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Menopause causes, symptoms and treatments

The menopause is the end of the reproductive period of women , usually around the age of 50 years. It is marked by the cessation of menstruation and the cessation of ovulation and secretion by the ovaries of sex hormones ( estrogenand progesterone ).

Medically speaking, a woman is known to be in the menopause when she has not menstruated for 12 consecutive months . Nevertheless, the beginning of the menopause, that is to say the permanent cessation of the rules, is at the beginning of these 12 months. It can only be established retrospectively.

The 2- to 7-year period before menopause is called perimenopause (not premenopausal). Ovulation becomes more irregular. The estrogen level can vary very significantly. It is during these transitional years that menstrual irregularities and uncomfortable symptoms appear: hot flashes, sleep disturbances, mood swings, and so on.

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Premenopause: Fertility period, from puberty
Perimenopause: Irregular menstruation: from 2 to 7 years
Menopause *: No menstruation for at least 1 year

* Some use the term post-menopause to describe the period of time following menopause, which is not entirely appropriate since menopause is a definitive state. It will be said of a woman that she is “menopausal”.

The intensity of the symptoms varies from one woman to another: some have no other symptom than the cessation of menstruation , while others have symptoms of moderate to severe intensity (20 to 30%). women).

Note. After the menopause, even if the ovaries no longer secrete estrogen, the adrenal glands and adipose tissue (fat reserves) continue to release small amounts.

Premature menopause

What triggers menopause? 
Every woman starts her life with a determined amount of oocytes, female sex cells. Menopause is not triggered when all oocytes have been used. A woman has about 30,000 oocytes. Only 500 of them will go through the ovulation cycle. The age of menopause is mostly determined by the genes. It can also be influenced by the state of health.

When menopause occurs before the age of 40 , it is considered premature. Premature menopause can occur spontaneously or be caused by illness, medication, surgery, or radiation therapy or chemotherapy.

For example, surgical removal of both ovaries causes menopause. On the other hand, removal of the uterus alone (hysterectomy) is not enough to cause menopause (because the ovaries continue to produce estrogen), but stops the menstruation. The cancer treatments, by chemotherapy or radiotherapy, can lead to a more gradual cessation of the rules. The effect of these treatments on the menstrual cycle depends on their potency. The rules can come back with the stop of the treatment.

Consequences to more or less long term

The decline in estrogen makes women more at risk for various health problems, such as osteoporosis, stress urinary incontinence and cardiovascular disorders. This is one risk factor among others. To learn more about preventing these conditions, see these factsheets.

The symptoms of menopause

The symptoms are usually more marked during perimenopause . These symptoms are related to the hormonal changes that occur during this transition period, but also to aging. They are unpredictable and vary a lot from month to month.

  • Irregular menstruation. They are a common manifestation of the hormonal instability that occurs during perimenopause.
  • Hot flashes and night sweats. Hot flashes are usually felt first in the abdomen or chest. The heat rises in seconds to the neck and face. Their duration varies from a few seconds to a few minutes. Their frequency and intensity are very variable from one woman to another. They are sometimes accompanied by palpitations and sweats. 50 to 80% of women feel it. Hot flashes are the main reason women visit a menopausal health professional.
  • Nocturnal sweats : they are characterized by significant sweating throughout the body. They occur at night and can interrupt sleep. The important thing is to ask if hot flashes and night sweats are sufficiently detrimental to quality of life to require treatment.
  • Disturbances of sleep. Sleep problems are a very common complaint during this transition period. In general, with age, the nights are shorter and the quality of sleep tends to be less good. Hormonal changes can also affect sleep. For example, difficulty falling asleep and frequent awakenings during the night are usually related to hot flashes and night sweats. These sleep disorders can lead to significant fatigue, irritability, mood disorders and difficulty concentrating.
  • Mood disorders. Although controversial, the period around menopause appears to be a period of greater emotional vulnerability. Irritability, the tendency to cry more often, mood changes, anxiety, and lack of motivation or energy are the most common complaints during this time of life. Women who had depression before menopause also sometimes get worse.
  • Drop in libido. Sexual desire is a complex human phenomenon which, in terms of hormones, depends mainly on sex hormones: estrogens and androgens (testosterone and dehydroepiandrosterone or DHEA). According to the results of a large study of menopausal women, libido and sexual arousal tend to decline over the years. For more information about sexuality with age, see our Sexuality section.
  • Dryness of the mucous membranes. Stopping secretion of estrogen by the ovaries reduces the production of mucus in the vagina and bladder. This drop in production causes the drying and thinning of the mucous membranes. In addition, vaginal secretions change: they become more aqueous and more alkaline (less acidic). More than half of menopausal women experience discomfort related to vaginal dryness. These discomforts are manifested by itching, a burning sensation in the vagina and vulva, and pain during intercourse. This dryness of the mucous membranes does not present a risk for health. There are solutions to relieve the discomfort it causes.
  • Aging skin, drier hair. The skin tends to become drier, and the wrinkles more pronounced. The hair becomes drier and brittle. Indeed, the reduction of estrogen causes a reduction in the production of collagen and elastin , 2 substances that play an important role in the elasticity of the skin and its tone. However, the main causes of the appearance of wrinkles are time (aging) and cumulative exposure to the sun. In addition, other factors can change the appearance of skin and hair, such as a slowdown in thyroid gland activity (hypothyroidism). It is therefore necessary to evaluate the situation globally.
  • Slight weight gain. Women who take 2 to 4 kg (5 to 10 pounds) at menopause would stay healthy longer and survive longer than those who do not gain weight, lose or take more. The fat cells turn the hormones of the adrenals into female hormones. A slight weight gain, because it alleviates the hormonal decline of menopause, thus seems beneficial for health.

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People at risk for Menopause

People at risk of having more severe symptoms:

  • Western women.

Risk factors

Factors that may influence the intensity of menopausal manifestations

  • Cultural factors.  The intensity of the symptoms depends very much on the conditions in which the menopause occurs. In North America, for example, nearly 80% of women have symptoms at the onset of menopause, especially hot flashes. In Asia, it’s barely 20%.
    These differences can be explained by the following two factors characteristic of Asia:
    – abundant consumption of soy products (soybeans), a food with a high content of phytoestrogens;
    – a change of status leading to an appreciation of the older woman’s role for her experience and wisdom.
    Genetic factors do not seem to be in question, as studies on immigrant populations have shown.
  • Psychological factors.  Menopause occurs at a time in life that often brings other changes: the departure of children, early retirement, etc. Moreover, the end of the possibility of giving birth (even if most women have given up this age) is a psychological factor that confronts women to aging, thus to death.
    The state of mind in front of these changes influences the intensity of the symptoms.
  • Other factors . Lack of exercise, sedentary lifestyle and poor nutrition.

Note.  The age at which menopause occurs is partly hereditary.

Prevention of menopause

Menopause is the result of a natural evolution . However, studies conducted worldwide show that differences in lifestyle, diet and physical activity can influence the intensity and type of symptoms that women experience during menopause.

In general, we will put all the chances on his side by adopting the following preventive measures before 50 years, especially during the quarantine .

  • Focus on foods that promote healthy bones and heart: rich in calcium, vitamin D, magnesium, phosphorus, boron, silica, vitamin K and essential fatty acids (including omega-3), but low in saturated fat, and providing vegetable protein instead of animal protein;
  • Eat foods rich in phytoestrogens (soy, flaxseed, chickpeas, onions, etc.);
  • If needed, take calcium and vitamin D supplements;
  • Regularly engage in physical activity that makes the heart and joints work, as well as flexibility and balance exercises;
  • Cultivate a positive attitude to life;
  • Stay sexually active
  • Practice Kegel exercises , both to combat urinary stress incontinence and to improve sex life by increasing the tone of the vaginal muscles;
  • No smoking. In addition to damaging bones and heart, tobacco destroys estrogen.

Moreover, as explained above, women, because they are menopausal, but especially because they are getting older, are at higher risk for osteoporosis, cardiovascular disease, cancer of the skin, endometrium and breast cancer. We will therefore take care to apply the preventive measures associated with these diseases.

Medical treatments for menopause

Way of life

healthy lifestyle helps reduce the intensity of menopausal symptoms, improves cardiovascular and bone health, and provides some protection against many health problems.

Food

To reduce hot flashes

  • Instead of taking 3 main meals, reduce portions and provide healthy snacks between meals;
  • To drink a lot of water ;
  • Avoid or greatly reduce the consumption of excitants: hot drinks, coffee, alcohol, spicy food;
  • Decrease your consumption of concentrated sugars;
  • Consume foods rich in phytoestrogens regularly.

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Physical exercise

Any form of physical activity is better than no physical activity. For all women, especially those entering this transition period, daily exercise has several important benefits:
– maintain or achieve a healthy weight;
– keep the cardiovascular system in shape;
– reduce the loss of bone density and the risk of falling;
– reduce the risk of breast cancer;
– stimulate sexual desire.

In addition, studies indicate that sedentary women are more likely to experience moderate to severe hot flashes compared to women who exercise regularly.

It is recommended to be moderately active for at least 30 minutes a day and to incorporate flexibility exercises into one’s routine: stretching, tai chi or yoga for example. For appropriate advice, consult a kinesiologist (the specialist in physical activity).

Relaxation techniques

Deep breathing, massage, yoga, visualization, meditation, etc. can help to counteract sleep problems, if any. Relaxation may help relieve other symptoms of menopause (see Complementary Approaches).

Medication

To combat the various problems associated with menopause, doctors resort to 3 types of pharmacological approaches:

  • general hormonal treatment;
  • local hormone treatment;
  • Non-hormonal treatments.

General hormonal treatment

The hormone supplements the hormones that the ovaries stop secreting. It allows the majority of women to see decrease or even disappear their symptoms (hot flushes, sleep disorders, mood changes) for the duration of hormone therapy.

It is important to know that most women who are undergoing general hormonal treatment will regain their symptoms when they stop treatment because the body will once again undergo a hormonal transition. Some women might, for example, make the decision to take hormone therapy for a few years and then decide to stop it at the time of retirement, knowing that it will be easier to manage their symptoms at this time of life.

General hormonal therapy usually uses a combination of estrogen and progestin . The estrogen aloneare reserved for women who have undergone removal of the uterus (hysterectomy) since taken over a prolonged period, they increase the risk of uterine cancer. Adding a progestogen reduces this risk.

Nowadays, hormone therapy is reserved for women whose menopause symptoms are pronounced and whose quality of life is sufficiently compromised to justify it. The Society of Obstetricians and Gynecologists of Canada recommends that physicians prescribe the lowest effective dose for the shortest period possible. The maximum recommended duration is 5 years .

Hormone therapy can help slow bone loss and reduce the risk of fracture. On the other hand, it should not be prescribed for this single purpose.

Sometimes hormone replacement therapy has non-dangerous, but unpleasant, side effects . Ask your doctor.

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Some women take hormones on a continuous basis , that is, they take estrogens and progestins every day. Menstruation stops then. Generally, they do not resume when hormone therapy stops, if it lasted long enough. Other women take cyclic treatment , and take progestins only 14 days a month and estrogen each day. Hormone therapy taken cyclically generates “false menstruation” or withdrawal bleeding (not related to ovulation, as in the case of the birth control pill).

Classic Hormone Therapy

In Canada, equine conjugated estrogens (Premarin) have long been the most prescribed . These estrogens are extracted from the urine of pregnant mares and are administered orally. This is no longer the case. On 1 st  February 2010, Premarin was removed from the list of drugs covered by the public drug insurance plan in Quebec, because of a very significant increase in its selling price. (Premplus, a combination of equine conjugated estrogens and synthetic progesterone, has also been withdrawn.)

Since then, doctors can prescribe any of the following estrogens. These are tablets to take by mouth.

– Estrace : 17ß-estradiol;
– Ogen : estropipate (a form of estrone);
– CES : synthetic conjugated estrogens.

Estrogens are usually prescribed in combination with synthetic progestins  : medroxyprogesterone acetate (MPA) such as Provera  or micronized progesterone from plants such as Prometrium . Micronized progesterone is a type of “bio-identical” hormone (see below).

Risks related to conventional hormone therapy

The Women’s Health Initiative Study (WHI), a large study in the United States from 1991 to 2006 to more than 160,000 postmenopausal women, has had a major impact on the treatment of menopausal symptoms. Participants took either Premarin  and Provera , or Premarin  alone (for women with no uterus), or placebo . The first results were published in 2002. This hormone intake has been associated with an increased long-term risk of the following health problems.

  • Blood clot formation , 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 postmenopausal women for 10 years or more.
  • Breast cancer (6 more women per 10,000 per year) and, in the case of breast cancer, more deadly. This is partly explained by the fact that breast cancer is more difficult to detect in women on hormone therapy because their breasts are denser.
  • Dementia in women over 65 years old.

These risks increased with duration of use and with individual risk factors (age, genetic and other factors).

Note . Although the WHI study did not include hormone therapy with Estrace, Ogen, and CES, it is likely that these types of hormones place women at cardiovascular risk similar to Premarin because they are taken by mouth. Oral.

Bioidentical Hormone Therapy

The bio-identical hormones have the same molecular structure as hormones secreted by the ovaries: estradiol-17 (the main estrogen produced by the female body) and progesterone. They are synthesized in the laboratory from plants such as soybeans or wild yams.

Bio-identical estradiol-17ß is administered cutaneously , which distinguishes it from conventional hormone therapy. It is obtained in the form of patches (Estraderm, Oesclim, Estradot, Sandoz-Estradiol Derm or Climara) or gel (Estrogel).

In addition to oestradiol-17ß , physicians who use bioidentical treatment usually prescribe micronized progesterone . The micronization technique turns progesterone into tiny particles that are well absorbed by the body. It is offered orally ( Prometrium ).

Bio-identical hormones have been prescribed for several years in Canada and France (the bio-identical name is however recent). At the time of writing, these drugs were covered by the Quebec public prescription drug insurance plan only in certain special cases. However, most private insurance plans pay them back.

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Note . It is also possible to obtain over-the-counter products of masterful bio-identical estrogen preparations , in the form of a cream containing a compound of the 3 natural estrogenic molecules of women, namely estradiol, estriol and estrone. However, no scientific data has been shown to be effective and most doctors advise against this. Also in the pharmacy are master preparations of progesterone in the form of cream. These are formally discouraged. The absorption of progesterone by the skin is not very effective, varies a lot from one woman to another and does not allow to obtain an adequate concentration to protect the uterus. Recall that taking estrogen alone increases the risk of uterine cancer, and that the addition of progesterone serves to reduce this risk.

Safer, bio-identical hormone therapy?

No study can say that.  we will never have an answer to this question, because a comparative study (as large as the Women’s Health Initiative Study) would be far too expensive. Thus, women must make a choice in a context of uncertainty . However, the fact that estrogens are administered cutaneously reduces the cardiovascular risks associated with taking conventional oral hormone therapy. Indeed, by crossing the digestive system, and more specifically the liver, estrogens form metabolites , which does not occur with bioidentical hormones taken by the dermal route..? That’s why some doctors prefer it in women at risk for heart problems, for example.

Local hormone treatment

The application of small doses of vaginal estrogens is intended to relieve the symptoms of vaginal dryness and thinning of the mucous membranes. However, it has no therapeutic effect on hot flashes, sleep disorders and mood disorders. Local hormone therapy does not cause the side effects and risks associated with general hormone therapy.

Estrogens can be administered into the vagina with a cream , a ring or tablets . Their effectiveness is the same. Vaginal cream and tablets are inserted into the vagina using an applicator. The vaginal ring impregnated with estrogen is made of a flexible plastic. It fits at the bottom of the vagina and must be changed every 3 months. Most women tolerate it well, but some feel it is uncomfortable or sometimes has a tendency to move and exit the vagina.

At the beginning of treatment, when the vaginal mucosa is very thin, it happens that estrogen applied locally in the vagina diffuse into the body. However, no adverse health effects in the long term have been reported at the recommended doses.

Non-hormonal treatments

Non-hormonal medications can help relieve some menopausal manifestations.

Against hot flashes
Antidepressants
 . Studies suggest that some antidepressants may reduce hot flashes (but the effect is less than that of hormone therapy), whether or not there is underlying depression. This option may be an interesting choice for a woman who has depressive symptoms and hot flashes, but who does not wish to take hormones.
Antihypertensives Clonidine, a medication used to lower blood pressure, has been shown to be slightly more effective than placebo in relieving hot flashes. However, this medicine is not widely used because it causes several side effects, such as dryness of the mouth, drowsiness and constipation.

Vaginal Dryness
Replens Moisturizing Gel has been shown to be an effective vaginal moisturizer to relieve itching and irritation as well as pain during intercourse. It applies every 2 to 3 days.

Against mood swings
the use of antidepressants, anxiolytics and sleeping pills should not be part of the arsenal of basic menopausal care. Their prescription must meet the same criteria and the same rigor as for any other period of life.

Against osteoporosis
several non-hormonal drugs are used to increase bone density and reduce the risk of fracture.

 Against sleep problems
some ideas to facilitate sleep: practice regular exercise, use various means to relax (deep breathing, massage, etc.), avoid caffeine and alcohol and drink a German chamomile tea or valerian before bedtime.

 Sex life

Studies suggest that women with active sex life have fewer symptoms of menopause than those who have little or no sex life active. But we do not know if there is a causal link or if it is a mere coincidence between the two.

Anyway, it is obvious that a menopause punctuated by many symptoms disturbs the sex life. However, one can still maintain an active and satisfying sex life by resorting to a vaginal hormone therapy, a vaginal moisturizer or a lubricant.

Remember that exercise can also arouse desire in women. To maintain active libido , it is also important to maintain good communication with the spouse and to manage stress in general (work, etc.).

Testosterone. The prescription of testosterone to menopausal women is still a marginal phenomenon in North America. However, more and more doctors are doing this to restore and stimulate libido, especially in women who have had both ovaries surgically removed. The potential side effects of using testosterone in women are still poorly understood. We must therefore consider this treatment as experimental.

Supplements

The only official recommendation is the use of calcium and vitamin D supplements to fight osteoporosisin some cases. For more details, see the fact sheet on osteoporosis as well as those devoted to these two products.

Tips for preventing hot flashes

Take the time to determine what may be causing your hot flashes and then better avoid them. For example :

  • certain foods or drinks (see above);
  • high temperatures outside or in the house;
  • prolonged exposure to the sun;
  • hot showers or baths;
  • abrupt change in temperature, such as when moving from an air-conditioned room to a place where excessive heat prevails;
  • Synthetic fiber clothing.

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