Perimenopause; Postmenopause

Menopause is a natural process. It does not require treatment unless the symptoms, such as hot flashes or vaginal dryness, are particularly bothersome.

One big decision you may face is whether or not to take hormones to relieve your symptoms. Discuss this thoroughly with your doctor, weighing your risks against any possible benefits. Pay careful attention to the many options currently available to you that do not involve taking hormones.

If you have a uterus and decide to take estrogen, you must also take progesterone to prevent endometrial cancer (cancer of the lining of the uterus). If you do not have a uterus, progesterone is not necessary.

HORMONE REPLACEMENT THERAPY

For years, hormone replacement therapy (HRT) was the main treatment for menopause symptoms. Many physicians believed that HRT was not only good for reducing menopausal symptoms, but also reduced the risk of heart disease and bone fractures from osteoporosis. However, the results of a major study -- called the Women's Health Initiative -- has led physicians to revise their recommendations.

In fact, this important study was stopped early because the health risks outweighed the health benefits. Women taking the hormones did see some benefits. But they greatly increased their risk for breast cancer, heart attacks, strokes, and blood clots.

If your symptoms are severe, you may still want to consider HRT for short-term use (2-4 years) to reduce vaginal dryness, hot flashes, and other symptoms.

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

• Using estrogen/progesterone regimens that do not contain the form of progesterone used in the study.
• 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.

ALTERNATIVES TO HRT

The good news is that you can take many steps to reduce your symptoms without taking hormones:

• Dress lightly and in layers
• Avoid caffeine, alcohol, and spicy foods
• Practice slow, deep breathing whenever a hot flash starts to come on (try taking six breaths per minute)
• See an acupuncturist
• Use relaxation techniques like yoga, tai chi, or meditation
• Eat soy foods
• Remain sexually active to preserve elasticity of your vagina
• Perform Kegel exercises daily to strengthen the muscles of your vagina and pelvis
• Use water-based lubricants during sexual intercourse

There are also some medications available to help with mood swings, hot flashes, and other symptoms. These include low doses of antidepressants such as paroxetine (Paxil), venlafaxine (Effexor), and fluoxetine (Prozac), or clonidine, which is normally used to control high blood pressure.

Estrogen is responsible for the buildup of the lining of the uterine cavity. During the reproductive years, this buildup occurs and then is shed (menstruation). This usually happens about a once a month.

The menopausal decrease in estrogen prevents this buildup from occurring. However, 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.

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

Call your health care provider if:

• You are spotting blood between periods
• You have had 12 consecutive months with no period and suddenly vaginal bleeding begins again

Weismiller D. The Perimenopause and Menopause Experience: An Overview. Clin Fam Practice. 2002; 4(1).

Stenchever, MA. Comprehensive Gynecology, 4th ed. St. Louis, Mo:Mosby, Inc.; 2001:1217-1250.