Menopause is a normal part of life, just like puberty. It is the time of your last period, but symptoms can begin several years earlier. Some symptoms of menopause can last for months or years after.

Changing levels of estrogen and progesterone, which are two female hormones made in your ovaries, might lead to these symptoms. This time of change is known as the menopausal transition, but it is also called perimenopause by many women and their doctors. It can begin several years before your last menstrual period. Perimenopause lasts for 1 year after your last period.

After a full year without a period, you can say you have been “through menopause.” Postmenopause follows menopause and lasts the rest of your life. The average age of a woman having her last period is 51. But, some women have their last period in their forties, and some have it later in their fifties.

Menopause is the permanent end of a woman's menstrual periods.Menopause can occur naturally or be caused by surgery, chemotherapy, or radiation.Smoking can lead to early menopause. Some types of medical operations , for example, surgery to remove your uterus (called a hysterectomy) will make your periods stop, and that’s menopause. But you might not have menopause symptoms like hot flashes right then because if your ovaries are untouched, they still make hormones.

In time, when your ovaries start to make less estrogen, menopause symptoms could start. But, sometimes both ovaries are removed (called an oophorectomy), usually along with your uterus. That’s menopause too. In this case, menopause symptoms can start right away, no matter what age you are, because your body has lost its main supply of estrogen.

Women may have different signs or symptoms at menopause. That’s because estrogen is used by many parts of your body. So, as you have less estrogen, you could have various symptoms. Here are the most common changes you might notice at midlife. Some may be part of aging rather than menopause.

Change in your period. This might be what you notice first. Your periods may no longer be regular. They may be shorter or last longer. You might bleed less than usual or more. These are all normal changes, but to make sure there isn’t a problem, see your doctor if:

• Your periods come very close together
• You have heavy bleeding
• You have spotting
• Your periods last more than a week

Common Symptoms During the Menopausal Transition

Some symptoms that women experience are related to menopause and decreased activity of the ovaries. Others may be related to aging in general.

Scientific evidence of a link to menopause is strongest for the following symptoms:

• Hot flushes and night sweats

  Also called vasomotor symptoms, because they involve the expansion of the blood vessels).Many women have hot flushes around the time of menopause. They may be related to changing estrogen levels. Hot flashes may last a few years after menopause.

  A hot flash is a sudden feeling of heat in the upper part or all of your body. Your face and neck become flushed. Red blotches may appear on your chest, back, and arms. Heavy sweating and cold shivering can follow. Flashes can be very mild or strong enough to wake you from your sleep (called night sweats). Most hot flashes last between 30 seconds and 10 minutes.

• Sleep difficulties

  Around mid life, 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 during the night.

• Vaginal dryness, which can lead to painful intercourse and other sexual problems

  Changing estrogen levels can cause your genital area to get drier and thinner. This could make sexual intercourse uncomfortable. Or, you could have more vaginal or urinary infections .

It is not certain whether the following symptoms are due to menopause, other factors that can come with aging, or a combination of menopause and these factors:

• Problems in thinking or in remembering things

  You might have memory problems.

• Urinary incontinence

  Some women find it hard to hold their urine long enough to get to the bathroom. Sometimes urine leaks during exercise, sneezing, coughing, laughing, or running.

• Physical complaints, such as tiredness and stiff or painful joints

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

• Mood changes, such as depression, anxiety, and/or irritability.

  You might find yourself more moody or 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.

• 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. You increase your risk for an STD if you are having sex with more than one person or with someone who is having sex with others. If so, make sure your partner uses a condom each time you have sex.

Two common health problems can start to happen at menopause, and you might not even notice.

Day in and day out, your body is busy breaking down old bone and replacing it with new healthy bone. Estrogen helps control bone loss, and losing estrogen around the time of menopause causes women to lose more bone than is replaced. In time, bones can become weak and break easily. This condition is called osteoporosis. Talk to your doctor to see if you should have a bone density test to find out if you are at risk.

After menopause, women are more likely to have heart disease. Changes in estrogen levels may be part of the cause. But, so is getting older. As you age, you may gain weight and develop other problems, like high blood pressure. These could put you at greater risk for heart disease. Be sure to have your blood pressure and levels of triglycerides, fasting blood glucose, and LDL, HDL, and total cholesterol checked regularly.

Talk to your health care provider to find out what you should do to protect your heart.

These days you hear a lot about whether you should use hormones to help relieve some menopause symptoms. It’s hard to know what to do, although there is some information to help you.

During perimenopause, some doctors suggest birth control pills to help with very heavy, frequent, or unpredictable menstrual periods. These pills might also help with symptoms like hot flashes, as well as prevent pregnancy.

If you are bothered by symptoms like hot flashes, night sweats, or vaginal dryness, your doctor might suggest taking estrogen (as well as progesterone, if you still have a uterus). This is known as menopausal hormone therapy (MHT). Some people still call it hormone replacement therapy or HRT. Taking these hormones will probably help with menopause symptoms. It also can prevent the bone loss that can happen at menopause.

For decades, hormone replacement therapy (HRT)—more recently known as menopausal hormone therapy (MHT)—was conventional medicine's main treatment for menopausal symptoms. In 2002, findings from a large study called the Women's Health Initiative raised serious concerns about the long-term safety of MHT. These concerns are one reason that many women are turning to CAM therapies.

Menopausal hormone therapy has risks. That is why the U.S. Food and Drug Administration suggests that women who want to try MHT to manage their hot flashes or vaginal dryness should use the lowest dose that works for the shortest time it’s needed. Your symptoms may come back when you stop taking hormones. Right now, there is a lot still to learn about taking hormones.

If you are having bothersome symptoms, talk to your health care provider for help deciding how to best manage menopause. You can see a gynecologist, geriatrician, general practitioner, or internist. Make sure the doctor knows your medical history and your family medical history. This includes whether you are at risk for heart disease, osteoporosis, and breast cancer.

It may be helpful to remember that your decision is never final. You can—and should—review it with your doctor during your yearly checkup. Your needs may change over time, and so might what we know about menopause.

These concerns are one reason that many women are turning to CAM therapies.Many women use complementary and alternative medicine (CAM) for menopausal symptoms.

The NIH (National Institute of Health) State-of-the-Science conference panel discussed the evidence on several CAM therapies:-

• Six botanicals
• black cohosh
• dong quai root
• ginseng
• kava
• red clover
• soy
• DHEA (dehydroepiandrosterone), a dietary supplement

Very little well-designed research has been done on CAM therapies for menopausal symptoms. A small number of studies have been published, but they have had limitations (such as the way the research was done or treatment periods that may not have been long enough). As a result, the findings from these studies are not strong enough for scientists to draw any conclusions.

Also, many studies of botanicals have not used a standardized product (i.e., one that is chemically consistent). The National Center for Complementary and Alternative Medicine (NCCAM) is sponsoring a number of studies on botanicals using products that are both well characterized (i.e., their ingredients have been carefully studied) and well standardized and on other CAM therapies that have shown possible promise for reducing menopausal symptoms.

Because CAM products used for menopausal symptoms can have side effects and can interact with other botanicals or supplements or with drugs, research in this area is addressing safety as well as efficacy. Some findings from this research are highlighted below.

Botanicals

• Black cohosh (Actaea racemosa, Cimicifuga racemosa)

  This herb has received more scientific attention for its possible effects on menopausal symptoms than other botanicals. Studies of its effectiveness in reducing hot flashes have had mixed results.

  A study funded by NCCAM and the National Institute on Aging found that black cohosh, whether used alone or with other botanicals, failed to relieve hot flashes and night sweats in postmenopausal women or those approaching menopause.

  Other research suggests that black cohosh does not act like estrogen, as once was thought. Black cohosh has had a good safety record over a number of years. Some concerns have been raised about whether it may cause liver problems, but an association has not been proven.

• Dong quai (Angelica sinensis)

  Only one randomized clinical study of dong quai has been done. The researchers did not find it to be useful in reducing hot flashes. Dong quai is known to interact with the blood-thinning medicine warfarin. This can lead to bleeding complications in women who take this medicine.

  We recommend that you seek the advice of your health care provider before consuming this herb.

• Ginseng (Panax ginseng or Panax quinquefolius)
  The panel concluded 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 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.

• Red clover (Trifolium pratense)

  The panel reported that five controlled studies found no consistent or conclusive evidence that red clover leaf extract reduces hot flushes. Clinical studies in women report few side effects, and no serious health problems have been discussed in the literature.

  However, there are some cautions. Some studies have raised concerns that red clover, which contains phytoestrogens, might have harmful effects on hormone-sensitive tissue (for example, in the breast and uterus).

• Soy

  The scientific literature includes both positive and negative results on soy extracts for hot flushes. When taken for short periods of time, soy extracts appear to have few if any serious side effects.

  However, long-term use of soy extracts has been associated with thickening of the lining of the uterus.

A new product called "NUTRAFEM" has been discovered by the Health Life Sciences Division at the University of Singapore. NUTRAFEM is a natural and safe alternative to HRT for menopause relief. It is a unique herbal combination that has proven to lessen or eliminate suffering through the years of hormone changes.

DHEA

DHEA is a naturally occurring substance that is changed in the body to the hormones estrogen and testosterone. It is also manufactured and sold as a dietary supplement.

A few small studies have suggested that DHEA might possibly have some benefit for hot flashes and decreased sexual arousal, although small randomized controlled trials have shown no benefit.

Because levels of natural DHEA in the body decline with age, some people believe that taking a DHEA supplement can help treat or prevent conditions related to aging; however, there is no good scientific evidence to support this notion.

Concerns have been raised about whether DHEA is safe and effective. Its long-term effects, risks, and benefits have not been well studied, and scientists are not certain whether it might increase the risk for breast or prostate cancer.

Before using DHEA for any purpose, people should talk to their health care provider about potential benefits and risks.

Although there is very little scientific evidence to support the effectiveness of CAM therapies for menopausal symptoms, it is possible that some CAM therapies may provide some relief to women during the menopausal transition. Here are two important points to keep in mind if you are considering these therapies:

• Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.
• "Natural" does not automatically mean "safe." As noted earlier, botanical and other dietary supplements can interact with each other and with prescription and over-the-counter drugs, affecting how the body reacts. Supplements can pose other safety issues as well. Some have been found to be contaminated, contain unlabeled ingredients, or have different amounts of ingredients than are listed on the label.

Women who are looking for alternatives to MHT should be aware that CAM therapies are not their only option. Certain lifestyle changes can contribute to healthy aging, including during the menopausal transition. For example, quitting smoking, eating a healthy diet, and exercising regularly have been shown to reduce the risks of heart disease and osteoporosis.

Menopause is not a disease that has to be treated. But you might need help if symptoms like hot flushes bother you. Here are some ideas that have helped some women:

• Try to keep track of when hot flushes happen—a diary can help. You might be able to use this information to find out what triggers your flushes and then avoid those triggers.
• When a hot flush starts, try to go somewhere cool.
• If night sweats wake you, sleep in a cool room or with a fan on.
• Dress in layers that you can take off if you get too warm.
• Use sheets and clothing that let your skin “breathe.”
• Have a cold drink (water or juice) when a flush is starting.

You could also talk to your doctor about whether there are any medicines to manage hot flushes. A few drugs that are approved for other uses, for example, certain anti-depressants, seem to be helpful to some women.

Staying healthy after menopause may mean making some changes in the way you live.You may want to consider these tips.

• Don’t smoke. If you do use any type of tobacco, stop—it’s never too late to benefit from quitting smoking.
• Eat a healthy diet, low in fat, high in fiber, with plenty of fruits, vegetables, and whole-grain foods, as well as all the important vitamins and minerals.
• Make sure you get enough calcium and vitamin D—in your diet or with vitamin/mineral supplements.
• Learn what your healthy weight is, and try to stay there.
• Do weight-bearing exercise, such as walking, jogging, or dancing, at least 3 days each week for healthy bones. But try to be physically active in other ways for your general health.

• Take medicine if your doctor prescribes it for you, especially if it is for health problems you cannot see or feel—for example, high blood pressure, high cholesterol, or osteoporosis.
• Use a water-based vaginal lubricant (not petroleum jelly) or a vaginal estrogen cream or tablet to help with vaginal discomfort.
• Get regular pelvic and breast exams, Pap tests, and mammograms. You should also be checked for colon cancer, rectal cancer and for skin cancer. Contact your doctor right away if you notice a lump in your breast or a mole that has changed.