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Menopause, also known as the climacteric, is the time in women's lives when
menstrual periods The menstrual cycle is a series of natural changes in hormone A hormone (from the Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic Republic, is a country l ...
stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 48 and 52. Medical professionals often define menopause as having occurred when a woman has not had any menstrual bleeding for a year. It may also be defined by a decrease in
hormone A hormone (from the Greek#REDIRECT Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic Republic, is a country located in Southeast Europe. Its population is appr ...

hormone
production by the
ovaries The ovary is an organ found in the female reproductive system 300px, 1. Labia_majora.html"_;"title="Vulva: 2. Labia_majora">Vulva: 2. Labia_majora; 3. Labia_minora; 4. Vulval_vestibule.html" "title="Labia_minora.html ...

ovaries
. In those who have had
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical or dental specialty that uses operative manual and instrumental techniques on a person to investigate or t ...

surgery
to remove their
uterus The uterus (from Latin "uterus", plural ''uteri'') or womb () is the main female hormone-responsive, sex organ, secondary sex organ of the reproductive system in humans and most other mammals. Things occurring in the uterus are described with t ...

uterus
but still have ovaries, menopause may be considered to have occurred at the time of the surgery or when their hormone levels fell. Following the removal of the uterus, symptoms typically occur earlier, at an average of 45 years of age. In the years before menopause, a woman's periods typically become irregular, which means that periods may be longer or shorter in duration or be lighter or heavier in the amount of flow. During this time, women often experience
hot flash Hot flashes (also known as hot flushes) are a form of flushing Flushing may refer to: Places * Flushing, Cornwall, a village in the United Kingdom * Flushing, Queens, New York City ** Flushing Bay, a bay off the north shore of Queens ** Flushi ...
es; these typically last from 30 seconds to ten minutes and may be associated with shivering,
sweating Perspiration, also known as sweating, is the production of fluids secreted by the sweat glands in the skin of mammal Mammals (from Latin language, Latin , 'breast') are a group of vertebrate animals constituting the class (biology), cla ...

sweating
, and reddening of the skin. Hot flashes often stop occurring after a year or two. Other symptoms may include
vaginal dryness Vaginal lubrication is a naturally produced fluid that lubricates a vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vulva to the cervix. The outer vaginal opening is nor ...
, trouble sleeping, and mood changes. The severity of symptoms varies between women. While menopause is often thought to be linked to an increase in
heart disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina pectoris, angina and myocardial infarction (commonly known as a heart attack). Other CVDs inc ...
, this primarily occurs due to increasing age and does not have a direct relationship with menopause. In some women, problems that were present like
endometriosis Endometriosis is a disease of the female reproductive system in which cells Cell most often refers to: * Cell (biology), the functional basic unit of life Cell may also refer to: Closed spaces * Monastic cell, a small room, hut, or cave in ...

endometriosis
or
painful periods Dysmenorrhea, also known as painful periods or menstrual cramps, is pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and ...
will improve after menopause. Menopause is usually a natural change. It can occur earlier in those who smoke tobacco. Other causes include surgery that removes both
ovaries The ovary is an organ found in the female reproductive system 300px, 1. Labia_majora.html"_;"title="Vulva: 2. Labia_majora">Vulva: 2. Labia_majora; 3. Labia_minora; 4. Vulval_vestibule.html" "title="Labia_minora.html ...

ovaries
or some types of
chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment Cancer Cancer is a group of diseases A disease is a particular abnormal condition that negatively affects the structure or f ...

chemotherapy
. At the physiological level, menopause happens because of a decrease in the ovaries' production of the hormones
estrogen Estrogens or oestrogens, are a class of natural or synthetic s responsible for the development and regulation of the female and s. There are three major estrogens that have estrogenic hormonal activity: (E1), (E2), and (E3). Estradiol, an ...

estrogen
and
progesterone Progesterone (P4) is an endogenous Endogenous substances and processes are those that originate from within a system such as an organism, Tissue (biology), tissue, or Cell (biology), cell. Endogenous substances and processes contrast with exo ...

progesterone
. While typically not needed, a diagnosis of menopause can be confirmed by measuring hormone levels in the blood or urine. Menopause is the opposite of
menarche Menarche ( ; ) is the first menstrual cycle, or first Menstruation, menstrual bleeding, in female humans. From both social and medical perspectives, it is often considered the central event of female puberty, as it signals the possibility of fe ...
, the time when a girl's periods start. Specific treatment is not usually needed. Some symptoms, however, may be improved with treatment. With respect to hot flashes, avoiding smoking, caffeine, and alcohol is often recommended. Sleeping in a cool room and using a fan may help. The following medications may help:
menopausal hormone therapy Hormone replacement therapy (HRT), also known as menopausal hormone therapy or postmenopausal hormone therapy, is a form of hormone therapy used to treat menopausal symptoms, symptoms associated with female menopause. These symptoms can include ho ...
(MHT),
clonidine Clonidine, sold as the brand name Catapres among others, is a medication used to treat hypertension, high blood pressure, attention deficit hyperactivity disorder, drug withdrawal (Alcohol withdrawal syndrome, alcohol, Opioid withdrawal, opioids, ...

clonidine
,
gabapentin Gabapentin, sold under the brand name Neurontin among others, is an anticonvulsant Anticonvulsants (also commonly known as antiepileptic drugs or as antiseizure drugs) are a diverse group of pharmacological agents used in the treatment of epil ...

gabapentin
, or
selective serotonin reuptake inhibitors Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs A drug class is a set of medication A medication (also referred to as medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to medical diagnosis, d ...
. Exercise may help with sleeping problems. While MHT was once routinely prescribed, it is now only recommended in those with significant symptoms, as there are concerns about side effects. High-quality evidence for the effectiveness of
alternative medicine Alternative medicine is any practice that aims to achieve the healing effects of medicine, but which lacks biological plausibility and is Argument from ignorance, untested, Pseudoscience, untestable or proven ineffective. Complementary medicin ...
has not been found. There is tentative evidence for
phytoestrogensA phytoestrogen is a plant-derived xenoestrogen (see estrogen Estrogen, or oestrogen, is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are ...

phytoestrogens
.


Signs and symptoms

During early menopause transition, the
menstrual cycles The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that make pregnancy possible. The ovarian cycle controls the production and release of eggs an ...
remain regular but the interval between cycles begins to lengthen. Hormone levels begin to fluctuate. Ovulation may not occur with each cycle. The term ''menopause'' refers to a point in time that follows one year after the last
menstruation Menstruation (also known as a period and many other Colloquialism, colloquial terms) is the regular discharge of blood and Mucous membrane, mucosal tissue from the endometrium, inner lining of the uterus through the vagina. The menstrual cycl ...
. During the menopausal transition and after menopause, women can experience a wide range of symptoms.


Vagina and uterus

During the transition to menopause, can show shorter cycling (by 2–7 days); longer cycles remain possible. There may be irregular bleeding (lighter, heavier, spotting).
Dysfunctional uterine bleeding Abnormal uterine bleeding (AUB), also known as atypical vaginal bleeding, is vaginal bleeding Vaginal bleeding is any expulsion of blood Blood is a body fluid in humans and other animals that delivers necessary substances such as nutrients ...
is often experienced by women approaching menopause due to the hormonal changes that accompany the menopause transition. Spotting or bleeding may simply be related to vaginal
atrophy Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations (which can destroy the gene to build up the organ), poor nourishment, poor circulatory system, circulation, loss of hormone, hormonal sup ...
, a benign sore ( polyp or lesion), or may be a functional endometrial response. The
European Menopause and Andropause Society The European Menopause and Andropause Society is an institution that promotes the study, and encourages research, of midlife health. Mission EMAS "strives to encourage the study of Menopause Menopause, also known as the climacteric, is the ti ...
has released guidelines for assessment of the
endometrium The endometrium is the inner epithelial Epithelium is one of the four basic types of animal Tissue (biology), tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly pac ...

endometrium
, which is usually the main source of spotting or bleeding. In post-menopausal women, however, any genital
bleeding Bleeding, also known as a hemorrhage, haemorrhage, or simply blood loss, is blood Blood is a body fluid Body fluids, bodily fluids, or biofluids are liquid A liquid is a nearly incompressible In fluid mechanics or more generally ...

bleeding
is an alarming symptom that requires an appropriate study to rule out the possibility of malignant diseases. Symptoms that may appear during menopause and continue through postmenopause include: * painful intercourse *
vaginal dryness Vaginal lubrication is a naturally produced fluid that lubricates a vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vulva to the cervix. The outer vaginal opening is nor ...
*
atrophic vaginitis Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to not enough estrogen Estrogen, or oestrogen, is a category of sex hormone responsible for the development and regulation of the female reproductive system ...
– thinning of the membranes of the
vulva The vulva (plural: vulvas or vulvae; derived from Latin for wrapper or covering) consists of the external female sex organs. The vulva includes the mons pubis In human anatomy The human body is the structure of a human being. It is com ...

vulva
, the
vagina In mammal Mammals (from Latin language, Latin , 'breast') are a group of vertebrate animals constituting the class (biology), class Mammalia (), and characterized by the presence of mammary glands which in Female#Mammalian female, femal ...

vagina
, the
cervix The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus The uterus (from Latin Latin (, or , ) is a classical language belonging to the Italic languages, Italic branch of the Indo-European languages. L ...

cervix
, and the outer
urinary tract The urinary system, also known as the renal system or urinary tract, consists of the kidneys, ureters, bladder The urinary bladder, or simply bladder, is a hollow muscular organ in humans and other vertebrates that stores urine Urine is ...
, along with considerable shrinking and loss in elasticity of all of the outer and inner genital areas.


Other physical

Other physical symptoms of menopause include lack of energy, joint soreness,
stiffness Stiffness is the extent to which an object resists deformation Deformation can refer to: * Deformation (engineering), changes in an object's shape or form due to the application of a force or forces. ** Deformation (mechanics), such changes co ...
,
back pain Back pain is pain felt in the back. Back pain is divided into neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) based on the segment affected. The lumbar area is the most common are ...
, breast enlargement,
breast pain Breast pain is the symptom of discomfort in the breast. Pain that involves both breasts and which occurs repeatedly before the menstrual period is generally not serious. Pain that involves only one part of a breast is more concerning. It is particu ...
,
heart palpitation Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle Cardiac muscle (also called heart muscle or myocardium) is one of three types of vertebrate Vertebrates () comprise all species of animal ...
s,
headache Headache is the symptom of pain Pain is a distressing feeling often caused by intense or damaging stimuli. The defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or ...

headache
,
dizziness Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo Vertigo is a condition where a person has the sensation of moving or of surrounding objects moving when they are not. Often it feels like a spinnin ...

dizziness
, dry,
itch ITCH is a HECT domain In molecular biology, the HECT domain is a protein domain A protein domain is a region of the protein's Peptide, polypeptide chain that is self-stabilizing and that folds independently from the rest. Each domain forms a c ...

itch
y skin, thinning, tingling skin,
rosacea Rosacea is a long-term Long-Term Capital Management L.P. (LTCM) was a hedge fund''A financial History of the United States Volume II: 1970–2001'', Jerry W. Markham, Chapter 5: "Bank Consolidation", M. E. Sharpe, Inc., 2002 based in Greenwich ...

rosacea
,
weight gain Weight gain is an increase in body weight Human body weight refers to a person's mass or weight. Strictly speaking, body weight is the measurement of weight without items located on the person. Practically though, body weight may be measured w ...

weight gain
,
urinary incontinence Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life Quality of life (QOL) is defined by the World Healt ...

urinary incontinence
,
urinary urgency Urinary urgency is a sudden, compelling urge to urination, urinate. MedNet defines it as “an immediate unstoppable urge to urinate, due to a sudden involuntary contraction of the muscular wall of the bladder.” It is often, though not necessar ...
, interrupted sleeping patterns, heavy
night sweat Night sweats, or also referred to as nocturnal hyperhidrosis (Hyperhidrosis - a medical term for excessive sweating + nocturnal - night) is the repeated occurrence of excessive sweating during sleep Sleep is a naturally recurring state of ...
s, and
hot flash Hot flashes (also known as hot flushes) are a form of flushing Flushing may refer to: Places * Flushing, Cornwall, a village in the United Kingdom * Flushing, Queens, New York City ** Flushing Bay, a bay off the north shore of Queens ** Flushi ...
es.


Mood and memory effects

Psychological symptoms include
anxiety Anxiety is an emotion Emotions are mental state, psychological states brought on by neurophysiology, neurophysiological changes, variously associated with thoughts, feelings, behavioural responses, and a degree of pleasure or suffering, disp ...

anxiety
, poor memory, inability to concentrate, depressive mood,
irritability Irritability is the excitatory ability that living organisms In biology Biology is the natural science that studies life and living organisms, including their anatomy, physical structure, Biochemistry, chemical processes, Molecular bi ...
,
mood swing A mood swing is an extreme or rapid change in mood. Such mood swings can play a positive part in promoting problem solving and in producing flexible forward planning. However, when mood swings are so strong that they are disruptive, they may be ...
s, and less interest in sexual activity. Menopause-related cognitive impairment can be confused with the
mild cognitive impairment Mild cognitive impairment (MCI) is a neurocognitive disorder which involves cognitive impairments beyond those expected based on an individual's age and education but which are not significant enough to interfere with instrumental activities of d ...
that precedes
dementia Dementia manifests as a set of related symptoms, which usually surface when the brain is damaged by injury or disease. The symptoms Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or ...
. Tentative evidence has found that forgetfulness affects about half of menopausal women and is probably caused by the effects of declining estrogen levels on the brain, or perhaps by reduced blood flow to the brain during
hot flash Hot flashes (also known as hot flushes) are a form of flushing Flushing may refer to: Places * Flushing, Cornwall, a village in the United Kingdom * Flushing, Queens, New York City ** Flushing Bay, a bay off the north shore of Queens ** Flushi ...
es.


Long-term effects

Menopause confers: *A possible but contentious increased risk of
atherosclerosis Atherosclerosis is a disease in which the wall of the artery An artery (plural arteries) () is a blood vessel The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels tr ...

atherosclerosis
. The risk of
acute myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow Hemodynamics American and British English spelling differences#ae and oe, or haemodynamics are the Fluid dynamics, dynamics of blood flow. The circulatory sys ...
and other
cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart The heart is a cardiac muscle, muscular Organ (biology), organ in most animals, which pumps blood through the blood vessels of the circulatory system. The pumped ...
s rises sharply after menopause, but the risk can be reduced by managing risk factors, such as tobacco smoking, hypertension, increased
blood lipidBlood lipids (or blood fats) are lipids In biology Biology is the natural science that studies life and living organisms, including their anatomy, physical structure, Biochemistry, chemical processes, Molecular biology, molecular interaction ...
s and body weight. *Increased risk of
osteopenia Osteopenia, preferably known as "low bone mass" or "low bone density", is a condition in which bone mineral density is low. Because their bones are weaker, people with osteopenia may have a higher risk of fractures, and some people may go on to deve ...
,
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone massImage:Bone density scanner.jpg, A scanner used to measure bone density using dual energy X-ray absorptiometry Bone density, or bone mineral density (BMD), is the amount ...
, and accelerated lung function decline. Women who experience menopause before 45 years of age have an increased risk of
heart disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina pectoris, angina and myocardial infarction (commonly known as a heart attack). Other CVDs inc ...
, death, and impaired lung function.


Causes

Menopause can be induced or occur naturally. Induced menopause occurs as a result of medical treatment such as
chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment Cancer Cancer is a group of diseases A disease is a particular abnormal condition that negatively affects the structure or f ...

chemotherapy
,
radiotherapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation Ionizing radiation (or ionising radiation), including nuclear radiation, consists of subatomic particles or electromagnetic waves that h ...
,
oophorectomy Oophorectomy (; from Greek , , 'egg-bearing' and , , 'a cutting out of') is the surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical or dental specia ...
, or complications of
tubal ligation Tubal ligation (commonly known as having one's "tubes tied") is a surgical procedure for female sterilization in which the fallopian tube The Fallopian tubes, also known as uterine tubes, salpinges (singular salpinx), or oviducts, are tubes that ...
,
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovary, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynaecology, gynecologist, a h ...

hysterectomy
, unilateral or bilateral salpingo-oophorectomy or
leuprorelin Leuprorelin, also known as leuprolide, is a manufactured version of a hormone A hormone (from the Greek participle , "setting in motion") is any member of a class of signaling molecules in multicellular organisms, that are transported to dist ...

leuprorelin
usage.


Age

Menopause typically occurs between 48 and 52 years of age. According to various data, more than 85% of women have their last period between the ages of 46-54 (median 49). 2% of women under the age of 40, 5% between the ages of 40-45 and the same number between the ages of 55-58 have the last bleeding.. The average age of the last period in the United States is 51 years, in the United Kingdom is 52 years, in Ireland is 50 years and in Australia is 51 years. In
India India, officially the Republic of India (Hindi Hindi (Devanagari: , हिंदी, ISO 15919, ISO: ), or more precisely Modern Standard Hindi (Devanagari: , ISO 15919, ISO: ), is an Indo-Aryan language spoken chiefly in Hindi Belt, ...

India
and the
Philippines The Philippines (; fil, Pilipinas, links=no), officially the Republic of the Philippines ( fil, Republika ng Pilipinas, links=no), * bik, Republika kan Filipinas * ceb, Republika sa Pilipinas * cbk, República de Filipinas * hil, Republ ...

Philippines
, the median age of natural menopause is considerably earlier, at 44 years. The menopausal transition or perimenopause leading up to menopause usually lasts 7 years (sometimes as long as 14 years). In rare cases, a woman's ovaries stop working at a very early age, ranging anywhere from the age of
puberty Puberty is the process of physical changes through which a child Biologically, a child (plural children) is a human Humans (''Homo sapiens'') are the most abundant and widespread species In biology Biology is the natur ...

puberty
to age 40. This is known as
premature ovarian failure Primary ovarian The ovary is an organ found in the female reproductive system that produces an ovum. When released, this travels down the fallopian tube into the uterus, where it may become fertilized by a sperm. There is an ovary () found on ...
and affects 1 to 2% of women by age 40. Undiagnosed and untreated
coeliac disease Coeliac disease or celiac disease is a long-term autoimmune disorder An autoimmune disease is a condition arising from an abnormal immune response to a functioning body part. There are at least 80 types of autoimmune diseases. Nearly any bo ...
is a risk factor for early menopause. Coeliac disease can present with several non-gastrointestinal symptoms, in the absence of gastrointestinal symptoms, and most cases escape timely recognition and go undiagnosed, leading to a risk of long-term complications. A strict
gluten-free diet A gluten-free diet (GFD) is a nutritional plan that strictly excludes gluten, which is a mixture of proteins found in wheat (and all of its species and hybrids, such as spelt, Khorasan wheat, kamut, and triticale), as well as barley, rye, and oa ...
reduces the risk. Women with early diagnosis and treatment of coeliac disease present a normal duration of fertile life span. Women who have undergone
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovary, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynaecology, gynecologist, a h ...

hysterectomy
with ovary conservation go through menopause on average 3.7 years earlier than the expected age. Other factors that can promote an earlier onset of menopause (usually 1 to 3 years early) are smoking cigarettes or being extremely thin.


Premature ovarian failure

Premature ovarian failure Primary ovarian The ovary is an organ found in the female reproductive system that produces an ovum. When released, this travels down the fallopian tube into the uterus, where it may become fertilized by a sperm. There is an ovary () found on ...
(POF) is when the ovaries stop functioning before the age of 40 years. It is diagnosed or confirmed by high blood levels of
follicle stimulating hormone Follicle-stimulating hormone (FSH) is a gonadotropin Gonadotropins are glycoprotein hormones secreted by gonadotropic cells of the anterior pituitary A major Organ (anatomy), organ of the endocrine system, the anterior pituitary (also call ...
(FSH) and
luteinizing hormone Luteinizing hormone (LH, also known as lutropin and sometimes lutrophin) is a hormone A hormone (from the Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic R ...
(LH) on at least three occasions at least four weeks apart. Known causes of premature ovarian failure include
autoimmune disorder An autoimmune disease is a condition arising from an abnormal immune response to a functioning body part. There are at least 80 types of autoimmune diseases. Nearly any body part can be involved. Common symptoms include low grade fever and fatigue ...
s,
thyroid The thyroid, or thyroid gland, is an endocrine gland Endocrine glands are ductless glands of the endocrine system The endocrine system is a messenger system comprising feedback loops of the hormones released by internal glands of an organi ...

thyroid
disease,
diabetes mellitus Diabetes mellitus, commonly known as just diabetes, is a group of metabolic disorders characterized by a hyperglycemia, high blood sugar level over a prolonged period of time. Symptoms often include frequent urination, Polydipsia, increased th ...
,
chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment Cancer Cancer is a group of diseases A disease is a particular abnormal condition that negatively affects the structure or f ...

chemotherapy
, being a carrier of the
fragile X syndrome Fragile X syndrome (FXS) is a genetic disorder A genetic disorder is a health problem caused by one or more abnormalities in the genome In the fields of molecular biology and genetics Genetics is a branch of biology concerned ...
gene, and
radiotherapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation Ionizing radiation (or ionising radiation), including nuclear radiation, consists of subatomic particles or electromagnetic waves that h ...
. However, in about 50–80% of spontaneous cases of premature ovarian failure, the cause is unknown, i.e., it is generally
idiopathic An idiopathic disease is any disease with an unknown cause or mechanism of apparent wikt:spontaneous, spontaneous origin. From Ancient Greek, Greek ἴδιος ''idios'' "one's own" and πάθος ''pathos'' "suffering", ''idiopathy'' means approxi ...
.Kalantaridou SN, Davis SR, Nelson LM. ''Endocrinology Metabolism Clinics of North America'', December 1998; 27(4) 989–1006. Women who have a functional disorder affecting the reproductive system (e.g.,
endometriosis Endometriosis is a disease of the female reproductive system in which cells Cell most often refers to: * Cell (biology), the functional basic unit of life Cell may also refer to: Closed spaces * Monastic cell, a small room, hut, or cave in ...

endometriosis
,
polycystic ovary syndrome Polycystic ovary syndrome, or PCOS, is the most common endocrine The endocrine system is a messenger system comprising feedback loops of the hormone A hormone (from the Greek Greek may refer to: Greece Anything of, from, or related to G ...
, cancer of the reproductive organs) can go into menopause at a younger age than the normal timeframe. The functional disorders often significantly speed up the menopausal process. An early menopause can be related to
cigarette A cigarette is a narrow cylinder containing burnable material, typically tobacco, that is rolled into Rolling paper, thin paper for smoking. The cigarette is ignited at one end, causing it to smolder; the resulting smoke is orally inhaled via ...

cigarette
smoking, higher
body mass index Body mass index (BMI) is a value derived from the mass (Mass versus weight, weight) and height of a person. The BMI is defined as the human body weight, body mass divided by the square (algebra), square of the human height, body height, and is ...

body mass index
, racial and ethnic factors, illnesses, and the surgical removal of the ovaries, with or without the removal of the uterus.Bucher, et al. 1930 Rates of premature menopause have been found to be significantly higher in fraternal and identical
twins Twins are two offspring In biology, offspring are the young creation of living organisms, produced either by a Asexual reproduction, single organism or, in the case of sexual reproduction, two organisms. Collective offspring may be known as a ...

twins
; approximately 5% of twins reach menopause before the age of 40. The reasons for this are not completely understood. Transplants of ovarian tissue between identical twins have been successful in restoring fertility.


Surgical menopause

Menopause can be surgically induced by bilateral
oophorectomy Oophorectomy (; from Greek , , 'egg-bearing' and , , 'a cutting out of') is the surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical or dental specia ...
(removal of ovaries), which is often, but not always, done in conjunction with removal of the Fallopian tubes (salpingo-oophorectomy) and uterus (hysterectomy). Cessation of menses as a result of removal of the ovaries is called "surgical menopause". Surgical treatments, such as the removal of ovaries, might cause periods to stop altogether. The sudden and complete drop in hormone levels usually produces extreme withdrawal symptoms such as hot flashes, etc. The symptoms of early menopause may be more severe. Removal of the uterus ''without'' removal of the ovaries does ''not'' directly cause menopause, although pelvic surgery of this type can often precipitate a somewhat earlier menopause, perhaps because of a compromised blood supply to the ovaries.. The time between surgery and possible early menopause is due to the fact that ovaries are still producing hormones.


Mechanism

The menopausal transition, and postmenopause itself, is a natural change, not usually a disease state or a disorder. The main cause of this transition is the natural depletion and aging of the finite amount of
oocytes An oocyte (, ), oöcyte, ovocyte, or rarely ocyte, is a female gametocyte or germ cell involved in reproduction Reproduction (or procreation or breeding) is the biological process by which new individual organism In biology, an orga ...
(
ovarian reserve 420px, Model of ovarian reserve from conception to the menopauseOvarian reserve is a term that is used to determine the capacity of the ovary to provide egg cells that are capable of fertilization resulting in a healthy and successful pregnancy. Wit ...
). This process is sometimes accelerated by other conditions and is known to occur earlier after a wide range of gynecologic procedures such as
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovary, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynaecology, gynecologist, a h ...

hysterectomy
(with and without
ovariectomy Oophorectomy (; from Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic Republic, is a country located in Southeast Europe. Its population is approximately 10.7 m ...
),
endometrial ablation Endometrial ablation is a surgical procedure that is used to remove (ablate Ablation is removal or destruction of material from an object by vaporization, chipping, or other erosion, erosive processes. Examples of ablative materials are describe ...
and uterine artery embolisation. The depletion of the ovarian reserve causes an increase in circulating
follicle-stimulating hormone Follicle-stimulating hormone (FSH) is a gonadotropin Gonadotropins are glycoprotein hormones secreted by gonadotropic cells of the anterior pituitary A major Organ (anatomy), organ of the endocrine system, the anterior pituitary (also call ...
(FSH) and
luteinizing hormone Luteinizing hormone (LH, also known as lutropin and sometimes lutrophin) is a hormone A hormone (from the Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic R ...
(LH) levels because there are fewer
oocyte An oocyte (, ), oöcyte, ovocyte, or rarely ocyte, is a female gametocyte A gametocyte is a eukaryotic germ cell that divides by mitosis into other gametocytes or by meiosis into gametids during gametogenesis. Male gametocytes are called ''sperm ...
s and follicles responding to these hormones and producing estrogen. The transition has a variable degree of effects. The stages of the menopause transition have been classified according to a woman's reported bleeding pattern, supported by changes in the pituitary
follicle-stimulating hormone Follicle-stimulating hormone (FSH) is a gonadotropin Gonadotropins are glycoprotein hormones secreted by gonadotropic cells of the anterior pituitary A major Organ (anatomy), organ of the endocrine system, the anterior pituitary (also call ...
(FSH) levels. In younger women, during a normal
menstrual cycle The menstrual cycle is a series of natural changes in hormone A hormone (from the Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic Republic, is a country l ...

menstrual cycle
the ovaries produce
estradiol Estradiol (E2), also spelled oestradiol, is an estrogen steroid hormone and the major female sex hormone. It is involved in the regulation of the estrous cycle, estrous and menstrual cycle, menstrual female reproductive cycles. Estradiol is resp ...

estradiol
,
testosterone Testosterone is the primary sex hormone and anabolic steroid in males. In humans, testosterone plays a key role in the development of Male reproductive system, male reproductive tissues such as testes and prostate, as well as promoting secondar ...
and
progesterone Progesterone (P4) is an endogenous Endogenous substances and processes are those that originate from within a system such as an organism, Tissue (biology), tissue, or Cell (biology), cell. Endogenous substances and processes contrast with exo ...

progesterone
in a cyclical pattern under the control of FSH and
luteinizing hormone Luteinizing hormone (LH, also known as lutropin and sometimes lutrophin) is a hormone A hormone (from the Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic R ...
(LH), which are both produced by the
pituitary gland upright=1.2, The Hypothalamus-Pituitary Complex. In vertebrate Vertebrates () comprise all species of animal Animals (also called Metazoa) are multicellular eukaryotic organisms that form the Kingdom (biology), biological kingd ...

pituitary gland
. During perimenopause (approaching menopause),
estradiol Estradiol (E2), also spelled oestradiol, is an estrogen steroid hormone and the major female sex hormone. It is involved in the regulation of the estrous cycle, estrous and menstrual cycle, menstrual female reproductive cycles. Estradiol is resp ...

estradiol
levels and patterns of production remain relatively unchanged or may increase compared to young women, but the cycles become frequently shorter or irregular. The often observed increase in estrogen is presumed to be in response to elevated FSH levels that, in turn, is hypothesized to be caused by decreased feedback by
inhibin Activin and inhibin are two closely related protein Proteins are large biomolecules or macromolecules that are comprised of one or more long chains of amino acid residue (biochemistry), residues. Proteins perform a vast array of functions ...
. Similarly, decreased inhibin feedback after
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovary, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynaecology, gynecologist, a h ...

hysterectomy
is hypothesized to contribute to increased ovarian stimulation and earlier menopause. The menopausal transition is characterized by marked, and often dramatic, variations in FSH and estradiol levels. Because of this, measurements of these hormones are ''not'' considered to be reliable guides to a woman's exact menopausal status. Menopause occurs because of the sharp decrease of estradiol and progesterone production by the ovaries. After menopause, estrogen continues to be produced mostly by
aromatase Aromatase, also called estrogen synthetase or estrogen synthase, is an enzyme Enzymes () are proteins that act as biological catalysts (biocatalysts). Catalysts accelerate chemical reactions. The molecules upon which enzymes may act are calle ...
in fat tissues and is produced in small amounts in many other tissues such as ovaries, bone, blood vessels, and the brain where it acts locally. The substantial fall in circulating estradiol levels at menopause impacts many tissues, from brain to skin. In contrast to the sudden fall in estradiol during menopause, the levels of total and free testosterone, as well as dehydroepiandrosterone sulfate (DHEAS) and
androstenedione Androstenedione, or 4-androstenedione (abbreviated as A4 or Δ4-dione), also known as androst-4-ene-3,17-dione, is an endogenous weak androgen An androgen (from Greek ''andr-'', the stem of the word meaning "man") is any natural or syntheti ...

androstenedione
appear to decline more or less steadily with age. An effect of natural menopause on circulating
androgen An androgen (from Greek ''andr-'', the stem of the word meaning "man") is any natural or synthetic steroid hormone A steroid hormone is a steroid , hypothetical a steroid with 32 carbon atoms. Its core ring system (ABCD), composed of 17 c ...
levels has not been observed. Thus specific tissue effects of natural menopause cannot be attributed to loss of androgenic hormone production. Hot flashes and other vasomotor symptoms accompany the menopausal transition. While many sources continue to claim that hot flashes during the menopausal transition are caused by low estrogen levels, this assertion was shown incorrect in 1935, and, in most cases, hot flashes are observed despite elevated estrogen levels. The exact cause of these symptoms is not yet understood, possible factors considered are higher and erratic variation of estradiol level during the cycle, elevated FSH levels which may indicate hypothalamic dysregulation perhaps caused by missing feedback by inhibin. It has been also observed that the vasomotor symptoms differ during early perimenopause and late menopausal transition and it is possible that they are caused by a different mechanism. Long-term effects of menopause may include
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone massImage:Bone density scanner.jpg, A scanner used to measure bone density using dual energy X-ray absorptiometry Bone density, or bone mineral density (BMD), is the amount ...
,
vaginal atrophy Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to not enough estrogen Estrogen, or oestrogen, is a category of sex hormone responsible for the development and regulation of the female reproductive system ...
as well as changed metabolic profile resulting in cardiac risks.


Ovarian aging

Decreased inhibin feedback after
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovary, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynaecology, gynecologist, a h ...

hysterectomy
is hypothesized to contribute to increased ovarian stimulation and earlier menopause. Hastened ovarian aging has been observed after
endometrial ablation Endometrial ablation is a surgical procedure that is used to remove (ablate Ablation is removal or destruction of material from an object by vaporization, chipping, or other erosion, erosive processes. Examples of ablative materials are describe ...
. While it is difficult to prove that these surgeries are causative, it has been hypothesized that the
endometrium The endometrium is the inner epithelial Epithelium is one of the four basic types of animal Tissue (biology), tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly pac ...

endometrium
may be producing endocrine factors contributing to the endocrine feedback and regulation of the ovarian stimulation. Elimination of these factors contributes to faster depletion of the ovarian reserve. Reduced blood supply to the ovaries that may occur as a consequence of hysterectomy and uterine artery embolisation has been hypothesized to contribute to this effect. Impaired
DNA Deoxyribonucleic acid (; DNA) is a molecule A scanning tunneling microscopy image of pentacene molecules, which consist of linear chains of five carbon rings. A molecule is an electrically Electricity is the set of physical ...

DNA
repair mechanisms may contribute to earlier depletion of the ovarian reserve during aging. As women age, double-strand breaks accumulate in the DNA of their primordial follicles. Primordial follicles are immature primary oocytes surrounded by a single layer of granulosa cells. An enzyme system is present in oocytes that ordinarily accurately repairs DNA double-strand breaks. This repair system is called "
homologous recombination Homologous recombination is a type of genetic recombination in which genetic information is exchanged between two similar or identical molecules of double-stranded or single-stranded nucleic acids (usually DNA as in Cell (biology), cellular organi ...

homologous recombination
al repair", and it is especially effective during meiosis. Meiosis is the general process by which germ cells are formed in all sexual eukaryotes; it appears to be an adaptation for efficiently removing damages in germ line DNA. Human primary oocytes are present at an intermediate stage of meiosis, termed prophase I (see
Oogenesis Oogenesis, ovogenesis, or oögenesis is the differentiation of the ovum The egg cell, or ovum (plural ova), is the female reproductive Reproduction (or procreation or breeding) is the biological process by which new individual organisms ...

Oogenesis
). Expression of four key DNA repair genes that are necessary for homologous recombinational repair during meiosis (BRCA1, MRE11, Rad51, and ATM) decline with age in oocytes. This age-related decline in ability to repair DNA double-strand damages can account for the accumulation of these damages, that then likely contributes to the depletion of the ovarian reserve.


Diagnosis

Ways of assessing the impact on women of some of these menopause effects, include the Greene climacteric scale questionnaire, the Cervantes scale and the Menopause rating scale.


Premenopause

Premenopause is a term used to mean the years leading up to the last period, when the levels of reproductive hormones are becoming more variable and lower, and the effects of hormone withdrawal are present. Premenopause starts some time before the monthly cycles become noticeably irregular in timing.


Perimenopause

The term "perimenopause", which literally means "around the menopause", refers to the menopause transition years before the date of the final episode of flow. According to the North American Menopause Society, this transition can last for four to eight years. The Centre for Menstrual Cycle and Ovulation Research describes it as a six- to ten-year phase ending 12 months after the last menstrual period. During perimenopause,
estrogen Estrogens or oestrogens, are a class of natural or synthetic s responsible for the development and regulation of the female and s. There are three major estrogens that have estrogenic hormonal activity: (E1), (E2), and (E3). Estradiol, an ...

estrogen
levels average about 20–30% higher than during premenopause, often with wide fluctuations. These fluctuations cause many of the physical changes during perimenopause as well as menopause, especially during the last 1–2 years of perimenopause (before menopause). Some of these changes are
hot flash Hot flashes (also known as hot flushes) are a form of flushing Flushing may refer to: Places * Flushing, Cornwall, a village in the United Kingdom * Flushing, Queens, New York City ** Flushing Bay, a bay off the north shore of Queens ** Flushi ...
es, night sweats, difficulty sleeping, mood swings,
vaginal dryness Vaginal lubrication is a naturally produced fluid that lubricates a vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vulva to the cervix. The outer vaginal opening is nor ...
or
atrophy Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations (which can destroy the gene to build up the organ), poor nourishment, poor circulatory system, circulation, loss of hormone, hormonal sup ...
,
incontinence Incontinence or Incontinent may refer to: *Fecal incontinence, the involuntary excretion of bowel contents *Urinary incontinence, the involuntary excretion of urine * Lack of moderation or self-control, especially related to sexual desire - see In ...

incontinence
,
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone massImage:Bone density scanner.jpg, A scanner used to measure bone density using dual energy X-ray absorptiometry Bone density, or bone mineral density (BMD), is the amount ...
, and heart disease. During this period,
fertility Fertility is the capability to produce offspring through reproduction following the onset of sexual maturity. The fertility rate is the average number of children born by a female during her lifetime and is quantified Demography, demographicall ...
diminishes but is not considered to reach zero until the official date of menopause. The official date is determined retroactively, once 12 months have passed after the last appearance of menstrual blood. The menopause transition typically begins between 40 and 50 years of age (average 47.5). The duration of perimenopause may be for up to eight years. Women will often, but not always, start these transitions (perimenopause and menopause) about the same time as their mother did. In some women, menopause may bring about a sense of loss related to the end of fertility. In addition, this change often occurs when other stressors may be present in a woman's life: * Caring for, and/or the death of, elderly parents * Empty nest syndrome when children leave home * The birth of grandchildren, which places people of "middle age" into a new category of "older people" (especially in cultures where being older is a state that is looked down on) Some research appears to show that
melatonin Melatonin is a hormone A hormone (from the Greek#REDIRECT Greek Greek may refer to: Greece Anything of, from, or related to Greece Greece ( el, Ελλάδα, , ), officially the Hellenic Republic, is a country located in Southeast E ...

melatonin
supplementation in perimenopausal women can improve thyroid function and gonadotropin levels, as well as restoring fertility and menstruation and preventing depression associated with menopause.


Postmenopause

The term "postmenopausal" describes women who have not experienced any menstrual flow for a minimum of 12 months, assuming that they have a
uterus The uterus (from Latin "uterus", plural ''uteri'') or womb () is the main female hormone-responsive, sex organ, secondary sex organ of the reproductive system in humans and most other mammals. Things occurring in the uterus are described with t ...

uterus
and are not pregnant or . In women without a uterus, menopause or postmenopause can be identified by a blood test showing a very high FSH level. Thus postmenopause is the time in a woman's life that takes place after her last period or, more accurately, after the point when her ovaries become inactive. The reason for this delay in declaring postmenopause is because periods are usually erratic at this time of life. Therefore, a reasonably long stretch of time is necessary to be sure that the cycling has ceased. At this point a woman is considered infertile; however, the possibility of becoming pregnant has usually been very low (but not quite zero) for a number of years before this point is reached. A woman's reproductive hormone levels continue to drop and fluctuate for some time into post-menopause, so hormone withdrawal effects such as hot flashes may take several years to disappear. A period-like flow during postmenopause, even spotting, may be a sign of
endometrial cancer Endometrial cancer is a cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumor A benign tumor is a mass of cells Cell ...
.


Management

Perimenopause is a natural stage of life. It is not a disease or a disorder. Therefore, it does not automatically require any kind of medical treatment. However, in those cases where the physical, mental, and emotional effects of perimenopause are strong enough that they significantly disrupt the life of the woman experiencing them, palliative medical therapy may sometimes be appropriate.


Hormone replacement therapy

In the context of the menopause,
hormone replacement therapy Hormone replacement therapy (HRT), also known as menopausal hormone therapy or postmenopausal hormone therapy, is a form of hormone therapy Hormone therapy or hormonal therapy is the use of hormones in medical treatment. Treatment with hormone a ...
(HRT) is the use of
estrogen Estrogens or oestrogens, are a class of natural or synthetic s responsible for the development and regulation of the female and s. There are three major estrogens that have estrogenic hormonal activity: (E1), (E2), and (E3). Estradiol, an ...

estrogen
in women without a uterus and estrogen plus
progestin A progestogen, also referred to as a progestagen, gestagen, or gestogen, is a type of medication A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug Uncoated tablets, consist ...
in women who have an intact uterus. HRT may be reasonable for the treatment of menopausal symptoms, such as hot flashes. It is the most effective treatment option, especially when delivered as a skin patch. Its use, however, appears to increase the risk of
stroke A stroke is a medical condition A disease is a particular abnormal condition that negatively affects the structure or function (biology), function of all or part of an organism, and that is not due to any immediate external injury. Di ...

stroke
s and
blood clots A thrombus, colloquially called a blood clot, is the final product of the blood coagulation Coagulation, also known as clotting, is the process by which blood Blood is a body fluid in humans and other animals that delivers necessary sub ...
. When used for menopausal symptoms some recommend it be used for the shortest time possible and at the lowest dose possible. Evidence to support long-term use, however, is poor. It also appears effective for preventing bone loss and osteoporotic fracture, but it is generally recommended only for women at significant risk for whom other therapies are unsuitable. HRT may be unsuitable for some women, including those at increased risk of cardiovascular disease, increased risk of thromboembolic disease (such as those with obesity or a history of venous thrombosis) or increased risk of some types of cancer. There is some concern that this treatment increases the risk of breast cancer. Adding
testosterone Testosterone is the primary sex hormone and anabolic steroid in males. In humans, testosterone plays a key role in the development of Male reproductive system, male reproductive tissues such as testes and prostate, as well as promoting secondar ...
to hormone therapy has a positive effect on sexual function in postmenopausal women, although it may be accompanied by hair growth, acne and a reduction in high-density lipoprotein (HDL) cholesterol. These side effects diverge depending on the doses and methods of using testosterone.


Selective estrogen receptor modulators

SERMs are a category of drugs, either synthetically produced or derived from a botanical source, that act selectively as agonists or antagonists on the
estrogen receptor Estrogen receptors (ERs) are a group of proteins found inside cell (biology), cells. They are receptor (biochemistry), receptors that are activated by the hormone estrogen (17β-estradiol). Two classes of ER exist: nuclear estrogen receptors (ER ...
s throughout the body. The most commonly prescribed SERMs are
raloxifene Raloxifene, sold under the brand name Evista among others, is a medication used to prevent and treat osteoporosis in postmenopausal women and those on glucocorticoids. For osteoporosis it is less preferred than bisphosphonates. It is also used t ...

raloxifene
and
tamoxifen Tamoxifen, sold under the brand name Nolvadex among others, is a selective estrogen receptor modulator used to prevent breast cancer Breast cancer is cancer Cancer is a group of diseases involving abnormal cell growth with the poten ...

tamoxifen
. Raloxifene exhibits oestrogen agonist activity on bone and lipids, and antagonist activity on breast and the endometrium. Tamoxifen is in widespread use for treatment of hormone sensitive breast cancer. Raloxifene prevents vertebral fractures in postmenopausal, osteoporotic women and reduces the risk of invasive breast cancer.


Other medications

Some of the
SSRIs Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs increase the extracellul ...
and SNRIs appear to provide some relief from vasomotor symptoms. Low dose
paroxetine Paroxetine, sold under the brand names Paxil and Seroxat among others, is an antidepressant Antidepressants are medications used to treat major depressive disorder, some anxiety disorders, some chronic pain conditions, and to help manage som ...

paroxetine
is the only non-hormonal medication that was
FDA The United States The United States of America (USA), commonly known as the United States (U.S. or US), or America, is a country Contiguous United States, primarily located in North America. It consists of 50 U.S. state, states, a Wash ...
-approved to treat moderate-to-severe vasomotor symptoms associated with menopause as of 2016. They may, however, be associated with appetite and sleeping problems, constipation and nausea.
Gabapentin Gabapentin, sold under the brand name Neurontin among others, is an anticonvulsant Anticonvulsants (also commonly known as antiepileptic drugs or as antiseizure drugs) are a diverse group of pharmacological agents used in the treatment of epil ...

Gabapentin
or
clonidine Clonidine, sold as the brand name Catapres among others, is a medication used to treat hypertension, high blood pressure, attention deficit hyperactivity disorder, drug withdrawal (Alcohol withdrawal syndrome, alcohol, Opioid withdrawal, opioids, ...

clonidine
may help but do not work as well as hormone therapy. Gabapentin can decrease the amount of hot flashes. Side effects associated with its use include drowsiness and headaches. Clonidine is used to improve vasomotor symptoms and may be associated with constipation, dizziness, nausea and sleeping problems.


Therapy

One review found
mindfulness Mindfulness is the practice of purposely bringing one's attention in the present moment without evaluation,Mindfulness Training as a Clinical Intervention: A Conceptual and Empirical Review, by Ruth A. Baer, available at http://www.wisebrain.or ...

mindfulness
and
cognitive behavioural therapy Cognitive behavioral therapy (CBT) is a Psychosocial, psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviors, improving e ...
decreases the amount women are affected by hot flushes. Another review found not enough evidence to make a conclusion. A 2018 study found that 85% of study participants reported reduced hot flashes and night sweats when using a climate control system in their beds.


Exercise

Exercise has been thought to reduce postmenopausal symptoms through the increase of endorphin levels, which decrease as estrogen production decreases. Additionally, high is a risk factor for vasomotor symptoms in particular. However, there is insufficient evidence to support the benefits of weight loss for symptom management. There are mixed perspectives on the benefits of physical exercise. While one review found that there was a lack of quality evidence supporting a benefit of exercise, another review recommended regular healthy exercise to reduce comorbidities, improve mood and anxiety symptoms, enhance cognition, and decrease the risk of fractures. Yoga may help with postmenopausal symptoms similar to other exercise. There is insufficient evidence to suggest that relaxation techniques reduce menopausal symptoms.


Alternative medicine

There is no evidence of consistent benefit of alternative therapies for menopausal symptoms despite their popularity. The effect of soy isoflavones on menopausal symptoms is promising for reduction of hot flashes and vaginal dryness. Evidence does not support a benefit from
phytoestrogensA phytoestrogen is a plant-derived xenoestrogen (see estrogen Estrogen, or oestrogen, is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are ...

phytoestrogens
such as coumestrol, femarelle, or the non-phytoestrogen black cohosh. As of 2011 there is no support for herbal or dietary supplements in the prevention or treatment of the mental changes that occur around menopause. Hypnosis may reduce the severity of hot flashes. In addition, relaxation training with at-home relaxation audiotapes such as deep breathing, paced respiration, and guided imagery may have positive effects on relaxing muscles and reducing stress. There is no evidence to support the efficacy of acupuncture as a management for menopausal symptoms. A 2016 Cochrane review found not enough evidence to show a difference between Chinese herbal medicine and placebo for the vasomotor symptoms.


Other efforts

*Lack of lubrication is a common problem during and after perimenopause. Vaginal moisturizers can help women with overall dryness, and lubricants can help with lubrication difficulties that may be present during intercourse. It is worth pointing out that moisturizers and lubricants are different products for different issues: some women complain that their genitalia are uncomfortably dry all the time, and they may do better with moisturizers. Those who need only lubricants do well using them only during intercourse. *Low-dose prescription vaginal estrogen products such as estrogen creams are generally a safe way to use estrogen topically, to help vaginal thinning and dryness problems (see
vaginal atrophy Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to not enough estrogen Estrogen, or oestrogen, is a category of sex hormone responsible for the development and regulation of the female reproductive system ...
) while only minimally increasing the levels of estrogen in the bloodstream. *In terms of managing hot flashes, lifestyle measures such as drinking cold liquids, staying in cool rooms, using fans, removing excess clothing, and avoiding hot flash triggers such as hot drinks, spicy foods, etc., may partially supplement (or even obviate) the use of medications for some women. *Individual counseling or support groups can sometimes be helpful to handle sad, depressed, anxious or confused feelings women may be having as they pass through what can be for some a very challenging transition time. *Osteoporosis can be minimized by smoking cessation, adequate vitamin D intake and regular weight-bearing exercise. The bisphosphonate drug alendronate may decrease the risk of a fracture, in women that have both bone loss and a previous fracture and less so for those with just osteoporosis. *A surgical procedure where a part of one of the ovaries is removed earlier in life and frozen and then over time thawed and returned to the body has been tried. While at least 11 women have undergone the procedure and paid over £6,000, there is no evidence it is safe or effective.


Society and culture

The cultural context within which a woman lives can have a significant impact on the way she experiences the menopausal transition. Menopause has been described as a subjective experience, with social and cultural factors playing a prominent role in the way menopause is experienced and perceived. The word menopause was invented by French doctors at the beginning of the nineteenth century. Some of them noted that peasant women had no complaints about the end of menses, while urban middle-class women had many troubling symptoms. Doctors at this time considered the symptoms to be the result of urban lifestyles of sedentary behaviour, alcohol consumption, too much time indoors, and over-eating, with a lack of fresh fruit and vegetables. Within the United States, social location affects the way women perceive menopause and its related biological effects. Research indicates that whether a woman views menopause as a medical issue or an expected life change is correlated with her socio-economic status. The paradigm within which a woman considers menopause influences the way she views it: Women who understand menopause as a medical condition rate it significantly more negatively than those who view it as a life transition or a symbol of aging. Ethnicity and geography play roles in the experience of menopause. American women of different ethnicities report significantly different types of menopausal effects. One major study found Caucasian women most likely to report what are sometimes described as psychosomatic symptoms, while African-American women were more likely to report vasomotor symptoms. It seems that Japanese women experience menopause effects, or ''konenki'', in a different way from American women. Japanese women report lower rates of hot flashes and night sweats; this can be attributed to a variety of factors, both biological and social. Historically, konenki was associated with wealthy middle-class housewives in Japan, i.e., it was a "luxury disease" that women from traditional, inter-generational rural households did not report. Menopause in Japan was viewed as a symptom of the inevitable process of aging, rather than a "revolutionary transition", or a "deficiency disease" in need of management. In Japanese culture, reporting of vasomotor symptoms has been on the increase, with research conducted by Melissa Melby in 2005 finding that of 140 Japanese participants, hot flashes were prevalent in 22.1%. This was almost double that of 20 years prior.Lock, M. & Nguyen, V. (2010) ''An Anthropology of Biomedicine'', Chapter 4 "Local Biologies and Human Difference" (pp. 84–89), West Sussex, Wiley-Blackwell Whilst the exact cause for this is unknown, possible contributing factors include significant dietary changes, increased medicalisation of middle-aged women and increased media attention on the subject. However, reporting of vasomotor symptoms is still significantly lower than North America. Additionally, while most women in the United States apparently have a negative view of menopause as a time of deterioration or decline, some studies seem to indicate that women from some Asian cultures have an understanding of menopause that focuses on a sense of liberation and celebrates the freedom from the risk of pregnancy. Diverging from these conclusions, one study appeared to show that many American women "experience this time as one of liberation and self-actualization".


Etymology

Menopause literally means the "end of monthly cycles" (the end of monthly periods or
menstruation Menstruation (also known as a period and many other Colloquialism, colloquial terms) is the regular discharge of blood and Mucous membrane, mucosal tissue from the endometrium, inner lining of the uterus through the vagina. The menstrual cycl ...
), from the Greek word ''pausis'' ("pause") and ''mēn'' ("month"). This is a medical calque; the Greek word for menses is actually different. In Ancient Greek, the menses were described in the plural, ''ta emmēnia'', ("the monthlies"), and its modern descendant has been clipped to ''ta emmēna''. The Modern Greek medical term is ''emmenopausis'' in Katharevousa or ''emmenopausi'' in Demotic Greek. The word "menopause" was coined specifically for human females, where the end of fertility is traditionally indicated by the permanent stopping of monthly menstruations. However, menopause exists in some other animals, many of which do not have monthly menstruation; in this case, the term means a natural end to fertility that occurs before the end of the natural lifespan.


Evolutionary rationale

Few animals have a menopause: humans are joined by just four other species in which females live substantially longer than their ability to reproduce. The others are all cetaceans: beluga whales, narwhals, killer whales and short-finned pilot whales. Various theories have been suggested that attempt to suggest evolutionary benefits to the human species stemming from the cessation of women's reproductive capability before the end of their natural lifespan. Explanations can be categorized as adaptive and non-adaptive:


Non-adaptive hypotheses

The high cost of female investment in offspring may lead to physiological deteriorations that amplify susceptibility to becoming infertile. This hypothesis suggests the reproductive lifespan in humans has been optimized, but it has proven more difficult in females and thus their reproductive span is shorter. If this hypothesis were true, however, age at menopause should be negatively correlated with reproductive effort, and the available data do not support this. A recent increase in female longevity due to improvements in the standard of living and social care has also been suggested. It is difficult for selection, however, to favor aid to offspring from parents and grandparents. Irrespective of living standards, adaptive responses are limited by physiological mechanisms. In other words, senescence is programmed and regulated by specific genes.


Early human selection shadow

While it is fairly common for extant hunter-gatherers to live past age 50 provided that they survive childhood, fossil evidence shows that mortality in adults has decreased over the last 30,000 to 50,000 years and that it was extremely unusual for early ''Homo sapiens'' to live to age 50. This discovery has led some biologists to argue that there was no selection for or against menopause at the time at which the ancestor of all modern humans lived in Africa, suggesting that menopause is instead a random evolutionary effect of a selection shadow regarding aging in early ''Homo sapiens''. It is also argued that since the population fraction of post-menopausal women in early ''Homo sapiens'' was so low, menopause had no evolutionary effect on mate selection or social behaviors related to mate selection.


Adaptive hypotheses


"Survival of the fittest" hypothesis

This hypothesis suggests that younger mothers and offspring under their care will fare better in a difficult and predatory environment because a younger mother will be stronger and more agile in providing protection and sustenance for herself and a nursing baby. The various biological factors associated with menopause had the effect of male members of the species investing their effort with the most viable of potential female mates. One problem with this hypothesis is that we would expect to see menopause exhibited in the animal kingdom, and another problem is that in the case of extended child development, even a female who was relatively young, still agile, and attractive when producing a child would lose future support from her male partner due to him seeking out fertile mates when she reaches menopause while the child is still not independent. That would be counterproductive to the supposed adaptation of getting male support as a fertile female and ruin survival for children produced over much of the female's fertile and agile life, unless children were raised in ways that did not rely on support from a male partner which would eliminate that type of resource diverting selection anyway.


Young female preference hypothesis

The young female preference hypothesis proposes that changes in male preferences for younger mates allowed late-age acting fertility mutations to accumulate in females without any evolutionary penalty, giving rise to menopause. A computer model was constructed to test this hypothesis, and showed that it was feasible. However, in order for deleterious mutations that affect fertility past roughly age fifty to accumulate, human maximum lifespan had to first be extended to about its present value. As of 2016 it was unclear if there has been sufficient time since that happened for such an evolutionary process to occur.


Male-biased philopatry hypothesis

The male-biased philopatry theory proposes that male-biased philopatry in social species leads to increased relatedness to the group in relation to female age, making inclusive fitness benefits older females receive from helping the group greater than what they would receive from continued reproduction, which eventually led to the evolution of menopause. In a pattern of male-biased dispersal and local mating, the relatedness of the individuals in the group decreases with female age, leading to a decrease in kin selection with female age. This occurs because a female will stay with her father in her natal group throughout life, initially being closely related to the males and females. Females are born and stay in the group, so relatedness to the females stays about the same. However, throughout time, the older male relatives will die and any sons she gives birth to will disperse, so that local relatedness to males, and therefore the whole group, declines. The situation is reversed in species where males are philopatric and either females disperse, or mating is non-local. Under these conditions, a female's reproductive life begins away from her father and paternal relatives because she was either born into a new group from non-local mating or because she dispersed. In the case of female-biased dispersal, the female is initially equally unrelated with every individual in the group, and with non-local mating, the female is closely related to the females of the group, but not the males since her paternal relatives are in another group. As she gives birth, her sons will stay with her, increasing her relatedness to males in the group over time and thus her relatedness with the overall group. The common feature that connects these two otherwise different behaviors is male-biased philopatry, which leads to an increase in kin selection with female age. While not conclusive, evidence does exist to support the idea that female-biased dispersal existed in pre-modern humans. The closest living relatives to humans, Common chimpanzee, chimpanzees, bonobos, and both mountain gorillas and western lowland gorillas, are female-biased dispersers. Analysis of sex specific genetic material, the non-recombining portions of the Y chromosome and mitochondrial DNA, show evidence of a prevalence of female-biased dispersal as well; however, these results could also be affected by the effective breeding numbers of males and females in local populations. Evidence of female-biased dispersion in hunter-gatherers is not definitive, with some studies supporting the idea, and others suggesting there is no strong bias towards either sex. In killer whales, both sexes mate non-locally with members of a different pod but return to the pod after copulation. Demographic data shows that a female's mean relatedness to the group does increase over time due to increasing relatedness to males. While less well-studied, there is evidence that short-finned pilot whales, another menopausal species, also display this behavior. However, mating behavior that increases local relatedness with female age is prevalent in non-menopausal species, making it unlikely that it is the only factor that determines if menopause will evolve in a species.


Mother hypothesis

The mother hypothesis suggests that menopause was selected for humans because of the extended development period of human offspring and high costs of reproduction so that mothers gain an advantage in reproductive fitness by redirecting their effort from new offspring with a low survival chance to existing children with a higher survival chance.


Grandmother hypothesis

The grandmother hypothesis suggests that menopause was selected for humans because it promotes the survival of grandchildren. According to this hypothesis, post-reproductive women feed and care for children, adult nursing daughters, and grandchildren whose mothers have weaned them. Human babies require large and steady supplies of glucose to feed the growing brain. In infants in the first year of life, the brain consumes 60% of all calories, so both babies and their mothers require a dependable food supply. Some evidence suggests that hunters contribute less than half the total food budget of most hunter-gatherer societies, and often much less than half, so that foraging grandmothers can contribute substantially to the survival of grandchildren at times when mothers and fathers are unable to gather enough food for all of their children. In general, selection operates most powerfully during times of famine or other privation. So although grandmothers might not be necessary during good times, many grandchildren cannot survive without them during times of famine. Post-reproductive female killer whales tend to lead their pods, especially during years of food scarcity. Furthermore, the increased mortality risk of a killer whale individual due to losing a grandmother is stronger in years food scarcity Analysis of historical data found that the length of a female's post-reproductive lifespan was reflected in the reproductive success of her offspring and the survival of her grandchildren. Another study found comparative effects but only in the maternal grandmother—paternal grandmothers had a detrimental effect on infant mortality (probably due to paternity uncertainty). Differing assistance strategies for maternal and paternal grandmothers have also been demonstrated. Maternal grandmothers concentrate on offspring survival, whereas paternal grandmothers increase birth rates. Some believe variations on the mother, or grandmother effect fail to explain longevity with continued spermatogenesis in males (oldest verified paternity is 94 years, 35 years beyond the oldest documented birth attributed to females). Notably, the survival time past menopause is roughly the same as the maturation time for a human child. That a mother's presence could aid in the survival of a developing child, while an unidentified father's absence might not have affected survival, could explain the paternal fertility near the end of the father's lifespan. A man with no certainty of which children are his may merely attempt to father additional children, with support of existing children present but small. Note the existence of partible paternity supporting this. Some argue that the mother and grandmother hypotheses fail to explain the detrimental effects of losing ovarian follicular activity, such as
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone massImage:Bone density scanner.jpg, A scanner used to measure bone density using dual energy X-ray absorptiometry Bone density, or bone mineral density (BMD), is the amount ...
, osteoarthritis, Alzheimer's disease and coronary artery disease. The theories discussed above assume that evolution directly selected for menopause. Another theory states that menopause is the byproduct of the evolutionary selection for follicular atresia, a factor that causes menopause. Menopause results from having too few ovarian follicles to produce enough estrogen to maintain the ovarian-pituitary-hypothalamic loop, which results in the cessation of menses and the beginning of menopause. Human females are born with approximately a million oocytes, and approximately 400 oocytes are lost to ovulation throughout life.


= Reproductive conflict hypothesis

= In social vertebrates, the sharing of resources among the group places limits on how many offspring can be produced and supported by members of the group. This creates a situation in which each female must compete with others of the group to ensure they are the one that reproduces. The reproductive conflict hypothesis proposes that this female reproductive conflict favors the cessation of female reproductive potential in older age to avoid reproductive conflict, increasing the older female's fitness through Inclusive fitness, inclusive benefits. Female-biased dispersal or non-local mating leads to an increase in relatedness to the social group with female age. In the human case of female-biased dispersal, when a young female enters a new group, she is not related to any individual and she reproduces to produce an offspring with a Coefficient of relationship, relatedness of 0.5. An older female could also choose to reproduce, producing an offspring with a relatedness of 0.5, or she could refrain from reproducing and allow another pair to reproduce. Because her relatedness to males in the group is high, there is a fair probability that the offspring will be her grandchild with a relatedness of 0.25. The younger female experiences no cost to her inclusive fitness from using the resources necessary to successfully rear offspring since she is not related to members of the group, but there is a cost for the older female. As a result, the younger female has the advantage in reproductive competition. Although a female killer whale born into a social group is related to some members of the group, the whale case of non-local mating leads to similar outcomes because the younger female relatedness to the group as a whole is less than the relatedness of the older female. This behavior makes more likely the cessation of reproduction late in life to avoid reproductive conflict with younger females. Research using both human and killer whale demographic data has been published that supports the role of reproductive conflict in the evolution of menopause. Analysis of demographic data from pre-industrial Finnish populations found significant reductions in offspring survivorship when mothers-in-laws and daughters-in-laws had overlapping births, supporting the idea that avoiding reproductive conflict is beneficial to offspring survivorship. Humans, more so than other primates, rely on food sharing for survival, so the large survivorship reduction values could be caused by a straining of community resources. Avoiding such straining is a possible explanation for why the reproductive overlap seen in humans is much lower than other primates. Food sharing is also prevalent among another menopausal species, killer whales. Reproductive conflict has also been observed in killer whales, with increased calf mortality seen when reproductive overlap between a younger and older generational female occurred.


Other animals

Menopause in the animal kingdom appears to be uncommon, but the presence of this phenomenon in different species has not been thoroughly researched. Biological life cycle, Life histories show a varying degree of senescence; rapid senescing organisms (e.g., Pacific salmon and annual plants) do not have a post-reproductive life-stage. Gradual senescence is exhibited by all placental mammalian life histories. Menopause has been observed in several species of nonhuman primates, including rhesus monkeys and Common chimpanzee, chimpanzees. Some research suggests that wild chimpanzees do not experience menopause, as their fertility declines are associated with declines in overall health. Menopause also has been reported in a variety of other vertebrate species including elephants, short-finned pilot whales, killer whales, narwhals, beluga whales, and the guppy. However, with the exception of the short-finned pilot whale, killer whale, narwhals, and beluga whales, such examples tend to be from captive individuals, and thus they are not necessarily representative of what happens in natural populations in the wild. Dogs do not experience menopause; the Canine reproduction#The reproductive cycle, canine estrus cycle simply becomes irregular and infrequent. Although older female dogs are not considered good candidates for breeding, offspring have been produced by older animals. Similar observations have been made in cats.


See also

*
European Menopause and Andropause Society The European Menopause and Andropause Society is an institution that promotes the study, and encourages research, of midlife health. Mission EMAS "strives to encourage the study of Menopause Menopause, also known as the climacteric, is the ti ...
* Menopause in the workplace * Pregnancy over age 50


References


External links


Menopause: MedlinePlusMenopause and Menopause Treatments
{{Authority control Menopause, Developmental stages Endocrinology Menstrual cycle Middle age Senescence Wikipedia medicine articles ready to translate Human female endocrine system