Menopause (also called the "change of life" or climacteric) is a natural event in a woman's life, which normally occurs between the ages of 40 and 55. On average, menopause begins at about age 51.

During menopause, ovulation (egg production) ceases, eliminating the possibility of pregnancy, and menstruation becomes less frequent and eventually stops.

In some women, menstrual activity stops suddenly, but usually it tapers off, both in amount and duration of flow, and frequently the menstrual periods become more closely or more widely spaced. This irregularity may last for 2 or 3 years before menstruation finally ceases.

The symptoms of menopause are caused by changes in estrogen and progesterone levels. As the ovaries become less functional, they produce less estrogen/progesterone and the body subsequently reacts. Some women experience few if any symptoms, while others experience various symptoms ranging from mild to fairly severe.

This variation is normal. A gradual decrease of estrogen allows the body to slowly adjust to the hormone change, but in some women a sudden decrease in estrogen level occurs, causing severe symptoms. This result is often seen when menopause is caused by surgical removal of the ovaries (surgical menopause).

Estrogen is responsible for the buildup of the epithelial lining of the uterine cavity. During the reproductive years this buildup occurs and is then shed (menstruation) on a monthly basis (usually).

The menopausal decrease in estrogen prevents this buildup from occurring. However, androgenic hormones produced by the adrenal glands are converted to estrogen, and sometimes this will cause postmenopausal bleeding.

This is often nothing to worry about, but because postmenopausal bleeding may also be an early indication of other problems, including cancer, a physician should always check any postmenopausal bleeding.

A reduction in estrogen is associated with a number of side effects that can be very annoying. Hot flashes, caused by a sudden (inappropriate) release of body heat, and vaginal dryness, caused by thinning of the tissues of the vaginal wall, are the two side effects most frequently experienced.

The mood changes and lack of sex drive that are sometimes associated with menopause may result partially from the hormone decrease, but may also result from having to adjust to hot flashes and vaginal dryness.

In addition to these side effects, there are others that may develop over many months or years. Decreased estrogen levels increase the risk for osteoporosis (loss of calcium from the bones, causing bone fragility), which sometimes isn't detected until a bone fracture occurs.

The decreasing estrogen levels seen with menopause also cause changes in cholesterol levels that may increase a woman's risk for heart disease.

• Hot flashes and skin flushing
• Mood changes
• Amenorrhea (no menstrual periods) or irregular menstrual periods
• Vaginal dryness and dyspareunia (painful sexual intercourse)
• Decreased libido (sex drive)

• Estradiol - test
• FSH
• LH

A Pap smear may indicate changes in the vaginal lining (mucosa) caused by changes in estrogen levels. A bone density test may be performed to screen for low bone density levels seen with osteoporosis.

The most common treatment used by women in these cases is estrogen replacement therapy (ERT) or hormone replacement therapy (HRT), but other treatments are available if ERT is not appropriate for you. Not all postmenopausal women need to be treated with ERT or HRT. Each woman should discuss her individual risks and benefits with her health care provider.

Many different types of estrogen are available for use, and ERT can be given through pills, patches, and vaginal creams or tablets. HRT is ERT that includes another hormone along with estrogen (usually progesterone). HRT is usually recommended for women who have not had a hysterectomy (see below).

ERT and HRT are the best treatments available to:

• Help decrease vaginal dryness
• Prevent hot flashes

ERT and HRT can also prevent osteoporosis after menopause. Other medications besides ERT or HRT are also available for preventing osteoporosis, and calcium supplementation is recommended for all postmenopausal women to help to reduce bone loss.

Numerous studies have been done on the other beneficial effects of ERT/HRT, but the results are less clear. Many long-term studies have suggested that ERT helps to prevent heart disease, although recent studies have been conflicting.

Promising new research has also suggested that ERT may help prevent Alzheimer's disease or decrease the risk of colon cancer, although these results are too preliminary to regard seriously.

ERT has been shown to improve irritating bladder symptoms (frequent urination, urinary urgency and burning) that are often associated with urinary incontinence, but the amount of incontinence or urinary leaking does not appear to improve with estrogen treatment.

ERT and HRT are also associated with potential risks. ERT (when given by itself) can cause increased growth of the uterine lining (endometrium) and endometrial cancer. However, when progesterone is added to the estrogen therapy (HRT), that risk disappears. Therefore, women who have not had their uterus removed are usually treated with HRT rather than ERT.

Some studies have shown that ERT and HRT are associated with a small increased risk for breast cancer. This risk seems to be limited to women who take ERT or HRT for more than 5 years.

Other studies have not found this increased breast cancer risk. However, it is usually recommended that women who are at a very high risk for developing breast cancer, or those who have been treated for breast cancer in the past, should not take ERT or HRT.

Other potential risks associated with ERT or HRT use include an increase in gallbladder disease and a small increased risk for venous blood clots, such as deep venous thrombosis (blood clots in the legs).

There are now many ongoing research studies investigating the effects of menopause. The results of these studies may help physicians advise their patients on how to effectively and safely manage menopause.

Until more is known about ERT and HRT, women should weigh the benefits and the possible risks against the symptoms being experienced. Thorough discussion with a physician is recommended.

To reduce the risks of estrogen replacement therapy and still gain the benefits of the treatment, physicians may recommend:

• Adding progesterone to the estrogen (HRT)
• Using a lower dose of estrogen or a different estrogen preparation (for instance a vaginal cream rather than a pill)
• Having frequent and regular pelvic exams and Pap smears to detect problems as early as possible
• Having frequent and regular physical exams, including breast exams and mammograms

Side effects of estrogen replacement are generally rare but may include:

• Vaginal bleeding
• Breast tenderness
• Nausea
• Abdominal bloating
• Uterine cramps

Although menopause is a difficult period for some, most women will experience menopause without long-term problems. Many women report an increase in energy, more self-confidence, and a better attitude.

Decreased estrogen levels are associated with an increased risk of developing osteoporosis and possibly an increased risk of cardiovascular disease.

• Irregular menstrual periods
• Hot flashes
• Vaginal dryness

Call if you are postmenopausal and are experiencing any bleeding.

Also call if you are experiencing the symptoms of menopause and you are under age 40.

Menopause is a natural and expected part of a woman's development and does not need to be prevented. However, there are ways (both medical and non-medical) to reduce or eliminate some of the symptoms that accompany menopause.