are progesterone only and the last group is blends of different hormones. These treatments come in various forms including pills, creams, gels, patches, vaginal rings, vaginal tablets and vaginal gels.

Some FDA approved BHRT drugs:

Alora
Climara
Climara Pro*
Combipatch*
Esclim
Estrace
Estraderm
Estrasorb
Estring
Estrogel
Femring
Prefest*
Prochieve 4%
Prometrium
Vagifem
Vivelle
*These are combination blends that are only partially made of plant based products

Phytoestrogen is divided into three categories: isoflavonoids, coumestans and lignans.

Isoflavonoids

Soy beans and soy food products are the highest source of isoflavonoids. Other beans and legumes such as kidney, red, mung, pinto, small white and navy beans are also excellent sources of isoflavonoids.

Lignans

Lignans are usually found in foods that also have a lot fiber, such as seeds. Flaxseeds are the best source of lignans while other seeds such as poppy, sesame and sunflower are also high in lignans.

Other sources of lignans include:

• Raisins
• Apricots – among fruit, this is the best source
• Cherries
• Grapefruit
• Mandarin
• Kiwi
• Plums
• Pears
• Peaches
• Oranges
• Strawberries
• Brussel sprouts
• Onions
• French beans
• Red and green peppers
• Tomatoes
• Cabbage
• Cucumbers
• Broccoli
• Kale
• Leeks – among vegetables, this is the best source
• Garlic
• Cauliflower
• Carrots
• Spinach
• Tomato paste
• Chocolate
• Tofu
• Whole grains
• Products made with wheat and rye flours
• White rice

Coumestan

Split peas and lima beans are good sources of coumestan, but the best source is clover and alfalfa sprouts.

Pre menopause is more correctly referred to by the medical term perimenopause, although pre menopause is a completely accurate description. Perimenopause is a transition that eventually all women will go through. Usually the pre menopause phase lasts about 2 – 8 years. There are no exacts when it comes to pre menopause or menopause, because each women is physically and emotionally unique with different life style habits. Typically symptoms will begin to exhibit when women reach their mid 40’s, but a smaller percentage of women may get symptoms as early as their mid 30s.

Pre menopause marks the start of a women’s declining fertility. Once menopause is reached, a woman is completely infertile, but during pre menopause it is still possible to get pregnant. Menopause is the day a woman has her final day of menstrual bleeding, however it takes one full year with absolutely no bleeding to fully confirm menopause. The year it takes to fully confirm menopause is still considered perimenopause so a woman is still considered possibly fertile until the full year has elapsed.

Pre Menopause Symptoms

• Fluctuating hormone levels. During pre menopause hormone production become erratic, estrogen levels may be higher than normal or lower than normal. It’s these fluctuating hormones that are thought to be responsible for most symptoms.
  Irregular periods. During pre menopause, it’s possible to have more or less periods with heavier or lighter flow.
• Ovulation becomes erratic. During some menstruation cycles, a woman will still drop mature eggs to be potentially fertilized, this is called ovulation, and if this occurs it is possible to get pregnant. During cycles where ovulation does not occur, pregnancy is not possible.
• Hot flashes. This is the mostly commonly reported symptom during pre menopause and menopause.
• Night sweats. These are similar to hot flashes but more irritating because they sometimes result in insomnia. A lack of sleep can also increase stress level potentially exacerbating other symptoms such as mood swings and anxiety.
• Mood swings. Just like during PMS, this is also common during pre menopause. It’s not fully known if this is due to hormone fluctuations or other symptoms such as insomnia.
• Vaginal dryness and painful intercourse. This is due to a loss of natural lubrication and elasticity in the vaginal tissue.
• Drop in sexual interest. Generally if women had healthy sex lives before pre menopause this will continue past menopause if physical problems like the loss of vaginal dryness are overcome with vaginal lubrication.
• Osteoporosis. This is one of the long term risks associated with menopause, but the loss of bone density can begin to happen during pre menopause.
• Potentially dangerous cholesterol levels. During this phase, bad cholesterol levels (LDL) may rise while good cholesterol levels (HDL) may decrease; this increases the risk of heart disease. 
• Depression and anxiety. A small percentage of women experience clinical depression or anxiety during pre menopause.
• Heart palpitations
• Tinnitus (ear ringing)
• Memory loss
• Formication . This is the sensation that insects are crawling under or on the skin or the sensation of pins and needles.
• Urine leakage. This usually happens during laughing or coughing.
• Bladder infections
• Joint pain

Pre Menopause Treatment

Pre menopause isn’t considered a medical condition needing treatment, however if the symptoms are serious enough, they may require treatment. Symptoms such as insomnia, hot flashes, night sweats, vaginal dryness, mood swings, depression and anxiety are all symptoms that may require medical treatment.

Up until recently, hormone replacement therapy (HRT) was widely used for symptoms associated with pre menopause, but widespread use of this treatment fell off after a study reported that it increased the risks of heart disease, breast cancer and blood clots. Now, the seriousness of the symptoms has to be carefully weighed against the risks of the treatment. In addition, because of the health risks associated with HRT, it is usually only prescribed for short time frames.

There are a few treatments available for hot flashes besides HRT, but these treatments aren’t specifically approved for the treatment of hot flashes, but some women have reported success using them for menopause related symptoms. Low dose antidepressants, Gabapentin (a seizure medication) and Clonidine (a medication used to treat high blood pressure) have all shown results in treating hot flashes, but once again, the risk/reward ratio has to be carefully weighed.

Vaginal dryness can usually be treated quite easily with over the counter vaginal lubricants. Depression, anxiety, and insomnia symptoms should all be discussed with a doctor. There are many well know treatments for these symptoms such as anti depressants and sleeping pills.

Diagnosing Pre Menopause

There are a few blood and urine tests that can help your doctor determine if you are entering into pre menopause, these tests include Estradiol, FSH, and LH.

At this time, your doctor may also conduct a bone density test to see if you’re at risk for osteoporosis.

Black cohosh was used in Native American medical treatments and it was also used since the mid 1800s in home treatments. It’s a member of the buttercup family and not related at all to blue cohosh or white cohosh, which may be potentially dangerous. The roots and stems are used either fresh or dried and can be used in teas, capsules, pills or tinctures which are alcohol based drinks were the herbs are soaked in the alcohol over a period of time to infuse the alcohol with the herb.

Historic Uses of Black Cohosh

In the past, black cohosh has been used for the following treatments:

• A topical treatment for bug repellant to a treatment
• Wart removal
• Acne
• Menopause symptoms such as hot flashes
• Menstrual pain
• Inducing labor
• Rheumatism
• Anxiety
• Fever
• Sore throat
• Cough
• Osteoporosis
• Some old legends suggest that it was even effective on rattlesnake bites

Modern Usage of Black Cohosh

Most of these historical uses for black cohosh have fallen by the wayside, but black cohosh still remains popular as a menopause treatment.

Does Black Cohosh Work on Menopause?

Well, the verdict isn’t in yet. Of course some women take black cohosh for menopause symptoms and swear by its benefits, but from a scientific point of view, the results are inconclusive at this point.

According to the National Center for Complementary and Alternative Medicine (NCCAM), an organization dedicated in part to the scientific testing of complementary and alternative treatment methods as well as educating the public about these options they have determined the following about black cohosh:

• Studies on black cohosh show mixed results.
• Results of testing on black cohosh for menopause symptoms are mixed and inconclusive.
• Most of the studies on black cohosh have been less than 6 months in length, so the long term safety of black cohosh usage is unknown at this time.
• A study funded by the NCCAM testing both black cohosh alone and black cohosh with other natural ingredients showed no results relieving hot flashes or night sweats in perimenopausal or postmenopausal women.
• There isn’t enough reliable information to verify that black cohosh has any reliable medical benefits.

Potential Side Effects and Contraindications

• Some people may experience stomach problems, headaches or rash.
• There is the possibility of interactions with other medications.
• People with liver disorders should not use black cohosh.
• Anyone who experiences any indication of potential liver problems such as stomach pain, jaundice (yellowing of the skin and eyes) or dark urine should not use black cohosh.
• It’s not recommended for pregnant or nursing women.
• It’s also not recommended for women who have conditions that may be hormone sensitive such as breast cancer, ovarian cancer, uterine cancer, endometriosis and fibroids.
• It’s not recommended for people who have had kidney transplants. Although the risks aren’t fully understood at this time, black cohosh, when taken in products also containing alfalfa, has been linked to kidney transplant rejection.
• People with Protein S deficiency should not use black cohosh, because people with this deficiency have an increased risk of developing blood clots and black cohosh may increase this risk.

The risks of drug interactions and minor side effects are considered to be minimal, but all potential risks need to be considered. In 2008, the Dietary Supplement Expert Committee reversed its 2002 decision that black cohosh products did not need to be labeled with a warning label, even though their comparison study revealed no definitive results and it’s still not fully understood how black cohosh may impact liver disease, or even if it does.

When treating menopause, both the symptoms of menopause and the underlying hormone fluctuations of menopause need to be treated in order to achieve maximum relief. Unfortunately at this time, there are very limited treatment options available for the vast majority of menopause symptoms and it’s important to keep in mind that menopause itself is not a disease, it’s the most natural occurrence on earth just like puberty and pregnancy.

Prescription drugs- Bio-identical hormone therapy is one option available for menopausal woman. These drugs have similar chemical hormone balances as the female body. It is the most natural, prescription choice available on the market, due to the fact that the hormones are derived and extracted from plants. These hormones are available in cream and gel form for quick absorption, reducing side-effects significantly. The only disadvantage to the therapy is the lack of research on safety and effectiveness of the product range. Of all the therapy types, estrogen therapy also known as hormone replacement therapy or HRT, a combination of progesterone and estrogen, is probably the best known. Estrogen assists in reduction of hot flashes and cholesterol while also successfully treating uncomfortable urinary and vaginal problems related to menopause.

Estrogen disadvantages- Estrogen therapy unfortunately has some major disadvantages such as increased risk of cancer specifically breast and endometrial, heart attacks, strokes, thrombosis, clotting, discomfort during sex and gallstones. Estrogen is available in creams, gels, patches and capsules

SSRI’s – Selective serotonin reuptake inhibitors also known as SSRI’s
are a class of medications used to treat depression. When depressed menopausal women were taking SSRI’s, they had fewer hot flashes. Many women, whether depressed or not, have found relief from hot flashes while using SSRI’s. Only a short dose is needed to tell whether the treatment will work or not, usually you will know in a week or two if SSRI’s will get results. Unfortunately, SSRI’s don’t work on all women for treating menopause.

Clonidine and Gabapentin – Limited testing of these drugs on menopausal women for the treatment of hot flashes has yielded positive results, but not enough clinical testing has been done. Clonidine is typically used to treat ADHD and gabapentin is used to treat epilepsy so they have been tested for the treatment of these diseases, just not for the treatment of hot flashes.

Other traditional treatments- Calcium intake can be increased to 1500 mg’s per day, this will help combat osteoporosis. Anti- depressants as well as anti-anxiety medication are also prescribed to reduce panic, depression and anxiety attacks often associated with menopause. Vitamin and mineral supplements are highly recommended as nutritional deficiencies are also common during menopause.

Of the treatments listed above, only estrogen has been tested extensively for the treatment of menopause. SSRI’s, clonidine, and gabapentin have been found to give results for hot flashes but more testing needs to be done. Sometimes a doctor may be willing to try these options if you aren’t getting relief from other medical treatments.