Menopause, is when a woman stops menstruating. It is a natural event, not a disease or illness. However, for some women the physical and emotional symptoms can be difficult.

Menopause involves hormonal changes that may cause physical symptoms. The ovaries stop producing female sex hormones (estrogen and progesterone), and estrogen levels decline over several years. That decline can cause:

• Hot flashes
• Night sweats
• Mood swings

For some women, menopause may bring on feelings of sadness. However, it is important to remember that menopause does not mean an end to your sexuality, or that you are any less feminine. In fact, some women find the years after menopause to be a time of freedom, when they no longer have to think about having a period or becoming pregnant.

Today, an estimated 50 million women in the United States have reached menopause. Most women will spend at least one-third of their lives in or beyond menopause.

Technically, menopause is considered complete when a woman has not had a period for an entire year. On average, menopause occurs at age 51, but it varies from person to person. Because menopause is a process that happens over several years, it is divided into two phases:

• Perimenopause, when you begin having symptoms but are still having periods, which can last 4 to 5 years. You can still become pregnant during this time.
• Postmenopause, which occurs once you have gone 12 months without a period. Your ovaries have stopped releasing eggs and produce much less estrogen.

Another type of menopause, known as surgical menopause, happens if both ovaries are removed for medical reasons. This may be done if you have a hysterectomy, the removal of the uterus.

After menopause, women lose the protective effects of estrogen and are at increased risk for osteoporosis and heart disease. There are a variety of treatments available, however, to help ease the symptoms and reduce health risks associated with menopause.

Symptoms of menopause vary from woman to woman. Some studies suggest that the signs and symptoms of menopause may vary between cultural groups. For example, up to 80% of American women experience hot flashes while only 10% of Japanese women have that symptom. Some researchers think that may be due to differences in diet, lifestyle, or cultural attitudes toward aging.

The following are general symptoms of menopause:

• Irregular periods
• Hot flashes, including the flushing of the face and chest. These may be accompanied by heart palpitations, dizziness, and headaches.
• Night sweats
• Cold hands and feet
• Vaginal dryness
• Insomnia
• Abnornmal bleeding
• Menstrual migraines
• Issues with balance and osteoporosis
• Mood changes, including depression, irritability, tension (usually happens with sleep problems)
• Gain in abdominal fat
• BRCA-1 or -2 genetic mutation

Post menopausal women are at increased risk for:

• Osteoporosis
• Heart disease
• Macular degeneration, a serious eye disorder and the leading cause of blindness in the Western world
• Glaucoma
• Colon cancer

Menopause is caused by a gradual reduction in the amount of estrogen and progesterone made by the ovaries. Both hormones regulate your periods and enable you to become pregnant. In the years leading up to menopause, the ovaries start to produce lower amounts of estrogen and progesterone. The timing of menopause can vary greatly from woman to woman. Studies indicate that women who smoke may reach menopause 1 to 2 years earlier than those who do not smoke. Women who have a greater number of children tend to have a later menopause. In the U.S., African American and Hispanic women tend to go through menopause 2 years earlier than Caucasian women. Studies also suggest that the timing of menopause may be hereditary. By age 58, 97% of women have gone through menopause.

Although menopause usually happens naturally, it can happen through surgical removal of the ovaries (surgical menopause). Menopause can also be caused by ovarian failure from cancer treatments, such as chemotherapy or radiation.

Menopause is part of the natural aging process for all women, unless it is caused by surgical removal of both ovaries. Surgical menopause typically causes symptoms to come on more quickly. The following risk factors may also make menopausal symptoms occur faster:

• Radiation or chemotherapy
• Premature ovarian failure, when ovaries stop producing hormones before age 40
• Smoking
• Hypothyroidism, a lack of thyroid hormone
• Low production of hormones by the adrenal glands
• Never having children
• Low body mass index (BMI) or weight
• Alcohol abuse
• Family history of early menopause

Most women will notice the signs that they are going through menopause. However, if you start to skip periods suddenly, you should see your doctor for a pregnancy test. It is possible to become pregnant when going through perimenopause, as long as you are having periods, even if they are irregular, you can get pregnant. In some cases, your doctor may order blood tests to check hormone levels. Your doctor may also suggest a bone density measurement. If you have moderate or severe symptoms that interfere with your life, talk to your doctor about what treatments might be right for you.

Although you cannot prevent menopause, you can take action to reduce your risk of complications, such as osteoporosis and heart disease:

• Stop smoking. Smokers tend to start menopause 1 to 2 years earlier than nonsmokers, and are also at higher risk for heart disease and osteoporosis.
• Ask your doctor whether you should take calcium and vitamin D supplements to protect against bone loss.
• Exercise. Exercise can reduce hot flashes and improve mood, and weight-bearing exercise, such as walking, helps keep bones strong.
• Eat a healthy, balanced diet to avoid weight gain and keep cholesterol levels in check.
• Talk to your doctor about hormone replacement therapy (HRT). For some women the benefits of HRT may outweigh the increased risk of breast cancer and stroke. (See Medications.)

Menopause itself does not need treatment, but you may want to treat some symptoms and reduce your risk of long-term medical conditions, such as heart disease and osteoporosis, that are more common after menopause. Many treatment options are available, so it is important to discuss them with your doctor.

In the past, a number of women took hormone replacement therapy (HRT), which consists of supplemental estrogen and progesterone. Those without a uterus (womb) sometimes took (ERT), which consists of estrogen alone. Only women who have had a hysterectomy usually take ERT, because taking estrogen without progesterone increases the risk of uterine cancer.

Taking HRT seemed to help reduce symptoms such as hot flashes, and researchers also believe it reduced a woman's risk for heart disease. But an important 2002 study, the Women's Health Initiative (WHI), found that HRT and ERT posed more risks than benefits. That study showed that women who took HRT for several years had an increased risk of:

• Breast cancer
• Heart disease
• Stroke
• Blood clots

Women who took ERT for more than 7 years had a greater risk of stroke.

While the WHI did not find a greater risk of breast cancer among women who took ERT for 7 years, other studies have found a slightly increased risk at 10 years. Right now the evidence shows that taking estrogen long term slightly increases the risk for breast cancer, and taking it with progesterone increases the risk more.

Researchers have begun new studies to look at HRT, but the results are not known yet. The WHI looked at women who were already past menopause, the average age was 63, so researchers do not know if the same results would apply to women who took HRT early in menopause, and for a shorter period of time. Currently, the decision about whether to take HRT is an individual one. If your menopause symptoms are so severe that they interfere with your daily life, talk to your doctor about the risks and benefits of using HRT for a short period of time.

The discussion becomes even more complicated when you introduce the subject of Bioidentical Hormone Replacement Therapy (BHRT) versus conventional HRT. Researchers and clinicians disagree on the pros and cons of each approach. People should educate themselves and consult a knowledgable physician to help them make decisions about:

• Whether or not to use HRT, and what kind (BHRT or HRT)
• For what reason (what are the therapeutic goals)
• The risks and benefits
• How key factors will be monitored during treatment

In addition, there are non-hormonal medications and non-drug therapies that can help reduce your symptoms and lower your risk for long-term medical problems that sometimes occur after menopause.

Lifestyle

Exercise

The benefits of exercise include:

• Keeping bones strong and warding off osteoporosis through weight-bearing exercise, such as walking
• Reducing hot flashes
• Boosting mood
• Enhancing memory and concentration
• Lowering cholesterol
• Kegel exercises help strengthen the pelvic floor

Diet

Eating a healthy, well-balanced diet can help reduce the risks and discomforts associated with menopause. A diet low in saturated fat and cholesterol, for example, may reduce your risk of heart disease by providing the following benefits:

• Lower LDL (bad) cholesterol and triglycerides (fats in the blood)
• Lower blood pressure
• Maintain a healthy weight

Some evidence suggests that eating soy-based foods, such as tofu, might help reduce certain symptoms of menopause, including hot flashes. Adding plenty of calcium and vitamin D to your diet should help prevent bone loss. Foods rich in calcium include:

• Dairy products
• Leafy green vegetables
• Almonds
• Dried beans

High-fiber foods may also help lower your risk of high cholesterol and heart disease.

Medications

Several medications are available to treat the symptoms of menopause, and to help you maintain your health as you grow older. These include:

• HRT. Your doctor may suggest using supplemental estrogen to provide relief from your symptoms depending on a number of factors, including your medical and family history, risk for hormone-related cancers, such as breast cancer, age, and the severity of your symptoms. You and your doctor will carefully weigh the risks and benefits of HRT and prescribe the lowest dose of estrogen for your symptoms.
• Low-dose antidepressants. Venlafaxine (Effexor), an antidepressant that is related to the class of drugs known as selective serotonin uptake inhibitors (SSRIs), can help reduce hot flashes. Other SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), may also help.
• Gabapentin (Neurontin). This drug, which is approved to treat seizures, also helps reduce hot flashes.
• Bisphosphonates. These drugs are used to prevent and treat osteoporosis. They reduce bone loss and the risk of fractures. They include: alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronate (Zometa).
• Selective estrogen receptor modulators (SERMs). This type of drug has a positive effect on bone health, much like estrogen, but without estrogen's side effects. Currently one drug, raloxifene (Evista), is approved for use. It can cause hot flashes, and should not be taken by anyone with a history of blood clots.
• Vaginal estrogen. Estrogen tablets, rings, or creams can be applied locally to relieve vaginal dryness.

Nutrition and Dietary Supplements

• Soy. Soy foods contain substances that act like estrogen (phytoestrogens), though researchers are not sure how strong the effects are. Some researchers think these phytoestrogens, called isoflavones, could help treat symptoms of menopause, including hot flashes, vaginal dryness, and mood swings. But so far the evidence is mixed: about half of the studies show that isoflavones can help reduce symptoms, while the other half find them no better than placebo. Some symptoms of menopause, especially hot flashes, show improvement when women take placebo, making it harder to tell if a treatment is working. Some researchers think other nutrients in soy are responsible for reducing symptoms. Researchers also are not sure whether isoflavone supplements would increase risk of breast cancer after menopause, just as supplemental estrogen does. More studies are needed. In the meantime, it may be better to include soy foods in your diet instead of taking supplements. Talk to your doctor to see which is best for you. Tofu, soy nuts, tempeh, and soy milk are good sources of soy.
• Flaxseed (Linum usitatissimum). Like soy, flaxseed and flaxseed oil contain plant-based chemicals that act like estrogen and may help reduce symptoms of menopause. One study found that women who took phytoestrogens from both soy and flaxseed reduced hot flashes and vaginal dryness, although there was also improvement in symptoms among women who took placebo. As with soy, researchers are not sure whether flaxseed supplements would increase risk of breast cancer after menopause, just as supplemental estrogen does. More studies are needed. In the meantime, it may be better to include flaxseed in your diet instead of taking supplements. Talk to your doctor to see which is best for you. Flaxseed also contains alpha-linolenic acid, which the body can convert into omega-3 fatty acids. These fatty acids are good for heart health.
• Calcium. As estrogen levels decline with menopause, women are at risk for osteoporosis. The National Institutes of Health (NIH) recommends that women over 50 get 1,200 mg of calcium per day through diet and supplements to keep bones strong. Foods rich in calcium include low-fat dairy, such as milk, yogurt, and cheese, green leafy vegetables, black strap molasses, almonds, and dried beans. It can be hard to get enough calcium through your diet, so you may need to take a supplement. It is important to read the label to see how much elemental calcium a supplement contains (that is how much calcium your body can actually use). There are several kinds of calcium supplements. Calcium citrate seems to be more easily absorbed by the body, but it has less elemental calcium than calcium carbonate. Calcium carbonate, however, needs an acid environment to be absorbed, so is best taken with a glass of orange juice. No matter which form of calcium you take, it is better to divide your doses throughout the day so that you are not taking more than 500 mg at a time. You may have to take more than one dose as a result. Remember you should also include calcium you get from your diet in your total for the day.
• Vitamin D. Your body needs vitamin D to absorb calcium. Levels of vitamin D can decline as you get older, so ask your doctor whether you need a supplement. Sources of this vitamin include sunlight, fatty fish, and low-fat dairy fortified with vitamin D. The recommended dietary intake for vitamin D is currently 600 IU per day for women between 50 to 70 years of age and 800 IU for those older than age 70.
• Omega-3 fatty acids (fish oil). Omega-3 fatty acids help reduce LDL (bad) cholesterol and lower the risk of heart disease. Women who are at greater risk of heart disease after menopause may want to ask their doctor whether they should take a fish oil supplement, or simply increase the amount of fish they eat. The American Heart Association recommends having at least two servings of fish per week. One study also found that taking EPA (one of the omega-3 fatty acids found in fish oil) as a supplement reduced the number, but not the severity, of hot flashes in menopausal women. Fish oil may increase the risk of bleeding, especially if you take blood-thinneing medications, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin.

Herbs

The use of herbs is a time honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care practitioner. Treatments used to relieve menopause symptoms vary in their effectiveness from woman to woman. As with prescription medication taken to relieve menopause symptoms, some women may find relief with complementary therapies while others may not. Such herbs include:

• Black cohosh (Cimicifuga racemosa or Actaea racemosa). Black cohosh is used to relieve symptoms of menopause including hot flashes, irritability, mood swings, and feelings of depression. Evidence is mixed, but several studies show that it is effective. Researchers are not sure exactly how black cohosh works like estrogen in the body. It appears to provide the benefits of estrogen, such as reducing hot flashes and vaginal dryness, and possibly protecting against osteoporosis, without the negative effects. Until more is known, women who are at risk of hormone-related cancers, such as breast cancer, should only take black cohosh under a doctor's strict supervision. Black cohosh interacts with several medications, so ask your doctor before taking black cohosh if you take any other medications.
• Pycnogenol (Pinus pinaster). One early study found that pycnogenol, an extract of pine bark, helped relieve symptoms including fatigue, headache, depression and anxiety, sleep problems, vaginal dryness, and hot flashes in perimenopausal women. Pycnogenol may interact with drugs taken to suppress the immune system. People who take such medications, or who have autoimmune diseases, such as rheumatoid arthritis or lupus, should not take pycnogenol.

The following herbs are also sometimes suggested to relieve symptoms such as hot flashes, vaginal dryness, and mood swings, although evidence is mixed or lacking. Like soy, they may contain plant-based estrogens (phytoestrogens) that could act like estrogen in the body and possibly raise the risk of breast cancer. Talk to your doctor before taking these herbs:

• Red clover (Trifolium pratense). Red clover may interact with medications, such as birth control pills, bloodthinners, and other drugs.
• Asian ginseng (Panax ginseng). DO NOT take Asian ginseng with stimulants. Asian ginseng may interact with many medications, including insulin and bloodthinners.

In the past, wild yam (Dioscorea villosa) has sometimes been mentioned as a treatment for menopausal symptoms, because hormones including progesterone were manufactured from wild yam in the 1960s. However, studies show that the body is not able to convert wild yam into progesterone, so it is not likely to relieve menopausal symptoms.

Acupuncture

Several studies show acupuncture may help many women with symptoms of menopause, particularly with hot flashes and mood changes.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of menopause based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Lachesis, helps with hot flashes and irritability
• Sepia, helps with low energy, mood swings, vaginal dryness, and irritability
• Pulsatilla, helps with mood swings and insomnia
• Sulfur, helps with hot flashes and irritability
• Lycopodium, helps with bloating, flatulence, and pain with intercourse
• Argentum nitricum, helps with anxiety, nervousness, irritability, and insomnia
• Calcarea phosphorica, improves bone density
• Belladonna, helps with hot flashes, especially if they begin abruptly

Mind-Body Medicine

Some studies suggest that learning to relax the body (through slow, deep breathing) may reduce the intensity of hot flashes.

Prognosis and Complications

As estrogen levels decline during menopause, a woman's risk of developing the following conditions may increase:

• Heart disease
• Osteoporosis
• Alzheimer disease
• Macular degeneration, a serious eye disorder and the leading cause of blindness in the Western world
• Glaucoma
• Colon cancer

Menopause is part of the natural aging process for all women. There are many therapies available, however, to help ease the symptoms and reduce health risks associated with menopause. Selecting the right treatment can minimize discomfort and maximize the opportunities for a vital, healthy, satisfying life during and after menopause.

Al-Azzawi F, Palacios S. Hormonal changes during menopause. Maturitas. 2009;63(2):135-7.

Bai W, Henneicke-von Zepelin HH, Wang S, Zheng S, Liu J, Zhang Z, et al. Efficacy and tolerability of a medicinal product containing an isopropanolic black cohosh extract in Chinese women with menopausal symptoms: a randomized, double blind, parallel-controlled study versus tibolone. Maturitas. 2007 Sep 20;58(1):31-41.

Bope & Kellerman. Conn's Current Therapy 2013. 1st ed. Philadelphia, PA: Elsevier Saunders; 2012.

Briese V, Stammwitz U, Friede M, Henneicke-von Zepelin HH. Black cohosh with or without St. John's wort for symptom-specific climacteric treatment -- results of a large-scale, controlled, observational study. Maturitas. 2007 Aug 20;57(4):405-14.

Buhling KJ, Daniels BV, Studnitz FS, Eulenburg C, Mueck AO. The use of complementary and alternative medicine by women transitioning through menopause in Germany: results of a survey of women aged 45-60 years. Complement Ther Med. 2014;22(1):94-8.

Chandeying V, Sangthawan M. Efficacy comparison of Pueraria mirifica (PM) against conjugated equine estrogen (CEE) with/without medroxyprogesterone acetate (MPA) in the treatment of climacteric symptoms in perimenopausal women: phase III study. J Med Assoc Thai. 2007 Sep;90(9):1720-6.

Ferri. Ferri's Clinical Advisor 2013. 1st ed. Philadelphia, PA: Elsevier Mosby; 2012.

Finch A, Valentini A, Greenblatt E, et al. Frequency of premature menopause in women who carry a BRCA1 or BRCA2 mutation. Fertil Steril. 2013;99(6):1724-8.

Goto V, Frange C, Andersen ML, Junior JM, Tufik S, Hachul H. Chiropractic intervention in the treatment of postmenopausal climacteric symptoms and insomnia: A review. Maturitas. 2014;78(1):3-7.

Green J, Denham A, Ingram J, Hawkey S, Greenwood R. Treatment of menopausal symptoms by qualified herbal practitioners: a prospective, randomized controlled trial. Fam Pract. 2007 Oct;24(5):468-74.

Hammes AE, Wahner-Roedler DL, Bauer BA. Treating the root cause: acupuncture for the treatment of migraine, menopausal vasomotor symptoms, and chronic insomnia. Explore. 2014;10(4):256-9.

Hidalgo LA, Chedraui PA, Morocho N, et al. The effect of red clover isoflavones on menopausal symptoms, lipids and vaginal cytology in menopausal women: A randomized, double-blind, placebo-controlled study. Gynecol Endocrinol. 2005;21:257-64.

Huang MI, Nir Y, Chen B, et al. A randomized controlled pilot study of acupuncture for postmenopausal hot flashes: effect on nocturnal hot flashes and sleep quality. Fertil Steril. 2006;86:700-10.

Kreijkamp-Kaspers S, Kok L, Grobbee DE, et al. Effect of soy protein containing isoflavones on cognitive function, bone mineral density, and plasma lipids in postmenopausal women. JAMA. 2004;292:65-74.

Lentz. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Elsevier Mosby; 2012.

Lin WT, Beattie M, Chen LM, et al. Comparison of age at natural menopause in BRCA1/2 mutation carriers with a non-clinic-based sample of women in northern California. Cancer. 2013;199(9):1652-9.

Low Dog T. Menopause: a review of botanical dietary supplements. The American Journal of Medicine. 2005;118(12) Suppl 2.

Lucas M, Asselin G, Merette C, et al. Effects of ethyl-eicosapentaenoic acid omega-3 fatty acid supplementation on hot flashes and quality of life among middle-aged women: a double-blind, placebo-controlled, randomized clinical trial. Menopause. 2009;16:357-66.

Lund K. Menopause and the Menopausal Transition. Medical Clinics of North America. 2008;92(5).

Osmers R, Friede M, Liske E, et al. Efficacy and safety of isopropanolic black cohosh extract for climacteric symptoms. Obstet Gynecol. 2005;105:1074-83.

Peng W, Adams J, Sibbritt DW, Frawley JE. Critical review of complementary and alternative medicine use in menopause: focus on prevalence, motivation, decision-making, and communication. Menopause. 2014;21(5):536-48.

Pirotta M, Ee C, Teede H, et al. Acupuncture for menopausal vasomotor symptoms: study protocol for a randomised controlled trial. Trials. 2014;15:224.

Pockaj BA, Gallagher JG, Loprinzi CL, et al. Phase III Double-Blind, Randomized, Placebo-Controlled Crossover Trial of Black Cohosh in the Management of Hot Flashes: NCCTG Trial N01CC1. J Clin Oncol. 2006;24:2836-41.

Poulsen RC, Moughan PJ, Kruger MC. Long-chain polyunsaturated fatty acids and the regulation of bone metabolism. Exp Biol Med (Maywood). 2007 Nov;232(10):1275-88. Review.

Pruthi S, Thompson SL, Novotny PJ, Barton DL, Kottschade LA, Tan AD, et al. Pilot evaluation of flaxseed for the management of hot flashes. J Soc Integr Oncol. 2007 Summer;5(3):106-12.

Rani S. The psychosexual implications of menopause. Br J Nurs. 2009;18(6):370-3.

Robien K, Cutler GJ, Lazovich D. Vitamin D intake and breast cancer risk in postmenopausal women: the Iowa Women's Health Study. Cancer Causes Control. 2007 Sep;18(7):775-82.

Rosner B, Colditz GA. Age at menopause: imputing age at menopause for women with a hysterectomy with application to risk of postmenopausal breast cancer. Ann Epidemiol. 2011;21(6):450-60.

Sayakhot P, Teede HJ, Gibson-Helm M, Vincent A. Differences in clinician understanding and management of early menopause after breast cancer. Climacteric. 2013;16(4):479-89.

Secreto G, Chiechi LM, Amadori A, et al. Soy isoflavones and melatonin for the relief of climacteric symptoms: a multicenter, double-blind, randomized study. Maturitas. 2004;47:11-20.

Somjen D, Knoll E, Vaya J, et al. Estrogen-like activity of licorice root constituents: glabridin and glabrene, in vascular tissues in vitro and in vivo. J Steroid Biochem Mol Biol. 2004;91:147-55.

Spangler L, Newton KM, Grothaus LC, Reed SD, Ehrlich K, LaCroix AZ. The effects of black cohosh therapies on lipids, fibrinogen, glucose and insulin. Maturitas. 2007 Jun 20;57(2):195-204.

Uebelhack R, Blohmer JU, Graubaum HJ, et al. Black cohosh and St. John's wort for climacteric complaints: a randomized trial. Obstet Gynecol. 2006;107:247-55.

Wuttke W, Jarry H, Seidlová-Wuttke D. Isoflavones -- safe food additives or dangerous drugs? Ageing Res Rev. 2007 Aug;6(2):150-88.

Yang HM, Liao MF, Zhu SY, et al. A randomised, double-blind, placebo-controlled trial on the effect of Pycnogenol on the climacteric syndrome in peri-menopausal women. Acta Obstet Gynecol Scand. 2007;86:978-85.

Zaborowska E, Brynhildsen J, Damberg S, et al. Effects of acupuncture, applied relaxation, estrogens, and placebo on hot flushes in postmenopausal women: an analysis of two prospective, parallel, randomized studies. Climacteric. 2007;10:38-45.