Beyond Hot Flashes: Understanding Menopause, Symptoms, and Treatment

February 22, 2023 - The lack of understanding by clinicians about menopause is jarring, considering that nearly every person with female reproductive organs will undergo this experience. An estimated 85% will experience menopausal symptoms, which go far beyond hot flashes and irregular menstruation. An article published in the New York Times detailed the experiences of many women whose menstrual symptoms have been waved off as usual and not requiring treatment. However, many symptoms can be managed through medical interventions.

A 2019 study published in the Mayo Clinic Proceedings reported that very few medical residents know or understand how to manage menopause. The study surveyed 183 family medicine, internal medicine, and obstetrics and gynecology residents in the United States. While nearly all the residents (93.8%) felt it was essential to learn how to manage menopause, roughly one-fifth reported not having a menopause lecture during residency. A lack of education or understanding about menopause has left 93.2% of residents feeling inadequately prepared to manage menopause.

What Is Menopause?

The National Institute of Aging states menopause begins one year after a person’s last menstrual cycle. What many people call menopause — the transition period before the last menstrual cycle, characterized by hot flashes and mood change — is called the menopausal transition or perimenopause; however, clinicians and many articles use the terms interchangeably.

Causes

Physiologically menopause is triggered by the slowed or lack of production of estrogen and progesterone, which prevents menstruation. According to the Mayo Clinic, natural aging, surgical interventions, medications, and primary ovarian insufficiency can trigger menopause.

In those with female reproductive organs, aging is associated with a fertility decline caused by the reduced production of estrogen and progesterone, leading to menopause.

Surgical interventions can also trigger menopause. An oophorectomy, removal of the ovaries, causes immediate menopause as the ovaries that produce the hormone are no longer present. Hysterectomies do not typically trigger menopause instantly as ovaries are still present; however, they can be associated with similar symptoms.

Chemotherapy and radiation may also trigger menopause, depending on the patient and treatment regimen. Radiation will only affect menopause if it is directed at the ovaries.

The WHO notes that some women may experience menopause before 40, called premature menopause. This type of menopause can be associated with genetics and existing conditions or be idiopathic. Primary ovarian insufficiency (POI) is the leading cause of premature menopause. POI occurs when the ovaries cannot produce adequate levels of hormones due to genetic factors or autoimmune diseases.

While only about 1% of women will experience premature menopause, those who experience early menopause are usually recommended for hormone therapy until the natural age of menopause.

Diagnosis

Menopause can typically be diagnosed through medical history and a physical during a routine exam by a provider. In some cases, providers may confirm menopause with blood tests measuring follicle-stimulating hormone (FSH), estrogen, and thyroid-stimulating hormone (TSh) levels. FSH levels typically increase during menopause, which can confirm the condition. Conversely, TSH tests are done to rule out hypothyroidism, which may have similar symptoms to menopause.

Many people begin perimenopause between 45 and 55. According to Planned Parenthood, the most common age for menopause to start is 51.  The transition period's length varies based on factors including general health, age of onset, smoking status, and ethnicity. On average, the menopausal transition is seven years long; however, some people experience it for up to 14 years.

Symptoms of Menopause

One common misconception about menopause is that it only causes changes to menstrual cycles and hot flashes. While those are the most common and well-discussed changes, menopause can impact multiple organ systems, including the reproductive, cardiovascular, and musculoskeletal systems. Planned Parenthood notes that perimenopause may be inconsistent, meaning symptoms may stop and start throughout this period.

Menstruation

Some of the most common changes associated with perimenopause are changes in the menstrual cycle. Those with a regular period may become irregular and have changes in period length, cycle length, heavy bleeding, and spotting. The lack of estrogen and progesterone prevents the body from regulating ovulation, resulting in irregular menstruation and potentially altering premenstrual syndrome symptoms. Irregular periods are often managed through low-dose birth control.

Vasomotor Symptoms

According to StatPearls, vasomotor symptoms, including hot flashes, night sweats, palpitations, and migraines, are the most common menopause symptoms, affecting over 70% of the population of people going through menopause.

For many, hot flashes last well after menopause. According to the NIH, most hot flashes last between 30 seconds and 10 minutes, but the frequency varies from person to person.

A low dose of selective serotonin reuptake inhibitors (SSRIs) may be able to manage hot flashes associated with menopause. For some individuals who cannot take hormones or need an antidepressant, this is a better alternative to hormone replacement therapy.  Gabapentin, an antiseizure medication, and clonidine, a hypertension medication, have also been used to manage hot flashes.

Cardiovascular Disease

One common complication of menopause is an increased risk of cardiovascular disease. StatPearls explains that estrogen deficiency is linked to vasoconstriction and a build-up of low-density lipoprotein, a marker of high cholesterol. These two conditions contribute to a 2–3 times higher risk of cardiovascular disease.

Patients with chronic conditions, such as hypertension, diabetes, and obesity, that contribute to poor cardiovascular health may be advised to take medication and make lifestyle changes during menopause to reduce the risk of heart disease and stroke.

Urogenital Symptoms

Many individuals also experience bladder control issues or incontinence during menopause. This symptom is critical to treat as it can be associated with bladder and urinary tract infections.

Urinary incontinence during menopause is caused by loss of elasticity in vaginal and urethral tissues. StatPearls notes, “The mucosa layer of the vagina begins to atrophy due to decreased estrogen, which causes this cell layer to become drier and thinner. As a result, the vaginal mucosa loses its elasticity and becomes fragile.”

Sexual function changes include vaginal dryness, pain with intercourse, and decreased libido. However, pelvic floor exercises and topical vaginal estrogen can help manage symptoms.

Psychological and Neurological Symptoms

According to the United Kingdom National Health Service (NHS), mental health symptoms such as mood changes, low self-esteem, and memory issues are also common during menopause. An estimated 45% of women have symptoms such as irritability, anxiety, depression, sleep changes, and confidence issues throughout menopause.

A New York Times article explains that cognitive decline occurs in nearly 20% of people during perimenopause. Often described as brain fog, this condition affects verbal learning and information synthesis. While less widely discussed, these symptoms can severely impact a patient’s quality of life.

Osteoporosis

Another complication caused by menopause is decreased bone density. Data suggests that low estrogen levels trigger the release of cytokines that facilitate the creation of osteoclasts. Osteoclasts are involved in bone reabsorption in the remodeling process. An overproduction of osteoclasts due to low estrogen levels can cause osteoporosis, making women more susceptible to broken bones.

Common treatments for osteoporosis include bisphosphonates, calcium, vitamin D, calcitonin, parathyroid hormone, and raloxifene. Lifestyle changes that may help manage osteoporosis include smoking cessation, minimizing caffeine intake, minimizing alcohol consumption, eating a balanced diet, and exercising most days of the week.

Hormone Therapy

Hormone therapy is a complicated discussion when it comes to menopause. According to the NIH, “Physicians used to routinely prescribe hormone replacement therapy (HRT) with estrogen and, sometimes, progesterone to treat the general symptoms of menopause. However, this is no longer routine after several large studies showed that HRT can raise the risk of breast cancer, heart attacks, strokes, and blood clots.”

The NIH notes that menopausal hormone therapy (MHT) is now the most common approach for providers treating menopause. However, providers only consider patients eligible for MHT if they do not have a high risk of stroke, blood clots, and breast cancer.

Endocrine Web differentiates between the two by their purpose, noting that HRT refers to replacing hormones while MHT is a low-dose hormone therapy to manage menopausal symptoms. Regardless of the name, hormone therapy may be a viable option for many patients, depending on their risk factors.

Types of Hormone Therapy

Estrogen therapy replaces only estrogen and is a common option for those experiencing hot flashes, night sweats, or vaginal dryness. This hormone therapy is the only type prescribed for individuals who have had a hysterectomy. Alternative hormone therapy is combined hormone therapy, which is estrogen and progestin — a synthetic form of progesterone.

Like many hormonal forms of birth control, hormone therapy for menopause can be a pill, patch, or ring. Vaginal creams may also be used for hormone therapy; however, this is usually for people who exclusively experience vaginal dryness.

Side Effects and Risks

While incredibly helpful for some people, hormone therapy can come with side effects and risks depending on the patient. The most common side effects of hormone therapy are bloating, headaches, stomach pain, vaginal bleeding, and sore breasts.

Aside from side effects, hormone therapy may also be risky depending on the patient’s personal and family medical history. Risks associated with combined hormone therapy include heart disease and blood clots. Taking combined hormone therapy for more than 3–5 years may also increase the risk of breast cancer. In addition, estrogen therapy increases the risk of blood clots, gallbladder disease, heart disease, uterine cancer, and breast cancer. Breast cancer risk only increases after 10–15 years of using estrogen therapy.

Planned Parenthood notes that, ideally, patients would take the lowest dose of hormone therapy for the shortest time possible to minimize the risks associated with treatment.

Looking Ahead

While some options exist for individuals struggling with menopause symptoms, the stigma and lack of understanding about the condition disadvantage those with female reproductive organs. Moving forward, it is critical that additional research is allocated to understanding menopause and developing low-risk treatment methods.

The WHO notes, “It is critical to see menopause as just one point in a continuum of life stages. A woman’s health status entering the perimenopausal period will largely be determined by prior health and reproductive history, lifestyle, and environmental factors. Perimenopausal and postmenopausal symptoms can be disruptive to personal and professional lives, and changes associated with menopause will affect a woman’s health as she ages. Therefore, perimenopausal care plays an important role in the promotion of healthy aging and quality of life.”