Frequently Asked Questions

When we menstruate, we have fluctuating hormones throughout our cycle. Right before our period starts, we have low estrogen levels, which can contribute to less lubrication in the vagina. Some people report that their incontinence and prolapse symptoms worsen right before their period. This is a glimpse into what happens once we reach Menopause and no longer have circulating estrogen. Vaginal dryness, incontinence, prolapse symptoms, and UTI are more likely as we approach and move beyond Menopause.

The pelvic floor plays a role in helping keep our internal organs in place. When the bladder, the uterus and/or the rectum shift out of their proper anatomical position, they can bulge into or descend into the vagina. Pelvic organ prolapse is the overall term, but we can get more specific based on the organ. A bladder prolapse is also called a cystocele or anterior wall prolapse. A uterine prolapse is called a uterine prolapse or womb prolapse. When the rectum bulges into the vagina, it is called a rectocele or a posterior wall prolapse. When the rectum bulges out of the anus, it is called a rectal prolapse, which can happen in both male and female anatomy.

Prolapse is graded based on how close the bulge is to the entrance to the vagina. Early-stage prolapse is often asymptomatic, and we have the best chance of improving or sometimes even reversing the condition. More advanced prolapse when the bulge is at the entrance to the vagina or protruding outside of the entrance is not reversible but can be improved.

Pelvic floor muscle training is an essential element in healing prolapse. Some may benefit from a pessary like an orthotic for the pelvic organs. An exercise technique called the hypopressive method or low-pressure fitness is beneficial in improving symptoms, especially for bladder and uterine prolapse. A combination of pelvic floor exercise, hypopressives, and avoiding constipation is the best home treatment.

Surgery is an option and can be a great choice, but trying conservative approaches like physical therapy, pelvic floor exercise, hypopressives, and pessaries is crucial. It is also essential to address constipation, which often contributes to pelvic floor dysfunction. All these steps will help and may even allow someone to avoid surgery, but if it is still chosen, it can be considered pre-hab before surgery. It is also crucial for people to remember that even though surgery can eliminate symptoms, the need for pelvic floor muscle training remains an essential part of life.

The tissues in our pelvis and vagina love estrogen. When we reach Menopause, we are no longer producing estrogen, so the tissues that have relied on estrogen for their suppleness and integrity start to become thinner and drier. This can contribute to itching, burning, pain, and incontinence and is often referred to as genitourinary syndrome of Menopause. Local vaginal estrogen is beneficial, as is a vaginal moisturizer formulated with hyaluronic acid.

Post-menopause includes all the years beyond Menopause.

Each woman's menopause experience is different. Many women who undergo natural Menopause report no physical changes during the perimenopausal years except irregular menstrual periods that eventually stop when they reach Menopause. Other changes may include hot flashes, difficulty sleeping, memory problems, mood disturbances, vaginal dryness, and weight gain. Not all these changes are hormone-related, and some, such as hot flashes and memory problems, tend to resolve after Menopause. Maintaining a healthy lifestyle during this transition is essential and can prevent or blunt some changes

Some women report sleep disturbances (insomnia) around Menopause, and women and their healthcare providers sometimes attribute them to menopause symptoms. However, there are many reasons for sleep disturbances besides menopausal night sweats (simply hot flashes at night). Your sleep disturbances may be caused by factors affecting many women beginning at midlife, such as sleep-disordered breathing (sleep apnea), restless legs syndrome, stress, anxiety, depression, painful chronic illnesses, and some medications. Any treatment should first focus on improving your sleep routine—use regular hours to sleep each night, avoid getting too warm while sleeping, and avoid stimulants such as caffeine and dark chocolate. When lifestyle changes fail to alleviate sleep disturbances, your clinician may want to refer you to a sleep center to rule out sleep-related disorders before initiating prescription treatment. If your sleep disturbance is related solely to hot flashes, hormone therapy will likely help.

Memory and other cognitive abilities change throughout life. Difficulty concentrating and remembering are common complaints during perimenopause and the years right after Menopause. Some data imply that even though there is a trend for memory to be worse during the menopause transition, memory after the transition is as good as it was before. Memory problems may be more related to normal cognitive aging, mood, and other factors than to Menopause or the menopause transition. Maintaining an extensive social network, remaining physically and mentally active, consuming a healthy diet, not smoking, and consuming alcohol in moderation may all help prevent memory loss. Atherosclerosis (hardening of the arteries) may also contribute to mental decline. Aim for normal cholesterol, average weight, and normal blood pressure to help protect your brain. Women concerned about declining cognitive performance are advised to consult their healthcare providers.

Studies suggest that hormones may play a role in headaches. Women at increased risk for hormonal headaches during perimenopause have already had headaches influenced by hormones, such as those with a history of headaches around their menstrual periods (so-called menstrual migraines) or when taking oral contraceptives. Hormonal headaches typically stop when Menopause is reached and hormone levels are consistently low. Most headaches are not required or can be treated with non-prescription pain medications. Some headaches, however, can be severe. More serious headaches, including migraines, may require prescription drugs; however, care should be taken to monitor the use of these drugs. If a headache is unusually painful or different from those you have had before, seek medical help promptly.

Most women transition into Menopause without experiencing depression, but many report symptoms of moodiness, depressed mood, anxiety, stress, and a decreased sense of well-being during perimenopause. Women with a history of clinical depression or a history of premenstrual syndrome (PMS) or postpartum depression seem to be particularly vulnerable to recurrent depression during perimenopause, as are women who report significant stress, sexual dysfunction, physical inactivity, or hot flashes. The idea of growing older may be difficult or depressing for some women. Sometimes Menopause comes at the wrong time in a woman's life. She may have other challenges in midlife, and Menopause gives her one more problem on her list. It has been suggested that mood symptoms may be related to erratic fluctuations in estrogen levels, but limited data exist on why this occurs. Antidepressants are the primary pharmacologic treatment for menopause-associated depression. Menopause hormone therapy and contraceptives can be off-label, especially in women with concurrent hot flashes. The wide range of psychological symptoms reported during the menopause transition, from irritability and blue moods to the recurrence of major depression, can be identified and often treated by a woman's primary care provider or a menopause practitioner.

Vaginal dryness is widespread during Menopause. It is just one of a collection of symptoms known as the genitourinary syndrome of Menopause (GSM) that involves changes to the vulvovaginal area and the urethra and bladder. These changes can lead to vaginal dryness, pain with intercourse, urinary urgency, and sometimes more frequent bladder infections. These body changes, and symptoms are commonly associated with decreased estrogen. However, decreased estrogen is not the only cause of vaginal dryness. It is essential to stop using soap and powder on the vulva, stop using fabric softeners and softener products on your underwear, and avoid wearing panty liners and pads. Vaginal moisturizers and lubricants may help. Your healthcare provider should evaluate persistent vaginal dryness and painful intercourse. If it is determined to be a symptom of Menopause, vaginal dryness can be treated with low-dose vaginal estrogen or the oral selective estrogen-receptor modulator ospemifene can be used. Regular sexual activity can help preserve vaginal function by increasing blood flow to the genital region and helping maintain the size of the vagina. Without sexual activity and estrogen, the vagina can become smaller and dryer.

Sexual desire decreases with age in both sexes, and low desire is common in women in their 40s and 50s but not universal. Some women have increased interest, while others notice no change at all. There is no significant drop in testosterone at Menopause. If lack of interest is related to discomfort with intercourse, estrogen may help. What is important to remember is that a full range of psychological, cultural, personal, interpersonal, and biological factors can contribute to declining sexual interest, so if the decline in desire is bothering you, tell your healthcare provider. A clinical evaluation can identify any underlying medical or psychological causes of low sexual desire, which can be treated appropriately.

Aging skin undergoes loss of structural proteins (collagen) and elasticity, which creates sags and wrinkles. It also becomes less able to retain moisture, leading to increased dryness. Hormones play an essential role in skin health. In particular, for women, diminished estrogen levels at Menopause contribute to a decline in skin collagen and thickness. Beyond hormone changes, several other factors can increase the visible signs of aging skin. In smokers, the effects of aging are more pronounced, and long-time smokers have more skin damage. Maintaining skin health is one of several good reasons not to smoke or to quit smoking. Exposure to sunlight and other ultraviolet (U.V.) light sources is another significant factor in skin changes. Long-term U.V. ray exposure causes adverse effects on skin appearance, including lines, wrinkles, rough texture, and brown spots, to build up over time. Aging skin also is more prone to skin cancer.

For this reason, use of a good sunscreen is essential. Women should use a broad-spectrum sunscreen for optimal U.V. protection, which blocks UVA and UVB rays. Ideally, it should be applied daily to exposed areas and reapplied every 2 to 3 hours during outdoor activities. Avoiding the sun during peak hours (11 am to 3 pm) and wearing a broad-brimmed hat and solar protective clothing are also advised. Avoid tanning to ensure healthier, more attractive skin—tanned skin means that skin is damaged. Other skin-healthy habits include eating a well-balanced diet, getting adequate sleep, and drinking adequate water. A moisturizer also can minimize water loss from the skin and make it appear more hydrated. Most cream-based moisturizers contain ingredients that boost the outer layer of the skin. Other components, such as hyaluronic acid and topical retinoids, have been shown to provide skin benefits.

No. Women and girls have urinary incontinence (involuntary leaking of urine), but it increases with age. Other factors associated with incontinence include diabetes, obesity, weight gain, depression, hysterectomy, family history, and use of hormone therapy. Some pelvic floor disorders (the muscles, ligaments, and connective tissue that support a woman's internal organs) also may be responsible for urinary leakage. Embarrassment and lack of awareness about effective treatments are the main reasons women do not seek care. Once you have been examined to determine the cause of the leakage, your healthcare provider can provide strategies and treatments to manage this condition, no matter the cause.

Hot flashes are the hallmark symptom of Menopause. Although their exact cause still is not fully understood, hot flashes are thought to result from changes in the hypothalamus, the part of the brain that regulates the body's temperature. If the hypothalamus senses that a woman is too warm, it starts a chain of events to cool her down. Blood vessels near the skin's surface begin to dilate (enlarge), increasing blood flow to the surface to dissipate body heat. This produces a red, flushed look on the face and neck of light-skinned women. It may also make a woman perspire to cool the body down. Women may sense their hearts beating faster. A cold chill often follows a hot flash. A few women experience only the chill.

Menopause-related hot flashes usually follow a consistent pattern unique to each woman, but the pattern differs significantly from woman to woman. Some hot flashes are easily tolerated, some annoying or embarrassing, and others debilitating.

Other medical conditions such as thyroid disease, infection, or (rarely) cancer can cause hot flashes too. Drug therapies such as tamoxifen for breast cancer, raloxifene for osteoporosis, and some antidepressants also produce them. Do not assume that all hot flashes are caused only by Menopause. If it is unlikely that Menopause is the cause or if there are other unusual symptoms, consult your healthcare provider.

Most women experience hot flashes for six months to 2 years, although some reports suggest that they last considerably longer—as long as ten years, depending on when they began. For a small proportion of women, they may never go away. It is not uncommon for women to experience a recurrence of hot flashes more than ten years after Menopause, even into their 70s or beyond. There is no reliable way of predicting when they will start—or stop.

Although the treatments for hot flashes do not cure hot flashes, they offer relief. Hot flashes usually fade away without treatment, and no treatment is necessary unless hot flashes are bothersome. A few women have an occasional hot flash forever. Several low-risk coping strategies and lifestyle changes may help manage hot flashes, but prescription drug therapy may be considered if hot flashes remain very disruptive. Prescription hormone therapy approved by FDA and Health Canada—systemic estrogen therapy and estrogen-progestogen therapy for women with a uterus—are the standard treatments. Another FDA-approved hormone product for women with a uterus combines estrogen with the selective estrogen receptor modulator bazedoxifene instead of a progestogen. Bazedoxifene is an estrogen agonist/antagonist, which works like estrogen in some tissues while inhibiting estrogen activity in others. In this case, it helps to protect the uterus from cancer. For women who prefer not to take hormones or cannot take hormones safely, nonhormone drugs approved to treat depression called selective serotonin-reuptake inhibitors (SSRIs), be effective in treating hot flashes in women who do not have depression. The only SSRI FDA has approved thus far for treating hot flashes is paroxetine 7.5 mg. Other antidepressants, certain drugs used to treat high blood pressure, a medication for sleep, and gabapentin, a drug used to treat epilepsy and migraine, have shown some effectiveness.

Hormone therapies are the prescription drugs used most often to treat hot flashes and genitourinary syndrome of Menopause (GSM), which includes vaginal dryness after Menopause. For hot flashes, hormones are given in pills, patches, sprays, gels, or a vaginal ring that delivers hormones throughout the body—known as systemic therapy. For genitourinary symptoms, hormones are given in creams, pills, or rings inserted into the vagina. An approved pill is also available to treat genitourinary symptoms that are not considered a hormone but do affect estrogen receptors, mostly in and around the vagina.

Systemic hormones include estrogens—the same or similar to the body's natural estrogens—and progestogens, which include progesterone, the body's natural progestogen, or a similar compound. Another approach to systemic hormone therapy is a pill that combines conjugated estrogens and a compound known as a SERM (selective estrogen receptor modulator) that protects the uterus but is not a progestogen. Women who have had a hysterectomy (had their uterus removed) can use estrogen alone to control their hot flashes. Women who still have a uterus must take a progestogen in addition to estrogen or the estrogen-SERM combination to protect against uterine cancer. Systemic hormones are very effective for hot flashes and have other benefits, such as protecting your bones. They also can carry risks, such as blood clots and breast cancer. Vaginal estrogen therapy for GSM after Menopause is administered into the vagina and is effective for moisturizing and rebuilding tissue. Very little goes into blood circulation, so the risks are far lower. It would help if you discussed your risks and preferences with your healthcare team to determine whether hormone therapy or alternatives, including FDA-approved nonhormonal therapies, suit you.

Sometimes women have side effects from hormone therapy. If any of these symptoms occur, discuss them with a healthcare provider:

• Uterine bleeding
• Nausea
• Breast tenderness or pain • Abdominal bloating
• Fluid retention in arms or legs
• Blurry vision
• Headaches
• Dizziness
• Mood change

Many side effects are temporary, so unless they are severe or include bleeding, give hormone therapy for three months to see whether the discomfort resolves. Lowering the dose or switching to another type of estrogen or progestogen may help reduce side effects.

Hormone therapy is not a good choice for every woman. For some, the risks outweigh the benefits, so careful consideration with a healthcare provider is advised. Women with breast cancer, uterine cancer, unexplained uterine bleeding, liver disease, a history of blood clots, and cardiovascular disease should not use hormone therapy/p>

The term bioidentical hormone therapy began as a marketing term for custom-compounded hormones. However, it is taken to mean hormones with the same chemical and molecular structure as hormones produced in the body. Bioidentical hormones do not have to be custom-compounded (meaning custom mixed). Many well-tested, FDA-approved hormone therapy products meet this definition and are commercially available from retail pharmacies in various doses, allowing you and your doctor to customize your therapy to meet your needs. Custom-compounded hormones are not safer or more effective than approved bioidentical hormones. They are not tested for safety and effectiveness or to prove that the active ingredients are absorbed appropriately or provide predictable levels in blood and tissue. They may not even contain the prescribed hormones, which can be dangerous. For example, when the progesterone level is too low, you are not protected against endometrial (uterine) cancer. When estrogen levels are too high, there can be an overstimulation of the endometrium and breast tissue, putting you at risk of endometrial and possibly breast cancer.

A. Menopause, whether natural or induced, is called premature when it happens at age 40 or younger. This occurs in about 1% of women in the United States. Premature Menopause that is not induced can be genetic, metabolic, autoimmune, or the result of other poorly understood conditions. Menopause that occurs before age 40 should be evaluated thoroughly.

A. Women experiencing premature Menopause that is not medically induced go through perimenopause and may have the same symptoms as women with natural Menopause, including hot flashes, sleep disturbances, and vaginal dryness. However, compared with women who reach Menopause at the typical age, women who experience premature Menopause—whether natural or induced—spend more years without the benefits of estrogen and are at greater risk for some health problems later in life, such as osteoporosis and heart disease. You may need a complete evaluation to diagnose the reason for your Menopause—it could be an underlying condition that needs treatment.