Menopause

Menopause is the natural cessation of menstrual periods, defined as 12 months of amenorrhea without other pathologic or physiologic explanation. This event marks the complete or near complete loss of functional ovarian follicles leading to decreased estrogen production and elevated follicle stimulating hormone (FSH) concentrations. The mean age of menopause in the US is 51. During the years leading up to menopause, multiple endocrine alterations occur and periods become less regular. Women may experience hot flashes, vaginal changes, and sleep and mood disturbances. This perimenopausal phase lasts, on average, about 4 years. When these changes occur before age 40, the condition is called primary ovarian insufficiency.[1]

Hot flashes are the most common initial symptom, occurring in up to 80% of women in some ethnic groups in the US.[2] A hot flash is a sensation of heat and perspiration that may last several minutes, often preceded or followed by chills and shivering. In some cases, palpitations with or without anxiety accompany these symptoms. Hot flashes are more common at night and often cause disruptions in sleep. This phenomenon is due to estrogen withdrawal and consequent bursts of gonadotropin-releasing hormone from the hypothalamus, which alters thermoregulatory function. It is important to educate patients that hot flashes can begin years before the last menstrual period and last many years after the last menstrual period.

Anxiety and depression are common during this time and aggravate sleep disturbances. Vaginal dryness, due to the decrease in estrogen stimulation of the vagina and urethra, is common and may cause dryness, itching, and dyspareunia.

Other findings that occur as a result (or are believed to be a result) of decreasing estrogen include:

:

  • Increased rate of bone loss
  • Increased cardiovascular disease risk
  • Memory changes
  • Body composition changes
  • Impaired balance

Risk Factors

Black women report more frequent hot flashes, compared with whites.[1] Historically, Asian women have reported a much lower frequency of menopausal symptoms, compared with North American women, although that has changed as Asian diets have Westernized (see Nutrition Considerations).

Risk factors that predict severity of menopausal symptoms include smoking, lower socioeconomic status, low calcium intake, and higher body mass index.[3]

Assessment

In women over age 45 who present with changes in menstrual intervals, with or without other menopausal symptoms, the diagnosis of menopausal transition can be made without other laboratory workup. A follicle stimulating hormone (FSH) level can be drawn, but during the early years of menopause these levels fluctuate widely and may be misleading. The possibility of pregnancy should be kept in mind in sexually active women. If symptoms suggest other causes of amenorrhea, such as hyperprolactinemia or hyperthyroidism, these possibilities should be evaluated with appropriate laboratory testing.

If menopausal status is in doubt (e.g., in a woman under 45 with amenorrhea), pregnancy, thyroid disease, and prolactin elevation should be ruled out. Primary ovarian insufficiency should be considered and is suggested by a low serum estradiol level and elevated serum FSH level.

For women at risk for osteoporosis, dual-energy x-ray absorptiometry (DEXA) may be used to measure bone density. An initial examination at age 65 is reasonable, although an earlier screening has been suggested for women who smoke or have family histories of early-onset fragility fractures.

Women with risk factors for coronary artery disease should be followed regularly and treated as necessary for prevention, including nutrition interventions and treatment for hypertension, hyperlipidemia, and other cardiovascular complications. This and other screening recommendations (e.g., for breast cancer and colon cancer) are based on woman’s age and not menopausal status.

Treatment

Menopause is a normal part of life, and no treatment is typically required. Symptoms, when they occur, are usually tolerable and eventually pass. However, for women with particularly bothersome symptoms, the following considerations may be helpful.

Weight loss. Since excess weight is associated with worse menopausal vasomotor symptoms, weight loss should be part of any treatment plan for overweight women. Those who successfully lose weight experience typically find that hot flashes become less bothersome.[4]

Oral hormone therapy reduces menopausal symptoms, particularly hot flashes, but women considering this therapy should be advised that symptoms may recur after treatment cessation and that hormonal therapy has been associated with an increased risk of thromboembolic events, breast cancer, and endometrial cancer.

Combined hormonal contraceptives (CHC) may be a treatment option in select perimenopausal women who also need contraception. The Centers for Disease Control and Prevention state that CHC are a category 2 medication, meaning the benefits outweigh the theoretical or proven risks, in the perimenopausal years.[5] Other common medications used off label for hot flashes include the SNRI antidepressant venlafaxine, clonidine, and gabapentin. The SSRI paroxetine is the only non-hormonal medication to gain FDA approval for the treatment of vasomotor symptoms.

Nutritional therapies may be useful (see Nutritional Considerations).

For vaginal dryness, over-the-counter moisturizers may be used. If vaginal moisturizers are of insufficient benefit, vaginal estrogens may be used (at lower doses than for oral therapy). The vehicle for disbursement (e.g., cream, ring, pessary, tablet) is not important. Systemic symptoms are generally not improved by local therapy, but systemic side effects also rarely occur. Non-pharmaceutical treatments are also available for restoring vaginal tissues, using fractional CO2 laser energy, radiofrequency energy, or low-level light, gentle heat, and sonic technology.

While calcium plays important physiologic roles in the body, new evidence suggests that increasing calcium intake, through diet or supplementation, does not significantly increase bone mineral density or decrease risk of fracture.[6],[7] Adequate exposure to vitamin D, either via dietary sources, supplements, or sun exposure, is beneficial for fracture prevention.[8]

Antiresorptive medications, such as bisphosphonates, can be considered for patients with low bone-mineral density. These medications are now preferred over estrogen for prevention and treatment of postmenopausal fractures. This class of medications comes with rare but serious side effects, including osteonecrosis of the jaw, esophageal ulcers, and chronic musculoskeletal pain.

Exercise has not been consistently correlated with reduced intensity or frequency vasomotor symptoms.[9] However, regular exercise is associated with improved quality of life in menopausal women.[10] Exercise is also important for stimulating bone formation and decreasing resorption, as well as for cardiovascular health.

Cognitive behavioral therapy has been shown to reduce frequency of vasomotor symptoms.[11]

Relaxation and other stress management techniques have been recommended by some, with the theoretical basis that norepinephrine release plays a role in hot flashes; these techniques reduce central nervous system adrenergic tone.[12] However, a Cochrane systematic review concluded that there is lack of good data to suggest significant benefit.[13]

Data regarding benefits of acupuncture for treatment of menopausal symptoms are conflicting.[14]

Nutritional Considerations

The use of nutritional interventions for menopausal symptoms began with the observation that menopausal symptoms were rare in Japan in the 1980s when the diet was high in rice and low in animal products, but were much more frequently reported in subsequent years as the diet Westernized.[15],[16] This led to speculation that the apparent beneficial effect of a traditional Japanese diet stemmed from its low fat content, high fiber content, and frequent use of soy products.

A low-fat, plant-based diet has several beneficial effects. First, plant-based diets are associated with a lower risk for experiencing menopausal symptoms. , Second, a low-fat, planted-based diet excludes animal fats and minimizes oils. Some evidence suggests that reducing dietary fat may improve vasomotor symptoms.[17],[18]In the Women’s Health Initiative, perimenopausal women following reduced-fat diets scored significantly lower on the vasomotor symptoms subscale (including hot flashes and night sweats), compared with those whose diets derived approximately 30% of energy from fat.[19]

Third, a low-fat, plant-based diet promotes healthful weight loss. In a study of more than 17,000 women with baseline vasomotor symptoms, those who lost more than 10 pounds or 10% or more of their baseline weight were significantly more likely to experience elimination of these symptoms compared with women who did not lose weight.[20]

Fourth, a plant-based diet improves cardiovascular health. This is important because women who experience more severe vasomotor symptoms tend to weigh significantly more and have higher blood pressure and cholesterol levels, a greater extent of aortic calcification and carotid intima media thickness, and poorer endothelial function, compared with women with less pronounced symptoms.[21],[22]

Consider adding soy foods. Some evidence supports the use of soy products for the treatment of vasomotor symptoms. In a 12-week study, Australian researchers encouraged women to mix a special soy flour into drinks, cereal, or muffins, finding that hot flashes became 40% less frequent in 12 weeks.[23] Other studies have had mixed results.[24],[25] Overall, soy products seem to help some women, but do not entirely eliminate hot flashes.[26],[27],[28]

Evidence is weak for beneficial effects of botanical supplements on menopausal symptoms. Products that have been studied include red clover (Trifolium pretense), Black cohosh (Cimicifuga racemosa), dong quai (Angelica sinensis), and Chaste tree (Vitex agnus castus).[29],[30],[31],[32] Clinical practice guidelines issued by North American women’s health and endocrine organizations address an even broader variety of supplements purported to have benefits for menopause-related vasomotor symptoms, as summarized by Jurgens et al.[33] Additional information on herbal supplements is available from the National Center for Complementary and Integrative Health.[34]

Orders

See Basic Diet Orders Chapter.

What to Tell the Family

It is useful for the patient and family to understand that menopause is a normal condition, not a disease or diagnosis. It can, however, be accompanied by symptoms and, in some cases, mood changes, all of which decrease over time. Diet changes and other lifestyle modifications may reduce vasomotor symptoms, in addition to their other benefits.

References

  1. Shifren JL, Gass ML, NAMS Recommendations for Clinical Care of Midlife Women Working Group. The North American Menopause Society recommendations for clinical care of midlife women. Menopause. 2014;21(10):1038-62.  [PMID:25225714]
  2. Gold EB, Colvin A, Avis N, et al. Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: study of women's health across the nation. Am J Public Health. 2006;96(7):1226-35.  [PMID:16735636]
  3. Pérez JA, Garcia FC, Palacios S, et al. Epidemiology of risk factors and symptoms associated with menopause in Spanish women. Maturitas. 2009;62(1):30-6.  [PMID:19010615]
  4. Huang AJ, Subak LL, Wing R, et al. An intensive behavioral weight loss intervention and hot flushes in women. Arch Intern Med. 2010;170(13):1161-7.  [PMID:20625026]
  5. Centers for Disease Control and Prevention (CDC). U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep . 2010;59:1-86.
  6. Bolland MJ, Leung W, Tai V, et al. Calcium intake and risk of fracture: systematic review. BMJ . 2015;351-365.
  7. Tai V, Leung W, Grey A, Reid IR, Bolland MJ. Calcium intake and bone mineral density: systematic review and meta-analysis. BMJ . 2015;351-365.
  8. Pludowski P, Holick MF, Pilz S, et al. Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality-a review of recent evidence. Autoimmun Rev. 2013;12(10):976-89.  [PMID:23542507]
  9. Daley A, Stokes-Lampard H, Thomas A, et al. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev. 2014.  [PMID:25431132]
  10. Daley A, Macarthur C, Stokes-Lampard H, et al. Exercise participation, body mass index, and health-related quality of life in women of menopausal age. Br J Gen Pract. 2007;57(535):130-5.  [PMID:17266830]
  11. Ayers B, Smith M, Hellier J, et al. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012;19(7):749-59.  [PMID:22336748]
  12. Shanafelt TD, Barton DL, Adjei AA, et al. Pathophysiology and treatment of hot flashes. Mayo Clin Proc. 2002;77(11):1207-18.  [PMID:12440557]
  13. Saensak S, Vutyavanich T, Somboonporn W, et al. Relaxation for perimenopausal and postmenopausal symptoms. Cochrane Database Syst Rev. 2014.  [PMID:25039019]
  14. Dodin S, Blanchet C, Marc I, et al. Acupuncture for menopausal hot flushes. Cochrane Database Syst Rev. 2013;7:CD007410.  [PMID:23897589]
  15. Lock M. Menopause: lessons from anthropology. Psychosom Med. 1998;60(4):410-9.  [PMID:9710286]
  16. Melby MK. Vasomotor symptom prevalence and language of menopause in Japan. Menopause. 2005;12(3):250-7.  [PMID:15879913]
  17. Liu ZM, Ho SC, Xie YJ, et al. Whole plant foods intake is associated with fewer menopausal symptoms in Chinese postmenopausal women with prehypertension or untreated hypertension. Menopause. 2015;22(5):496-504.  [PMID:25387345]
  18. Beezhold B, Radnitz C, McGrath RE, et al. Vegans report less bothersome vasomotor and physical menopausal symptoms than omnivores. Maturitas. 2018;112:12-17.  [PMID:29704911]
  19. Kroenke CH, Caan BJ, Stefanick ML, et al. Effects of a dietary intervention and weight change on vasomotor symptoms in the Women's Health Initiative. Menopause. 2012;19(9):980-8.  [PMID:22781782]
  20. Biglia N, Cagnacci A, Gambacciani M, et al. Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases? Climacteric. 2017;20(4):306-312.  [PMID:28453310]
  21. Franco OH, Muka T, Colpani V, et al. Vasomotor symptoms in women and cardiovascular risk markers: Systematic review and meta-analysis. Maturitas. 2015;81(3):353-61.  [PMID:26022385]
  22. Yim G, Ahn Y, Chang Y, et al. Prevalence and severity of menopause symptoms and associated factors across menopause status in Korean women. Menopause. 2015;22(10):1108-16.  [PMID:25783469]
  23. Murkies AL, Lombard C, Strauss BJ, et al. Dietary flour supplementation decreases post-menopausal hot flushes: effect of soy and wheat. Maturitas. 2008;61(1-2):27-33.  [PMID:19434877]
  24. Lewis JE, Nickell LA, Thompson LU, et al. A randomized controlled trial of the effect of dietary soy and flaxseed muffins on quality of life and hot flashes during menopause. Menopause. 2006;13(4):631-42.  [PMID:16837885]
  25. Lethaby A, Marjoribanks J, Kronenberg F, et al. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database Syst Rev. 2013.  [PMID:24323914]
  26. Franco OH, Chowdhury R, Troup J, et al. Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis. JAMA. 2016;315(23):2554-63.  [PMID:27327802]
  27. Chen MN, Lin CC, Liu CF. Efficacy of phytoestrogens for menopausal symptoms: a meta-analysis and systematic review. Climacteric. 2015;18(2):260-9.  [PMID:25263312]
  28. Thomas AJ, Ismail R, Taylor-Swanson L, et al. Effects of isoflavones and amino acid therapies for hot flashes and co-occurring symptoms during the menopausal transition and early postmenopause: a systematic review. Maturitas. 2014;78(4):263-76.  [PMID:24951101]
  29. Ghazanfarpour M, Sadeghi R, Roudsari RL, et al. Red clover for treatment of hot flashes and menopausal symptoms: A systematic review and meta-analysis. J Obstet Gynaecol. 2016;36(3):301-11.  [PMID:26471215]
  30. Beer AM, Osmers R, Schnitker J, et al. Efficacy of black cohosh (Cimicifuga racemosa) medicines for treatment of menopausal symptoms - comments on major statements of the Cochrane Collaboration report 2012 "black cohosh (Cimicifuga spp.) for menopausal symptoms (review)". Gynecol Endocrinol. 2013;29(12):1022-5.  [PMID:23992293]
  31. Beer AM, Neff A. Differentiated Evaluation of Extract-Specific Evidence on Cimicifuga racemosa's Efficacy and Safety for Climacteric Complaints. Evid Based Complement Alternat Med. 2013;2013:860602.  [PMID:24062793]
  32. De Leo V, Cappelli V, Di Sabatino A, Morgante G. Phyto-oestrogens and chaste tree berry: a new option in the treatment of menopausal disorders. J Women’s Health Care. 2014;3:182-188.
  33. Jurgens T, Chan B, Caron C, et al. A comparative analysis of recommendations provided by clinical practice guideline for use of natural health products in the treatment of menopause-related vasomotor symptoms. Complement Ther Med. 2020;49:102285.  [PMID:32147040]
  34. National Center for Complementary and Integrative Health. Herbs at a Glance. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/herbsataglance. Accessed May 13, 2020.
  35. Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings from the Study of Women's Health across the Nation. Obstet Gynecol Clin North Am. 2011;38(3):489-501.  [PMID:21961716]
  36. Zhang YB, Chen WH, Guo JJ, et al. Soy isoflavone supplementation could reduce body weight and improve glucose metabolism in non-Asian postmenopausal women--a meta-analysis. Nutrition. 2013;29(1):8-14.  [PMID:22858192]