Menopause

Menopause is a natural transition that all women go through; it signifies the beginning of the life stage where women no longer have their period ^[1]. Menopause refers to the pause in menstruation ^[2]. It is defined as a time frame of at least twelve months where a woman has not had a period ^[1]. Menopause also marks infertility as women can no longer get pregnant. Menopause naturally occurs when ovaries no longer respond to stimulation from the pituitary gland to secrete estrogen and progesterone ^[3].

Menopause typically occurs in women between the ages of 45 and 55^[2], with the average age of menopause being 51. At this time, the body undergoes hormonal changes and these changes affect all women differently. Women in and around their mid-forties start making less of the female sex hormone called estrogen. As a result, women begin to have less frequent menstrual periods which eventually stop completely ^[1]. The one or two years leading up to a woman’s last menstrual period is referred to as perimenopause. In the later stages of perimenopause we typically start to see two or more missed periods in a year, with the cycle being 60 days or longer. A small number of these women stop having their monthly menstrual cycles abruptly. Meanwhile, most women experience an irregular pattern of bleeding due to a decrease in the number of ovarian follicles ^[4]. The time following menopause is known as post-menopause. Post-menopause begins after the time of the final menstrual period and continues until the end of life ^[2].

Symptoms

While not all women experience symptoms, most menopausal women experience vasomotor symptoms such as hot flashes and night sweats. Vasomotor symptoms are very bothersome, and are hypothesized to result from a narrowing of the thermoregulatory threshold between shivering and sweating in the hypothalamus. The narrowing is thought to be caused by changes in the levels of circulating serotonin (decreasing concentration), norepinephrine (increasing concentration), and estrogen (decreasing concentration) ^[5].

Hot flashes are episodes of flushing (often described as a wavelength sensation over the body: particularly over the torso, face, and head)^[2] lasting seconds to a few minutes, and are often accompanied by increased heart rate, palpitations, skin blood flow, temperature, and a sensation of heat and dizziness ^[3]. Common triggers of hot flashes include: stress; hot or spicy foods; hot drinks; warm environments; alcohol; and caffeine. Meanwhile, night sweats are hot flashes which occur at night and are associated with perspiration ^[2]. The vaginal lining also changes during menopause: the wall becomes thinner and drier. Estrogen is responsible for the thickened, elastic, and lubricated tissue. As a result, vaginal tissue becomes flattened, thin, dry, and loses tone ^[2]. When estrogen levels decline, the vulva loses its collagen, fat, and water-retaining ability. This change can often make sex feel uncomfortable and no longer enjoyable. Women become at an increased risk of vaginal infections as pH levels change from 4.0 to 6.0 and the amount of good, beneficial bacteria decline ^[3]. Meanwhile, as women age their risk of bone fractures increases. This increase in the incidence of bone fractures is related to the fact that less estrogen is being produced by the body which increases ones risk of osteoporosis. Not only are bone fractures more relevant because of these hormonal changes (one of estrogen’s roles is to suppress the breakdown of bone)^[3], but bones generally tend to become more brittle as one ages. Mood swings may also be more pronounced as hormone levels fluctuate and women attempt to adapt to the seemingly foreign changes their bodies are going through ^[1]. Additional climacteric symptoms of menopause include: difficulty sleeping, weight gain/bloating, mood changes, irregular menses, breast pain/tenderness, and headache. These symptoms are related to irregular ovarian function and the estrogen level fluctuation ^[4].

Estrogen, however, continues to be manufactured in insufficient amounts from the ovarian stroma and adrenal glands via secretion of androstenedione, which is aromatized to estrone in the peripheral circulation ^[4].

Outlook

Women going through menopause may notice only subtle changes whereas other women may have noticeable symptoms ^[1]. There is some evidence that the age of menopause might be genetically determined: a mother and daughter might experience menopause at the same age. Meanwhile, the number of children a woman has might also play a role in determining the age at which menopause occurs. Women in some developing countries go through menopause earlier, and this might be because they tend to have more children ^[1]. Other lifestyle factors such as smoking, being overweight and toxic chemical exposure also play a role. There appears to be no link between age of menopause and history of hormonal contraception, socioeconomic or marital status, race, or age of first menstrual cycle ^[2].

Diagnosis

A woman who is experiencing menopausal symptoms in her mid-forties or older can have her hormone levels checked by a doctor. The overall level of estrogen (particularly the estradiol form) decreases during menopause. The body reacts to this change in estrogen level by producing more follicle-stimulating hormone (FSH) in a feedback attempt to increase estrogen production in follicles ^[1]. The FSH reading is consistently above 30 mIU/mL in menopausal women ^[2]. Luteinizing hormone (LH) levels also increase with the significant drop in circulating estrogen ^[4]. However, FSH can be used exclusively to diagnose menopause as long as the clinical history is consistent with signs and symptoms of menopause ^[4].

Treatments to follow will focus mainly on managing the vasomotor symptoms (hot flashes and night sweats) associated with menopause:

Dietary and Lifestyle Modifications

1. Phytoestrogens: Dietary consumption of foods rich in phytoestrogens may be one of the simplest ways of reducing hot flashes and other menopausal symptoms. These compounds are found in soy products, high-lignan flaxseed oil, clover sprouts, nuts, and seeds. They have very weak estrogenic effects and are capable of reducing hot flashes, vaginal dryness, and other menopausal symptoms ^[4]. Phytoestrogens may also help maintain bone density in post-menopausal women ^[6] .
2. Exercise: Exercise has significant impacts on overall health and wellbeing, and it is also considered beneficial for menopausal women. It can reduce risk of cardiovascular disease, breast cancer, increase bone density, and lower body fat. Exercise can help prevent exaggerated menopausal symptoms. It appears as though moderate exercise may be beneficial for hot flashes and more vigorous exercise may exacerbate them ^[2] .

Nutritional and Herbal Treatments

1. Vitamin C and Bioflavonoids: Bioflavonoids (such as hesperidin, rutin, and quercetin) are known for their antioxidant and anti-inflammatory properties and their ability to strengthen capillaries. ^[2] These compounds increase the similar therapeutic properties of vitamin C. This combination was shown to relieve hot flashes and easy bruising ^[4].
2. 5-Hydroxytryptophan (5-HTP): Hot flashes are thought to be associated with a reduction in endorphin production, which decreases the hypothalamic thermoregulatory set point. This leads to heat loss, resulting in a hot flash as a means to maintain the desired temperature within a set point. Low estrogen levels are associated with decreased levels of endorphins and serotonin; therefore 5-HTP supplementation might restore endorphin levels resulting in regulation of the normal set point. 5-HTP is a precursor of serotonin, which is involved in mood regulation, and therefore might help regulate mood swings ^[4].
3. Black Cohosh (Cimicifuga racemosa): The exact mechanism of action is unclear; however, its constituents may bind to opiate receptors and activate responses, including core temperature regulation. It is effective for hot flashes, mood swings, and sleep disorders ^[2]. Data shows that black cohosh might also exert a beneficial effect on serotonin receptors, which can help with mood regulation. Black cohosh might also decrease luteinizing hormone (LH) levels, leading to a reduction in hot flashes ^[7].
4. Red Clover (Trifolium Pratense): the isoflavone content of red clover has been shown to significantly reduce hot flashes more rapidly compared to baseline treatment ^[8]. Red clover may also slow bone loss of the lumbar spine ^[9].

Conclusion

Menopause is a part of a women’s transition and a natural part of the female aging process; it is not a disease. Menopause is marked by a decrease in circulating estrogen levels resulting in the absence of menstrual periods. Various symptoms may arise for menopausal women, and each woman will experience different symptoms when reaching menopause. Vasomotor symptoms such as hot flashes and night sweats are among the most common and bothersome symptoms experienced by menopausal women. There are many treatment options that can be used to manage individualized menopausal symptoms. It is always important to discuss menopause with your healthcare practitioner before beginning any treatment regimen. Healthcare practitioners can help determine which treatment options will be best for you based on your situation and presentation. Medications can interact with natural prescriptions and this needs to be evaluated prior to commencing a new treatment.