Instruct: Given a question, retrieve documents that answer the question.
Query: When does Menopause start?
Menopause, also known as the climacteric, is the time in most women's lives when menstrual periods stop permanently, and they are no longer able to bear children.[2][8] Menopause typically occurs between 49 and 52 years of age.[3] Medical professionals often define menopause as having occurred when a woman has not had any vaginal bleeding for a year.[4] It may also be defined by a decrease in hormone production by the ovaries.[9] In those who have had surgery to remove their uterus but still have ovaries, menopause may be viewed to have occurred at the time of the surgery or when their hormone levels fell.[9] Following the removal of the uterus, symptoms typically occur earlier, at an average of 45 years of age.[10]
In the years before menopause, a woman's periods typically become irregular,[11][12] which means that periods may be longer or shorter in duration or be lighter or heavier in the amount of flow.[11] During this time, women often experience hot flashes; these typically last from 30 seconds to ten minutes and may be associated with shivering, sweating, and reddening of the skin.[11] Hot flashes often stop occurring after a year or two.[8] Other symptoms may include vaginal dryness, trouble sleeping, and mood changes.[11] The severity of symptoms varies between women.[8] While menopause is often thought to be linked to an increase in heart disease, this primarily occurs due to increasing age and does not have a direct relationship with menopause.[8] In some women, problems that were present like endometriosis or painful periods will improve after menopause.[8]
Bree is rollerskating with Keith when she gets hot and dizzy out of nowhere and falls off her skates. She is examined by a medic who tells her that it is a hot flash and she is starting menopause. Bree is horrified. She goes to her OB/GYN, but there is a substitute working as her regular OB/GYN is out on maternity leave. She and the sub hit it off, and Bree reveals that she is in a relationship with a man 17 years her junior, and asks for ways to hide the symptoms. Later, Bree meets Keith's parents for dinner at a local restaurant; Keith's mother just happens to be the substitute OB/GYN. Throughout dinner, Keith's mom drops hints about Bree's visit to her until Bree finally admits to being menopausal. Ashamed, Bree leaves the restaurant. Keith finds her later, and tells her that he doesn't care about her being menopausal or having children with his DNA. They can always adopt. Bree sadly tells him that she does not want to have children again. Keith is upset, but asks Bree to forget the conversation for a while so that they can be happy. Bree agrees.
Utian is credited for describing menopause as a potential health-related issue in 1967. He has described the situation that led to his discovery as occurring when he was invited to visit a large pharmaceutical firm in West Berlin. He has stated that "A new female hormone was mentioned and thereby started my interest in the subject. Upon me return [home] I approached the Chairman of the Department of Gynaecology of the University of Cape Town ... and spelled out my plans for a menopause clinic." This clinic, named the Femininity Clinic (later renamed the Mature Woman Clinic), was the first of its kind in the world, located at the Groote Schuur Hospital. In 1976 he also became one of the three co-founders of the International Menopause Society. Utian ultimately left South Africa due to conflicts with the Apartheid government, including his objections to the treatment of non-white physicians in the country's hospitals.
The aim of the WSSM is to promote knowledge among health-care providers on menopause-related issues. It provides courses, educational programs and lectures in the field of adult women's health and menopause in liaison with national or regional menopause societies when requested.
In 1994 NAMS launched "Menopause", a peer-reviewed scientific journal meant to provide a forum for clinical research, applied basic science, and practice guidelines on all aspects of menopause.The scope of "Menopause" encompasses many varied biomedical areas, including internal medicine, family practice, obstetrics, gynecology, medical subspecialties such as cardiology and geriatrics, epidemiology, pathology, sociology, psychology, anthropology, and pharmacology. Additional professional educational material provided by NAMS includes the textbook "Menopause Practice: A Clinician's Guide"; position statements on hormone therapy, management of menopausal symptoms, prevention and treatment of osteoporosis, and other topics; an annual scientific conference; and the e-mail newsletters "First to Know," "Menopause Care Updates", and "Menopause e-Consult".
Removal of the uterus without removal of the ovaries does not directly cause menopause, although pelvic surgery of this type can often precipitate a somewhat earlier menopause, perhaps because of a compromised blood supply to the ovaries.. The time between surgery and possible early menopause is due to the fact that ovaries are still producing hormones.[30]
Testing serum LH and FSH levels are often used to assess hypogonadism in women, particularly when menopause is believed to be happening. These levels change during a woman's normal menstrual cycle, so the history of having ceased menstruation coupled with high levels aids the diagnosis of being menopausal. Commonly, the post-menopausal woman is not called hypogonadal if she is of typical menopausal age. Contrast with a young woman or teen, who would have hypogonadism rather than menopause. This is because hypogonadism is an abnormality, whereas menopause is a normal change in hormone levels. In any case, the LH and FSH levels will rise in cases of primary hypogonadism or menopause, while they will be low in women with secondary or tertiary hypogonadism.
Equally challenging for women are the physiological and emotional changes associated with the cessation of menses (menopause or climacteric). While typically occurring gradually towards the end of the fifth decade in life marked by irregular bleeding the cessation of ovulation and menstruation is accompanied by marked changes in hormonal activity, both by the ovary itself (oestrogen and progesterone) and the pituitary gland (follicle stimulating hormone or FSH and luteinizing hormone or LH). These hormonal changes may be associated with both systemic sensations such as hot flashes and local changes to the reproductive tract such as reduced vaginal secretions and lubrication. While menopause may bring relief from symptoms of menstruation and fear of pregnancy it may also be accompanied by emotional and psychological changes associated with the symbolism of the loss of fertility and a reminder of aging and possible loss of desirability. While menopause generally occurs naturally as a physiological process it may occur earlier (premature menopause) as a result of disease or from medical or surgical intervention. When menopause occurs prematurely the adverse consequences may be more severe.
HRT may be reasonable for the treatment of menopausal symptoms, such as hot flashes.[67] It is the most effective treatment option, especially when delivered as a skin patch.[68][69] Its use, however, appears to increase the risk of strokes and blood clots.[70] When used for menopausal symptoms some recommend it be used for the shortest time possible and at the lowest dose possible.[70] Evidence to support long term use however is poor.[68]
"World Menopause Day / Month". IMS has designated October 18 as World Menopause Day. In observation of the Day, the IMS and the member national societies of CAMS distribute materials and organize activities to inform women about menopause, its management and the impact of estrogen loss. Since it is not always possible for local societies to arrange activities for this specific day, the IMS has now designated October as World Menopause Month. Local societies can also collaborate with other organizations working in the field of adult women's health, such as societies for osteoporosis and breast cancer, to organize joint events. World Menopause Month can also be a call to implement policies that support research and treatment in the area of menopausal health.
The use of hormone replacement therapy (HRT), to lessen the effects of menopause, has shown severe negative effects on the seizure patterns of women with catamenial epilepsy. During perimenopause, women with catamenial epilepsy generally experience an increase in seizure frequency, and HRT use does not change this likelihood. However HRT use after perimenopause has been significantly associated with an increase in seizure frequency and severity. Women progressing through peri- and post-menopause using HRT may be in greater need of anticonvulsant medication monitoring to maintain or reduce seizure occurrence. These same results have not been seen in laboratory counterparts. Adult female rats that have been ovariectomized, a parallel state to menopause, show increased seizure frequency overall. There are, however, several factors that could explain this difference, including ovariectomized rats do not have the analogous brain hormones milieu as menopausal women. Several studies following HRT use in women with catamenial epilepsy have demonstrated more influencable data than animal models, in this case.
The WHI trial was limited by low adherence, high attrition, inadequate power to detect risks for some outcomes, and evaluation of few regimens. Subsequent to publication of the WHI, controversy arose regarding the applicability of its findings to women just entering menopause. To be properly double blinded, the study required that women not be perimenopausal or have symptoms of menopause. As the average age of menopause is 51, this resulted in an older study population, with an average age of 63. Only 3.5% of the women were 50–54 years of age, the time when women usually decide whether to initiate hormonal therapy. Further analysis of WHI data, however, demonstrated that there is no gained preventive benefit in starting hormone therapy soon after menopause.
There is no evidence of consistent benefit of alternative therapies for menopausal symptoms despite their popularity.[80] The effect of soy isoflavones on menopausal symptoms is promising for reduction of hot flashes and vaginal dryness.[16][81] Evidence does not support a benefit from phytoestrogens such as coumestrol,[82] femarelle,[83] or the non-phytoestrogen black cohosh.[16][84] There is no evidence to support the efficacy of acupuncture as a management for menopausal symptoms.[85] As of 2011 there is no support for herbal or dietary supplements in the prevention or treatment of the mental changes that occur around menopause.[86] A 2016 Cochrane review found not enough evidence to show a difference between Chinese herbal medicine and placebo for the vasomotor symptoms.[87]
Menopause is usually a natural change.[5] It can occur earlier in those who smoke tobacco.[4][13] Other causes include surgery that removes both ovaries or some types of chemotherapy.[4] At the physiological level, menopause happens because of a decrease in the ovaries' production of the hormones estrogen and progesterone.[2] While typically not needed, a diagnosis of menopause can be confirmed by measuring hormone levels in the blood or urine.[14] Menopause is the opposite of menarche, the time when a girl's periods start.[15]
The date of the final menstrual period is usually taken as the point when menopause has occurred.[17] During the menopausal transition and after menopause, women can experience a wide range of symptoms.
Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).
The theories discussed above assume that evolution directly selected for menopause. Another theory states that menopause is the byproduct of the evolutionary selection for follicular atresia, a factor that causes menopause. Menopause results from having too few ovarian follicles to produce enough estrogen to maintain the ovarian-pituitary-hypothalamic loop, which results in the cessation of menses and the beginning of menopause. Human females are born with approximately a million oocytes, and approximately 400 oocytes are lost to ovulation throughout life.[129][130]
Cognitively, those of this age period tested better than when they were 25, in tasks measuring long-ago memorized information, or "crystallized intelligence". This refutes the presumption of women losing much of their cognitive ability during menopause. Forgetting words or numbers does not happen to the degree popular culture would suggest of menopausal women. Conversely, people over the age of 25 perform worse at tasks that require fluid intelligence, understood as inventive, adaptive cognition that is able to learn new ideas and synthesize new strategies. In general, as people age, they gain more accumulated information, but gradually lose the ability to analyze and synthesize novel information.
Tamoxifen is also used to treat hormonally-responsive breast cancer, but it does so by interfering with the estrogen receptor. However, letrozole is effective only in post-menopausal women, in whom estrogen is produced predominantly in peripheral tissues (i.e. in adipose tissue, like that of the breast) and a number of sites in the brain. In pre-menopausal women, the main source of estrogen is from the ovaries not the peripheral tissues, and letrozole is ineffective.
Women who have had bilateral oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone, and subsequently enter what is known as "surgical menopause" (as opposed to normal menopause, which occurs naturally in women as part of the aging process). In natural menopause the ovaries generally continue to produce low levels of hormones, especially androgens, long after menopause, which may explain why surgical menopause is generally accompanied by a more sudden and severe onset of symptoms than natural menopause, symptoms that may continue until the natural age of menopause. These symptoms are commonly addressed through hormone therapy, utilizing various forms of estrogen, testosterone, progesterone, or a combination.
Human menopausal gonadotropin (hMG) is a very powerful treatment for infertility. It consists of a combination of LH and FSH. From menopause onwards, the body starts secreting LH and FSH in large quantities due to the slowing down of the ovarian function. This excess of hormones is not used by the body and is expelled in the urine. HMG is therefore collected from the urine of menopausal women. The urine then undergoes purification and a chemical treatment. The resulting hMG induces the stimulation of several ovarian follicles. This increases the risk of producing several oocytes during the same cycle, and thus the risk of multiple pregnancies.
While not conclusive, evidence does exist to support the idea that female-biased dispersal existed in pre-modern humans. The closest living relatives to humans, chimpanzees, bonobos, and both mountain gorillas and western lowland gorillas, are female-biased dispersers.[113] Analysis of sex specific genetic material, the non-recombining portions of the Y chromosome and mitochondrial DNA, show evidence of a prevalence of female-biased dispersal as well; however, these results could also be affected by the effective breeding numbers of males and females in local populations.[114] Evidence of female-biased dispersion in hunter-gatherers is not definitive, with some studies supporting the idea,[113] and others suggesting there is no strong bias towards either sex.[115] In killer whales, both sexes mate non-locally with members of a different pod but return to the pod after copulation.[116] Demographic data shows that a female’s mean relatedness to the group does increase over time due to increasing relatedness to males.[117] While less well-studied, there is evidence that short-finned pilot whales, another menopausal species, also display this behavior.[118] However, mating behavior that increases local relatedness with female age is prevalent in non-menopausal species,[113] making it unlikely that it is the only factor that determines if menopause will evolve in a species.
Anovulation is when the ovaries do not release an oocyte during a menstrual cycle. Therefore, ovulation does not take place. However, a woman who does not ovulate at each menstrual cycle is not necessarily going through menopause. Chronic anovulation is a common cause of infertility.
Pritchard also explored the effects of HRT on women and the potential for developing breast cancer. HRT is usually given to women who are estrogen deficient or menopausal women to lessen their symptoms of menopause. Through her studies of long-term HRT effects, Pritchard discovered there is a 53% higher risk for women developing cancer with a HRT combination of progesterone and estrogen, but only a 34% higher risk in women who just receive estrogen. Another risk of HRT is its cardiovascular effects such as blood clotting and dense breast tissue making it harder to read a mammogram. Pritchard suggests alternatives to combat estrogen deficiency and menopausal symptoms. Alternatives include Vitamin E, calcium supplements, venlafaxine, clonidine, and diet. She concludes that it may not be as effective, but it does not have the increased risk for breast cancer.