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What is Menopause?
Menopause happens to every person with ovaries and occurs at the average age of 51 in the United States but can occur as early as 40 and as late as 60 years of age. A person is in menopause when the ovaries stop producing enough hormones and cause them to skip periods for 12 consecutive months. This can happen naturally, because of surgical removal of the ovaries, or due to medications affecting the health of the ovary like chemotherapy for cancer. There are many factors that decide the onset of menopause including the genetics and health of a person.
Frequently Asked Questions (FAQ)
Perimenopause, also called the menopause transition, is a period prior to menopause where a person may experience irregular or skipped periods. This can last from 2-10 years. During this time, people experience hormone changes that can cause symptoms like hot flashes, sleep and mood disturbance.
Early menopause is defined by menopause occurring between the ages of 40 and 45. However, certain health conditions, surgeries, or medications may induce menopause even earlier in some people. It is important to discuss this timing with your provider because earlier menopause is linked to a higher risk for chronic medical conditions like osteoporosis and cardiovascular disease. Hormone replacement therapy may be strongly recommended to help decreased these risks, as well as address earlier and more severe menopausal symptoms.
Everyone experiences menopause differently, but common symptoms include hot flashes, vaginal dryness, mood and sleep disturbance. Other symptoms may include changes in cognition and sexual health. The length of time and the severity of the symptoms varies for each person. Some factors that can impact a person’s experience in menopause include race and ethnicity, general health status, social and economic status, and age. For example, studies have shown that Black and Hispanic people may have a longer duration and more severe symptoms compared to Whites and Asians.
A hot flash is a sudden and intense sensation of heat in your face, neck and chest, and may be accompanied by sweating, reddening of the skin, chills, and a rapid heartbeat. They can cause panic or anxiety for some people. Night sweats are hot flashes that happen while you are sleeping and can affect the quality of your sleep. Hot flashes or vasomotor symptoms (VMS) are experienced by 80% of those going through menopause. Over 50% of people with VMS in the US remain untreated. For some, symptoms may be transitory but for others, hot flashes can last over 10 years and well beyond the perimenopause and early menopause period.
There is evidence that hot flashes, especially if severe and frequent, are linked to an increased risk of cardiovascular disease and other chronic diseases like osteoporosis. For this reason, it is important to talk with your menopause provider to address your symptoms.
The earlier the better! We recommend talking with your doctor when you start to have symptoms or irregular and/or skipped periods. This commonly occurs in a person’s late 40s but can occur as early as 40 and as late as 55. There are large fluctuations of hormones during perimenopause and early menopause which include a drop in estrogen level that can impact all the major organs in your body short and long-term. For this reason, it is important to seek attention to not only address the burdensome symptoms of perimenopause, but also to use this as an opportunity to address your long-term health so you can ensure living your best life moving forward.
Yes, The Menopause Society has a list of certified providers. In 2002, The Menopause Society recognized a need to set essential standards for health providers, thereby assuring high-quality evidence-based care for people going through menopause. To meet this need, The Menopause Society developed a competency examination. Those who pass have demonstrated their expertise in the field and are awarded the credential of MSCP or the Menopause Society Certified Practitioner. At the UCLA Comprehensive Menopause Program, all the core menopause providers are certified.
Menopause is usually determined by clinical signs and symptoms, and not based on lab tests. It is determined by changes in your menstrual pattern and symptoms like hot flashes. However, there are some situations where your menopause provider may find it helpful to order labs tests, such as follicle stimulating hormone (FSH) and estradiol.
Every insurance company is different, but most will typically cover labs that your provider deems necessary to fully evaluate your health.
Sleep and menopause are closely related to each other. The physiological and hormonal changes which occur during menopause have a significant impact on sleep and can lead to insomnia. Sleep symptoms commonly seen in menopause include difficulty falling asleep, frequent nighttime awakenings, early morning awakenings and difficulty falling back asleep after an awakening. Hot flashes can occur at night, contributing to this sleep disturbance. There is also an increased risk for primary sleep disorders such as obstructive sleep apnea and restless leg syndrome during the menopause transition. There is evidence that poor sleep over time leads to increased risk of developing chronic medical conditions like obesity, diabetes, and cardiovascular diseases. It is therefore essential for you to prioritize healthy sleep habits and seek medical guidance if sleep disturbances persist.
Perimenopause is a high-risk time for new, recurrence, or worsening of mood disorders due to hormonal changes and increased psychosocial stress levels at this time in a person’s life. Also, people are at greater risk for mood and anxiety problems if they are experiencing problematic vasomotor symptoms (hot flashes) or insomnia. Menopausal distress disproportionately affects BIPOC and low-income people and they are less likely to seek out help for mental health problems due to barriers at the community, provider, and systems levels. Seeking out a menopause provider is crucial in treating mood, anxiety, and general menopausal distress as well as hot flashes and sleep disturbance, to improve your quality of life and long-term health in menopause.
Bone loss occurs most rapidly during the menopause transition. Decreased estrogen production during the menopause transition leads to a rapid rise in bone breakdown and rapid bone loss. This decline usually starts in your 40s but accelerates in the few years leading up to menopause and lasts up to 10 years afterwards. One in two people going through menopause will suffer an osteoporosis-related fracture in their lifetime. This means that 50% of will break their hip, spine, wrist, or other bone with a simple fall or twist because of weakened bone.
For this reason, it is important to ensure you are getting at least 1000mg of calcium (dietary and/or supplementation) and 400 international units (IU) of vitamin D daily, along with regular weight-bearing exercise and avoidance of smoking and excessive alcohol consumption to maximize your bone health.
Several different treatments exist including hormone therapy, non-hormone therapy, cognitive behavioral therapy, menopause group therapy, lifestyle changes, mind-body relaxation, and pelvic floor physical therapy. It is important for your menopause provider to understand your health and experience during menopause, and then work with you to develop an individualized treatment plan.
MHT is best used to treat hot flashes and prevent osteoporosis. There can be other benefits of using MHT including improvement in mood and sleep. It is best to talk with your provider about whether you are a good candidate for starting this treatment as every person comes into menopause with different symptoms, genetics, health status, and lifestyle behaviors. The risks and benefits for use should be individualized so you can make an informed decision on whether this treatment is right for you.
It is typically recommended that a person take progesterone and estrogen for systemic menopause hormone therapy to alleviate hot flashes. Estrogen is the hormone that helps alleviate the menopausal symptoms. Progesterone is recommended to prevent overgrowth in the uterus while using estrogen therapy. For those without a uterus, estrogen is the only hormone needed.
Vaginal estrogen therapy is the primary treatment for vaginal atrophy related symptoms like vaginal dryness, recurrent UTI, pain with sexual intercourse. This is NOT the same as systemic menopause hormone therapy and does not carry the same risks. Most of the medication is delivered locally in the vagina with minimal systemic absorption. Systemic hormone therapy is used for treatment of hot flashes. Hormone therapy may help with vaginal dryness, but many will need both vaginal and systemic estrogen.
Hormone therapy can be in the form of an oral pill, a skin patch, gel, or spray, or a vaginal ring. There is equivalent dosing for each of these options. The decision about which option is the best suited for you should be made after discussing your symptoms, health, lifestyle, and values with your menopause provider.
Hormone pellets are NOT recommended as the drug absorption into the body is unregulated and can wildly fluctuate causing unwanted side effects for a person but also put them at increased risk for conditions like uterine cancer and blood clots. This form of therapy is not regulated by the FDA for purity, potency, or efficacy.
The term “bioidentical hormones” refers to hormones that are artificially derived from a plant but identical to those made by your own body. There are many FDA tested and approved bioidentical menopausal hormone therapy options that you can choose from that are regulated for purity, potency, and efficacy.
Compounded hormones are often advertised as being safer, more effective, and more natural than hormone therapy provided by a retail pharmacy. However, this claim remains unsupported. The FDA does not oversee the purity and safety of these products. Although, people often feel they are being given tailored and custom individualized hormone treatment, they often contain hormone formulations that have not been tested for safety or efficacy by the FDA and are not usually recommended by menopausal experts.
In general, healthy people who don’t have contraindications to and/or aren't advised against use of MHT due to their medical history have a low risk while using MHT. However, every person carries different genetics, health status, and lifestyle behaviors as they enter menopause, and the risks and benefits should be individualized to you and discussed with your menopause provider prior to initiation. Risks of MHT include blood clots, stroke, heart disease, gallbladder disease, and breast cancer. These risks are especially increased if you are older than age 60, use hormonal therapy greater than 10 years out from final menstrual period, and/or use hormonal therapy for greater than 5 years duration. The overall goal is the smallest dosage for the shortest amount of time using a delivery method best suited to provide the desired benefits for a you.
In general, the recommendation based on evidence around safety is to consider stopping after 5 years of use, 10 years after your final menstrual period, and/or after age 60.
However, there is no absolute age cutoff when MHT must be stopped. It is important to have at least a yearly discussion with your menopause provider regarding the risks and benefits of continued use of MHT as your health status, lifestyle, and symptoms may change with age.
There is sufficient evidence to show that systemic MHT effectively reduces hot flashes which improve a person’s quality of life which includes the beneficial effects on mood, sleep, and daytime functioning. There is also sufficient evidence showing systemic MHT prevents osteoporosis while on the hormones. There is inconclusive evidence showing possible prevention of future cardiovascular disease and dementia when using systemic MHT early around the time of perimenopause for a short duration. There is much more research that is needed in this area to understand how MHT can impact a person’s overall health.
Vaginal estrogen therapy has been shown to effectively relieve genitourinary symptoms like vaginal dryness, pain with sex, recurrent UTI.
There are several evidence-based options for treating hot flashes including psychotropic medications (SSRIs) and a new FDA-approved drug (Fezolinetant) that works within the hypothalamus to help regulate the temperature control center of the brain. Non-medication options include cognitive behavioral therapy, menopause group therapy, lifestyle changes, and mind-body relaxation. Similarly, methods have been used to help treat mood and sleep disturbances during menopause. For genitourinary symptoms of menopause, there are many non-hormonal lubricants and moisturizers that can be used, as well as pelvic floor physical therapy and behavioral therapy. It is important for your menopause provider to understand your symptoms, health, lifestyle behaviors, and health during menopause, and then work with you to develop an individualized treatment plan best suited to address your needs.
Hormone therapy is not a good choice for everyone. MHT may be recommended by your menopause provider if your symptoms are more severe, negatively affecting your quality of life or health, but alternatives exist if you would like to avoid hormones. There is no solid evidence showing that not using MHT will adversely affect your health in the future. There are also contraindications and cautions against use of MHT for some people. A certified menopause provider can help you navigate what is right for you.
The practice of Integrative Medicine blends conventional care with evidence-based traditional and complementary approaches to support whole-person health and wellness. Integrative medicine has a unique role in supporting a person’s mind-body-spirit as they transition through menopause. Yoga, tai chi, and mindfulness have been shown to improve symptoms in menopause including hot flashes and mood disturbances. Incorporating integrative mind-body-spirit practices into a treatment plan can also be incredibly helpful in coping with stress and supporting healthy sleep. There is also emerging data to support other integrative approaches including hypnotherapy and acupuncture which can be helpful in managing difficult to control symptoms during menopause.
Natural products and dietary supplements remain a popular approach for people seeking symptom relief during menopause, but the data supporting use of these products is limited and inconclusive. There can also be a significant risk of harm from these products due to adverse side effects, lack of testing on the purity and potency, and/or interactions with current used medications. Finding reliable information about the safe and careful use of supplements remains a challenge for many persons experiencing menopausal symptoms. Using an integrative approach, patients can discuss the use of these products with their menopause provider to determine a risk and benefit assessment of using these products that is tailored to their individual health goals. The use of integrative medicine supports a personalized approach to care that can support a person going through perimenopause or in menopause.
Testosterone therapy is occasionally used as part of menopause hormone therapy when a person is suffering from distress due to decreased libido. It has no effect on hot flashes and should not be used to treat this symptom. It is important to keep in mind that everyone’s testosterone declines over time with age. In addition, there are many other factors that play into the level of libido including your current health status, mood and stress levels, sleep quality, and relationship health. While decreased testosterone level plays a role, it does not play the only role in causing decreased libido. Also, not everyone feels distressed by low libido and/or decreased testosterone levels, and therefore should not be automatically placed on testosterone therapy.
It is important to be informed of the safety and risks with testosterone use. Currently, there is only short-term data showing safety with close monitoring by your menopause provider. There is no long-term safety data. Side effects of continued use include adverse effects on your cholesterol and liver, as well as acne, unwanted hair growth, deepening of your voice, and enlarged clitoris. Other options for management of low libido besides testosterone include cognitive behavioral therapy and treatment of underlying medical and non-medical stressors. It is important to discuss your symptoms with your menopause provider to help you decide what treatment is best for you.