This video will talk about menopause, including the changes you can expect and the treatments for symptoms that are available.

DOCTOR: How have you been? When was your last menstrual period?

PATIENT: Not for about 18 months, but I generally feel OK.

DOCTOR: It sounds like you have transitioned into menopause now that you haven’t had a menstrual period for over a year. The last time you were in, you were having a lot of trouble with hot flashes. Is that still going on?

PATIENT: Actually, those are getting much better- I still have a few night sweats.

DOCTOR: Are you having any other menopausal symptoms?

PATIENT: Like what?

DOCTOR: Menopausal women can have a wide range of symptoms, some physical and some emotional. I’d like to go through the list one by one.

PATIENT: Sounds good

DOCTOR: Are you having trouble with vaginal dryness? Are you sexually active? Any discomfort during sex?

Vaginal dryness and discomfort is a common symptom of reproductive aging but unfortunately is one that women often do not complain of unless asked about (as evident with Mrs. X).  A dramatic decrease in ovarian estrogen is the major factor that results in reduced moisture and thinning of the skin and tissue around the opening and inside of the vagina.

Vaginal dryness begins before the onset of menopause in many women. This symptom is noticed earlier in the process in sexually active women. Many women find that using vaginal lubricants is an effective strategy to overcome discomfort and make sex pleasurable. 

Other women may notice discomfort particularly when wiping the vaginal area.

Both the amount and quality of sex are important for the overall quality of life. Uncomfortable sex may cause women to avoid intimacy which can affect both quality of life and the quality of a relationship. Women should talk about concerns related to their sexual wellbeing with their health care providers.

Of all the symptoms that women experience with aging and menopause, vaginal dryness is one that can be most successfully treated with few treatment-related risks.  A number of products are available, such as over the counter agents that include lubricants and moisturizers, a variety of vaginal estrogen products that have minimal absorption into the bloodstream, and oral or transdermal (across the skin) hormone options, to help address the problem of vaginal dryness.

DOCTOR: What about your sex drive?

Problems of sexual desire are a type of sexual dysfunction. They are commonly found in women approaching the menopause transition as well as those in established menopause. Menopause-related vaginal dryness and discomfort can dampen a woman’s sexual response. This form of sexual dysfunction can be improved through a combination of partner awareness of the situation, trial of vaginal (hormonal as well as non-hormonal strategies such as  a vaginal lubricant and/or moisturizer). Both oral or transdermal (across the skin) hormone options can also help improve sexual wellbeing mainly by improving vaginal dryness and discomfort

Surgically menopausal women (those who have had removal of both ovaries with or without a hysterectomy), low blood levels of ovarian hormones, particularly ovarian estrogen and testosterone, may play a role in decreased sexual desire. This is especially true in women who previously had no problems with sexual function and sexuality. This group of women may benefit from individualized hormone therapy. 

When lack of sexual desire is due to poor sleep or fatigue, ensuring restful sleep should translate into improved sexual wellbeing.

While sexual satisfaction important in helping sustain relationships, issues relating to sexual function are usually not volunteered by patients until the problem looms large in a relationship. Occasionally, an underlying medical issue, such as depression or thyroid dysfunction, may contribute to the picture. 

DOCTOR: Are you having trouble with your sleep?

It is important to recognize that the quality of sleep affects how a person feels during the day. In her 20s, 30s and 40s, sleep interruptions are commonly tied to the needs of a young family. Women approaching and entering menopause can go through a second phase of life when the quality of sleep may be disrupted. A single hot flash, sudden night sweats, or a sense of chill could disrupt sleep. Restlessness without any obvious temperature sensation may be experienced by some women.

However, women who have chronic disturbed sleep must not assume that their sleep problems are due to menopause. Medical disorders can frequently contribute to sleep difficulties. Women should bring this up for discussion with their health care provider.

A number of treatment options exist. Over the counter medicines, hormonal therapies, and non-hormonal prescriptions that include sedatives and antiseizure medications can help improve sleep. Lifestyle strategies can also bring relief. For instance, good sleep hygiene includes attention to timing and limiting distractions and stimuli before bedtime. Weight loss for obese women and exercise for sedentary women can also improve sleep quality and quantity.

DOCTOR: Have you been feeling depressed?

PATIENT: Maybe a little. Why do you ask?

It is common for women in menopause to experience symptoms of depression.  Life experiences (financial status, parental health concerns, kids moving away, relationship changes), disturbed sleep, physical distress from hot flashes and night sweats, or dissatisfying sexual encounters may all contribute to depressive symptoms.

A decline in ovarian hormones may also play a role in depressive symptoms during early menopause. In these cases, the use of menopausal hormone therapy may improve depressive symptoms in some women.

New-onset depression symptoms can also be due to an underlying and undiagnosed medical condition such as thyroid dysfunction. 

It is important to appreciate that menopause does not cause depression but rather sets the stage for other players to act out.  Although a trial of menopausal hormones and/or antidepressant therapy may improve depressive symptoms in some women, the majority will find help with psychological evaluation and counseling.  Depression and a sense of feeling low lasting for more than a few days should not be dismissed and should be discussed with their health care provider. 

DOCTOR: Have you noticed any changes in your memory?

Increasing forgetfulness and lapse in short-term memory are common complaints of women approaching and going through menopause.  As with depressive symptoms, a combination of factors may contribute to the midlife changes in memory including distracting life experiences that pull a woman in many directions, disturbed sleep, fatigue and physical and psychological distress.

Unlike hot flashes, night sweats, and vaginal dryness that are clearly symptoms of menopause, deterioration in memory CANNOT be attributed just to a loss of ovarian function.  A decline in ovarian estrogen may contribute to some short-term memory changes and affect thought processing. However, menopausal hormone therapy has not been shown to improve problems with memory or thought processing in postmenopausal women.

A number of diseases and disorders become more common as we grow older. Some of these changes and diseases can contribute to memory loss (for example high blood pressure, diabetes, stroke and thyroid disease).  A decline in memory that is noticeable to you and to others should not be dismissed as “menopause-related.” Women should bring this up for discussion with their health care provider. 

DOCTOR: Have you noticed any changes to your skin or hair?

PATIENT: I have, my skin is dryer and my hair is thinner.

Most women in menopause notice a change in the quality of their skin and hair. Increasing skin dryness, loss of elasticity, and worsening wrinkling are a natural part of aging. These changes are not necessarily due to the loss of ovarian function, though this can have some impact.

PATIENT: Does that mean I can take hormones to keep me looking younger?

DOCTOR: While some have suggested that menopausal hormones can reduce the process of aging, this has not been proven.  At this time, hormone therapy is not recommended to guard against skin aging.

The best treatment is to take care of your skin. Excessive sun exposure, tanning beds, and smoking are all recognized as “skin insults” and should be avoided.

Genetic predisposition is a major factor in determining who will be at risk for scalp hair thinning during menopause. Some women notice improvement in scalp hair growth with the use of certain prescription medicines. Hair follicle transplant remains a costly, yet more permanent solution to a problem that may be particularly bothersome for some women. 

It is important to realize that an individual woman’s distress due to changes in her physical appearance can be substantial. This can contribute to many of the symptoms associated with menopause (such as depressive symptoms, poor sleep, and weight gain). These concerns must not be dismissed as “vanity.” Furthermore, changes in skin and hair may reflect an underlying medical disorder such as thyroid disease or anemia.  

PATIENT: So far, I haven’t had too much trouble with those symptoms, but I have gained some weight.  It seems harder than it used to be to stay my usual size!

DOCTOR: Regular physical activity and adding weight-bearing exercise to your workout can help keep you from gaining weight, plus it can help prevent osteoporosis, which menopausal women are more at risk for developing.

Ovarian function is important for bone gain and loss of ovarian function  due to natural menopause or following surgical loss of ovaries, is followed by rapid bone loss.   Women can lose up to 20% of their bone within the first 5 years following menopause. 

PATIENT: My mom has osteoporosis, how can I find out if I have it?

DOCTOR: A bone density scan or DXA scan can provide us insight into the state of your skeleton, and should be considered given your mom’s history of osteoporosis.

For the otherwise healthy women who are experiencing bothersome menopausal symptoms, hormone therapy offers the benefits of symptom control and slowing down the bone loss that would otherwise be accelerated at the time of menopause. 

Simple strategies such as regular physical activity, healthy eating habits, adequate calcium and vitamin D intake, and avoidance of smoking and alcohol go a long way in improving bone health and in lowering risk for bone fracture.

DOCTOR: There are several other screening tests we should consider for you at this age. 

PATIENT: What do you mean, screening tests?

DOCTOR: These tests are used in otherwise healthy individuals to catch a problem early in the process. Getting a mammogram to look for earliest suspicion of breast cancer is one example. A Pap smear, where cells from the cervix are tested for precancer, and colonoscopy for detection of earliest stages of bowel cancer and DXA to diagnose low bone mass and hence susceptibility to fracture before a fracture has actually occurred are all examples of “screening” tests. Each test has a recommended schedule that can vary from once a year to less often, depending on the woman’s age, personal health history, and family history.

PATIENT: Is there anything else I should be worried about?

DOCTOR: While menopause itself is not a disease, it is a part of normal aging. With the loss of ovarian function (as happens with menopause), aging-related disease processes get accelerated. Menopause can speed up the onset of conditions generally associated with aging, such as heart disease and stroke. Also, the younger the age at menopause, the higher the risk of this occurrence.

Heart disease rises following menopause and is the most common cause of death among aging women.

Much has been learned about the relationship between ovarian hormones and risks versus benefits of hormone therapy in relation to age, time since menopause and the underlying health of blood vessels. 

The road to heart disease is paved by a number of factors that may or may not be under a woman’s control. Some examples of factors that can be changed include sedentary lifestyle, excess body weight, smoking, poor diet, and stress. Things that are not under a woman’s control would include genetics, race and gender. The presence or absence of ovarian hormones is only one additional factor.

For the relatively healthy woman in early menopause who is physically active, of normal weight, a non-smoker who has normal blood pressure and is not a diabetic, menopausal hormone therapy is a safe and effective strategy for managing bothersome menopausal symptoms.

However, menopausal hormone therapy must be considered with caution for some women. For aging women who are already at increased risk for heart disease, such as those with obesity, high blood pressure, diabetes, a poor cholesterol profile, or those who smoke, the potential risks of adding menopausal hormone therapy like clot formation, stroke, and heart attack must be given serious thought. Non-hormonal strategies may be preferred as first-line approach to managing menopausal symptoms in this group. . Also, for women who are well into menopause, that is more than 5 years beyond their last menstrual period, heart and blood vessel disease may have already set in and non-hormonal strategies may be preferred as first-line approach to managing menopausal symptoms in this group.

DOCTOR: What are you using for birth control?

PATIENT: I am not having periods, so I’m not using any. Should I be?

DOCTOR: Given your age and the fact that you haven’t had a period in over a year, you are now considered menopausal and you do not need to use birth control to prevent pregnancy.

For the perimenopausal woman however, she could still get pregnant and for her some form of birth control is recommended until she remains period free for more than one year. Only  then can she be considered menopausal and can safely stop using birth control methods.

Regardless of age and menopausal status however, barrier contraceptive methods (condoms) must be considered by all sexually active women who are at risk for sexually transmitted infections, like those with a new partner or multiple partners.

DOCTOR: So, to recap, the plan is:

• We did a Pap smear today, and if it’s normal, you won’t need another for 3 years since your last two yearly pap smears were all normal. 
• Your hot flashes are less frequent and seem not to be a bother anymore; I therefore do not see any need for hormone therapy at this point.
• You will try using vaginal lubricants and/or moisturizers to improve vaginal dryness and make sex more comfortable. If these strategies do not work, I would recommend a trial of vaginal estrogen as the next step.
• You will consider talking to a counselor to see if that helps with your depression symptoms. We’ve also drawn labs to check your thyroid to make sure that’s not the cause of your depression and we will continue to check for other physical problems that could be altering your mood.
• Let’s get you set up for a mammogram and, because of your risk of osteoporosis given your mother’s history, we’ll schedule a DXA scan for you. You will discuss and arrange for routine screening colonoscopy with your primary physician.
• You are going to keep up your walking regimen and think about adding some light weight training to your workout routine to keep your bones strong and healthy.
• You will work on getting enough calcium and vitamin D into your diet through a combination of food and supplements, aiming for daily intake of 1000mg of calcium and 600IU of vitamin D.
• We’ll touch base in 3 months to discuss your DXA scan, your mood, and whether using lubricant is helping to make sex more comfortable.
• We’ll talk more about whether to consider additional tests and even start medication to prevent bone loss and reduce your fracture risk at your next visit when your bone density results are available.

PATIENT: Thank you, Doctor. I’ll call if I have any problems!