MENOPAUSE

One Woman’s Story, Every Woman’s Story

A Resource for Making Healthy Choices
1

Table of Contents

What is menopause? Basic definition, average age, who is affected 4

But what is Reproductive life stages 4

menopause, really?

What symptoms Signs that menopause is approaching 6 

should I look for?

Why do menopause Changing hormone levels, irregular

symptoms develop? menstrual cycles 9

What about sex, Changes in interest in sex, chance of pregnancy,

pregnancy, and AIDS? risk of HIV/AIDS 11

What could happen Osteoporosis, cardiovascular disease 12

after menopause?

How can I Estrogen replacement therapy, hormone 

manage the symptoms replacement therapy 16

of menopause?

What are the benefits Can hormones protect against heart disease, 

and risks of using hormones increase breast cancer risk, help memory

after menopause? problems, prevent Alzheimer’s disease 18 

What can I do now? Other approaches to preventing or controlling 

heart disease, osteoporosis, breast cancer, and 

urinary problems 24

Would plant estrogens Explanation of phytoestrogens 25

help my symptoms?

Are there other things Tips for being fit and active as you age 26

I should do to stay healthy?

What does the future hold? Discussion of some research underway 28

What does that word mean? Glossary (Look for the italicized words in the text) 30

Where can I get more Resources 31

information?
3

I am a woman approaching middle age. My

name might be Carol or Isabella or Arlene 

or Lily. I might be Hispanic/Latino, AfricanAmerican, Asian, Native American, Caucasian, or belong to any other

racial or ethnic group. I might be thin, average weight, or overweight. I am any woman, but, perhaps, I am you. Middle age. It’s

hard to believe. That used to sound so old, but

I know I’m not old. I am noticing some changes

in my body though. Sometimes at night I

wake, kicking off the covers and sweating, even in the middle of winter. My menstrual cycle, which was always regular, is now irritatingly

unpredictable. I’ve put on weight, especially

around my waist. I never seem to get enough

sleep. Could this be menopause?
Menopause. That’s something that happens to your

mother. Except my mother

never talked to me about it. She

says her mother never talked about

it either. Now my friends and I are

starting to discuss menopause

often when we’re together...on the

sidelines of our kids’ soccer games, at

parties, during coffee breaks at work.

And there are ads for menopause

treatments everywhere—my women’s

magazines, the Internet, television.

They even talk about it on the

evening news! I’m not sure what to

expect, but I feel better knowing I’m

not going through this alone. 

Menopause, also known as “the

change” or “change of life,”

occurs at a time in the reproductive life of women when the production of estrogen (ES-tro-jen)

and progesterone (pro-JES-te-rone),

two hormones, changes dramatically. After menopause, women

are no longer able to have children and may become more

prone to certain diseases. Women

have gone through menopause

at around the age of 50 for hundreds, if not thousands of years.

According to some experts, even

the ancient Greeks described it as

occurring around age 50. 

Why do we seem to hear so

much about menopause now? 

Numbers, for one thing. 

The baby boomers—people born

between 1946 and 1964—are 

getting older. Almost 2 million

women turn 50 each year now.

In the year 2000, most of the

nearly 42 million American

women over the age of 50 were

past menopause. That’s almost

one out of every three American

women. And many of the 

female baby boomers want to

understand what is happening 

to their bodies. 

Progress in research to answer

their questions keeps menopause

in the news. Some of these investigations are conducted or supported by the National Institute

on Aging (NIA), part of the

National Institutes of Health

(NIH). Some studies are examining how estrogen affects different

parts of the body; others are evaluating the possible protective

effects of this hormone on the

heart and brain. Researchers are

also exploring the possible risks

associated with replacing some of

the estrogen the body no longer

produces after menopause.

Sometimes these investigations

stimulate even more questions,

but scientists hope that this

decade will be a time when we

gain a better understanding of

estrogen and its benefits and risks.

When I hear “menopause,”

I think “hot flashes.” Is

that what it is? Is it a disease that I need to treat?

Menopause is a part of every

woman’s reproductive life cycle.

It is not an illness that necessitates treatment. To understand

menopause, you first need to

understand the whole reproductive process and how your body

changes from stage to stage.

Some of the important times in

your reproductive life are:

Puberty is the time in a young

girl’s life when increased estrogen

production begins to cause 

physical changes in her body,

such as the development of

breasts. During this time her

menstrual cycle begins, and 

her first “period” occurs, 

generally around the age of 

12-1/2 years. This is known 

as menarche (me-nar-key). 

4

is menopause, really?

But what 

menopause?

What is 
Premenopause includes the

years between puberty and

menopause. For many women

their production of hormones is

regular, so their periods are usually predictable. 

Perimenopause, also formerly

known as the climacteric, begins

before menopause. Again your

body begins to experience

changes—both physical and hormonal. The symptoms we associate with menopause such as hot

flashes and irregular menstrual

cycles may start to appear. The

average perimenopause lasts for 

4 years. It continues, by definition, through the 12 months 

following your last period.

Menopause is a point in time—

the time of your last menstrual

cycle. However, your doctor cannot know for sure that it was

your last period until you have

been period-free for 1 year without being pregnant, breastfeeding, or using certain medicines,

all of which can also cause menstrual cycles to cease.

◗ Natural menopause usually

occurs some time between the

age of 45 and 55. 

◗ Surgical menopause may

occur at any age if you and your

physician decide that removal

of your uterus (hysterectomy)

and/or both ovaries (bilateral

oophorectomy) is medically

necessary.

◗ Premature menopause is said

to occur before the age of 40.

What factors affect when you

have your last period? If you

smoke, you could go through

menopause about 1-1/2 years earlier than your friends who don’t

smoke. Some studies indicate that

thinner women, and AfricanAmerican and Hispanic women

also tend to go through

menopause at an earlier age.

Other evidence suggests that if

you used oral contraceptives (“the

pill”) or have had children, you

might go through menopause just

a little later than other women. 

Postmenopause is the stage of

life after menopause. It begins

with your last period and continues for the rest of your life. One

hundred years ago some women

associated menopause with the

end of life. The average life

expectancy for a woman born in

1900 was 50.7 years. Indeed,

throughout history many women

did not live long enough to go

through menopause. It’s easy to

see why they connected

menopause with death. However,

advances in medicine and disease

prevention have greatly increased

life expectancy. A girl born in

1990 can expect to live nearly 

79 years. This means that she will

probably live a third of her life

after menopause. 

▼ Puberty

▼ Premenopause

▼ Perimenopause

▼ Menopause

▼ Postmenopause

Reproductive life stages:

5

Menopause timeline

12 months

Perimenopause

Menopausal transition Postmenopause

World Health Organization. Research on the menopause in the 1990s: report of WHO scientific group. 

Geneva: WHO Technical Series 866; 1996; page 13.

Final menstrual period/menopause
A few months ago I started

waking up in the middle 

of the night sweating. I

thought it was because our

region was experiencing a

heat wave. But, now it’s

almost the end of November and

cold outside. Not only do I still

wake up hot sometimes during the

night, but I also find myself

flushed and sweating at times during the day. I would turn the heat

down, except the rest of my family

think the house is already cold.

And I can never predict when my

period is coming. Is that perimenopause?

If you are in your forties, all those

symptoms could well be an indication that you are approaching

menopause, although some

women do not report any signs

during perimenopause. Some of

the things to look for are:

Irregular menstrual cycles or

changes in bleeding are often

the first sign of perimenopause.

Most women experience irregular

periods—sometimes longer

cycles, other times shorter ones.

The actual period may last longer

or end more quickly. The flow

could be lighter or heavier. There

are many ways your cycle can

change during perimenopause. If

you are concerned about the

irregularities, check with 

your doctor.

Hot flashes or flushes are one

of the most common signs of

perimenopause. As many as 

75 percent of Caucasian women

get them, but in some ethnic

groups, they are much less common. A hot flash begins with a

feeling of heat in your face and

upper body. The skin may appear

flushed or red as blood vessels

expand. Sometimes heavy sweating and cold shivering follow.

Some hot flashes may cause only

a slight feeling of warmth or a

light blush. Others may drench

your clothes. Night sweats are

hot flashes that occur during

your sleep. Often, they are severe

enough to wake you, which can

leave you feeling tired during the

day. Hot flashes can occur several

times an hour, a few times a day,

or once or twice a week. 

You might wish to try to identify

if there is a trigger for your hot

flashes—stress, caffeine, spicy

foods, hot drinks, and alcohol are

a few that seem to bother some

women. Avoiding a trigger might

help reduce the number of hot

flashes that trouble you. Estrogen

supplements (page 16) are quite

effective in controlling this

symptom—70 to 90 percent of

women using postmenopausal

hormone therapy gain relief this

way. However, if you prefer not

to take estrogen, early studies of

two antidepressants, fluoxetine

and paroxetine, suggest that in

the future they may prove to be

promising possible treatments. 

Other steps to relieve hot flashes

include: 

◗ sleeping in a cool room,

◗ dressing in layers which can 

be removed at the start of a 

hot flash,

◗ having a drink of cold water or

juice when you feel a hot flash

coming on, 

◗ using sheets and clothing that

let your skin “breathe,” and 

◗ avoiding spicy foods, alcohol,

and caffeine. 

Once you are past menopause,

the frequency of hot flashes

should diminish. They 

usually disappear altogether 

in a few years.

Changes in the vaginal and

urinary tracts result from the

loss of the fatty tissue and collagen under your skin and lessened

6

▼ Irregular menstrual 

periods,

▼ Changes in bleeding 

patterns during the 

menstrual cycle,

▼ Hot flashes, and

▼ Sleep problems and 

tiredness.

Signs of the approach 

of menopause:

should I look for?

What symptoms 
blood flow as we age and as

estrogen levels change. The tissues in the vagina become dry

and thinner and secrete less

mucus. This, in turn, makes

them more delicate and susceptible to tearing and infection.

Sexual intercourse may become

painful, but some experts believe

that if you continue to have 

sexual relations, you might have

fewer problems with dryness or

tightening of the vagina. A

water-based lubricant, but not

petroleum jelly, may relieve your

vaginal discomfort. Urinary problems such as frequent infections

and urine leakage sometimes

develop at this time also. While

these changes are not unusual,

you should still see your doctor

who may help you control any

problems that result. 

Libido, interest in having sex, 

as well as the ability to become

sexually aroused, change for

some women. Some lose interest

in sex or find it uncomfortable.

Other women, however, become

more interested in sex after

menopause. Pregnancy is no

longer a concern and they 

feel freer and more relaxed 

in general.

Problems sleeping and the

resulting fatigue may bother

you. You might wake in the middle of the night because of night

sweats or the need to go to the

bathroom. Then you may have

trouble getting back to sleep. Or,

you could have a problem falling

asleep when you go to bed or

waking early in the morning.

The tiredness that results makes

working or performing mental

activities during the day difficult.

Physical changes are common

at this time of life. These could

be related to perimenopause or

could simply be a result of getting older. You might experience

a thickening around your waist.

You could lose muscle mass and

gain more fatty tissue. Your skin

might become thinner and lose

its elasticity. Some women also

experience joint and muscle pain

and stiffness. 

Memory problems, as well as

psychological and emotional

symptoms, such as depression,

mood swings, and irritability, are

some complaints of women in

perimenopause. Some of these,

especially memory problems,

may be associated with growing

older. Fatigue and mid-life

stresses may contribute to these

symptoms. Both middle-age

women and men commonly

report short-term memory problems. Whether changing estrogen levels cause any of these is

not known, but the brain is one

of several body organs sensitive

to the effects of this hormone. 

Changes in your hormones and

body are not the only things 

that women may have to adjust

to at this age. There are several

potential mid-life issues that

could create stress and make

menopausal problems more 

difficult to handle. If you have 

a family, there are probably

changes at home—the “empty 

7
nest,” children leaving home for

college, work, or marriage. If you

waited to start a family, young

children are still in need of attention when you are possibly tired

from having trouble sleeping.

Perhaps there are marital problems; you might even be going

through a divorce. If you work,

you may be taking a different

look at your career, beginning to

contemplate retirement, or feeling challenged by younger

coworkers. A major stress might

be caring for aging parents. As

our parents grow older, we are all

faced with many related issues—

their illnesses, their need for

assistance and caregiving, and

eventually their loss.

As part of the Study of Women’s

Health Across the Nation (SWAN)

supported by NIH, including the

NIA, scientists around the country are studying how women

from various ethnic groups in 7

American cities respond during

menopause. Early results 

suggest that there are indeed 

differences between these 

groups in the types and severity

of their menopausal symptoms.

For example, African-American

women report more symptoms

such as hot flashes and fewer

problems like stiffness, headache,

or insomnia than other groups.

Hispanic women reported urinary leakage more often than

others. Asian-American women

had fewer symptoms in general.

Women who were less active

reported more symptoms.

Caucasian women, especially

those with more education, 

were more likely to use postmenopausal hormones to treat

their symptoms. These investigators also found that of the ethnic

groups studied, African-American

women had the most positive

attitude about menopause, and

foreign-born Asian-American

women were the most negative

in their feelings about this

time of life.

If you have experienced surgical

menopause, you may face more

severe menopausal symptoms

than someone going through

natural menopause. Your symptoms may begin soon after

surgery. Your hot flashes may be

more severe, more frequent, and

longer lasting. You may be more

likely to develop heart disease

and osteoporosis. If the surgeon is

able to leave your uterus and at

least one ovary, menopause

should occur naturally. If only

your uterus is removed, your

menstrual periods will stop. In

some of these women who had

surgery, symptoms of menopause

may then occur immediately; in

others they may develop later or

not at all. 

8
I understand that menopause is a natural stage 

of life. I’d like to know 

how it happens. In the

1970s I burned my bra 

and demonstrated for

women’s rights. I’m not

going to just sit back and

suffer hot flashes like my mother

did—if I understand menopause,

maybe I can do something about it. 

Estrogen is produced by the

ovaries, and as you age, significant internal changes take place

that affect your production of

this hormone. Your two ovaries

are small oval-shaped organs

located on either side of the top

of your uterus. At birth they contained about 700,000 sac-like follicles which each enclose an egg.

Only about 400 to 500 of these

follicles ever mature fully and

release an egg during your menstrual cycles. The rest degenerate

and disappear over the years.

The maturing follicles are

involved in the production of

estrogen and in the ripening 

of an egg. 

During your reproductive years,

the hypothalamus, a part of your

brain, releases gonadotropinreleasing hormone (GnRH). This

causes your pituitary gland,

located at the base of the brain,

to secrete luteinizing hormone

(LH) and follicle-stimulating hormone (FSH). LH and FSH in turn

stimulate the maturation of the

follicles in your ovaries and the

release of a new egg from its 

follicle each month. The follicle

also increases production of the

sex hormones estrogen and progesterone, which thicken the lining of your uterus. This enriched

lining is prepared to receive and

nourish a fertilized egg following

conception. If fertilization does

not occur, estrogen and progesterone levels drop, the lining of

your uterus breaks down, and

your period starts.

As perimenopause progresses,

your ovaries begin to shrink and

follicles disappear at an accelerating rate. Hormone levels fluctuate as your ovaries attempt to

maintain their former level of

hormone production. Your

ovaries become resistant to FSH,

and the pituitary releases more

and more of it trying to keep up

estrogen production. This can

cause irregular menstrual cycles

9

Why do menopausesymptoms develop?

▼ Levels of estrogen and 

progesterone can 

change erratically from

month to month as 

you age and get closer 

to menopause.

▼ Pregnancy is still 

possible until periods 

stop for 1 year.

▼ Ovaries stop releasing 

eggs around the time 

of menopause. Ovary

Fallopian Tube

Uterus

Cervix

Vagina Endometrium

Remember:

Reproductive System
and unpredictable episodes of

heavy bleeding during your

period. Your doctor may do a

blood test for FSH. When you

have been period-free for 1 year

and have an elevated FSH level

(usually over 30-40 IU, international units), you have reached

menopause. FSH levels tend to

fluctuate during perimenopause,

so these test results alone are not

used to diagnose menopause.

Even after menopause, estrogen

production by your ovaries does

not always stop completely.

Although levels of estradiol, one

form of estrogen, drop, a weaker

estrogen, estrone, continues to be

produced especially in fat tissue

with help from the adrenal

glands. Although this form of

estrogen is weaker than the estradiol produced by your ovaries, it

increases with age and with the

amount of fat tissue. 

Progesterone is another sex hormone also produced by your

ovaries. Its job is to help prepare

your uterus for the arrival of a

fertilized egg and to shed this 

lining if an egg is not fertilized. 

If the ovary does not produce

enough progesterone to do 

this, the lining may continue 

to grow until a drop in the 

amount of estrogen brings on 

a menstrual cycle. Heavy 

bleeding may then accompany

that period as the uterus sheds 

its unusually full lining. 

10

Pineal body

Endocrine glands 

secrete hormones 

into the blood and 

interact with one 

another to help 

regulate total body 

metabolism, growth, 

and reproduction.

Hypothalamus

Pituitary gland

Parathyroid

glands

Thyroid

Thymus

Pancreas

Adrenal gland

Hormone Levels

Premenopause (180 days)

Perimenopause (180 days)

Postmenopause (180 days)

Excerpted from the September 1999, issue of

the Harvard Women’s Health Watch, 

© 1999, President and Fellows of Harvard

College.

Estrogen Progesterone

FSH LH

Ovary

Endocrine System

How they change as you age
My husband calls me “red

hot mama.” But he’s talking about my hot flashes,

not my interest in sex! That

seems to have almost disappeared. When we do have

sex, do I have to worry

about getting pregnant?

What should I do?

Sex 

Many people think menopause

brings a reduced interest in sex.

Both men and women may find

themselves taking longer to

become sexually aroused as they

age. However, medications such

as antidepressants, tranquilizers,

and high blood pressure drugs

can alter your sexual desire.

Health problems such as heart

disease, diabetes, or arthritis,

concern about your appearance,

and stress in your daily life can

also inhibit your sexual response. 

In the year 2000, scientists at 

the New England Research

Institute and the University of

Massachusetts Medical School

found that some women do

experience changes in libido

with menopause and that these

women also believe that a lessening interest in sex accompanies

growing older. Interestingly, the

researchers determined that such

changes are not related to estrogen loss, but instead to other factors such as attitudes, general

health, and marital status.

Estrogen loss was related only to

pain during intercourse.

If you are one of the women who

loses interest in sex around this

time, talk to your doctor. He or

she will consider all possible

causes. Women’s bodies also produce some of the male hormone

testosterone, and some scientists

think that changes in testosterone levels can lead to a drop

in libido. There is a little evidence suggesting that some

women may benefit from a small

amount of testosterone supplement, but the effectiveness of

this treatment needs further

study. Side effects of testosterone

in women include skin problems,

extra hair on the face and body,

and voice changes. 

Talk to your sexual partner also.

Let him or her know that 

you both may need to spend

extra time touching and kissing

before you become fully aroused.

If your intimacies have become

routine, try new ways or places—

be creative. 

Pregnancy

If you do not wish to become

pregnant at this age, continue

using contraception until your

doctor determines that you are

indeed past menopause. Since

estrogen and other reproductive

hormones are still produced by

the body during perimenopause,

an egg may still be released, and

pregnancy is possible. Irregular

menstrual cycles make it more

difficult to predict the time of

ovulation, when sexual intercourse is more likely to result in

pregnancy. If you are currently

using “the pill” as contraception,

your periods will continue to 

be regular even after you have

passed menopause. An oral 

contraceptive, even one with 

a low dose of estrogen, may 

also help control symptoms 

such as hot flashes.

and AIDS ? 

What about sex, pregnancy,

Points to remember:

▼ Most women do not lose

their ability to enjoy sex.

▼ Loss of interest in sex is 

not usually related to 

lack of estrogen.

▼ Use contraception if you 

do not want to become 

pregnant.

▼ Practice safe sex if you 

are not in a long-term 

relationship with one 

person. Take precautions 

to protect yourself from 

HIV/AIDS.

11
HIV/AIDS

The possibility of pregnancy will

disappear once you are a year

past your last period. The chance

of becoming infected by HIV

(human immunodeficiency

virus) and developing AIDS

(acquired immunodeficiency

syndrome) is something you

must consider as long as you are

sexually active. In fact, about 

10 percent, possibly as many as

15 percent of all people diagnosed with AIDS in the United

States are age 50 and older—

more than 75,000 Americans.

And this group is growing at an

increasing rate. Women who are

recently widowed or divorced 

but were married for many years

have probably never worried

about AIDS. Now they may be

starting to date again, and many

have no idea that HIV is a risk or

how it is spread. You can get HIV

by having unprotected sex with

an infected person, so always use

a male latex condom. The virus,

found in body fluids such as

blood, semen, and vaginal secretions, can enter your body

through any opening in the skin.

This means postmenopausal

women are especially at risk

because the tissues of the vulva

(the external female genital area

around the opening of the

vagina) or the lining of the

vagina become more fragile and

easily torn as estrogen levels fall.

Postmenopausal women having

sexual contact with other women

must remember that the membranes lining any body opening,

including the mouth and vagina,

are susceptible to HIV infection.

At this time, the Food and Drug

Administration has approved

two barrier methods for oral sex.

The Centers for Disease Control

and Prevention has information

on preventing HIV transmission

in lesbian couples, as well as heterosexual ones. 

My last period was 2 years

ago, and the hot flashes

and night sweats have

almost disappeared. Menopause wasn’t so bad. I guess

there’s nothing else to worry

about. I’m home free!

Not necessarily. Many tissues in

the body are sensitive to the

effects of estrogen—breast, bone,

heart and arteries, central nervous system, urinary and genital

tracts, and parts of the gastrointestinal system. Changing 

levels of estrogen could cause

problems in some of these. 

For example, as you age and go

through menopause, bone 

loss increases significantly, and

osteoporosis can develop. At 

this age cardiovascular (heart and

blood vessel) disease begins to

pose a significant threat to the

continued health and well being

of many women. Researchers are

12

after menopause?

What could happen
working to understand osteoporosis and the connection

between menopause, aging, and

heart disease. Perhaps then they

will be able to provide safe and

effective protection against these

illnesses in later life.

Osteoporosis

Many older women, and some

older men also, face the threat of

osteoporosis. At present 10 million Americans have this boneweakening disorder, and another

18 million are at risk of developing this disease because of bone

loss. Four out of every five of

these older adults at risk are

women. One out of every two

American women over the age 

of 50 will experience an osteoporosis-related fracture during

her life. For too many of those,

the fracture, especially if it is a

hip fracture, will end their ability

to live independently. 

These fractures are costly—both

in dollars, but also in personal

suffering. Treatment for osteoporotic fractures costs this country an estimated $13.8 billion per

year. Vertebral fractures lead to

curvature of the spine, loss of

height, and pain. Hip fractures,

which require major surgery and

hospitalization, are the most

expensive. Recovery from hip

fractures may necessitate many

hours of physical therapy. Worse,

between 12 and 20 percent of

those who suffer a hip fracture

do not survive for 6 months after

the break. At least half of those

who do survive require help in

performing daily living activities,

and 15 to 25 percent will need

long-term care. Still, with time

and appropriate therapy, many

hip-fracture sufferers can return

to living independently.

Bone is living tissue that is continuously undergoing two processes—the breakdown of old

bone and the formation of new

bone in its place. When more

bone is broken down than is

replaced with new tissue, osteoporosis can eventually result. The

bone becomes fragile. Its structure is less dense. Gradually, and

without discomfort, bone loss

leads to a weakened skeleton

incapable of supporting your

normal daily activities. Often,

the first sign of osteoporosis is a

bone that breaks under less stress

than would usually be needed to

break it, especially a bone in your

spine, wrist, or hip. 

For osteoporosis, the first step in

prevention is achieving maximum “peak” bone density when

you are young. This should be

done before the age of 30

because after that women (and

men) may begin to lose bone

strength slowly. Initially, this loss

is slow. In women it picks up

speed around the time of

menopause, slowing again a few

years later, but bone loss continues into old age. Building bone

density is achieved by eating calcium-rich foods as well as those

containing vitamin D, possibly

taking calcium and vitamin D

supplements (or getting at least

20 minutes of sunlight every

day), and doing regular weightbearing exercise (walking, running, stair climbing, or using

weights to exercise). 

Preserving bone strength after

menopause is the next step

toward preventing osteoporosis.

The same steps that helped build

bone early in life will help slow

13

Normal bone

Osteoporotic bone

Reproduced from J Bone Miner Res 1986; 1:15-21 with permission of the American Society 

for Bone and Mineral Research.
its loss after menopause, but

estrogen plays a role in building

bone. Falling estrogen levels contribute to the increased bone loss

that occurs at menopause. 

Replacing estrogen after

menopause through hormone

replacement therapy is considered the most effective way to

control bone loss. However,

estrogen effects are not limited to

bone. Sometimes it can affect

other tissues in the body in a

positive or negative way.

Researchers are taking a closer

look at estrogen to determine the

benefits and risks of hormone

replacement therapy. They are

also exploring ways to improve

its use. For example, scientists at

the University of California at

San Francisco demonstrated that

some women whose bodies produce modest amounts of estrogen after menopause have more

protection from hip or spine fracture after the age of 65 than

women who have undetectable

levels of estrogen in their blood.

This suggests that older, postmenopausal women may benefit

from low-dose estrogen supplements although further research

is necessary. 

There are several approaches, in

addition to estrogen supplementation, to preserving bone after

menopause. Drugs available to

prevent further bone loss include

bisphosphonates like alendronate and risedronate, calcitonin, and the SERM (selective

estrogen receptor modulator)

raloxifene (page 28). Still others,

including fluoride, parathyroid

hormone, and newer SERMs, are

under investigation. 

Cardiovascular Disease

The cardiovascular diseases

(CVD), which include heart disease and stroke, are the number

one cause of death in American

men. Most of us know that.

What many of us don’t always

realize is that this is true for

women, too. Between the ages of

45 and 64 years 1 in 10 American

women have some form of heart

disease. By age 65 one in four

women have heart disease. In

fact, more women that age die of

heart disease and stroke each

year than men do—more than

423,000 deaths in women in

1998. Heart disease kills more

than twice as many women as

the next biggest cause of death—

all forms of cancer combined—

and more than 11 times the

deaths due to breast cancer. 

Disorders of the heart and blood

vessel system include atherosclerosis (a narrowing and hardening

of the arteries), high blood pressure, angina (chest pain that

results from insufficient blood

getting to the heart), heart attack,

and stroke. Estrogen appears to

protect women against heart disease during their reproductive

years. After menopause, if you

14

▼ An increased risk of 

osteoporosis.

▼ Changing cholesterol 

levels—“bad” cholesterol 

levels go up. 

▼ A much greater chance of 

heart disease and stroke.

Vitamin D

400 IU* (international units)

600 IU*

Calcium

1,200** mg 

1,200** mg 

(The NIH recommends 1,000 mg daily if you are a woman over 50 using HRT

or 1,500 mg daily if you are a woman over age 50 and not using HRT, or anyone over age 65, with a maximum daily dose of 2,000 mg)

Age

National Academy of Sciences:

Daily calcium and vitamin D recommendations

*not to exceed 2,000 IU, **not to exceed 2,500 mg

51–70 

70 + 

After menopause be 

aware of:
have your cholesterol checked, you

may notice some changes there—

and not for the better.

Cholesterol and LDL (low-density

lipoproteins) levels may go up,

and your HDL (high-density

lipoproteins—the so-called

“good” cholesterol) level may go

down slightly. LDLs are the part of

cholesterol that enables fats to

attach to the walls of arteries, narrowing and, eventually, blocking

them. HDLs (think of H as in

healthy) help keep the arteries

clear, so that blood can flow

freely. If left untreated, elevated

LDL and total cholesterol levels

can increase the risk of stroke,

heart attack, and death. 

Some risk factors for cardiovascular disease such as a family history of heart disease cannot be

changed. But, the good news is

that there are things you can do

to reduce your chance of developing CVD. Early recognition of

your risk factors and lifestyle

changes can make a difference.

For example, in the year 2000, 

a report from the NIH-funded

Nurses’ Health Study supported

the idea that diet, exercise, and

not smoking help prevent heart

disease. Scientists at Brigham 

and Women’s Hospital in Massachusetts, Harvard Medical

School, and Harvard School of

Public Health began following

more than 84,000 nurses 

who did not have heart disease,

cancer, or diabetes in 1980. 

After 14 years of observation, 

the researchers found that 

certain women were less likely 

to develop heart disease. 

These women: 

◗ did not smoke, 

◗ exercised moderately (such as

brisk walking) at least 30 minutes a day, and 

◗ followed a diet that included a

lot of fiber, the vitamin folate, 

and unsaturated fatty acids, 

but was low in trans fat, foods 

that increase blood sugar, and 

saturated fat. 

15

Common causes of death in older women in 1998*

45-64 years 65 years and older

Heart Disease and Stroke 36,882 423,564

All Cancers, except Breast Cancer 48,315 159,897 

Breast Cancer 13,720 24,495

Chronic Obstructive Pulmonary Diseases 6,253 48,520

Diabetes Mellitus 5,952 28,112

Pneumonia and Influenza 2,434 47,199

Accidents and adverse effects 5,315 16,799 

Total deaths (all causes) 148,342 960,608

*Source: National Center for Health Statistics,www.cdc.gov/nchs/datawh/statab/unpubd/mortabs/gmwk250a.htm
16

I’ve tried unsuccessfully to

find a trigger for my hot

flashes, and dressing in layers only helps a little. Plus,

I’m worried about osteoporosis because my mom

has it. I’ve heard about

estrogen supplements. What

exactly are they?

There are three types of

estrogen produced by the

body—estrone (ES-trone),

estradiol (es-tra-DYE-ole), and

estriol (es-TREE-ol). Estradiol is

the strongest and most important before menopause. More

than 60 years ago, physicians

realized that restoring estrogen to

a woman passing through

menopause could relieve some of

the annoying symptoms of that

time and possibly protect her

against osteoporosis. In 1942 the

Food and Drug Administration

(FDA) approved the use of

Premarin, conjugated (or mixed)

equine estrogens (CEE) that

come from the urine of pregnant

mares, for treating the symptoms

of menopause. Since then, several forms of synthetic estrogens

have also become available to

treat menopausal symptoms and

to prevent osteoporosis. These

come in a variety of forms—

tablet, patch, cream, and vaginal

insert. Treatment with estrogen

alone (“unopposed estrogen”) is

called estrogen replacement therapy

Brand names of some, but not all, postmenopausal hormones

Estrogens

Pills Cenestin, Estinyl, Estrace, Estratab, Menest, Ogen, 

Ortho-Est, Premarin

Cream Estrace, Ogen, Ortho Dienestrol, Premarin

Vaginal Ring Estring

Patch Alora, Climara, Esclim, Estraderm, Estradiol, FemPatch, Vivelle

Injection Delestrogen, dep Gynogen, Depo-Estradiol, 

Depogen, Estra-L, Gynogen LA, Kestrone 5, Premarin, Valergen

Progestins

Pills/Capsules Amen, Aygestin, Curretab, Cycrin, Prometrium, Provera

Vaginal Gel Crinone

Injection Hylutin

Combinations

Pills Activella, Estratest, Femhrt, Ortho-Prefest, Premphase, Prempro

Patch Combipatch

Injection Depo-Testadiol, Depotestogen, Duo-Cyp, Valertest

of menopause?

How can I manage the symptoms

October 2000.

Sources: Physician’s Desk Reference 2000, Drug Facts and Comparisons, www.home.mdconsult.com,

www.druginfo.cc.nih.gov, www.nlm.nih.gov/medlineplus
(ERT), or sometimes postmenopausal estrogen therapy. 

Originally, doctors only prescribed estrogen alone. Since

estrogen stimulates the growth of

the endometrium (the lining of

the uterus) in preparation for

implanting a fertilized egg, it

turned out that giving unopposed estrogen could lead to

excessive growth of the cells in

the endometrial lining and

potentially endometrial cancer.

Today the preferred treatment in

women who still have their

uterus is called hormone replacement therapy (HRT), or sometimes

postmenopausal hormone therapy.

In this therapy estrogen is combined with another female sex

hormone, progesterone, to prevent uncontrolled growth of the

endometrium. Progestin, a synthetic progesterone, is usually

prescribed. Commonly taken as a

pill, progestin is also available as

an IUD (intrauterine device),

vaginal gel, patch, or shot. The

progestins most often used are

medroxyprogesterone acetate,

norethindrone, and micronized

progesterone. A woman whose

uterus has been removed does

not need progesterone and can

use estrogen alone.

There are two methods for taking

postmenopausal hormones—

cyclic (or sequential) and 

continuous combined. Often in

the cyclic or sequential method a

pill containing 0.625 mg of conjugated estrogens is taken daily,

with 5 or 10 mg of progestin

added for 10-14 days each

month. This regimen may cause

bleeding similar to menstrual

periods in most women. Another

approach is the continuous combined regimen in which 2.5 or 5

mg of progestin is taken every

day with the estrogen. With this

approach there is irregular spotting and bleeding that appears to

diminish within a year in most

women. If the light period or

spotting is too annoying, your

physician might consider altering the progestin dose. 

The patch is another way to

administer postmenopausal hormones. A patch is an adhesive

material containing hormones

that is placed on the lower

abdomen or buttocks and 

changed once or twice a week.

Sometimes the patch contains

estrogen and a progestin pill is

used to supplement it, if needed.

A combination patch containing

both hormones is now available.

The patch method can be better

for some women because hormones are absorbed slowly and

directly into the bloodstream

from the patch. When a pill is

taken, the medication goes first

from the stomach and intestines

into the liver where it is metabolized or broken down. This pass

through the liver leads to higher

levels of triglycerides and blood

clotting factors and an increased

incidence of gallbladder disease

in menopausal women, as well as

the positive effects estrogen has

on cholesterol, LDL, and HDL

levels. Some women have a bit of

irritation at the site where the

patch is placed.

17

Common generic forms of estrogen and progesterone

Estrogens

Conjugated estrogens Pill, cream, injection

Estradiol Pill, patch, injection, cream, 

vaginal ring insert

Esterified estrogens Pill

Estropipate (estrone) Pill, cream

Progesterones

Medroxyprogesterone acetate Pill, injection 

Norethindrone acetate Pill, patch (in combination with estradiol)

Micronized progesterone Pill, vaginal gel, suppositories

Combination

Conjugated estrogens and 

medroxyprogesterone Pill

Estradiol and norethindrone 

acetate Patch
If your symptoms are limited to

vaginal dryness, urinary leakage,

or vaginal or urinary infections,

you could use a vaginal estrogen

ring or cream instead of the 

oral or patch form. The vaginal

ring is a flexible ring placed in

the upper part of the vagina. It

contains such a low dose of 

estrogen that it may not protect

against osteoporosis. It needs to

be changed every 3 months.

Besides monthly bleeding, there

are a few other possible side

effects from taking estrogen and

progesterone. Breast tenderness

or enlargement, nausea, abdominal bloating, and headache are

some of the more common complaints associated with using

estrogen supplements. The addition of progesterone could lead

to irritability and mood changes

—almost like PMS, premenstrual

syndrome, which troubles some

young premenopausal women. 

Now I understand better

how estrogen works and how

it can help me, but I’ve

heard it may not protect me

from heart disease and that

it might even cause breast

cancer. Are there risks

involved in using unopposed

estrogen or estrogen and 

progestin? What are they?

Estrogen and estrogen with

progestin appear to be

effective and relatively safe,

particularly if used for less

than 5 years to control

your menopausal symptoms. However, there are

still many unanswered

questions about menopause and the benefits and risks

of long-term hormone replacement therapy. For example:

◗ Who will benefit from estrogen

supplements, and who will be

at increased risk of disease?

◗ Does estrogen prevent heart disease? Does it prevent heart

attacks? What about estrogen

in women who already have

heart disease?

◗ Does estrogen or progesterone

cause cancer? 

◗ Is estrogen the best way to prevent osteoporosis?

◗ Will estrogen protect a woman’s

memory? Does it prevent

Alzheimer’s disease?

◗ What is the best method 

of providing estrogen and 

progesterone?

Several long-term studies are

underway. They should answer

many of these questions and

help you and your doctor evaluate your needs as you go through

menopause and in the years

following. But here’s what we

know now:

Does estrogen prevent heart 

disease? 

Since heart disease in women

only becomes a major health

problem after the age of

menopause, doctors have long

suspected that estrogen protects

women from heart disease.

Beginning in 1987 the National

Institutes of Health sponsored

PEPI, the Postmenopausal

Estrogen/Progestin Interventions

Trial, to try to find out the effect

of estrogen on risk factors for

heart disease. The investigators

gave 875 postmenopausal

women either estrogen alone,

estrogen with synthetic progestin

cyclically, estrogen with natural

progesterone cyclically, estrogen

with synthetic progestin continuously, or a placebo. They then

looked at what effect, if any,

these forms of hormone replacement would have on risk factors

for heart disease. They found

that there was a beneficial effect

on HDL and LDL levels, but an

unfavorable effect on triglycerides for all the forms of oral

18

after menopause?

What are the benefits and risks of using hormones

▼ May use estrogen alone 

(ERT) or with progesterone (HRT),

▼ Reduce hot flashes and 

vaginal dryness,

▼ Prevent bone loss,

▼ Use estrogen as pill, 

patch, cream or gel, or 

estrogen vaginal ring, 

▼ Use progesterone as pill, 

vaginal gel, patch, IUD, 

or shot, and

▼ Have potential side effects.

Postmenopausal hormones:
The pros and cons for hormone replacement therapy

This is what scientists know to date.

PRO

HRT and ERT reduce the risk of osteoporosis.

HRT and ERT relieve hot flashes and night sweats.

HRT and ERT relieve vaginal dryness.

HRT and ERT improve cholesterol levels.

HRT and ERT may reduce the risk of heart disease.

HRT and ERT may improve mood and psychological well-being.

HRT and ERT may prevent the decline of mental

abilities with age.

CON

ERT, without the use of a progestin, modestly

increases the low risk of cancer of the uterus

(endometrial cancer).

HRT and ERT can have unpleasant side effects,

such as bloating or breast tenderness.

HRT and ERT may increase risk of breast 

cancer while they are being used; long-term 

use may pose the greatest risk. When 

hormones are discontinued, risk gradually

returns to almost normal.

HRT may increase cardiovascular events 

such as heart attack and stroke at first, but 

this increased risk appears to grow smaller 

over time. 

HRT and ERT increases the risk for blood clots.

HRT and ERT in pill form may raise 

triglyceride levels and might contribute 

to gallbladder disease.

19
hormone replacement studied.

The hormone therapy did not

increase blood pressure or cause

weight gain. The therapy also

seemed to decrease levels of a

substance known as fibrinogen

which has a role in blood clotting. Increased fibrinogen levels

can contribute to heart disease

and stroke. The study also reinforced the importance of using

progesterone in women with a

uterus to reduce the risk of

endometrial cancer. Lastly, it

showed that HRT slowed

menopausal bone loss and even

increased bone mass.

What PEPI didn’t do was to study

a large enough group of women

or follow the group long enough

to determine whether heart

attacks and heart disease-related

deaths would actually be reduced

by postmenopausal hormones or

what was the breast cancer risk

associated with long-term use of

hormone therapy. It also didn’t

look at the effects of other 

methods of giving hormones,

such as the patch or cream, on

the risk factors for heart disease.

However, the changes documented as a consequence of taking HRT have been shown in a

variety of studies to correlate

with a lower death rate from

heart disease.

What about estrogen in 

women who already have 

heart disease? 

Heart and Estrogen/ Progestin

Replacement Study (HERS) followed 2,763 women with heart

disease for 4 years beginning in

1993. Half received estrogen and

progestin, and half did not. The

scientists found that participants

using hormones had a greater

chance of having a heart attack

during the first year of their treatment despite the positive effects

of this therapy on their blood

lipid levels. Their risk of heart

disease declined each year after

that. One suggested explanation

for this is that at first the effects

of the hormones may lead to the

loosening of fatty plaques in the

walls of the blood vessels. These

plaques might then develop into

clots that could block the flow of

blood from the heart. Other

experts suggest that the form of

continuous progestin used in this

study, medroxyprogesterone

acetate (MPA), reduced the heart

protective effects of estrogen. 

Other studies now under way

like the Women’s Health

Initiative (WHI) (page 23) will

help determine if postmenopausal hormones have a

significant role in preventing

heart disease. Early results from

WHI have found a small increase

in heart attack, stroke, and blood

clots in the participants using

hormones, not placebo pills, during the first 2 years of the study.

Since then, this increased risk

seems to be getting smaller, and

the research is continuing in

order to find out whether there

will be beneficial effects by the

end of the study. Because the

WHI study will last for up to 

12 years, it should provide useful

20
information about the longterm effects of hormone replacement therapy. 

Do estrogen or progesterone

supplements contribute to 

breast cancer? 

In 1997 the Collaborative Group

on Hormonal Factors in Breast

Cancer reviewed information collected on more than 53,000 

postmenopausal women during

51 studies in 21 countries, representing about 90 percent of the

data on this subject. They determined that using hormone

replacement therapy, mostly

unopposed estrogen, led to a

small increased risk of localized

breast cancer—an increase of 

2.3 percent for each year hormones were used. This increased

risk, which was greater in lean

women than heavy women,

returned almost to normal

within 5 years of stopping therapy. The researchers were unable

to resolve whether the risk associated with estrogen and progestin

differed from the risk from using

estrogen alone. The Collaborative

Group observed that in North

America and Europe they would

usually expect 45 cases of breast

cancer per 1,000 women, ages 50

to 70, who had never used HRT.

They suggest that the increased

risk from hormone therapy

would lead to an extra two cases

per 1,000 women using HRT 

for 5 years, six cases per 1,000

using it for 10 years, and 

12 cases per 1,000 for those using

it for 15 years.

Several recent studies have examined whether the addition of

progestin to hormone therapy

changes the risk of developing

breast cancer. In the year 2000

scientists at the NIH’s National

Cancer Institute (NCI) reported

on a review of medical histories

of more than 46,000 postmenopausal women between

1980 and 1995; 2,082 of whom

had breast cancer. The NCI report

showed that both estrogen and

estrogen/progestin therapy led to

a small increase in the risk of

breast cancer, but the increase

was greater with estrogen and

progestin than with estrogen

alone. Their analysis suggested

that estrogen/progestin therapy

over a 4-year period increased 

a woman’s risk of developing

breast cancer by about 

30 percent—a result similar to

that reported by the Collaborative Group for hormone 

use for 5 years or longer. Lean

women also appeared to be at

greater risk than heavier women.

That same year a study at the

University of Southern 

California reported similar 

results in a group of 3,534

women, 1,897 of whom had

breast cancer. The long-term

nationwide WHI study may 

provide further information

about the possible role of 

postmenopausal estrogen and

estrogen/progestin therapy in

breast cancer. 

Will estrogen supplements help

your memory and perhaps even

prevent Alzheimer’s disease? 

The brain is sensitive to the

effects of estrogen, and because

men and women may experience

memory problems as they age,

some scientists have thought

that giving estrogen supplements

to women might protect their

memory and might even be used

to treat, delay, or prevent

Alzheimer’s disease (AD). Studies

so far have been promising in

some areas in animals but inconclusive in humans. 

For example, recently researchers

at Duke University, Utah State

University at Logan, and The

Johns Hopkins University looked

at the effect of estrogen use on

mental abilities in a group of

2,338 women over the age of 

65 in Utah. They found that

women currently using estrogen 

21
performed better on cognitive

(mental abilities) tests than did

women who used estrogen in 

the past or had never used it.

In addition, in 1997 scientists 

at NIA’s Gerontology Research

Center and The Johns Hopkins

Bayview Medical Center, both 

in Baltimore, Maryland, reported

on 472 women they had followed

for 16 years. The women who 

had a history of estrogen therapy

after menopause had a 50 percent

reduction in their risk of developing Alzheimer’s disease. 

Both of these studies were observational, only looking at the

effects of estrogen on mental

abilities or Alzheimer’s disease

without controlling for other factors that could influence the

findings. A rigorously controlled

clinical trial can more effectively

look at the cause and effect of a

potential therapy by randomly

assigning the drug being tested

or a placebo to a controlled

group of people. For example, a

clinical trial reported in the year

2000 by scientists taking part in

the multi-center Alzheimer’s

Disease Cooperative Study found

that estrogen did not slow the

progression of AD in patients

who already had the disease.

Further study is needed to determine whether estrogen can be

used to prevent or delay the

development of AD, even if it

might not be used to treat this

debilitating disease.

22
Are there any other risks 

from using postmenopausal 

hormones? 

There are two other notable

risks—blood clots and gallbladder disease—that accompany the

use of estrogen during or after

menopause. A third risk—

endometrial cancer—is a problem

only in women with a uterus

who receive no or insufficient

progestin along with the estrogen.

Estrogen and some of the

designer estrogens or SERMs

(page 28) carry an increased risk

of blood clots in your blood vessels. A blood clot can be lifethreatening if it comes loose and

travels to your lungs or brain. If

you have a history of venous

thromboembolism (blood clots

in the veins), are very overweight, or are often unable to

move about for health reasons,

you need to seriously consider

this risk associated with using

estrogen. The average menopausal woman has a risk for

blood clots of one in 10,000

women per year, but the use of

estrogen increases this to almost

three in 10,000 women. This is

slightly less than your risk of

accidental death, for example,

dying from a motor vehicle accident, an allergic reaction to a

drug, or a medical or surgical

procedure. Some women, such as

those with heart disease, are at

much higher risk for blood clots

if they take hormones—as many

as one in every 250 women per

year may get blood clots as a

result of the therapy.

Using oral estrogen increases your

chance of developing gallbladder

disease because the estrogen first

passes through your liver (page

17). Gallstones might be produced as a result, and you might

then need surgery to remove your

gallbladder. Thus, if you have a

history of gallbladder disease, liver

disease, or high triglyceride levels,

but want to try estrogen, you

might consider using estrogen in

a skin patch, thus bypassing

breakdown in the liver. 

How will experts ever know

what an individual woman

should do? 

Answering such questions about

the effect of estrogen on the

heart, memory, bone, and breast

cancer requires a long-term,

multi-faceted study using thousands of participants. These 

questions may be at least better

understood later this decade

when the Women’s Health

Initiative study is completed after

2005. This NIH-sponsored study

of more than 161,000 women is

gathering information on ways

to prevent and reduce heart disease, breast and colorectal (colon

and rectum) cancer, and osteoporosis in postmenopausal

women, as well as identifying the

benefits and risks of using hormones. More than 27,000 of

these women are taking part in

the hormone portion of this

study. Approximately half of

these take oral estrogen 

or estrogen and progestin (if they

have a uterus); the other half

takes a placebo. Participants are

being followed for 8 to 12 years.

This is important because

postmenopausal hormones

would need to be taken for many

years in order to be effective in

preventing heart disease and

osteoporosis.

23

Estrogen or estrogen 

with progestin:

▼ May prevent heart 

disease,

▼ May increase risk of 

breast cancer while 

using the hormones,

▼ May protect memory and

mental abilities and possibly delay development 

of Alzheimer’s disease,

▼ Can increase chance of 

blood clots in some 

women, and

▼ Can cause gallbladder 

disease.
This is getting confusing.

Like many women I’m

afraid of developing breast

cancer, but now you tell me

that I am much more likely

to die of heart disease. Last

year, my doctor told me hormones would help prevent heart

disease, but now you’re not so

sure. And I certainly don’t want to

end up in a bed in a nursing home

after a hip fracture like my mom’s

mother. How do I decide what to do? 

Talk to your doctor about your

medical history and that of your

family, especially any relatives

with osteoporosis, heart disease,

stroke, and cancer. Also, discuss

the potential benefits and risks 

of postmenopausal hormones

and whether there are other

treatments that could be used

instead. Discuss your health 

concerns. If you are bothered a

lot by symptoms such as hot

flashes, you might wish to use

estrogen in the short term,

maybe for 5 years or less. Most

studies indicate that any

increased risk of breast cancer

that might be associated with the

use of estrogen does not become

significant until you have used it

for at least 5 years. Even then,

after you stop, the risk appears to

return almost to normal. 

If hot flashes or other symptoms

are not particularly bothersome

now, you could wait and begin

hormone therapy when you are

in your sixties. Some studies 

have indicated that this will still

provide significant protection

against osteoporosis and bone

fractures, while avoiding the risks

possibly associated with being on

such therapy for many years.

Always remember that you can

discontinue the hormone supplements at any time. Also, you

should review your case with

your doctor at least once a year.

Then you and your physician

can make any changes necessary

as more information is reported

from hormone studies. 

When making this decision, you

should talk with your doctor

about other ways you could prevent or treat the more disabling

conditions that often accompany

aging. For example:

Heart Disease—First of all, if

you smoke, stop; if you don’t, do

not start. Healthier cholesterol

levels can be achieved by watching fats in your diet and regular

aerobic exercise such as walking,

running, swimming, or bike riding. If you are overweight, this

combination of diet and exercise

may also help you lose weight,

which would relieve some of the

strain on your heart. A variety of

medicines are also available to

control high blood pressure and

to lower total cholesterol, 

triglycerides, and LDLs and to

raise HDLs. 

Osteoporosis—A diet rich in

calcium and vitamin D and

weight-bearing exercise will help

keep your bones healthy. After

menopause, if you are at high

risk of developing osteoporosis, it

may be necessary to supplement

this with one of the drugs currently available to build bone or

prevent loss of the bone you

have (page 14).

Breast Cancer—Routine visits

to your doctor for regular breast

examinations, and mammograms every 1 or 2 years after you

are in your forties, according to

the National Cancer Institute, are

24

▼ Talk to your doctor 

about which option is 

best for YOU.

▼ Exercising.

▼ Watching your diet.

▼ Not smoking.

▼ Trying medications available for cholesterol problems and osteoporosis.

▼ Remember that taking 

hormones for up to 

5 years probably does not 

increase most women’s 

risk of breast cancer.

▼ Remember that stopping 

the use of postmenopausal hormones, however, will put you at risk 

for osteoporosis again.

If not postmenopausal 

hormones, then what?

I do now?

What can 
the best way we have to detect

breast cancer as early as possible.

Your risk of breast cancer

increases as you age, so breast

cancer screening continues to be

important. Hormones can

increase breast density, which

can make reading your mammogram more difficult. One study

has suggested that discontinuing

the hormones 2 weeks before

your mammogram will eliminate

some of that increased density,

but more research is needed to

prove this.

Urinary Problems—If you suffer from urinary leakage or urinary incontinence, such as an

inability to get to the toilet in

time or losing control when you

sneeze, laugh, or step off a curb,

be sure to consult your doctor.

There are a variety of causes for

loss of bladder control, including

lower levels of estrogen, infections, diabetes, and medication

side effects. Your doctor might

prescribe specific drugs designed

for this problem. You could try

Kegel exercises, which are

designed to strengthen certain

pelvic muscles, giving more support to the bladder. In addition,

your doctor might suggest that

you use estrogen cream applied

locally or insert a vaginal ring

containing estrogen. Some

experts believe caffeine can irritate the bladder and should be

avoided if you have urinary control problems.

What about using “natural

substances” to treat hot

flashes? Dietary supplements are being sold everywhere to treat a variety of

health problems. The nutrition store in the mall, a section in my grocery store, and

lots of websites on the

Internet sell them. They are

even advertised on TV. Makes

sense. Isn’t something made from

a plant safer than the chemicals in

a pill?

Not necessarily. Right now there

is a lot of discussion about phytoestrogens, estrogen-like substances from some plants, such

as soy products. Phytoestrogens

25

my symptoms?

Would plant estrogens help 
are also found in other plant

materials such as legumes, vegetables, cereals, and some herbs.

These “plant estrogens” work like

a weak form of estrogen. The fact

that Asian women eat a lot of

foods containing soy and seem

to report fewer hot flashes

increased the interest of

researchers in this subject. Eating

soy can improve cholesterol levels. It has also been suggested to

increase bone density and even

to protect against breast cancer,

but solid evidence is lacking. 

Today some women use soy and

herbal products such as black

cohosh, wild yams, dong quai,

and valerian root which claim to

relieve menopausal symptoms

like hot flashes. There is little, if

any, proof for these claims.

However, since these products

are considered dietary supplements, they are covered by less

stringent regulations than those

involving prescription medicines

and can be sold without the

supervision or approval of the

FDA. The manufacturers are supposed to make sure these substances are safe. The FDA can

only step in if there are many

serious reports of adverse effects,

but there is no way of insuring

the quality of these products. 

Soy contains plant estrogens currently under study. Researchers

hope to determine whether such

products can have the same therapeutic effects as estrogen. But,

also, they want to know whether

using plant estrogens brings risks,

especially risks similar to those of

estrogen, such as endometrial

cancer. The NIH has established

an Office of Dietary Supplements

and the National Center for

Complementary and Alternative

Medicine to support research on

this subject and others. NIA is

also conducting research on phytoestrogens and black cohosh. 

Until there is a better understanding of these substances, you

should proceed cautiously.

Always tell your doctor about

any dietary supplement you take.

There may be dangerous side

effects. If you do decide to

increase the amount of foods with

phytoestrogens you eat, let your

doctor know. If this does cause an

increase in the level of estrogens

in your body, this could interfere

with other prescription medications you are using or could even

cause an overdose. 

When I think about getting

older, I think of my dad’s

parents, and I don’t know

what to expect. My grandfather seemed so weak 

and frail and forgetful. 

My grandmother, however,

was busy and active her

whole life. Once I talk to 

my doctor and decide how 

to handle my menopause

symptoms, what else do I

need to do to stay healthy?

Certainly there are things that I

can do to ensure good health as I

get older.

Just remember that menopause

and aging in general do not necessarily lead to illnesses that

demand treatment; they are normal steps in any woman’s life.

You will not necessarily get sick

and have to take a lot of

medicine as you age. Also, aging

does not have to mean disability

and years in a nursing home. In

fact, in 1997 investigators at

26

▼ Phytoestrogens come 

from plant-based foods.

▼ Soy may help cholesterol 

levels and perhaps protect against bone loss.

▼ Dietary supplements are 

not regulated by the 

Food and Drug 

Administration.

▼ There are no assurances 

with regard to the exact 

dosage, efficacy, or 

purity of a given batch 

of a supplement.

▼ Some supplements can 

have serious side effects.

▼ Talk to your doctor 

before starting any 

dietary supplement.

▼ If you are already using 

dietary supplements, tell 

your doctor.

Remember:

to stay healthy?

Are there other things I should do
Duke University reported that

even though the number of older

people in this country is growing, the rate of disability in the

elderly is falling at an ever-increasing pace. They found that in

1994 approximately 1.2 million

fewer older people were disabled

than would have been predicted

based on the rates in 1982.

There are things everyone can 

do to maintain their health and

mental abilities as they age:

◗ Stop smoking.

◗ Exercise—both weight-bearing

and muscle-strengthening.

Studies have shown that even

people in their nineties can

improve their walking and

reduce their risk of falling by

exercising. Exercise benefits the

heart and bones and helps

maintain a healthy weight. The

NIA publishes Exercise: A Guide

from the National Institute on

Aging. It’s a great way to get

started exercising, and it’s free.

In addition, a kit containing

the book and a 48-minute exercise video, are available for $7

(page 31).

◗ Eat wisely. A balanced diet will

provide most of the nutrients

and calories your body needs to

stay healthy. Two nutrients that

can be safely taken as supplements are calcium and vitamin

D (page 14). Eat a variety of

foods from the five major food

groups. Choose foods that are

low in fat and watch how much

sugars, salt, sodium, and alcohol you consume. You don’t

have to eat all the required servings every day. For example, if

you don’t feel like having that

last serving of fruit today, don’t;

but try to eat an extra serving

tomorrow or the next day. Look

for foods that have lots of nutrients, like protein and vitamins,

but not a lot of calories—these

are called nutrient-rich foods.

As you age, you need fewer

calories for energy, but just as 

many nutrients. 

◗ Don’t forget to drink plenty 

of water.

◗ If you drink alcohol, do so in

moderation—only about one

drink a day for a woman,

according to the Department of

Agriculture’s Dietary Guidelines

for Americans.

◗ Through exercise and diet, try

to maintain a healthy weight.

Studies have shown that being

overweight, especially around

the abdomen, can increase your

chance of developing diabetes,

heart disease, high blood pressure, and osteoarthritis of the

knee as you grow older. Having

a waist measurement greater

than 35”, even if your weight is

normal, also puts you at greater

risk for these health problems.

◗ Continue to visit your doctor

regularly. He or she can do routine screening tests, pelvic and

breast exams, and a Pap test for

cervical cancer. After age 50,

don’t forget your mammogram

every 1 to 2 years. 

◗ Also after age 50, you need to

be checked for colon cancer.

Talk to your doctor about

which test is best for you.

◗ Around menopause, you

should ask your doctor about a

baseline bone density test, such

as a DEXA-scan (dual-energy xray absorptiometry) to see if

you are at risk for osteoporosis.

◗ You may want to get a flu shot

every fall, especially if you have

27

Food groups Amount

Bread, cereal, rice, and pasta 6 -11 servings

Vegetables 3 - 5 servings

Fruits 2 - 4 servings

Milk, yogurt, and cheese 2 - 3 servings

Meat, poultry, fish, dry 

beans, eggs, and nuts 2 - 3 servings
other health problems, and the

Centers for Disease Control and

Prevention recommends that

people over age 65 get a single

dose of the pneumococcal vaccine. You should also have a

tetanus shot every 10 years.

◗ Continue to practice safe sex. 

◗ See your dentist once or twice a

year. 

◗ After age 40, reading may

become more difficult—you

may need to hold things farther

away in order to see them

clearly. Perhaps you need reading glasses. Your eye doctor

may also want to check for

glaucoma, which becomes

more common after your forties. It can damage your vision

before you realize you have it.

◗ Take your medicines as

instructed, and be sure every

doctor that you see knows 

all the drugs you are currently

taking. This includes over-thecounter ones such as vitamins,

dietary supplements, painkillers, and antihistamines.

Some drug stores even keep a 

computer file of all your 

prescriptions so that they can

check for dangerous drug 

interactions if a new medicine

is added.

◗ Stay active—both physically

and mentally. If you don’t work

outside of the home, consider

getting a part-time job or volunteer with a nonprofit organization. Find a hobby. Learn to

play a musical instrument. Take

a single class at the local community college or work towards

a degree. Join a book group.

Learn to garden. Do something

you always wanted to try, but

never had the time before. This

is the time to explore your

world, expand your horizons,

and learn more about yourself—

and to really enjoy yourself.

My doctor says I’m just

beginning perimenopause

now. Will there be more

information to help me

decide what to do when I

actually reach menopause in a

few years?

Physicians may never be able to

make a single recommendation

about using hormone supplements for all women approaching menopause. There are too

many factors to consider that can

vary from woman to woman.

Personal and family medical history and health risks, lifestyle, 

and menopause symptoms are

just a few. However, in the coming years physicians should have

more reliable information about

menopause with which to counsel their patients as a result of

research underway now.

The Women’s Health Initiative

(page 23) will provide an understanding of how best to handle

some health problems often

found in postmenopausal

women. SWAN (page 8) is not

only revealing the ways women

from different ethnic, racial, and

economic backgrounds respond

to menopause, but is also looking

at their lives in a very broad way

to try to determine what factors

in women’s lives affect the perimenopause. By studying

changes in body composition,

bone density, cardiovascular and

endocrine function, and sexuality, SWAN is also contributing to

our basic understanding of

menopause and its treatment. For

example, SWAN investigators are:

◗ Considering whether a genetic

test or tests could predict a

woman’s rate of postmenopausal bone loss,

◗ Examining the influence of diet

and physical activity on health

and well-being,

◗ Looking at alternative therapies

used to deal with premenstrual

and menopausal symptoms, and

◗ Evaluating the possible relationship between menopause and

mood disorders and depression.

Another research subject that is

already benefiting women are

the so-called designer estrogens

or SERMs (selective estrogen

receptor modulators). Cells in

body tissues sensitive to estrogen

such as the breast, bone, and

heart, have estrogen receptors that

allow them to link with

molecules of estrogen. This then

allows this hormone to turn on

28

the future hold?

What does
certain activities in that cell. For

example, in bone, estrogen seems

to be involved in the breakdown

and rebuilding that takes place

continually, keeping bone

healthy and strong. Some experts

wonder if it might be possible to

modify estrogen in order to

change how it links with the

receptors in specific tissues. This

might reduce the risks associated

with using estrogen, but allow

the benefits to continue. These

SERMs could be a valuable

approach to postmenopausal

health problems. 

Some SERMs are available now.

Tamoxifen was first approved

more than 20 years ago as a treatment for breast cancer. More

recently, it has been proven to

decrease the risk of getting breast

cancer in women at high risk for

the disease. Scientists soon

learned that although this SERM

could be used to combat breast

cancer, it also increased the risk

of endometrial cancer and serious blood clots, just like estrogen. Unlike estrogen, hot flashes

are actually a side effect of this

drug. In 1998 a second SERM,

raloxifene, was approved to protect bone density like estrogen

does. Unlike estrogen or tamoxifen, it does not seem to cause

endometrial cancer, but like

tamoxifen, it can cause blood

clots and hot flashes. It is currently being compared to 

tamoxifen in a clinical trial for

breast cancer prevention in

women at high risk for breast

cancer. Other SERMs are under

development now.

Research is under way at several

institutions to find new ways 

to get information to women as

they make health care choices.

For example, a scientist at the

University of Washington in

Seattle hopes to develop a computerized guide for the World

Wide Web that women could use

to help them as they approach

menopause. By providing the scientific basis for the benefits and

risks of lifestyle changes, medications, and hormone replacement

therapy, women will be able to

choose the best way to handle

their menopausal symptoms, 

as well as health problems after

menopause, such as reducing

their risk of bone fractures. The

site might even provide features 

such as a chat room and access 

to an expert for answers to 

individual questions. Testing 

is underway to determine 

which age groups could benefit

the most from such a website.

Studies such as these should 

provide and disseminate the 

knowledge needed to make 

it easier to understand the 

transition through menopause 

in the future—if not for us, 

then perhaps for our daughters.

Until then, remember that 

you have much more health

information available to you

than your mother might have

had during her menopause—

use it and be sure to:

◗ Take care of yourself.

◗ Enjoy the extra time you get as

you are gradually freed from

the time constraints of child

rearing and/or a job.

◗ Remember a third of your life is

ahead of you—make the most

of it!

29
30

Glossary—the words in this glossary are italicized the first time

they appear in the text.

Alzheimer’s disease—most 

common form of dementia in

older people; interferes with 

the way the brain works and

affects the parts of the brain 

that control thought, memory,

and language.

cholesterol—a type of lipid or fat

in the blood which is produced

by the body as a source of fuel for

body cells.

collagen—a durable, flexible substance found in bone, cartilage,

tendons, and connective tissue. 

dietary supplements—something

eaten in addition to one’s normal

diet, usually a plant-based substance, vitamin, mineral, or hormone that is available without a

prescription.

estrogen—one of the sex hormones produced principally by

the ovaries.

estrogen receptors—parts of cells

which estrogen can attach to and

then “turn on" those cells to perform certain duties; found in

cells in the brain, breast, heart

and arteries, bone, central nervous system, urinary and genital

tract, and gastrointestinal tract.

estrogen replacement therapy—

using estrogen to supplement

postmenopausal levels of this

hormone in a woman who 

usually no longer has a uterus.

hormones—chemical substances

produced by one body part

which promote activity by cells

in another body part.

hormone replacement therapy—

using estrogen and progestin to

supplement postmenopausal levels of these hormones.

incontinence—the inability to

hold urine until you get to the

toilet, due to various causes.

Several forms including:

urge incontinence—trouble 

holding urine when

feeling the need to go to 

the bathroom.

stress incontinence—being 

unable to hold urine when 

you sneeze, cough, laugh, 

run, or step down.

IUD—intrauterine device—a

device made of metal or plastic

which contains hormones and is

placed in your uterus.

Kegel exercises—exercises to

strengthen pelvic floor muscles

by squeezing and holding 

these muscles for 3 counts, and

then relaxing them for 3. Repeat

these for 5 minutes 3 times a 

day. To find your pelvic floor

muscles try to stop the flow of

urine while on the toilet or 

pretend you are trying to stop

passing gas. Those are the 

muscles you want to exercise.

metabolize—to breakdown a substance so that it can be used by

body cells.

osteoporosis—a bone disorder,

especially common in older

women, in which bones become

weakened and easily broken.

phytoestrogens—estrogen-like

substances found in plants.

placebo—used in research, 

looks like the real medicine 

but with no health effects, a 

“sugar pill.” It is used to control

for psychological effects on the

results of a research study.

plaques—accumulations of a

layer of cholesterol and other

substances including cellular

debris along the walls of arteries

which contribute to hardening of

the arteries and increase the risk

of heart disease and stroke.

postmenopausal hormone 

therapy—another name for estrogen replacement therapy or 

hormone replacement therapy.

progesterone—one of the sex hormones produced mostly by your

ovaries.

progestin—a synthetic form of

progesterone.

unopposed estrogen—estrogen

prescribed alone without any

other hormone. 

What does that word mean?
31

More information on aging is available from the National Institute on

Aging (NIA), part of the National

Institutes of Health (NIH).

National Institute on Aging

NIA Information Center

P.O. Box 8057

Gaithersburg, MD 20898-8057

800-222-2225

800-222-4225 (TTY)

www.nih.gov/nia

Alzheimer’s Disease Education and

Referral (ADEAR) Center

P.O. Box 8250

Silver Spring, MD 20907-8250

800-438-4380

www.alzheimers.org/adear

Other parts of NIH that can also 

provide information on related 

topics include:

National Cancer Institute 

Office of Cancer Communications

Bldg. 31, Rm. 10A03

31 Center Dr., MSC 2580

Bethesda, MD 20892-2580

301-435-3848

Cancer Information Service

800-4-CANCER (800-422-6237)

www.nci.nih.gov

National Heart, Lung, 

and Blood Institute

NHLBI Information Center

P.O. Box 30105

Bethesda, MD 20824

301-592-8573

www.nhlbi.nih.gov

National Institute of Allergy and

Infectious Diseases

Bldg. 31, Rm. 7A50

31 Center Dr., MSC 2520

Bethesda, MD 20892-2520

301-496-5717

www.niaid.nih.gov

National Institute of Child Health

and Human Development

NICHD Clearinghouse

Bldg. 31, Rm. 2A32

31 Center Dr., MSC 2425

Bethesda, MD 20892-2425

800-370-2943

www.nichd.nih.gov

National Institute of Diabetes and

Digestive and Kidney Diseases

Office of Communications and

Public Liaison

31 Center Dr., MSC 2560

Bethesda, MD 20892-2560

301-496-3583

www.niddk.nih.gov

National Institute of Mental Health

6001 Executive Blvd., Rm. 8184

MSC9663

Bethesda, MD 20892-9663

301-443-4513

www.nimh.nih.gov

NIH Osteoporosis and Related

Bone Diseases~

National Resource Center

1232 22nd St., NW

Washington, DC 20037

800-624-BONE (800-624-2663)

202-466-4315 (TTY)

www.osteo.org

Office of Research on 

Women’s Health

9000 Rockville Pike

Bldg. 1, Rm. 201

Bethesda, MD 20892

301-402-1770

www4.od.nih.gov/orwh/

Women’s Health Initiative

1 Rockledge Centre, Suite 300 

MSC 7966

6705 Rockledge Dr.

Bethesda, MD 20892-7966

301-402-2900

www.nhlbi.nih.gov/whi/

This website offers access to several

clinical trials databases in case you

are interested in taking part in

research related to menopause.

National Library of Medicine

MEDLINEplus

www.nlm.nih.gov/medlineplus/

menopause.html

These are some of the many public

and private organizations that can

provide information about

menopause.

AARP (American Association of

Retired Persons) 

601 E St., NW

Washington, DC 20049

202-434-2277

800-424-3410

www.aarp.org

Administration on Aging

330 Independence Ave., SW

Washington, DC 20201

202-619-7501

Eldercare Locator: 800-677-1116

www.aoa.dhhs.gov

Alliance for Aging Research

2021 K St., NW, Suite 305

Washington, DC 20006

202-293-2856

www.agingresearch.org

American Cancer Society

1599 Clifton Rd., NE

Atlanta, GA 30329

800-ACS-2345 (800-227-2345)

www.cancer.org

American College of Obstetricians

and Gynecologists (ACOG)

409 12th St., SW

P.O. Box 96920

Washington, DC 20090

202-638-5577

www.acog.org

Where can I get more information?
32

American Dietetic Association

216 W. Jackson Blvd.

Chicago, IL 60606-6995

800-366-1655 (recorded messages)

312-899-0040

www.eatright.org

American Heart Association

National Center

7272 Greenville Ave.

Dallas, TX 75231

800-AHA-USA1 (800-242-8721)

888-4-STROKE (800-478-7653)

888-MY-HEART (800-694-3278) 

(for women’s health information) 

www.americanheart.org

women.americanheart.org

American Menopause 

Foundation, Inc.

350 Fifth Ave., Suite 2822

New York, NY 10118

212-714-2398

www.americanmenopause.org 

Centers for Disease Control and

Prevention (CDC) 

1600 Clifton Rd., NE

Atlanta, GA 30333

800-311-3435

404-639-3534

www.cdc.gov

National AIDS Hotline (CDC)

800-342-AIDS (800-342-2437)

800-344-SIDA (800-344-7432 

for Spanish)

800-AIDS TTY 

(800-243-7889 TTY)

www.ashastd.org

Children of Aging Parents

1609 Woodbourne Rd., Suite 302A

Levittown, PA 19057

215-945-6900

800-227-7294

www.careguide.net

Department of Agriculture (USDA)

Food and Nutrition Information

Center (FNIC)

10301 Baltimore Ave., Rm. 304

Beltsville, MD 20705-2351

301-504-5719

301-504-6856 (TTY)

www.nal.usda.gov/fnic

Food and Drug Administration

(FDA) Office of Women’s Health

HF-8, Rm. 16-65

5600 Fishers La.

Rockville, MD 20857

888-INFO-FDA (888-463-6332)

www.fda.gov/womens/default.htm

National Alliance for Caregiving

4720 Montgomery La., Suite 642

Bethesda, MD 20814

www.caregiving.org

National Center on Women 

and Aging

Heller Graduate School, MS 035

Brandeis University

Waltham, MA 02454-9110

800-929-1995

781-736-3866

www.heller.brandeis.edu/national/

ind.html

National Osteoporosis Foundation

1232 22nd St., NW

Washington, DC 20037

202-223-2226

www.nof.org

National Women’s Health

Information Center

Office on Women’s Health

Room 730B

200 Independence Ave., SW

Washington, DC 20201

202-690-7650

800-994-WOMAN (800-994-9662)

888-220-5446 (TDD)

www.4woman.gov

North American Menopause

Society

P.O. Box 94527

Cleveland, OH 44101

440-442-7550

www.menopause.org

Older Women’s League

666 11th St., NW, Suite 700

Washington, DC 20001

202-783-6686

800-825-3695

www.owl-national.org

Planned Parenthood Federation of

America, Inc.

800-230-PLAN (800-230-7526)

www.plannedparenthood.org
U.S. Department of Health and Human Services

Public Health Service

National Institutes of Health

NIH Publication No. 01-3886

February 2001