What is menopause

Menopause is defined as the final menstrual period and is usually confirmed when a woman has missed her period for 12 consecutive months (with no other obvious causes) ¹⁾. Menopause is also defined as a point in time 12 months after a woman’s last period ²⁾. Menopause results in lower levels of estrogen and other hormones. Menopause is a normal, natural biological process that all women experience if they live long enough. But the physical symptoms, such as hot flashes, and emotional symptoms of menopause may disrupt your sleep, lower your energy or affect emotional health. However, there are many effective treatments available, from lifestyle adjustments to hormone therapy. The years leading up to that point, when women may have changes in their monthly cycles, hot flashes or other symptoms, are called the menopausal transition or perimenopause.

• Most women experience menopause between ages 40 and 58. The average age is 51.
• Physical changes begin years before the final menstrual period. This transition phase is called perimenopause , most often begins between ages 45 and 55 and may last for 4 to 8 years (usually lasts about 7 years), but can last as long as 14 years. It begins with changes in the length of time between periods and ends 1 year after the final menstrual period.
• Induced menopause is when a woman’s menstrual periods end due to a medical intervention, particularly surgical removal of both ovaries or cancer treatments such as chemotherapy or pelvic radiation. If you have surgery to remove your ovaries or uterus and are not taking hormones, you will experience the symptoms of menopause immediately. Menopause symptoms related to induced menopause can be similar to those from natural menopause, including hot flashes, sleep disturbances, and vaginal dryness. But premenopausal women who experience induced menopause can have more intense symptoms and, therefore, a greater need for treatment to control them than women who undergo natural menopause. And because you may be going through menopause at a young age, you need ongoing monitoring and sometimes treatment to lower your risk of menopause associated diseases, such as osteoporosis, later in life.
• Smoking and genetics are two factors that can influence the timing of natural menopause. Smokers reach menopause about 2 years earlier.

During the perimenopause (menopausal transition), the body’s production of estrogen and progesterone, two hormones made by the ovaries, varies greatly. Bones become less dense, making women more vulnerable to fractures. During this period, too, the body begins to use energy differently, fat cells change, and women may gain weight more easily.

Menopause is often a time in a woman’s life that is also often full of other transitions—not just physical ones. Women may be caring for aging parents or relatives, supporting their children as they move into adulthood, or taking on new responsibilities at work.

What is postmenopause ?

Postmenopause includes all the years beyond menopause.

What is early or premature menopause ?

Menopause, whether natural or induced, is called premature when it happens at age 40 or younger. This occurs in about 1% of women in the United States. Premature menopause that is not induced can be genetic, metabolic, autoimmune, or the result of other poorly understood conditions. Premature menopause should be evaluated thoroughly by your healthcare provider.

Women experiencing premature menopause (age 40 or younger) that is not medically induced go through perimenopause and may have the same symptoms as women with natural menopause, including hot flashes, sleep disturbances, and vaginal dryness. However, compared to women who reach menopause at the typical age, women who experience premature menopause—whether natural or induced—spend more years without the benefits of estrogen and are at greater risk for some health problems later in life, such as osteoporosis and heart disease.

You may need a complete evaluation to diagnose the reason for your menopause — it could be an underlying condition that needs treatment.

Menopause symptoms

Each woman’s experience of menopause is different. Many women report no physical changes during perimenopause except irregular menstrual periods that stop when menopause is reached. Skipping periods during perimenopause is common and expected. Often, menstrual periods will skip a month and return, or skip several months and then start monthly cycles again for a few months. Periods also tend to happen on shorter cycles, so they are closer together. Despite irregular periods, pregnancy is possible. If you’ve skipped a period but aren’t sure you’ve started the menopausal transition, consider a pregnancy test.

Other women experience symptoms of hot flashes, night sweats (heavy sweating from hot flashes at night, often disturbing sleep), and thinning and drying of vaginal tissue that can make sex painful. How severe these body changes are varies from woman to woman, but for the most part these changes are perfectly natural and normal.

In the months or years leading up to menopause (perimenopause), you might experience these signs and symptoms ³⁾, ⁴⁾:

• Irregular periods
• Vaginal dryness or discomfort during sexual intercourse
• Hot flashes
• Chills
• Night sweats
• Sleep problems or insomnia
• Elevated heart rate
• Mood changes, such as irritability, anxiety, or depression
• Weight gain and slowed metabolism
• Thinning hair and dry skin
• Loss of breast fullness
• Urinary or bladder problems
• Memory or concentration problems
• Skin changes

Hot flashes are the most common menopause-related discomfort. A hot flash is a sudden feeling of heat or warmth in the upper part or all of your body, often accompanied by sweating, reddening of the skin, and rapid heart beat. Your face and neck become flushed. Red blotches may appear on your chest, back, and arms. Heavy sweating and cold shivering (cold chill) can follow. Hot flashes can be very mild or strong enough to wake you up (called night sweats). Most hot flashes last between 30 seconds and 10 minutes. They can happen several times an hour, a few times a day, or just once or twice a week.

Night sweats are hot flashes at night that interfere with sleep. While it’s a myth that menopause itself makes women irritable, the sleep disturbances that stem from hot flashes and night sweats can certainly make a woman irritable. Treatments for night sweats and hot flashes include lifestyle changes, nonprescription remedies, hormone therapy (with estrogen plus progestogen, or estrogen alone for women without a uterus), and nonhormonal prescription drugs.

For most women, hot flashes and trouble sleeping are the biggest problems associated with menopause. But, some women have other symptoms, such as irritability and mood swings, anxiety and depression, headaches, and even heart palpitations. Many of these problems, like mood swings and depression, are often improved by getting a better night’s sleep.

Sleep problems. Around midlife, some women start having trouble getting a good night’s sleep. Maybe you can’t fall asleep easily, or you wake too early. Night sweats might wake you up. You might have trouble falling back to sleep if you wake up during the night.

Not getting enough sleep can affect all areas of life. Lack of sleep can make you feel irritable or depressed, might cause you to be more forgetful than normal, and could lead to more falls or accidents.

Some women who have trouble sleeping may use over-the-counter sleep aids like melatonin. Others use prescription medicines to help them sleep, which may help when used for a short time. But, medicines are not a cure for insomnia. Developing healthy habits at bedtime can help you get a good night’s sleep.

Vaginal health. The drop in estrogen around menopause leads to vaginal atrophy (the drying and thinning of vaginal tissues) in many women. It can cause a feeling of vaginal tightness during sex along with pain, burning, or soreness. Over-the-counter vaginal lubricants and moisturizers are effective in relieving pain during intercourse. For women with more severe vaginal atrophy and related pain, low-dose vaginal estrogen products may be needed.

Vaginal dryness is extremely common during menopause. It’s just one of a collection of symptoms known as the genitourinary syndrome of menopause that involves changes to the vulvovaginal area, as well as to the urethra and bladder. These changes can lead to vaginal dryness, pain with intercourse, urinary urgency, and sometimes more frequent bladder infections. These body changes and symptoms are commonly associated with decreased estrogen. However, decreased estrogen is not the only cause of vaginal dryness. It is important to stop using soap and powder on the vulva, stop using fabric softeners and anticling products on your underwear, and avoid wearing panty liners and pads. Vaginal moisturizers and lubricants may help. Persistent vaginal dryness and painful intercourse should be evaluated by your healthcare provider. If it is determined to be a symptom of menopause, vaginal dryness can be treated with low-dose vaginal estrogen, or the oral selective estrogen-receptor modulator ospemifene can be used. Regular sexual activity can help preserve vaginal function by increasing blood flow to the genital region and helping maintain the size of the vagina. Without sexual activity and estrogen, the vagina can become smaller as well as dryer.

Bladder control. Some women also find it hard to hold their urine long enough to get to the bathroom. This loss of bladder control is called incontinence. You may have a sudden urge to urinate, or urine may leak during exercise, sneezing, or laughing.

Sex. You may find that your feelings about sex are changing. You could be less interested. Or, you could feel freer and sexier after menopause. After 1 full year without a period, you can no longer become pregnant. But remember, you could still be at risk for sexually transmitted diseases (STDs), such as gonorrhea or even HIV/AIDS. Your risk for an STD increases if you have sex with more than one person or with someone who has sex with others. If so, make sure your partner uses a condom each time you have sex.

Mood changes. You might feel moodier or more irritable around the time of menopause. Scientists don’t know why this happens. It’s possible that stress, family changes such as growing children or aging parents, a history of depression, or feeling tired could be causing these mood changes.

Skin changes. Genetics, sun damage, fat redistribution, smoking, and the decline in estrogen at menopause all contribute to the loss of collagen and elasticity and to the uneven skin tone of aging skin. Decreased water and fat content of the skin as well as reduced sweat and oil production contribute to dryness. Using effective sunscreen, moisturizing, staying hydrated, and not smoking all help improve your skin’s appearance and prevent further damage. (Just make sure you get adequate vitamin D if you are diligent about sunscreen and covering up.) There are many products on the market for aging skin, but only the topical retinoids have a well-documented ability to repair it. Even hormone therapy does not have solid evidence that it helps aging skin, so you should not use it just because it might be helpful.

Your body seems different. Your waist could get larger. You could lose muscle and gain fat. Your skin could get thinner. You might have memory problems, and your joints and muscles could feel stiff and achy. Are these changes a result of having less estrogen or just related to growing older? Experts don’t know the answer.

In addition, in some women, symptoms may include aches and pains, headaches, and heart palpitations. Since menopausal symptoms may be caused by changing hormone levels, it is unpredictable how often women will have hot flashes and other symptoms and how severe they will be. Talk with your doctor if these symptoms are interfering with your everyday life. The severity of symptoms varies greatly around the world and by race and ethnicity.

Causes of menopause

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 — and your fertility declines. In your 40s, your menstrual periods may become longer or shorter, heavier or lighter, and more or less frequent, until eventually — on average, by age 51 — your ovaries stop producing eggs, and you have no more periods.

• Hysterectomy. A hysterectomy that removes your uterus but not your ovaries usually doesn’t cause immediate menopause. Although you no longer have periods, your ovaries still release eggs and produce estrogen and progesterone. But surgery that removes both your uterus and your ovaries (total hysterectomy and bilateral oophorectomy) does cause immediate menopause. Your periods stop immediately, and you’re likely to have hot flashes and other menopausal signs and symptoms, which can be severe, as these hormonal changes occur abruptly rather than over several years.

• Chemotherapy and radiation therapy. These cancer therapies can induce menopause, causing symptoms such as hot flashes during or shortly after the course of treatment. The halt to menstruation (and fertility) is not always permanent following chemotherapy, so birth control measures may still be desired.

• Primary ovarian insufficiency. About 1 percent of women experience menopause before age 40 (premature menopause). 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 can be found. For these women, hormone therapy is typically recommended at least until the natural age of menopause in order to protect the brain, heart and bones.

Complications of menopause

After menopause, your risk of certain medical conditions increases. Examples include:

Heart and blood vessel (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. So it’s important to get regular exercise, eat a healthy diet and maintain a normal weight. Ask your doctor for advice on how to protect your heart, such as how to reduce your cholesterol or blood pressure if it’s too high.

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 with osteoporosis are especially susceptible to fractures of their spine, hips and wrists.

Urinary incontinence. As the tissues of your vagina and urethra lose elasticity, you may experience frequent, sudden, strong urges to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence). You may have urinary tract infections more often.

Strengthening pelvic floor muscles with Kegel exercises and using a topical vaginal estrogen may help relieve symptoms of incontinence. Hormone therapy may also be an effective treatment option for menopausal urinary tract and vaginal changes which can result in urinary incontinence.

Sexual function. Vaginal dryness from decreased moisture production and loss of elasticity can cause discomfort and slight bleeding during sexual intercourse. Also, decreased sensation may reduce your desire for sexual activity (libido).

Water-based vaginal moisturizers and lubricants may help. If a vaginal lubricant isn’t enough, many women benefit from the use of local vaginal estrogen treatment, available as a vaginal cream, tablet or ring.

Weight gain. Many women gain weight during the menopausal transition and after menopause because metabolism slows. You may need to eat less and exercise more, just to maintain your current weight.

Diagnosis of menopause

Signs and symptoms of menopause are usually enough to tell most women that they’ve started 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.

Tests typically aren’t needed to diagnose menopause. But under certain circumstances, your doctor may recommend blood tests to check your level of:

• Follicle-stimulating hormone (FSH) and estrogen (estradiol), because your FSH levels increase and estradiol levels decrease as menopause occurs
• Thyroid-stimulating hormone (TSH), because an underactive thyroid (hypothyroidism) can cause symptoms similar to those of menopause

Over-the-counter home tests to check FSH levels in your urine are available. The tests could tell you whether you have elevated FSH levels and might be in perimenopause or menopause. But, since FSH levels rise and fall during the course of your menstrual cycle, home FSH tests can’t really tell you whether or not you’re definitely in a stage of menopause.

Treatment of menopause

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

• Hormone therapy. Estrogen therapy is 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 and the shortest time frame needed to provide symptom relief for you. If you still have your uterus, you’ll need progestin in addition to estrogen. Estrogen also helps prevent bone loss. Long-term use of hormone therapy may have some cardiovascular and breast cancer risks, but starting hormones around the time of menopause has shown benefits for some women. You and your doctor will discuss the benefits and risks of hormone therapy and whether it’s a safe choice for you.

Hormone treatments (sometimes called menopausal hormone therapy) can take the form of pills, patches, rings, implants, gels, or creams. Patches, which stick to the skin, may be best for women with cardiac risk factors, such as a family history of heart disease.

There are many types of hormones available for women to treat hot flashes. These include estradiol, conjugated estrogen, selective estrogen receptor modulators (SERMs), and compounded or synthetic hormones. It is a common misconception that synthetic (“bioidentical”) hormones mixed by a compounding pharmacist are safer and less risky than other hormone therapies. This is not the case. You must assume they have the same risks as any hormone therapy.

Some of the relatively mild side effects of hormone use include breast tenderness, spotting or return of monthly periods, cramping, or bloating. By changing the type or amount of the hormones, the way they are taken, or the timing of the doses, your doctor may be able to help control these side effects or, over time, they may go away on their own.

• Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered directly to the vagina using a vaginal cream, tablet or ring. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissues. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.

• Low-dose antidepressants. Certain antidepressants related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs) may decrease menopausal hot flashes. A low-dose antidepressant for management of hot flashes may be useful for women who can’t take estrogen for health reasons or for women who need an antidepressant for a mood disorder. The U.S. Food and Drug Administration (FDA) has approved the use of paroxetine, a low-dose selective serotonin reuptake inhibitor (SSRI) antidepressant, to treat hot flashes. Researchers are studying the effectiveness of other antidepressants in this class. Women who use an antidepressant to help manage hot flashes generally take a lower dose than people who use the medication to treat depression. Side effects depend on the type of antidepressant you take and can include dizziness, headache, nausea, jitteriness, or drowsiness.

• Gabapentin (Neurontin, Gralise, others). Gabapentin is approved to treat seizures, but it has also been shown to help reduce hot flashes. This drug is useful in women who can’t use estrogen therapy and in those who also have nighttime hot flashes.

• Clonidine (Catapres, Kapvay, others). Clonidine, a pill or patch typically used to treat high blood pressure, might provide some relief from hot flashes.

• Medications to prevent or treat osteoporosis. Depending on individual needs, doctors may recommend medication to prevent or treat osteoporosis. Several medications are available that help reduce bone loss and risk of fractures. Your doctor might prescribe vitamin D supplements to help strengthen bones.

Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each. Review your options yearly, as your needs and treatment options may change.

Some women should not use hormones for their hot flashes. You should not take hormones for menopausal symptoms if:

• You have had certain kinds of cancers, like breast cancer or uterine cancer
• You have had a stroke or heart attack, or you have a strong family history of stroke or heart disease
• You have had blood clots
• You have had problems with vaginal bleeding or have a bleeding disorder
• You have liver disease
• You think you are pregnant or may become pregnant
• You have had allergic reactions to hormone medications

Talk with your doctor to find out if taking hormones to treat your symptoms is right for you.

Treating Hot Flashes and Night Sweats with Hormones

• The primary indications for hormone therapy are hot flashes, night sweats, vaginal dryness, and prevention of osteoporosis.

Some women may choose to take hormones to treat their hot flashes. A hormone is a chemical substance made by an organ like the thyroid gland or ovary. During the menopausal transition, the ovaries begin to work less and less well, and the production of hormones like estrogen and progesterone declines over time. It is believed that such changes cause hot flashes and other menopausal symptoms.

Hormone therapy steadies the levels of estrogen and progesterone in the body. It is a very effective treatment for hot flashes in women who are able to use it. There are risks associated with taking hormones, including increased risk of heart attack, stroke, blood clots, breast cancer, gallbladder disease, and dementia. The risks vary by a woman’s age and whether she has had a hysterectomy. Women are encouraged to discuss the risks with their healthcare provider.

Women who still have a uterus should take estrogen combined with progesterone or another therapy to protect the uterus. Progesterone is added to estrogen to protect the uterus against cancer, but it also seems to increase the risk of blood clots and stroke. Hormones should be used at the lowest dose that is effective for the shortest period of time possible.

What Are the Risks of Using Hormones for Hot Flashes ?

In 2002, a study that was part of the Women’s Health Initiative (WHI), funded by the National Institutes of Health, was stopped early because participants who received a certain kind of estrogen with progesterone were found to have a significantly higher risk of stroke, heart attacks, breast cancer, dementia, urinary incontinence, and gallbladder disease.

This study raised significant concerns at the time and left many women wary of using hormones.

However, research reported since then found that younger women may be at less risk and have more potential benefits than was suggested by the WHI study. The negative effects of the WHI hormone treatments mostly affected women who were over age 60 and post-menopausal. Newer versions of treatments developed since 2002 may reduce the risks of using hormones for women experiencing the menopausal transition, but studies are needed to evaluate the long-term safety of these newer treatments.

As a result of the Women’s Health Initiative (WHI) trial in 2002, the US Food & Drug Administration and Health Canada require all estrogen-containing prescription therapies to carry a “black box” warning in their prescribing information about the adverse risks of hormone therapy. Although only two products were studied in the WHI, Premarin and Prempro, the risks of all hormone therapy products, including “natural” bioidentical and compounded hormones, should be assumed to be similar until evidence shows otherwise.

In order to minimize serious health risks, hormone therapy is recommended at the lowest effective dose for the shortest time period and in consultation with a doctor. The real concern about hormone safety is with long-term use of systemic estrogen therapy or estrogen-progestogen therapy.

• Both estrogen therapy and estrogen with progestogen therapy increase the risk of blood clots in the legs (deep vein thrombosis) and lungs, similar to birth control pills, patches, and vaginal rings. Although the risks of blood clots and strokes increase with either type of hormone therapy, the risk is rare in the 50 to 59 age group. Forms of therapy not taken by mouth (patches, sprays, rings, and others) have less risk of causing DVT than those taken by mouth.

• An increased risk in breast cancer is seen with 5 or more years of continuous estrogen/progestogen therapy, possibly earlier. The risk decreases after hormone therapy is stopped. Use of estrogen alone for an average of 7 years in the Women’s Health Initiative trial did not increase the risk of breast cancer. Currently, it is recommended that women with a history of hormone-sensitive breast cancer try non-hormonal therapies first for the treatment of menopausal symptoms.

• Estrogen therapy causes the lining of the uterus to grow and can increase the risk of uterine cancer. Adding progestin decreases the risk of uterine cancer.

• Combined hormone therapy is linked to a small increased risk of heart attack. This risk may be related to age, existing medical conditions, and when a woman starts taking hormone therapy. Some research suggests that for women who start combined therapy within 10 years of menopause and who are younger than 60 years, combined therapy may protect against heart attacks. However, combined hormone therapy should not be used solely to protect against heart disease.

• Combined hormone therapy may cause vaginal spotting. Some women may have heavier bleeding like that of a menstrual period. If you are postmenopausal, it is important to tell your health care provider if you have bleeding. Although it is often an expected side effect of hormone therapy, it also can be a sign of endometrial cancer. All bleeding after menopause should be evaluated.Other side effects reported by women who take hormone therapy include fluid retention and breast soreness. This soreness usually lasts for a short time.

• There is a small increased risk of gallbladder disease associated with estrogen therapy with or without progestin. The risk is greatest with forms of therapy taken by mouth.

Weighing Benefits & Risks of Hormone Therapy

For most women, experts agree that hormone therapy is okay to control moderate to severe menopause symptoms, such as hot flashes and vaginal dryness, within 10 years of menopause and up to age 59. Also, women should use the lowest dose for the shortest amount of time needed to keep the symptoms under control.

In general, hormone therapy use should be limited to the treatment of menopausal symptoms at the lowest effective dose for the shortest amount of time possible. Continued use should be reevaluated on a yearly basis. Some women may require longer therapy because of persistent symptoms.

Benefits

Hormone therapy has the following benefits ⁵⁾, ⁶⁾:

• Systemic estrogen therapy (with or without progestin) has been shown to be the best treatment for the relief of hot flashes and night sweats.
• Systemic and local types of estrogen therapy relieve vaginal dryness.
• Systemic estrogen protects against the bone loss that occurs early in menopause and helps prevent hip and spine fractures.
• Combined estrogen and progestin therapy may reduce the risk of colon cancer.
• Help prevent diabetes. Good scientific evidence shows women who use hormone therapy have a lower risk of developing type 2 diabetes.
• Lower your risk of heart disease if—it’s a big if—you start hormone therapy within 10 years of menopause.
• Ease overactive bladder and maybe even recurring urinary tract infections with vaginal estrogen.

There is no single way to ensure the best possible quality of life around menopause and beyond. Each woman is unique and must weigh her discomfort against her fear of treatment. Risk is defined as the possibility or chance of harm; it does not indicate that harm will occur. Generally, hormone therapy risks are lower in younger women than originally reported in all women ages 50 to 70 combined. It is now believed that women taking estrogen alone—women who have had their uterus removed by a hysterectomy—have a more favorable benefit-risk profile than those taking estrogen-progestogen therapy. This is especially true for younger menopausal women (in their 50s or within 10 years of menopause) than for older women.

Medical professionals have modified their views about the role of hormones as more research has been conducted. Experts agree that there is much they still have to learn. Although recent studies such as the Women’s Health Initiative (WHI) have provided some clarity for large populations, they don’t necessarily address all of the issues an individual woman faces. Only she, with the counsel of her healthcare providers, can do that.

Many factors will be part of a woman’s decision to use a particular hormone product—her age, her risks, her preferences, available treatment options, and the cost of the product. Do her potential benefits outweigh her potential risks? Only after examining and understanding her own situation and after a thorough consultation with her clinician can a woman make the best treatment choice. As new therapies and guidelines are available, and as a woman’s body changes over time, reevaluation and adjustments should be made.

Lifestyle and home remedies for menopause

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. Dress in layers, have a cold glass of water or go somewhere cooler. Try to pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages, caffeine, spicy foods, alcohol, stress, hot weather and even a warm room.

Decrease vaginal discomfort. Use over-the-counter, water-based vaginal lubricants (Astroglide, K-Y jelly, others), silicone-based lubricants or moisturizers (Replens, others). Choose products that don’t contain glycerin, which can cause burning or irritation in women who are sensitive to that chemical. Staying sexually active also helps by increasing blood flow to the vagina.

Get enough sleep. Avoid caffeine, which can make it hard to get to sleep, and avoid drinking too much alcohol, which can interrupt sleep. 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.

Getting a Good Night’s Sleep During the Menopausal Transition

To improve your sleep through the menopausal transition and beyond:

• Follow a regular sleep schedule. Go to sleep and get up at the same time each day.
• Avoid napping in the late afternoon or evening if you can. It may keep you awake at night.
• Develop a bedtime routine. Some people read a book, listen to soothing music, or soak in a warm bath.
• Try not to watch television or use your computer or mobile device in the bedroom. The light from these devices may make it difficult for you to fall asleep.
• Keep your bedroom at a comfortable temperature, not too hot or too cold, and as quiet as possible.
• Exercise at regular times each day but not close to bedtime.
• Avoid eating large meals close to bedtime.
• Stay away from caffeine (found in some coffees, teas, or chocolate) late in the day.
• Remember, alcohol won’t help you sleep. Even small amounts make it harder to stay asleep.

If these changes to your bedtime routine don’t help as much as you’d like, you may want to consider cognitive behavioral therapy. This problem-solving approach to therapy has recently been shown to help sleep disturbances in women with menopausal symptoms. Cognitive behavioral therapy can be found through a class or in one-on-one sessions. Be sure that your therapy is guided by a trained professional with experience working with women during their menopausal transition. Your doctor may be able to recommend a therapist in your area.

Practice relaxation techniques. Techniques such as deep breathing, paced breathing, guided imagery, massage and progressive muscle relaxation may help with menopausal symptoms. You can find a number of books, CDs and online offerings on different relaxation exercises.

Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.

Eat a balanced diet. Include a variety of fruits, vegetables and whole grains. Limit saturated fats, oils and sugars. Ask your provider if you need calcium or vitamin D supplements to help meet daily requirements.

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 regular physical activity or exercise on most days to help protect against heart disease, diabetes, osteoporosis and other conditions associated with aging.

Lifestyle Changes to Improve Hot Flashes. Before considering medication, first try making changes to your lifestyle. Doctors recommend women make changes like these for at least 3 months before starting any medication.

If hot flashes are keeping you up at night, keep your bedroom cooler and try drinking small amounts of cold water before bed. Layer your bedding so it can be adjusted as needed. Some women find a device called a bed fan helpful. Here are some other lifestyle changes you can make:

• Dress in layers, which can be removed at the start of a hot flash.
• Carry a portable fan to use when a hot flash strikes.
• Avoid alcohol, spicy foods, and caffeine. These can make menopausal symptoms worse.
• If you smoke, try to quit, not only for menopausal symptoms, but for your overall health.
• Try to maintain a healthy weight. Women who are overweight or obese may experience more frequent and severe hot flashes.
• Try mind-body practices like yoga or other self-calming techniques. Early-stage research has shown that mindfulness meditation, yoga, and tai chi may help improve menopausal symptoms.

How to do Kegel exercises to help with vaginal muscle tone and help you control urine leakage

Kegel exercises can help make the muscles under the uterus, bladder, and bowel (large intestine) stronger. They can help both men and women who have problems with urine leakage or bowel control ⁷⁾.

Kegel exercises can be done any time you are sitting or lying down. You can do them when you are eating, sitting at your desk, driving, and when you are resting or watching television.

How to Find the Right Muscles

A Kegel exercise is like pretending you have to urinate and then holding it. You relax and tighten the muscles that control urine flow. It is important to find the right muscles to tighten.

Next time you have to urinate, start to go and then stop. Feel the muscles in your vagina (for women), bladder, or anus get tight and move up. These are the pelvic floor muscles. If you feel them tighten, you have done the exercise right. Your thighs, buttock muscles, and abdomen should remain relaxed.

If you still are not sure you are tightening the right muscles:

• Imagine that you are trying to keep yourself from passing gas.
• Insert a finger into your vagina. Tighten the muscles as if you are holding in your urine, then let go. You should feel the muscles tighten and move up and down.

How to do Kegel Exercises

Once you know what the movement feels like, do Kegel exercises 3 times a day:

1. Make sure your bladder is empty, then sit or lie down.
2. Tighten your pelvic floor muscles. Hold tight and count to 8.
3. Relax the muscles and count to 10.
4. Repeat 10 times, 3 times a day (morning, afternoon, and night).

Breathe deeply and relax your body when you are doing these exercises. Make sure you are not tightening your stomach, thigh, buttock, or chest muscles.

After 4 to 6 weeks, you should feel better and have fewer symptoms. Keep doing the exercises, but do not increase how many you do. Overdoing it can lead to straining when you urinate or move your bowels.

Some notes of caution:

• Once you learn how to do them, do not practice Kegel exercises at the same time you are urinating more than twice a month. Doing the exercises while you are urinating can weaken your pelvic floor muscles over time or cause damage to bladder and kidneys.
• In women, doing Kegel exercises incorrectly or with too much force may cause vaginal muscles to tighten too much. This can cause pain during sexual intercourse.
• Incontinence will return if you stop doing these exercises. Once you start doing them, you may need to do them for the rest of your life.
• It may take several months for your incontinence to lessen once you start doing these exercises.

When to Call the Doctor

Call your health care provider if you are not sure you are doing Kegel exercises the right way. Your provider can check to see if you are doing them correctly.You may be referred to a physical therapist who specializes in pelvic floor exercises.

Alternative Medicine for menopause

Many approaches have been promoted as aids in managing the symptoms of menopause, but few of them have scientific evidence to back up the claims. Some complementary and alternative treatments that have been or are being studied include:

Plant estrogens (phytoestrogens). These estrogens occur naturally in certain foods. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, lentils, 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 symptoms remains to be proved, but most studies have found them ineffective. Isoflavones have some weak estrogen-like effects, so if you’ve had breast cancer, talk to your doctor before supplementing your diet with isoflavone pills.

The herb sage is thought to contain compounds with estrogen-like effects, and there’s good evidence that it can effectively manage menopause symptoms. The herb and its oils should be avoided in people who are allergic, and in pregnant or breast-feeding women. Use carefully in people with high blood pressure or epilepsy.

At this time, it is unknown whether herbs or other “natural” products are helpful or safe. The benefits and risks are still being studied.

Bioidentical hormones. These hormones come from plant sources. The term “bioidentical” implies the hormones in the product are chemically identical to those your body produces. However, though there are some commercially available bioidentical hormones approved by the Food and Drug Administration (FDA), many preparations are compounded — mixed in a pharmacy according to a doctor’s prescription — and aren’t regulated by the FDA, so quality and risks could vary. There’s also no scientific evidence that bioidentical hormones work any better than traditional hormone therapy in easing menopause symptoms.

Black cohosh. Black cohosh (Actaea racemosa, Cimicifuga racemosa) – this herb has received quite a bit of scientific attention for its possible effects on hot flashes. Studies of its effectiveness in reducing hot flashes have produced mixed results. However, some women report that it has helped them. Recent research suggests that black cohosh does not act like estrogen, as once thought. This reduces concerns about its effect on hormone-sensitive tissue (eg, uterus, breast). Black cohosh has had a good safety record over a number of years. But there’s little evidence that black cohosh is effective, and there have been reports linking black cohosh to liver problems and this connection continues to be studied.

Red Clover. Red Clover (Trifolium pratense) In five controlled studies, no consistent or conclusive evidence was found that red clover leaf extract reduces hot flashes. As with black cohosh, however, some women claim that red clover has helped them. Studies report few side effects and no serious health problems with use. But studies in animals have raised concerns that red clover might have harmful effects on hormone-sensitive tissue.

Dong Quai. Dong quai (Angelica sinensis) has been used in Traditional Chinese Medicine to treat gynecologic conditions for more than 1,200 years. Yet only one randomized clinical study of dong quai has been conducted to determine its effects on hot flashes, and this botanical therapy was not found to be useful in reducing them. Some experts on Chinese medicine point out that the preparation studied was not the same as they use in practice. Dong quai should never be used by women with fibroids or blood-clotting problems such as hemophilia, or by women taking drugs that affect clotting such as warfarin (Coumadin) as bleeding complications can result.

Ginseng (Panax ginseng or Panax quinquefolius). Research has shown that ginseng may help with some menopausal symptoms, such as mood symptoms and sleep disturbances, and with one’s overall sense of well-being. However, it has not been found to be helpful for hot flashes.

Kava (Piper methysticum). Kava may decrease anxiety, but there is no evidence that it decreases hot flashes. It is important to note that kava has been associated with liver disease. The FDA has issued a warning to patients and providers about kava because of its potential to damage the liver. Because of this concern, Health Canada does not allow kava to be sold in Canada.

Evening Primrose Oil (Oenothera biennis). This botanical is also promoted to relieve hot flashes. However, the only randomized, placebo-controlled study (in only 56 women) found no benefit over placebo (mock medication). Reported side effects include inflammation, problems with blood clotting and the immune system, nausea, and diarrhea. It has been shown to induce seizures in patients diagnosed with schizophrenia who are taking antipsychotic medication. Evening primrose oil should not be used with anticoagulants or phenothiazines (a type of psychotherapeutic agent).

Yoga. There’s no evidence to support the practice of yoga in reducing menopausal symptoms. But, balance exercises such as yoga or tai chi can improve strength and coordination and may help prevent falls that could lead to broken bones. Check with your doctor before starting balance exercises. Consider taking a class to learn how to perform postures and proper breathing techniques.

Acupuncture. Acupuncture may have some temporary benefit in helping to reduce hot flashes, but in research hasn’t shown significant or consistent improvements. More research is needed.

Hypnosis. Hypnotherapy may decrease the incidence of hot flashes for some menopausal women, according to research from the National Center for Complementary and Integrative Health. Hypnotherapy also helped improve sleep and decreased interference in daily life, according to the study.

You may have heard of or tried other dietary supplements, such as DHEA, evening primrose oil and wild yam (natural progesterone cream). Scientific evidence on effectiveness is lacking, and some of these products may be harmful.

Talk with your doctor before taking any herbal or dietary supplements for menopausal symptoms. The FDA does not regulate herbal products, and some can be dangerous or interact with other medications you take, putting your health at risk.