Frequently Asked Questions

1. What is menopause?
2. What is the "climacteric"?
3. What symptoms might I experience during perimenopause?
4. What can I do to relieve symptoms of perimenopause?
5. When is a woman post menopausal?
6. Why is this season of the transition significant?
7. What health related issues are of concern for postmenopausal women?
8. What is hormone therapy?
9. Is HRT safe?
10. How long should I stay on ET or HT?
11. How do I stop taking hormone therapy

1. What is menopause?

By medical definition, menopause has occurred when your menstrual period has stopped for 12 months (cessation of menses), which means your ovaries are no longer functioning. However, when women say they are "menopausal", most often they mean they are experiencing symptoms of the menopause transition or climacteric. Also called the perimenopause, this transition:

• is a period of life when physical and psychological changes indicate the approach of the end of women's reproductive capacity;
• begins with a variation in menstrual cycle length around the age of 47.5 years of age and ends with the final menstrual period;
• lasts approximately four years for most women, but about 10% of women stop menstruating abruptly.

In the Western world, the average age for the final end of menstruation is 51.4 years.

Premature (or early) menopause is arbitrarily set at 40 years of age, meaning that menopause is considered within the normal range after the age of 40, but premature if it occurs before age 40.

Induced menopause is the cessation of menopause that follows either surgical removal of ovaries or destruction of ovarian function from chemotherapy or radiation.

Two factors have been shown to influence the timing of menopause:

1. Smoking: Smokers experience it 1.5 years earlier than non-smokers; and
   
   
2. Family Factors: Late menopause is more likely to occur in women who have had a lot of children or are overweight. Earlier menopause may be associated with having had:
   • no children;
   • depression;
   • toxic chemical exposure;
   • cancer in childhood that was treated with alkylating chemotherapy agents or pelvic radiation; or
   • frequent epileptic seizures.

In Canada in 2001, approximately 4.78 million women were above the age of 50.

(see also CWHN: Menopause (aussi en Français))

2. What is the "climacteric"?

The climacteric sounds like a weather system, but it isn't. The climacteric is a significant turning point in a sequence of events. Climacteric is a better term than menopause to explain this time of transition in a woman's life, because it denotes transition in life rather than an end of something. Climacteric is often used interchangably with perimenopause.

3. What symptoms might a woman experience during perimenopause?

• Changes in your menstrual cycle (longer or shorter periods, lighter or heavier flow, missed periods, or any combination)
• Hot flashes: A sudden flash of heat from your chest to your head
• Night sweats: Hot flashes that occur when you are sleeping and disturb your sleep
• Vaginal dryness
• Disrupted sleep
• Fatigue
• Mood swings, depression, irritability (and you thought PMS was bad!)
• Loss of desire for sex, painful intercourse
• Increased body fat around your waist (you now have an Equator!)
• Problems with memory and concentration
• Wrinkles where you smile (and where you don't)
• Rogue chin hairs (stray hairs willing to sprout just about anywhere!)
• Vision changes so you can't see those stray hairs until they are 3 inches long

• Crawly feeling under the skin
• Acne (it's back to haunt us!)
• Bouts of rapid heart beat
• Chills or periods of extreme warmth
• Vaginal or urinary tract infections
• Thinning hair on scalp
• Bloating, gas pains, flatulence
• Urinary leakage
• Migraine headaches
• Anxiety and panic attacks
• Sensitivity to touching by others
• Easily wounded feelings
• Sudden inappropriate bursts of anger
• Aching ankles, wrists ,knees, shoulders

(See also Perimenopause on our health issues page.

4. What can you do to relieve symptoms of perimenopause?

• Talk to your health care provider about the physical and emotional changes you are experiencing, including anxiety or depression.
• Keep a diary of your menstruation dates, flow, clots, etc.
• Keep track in your diary any other symptoms you may be experiencing, when they occur and the circumstances i.e. Hot flash every evening after you drink red wine. Three hot flashes per night on those nights you've had wine.
• See if there is a pattern or triggers for your symptoms. You can change or avoid these triggers and thereby avoid or lessen the symptom.
• Exercise a minimum of 30 minutes per day every day. Find a physical activity you enjoy doing.
• Dress in layers so you can peel off and put on layers as needed without shocking those around you!
• Wear cotton. Man-made fibers are hot and don't breathe or absorb perspiration during a hot flash or night sweat.
• Talk to friends about what you are going through. Chances are some of them have or will have experiences similar to yours. Anyway, it is a good time to get together to share some laughter and some tears.
• Use a vaginal lubricant for dryness or pain during sex.
• Remember, this is all new for you, so give yourself permission to go through it your own way, with a little help from your friends.

(See also Perimenopause on our health issues page.

5. When is a woman post menopausal?

This is the 10 or so years following the 12 months of being period free (true menopause).

6. Why is this season of the transition significant?

Many women identify the years after menopause to be the richest years of their lives. They experience more confidence about themselves and a certain zest for life.

7. What health related issues are of concern for postmenopausal women?

• Heart disease is the number one killer of women.
• Osteoporosis- bone loss is rapid the first five years post menopause.
• Cancer rears its ugly head: breast, colon, lung and skin cancer.

8. What is hormone therapy?

Hormone therapy (HT) used to be called hormone replacement therapy or HRT, and used to be limited to taking estrogen and progesterone, but there are now a number of "hormone therapies". Currently, the most commonly used form of hormone therapy is estrogen therapy (ET), used almost exclusively for women who have had a hysterectomy. Women who still have their uterus and go on hormone therapy require progesterone as well as estrogen (EPT). The progesterone protects the lining of the uterus from being over-stimulated by the estrogen and causing build-up that can lead to unpredictable bleeding and may increase the risk of cancer of the lining of the uterus (endometrial carcinoma). One of the problems with using topical progesterone cream in combination with estrogen is that it has not been proven to be protective of the uterus.

Hormone therapy also refers to the oral contraceptive pill when it is used therapeutically to control bleeding at the time of perimenopause (the three to five year period prior to menopause when estrogen levels begin to drop, causing a variety of symptoms). It also refers to testosterone therapy that may be used for treatment of sexual difficulties. Newer medications used to treat osteoporosis, such as Raloxifene or EVISTA™, act on the hormone receptors and are called selective estrogren receptor modulators. Studies are being done on a medication that can increase a woman's libido by acting on estrogen receptors.

(see also CWHN: Hormone Therapy (HT) or L'Hormonothérapie)

9. Is HRT safe?

(As discussed in the answer to Question 8 above, the hormone therapy that used to be called hormone replacement therapy (HRT) is to be referred to now as estrogen/progesterone therapy (EPT). However, because these terminology changes are relatively new, and changes often take a while to take effect, many resources you may use, including books, pamphlets, and web sites, still refer to HRT. We try to use the more current EPT whenever possible.)

The question of EPT safety is complex, and has a complex answer. When considering the safety of a medication, one needs to think about the incidence and severity of side effects, but also the short and long-term risks of the therapy. Women seeking relief from perimenopausal symptoms also need to know if EPT is a poor choice for them because of other medical conditions they may have.

• known or suspected breast cancer,
• serious heart, liver, or kidney disease,
• unexplained vaginal bleeding (once the cause has been found and treated, EPT use may be appropriate),
• been immobilized with a recent hip fracture, stroke, or heart attack, or
• a blood clot or a strong family history of blood clots or known blood-clotting abnormalities,

EPT is not recommended for you.

Some women report that they experience nausea, headache and/or breast tenderness when they begin taking EPT. These are side effects that may or may not dissipate over time. If they do not resolve within a reasonable time frame, switching the type of estrogen or progestin, or switching to a different dosage form (transdermal patch, transdermal gel) will often eliminate these adverse effects.

Weight gain is something many women attribute to taking EPT. However, weight gain is not a side effect of EPT, but rather is likely related more to menopause itself. Women who experience undesired weight gain should discuss dietary changes and, in particular, physical activity with their health care provider.

• Uterine Cancer
  
  Estrogen use alone seems to raise the risk of endometrial (uterine lining) cancer by 5 to l0 times over normal. The risk rises with higher doses and longer-term use. The risk is almost completely eliminated by appropriate use of a progestin (used daily or cyclically for 10-14 days each month).
  
  
• Breast Cancer
  
  In the short-term, EPT does not increase the risk of breast cancer. The Canadian Consensus Committee has stated that the use of EPT for a short period of four years or less does not increase the risk of breast cancer. Longer duration of EPT (more than four years) may be associated with a small increased risk of breast cancer. This risk returns to baseline five years after stopping therapy. In clinical studies with EPT, all the cancers found in the EPT users were confined to the breast (i.e., the cancer hadn't spread). This suggests earlier detection of cancer in EPT users. This early detection may have occurred because EPT users were more likely to have mammograms than were non-users.

Like all things, the balance of benefit and risk must be considered when decision-making. EPT is considered to be the most effective regimen for controlling the symptoms of menopause. It has also been shown to be beneficial in increasing bone mineral density, reducing colorectal cancer risk, and improving mood and oral health.

Reference: The Society of Obstetrics and Gynecology of Canada

(see also CWHN:

• Menopause and Heart Disease or La ménopause et les risques cardiovasculaires
  
  
• Pros and Cons of Hormone Therapy: Making an Informed Decision or Avantages et inconvénients de l'hormonothérapie: pour faire un choix éclairé
  
  
• The Medicalization of Menopause or La médicalisation de la ménopause
  
  
• HRT in the News: The Women's Health Initiative Study at a Glance or L'hormonothérapie en vedette! L'étude « Women's Health Initiative » expliquée.)
  
  

10. How long should I stay on EPT or HT?

Until the 2002 report of the Women's Health Initiative study, we thought the answer was "as long as possible", because we knew that the effectiveness of taking EPT to prevent bone loss is gradually lost after you stop taking it. As well, all previous studies had shown that there were definite benefits to cholesterol levels, and again, the effect lasted only as long as you took the medication. However, since the Women's Health Initiative, the answer is not so clear. That study showed that there was no protection for heart disease, even though cholesterol levels improved. In fact, out of 10,000 women, 30 women who took no medication had non-fatal heart attacks, while 37 taking Premarin™ and Provera™ had non-fatal heart attacks i.e. there was no significant difference in mortality in the two groups. This was very surprising—we expected an improvement for those women taking HT.

We don't know if this effect applies to other types of estrogen and progesterone or if it only relates to the combination of Premarin™ and Provera™. The current recommendation from the North American Menopause Society is that HT be used for as short a time as necessary to control vasomotor symptoms (hot flashes), sleep disturbance, vaginal dryness, painful intercourse, vaginal aging. It should not be started only to prevent heart disease. Each woman must be advised to take into consideration her own risks and benefits. This takes a lot of time and consideration since we are all different!

11. How do I stop taking hormone therapy?

(see also CWHN: How to Stop Taking Hormone Therapy)