Natural menopause, or change of life, literally means the cessation of menstruation and the termination of a woman's fertile period.

The climacteric is the period preceding menopause. During this time, the ovaries' production of estrogen and progesterone diminishes until it stops entirely. Meanwhile, the menstrual periods become irregular and infrequent, and eventually stop.

Sometimes women go through what is known as a surgical menopause by removal of the ovaries in the treatment of cancer, endometriosis or pelvic inflammatory disease.

An artificial menopause can also be brought on by intensive irradiation of the pelvis or by chemotherapy for cancer in another part of the body. In these cases, the symptoms of menopause are more intense.

Natural menopause comes around the ages of 45 to 52, with an average age of 50, but for approximately 7% of women it occurs before age 40. In regions where nutrition is poor, menopause occurs even earlier.

Life expectancy for women in the United States is now 83 years, which means that many women will continue to more than one-third their lives beyond menopause. Today's world emphasizes youth, particularly where women are concerned, so menopause can be a time of anxiety or even emotional devastation for women.

After 50, the average age of menopause, the signs of aging become more evident. You'll see more wrinkles, your hair will thin, and your breasts will lose their elastic support even more.

During this time of life, other changes also occur in many women's lives. Children are no longer at home. Especially if a woman has never worked outside the home, she may feel that her life has no meaning.

She might find herself divorced, with few skills for entering the working world. She might also have older parents who need her help. Her self-esteem may be at a low point.

Knowing what happens during menopause before it occurs and what symptoms can be corrected will make a woman more comfortable. One method that helps many women is estrogen therapy. There are several reasons why.

If you are menopausal but not on estrogen, you should be especially careful when entering a new sexual relationship.

The risk of HIV infection increases because of hormonal changes that make the vaginal lining drier and easier to break. Changes also occur in the central nervous system, skin, urinary tract and bones, and the metabolic rate slows down.

As in earlier phases of adulthood, heart disease and cancer are the biggest health threats, and the risk increases with age. Hormonal changes make osteoporosis another significant health problem.

If you follow the sensible diet and exercise plan suggested in this book, you will decrease the risk of all three health problems. How much? It depends on the length of time involved, as well as hereditary and lifestyle variations.

For the rest of this Step, I'll discuss menopause-related health problems, beginning with those that are most complained about.

Problems With the Nervous System
Reduction in estrogen production produces the "hot flashes" that women, men and comedians invariably associate with menopause. What's not so well known is that almost one in four women never experience them.

Hot flashes -- a wave of heat through the body and the sensation of burning in the neck and head -- result from the change in production of female hormones by the pituitary gland.

They can occur every few minutes or once or twice an hour. When they occur at night, disturbing sleep, they're called night sweats. Some women are awakened by them as many as 10 or 20 times a night, resulting in insomnia, irritability, fatigue, lack of concentration and sometimes depression.

More than 75% of women experience hot flashes during the first few months of menopause, and 45% still have them after five years. But some women have no symptoms at all, or they are so mild that the women don't even know they're entering menopause until their menstrual periods have stopped.

Weight Problems
In menopause, you may find it easier to gain weight than in earlier years. Scientists don't know if the gain is due to menopause or simply to the aging process, but weight gain is common. With age, the metabolic rate -- the way the body utilizes energy -- slows down.

Higher Cholesterol Levels
In every age group, increased weight is associated with higher levels of "bad" cholesterol, the kind that causes heart disease.

But a recent study at the University of Texas found that in women who had been through menopause, even those who were thin had higher levels of "bad" cholesterol. Women who were both post-menopausal and obese had the highest "bad" cholesterol levels of all, even higher than in older overweight men.

Skin Problems
As you grow older, your skin will change somewhat, but again it hasn't been proven that menopause is the direct cause. The skin gets thinner and loses its elasticity, resulting in wrinkles. Some of this is due to a reduction in the skin's collagen (structural material) content.

"Masculinization"
Throughout your adult life, your ovaries produce some testosterone, the male hormone. During menopause, the production of testosterone is reduced by two-thirds, but since the production of estrogen stops completely, the body is producing relatively more testosterone.

This explains why some women display some signs of masculinization, such as a deeper voice or greater hairiness.

Sexual Problems
There is a belief that with age a woman loses her sexuality as well as her fertility. This is true in some cases, but not in others.

Some women find that after menopause their sexuality remains the same or even increases. They know there is no chance of becoming pregnant, they feel more comfortable with their sexuality, and even without estrogen replacement the vagina produces enough lubricant.

The libido or sexual desire does disappear in some women. The lack of estrogen causes the uterus, the cervix and cervical and vaginal glands to atrophy (wither), producing less of their lubricating mucus. The vagina also loses its elasticity.

This combination produces irritation, burning sensations, vaginal dryness, itching, and sometimes vaginal discharge or even vaginal bleeding. The result is difficult and painful intercourse.

Urinary Problems
Urinary problems are more frequent during menopause. Estrogen maintains the functional tone of the mucosa (lining) of the bladder and the urethra. Estrogen deficiency causes changes in the structure of both organs and may result in painful urination, urinary urgency and urinary stress incontinence.

Osteoporosis
Osteoporosis -- loss of bone density of the vertebrae and the long bones, especially the hip, wrist and arm -- is also very common after menopause.

This can cause loss of height and the outward curve of the upper spine, often cruelly called "dowager's hump." It also increases the risk of bone fractures from trivial accidents.

Every year, women in the United States suffer at least 600,000 bone fractures directly caused by osteoporosis. The precise cause of osteoporosis is unknown, but studies show that inactivity and calcium deficiency are some of the precipitating factors.

A - nornal bone, B - osteoporotic bone.

Drawing of a woman's skeleton, showing bones most likely to suffer from osteoporosis.

You're at higher risk for osteoporosis if your ancestors came from Europe (especially northern Europe) or Asia. Other risk factors include being very thin, using steroids or anticonvulsive medication, smoking, alcohol abuse and lack of exercise. A recent study has shown that tooth loss is a sign that the woman probably has osteoporosis.

Estrogen replacement and regular weight-bearing exercise like walking, jogging, cycling and playing tennis -- beginning no later than age 35 -- can prevent osteoporosis.

Another preventive measure is a balanced diet containing about 1500 mg of calcium a day and vitamin D, which helps the body use calcium more efficiently. Cheese, nonfat milk and yogurt, other milk products, sesame seeds, legumes and almonds are rich in calcium. Vitamin D is added to fluid milk.

Estrogen Therapy
More than 80% of women experience menopause-related symptoms, for which estrogen therapy may be helpful.

You should consult your health-care provider about the risks and benefits of using estrogen replacement therapy, make the decision together, and choose the appropriate treatment. If you still have your uterus, you should also have a prescription for progesterone.

Benefits of Estrogen Therapy
It has been proven that the use of estrogen after menopause relieves hot flashes, irritability, vaginal atrophy and other unpleasant symptoms within two or three weeks. Estrogen also prevents osteoporosis and atrophy of the genito-urinary system.

It also improves the appearance of the skin by increasing its thickness and collagen content. Many women who use estrogen feel very comfortable and have few complications.

Estrogen may also help cancel out the increased risk of cardiovascular disease in post-menopausal women. Cardiovascular disease is the leading cause of death among women, with 478,000 deaths in 1990, according to the American Heart Association.

That same year, 447,900 men also died of cardiovascular disease. Disease-causing blocked blood vessels are less common in women than in men before age 55, but that difference decreases with age. By age 80, the rates are equal for men and women.

Scientists think that the production of estrogen by the ovaries before menopause may protect women against cardiovascular disease.

The fear that women on estrogen therapy could develop breast cancer has prevented its more widespread use.

About 40,000 women die each year of breast cancer, compared to about 480,000 who die of cardiovascular disease. No one knows why most breast cancers develop in women.

Many studies have shown that estrogen increases the "good" cholesterol or HDL and also decreases the "bad" (LDL) cholesterol that causes thickening of the blood vessel walls (arteriosclerosis). Women who use estrogen decrease their risk of heart attack by almost 50%.

Possible Risks of Estrogen Replacement Therapy
Estrogen promotes the growth of the endometrium (uterine lining) and the risk of uterine cancer. A woman with an intact uterus should also be given progesterone to counteract the effect of estrogen on the endometrium.

The breasts may become tender, lumpy and develop cysts. Some studies show a 21% increase in the risk of breast cancer with longterm use of estrogen. This increase may only occur in women who take large doses of estrogen, and may be outweighed by its other benefits.

Some women on estrogen experience irregular bleeding. In this case, the health-care provider uses a special instrument to take small samples of the endometrium (called performing a biopsy) and sends them to a laboratory for close examination.

The procedure is performed in the health-care provider's office and takes just a few minutes. The patient may experience mild cramps, but these quickly disappear. Some cases may require treatment by dilation and curettage (or D&C, the scraping away of part of the uterine lining).

Performing an endrometrial biopsy.

In a study of women who did not take estrogen, the incidence of uterine cancer was higher than among estrogen-takers. Among women who were using estrogen and developed uterine cancer, the diagnosis was usually made early and the disease was easier to cure.

When estrogen is taken orally, its action on the liver may possibly increase the risk of gallstones and thromboembolic (blood clot) disease.

To minimize the problem of blood clots, estrogen can be administered instead from a skin patch, so that it is absorbed directly into the blood, bypassing the liver. This decreases the body's production of blood-clotting chemicals.

When Estrogen Should NOT Be Used
Estrogen therapy should not be prescribed in women with unexplained vaginal bleeding, active liver disease, recent blood clots, breast cancer or uterine cancer.

Types of Estrogen
Estrogen comes in the form of tablets, vaginal cream, injection or the patch. Skin implants will probably be available in the near future.

Is Estrogen Therapy For You?
Consult your physician to see if hormonal therapy is for you. Before prescribing estrogen, your doctor will perform a complete physical exam, including a Pap smear, a mammogram and blood tests. Every patient on estrogen therapy should have a yearly checkup.

Many health-care providers strongly advocate the use of estrogen after menopause because of the multiple advantages estrogen therapy brings.

Estrogen therapy helps keep a woman healthy, improves her quality of life and extends her life expectancy. But everyone ages differently, depending on her health, heredity and personality. Individuals with young minds stay young.

Alternative Treatment for Managing Menopause
Hormone-replacement therapy is not for everyone. Some women cannot tolerate the side effects and others are concerned about the risks.

Some of these women are opting for alternative herbal remedies -- long used in many cultures to ease menopausal discomfort. Some plants, however, are sources of estrogens as well, and treatments or remedies derived from these will have the same effects that women concerned about estrogen are wary of.

Another alternative option is acupuncture. A 1991 study suggested that acupuncture decreased the frequency of hot flashes, but more studies are needed.

Food supplements such as Vitamin E have been enthusiastically touted by some. Research has not shown that Vitamin E works better than a placebo, and there is no concensus on how much to take.

Mind-body therapy, hypnosis and massage can relieve the anxiety and stress of menopause, as well.

A woman can develop her own self-awareness technique for mastering hot flashes. Each woman has a unique hot-flash pattern. Begin by keeping a diary: record your activities and what you eat. Your hot flashes may be more frequent or intense at certain times of the day. Learning when to expect them may bring a feeling of control.

You may find that certain foods or situations provoke hot flashes. Cotton night clothes and bedding are generally more comfortable than synthetics. Talk to other women and trade your tips.

Prescription drugs such as Bellergal and certain antihypertensive medications may help hot flashes.

Osteoporosis and heart disease are best offset by a balanced low-fat, high-fiber diet, calcium supplements and regular weight-bearing exercise.

In some cases, calcium and exercise are not enough to stop bone loss or strengthen bones if a woman has osteoporosis.

Alendronate sodium has been shown to rebuild bone in women past menopause. This drug should be used with caution, especially by women with certain digestive problems. It should not be used by women who have disorders of the esophagus or by women who are unable to stand, sit upright for at least 30 minutes, or who have low levels of calcium, severe kidney disease, or are pregnant or nursing.

Some Final Thoughts
The simplest formula for a healthy body is one every woman should stick to. Eat a balanced calcium-rich diet, don't smoke, don't abuse alcohol and other drugs, exercise a minimum of two to three times a week, and visit your health-care provider on a regular basis.

This formula, however, requires for many a drastic change from former habits, and may not be easy to adjust to.

I suggest beginning slowly. Take on what you can. You will see that the combination works. You will feel good as time begins to pass.

It is my hope, as a woman, a physician and a speaker on health and women's issues, that you will pass on what you have learned from this book and your own experience to those you love and care for. It has been my pleasure to share what I know with you.

Now it's your turn --share this website with a friend!

Wishing you the best of health and luck in taking good care of yourself,

Carolle Jean-Murat, MD, FACOG