MENOPAUSE

What is the menopause?

"I wasn't sure what to expect with the menopause, although I certainly looked forward to not having my period anymore. I have to admit, I'm concerned about how my body will change. My mother never talked about the menopause. She says her mother never did either, probably because then it was linked to old age and poor health. Now, you hear about it all the time. The "baby boom "generation is making the menopause a big issue because of their sheer numbers, and because they'll live with it much longer than their grandmothers did. Back then, the menopause did come near the end of life. Now I'm going through it, but I feel like I still have my whole life ahead of me."

More than one third of the women in the United States, about 36 million, have been through the menopause. With a life expectancy of about 81 years, a 50 year old woman can expect to live more than one-third of her life after the menopause. Scientific research is just beginning to address some of the unanswered questions about these years and about the poorly understood biology of the menopause.

The menopause is the point in a woman's life when menstruation stops permanently, signifying the end of her ability to have children. Known as the "change of life," the menopause is the last stage of a gradual biological process in which the ovaries reduce their production of female sex hormones--a process which begins about 3 to 5 years before the final menstrual period. This transitional phase is called the climacteric, or peri-menopause. The menopause is considered complete when a woman has been without periods for 1 year. On average, this occurs at about age 50. But like the beginning of menstruation in adolescence, timing varies from person to person. Cigarette smokers tend to reach the menopause earlier than non-smokers.

How does it happen?

The ovaries contain structures called follicles that hold the egg cells. You are born with about 500,000 egg cells and by puberty there are about 75,000 left. Only about 400 to 500 ever mature fully to be released during the menstrual cycle. The rest degenerate over the years. During the reproductive years, a gland in the brain generates hormones that cause a new egg to be released from its follicle each month. The follicle then produces the sex hormones oestrogen and progesterone, which thicken the lining of the uterus. This enriched lining is prepared to receive and nourish a fertilised egg which could develop into a baby. If fertilisation does not occur, oestrogen and progesterone levels drop, the lining of the uterus breaks down, and menstruation occurs.

For unknown reasons, the ovaries begin to decline in hormone production during the mid-thirties. In the late forties, the process accelerates and hormones fluctuate more, causing irregular menstrual cycles and unpredictable episodes of heavy bleeding. By the early to mid-fifties, periods finally end altogether. However, oestrogen production does not completely stop. The ovaries decrease their output significantly, but still may produce a small amount. Also, some oestrogen is produced in fat cells with help from the adrenal glands (near the kidney).

Progesterone, the other female hormone, works during the second half of the menstrual cycle to create a lining in the uterus as a viable home for an egg, and to shed the lining if the egg is not fertilised. If you skip a period, your body may not be making enough progesterone to break down the uterine lining. However, your oestrogen levels may remain high even though you are not menstruating.

At the menopause, hormone levels don't always decline uniformly. They alternately rise and fall again. Changing ovarian hormone levels affect the other glands in the body, which together make up the endocrine system. The endocrine system controls growth, metabolism and reproduction. This system must constantly readjust itself to work effectively. Ovarian hormones also affect all other tissues, including the

breasts, vagina, bones, blood vessels, gastrointestinal tract, urinary tract, and skin.

Surgical menopause

Pre-menopausal women who have both their ovaries removed surgically experience an abrupt menopause. They may be hit harder by menopausal symptoms than are those who experience it naturally. Their hot flashes may be more severe, more frequent, and last longer. They may have a greater risk of heart disease and osteoporosis, and may be more likely to become depressed.

The reasons for this are unknown. When only one ovary is removed, the menopause usually occurs naturally. When the uterus is removed (hysterectomy) and the ovaries remain, menstrual periods stop but other menopausal symptoms (if any) usually occur at the same age that they would naturally. However, some women who have a hysterectomy may experience menopausal symptoms at a younger age, possibly due to a decreased blood supply to the ovaries as a result of surgery.

" I had hot flashes, but they were fairly mild. Sometimes at night I'd suddenly start to sweat and have to throw all my covers off. But they never lasted long and I could usually get right back to sleep. During the day I noticed they tended to come whenever I had a big derision to make or when I felt a little tense. But they only lasted about 2 years. I feel blessed. I've had no other problems."

What to expect

The menopause is an individualized experience. Some women notice little difference in their bodies or moods, while others find the change extremely bothersome and disruptive. Oestrogen and progesterone affect virtually all tissues in the body, but everyone is influenced by them differently.

Hot flushes

Hot flashes, or flushes, are the most common symptom of the menopause, affecting more than 60 percent of menopausal women in the U.S. A hot flush is a sudden sensation of intense heat in the upper part or all of the body. The face and neck may become flushed, with red blotches appearing on the chest, back, and arms. This is often followed by profuse sweating and then cold shivering as body temperature readjusts. A hot flush can last a few moments or 30 minutes or longer.

Hot flushes occur sporadically and often start several years before other signs of the menopause. They gradually decline in frequency and intensity as you age. Eighty percent of all women with hot flushes have them for 2 years or less, while a small percentage have them for more than 5 years. Hot flushes can happen at any time. They can be as mild as a light blush, or severe enough to wake you from a deep sleep. Some women even develop insomnia. Others have experienced that caffeine, alcohol, hot drinks, spicy foods, and stressful or frightening events can sometimes trigger a hot flash. However, avoiding these triggers will not necessarily prevent all episodes.

Hot flushes appear to be a direct result of decreasing oestrogen levels. If there is no oestrogen, your glands release other hormones that dilate blood vessels and destabilise body temperature. Hormone therapy relieves the discomfort of hot flashes in most cases. Some women claim that vitamin E offers minor relief, although there has never been a study to confirm it. Aside from hormone therapy, which is not for everyone, here are some suggestions for coping with hot flushes:

• Dress in layers so you can remove them at the first sign of a flash.
• Drink a glass of cold water or juice at the onset of a flash.
• At night keep a thermos of ice water or an ice pack by your bed.
• Use cotton sheets, lingerie and clothing to let your skin "breathe."

Vaginal/urinary tract changes

With advancing age, the walls of the vagina become thinner, dryer, less elastic and more vulnerable to infection. These changes can make sexual intercourse uncomfortable or painful. Most women find it helpful to lubricate the vagina. Water-soluble lubricants are preferable, as they help reduce the chance of infection. Try to avoid petroleum jelly; many women are allergic, and it damages condoms. Be sure to see your gynaecologist if problems persist.

Tissues in the urinary tract also change with age, sometimes leaving women more susceptible to involuntary loss of urine (incontinence), particularly if certain chronic illnesses or urinary infections are also present. Exercise, coughing, laughing, lifting heavy objects or similar movements that put pressure on the bladder may cause small amounts of urine to leak. Lack of regular physical exercise may contribute to this condition. It's important to know, however, that incontinence is not a normal part of ageing, to be masked by using adult diapers. Rather, it is usually a treatable condition that warrants medical evaluation. Recent research has shown that bladder training is a simple and effective treatment for most cases of incontinence and is less expensive and safer than medication or surgery.

Within 4 or 5 years after the final menstrual period, there is an increased chance of vaginal and urinary tract infections. If symptoms such as painful or overly frequent urination occur, consult your doctor. Infections are easily treated with antibiotics, but often tend to recur. To help prevent these infections, urinate before and after intercourse, be sure your bladder is not full for long periods, drink plenty of fluids, and keep your genital area clean. Douching is not thought to be effective in preventing infection.

The menopause and mental health

A popular myth pictures the menopausal woman shifting from raging, angry moods into depressive, doleful slumps with no apparent reason or warning. However, a study by psychologists at the University of Pittsburgh suggests that the menopause does not cause unpredictable mood swings, depression, or even stress in most women.

In fact, it may even improve mental health for some. This gives further support to the idea that the menopause is not necessarily a negative experience. The Pittsburgh study looked at three different groups of women: menstruating, menopausal with no treatment, and menopausal on hormone therapy. The study showed that the menopausal women suffered no more anxiety, depression, anger, nervousness or feelings of stress than the group of menstruating women in the same age range. In addition, although more hot flashes were reported by the menopausal women not taking hormones, surprisingly they had better overall mental health than the other two groups. The women taking hormones worried more about their bodies and were somewhat more depressed.

However, this could be caused by the hormones themselves. It's also possible that women who voluntarily take hormones tend to be more conscious of their bodies in the first place. The researchers caution that their study includes only healthy women, so results may apply only to them. Other studies show that women already taking hormones who are experiencing mood or behavioural problems sometimes respond well to a change in dosage or type of oestrogen.

Studies indicate that women of childbearing age, particularly those with young children at home, tend to report more emotional problems than women of other ages.

The Pittsburgh findings are supported by a New England Research Institute study which found that menopausal women were no more depressed than the general population: about 10 percent are occasionally depressed and 5 percent are persistently depressed. The exception is women who undergo surgical menopause. Their depression rate is reportedly double that of women who have a natural the menopause.

Studies also have indicated that many cases of depression relate more to life stresses or "mid-life crises" than to the menopause. Such stresses include: an alteration in family roles, as when your children are grown and move out of the house, no longer "needing" mom; a changing social support network, which may happen after a divorce if you no longer socialise with friends you met through your husband; interpersonal losses, as when a parent, spouse or other close relative dies; and your own ageing and the beginning of physical illness. People have very different responses to stress and crisis. Your best friend's response may be negative, leaving her open to emotional distress and depression, while yours is positive, resulting in achievement of your goals. For many women, this stage of life can actually be a period of enormous freedom.

What about sex?

For some women, but by no means all, the menopause brings a decrease in sexual activity. Reduced hormone levels cause subtle changes in the genital tissues and are thought to be linked also to a decline in sexual interest. Lower oestrogen levels decrease the blood supply to the vagina and the nerves and glands surrounding it. This makes delicate tissues thinner, drier, and less able to produce secretions to comfortably lubricate before and during intercourse. Avoiding sex is not necessary, however. Oestrogen creams and oral oestrogen can restore secretions and tissue elasticity. Water-soluble lubricants can also help.

While changes in hormone production are cited as the major reason for changes in sexual behaviour, many other interpersonal, psychological, and cultural factors can come into play. For instance, a Swedish study found that many women use the menopause as an excuse to stop sex completely after years of disinterest. Many physicians, however, question if declining interest is the cause or the result of less frequent intercourse.

Some women actually feel liberated after the menopause and report an increased interest in sex. They feel relieved that the children are out of the house and pregnancy is no longer a worry.

For women in peri-menopause, birth control is a confusing issue. Doctors advise all women who have menstruated, even if irregularly, within the past year to continue using birth control. Unfortunately, contraceptive options are limited. Hormone-based oral and implantable contraceptives are risky in older women who smoke. Only a few brands of IUD are on the market. The other options are barrier methods -- diaphragms, condoms, and sponges -- or methods requiring surgery such as tubal ligation for women, and vasectomy for the male partner.

Is my partner still interested?

Some men go through their own set of doubts in middle age. They too, often report a decline in sexual activity after age 50. It may take more time to reach ejaculation, or they may not be able to reach it at all. Many fear they will fail sexually as they get older. Remember, at any age sexual problems can arise if there are doubts about performance. If both partners are well informed about normal genital changes, each can be more understanding and make allowances rather than unmeetable demands. Open, candid communication between partners is important to ensure a successful sex life well into your seventies and eighties.

Long-term effects of oestrogen deficiency
Osteoporosis

For most women, natural menopause is not a major crisis and does not influence their opinion of their general health.

In a society that places so much value on youth and beauty, it's not much fun to think about the menopause. But when you get there, you find it doesn't really make that much difference; you concentrate on how you feel about yourself, not on how you think others see you. I continue trying to improve myself, to keep learning and keep active. It's not your age that counts, it's how you handle it.

One of the most important health issues for middle-aged women is the threat of osteoporosis. It is a condition in which bones become thin, fragile, and highly prone to fracture. Numerous studies over the past 10 years have linked oestrogen insufficiency to this gradual, yet debilitating disease. In fact, osteoporosis is more closely related to the menopause than to a woman's chronological age.

Bones are not inert. They are made up of healthy, living tissue which continuously performs two processes: breakdown and formation of new bone tissue. The two are closely linked. If breakdown exceeds formation, bone tissue is lost and bones become thin and brittle. Gradually and without discomfort, bone loss leads to a weakened skeleton incapable of supporting normal daily activities.

Each year about 500,000 American women will fracture a vertebrae, the bones that make up the spine, and about 300,000 will fracture a hip. Nationwide, treatment for osteoporotic fractures costs up to $10 billion per year, with hip fractures the most expensive. Vertebral fractures lead to curvature of the spine, loss of height, and pain. A severe hip fracture is painful and recovery may involve a long period of bed rest.

Between 12 and 20 percent of those who suffer a hip fracture do not survive the 6 months after the fracture. At least half of those who do survive require help in performing daily living activities, and 15 to 25 percent will need to enter a long-term care facility. Older patients are rarely given the chance for full rehabilitation after a fall. However, with adequate time and care provided in rehabilitation, many people can regain their independence and return to their previous activities.

For osteoporosis, researchers believe that an ounce of prevention is worth a pound of cure. The condition of an older woman's skeleton depends on two things: the peak amount of bone attained before the menopause and the rate of the bone loss thereafter. Hereditary factors are important in determining peak bone mass. For instance, studies show that black women attain a greater spinal mass and therefore have fewer osteoporotic fractures than white women. Other factors that help increase bone mass include adequate intake of dietary calcium and vitamin D, exposure to sunlight, and physical exercise. These elements also help slow the rate of bone loss.

Certain other physiological stresses can quicken bone loss, such as pregnancy, nursing, and immobility. The biggest culprit in the process of bone loss is oestrogen deficiency. Bone loss quickens during peri-menopause, the transitional phase when oestrogen levels drop significantly.

Doctors believe the best strategy for osteoporosis is prevention because currently available treatments only halt bone loss -- they don't rebuild the bone. However, researchers are hopeful that in the future, bone loss will be reversible. Building up your reserves of bone before you start to lose it during peri-menopause helps bank against future losses. The most effective therapy against osteoporosis available today for postmenopausal women is oestrogen. Remarkably, oestrogen saves more bone tissue than even very large daily doses of calcium. Oestrogen is not a panacea, however. While it is a boon for the bones, it also affects all other tissues and organs in the body, and not always positively. Its impact on the other areas of the body must be considered.

Cardiovascular disease

Most people picture an older, overweight man when they think of a likely candidate for cardiovascular disease (CVD). But men are only half the story. Heart disease is the number one killer of American women and is responsible for half of all the deaths of women over age 50. Ironically, in past years women were rarely included in clinical heart studies, but finally physicians have realised that it is as much a woman's disease as a man's.

Influences on bone development

Increases bone formation Speeds bone loss
Dietary calcium Oestrogen deficiency
Vitamin D Pregnancy
Exposure to sunlight Nursing
Exercise Lack of exercise

CVDs are disorders of the heart and circulatory system. They include thickening of the arteries (atherosclerosis) that serve the heart and limbs, high blood pressure, angina, and stroke. For reasons unknown, oestrogen helps protect women against CVD during the childbearing years. This is true even when they have the same risk factors as men, including smoking, high blood cholesterol levels, and a family history of heart disease. But the protection is temporary. After the menopause, the incidence of CVD increases, with each passing year posing a greater risk. The good news, though, is that CVD can be prevented or at least reduced by early recognition, lifestyle changes and, many physicians believe, hormone replacement therapy.

The menopause brings changes in the level of fats in a woman's blood. These fats, called lipids, are used as a source of fuel for all cells. The amount of lipids per unit of blood determines a person's cholesterol count. There are two components of cholesterol: high density lipoprotein (HDL) cholesterol, which is associated with a beneficial, cleansing effect in the bloodstream, and low density lipoprotein (LDL) cholesterol, which encourages fat to accumulate on the walls of arteries and eventually clog them. To remember the difference, think of the H in HDL as the healthy cholesterol, and the L in LDL as lethal. LDL cholesterol appears to increase while HDL decreases in postmenopausal women as a direct result of oestrogen deficiency. Elevated LDL and total cholesterol can lead to stroke, heart attack, and death.

"I started taking oestrogen for my hot flushes. They went away immediately. I've felt no side effects, which I'm thankful for. I don't think I'll stay on it forever, though -- no one seems to know how long it's safe! My mother has never taken hormones and she's in great shape at 87. I hope I'm as lucky!"

Treatment
Hormone Replacement Therapy

To combat the symptoms associated with falling oestrogen levels, doctors have turned to hormone replacement therapy (HRT). HRT is the administration of the female hormones oestrogen and progesterone. Oestrogen replacement therapy (ERT) refers to administration of oestrogen alone. The hormones are usually given in pill form, though sometimes skin patches and vaginal creams (just oestrogen) are used. ERT is thought to help prevent the devastating effects of heart disease and osteoporosis, conditions that are often difficult and expensive to treat once they appear. The cardiovascular effects of progesterone, however, are yet unknown. Hormone treatment for the menopause is still quite controversial. Its long-term safety and efficacy remain matters of great concern. There is not enough existing data for physicians to suggest that HRT is the right choice for all women. Several large studies are currently attempting to resolve the questions, though it will take several more years to reach any definitive answers.

In the 1940's when oestrogen was first offered to menopausal women, it was given alone and in high doses. Today, after 50 years of trial and error, it is well known that oestrogen stimulates growth of the inner lining of the uterus (endometrium) that sheds during menstruation. This growth may continue uncontrollably, resulting in cancer. Today, doctors typically prescribe a lower dose of oestrogen. However, few doctors still prescribe oestrogen alone to women who have a uterus. Most now prefer to add a synthetic form of progesterone called progestogen to counteract oestrogen's dangerous effect on the uterus. Progestogen reduces the risk of cancer by causing monthly shedding of the endometrium. The obvious drawback to this approach is that menopausal women resume monthly bleeding. Once the menopause arrives, most women enjoy the freedom of life without a period. Many are reluctant to begin their cycles again. In addition, there are other unpleasant side effects of progestogen which often discourage women from continuing HRT.

These include breast tenderness, bloating, abdominal cramping, anxiety, irritability, and depression.

Only about 15 percent of women who are eligible for hormone replacement therapy are now receiving it. This leaves 85 percent who either do not want or need it, or do not know about it.

The good news is that researchers are evaluating different schedules of low-dose oestrogen and progestogen to completely eliminate monthly bleeding. Currently most women receive what is called cyclic HRT. They may take oestrogen continually and progestogen for the first 12 days of each month. The use of a continuous combined dose, where oestrogen and smaller amounts of progestogen are taken every day is also being studied. In theory, this use of progestogen stems endometrial growth so no bleeding will occur. Unfortunately, it may take 6 months or more until bleeding finally stops. In many cases, monthly bleeding has been replaced by more bothersome irregular bleeding patterns.

Obviously, further research is needed to evaluate and perfect this treatment. Various types of progestogens in different dosages, preparations, and schedules are being studied in hopes of reducing its other unpleasant side effects while retaining the known advantages of oestrogen.

Oestrogen and your bones

Oestrogen therapy is the most successful method of combating osteoporosis. As previously discussed, oestrogen halts bone loss but cannot necessarily rebuild bone. Long-term oestrogen use (10 or more years) may be required to prevent postmenopausal bone loss. Why oestrogen helps protect the skeleton is still unclear. We do know that oestrogen helps bones absorb the calcium they need to stay strong. It also helps conserve the calcium stored in the bones by encouraging other cells to use dietary calcium more efficiently. For instance, muscles require calcium to contract. If there is not enough calcium circulating in the blood for muscles to use, calcium is "borrowed" from the bone. Calcium is also needed for blood clotting, sending nerve impulses, and secreting various hormones. Prolonged borrowing from bone calcium for these processes speeds bone loss. That's why it's important to consume adequate amounts of calcium in your diet.

Oestrogen's effect on your heart

The majority of past clinical studies have shown that women who take oestrogen substantially reduce their risk of developing and dying from heart disease. One or two studies demonstrate conflicting evidence, but they are far outnumbered by the positive reports. Results from a 1001 study showed that after 15 years of oestrogen replacement, risk of death by CVD was reduced by almost 50 percent and overall deaths were reduced by 40 percent. Some researchers credit this reduction to oral oestrogen's ability to maintain HDL and LDL at their healthier, pre-menopausal levels, through its interaction with proteins in the liver. Others believe it is oestrogen's direct effect on the blood vessels themselves (through receptors on the vessel walls) which creates this benefit. In the latter case, both oral oestrogen and the skin patch would be effective.

Studies are underway to determine which mechanism contributes most to a healthy heart.

Clearly, oestrogen appears to benefit women at high risk for heart disease. The high risk group includes women with a strong family history of CVD, those with high blood pressure, smokers, and obese women. One study observed fewer cardiovascular deaths among oestrogen users compared to nonusers. Women whose ovaries had been surgically removed had the greatest reduction of risk. The same study also confirmed, as expected, the link between smoking, obesity and cardiovascular disease.

At any time of life, women who smoke are much more likely to develop heart disease or have a stroke than women who do not smoke. But after the menopause, a smoker's risk climbs dramatically. Low oestrogen levels and smoking are separate risk factors for CVD. When the two are combined, the risk is much higher than either one alone. Smoking also raises your risks for some types of cancer and for chronic lung disease, such as emphysema. Fortunately, quitting smoking--at any age--can cut the risk of disease almost immediately. Studies have shown that when older people quit, they increase their life expectancy.

Their risk of heart disease goes down, their lungs function better, and blood circulation improves. So quitting smoking, whether before, during or after the menopause, can have a definite impact on both the length and quality of your life.

Should women be treated with a drug to prevent a disease they might never get (osteoporosis, heart disease)? Some people will be placed at higher risk, while others will benefit. Each woman should make a decision about HRT based on her own family history and life experiences.

To me, exercise is the key to staying healthy. Some of these ladies have been coming to this class for 10 years. I think that really says a lot. Do you think they'd get up at 7:00 a.m. to jump around if it didn't make them feel better?

Many women who have quit smoking say they found support in group counselling sessions.

While we know that HRT users have a decreased risk of CVD, it is not clear how or if women with pre-existing heart disease can benefit. Because uncertainty exists, some of these women may be advised by their doctors not to take oestrogen. Researchers hope to further investigate non-hormonal methods of preventing heart disease such as weight reduction or control, exercise, smoking cessation, and dietary modification.

According to a 5-year study reported in 1988, weight gain (a common occurrence among many menopausal women) significantly raises blood pressure, total and LDL cholesterol, and fat levels. Together, these make up a dangerous recipe for heart disease. Several other studies also noted that moderate alcohol consumption, about one drink per day, had a protective effect on the heart. Physicians advise caution in this area, however, as excess alcohol can increase risks for other serious problems such as brain haemorrhaging, liver disease, and certain types of cancer.

While cardiovascular benefits associated with oral oestrogen are fairly well-known, there is surprisingly little information on the cardiovascular effects of progestogen combined with oestrogen. Some studies suggest that progestogens counteract the favourable HDL and LDL effects achieved by oestrogen alone, while other studies show no such effect. This remains just one more grey area where questions outnumber reliable answers.

Cautions to Oestrogen Use

Serious risk
Stroke
Recent heart attack
Breast cancer (current or family history)
Uterine cancer
Acute liver disease
Gall bladder disease
Pancreatic disease
Recent blood clot
Undiagnosed vaginal bleeding

Relative risk

Cigarette smoking
Hypertension
Benign breast disease
Benign uterine disease
Endometriosis Pancreatitis
Epilepsy
Migraine headaches

Subjective Complaints

Nausea
Headaches
Breakthrough bleeding
Depression
Fluid retention

Drawbacks of HRT: The cancer risk

As discussed previously, there is evidence that in women with an intact uterus, oestrogen may provoke growth of the tissues lining the uterus and increase the risk of uterine cancer. Also of great concern is the influence of oestrogen on breast cancer. Researchers believe that the longer your lifetime exposure to naturally occurring oestrogen, the greater your risk of breast cancer. It has not been proven, however, that oestrogen administered at the menopause has the same effect.

There is disagreement on the many trials conducted to date because of wide variations in the populations studied and the doses, timing, and types of oestrogen used. A recent analysis of previous studies suggests that low-dose oestrogen taken on a short-term basis (10 years or less) does not pose an increased risk of breast cancer. Long-term use (more than 10 years) at a high dose may significantly increase the risk. By how much is still a matter of heated debate. At the very most, researchers think long-term use could possibly increase the risk of getting breast cancer by 30 percent. This means that incidence would rise from 10 women per 10,000 each year to 13 women per 10,000 each year. To reach any consensus, however, more women need to be monitored for an extended period of time. The fear of cancer is one of the most common reasons that women are unwilling to use HRT. Interestingly, actual death rates for breast cancer have not risen at all. This is probably because oestrogen users have more frequent medical visits and obtain more preventive care including yearly mammograms.

While no one can determine who will eventually develop breast cancer, there are certain risk factors you should be aware of when considering HRT. A family history of breast cancer (sister or mother) is probably the most important risk factor of all. You may also be at an increased risk if: you menstruated before age 12; delayed motherhood until later in life; have a late menopause (after age 50). Also, the older you are, the higher the risk. Most doctors believe that if you are not in a high risk category for breast or endometrial cancer, the benefits of HRT far outweigh the risks. However, for some women, the side effects of therapy make it impossible to use. This is a personal decision to be made by each woman with help from her doctor.

Research shows that most women are concerned more with quality of life than quantity of life. They give higher priority to the short-term effects of hormone therapy (relief from hot flashes and vaginal dryness) than to long-term concerns (preventing osteoporosis).

Other risks

Physicians usually caution women not to use HRT if they are already at high risk for developing blood clots. Obesity, severe varicose veins, smoking, and a history of blood clots put you in this category. A history of gall bladder disease could also be cause to avoid HRT, as women taking oestrogen may have a greater chance of developing gallstones.

Happiness is when the last tuition is paid for, the youngest moves out and the dog dies. Now I can concentrate on what I want to do. My doctor puts everyone on oestrogen, so I tried it for a while -- but it brought my menstrual flow back just as heavy as before. Who needs that mess again? So now I just exercise, try to eat well, and generally, I feel pretty good.

Keeping healthy

Good nutrition and regular physical exercise are thought to improve overall health. Some doctors feel these factors can also affect the menopause. Although these areas have not been well studied in women, anecdotal evidence is strongly in favour of eating well and exercising to help lower risks for CVD and osteoporosis.

There is no consensus within the medical community about the risks and benefits associated with hormone therapy. There is no agreement on normal hormonal changes associated with ageing.

Nutrition

While everyone agrees that a well-balanced diet is important for good health, there is still much to be learned about what constitutes "well-balanced." We do know that variety in the diet helps ensure a better mix of essential nutrients.

Nutritional requirements vary from person to person and change with age. For instance, the Recommended Dietary Allowance (RDA) for calcium as determined by the National Research Council is 800 mg per day for a healthy man. A healthy pre-menopausal woman should have more, about 1,000 to 1,200 mg per day. The Council suggests that a postmenopausal woman consume 1,200 to 1,500 mg per day to help avoid bone loss. Foods high in calcium include milk, yoghurt, cheese and other dairy products; oysters, sardines and canned salmon with bones; and dark-green leafy vegetables like spinach and broccoli. If you are lactose intolerant, acidophilus milk is more digestible. Vitamin D is also very important for calcium absorption and bone formation. A 1992 study showed that women with postmenopausal osteoporosis who took vitamin D for 3 years significantly reduced the occurrence of new spinal fractures. However, the issue is still controversial. High doses of vitamin D can cause kidney stones, constipation, or abdominal pain, particularly in women with existing kidney problems. Other nutritional guidelines by the National Research Council include:

• Choose foods low in fat, saturated fat, and cholesterol. Fats contain more calories (9 calories per gram) than either carbohydrates or protein (each have only 4 calories per gram). Fat intake should be less than 30 percent of daily calories.
• Eat fruits, vegetables, and whole grain cereal products, especially those high in vitamin C and carotene. These include oranges, grapefruit, carrots, winter squash, tomatoes, broccoli, cauliflower, and green leafy vegetables. These foods are good sources of vitamins and minerals and the major sources of dietary fibre. Fibre helps maintain bowel mobility and may reduce the risk of colon cancer. Young and older people alike are encouraged to consume 20 to 30 grams of fibre per day.
• Eat very little salt-cured and smoked foods such as sausages, smoked fish and ham, bacon, bologna, and hot dogs. High blood pressure, which may become more serious with heavy salt intake, is more of a risk as you age.
• Avoid food and drinks containing processed sugar. Sugar contains empty calories which may substitute for nutritious food and can add excess body weight.

For people who can't eat an adequate diet, supplements may be necessary. A dietician should tailor these to meet your individual nutritional needs. Using supplements without supervision can be risky because large doses of some vitamins may have serious side effects. Vitamins A and D in large doses can be particularly dangerous.

As you age, your body requires less energy because of a decline in physical activity and a loss of lean body mass.

Raising your activity level will increase your need for energy and help you avoid gaining weight. Weight gain often occurs in menopausal women, possibly due in part to declining oestrogen.

In animal studies, scientists found that oestrogen is important in regulating weight gain. Animals with their ovaries surgically removed gained weight, even if they were fed the same diet as the animals with intact ovaries. They also found that progesterone counteracts the effect of oestrogen. The higher their progesterone levels, the more the animals ate.

Exercise

Exercise is extremely important throughout a woman's lifetime and particularly as she gets older. Regular exercise benefits the heart and bones, helps regulate weight, and contributes to a sense of overall well-being and improvement in mood. If you are physically inactive you are far more prone to coronary heart disease, obesity, high blood pressure, diabetes, and osteoporosis. Sedentary women may also suffer more from chronic back pain, stiffness, insomnia, and irregularity. They often have poor circulation, weak muscles, shortness of breath, and loss of bone mass. Depression can also be a problem. Women who regularly walk, jog, swim, bike, dance, or perform some other aerobic activity can more easily circumvent these problems and also achieve higher HDL cholesterol levels. Studies show that women performing aerobic activity or muscle-strength training reduced mortality from CVD and cancer.

Just like muscles, bones adhere to the "use it or lose it" rule; they diminish in size and strength with disuse. It has been known for more than 100 years that weight-bearing exercise (walking, running) will help increase bone mass. Exercise stimulates the cells responsible for generating new bone to work overtime. In the past 20 years, studies have shown that bone tissue lost from lack of use can be rebuilt with weight-bearing activity. Studies of athletes show they have greater bone mass compared to non-athletes at the sites related to their sport. In postmenopausal women, moderate exercise preserves bone mass in the spine helping reduce the risk of fractures.

Exercise is also thought to have a positive effect on mood. During exercise, hormones called endorphins are released in the brain. They are 'feel good' hormones involved in the body's positive response to stress. The mood-heightening effect can last for several hours, according to some endocrinologists.

Consult your doctor before starting a rigorous exercise program. He or she will help you decide which types of exercises are best for you. An exercise program should start slowly and build up to more strenuous activities. Women who already have osteoporosis of the spine should be careful about exercise that jolts or puts weight on the back, as it could cause a fracture.

Ongoing/future research

To gather more data to help women make a well-informed decision regarding hormone therapy, researchers at the National Institutes of Health (NIH) launched the Postmenopausal Oestrogen/Progestogen Interventions Trial (PEPI) in 1989. With 127 women enrolled at each of seven medical centres, PEPI will address the short-term safety and efficacy of various methods of HRT. The study will compare women who take oestrogen by itself to those who take it with different types of progestogen.

It will also examine the effects of both cyclical and continuous progestogen on cardiovascular risk factors, blood clotting factors, metabolism, uterine changes, bone mass, and general quality of life.

To date most large-scale studies have not fully reported on normal body changes as women move from pre- to post-menopause. This lack of data has been one problem in assessing the value of HRT. Without knowing what "normal" is, scientists have difficulty judging the effect of a particular treatment. Another problem with past studies is the "healthy user effect." In many trials preceding PEPI, the HRT users studied had freely chosen to begin treatment, with advice from their doctors. In general, most physicians discourage women with a pre-existing illness or long family history of breast cancer from taking HRT. This factor could skew study results to appear that nonusers became ill or died more frequently simply because they failed to take oestrogen. Only by randomly assigning study participants to the treatment can this bias be overcome. Until more random trials are completed, the jury is still out on HRT.

Many women feel that their physicians do not listen to their concerns. Nor do they give them enough information to make an educated decision about hormone therapy. Women's Health Initiative include:
Another NIH study, begun in 1992 is the Women's Health Initiative, a multicentre trial involving 70,000 postmenopausal women ages 50 to 79. The study will assess the long-term benefits and risk of hormone therapy as it relates to cardiovascular disease, osteoporosis, and breast and uterine cancer. It will also help determine the effects of calcium supplementation, dietary changes, and exercise on women in this age group. Some of the specific questions to be addressed by the Women's Health Initiative include:

• How long is oestrogen effective for each system of the body (skeletal, cardiovascular, nervous, endocrine)?
• What is the best dose and route of administration of oestrogen and progestogen to prevent side effects yet maintain efficacy?
• How long is oestrogen safe to take?
• Does oestrogen act the same way in older women as in younger women?
• Are there effective alternatives to HRT?

Clearly, no one has all the answers about the menopause. Medical research is beginning to give us more accurate information, but some myths and negative attitudes persist. Women are challenging old stereotypes, learning about what's happening in their bodies, and taking responsibility for their health. The important thing to remember as you go through the menopause is to be good to yourself. Take time to pursue your hobbies, be they gardening, painting or socialising with friends. Have a positive attitude toward life. Sharing concerns with friends, a spouse, relatives or a support group can help. Don't fight your body -- allow the changes that are happening to become a part of you, a part that is natural and that you accept.

Glossary

angina -- a disease marked by brief attacks of chest pain
biopsy -- removal and examination of living cells from the body
cardiovascular disease -- disorders of the heart and circulatory system
endometrium -- the tissues lining the uterus
oestrogen -- one of the female sex hormones produced by the ovaries
HDL -- high density lipoprotein cholesterol, the "good" cholesterol thought to have a cleansing effect in the bloodstream hysterectomy- surgical removal of the uterus
IUD -- Intrauterine birth control device, which prevents implantation of an embryo into the uterus should fertilisation occur
LDL -- low density lipoprotein cholesterol, the "bad" cholesterol believed to be linked to fat accumulation in the arteries
menopause -- the point when menstruation stops permanently
oral contraceptives -- pills which usually consist of synthetic oestrogen and progesterone that are taken for three weeks after the last day of a menstrual period. They inhibit ovulation, thereby preventing pregnancy
osteoporosis -- a disease in which bones become thin, weak and are easily fractured
peri-menopause -- the time around the menopause, usually beginning 3 to 5 years before the final period
progesterone -- one of the female sex hormones produced by the ovaries
progestogen -- the synthetic form of progesterone
tubal ligation -- a surgical procedure in which the uterine tubes are cut and tied to prevent pregnancy
urinary incontinence -- loss of bladder control
vasectomy -- in males, the surgical removal of part of the sperm duct (vas deferens) to induce infertility