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The Menopause Time of Liie.National Inst. on Aging (DHHS/NIH), Bethesda, MD.NIH-86-24618627p.National Institute on Aging Information Center/Meno,2209 Distribution Circle, Silver Spring, MD 20910(Single copy, free). For multiple copies contact theSuperintendent of Documents, U.S. Government PrintingOffice, Washington, DC 20402 (Stock No.017046-00056-0, $1.00).Reports - General (140)

EDRS PRICE MF01/PCO2 Plus Postage.DESCRIPTORS Adult Development; *Aging (Individuals); Eating

Habits; *Exercise; *Females; *Mental Health; MiddleAged Adults; *Nutrition; Older Adults; Sexuality;Smoking

IDENTIFIERS *Menopause; *Osteoporosis

ABSTRACTThis pamphlet examines menopause and the changes

associated with it. Menopause is briefly described, surgicalmenopause is explained, and the relationship between menopause andthe reproductive cycle is discussed. Signs of menopause aredescribed, including hot flashes and vaginal and urinary tractchanges. Postmenopausal osteoporosis is explained and women most atrisk of developing osteoporosis are identified. Suggestions, in theform of lifelong eating and exercise habits, are given for preventingor delaying the onset of osteoporosis. Situations are discussed inwhich treatment is needed for menopause and available treatments,such as estrogen replacement therapy (ERT), are explored. Cases inwhich ERT should not be used are considered. Mental health duringmenopause is discussed, mood changes and depression during menopauseare described, and the role of sexuality during and after menopauseis explained. The role of good nutrition in helping women stayhealthy as they grow older is examined. The dangers of smoking andthe need for physical exercise are also discussed. The book concludeswith a list of other National Institute on Aging publications ofinterest to older women. (NB)

k************************************************************r********** Reproductions supplied by EDRS are the best that can be made *

* from the original document. *************k**********************************************************

THEMENOPAUSETIME OF LIFE

U.S. DEPARTMENT OF EDUCATIONOffice of Educational Research and ImprovementEDU TIONAL RESOURCES INFORMATION

CENTER (ERIC)

his document has been reproduced asreceived I rcm the person or organizationoriginating it.

0 Minor changes have been made toimprovereproduction quality.

Points of view or opinions stated in this ctocu.ment do not necessarily represent officialOERI position or policy.

U.S. Public NationalDEPARTMENT Health InstitutesOF Service ofHEALTH HealthANDHUMANSERVICES

2

AktLArni

Contents

1 What is Menopause?

1 Surgical Menopause

4 The Reproductive Cycleand Menopause

5 What are Signs of Menopause?

7 Osteoporosis

9 When Does Menopause NeedTreatment? What Treatmentsare Available?

11 Mental Health and Menopause

15 Sexuality and Menopause16 Staying Healthy

19 Looking Ahead

3

Okt,LPWhat is Menopause?

Menopause or "change of life" isthe time in a woman's life whenmenstruation stops and the body nolonger produces the monthly ovumor egg from which a baby could beformed. It usually occurs at aboutage 50, although it can occur asearly as 4-5 or as late as 55.Menopause is usually consideredfinished when a woman has notmenstruated for a year. Completionof menopause marks the end of thechildbearing years.

Menopause is natural and takesplace smoothly for most women. Itis part of a gradual process some-times called the climacteric, whichbegins about 5 years before meno-pause and may last about 10 years.During the climacteric a woman'sbody produces decreasing amountsof the hormones estrogen andprogesterone. This reduction inhormone production causesmenstrual periods to stop.

Many women welcome menopauseno more periods, and after at least ayear without a period to be sure it'ssafe, no more worry about pregnancy.

Surgical Menopause

Surgical procedures involving theovaries (see diagram) and the uterus

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can affect how menopause takesplace. When the uterus is removed(called a hysterectomy) and theovaries remain, menstrual periodsstop; meanwhile, other aspects ofmenopause occur in the same wayand at the same age that they wouldoccur naturally. When only oneovary is removed, menopause occursnormally. With the removal of bothovaries, complete menopause takesplace abruptly, sometimes withintense effects.

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The Reproductive Cycle andMenopause

During puberty increasing amountsof the female hormones estrogen andprogesterone stimulate the reproduc-tive system to mature and menstrua-tion to begin. For more than 30years of a woman's life (exceptduring pregnancy) a monthly cycletakes place. The pituitary gland,located at the base of the brain,produces hormones that stimulatethe ovary to release a new ovum oregg cell each month. The ovumproduces the hormones estrogen andprogesterone which cause the liningof the uterus to become thicker inorder to receive and nourish afertilized egg which could developinto a baby. If fertilization does notoccur, estrogen and progesteronelevels drop, the lining of the uterus

breaks clown, and menstruationoccurs. 1 nen the whole processbegins again.

After age 35 estrogen and proges-terone levels begin a very gradualdecline. In the late forties thisprocess accelerates and hormonelevels eventually decrease so that themenstrual cycle becomes irregular orstops.

Following menopause the ovariesstill produce some estrogen; othertissues and organs also producehormones which are converted toestrogen.

What are Signs of Menopause?

The only sign of menopause formany women is the end ofmenstrual periods. They may stopsuddenly or become irregular, with alighter or heavier flow and withlonger intervals between periods,until they eventually stop. About 80percent of women experience mildor no signs of menopause; the other20 percent report symptoms severeenough to seek medical attention.

Two other signs associated withmenopause are hot flashes (whichare often accompanied by sweating)and vaginal dryness. The fatigue,heart palpitations, or depressionreported by some women during thistime may be symptoms of meno-pause in some cases, but there iswide disagreement about this.

Hot Flashes

Hot flashes, or hot flushes, are oneof the more common and earliestsign of menopause, sometimesbeginning several years before othersigns. They give a sudden feeling ofwarmth throughout the upper bodyor over all of the body. The face maybecome flushed, with red areasappearing on the chest, back,shoulders, and upper arms. This isoften followed by perspiration and acold clammy sensation as the bodytemperature readjusts. The processmay last anywhere from a fewseconds to a half-hour or more.

Hot flashes may occur several timesa day or only once a week. Thesensations vary from woman towoman and from one episode toanother. In most cases hot flashesare not severe and usually disappearafter a few months, although insome women they can continue forseveral years. Sometimes hot flashesdisturb sleep at night and may causeheavy perspiration.

Vaginal and Urinary Tract Changes

With age the walls of the vaginabecome thinner, less elastic, anddrier. The vagina is then morevulnerable to infection. Also, thesechanges sometimes result inuncomfortable or painful sexualintercourse, although continuingregular sexual activity will reduce

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the possibility of problemsdeveloping. (Also see section onsexuality and menopause.)

As body tissues change wAh agesome women experience urinarystress incontinence, which is theloss of a small quantity of urinewhen exercising, coughing, laughing,or performing other movements thatput pressure on the bladder. As wellas age changes, lack of physicalexercise may also contribute to thecondition. While incontinence canbe embarrassing, it is common andtreatablefor example, certainexercises can strengthen the affectedmuscles or sometimes surgery isperformed to cure it.

Some women are prone to urinal::tract infections. These tend to recurbut are easily treated with anti-biotics or other measures. Preventivetechniques include urinating afterintercourse, not keeping the bladderover-full for long periods, thinkingadequate amounts of fluids, andkeeping the genital area very clean.It is important to see a doctor assoon as any symptoms appear, suchas painful or frequent urination.

Osteoporosis

"Postmenopausal" osteoporosis isclosely associated with menopausesince it is caused in part by thedecrease in estrogen that occurswith menopause. It is a major cause

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of bone fractures in older women. Inwomen with this condition bonemass slowly decreases over the yearsto produce thinner, more porousbone. Osteoporotic bone is weakerthan normal bonc and fracturesmore easily. Common sites forfractures are the spine, wrists andforearms, and hips.

Osteoporosis is sometimes called the"silent disease" because there are nosymptoms during the early stages.Too often the condition is not recog-nized until it reaches an advancedstage when fractures are most likelyto OC CUT.

Once bone is lost it cannot bereplaced, so an early prediction ofwhich individuals are at high risk orhave already developed mild osteo-porosis is important. Unfortunately,accurate and inexpensive medicaltests are not yet widely accessible.The most accurate testssingle anddual photon absorptiometry and thecomputerized axial tomogram or CTscanare expensive and usuallyavailable only at major medical andresearch centers.

Who is most likely to developosteoporosis? In everyone the riskincreases with age, but it is highestin white women after menopauseparticularly in individuals who havean early or surgical menopause.Other people at high risk includethose with fair skin (especially

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blonds and redheads), those whosediets are low in calcium, and thosewho are physically inactive, under-weight, or smoke cigarettes. Womenwith a close relative (mother orsister) with the disea3e are also athigh risk.

Lifelong habits may be the best wayto prevent o3teoporosis. By practicingsimple health measures youngwomen can prevent bone loss andolder women who have alreadydeveloped osteoporosis can slowdown further bo le loss. Thesemeasures include eating foods highin calcium, going outdoors for ashort time every day (exposure tosunlight helps the body manufacturethe vitamin D necessary for calciumabsorntion), and exercising regularlyin activities that place stress on theweight-bearing bones (such as walk-ing, jogging, or aerobics). Also, forwomen most likely to develop osteo-porosis, some doctors recommendthe use of estrogen replacementtherapy (see next section).

k.A'vWhen Does Menopause NeedTreatment? What Treatments areAvailable?

Menopause is a natural part of agingand does not necessarily requiretreatment. But if you experiencegreat discomfort at this time,

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consult your physician.

For severe symptoms of menopause(hot flashes, vaginal changes) and toprevent osteoporosis, many doctorsprescribe estrogen replacementtherapy (ERT), a synthetic estrogenwhich supplements the decreasingamounts of estrogen produced by thebody. Estrogen in pill form is mostoften used for the pievention ofosteoporosis; topically appliedestrogen creams are used for severevaginal symptoms.

Third, cancer of the endometrium(lining of the uterus) has been foundto occur more frequently in womenwho use ERT containing estrogen asthe only ingredient, compared withuntreated women. However, today'sERT usually combines estrogen andprogestin (another female hormone),and this combination appears toreduce the risk of endometrialcancer. But even with this improvedform of estrogen therapy, experts donot yet know if its long-term use iscompletely safe. This is why ERT isrecommended primarily for womenwho are at greatest risk of develop-ing osteoporosis (see section onosteoporosis).

Who should not use ERT? Somewomen are not good candidatessince estrogen can worsen certainconditions or increase the risk ofcomplications. Persons who shouldavoid ERT are those who have had10 3

(or now have) heart disease, endo-metrial or breast cancer, stroke,migraine headaches, high bloodpressure, blood clots, or otherdisorders related to the circulatorysystem.

Other conditions warrant that ERTbe used with extra caution. Theseinclude exposure at birth to diethyl-stilbestrol (DES), obesity, a historyof cancer in the family, vaginalbleeding, liver or gallbladder disease,and diabetes.

Mental Health and Menopause

Most women have a healthy outlookthroughout the menopause processand afterward feel "in their prime,"glad to no longer be menstruating.

Mood changes may occur duringmenopause. Other symptoms com-monly reported are fatigue, nervous-ness, excess sweating, breathlessness,headaches, sleeplessness, joint pain,depression, irritability, and impa-tience. These symptoms may be duein part to shifting hormonalbalances or other factors such asheredity, general health, nutrition,medications, exercise, life events,and attitude. More research isneeded on the role hormones playand how they interact with theseother factors.

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Estrogen can be highly effective butit must be used with care. Oncreason for this caution is thatroughly 10 percent of women whouse estrogen experience side effectssuch as headaches, nausea, vaginaldischarge, fluid retention, swollenbreasts, and weight gain.

Second, some early studies suggestedthat breast cancer and heart diseaseare associated with estrogen use.Current evidence* indicates that norelation exists bet ween breast cancerand ERT. Studies on heart diseasehowever show contradictory results;for example; researchers at theHarvard Medical School recentlyfound that estrogen may possiblyreduce heart disease, while reportsfrom the Framingham Heart Studystated that heart attack and stroketend to occur more frequentlyamong persons using estrogen.

If you are at high risk of developingosteoporosis or have severe symp-toms accompanying menopause,discuss the use of ERT with yourdoctor. To help ensure that ERT issafe for you, he or she shouldperform a thorough medical history

*From thc NIEL Consensus DevelopmentConference on Osteoporosis held in April1984. A conference report is available fromthc NIH Office of Medical Applications ofResearch; Bldg. 1, Rrn. 216, Bethesda, MD20892.

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and examination before prescribingtreatment. Then, as treatmentproceeds, continue to see yourphysician for frequent follow-upexaminations.

Stay informed. Research is beingconducted at many universities andmedical centers, and this researchperiodically results in new infor-mation that may bear on yourtreatment.

Other Treatments fcr Menopause

Several drugs are available to reducehot flashes or to relieve other meno-pausal symptoms for women whocannot use ERT.

Some women report that certainvitamins are successful in reducinghot flashes or stress, although noscientific evidence supports theseclaims. (The safe use of vitamin andmineral supplements requires theadvice of a health professional; seesection on nutrition.)

Doctors sometimes prescribetranquilizers for women who areparticularly tense, irritable, ornervous, but they are not recom-mended for symptoms specificallyrelated to menopause. Tranquilizersare like other drugs: they can haveside effects and should be used withcare. Before turning to medication toreduce stress, many people first tryexercise, an improved diet, or relaxa-

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tion techniques.

There is no specific mental disorderassociated with menopause, andresearch shows that women experi-ence no more depression duringthese years than at other timesduring life. Tension or depressioncan occur at any stage, but whenthese states occur during meno-pause, there is a tendency to blamethe menopause process. Thuswomen with emotional problems areon occasion tagged "menopausal,"sometimes long after menopause hastaken place.

Impor,:ant life changes often coincidewith the menopause yeais: perhapsgrown children are leaving home,aged parents need more attentionand assistance, or a woman's life istaking on new directions. This is atime when many women thinkabout growing older and the changesit will bring.

Developing positive attitudes towardmenopause and aging is an impor-tant part of adjusting to life changes.As long as menopause is regarded assimply a normal life change and awoman goes on to participate insatisfying activities, coping with thetransitions and body changesbecomes easier. But viewing meno-pause as the end of a useful lifeonly makes the transition difficultso that if a crisis develops, such as a

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divorce or the need to care forparents who are ill, menopause islikely to seem an added burden.

Supportive friends and satisfyingactivities help ease any transition orcrisis. Emotional support can comefrom a variety of sources: a friend,your husband, or relatives. Varioustypes of support groups exist whichcan provide opportunities for you totalk with other people who aregoing through similar experiences.When coping is difficult, it may beuseful to consult a gynecologist orseek the services of a social worker,psychologist, psychiatrist, or othermental health professional.

jp41104

We'Sexuality and Menopause

An active and fulfilling sex life cancontinue throughout menopause.While some physical responses slowwith age, the capacity and need forsexual expression continues into oldage. Some women report that sex iseven more enjoyable after meno-pause, possibly because pregnancy isno longer a concern and there ismore time and privacy whenchildren are gone from home.

Although many women report nochange in their sexual feelings orperformance during and after meno-pause, certain physical changes

18,,2 15

occasionally cause sexual problemsfor some women. As the body pro-duces less estrogen, for example, thewalls of the vagina become smooth,drier, and less elastic. This maycause tiny sores on the vaginal wall,a burning or itching sensation, andintercourse may be uncomfortable.These physical changes can betreated successfully through anumber of methods includingvaginal lubricants and estrogencreams. Whether or not estrogen isused however depends on the natureof the problem and on whether theindividual can tolerate estrogen.

Staying Healthy

Good health depends on manyfactorsheredity, diet, exercise, rest,and if one smokes or drinks alcohol.No one has the correct formula for along and healthy life, but there aremeasures you can take to enhanceyour chances of staying healthy.

Nutrition

Just about everyone agrees that awell-balanced, nutritious diet isimportant for good health, but westill have a lot to learn about whatconstitutes a good diet. Nutritionalrequirements vary from person toperson and often change with age asmany people become less active andare able to handle fewer calories. Wedo know that eating a wide variety

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of foods every day is essential sinceno single food supplies all thenecessary nutrients.

Evidence shows that diet canincrease the likelihood of developingcertain types of cancer and heartdisease, as well as other disorders.The following guidelines (issued bythe National Research Council) offersuggestions to help reduce the riskof cancer and other diseases:

Eat fewer foods containingsaturated and unsaturated fat. Fatintake should be no more than 30percent of daily calories.Eat fruits, vegetables, and whole-grain cereal products, especiallythose high in vitamin C andcarotene (oranges, grapefruit, dark-green leafy vegetables, carrots,winter squash, tomatoes, cabbage,broccoli, cauliflower, and brusselsprouts).Eat very little salt-cured, salt-pickled, or smoked foods such assausages, smoked fish and ham,bacon, bologna, and hot dogs.

A balanced diet with adequatecalcium* can help avoid bone lossthat occurs with age. Foods high incalcium include milk and otherdairy products, sardines and salmon

*Experts recommend 1,500 nig of calciumeach day for women after menopause and1,000 mg for younger women.

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canned with bones, oysters, anddark-green leafy vegetables. Milkprocessed to be more digestible isavailable for those who have prob-lems digesting milk; soy or acido-philus milk can also be used. Inaddition, calcium supplements(especially calcium carbonate) arefrequently prescribed.

Getting enough vitamin D is alsoimportant since it is needed by thebody to absorb calcium. The recom-mended daily allowance (RDA) forvitamin D is 400 units (Interna-tional Units), and it is provided infoods such as fortified milk, eggyolk, liver, tuna, salmon, and codliver oil. Vitamin D is also producedin the body after exposure to sun-light (only a short period ofexposure each day is sufficient).

To further minimize bone loss, somedoctors suggest that women eat lessred meat and avoid certain carbon-ated soft drinks. These contain highlevels of phosphorus (a mineralnormally present in almost equalamounts in bone and teeth) andmight contribute to a phosphorus-calcium imbalance which has beenassociated with osteoporosis.

Other health-promoting guidelinesinclude avoiding excess coffee andtea, as well as foods high in sugar.Sugar contains empty calories thattake the Place of nutritious foodsand adds excess weight. Too much18

sugar can also cause a vaginaldischarge.

L.A§Looking Ahead

No one has all the answers aboutmenopause. Medical research isbeginning to give us more infor-mation, but myths and negativeattitudes remain deep-seated.Fortunately, more women arechallenging stereotypes, gainingsupport from other women, learningabout what takes place in theirbodies, and taking more respon-sibility for their health.

More and more women are movingin positive new directions at mid-lifeand assuming new roles in society.It is common to find mid-lifewomen in college classes, profes-sional schools, and other types ofeducational programs. Women aretraining for and holding jobs inmany areas once reserved for men.

There is wide disagreement con-cerning the use of vitamin supple-ments. Taking them without yourdoctor's instructions can be riskysince large doses of some vitaminscan have serious side effects. Vita-mins A and D in large doses areparticularly dangerous, and evenlarge doses of vitamin C can causeproblems. Vitamins depend on one

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another to be utilized in the body,so taking one without its counter-parts may be useless.

The Hazards of Smoking

There are many good reasons for notsmoking. Probably most importantis that smoking greatly increases thepossibility you will develop lungcancernow the leading cause ofdeath from cancer in women. Heavysmokers also tend to have an earliermenopause, which in turn has beenlinked to higher rates of cardiovas-cular disease and bone loss.

Physical Exercise

Many experts recommend physicalexercise to maintain a healthy body.Exercise is especially important forbones and can help prevent osteo-porosis. In addition, many womenreport that they are more relaxedand in a better mental state whenthey exercise regularly.

Consult your doctor before starting arigorous exercise piogram. He or shecan help you decide which types ofexercises are best for you. Also anexercise program should be gradu-ated: it should start slowly and buildup to more strenuous activities.

Aging is a normal part of the lifeprocess, but it is common to some-times fear growing older and toworry about the changes it will20

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bring. The incidence of diseaseincreases with age; still, mostwomen remain relatively healthyand independent until late in life.Advertising and fashion stress youthand beauty, but in time most peoplediscover that the finest aspects ofhuman relationships are based onmore enduring qualities whichenable us to maintain lovingrelationships and satisfying workand leisure activities throughout allstages of life.

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Other NIA Publications of Interestto Older Women

BrochuresAge Pages (a compilation of AgePage fact sheets, including thetitles listed below)Age Words: A Glossary on Health

and AgingNIA Publications ListQ & A: Alzheimer's DiseaseSelf-Care and Self-Help Groups for

the Elderly: A Directory

Age Page(a series of individual fact sheets)

How We Age:Aging and Your EyesHearing and the ElderlySexuality in Later LifeSkin: Getting the Wrinkles Outof AgingTaking Care of Your Teeth

Disorders and Diseases:Arthritis AdviceCancer Facts for People Over 50ConstipationDealing With DiabetesDigestive Do's and Don'tsHigh Blood Pressure: A Commonbut Controllable DisorderOsteoporosis: Thc Bone ThinnerUrinary Incontinence

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Health Promotion:Don't Take it EasyExercise!Safe Use of Medicines by OlderPeopleSmoking: It's Never Too Late toStop

Safety and Crime Prevention:Accidents and the ElderlyCrime and the ElderlyHealth QuackeryHeat, Cold, and Being Old

Medical Care:Considering Surgery?Finding Good Medical CareWho's Who in Health Care

Nutrition:Be Sensible About SaltDietary Supplements: More isNot Always BetterHints for Shopping, Cooking, andEnjoying MealsNutrition: A Lifelong Concern

To obtain single copies of thesepublications, write to theNIA Information Center2209 Distribution CircleSilver Spring, MD 20910or call 301/495-3455.

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National Institute on AgingNIH Publication No. 86-2461Revised July 1986* U.S. GOVERNMENT PRINTING OFFICE: 1986-165-482