Symptoms

Technically, you don't actually "hit" menopause until it's been one year since your final menstrual period. In the United States, that happens at about age 51, on average.

But in the months or years leading up to that point, you might experience these signs and symptoms:

• Irregular periods
• Decreased fertility
• Vaginal dryness
• Hot flashes
• Sleep disturbances
• Mood swings
• Increased abdominal fat
• Thinning hair
• Loss of breast fullness

When to see a doctor
Schedule regular visits with your doctor during the years leading up to menopause (perimenopause) and the years after menopause (postmenopause) for preventive health care as well as care of medical conditions that may occur with aging.

If you've skipped a period but aren't sure you've started the menopausal transition, you may want to see your doctor to determine whether you're pregnant. Always seek medical advice if you have bleeding from your vagina after menopause.

Causes

Menopause can result from:

• Natural decline of reproductive hormones. As you approach your late 30s, your ovaries start making less estrogen and progesterone, the hormones that regulate menstruation. During this time, fewer potential eggs are ripening in your ovaries each month, and ovulation is less predictable. Also, the post-ovulation surge in progesterone — the hormone that prepares your body for pregnancy — becomes less dramatic. Your fertility declines, partially due to these hormonal effects.

  These changes become more pronounced in your 40s. Your menstrual periods may become longer or shorter, heavier or lighter, and more or less frequent, until eventually, your ovaries stop producing eggs, and you have no more periods. It's possible, but very unusual, to menstruate every month right up to your last period. More likely, you'll experience some irregularity in your periods.

• Hysterectomy. A hysterectomy that removes your uterus, but not your ovaries, usually doesn't cause menopause. Although you no longer have periods, your ovaries still release eggs and produce estrogen and progesterone. But an operation that removes both your uterus and your ovaries (total hysterectomy and bilateral oophorectomy) does cause menopause, without any transitional phase. Your periods stop immediately, and you're likely to have hot flashes and other menopausal signs and symptoms.
• Chemotherapy and radiation therapy. These cancer therapies can induce menopause, causing symptoms such as hot flashes during the course of treatment or within three to six months.
• Primary ovarian insufficiency. Approximately 1 percent of women experience menopause before age 40. Menopause may result from primary ovarian insufficiency — when your ovaries fail to produce normal levels of reproductive hormones — stemming from genetic factors or autoimmune disease, but often no cause for primary ovarian insufficiency can be found.

Complications

Several chronic medical conditions can develop after menopause:

• Cardiovascular disease. When your estrogen levels decline, your risk of cardiovascular disease increases. Heart disease is the leading cause of death in women as well as in men.
• Osteoporosis. This condition causes bones to become brittle and weak, leading to an increased risk of fractures. During the first few years after menopause, you may lose bone density at a rapid rate, increasing your risk of osteoporosis. Postmenopausal women are especially susceptible to fractures of their hips, wrists and spine.
• Urinary incontinence. As the tissues of your vagina and urethra lose their elasticity, you may experience a frequent, sudden, strong urge to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence). Strengthening pelvic floor muscles with Kegel exercises or using a topical vaginal estrogen may help relieve symptoms of incontinence.
• Weight gain. Many women gain weight during the menopausal transition. You may need to eat less — perhaps as many as 200 to 400 fewer calories a day — and exercise more, just to maintain your current weight.

Preparing for your appointment

Your first appointment will likely be with either your primary care provider or a gynecologist.

Because appointments can be brief, and it can be difficult to remember everything you want to discuss, it's a good idea to prepare in advance of your appointment.

What you can do

• Keep track of symptoms you're experiencing. For instance, write down how many hot flashes you experience in a day or week and note how severe they are.
• Make a list of any medications and vitamin supplements you take. Write down doses and how often you take them.
• Have a family member or close friend accompany you, if possible. You may be given a lot of information at your visit, and it can be difficult to remember everything.
• Take a notebook or notepad with you. Use it to write down important information during your visit.
• Prepare a list of questions to ask your doctor. List your most important questions first, in case time runs out.

Some basic questions to ask include:

• What kind of tests might I need?
• What treatments are available to minimize my symptoms?
• Is there anything I can do to relieve my symptoms?
• What steps can I take to maintain my health?
• Are there any alternative therapies I might try?
• Do you have any printed material or brochures I can take with me? What websites do you recommend?

In addition, don't hesitate to ask questions as they occur to you during your appointment. Ask your doctor to repeat information, if needed, or ask follow-up questions for clarification.

What to expect from your doctor
Some potential questions your doctor might ask include:

• Are you still having periods?
• When was your last period?
• How often do you experience bothersome symptoms?
• How uncomfortable do your symptoms make you?
• Does anything seem to improve your symptoms?
• Does anything make your symptoms worse?

Tests and diagnosis

The signs and symptoms of menopause are enough to tell most women they have begun going through the menopausal transition. If you have concerns about irregular periods or hot flashes, talk with your doctor. In some cases further evaluation may be recommended.

Under certain circumstances, your doctor may check your level of follicle-stimulating hormone (FSH) and estrogen (estradiol) with a blood test. As menopause occurs, FSH levels increase and estradiol levels decrease. Your doctor may also recommend a blood test to determine your level of thyroid-stimulating hormone, because hypothyroidism can cause symptoms similar to those of menopause.

Treatment and drugs

Menopause itself requires no medical treatment. Instead, treatments focus on relieving your signs and symptoms and on preventing or lessening chronic conditions that may occur with aging. Treatments include:

• Hormone therapy. Estrogen therapy remains, by far, the most effective treatment option for relieving menopausal hot flashes. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose needed to provide symptom relief for you.
• Low-dose antidepressants. Venlafaxine (Effexor), an antidepressant related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs), has been shown to decrease menopausal hot flashes. Other SSRIs can be helpful, including fluoxetine (Prozac, Sarafem), paroxetine (Paxil, others), citalopram (Celexa) and sertraline (Zoloft).
• Gabapentin (Neurontin). This drug is approved to treat seizures, but it also has been shown to significantly reduce hot flashes.
• Clonidine (Catapres, others). Clonidine, a pill or patch typically used to treat high blood pressure, may significantly reduce the frequency of hot flashes, but unpleasant side effects are common.
• Bisphosphonates. Doctors may recommend these nonhormonal medications, which include alendronate (Fosamax), risedronate (Actonel) and ibandronate (Boniva), to prevent or treat osteoporosis. These medications effectively reduce both bone loss and your risk of fractures and have replaced estrogen as the main treatment for osteoporosis in women.
• Selective estrogen receptor modulators (SERMs). SERMs are a group of drugs that includes raloxifene (Evista). Raloxifene mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen.
• Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered directly to the vagina using a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.

Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each.

Lifestyle and home remedies

Fortunately, many of the signs and symptoms associated with menopause are temporary. Take these steps to help reduce or prevent their effects:

• Cool hot flashes. Get regular exercise, dress in layers and try to pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages, spicy foods, alcohol, hot weather and even a warm room.
• Decrease vaginal discomfort. Use over-the-counter water-based vaginal lubricants (Astroglide, K-Y) or moisturizers (Replens, Vagisil). Staying sexually active also helps.
• Optimize your sleep. Avoid caffeine and plan to exercise during the day, although not right before bedtime. If hot flashes disturb your sleep, you may need to find a way to manage them before you can get adequate rest.
• Practice relaxation techniques. Relaxation techniques, such as deep breathing, guided imagery and progressive muscle relaxation, can be helpful in relieving menopausal symptoms. You can find a number of books and tapes on different relaxation exercises.
• Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.
• Eat well. Eat a balanced diet that includes a variety of fruits, vegetables and whole grains and that limits saturated fats, oils and sugars. Ask your doctor about calcium supplements to help you meet daily requirements, if necessary.
• Don't smoke. Smoking increases your risk of heart disease, stroke, osteoporosis, cancer and a range of other health problems. It may also increase hot flashes and bring on earlier menopause.
• Exercise regularly. Get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis and other conditions associated with aging.

Alternative medicine

Many approaches have been promoted as aids in managing the symptoms of menopause, but not all of them have scientific evidence to back up the claims. Some complementary and alternative treatments that have been or are being studied include:

• Phytoestrogens. These estrogens occur naturally in certain foods. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, chickpeas and other legumes. Lignans occur in flaxseed, whole grains and some fruits and vegetables. Whether the estrogens in these foods can relieve hot flashes and other menopausal signs and symptoms remains to be proved, but most studies have found them ineffective. Isoflavones have some weak estrogen-like effects, so there's some concern about cancer risk. If you've had breast cancer, talk to your doctor before supplementing your diet with isoflavone pills.
• Vitamin E. This vitamin occasionally provides relief from mild hot flashes for some women. However, scientific studies haven't proved its overall benefit in relieving hot flashes, and taking more than 400 international units of vitamin E supplements daily may not be safe.
• Black cohosh. Black cohosh has been used widely in Europe for treating hot flashes and has been popular among women with menopausal symptoms in the United States. While its safety record has been good, there's no longer much reason to believe that it is effective for menopausal symptom relief.
• Yoga. Some studies show that yoga — a combination of controlled breathing, posing and meditation — may be effective in decreasing the number of hot flashes in perimenopausal women. Yoga classes are often offered at health clubs or through community education programs. Sign up for a class to learn how to perform yoga postures and the proper breathing techniques.

You may have heard of — or even tried — other dietary supplements, such as dong quai, licorice, chasteberry, evening primrose oil and wild yam (natural progesterone cream). Although some might swear by these remedies, scientific evidence of their safety and effectiveness is lacking.

Be sure to talk with your doctor before taking any herbal treatments or dietary supplements for menopausal symptoms. Herbal products can interfere or interact with other medications you may be taking, putting your health at risk.