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Symptoms of

comes from two Greek words that mean “month” and

“to end.” It translates as “the end of the

monthlies.”  The medical definition of menopause

is the absence of menstruation for 12 months. In

American women, the average age for menopause is

51. However, it can occur between a woman’s late

thirties and her late 50s. Menopause also occurs

when a woman’s uterus and ovaries are surgically

removed.  

two to fifteen year span before menopause during

which a woman experiences changes due to

declining levels of estrogen and progesterone.

For some women, the perimenopausal time can be

cycle is governed by the endocrine system. The

central glands, located deep in the brain are

the hypothalamus and the pituitary. These

structures regulate the sex hormones produced by

the ovaries. Other glands and structures are

also involved, but these are the main players.

When a woman is having regular menstrual cycles,

the hypothalamus releases Gonadotropin-Releasing

Hormone (GnRH.) This induces the pituitary to

release increased amounts of Follicular

Stimulating Hormone (FSH) during the first two

weeks of the menstrual cycle. The FSH stimulates

growth in some of the eggs in the ovary. The

ripening egg (follicle) produces estrogen, which

causes the lining of the uterus to thicken. At

about day 14 in the cycle, the pituitary

produces an increased amount of  luteinizing

hormone (LH.) This causes the release of the

follicle from the ovary. The area around the

released follicle becomes the corpus luteum. The

corpus luteum secretes a lower amount of

estrogen and an increasing amount of

progesterone.  If the egg is not fertilized in

the critical period after ovulation, the corpus

luteum produces declining amounts of estrogen

and progesterone. When the estrogen and

progesterone reach a low point, the hypothalamus

begins to start the next cycle, and menstruation

begins.  

changes in her menstrual cycle several years

before true menopause. The ovary has a finite

number of eggs, and these begin to run out. The

hypothalamus stimulates the pituitary to make

more FSH in an attempt to cause the remaining

eggs to mature. FSH and LH levels rise. Estrogen

levels may vary. FSH levels can help determine

whether a woman is entering menopause.  

perimenopause, ovulation occurs intermittently.

If there is no ovulation, the progesterone does

not increase and the estrogen production may

continue. This may cause the uterus to build up

a thicker lining. The menstrual period may occur

irregularly and may be quite heavy. Other cycles

may produce a light menstrual period. As

perimenopause moves into menopause, the ovaries

produce much less estrogen and progesterone and

Symptoms of

menopause, estrogen and progesterone levels are

low and fairly constant. However, during

perimenopause, their levels may fluctuate in an

irregular pattern. Some perimenopausal women

have an exacerbation of their premenstrual

symptoms. Fortunately, when menopause occurs,

the PMS symptoms cease. 

are experienced by up to two-thirds of

perimenopausal women. They usually occur one to

five years before the end of menstruation. These

symptoms are more severe in women who have had

their ovaries surgically removed. It is thought

that low levels of estrogen cause the brain to

release a surge of Gonadotropin-releasing

hormone. This may be the cause of the hot flash.

A woman suddenly feels hot and may perspire

profusely. She may then have a cold chill. They

are more common at night but can occur at any

time of day. They last from a few seconds up to

an hour.  

Menses may be heavier, or lighter. There may be

increased or decreased cramping. Eventually,

menses lighten, become less frequent and then

stop. 

This may be more common in women who have had

difficulty with PMS. There is some suggestion

that estrogen levels influence the production of

serotonin.  

Some women report difficulty with concentrating

or remembering specific words. A woman with

attention deficit disorder may first come for

treatment at this age because declining estrogen

level has exacerbated her ability to

concentrate. 

is a common complaint of women in perimenopause

or menopause itself. Night sweats may disrupt

sleep. Irritability and depression can impair

sleep. Reduced sleep can lead to tiredness and

irritability during the day. 

Before and after menopause, lowered estrogen

levels cause the lining of the vagina to become

drier and thinner. This may lead to painful

intercourse and decreased interest in sexual

relations.  

Some urinary symptoms may be related to pelvic

floor changes that occurred years ago during

labor and delivery.  As the estrogen level

drops, further changes can occur. Low estrogen

levels may weaken the urethral sphincter that

helps hold in urine. If the woman has gained

choices in dealing with symptoms associated with

approaching menopause. These include healthy

lifestyle changes, hormone replacement therapy,

other medications, social support and therapy. 

Regular exercise may decrease depression and

irritability. Good muscle tone can also improve

energy level and decrease aches and pains. Some

forms of exercise may help decrease bone loss.

Yoga or Tai Chi decrease stress and may reverse

the decreased flexibility often associated with

aging. Regular Tai Chi has been shown to

decrease the incidence of hip fractures in older

individuals. A diet high in complex

carbohydrates, including multiple small meals

may reduce irritability and improve one’s

feeling of well-being.  

women experience menopause as a time of

increased freedom and new possibilities. As

their own children grow up, they may have more

time and flexibility. However, some women

experience the empty nest as the loss of their

central role in life. Loss of a spouse through

death or divorce can increase isolation. The

physical changes associated with hormonal

fluctuations can be confusing. Menopause may

cause some women to start to think about the

finite nature of life. Supportive friends and

family can help a woman understand and cope with

life changes. Reading about menopause or talking

to one’s doctor can help make the changes less

mystifying. A return to spirituality can spur

growth at this phase of life.  

progesterone can help some of the symptoms

associated with approaching menopause. The

decision to take hormones is an individual one.

A woman considering HRT needs to consider the

severity of her symptoms, her health history and

her family history. She may also have personal

preferences about taking medications. Estrogen

is the hormone that seems to relieve many of the

symptoms of approaching menopause. If a woman

has already had her uterus removed, she may take

estrogen by itself.  However, if a woman with an

intact uterus takes estrogen without

progesterone, the lining of the uterus may build

up, and the woman may be at increased risk of

uterine cancer. Thus HRT often requires a

combination of estrogen and progesterone. The

doses of estrogen and progesterone used for HRT

are generally lower than the doses used for

birth control pills. Often, women only need HRT

for a limited number of years after menopause.

There can be benefits and drawbacks to the use

of HRT. Estrogen can relieve hot flashes,

vaginal dryness, urinary problems, and sometimes

insomnia. It can also promote a feeling of

well-being. Some women feel that it improves

memory and concentration. HRT can reduce the

chance of osteoporosis. Estrogen may help

prevent heart disease, but recent data has

suggested that this effect may not be as

dramatic as previously thought. For some women

there may be drawbacks to HRT. Some studies have

suggested a link between HRT and an increased

incidence of breast cancer. Estrogen may elevate

blood sugar, cause headaches, weight gain, or

other side effects.  

The Women’s Health

Initiative (WHI) a longitudinal study of women

on hormone replacement therapy, concluded that

overall, the treatments did not provide

protection from cardiovascular problems or

cognitive decline. There were some differences

between the estrogen-only and the

estrogen-progestin group. Women should discuss

this with their care provider. A good review of

the WHI results can be found in the November

2004 issue of Geriatrics.

For some women, social support, healthy

lifestyle changes and hormone replacement

therapy are not enough. The death of loss of a

spouse, heath changes and other stresses may

cause stress. Depression and mood swings are

more common during peri-menopause than after

menopause is well established. However, a woman

with a history of anxiety or major depression

may have a reoccurrence during either of these

periods.  Counseling may help some women deal

with losses. Counseling may also help a woman

review her life and make decisions about new

directions and interests. If a woman has a

persistent depression or experiences sleep,

appetite and energy changes, or has suicidal

thoughts, she may want to consider a psychiatric

consultation and antidepressant medication.  

life transition may leave one with a larger view