Menopause is medically defined as occurring twelve months after your last menstrual period. As menopause nears, the ovaries make less estrogen. One of the earliest and most common signs that menopause may be approaching is a change in your menstrual periods. You may skip one or more periods. The amount of flow may become lighter or heavier. Bleeding may last a shorter or longer time than is usual for you. 

Even though periods tend to be irregular at this time, you should be aware of bleeding that is not normal for you. This could be a sign of a problem. Talk to your health care provider if you: 

• Notice a change in your monthly cycle. 
• Have very heavy bleeding with clots. 
• Have bleeding that lasts longer than normal. 
• Bleed more often than every three weeks. 
• Bleed after sex or between periods. 

At some point, your ovaries stop making enough of the hormones needed to thicken the lining of your uterus. This is when your menstrual periods stop completely. 

Menopause also can occur when your ovaries are surgically removed. This may trigger severe symptoms because your hormone levels decrease all at once. 

Although the removal of the uterus (a hysterectomy) ends menstrual periods, it will not cause menopause unless your ovaries also are removed. If your ovaries remain after surgery, typically you will go through menopause around the usual age.

Menopause is a natural part of aging. The lower amounts of estrogen that come with menopause will cause changes in your body. These changes occur over time. Menopause is different for everyone. Some women notice little difference in their bodies. Others may find it difficult to cope with their symptoms. 

Hot flashes

The most common symptom of menopause is hot flashes (sometimes referred to as hot "flushes"). As many as 75 percent of menopausal women in the United States will have them. A hot flash is a sudden feeling of heat that rushes to your upper body and face. Your skin may redden. You also may break out in a sweat. A hot flash may last from a few seconds to several minutes or longer. 

Hot flashes can happen at any time—day or night. They can be mild or severe. Hot flashes may come a few times a month or several times a day, depending on the woman. Some women will have hot flashes for a few months, some for a few years and some not at all. 

Sleep problems

Many women experience sleep problems during perimenopause, and hot flashes are a common cause. A lack of sleep may be one of the biggest problems you face as you approach menopause. Too little sleep can affect your mood, health, weight, and ability to cope with daily activities. 

Vaginal and urinary tract changes

Loss of estrogen causes changes in your vagina. Its lining may become thin and dry. These changes can cause pain during sexual intercourse. They also can alter the normal pH and bacterial balance of your vagina, which can cause burning and itching.

Bone and other body changes

Bone loss is a normal part of aging. At menopause, the rate of bone loss can increase. Osteoporosis and low bone mass, which can result from this bone loss, increases the risk of breaking bones in older women. The bones of the hip, wrist and spine are affected most often. 

Emotional changes

Menopause does not directly cause clinical depression. However, the change in hormone levels may make you feel nervous, irritable or very tired. These feelings may be linked to other symptoms of menopause, such as lack of sleep. For women with a history of depression, perimenopause may be an emotionally challenging time and they may experience a recurrence of depression. 

If you are under a lot of stress, the changes of menopause may be harder to manage. Many women in midlife are going through major life changes anyway. If you find it hard to cope, talk about your feelings with your partner, a close friend, a therapist or your doctor. 

Sexuality

Menopause does not have to affect your ability to enjoy sex. Although the lack of estrogen may make your vagina dry, vaginal moisturizers and lubricants can help moisten your vagina and make sex more comfortable. There are a number of over-the-counter products available. 

Some women find that they have less interest in sex around and after menopause. Your ability to have an orgasm may change, or orgasms may feel different. Not all women consider changes in sexuality a problem, but for those who do there are many treatment options. It's important to discuss changes in sexuality openly with your partner, and seek help if those changes are causing you distress. 

You are not completely free of the risk of pregnancy during perimenopause. If you do not wish to become pregnant, it is important to use a method of birth control until you and your provider are certain that you have entered menopause (defined as 12 months without a menstrual period). Even if you are protected from pregnancy, it is always important to prevent sexually transmitted diseases. If you are at risk for sexually transmitted diseases, use a latex condom. 

Hormone therapy can help relieve the symptoms of menopause by replacing female hormones no longer made by the ovaries. In some cases, you may begin hormone therapy before menopause to help with symptoms. If you are taking birth control pills, they will be stopped when you begin treatment. 

For women with a uterus, estrogen usually is given along with progestin. This helps reduce the risk of cancer of the lining of the uterus that occurs when estrogen is used alone. The progestin may be taken every day with estrogen, or estrogen may be taken on some days and the progestin added on others. 

Hormone treatment is most often prescribed in the form of vaginal rings or patches placed on the skin. Topical gels and pills are also options. Hormone therapy can be used in different ways to either treat the whole body or locally treat the vagina. 

Estrogen creams and tablets, used in the vagina only, can treat dryness without systemic (whole body) use of hormones. These options may not help with symptoms in other areas of the body, so a discussion with your provider will help you decide if local or systemic treatment is best for you. 

Benefits

Hormone therapy is used to treat the most common symptom of menopause—hot flashes. It also relieves vaginal dryness and can help to relieve some changes that can cause problems in the urinary tract. Hormone therapy slows bone loss after menopause and helps prevent osteoporosis and bone fractures. It also can help reduce the risk of colon cancer. Starting hormone therapy close to the age of menopause (before age 60) has been shown to have cardiac benefits. There is no evidence of cardiac benefits for women who start hormone therapy after age 60 or more than 10 years after menopause.

Risks

Like any treatment, hormone therapy is not free of risk. If you do not have a uterus, you can take estrogen alone. If you have a uterus, using estrogen alone can increase the risk of endometrial cancer. That is because estrogen causes the lining of the uterus to grow. Taking a progestogen along with estrogen will help reduce the risk of uterine problems. The drawback of using some progestins is that they may increase the risk of breast cancer. Also, menopausal women may start bleeding again. Although bleeding may occur only for a short time, many women find this bleeding bothersome. 

The Women's Health Initiative (WHI), a study by the National Institutes of Health, raised concerns about the risks of heart attack, stroke and blood clots related to the use of hormones for postmenopausal women. Because of these findings, the U.S. Food and Drug Administration (FDA) announced that all products for use by postmenopausal women that contain estrogen should include a warning label. 

The WHI study, as well as other more recent studies, suggests that the risk of health problems from hormone therapy may vary from woman to woman depending on how far a woman is past menopause. For example, a woman who is 15 years past menopause may be at greater risk starting estrogen than a woman who is 2 years past menopause. You and your doctor should decide whether this treatment is right for you based on your symptoms, needs and personal risk factors. 

If a woman does not take hormone therapy, there are some other options for managing the symptoms of menopause. For example, some women use bisphosphonates or selective estrogen receptor modulators (SERMs) for preventing bone loss. Bisphosphonates are used to increase bone density and reduce the risk of fractures. 

SERMs are a type of medication that strengthens tissues of the bones. SERMs may be a good choice for women who need protection from osteoporosis, but cannot or do not want to take estrogen therapy. 

For women experiencing hot flashes, low doses of anti-depressants (SSRIs) can help. These are an especially good option for women who may also be experiencing mood changes.  

A variety of simple lifestyle changes can help women cope with hot flashes. For example, regular exercise, dressing in layers, having a fan at your desk, and avoiding spicy foods can all reduce discomfort from hot flashes. Smoking cessation and reducing alcohol use can also improve menopausal symptoms. 

Vaginal dryness can be treated with lubricants. Water, silicon, or oil-based lubricants are all effective at reducing pain during sex. Vaginal moisturizers inserted several times each week are another option. There are many alternative options for managing the symptoms of menopause such as naturopathy and acupuncture. Not every option works for every woman so it is important to discuss these with your providers to determine which are best for you.  

Good nutrition

Eating a balanced diet will help you stay healthy before, during and after menopause. It is important to eat a variety of foods to make sure you get all the essential nutrients. Choose a low-fat, low-cholesterol diet. Also, be sure to include enough calcium and Vitamin D in your diet to help maintain strong bones. Women aged 51 years and older need 1,200 mg of calcium per day. The National Institutes of Health recommends 1,500 mg of calcium per day for postmenopausal women who do not take hormone therapy and all women older than 65 years. 

It can be hard to get enough calcium from eating dairy products and certain vegetables, so you should consider using calcium supplements. Ask your primary care provider about a supplement to slow bone loss and for guidance on how much to take. Calcium cannot be absorbed without vitamin D. Milk that is fortified with vitamin D is one of the best sources. Another is sunlight. You also can use vitamin D supplements to get the recommended daily amount of vitamin D. Your provider can help you determine how much to take. 

Exercise

Exercise is very important, especially as you get older. Regular exercise can help you maintain a healthy weight, relieve stress, and even slow down bone loss. 

The US Department of Health and Human Services recommends moderate aerobic activity five days per week, and strength training exercises two days per week. Multiple studies have shown this level of exercise will help decrease obesity, depression, hypertension and diabetes. Try aerobic activities like walking, hiking, swimming or biking. When strength training, choose weights that challenge your muscles after 10-12 repetitions.