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Abnormal menstrual bleeding, Alzheimer's disease, amenorrhea, anti-androgen, anti-estrogen, atrophic vaginitis, bacterial vaginosis, breast cancer-related hot flashes, calcium, Candida, cervicitis, cervix, chronic pelvic pain, contraceptive, corpus luteum deficiency, cramps, cytokines, dysmenorrheal, ectopic pregnancy, emmenagogue, endometriosis, estrogen, fibrocystic breast disease, follicle-stimulating hormone, FSH, GABA, gardnerella, gonorrhea, gynecologist, hirsutism, hormonal disorders, hormone replacement therapy, hormone-related vaginitis, hot flashes, HRT, hypermenorrhea, hypothalamus, hypothyroidism, hysterectomy, hysteroscopy, incontinence, interleukins, irregular menstrual cycles, irritant vaginitis, laparoscopy, leukorrhea, LH, luteal phase deficiency, luteinizing hormone, menopausal disorders, menopausal hot flashes, menopausal symptoms, menopause, menorrhagia, menses, menstrual, menstrual pain, menstruation, neurochemicals, oophrectomy, osteoporosis, ovaries, ovariotomy, ovulation, PCOS, peri-menopause, pituitary gland, PMDD, PMS, polycystic ovary syndrome, postmenopause, premenstrual dysphoric disorder, premenstrual syndrome, premenstrual tension, progesterone, progestin, serotonin, uterine fibroids, uterus, vaginal dryness, vaginal inflammation, vaginal yeast infection, vaginitis, vitamin D, vulvovaginitis, xenoestrogens, yeast infection, yeast vaginitis.

Background

Healthcare for women includes the entire spectrum of a woman'slife, not just pregnancy and childbirth. Besides developing conditions such as diabetes, heart disease, and cancer, women have special health issues that revolve around hormonal changes in their bodies and their reproductive organs. Also, medical problems canaffect women and men differently.

Women's health issues include breast conditions, menstruation, infections, menopause, heart conditions, mental health, osteoporosis, and sexual health.

This monograph focuses on hormonal changes in the female body and the relationship these hormonal changes have on the overall health of a woman. Other women's health issues, such as osteoporosis, heart disease, breast cancer, and ovarian cancer, are covered in separate condition monographs.

Hormonal changes in women can cause health imbalances to arise, including menopause, pre-menstrual syndrome (PMS) and related conditions (such as dysmenorrhea, menorrhagia, amenorrhea, and polycystic ovary syndrome), and infections of the vagina.

For women, hormone imbalance is the term that describes the incorrect relationship between the two primary hormones, progesterone and estrogen, in the body.

For a woman to have regular menstrual cycles, the reproductive organs, including the ovaries and uterus, should all be functioning normally. The hypothalamus stimulates the pituitary gland to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The hypothalamus is a part of the brain that links the nervous system with hormone release. FSH and LH cause the ovaries to produce the hormones estrogen and progesterone. Estrogen and progesterone are responsible for the cyclical changes in the endometrium (uterine lining), including menstruation. In addition, a woman's genital tract should be free of any abnormalities to allow the passage of menstrual blood.

Normally, in the first 10-12 days of the menstrual cycle, only estrogen is produced in the female body. If ovulation occurs, then progesterone is produced by the ovaries. On or about day 28, levels of both hormones drop, resulting in menstruation. However, if ovulation does not occur, women can still have the menstrual period, but the estrogen is never "balanced" by progesterone, which needed ovulation to trigger its production. This results in symptoms of hormone imbalance;- estrogen is present but progesterone production drops to very low levels.

Variations in the estrogen/progesterone balance can have a dramatic effect on health. Hormonal imbalances are also thought to play a major role in PMS, or premenstrual syndrome.

Hormonal imbalances in women may be a result of aging, stress levels, a lack of exercise, poor nutrition, alcohol intake, poor sleep, synthetic hormone replacement therapy (HRT), and environmental toxins, called xenoestrogens, such as the pesticides DDT and dioxin.

Symptoms of hormone imbalance in women tend to increase as a woman ages and continue until menopause. Hormone imbalance symptoms can include: allergy symptoms, such as sneezing and runny nose; depression, fatigue and anxiety; endometriosis, a condition in which the tissue that lines the uterus is found to be growing outside the uterus, on or in other areas of the body; fibrocystic breasts or lumps in the breasts; hirsutism or hair loss and facial hair growth; headaches, dizziness and foggy thinking; low sex drive; osteoporosis or the gradual loss of bone; PMS or premenstrual syndrome; urinary tract infections and incontinence; uterine fibroids; weight gain, water retention and bloating; and wrinkly skin.

Signs and symptoms

Menopause:

Menstrual changes: Many women experience irregular periods due to the changing hormone levels and the decreased frequency of ovulation (egg release). The changes may be subtle at first and then gradually become more noticeable. Common changes include short cycles (less than 28 days), bleeding for fewer days than usual, heavier than usual bleeding, lighter than usual bleeding, and missed periods.

Although menstrual irregularities are expected during menopause, menstrual changes can also be caused by conditions such as fibroids or pregnancy. Women who experience heavy bleeding (usually with clots), periods that come more often than every three weeks, spotting between periods, or bleeding after intercourse, should see their doctor or other healthcare provider.

After menopause, women no longer menstruate. Any woman who experiences vaginal bleeding after menopause should see her doctor or other healthcare provider. Hormone treatments can sometimes cause vaginal bleeding to resume as a side effect.

Hot flashes: As many as 85% of women experience hot flashes during menopause. Hot flashes cause a warm or hot flushed sensation that usually begins in the head and face and then radiates down the neck to other parts of the body. There may be red blotches on the skin. Each hot flash averages 2.7 minutes and is characterized by a sudden increase in heart rate and an increase in blood flow to the extremities (such as feet and hands). This process leads to a rise in skin temperature and a sudden onset of sweating, particularly in the upper body. Hot flashes can occur before, during, or after menopause. Hot flashes can begin when a woman's cycles are still regular or, more commonly, as menopause approaches and her cycles become more irregular. They usually last for less than a year following the last menstrual period, although some women continue to experience hot flashes five to 10 years after menopause. Hot flashes can occur once a month, once a week, or several times an hour. They can happen any time of day or night. If they happen at night (such as night sweats), they can interrupt sleep and drench clothing and sheets. Loss of sleep can eventually lead to irritability and fatigue.

Skin and hair changes: Estrogen helps keep the skin smooth and moist. The loss of estrogen during menopause makes the skin dry, thin, lax, and transparent. The blood vessels are easier to see, and the skin bruises easily. The woman may experience growth of facial hair, but thinning of hair in the temple region.

Vaginal changes: Women may experience vaginal changes. In particular, the tissues of the vagina and vulva may become thin and dry (called vaginal atrophy), which can lead to itching and discomfort during sexual intercourse. In some women, vaginal dryness is the first sign of menopause.

Other changes: Other changes that may occur during menopause include: loss of bladder tone, which can result in stress incontinence (leaking urine when coughing, sneezing, laughing, or exercise); headaches; dizziness; loss of some muscle strength and tone; increasing loss of bones, increased risk for osteoporosis; increased risk for a heart attack when estrogen levels drop; emotional changes associated with menopause such as irritability, mood changes, lack of concentration, difficulty with memory, tension, anxiety, and depression; and insomnia that may result from hot flashes that interrupt sleep. Sex drive in women may also be affected by menopause. Decreases in sex drive are seen in approximately 25-40% of women experiencing menopause.

PMS:

For many women, the signs and symptoms of premenstrual syndrome are an uncomfortable and unwelcome part of their monthly menstrual cycle. The most common physical and emotional signs and symptoms associated with premenstrual syndrome include: weight gain from fluid retention; abdominal bloating; breast tenderness; tension or anxiety; depressed mood; crying spells; mood swings and irritability or anger; oily skin, acne, or greasy hair; appetite changes and food cravings; vertigo or dizziness; heart arrhythmias (irregular heart beat); insomnia or trouble falling asleep; joint or muscle pain; headache; and fatigue.

Although the list of potential signs and symptoms is long, most women with premenstrual syndrome experience only a few of these problems. For some women, the physical pain and emotional stress are severe enough to affect their daily routines and activities. For most of these women, symptoms disappear as the menstrual period begins. Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome with symptoms including severe depression, feelings of hopelessness, anger, anxiety, low self-esteem, difficulty concentrating, irritability, and tension.

Other conditions due to hormonal imbalances:

Premenstrual dysphoric disorder (PMDD): Premenstrual dysphoric disorder (PMDD) symptoms are similar to those of PMS, but they are generally more severe and debilitating. Symptoms occur during the last week of most menstrual cycles and usually improve within a few days after the period starts. Five or more of the following symptoms must be present: a feeling of sadness or hopelessness, possible suicidal thoughts; feelings of tension or anxiety; panic attacks; mood swings marked by periods of teariness; persistent irritability or anger that affects other people; disinterest in daily activities and relationships; trouble concentrating; fatigue or low energy; food cravings or binge eating; sleep disturbances; feeling "out of control;" and physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain.

Dysmenorrhea: Symptoms of dysmenorrheal include: cramping in the lower abdomen; pain in the lower abdomen; low back pain; pain radiating down the legs; nausea and vomiting; diarrhea; fatigue; weakness; fainting; and headaches.

Amenorrhea: The main symptom of amenorrhea is an absence of menstruation. Additional symptoms may be present depending on the associated condition, including: galactorrhea (breasts produce milk in a woman who is not pregnant or breastfeeding); headache or reduced peripheral vision could be a sign of an intracranial tumor; increased hair growth in a male pattern (hirsutism) may be caused by excess androgen (a hormone that encourages development of male sex characteristics); vaginal dryness, hot flashes, night sweats, or disordered sleep may be a sign of ovarian insufficiency or premature ovarian failure; a noticeable weight gain or weight loss may be present; and excessive anxiety may be present in women with associated psychiatric abnormalities.

Menorrhagia: The signs and symptoms of menorrhagia may include: menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours; the need to use double sanitary protection to control menstrual flow; the need to change sanitary protection during the night; menstrual periods lasting longer than seven days; menstrual flow that includes large blood clots; heavy menstrual flow that interferes with a regular lifestyle; constant pain in the lower abdomen during menstrual periods; or tiredness, fatigue, or shortness of breath.

Osteoporosis: In the early stages of osteoporosis, individuals probably will not have symptoms. As the disease progresses, the individual may develop symptoms related to weakened bones, including: back pain; loss of height and stooped posture; a curved upper back, known as dowager's hump; broken bones (fractures) that might occur with a minor injury, especially in the hip, spine, and wrist; and compression fractures in the spine that may cause severe back pain.

Polycystic ovary syndrome: Women with polycystic ovary syndrome (PCOS) usually have several of the many signs and symptoms associated with PCOS. These signs and symptoms include: irregular or no menstruation, which is the most common characteristic; signs of excess androgen (male hormone), such as long, coarse hair on the face, chest, lower abdomen, back, upper arms, or upper legs (hirsutism); acne; and male-pattern baldness (alopecia). However, not all women who have polycystic ovary syndrome have physical signs of androgen excess. Polycystic ovary syndrome is the most common cause of female infertility in the United States. The ability to use insulin effectively is impaired in PCOS and can result in high blood sugar levels and diabetes. Other symptoms that may occur with PCOS include: high blood pressure; high blood cholesterol; elevated levels of C-reactive protein, which may be associated with cardiovascular problems such as heart attack; nonalcoholic steatohepatitis (or fatty liver); and sleep apnea (pauses in breathing during sleep).

Vaginitis (yeast infection): Vaginal yeast infections can produce a variety of symptoms, such as abnormal or increased discharge, itching, fishy odor, irritation, painful urination, or vaginal bleeding.

Diagnosis

A doctor will review the woman's medical history and perform a physical examination, including a pelvic exam. During the pelvic exam, a doctor will check for any abnormalities in the reproductive organs and look for indications of infection. The doctor will insert an instrument (called a speculum) and/or fingers into the vagina to aid in examination. There are no unique physical findings or laboratory tests to positively diagnose premenstrual syndrome (PMS) or menopause.

The signs and symptoms of menopause, such as hot flashes and mood swings, are enough to tell most women they have begun going through the transition. Under certain circumstances, a doctor may check the level of follicle-stimulating hormone (FSH) and estrogen (estradiol) with a blood test. As menopause occurs, FSH levels increase and estradiol levels decrease. A doctor may also recommend a blood test to determine the level of thyroid-stimulating hormone, as hypothyroidism (low thyroid hormone levels) can cause symptoms similar to those of menopause.

PMS is difficult to diagnose because there is not a clear cause. The symptoms of PMS are varied and are found in other disorders. The cyclical pattern is crucial for a diagnosis - symptoms appear prior to menstruation and resolve when bleeding begins. Hormone levels in women with PMS are normal. Consequently, there are no laboratory tests that determine if a woman has PMS. However, a doctor may do blood tests to determine if the individual has another condition, such as a thyroid condition or early menopause (when menstruation stops, usually associated with aging).

The medical history and physical examination involve an evaluation of the symptoms and when they occur in relation to menstruation. Many healthcare providers advise women to keep a diary of menstrual cycles and the physical and psychological changes they experience over the course of several months. The menstrual diary provides clues to the physician and helps women understand and cope with the changes.

A doctor may attribute a particular symptom to PMS if it is part of a predictable premenstrual pattern. To establish a pattern, the physician may ask the individual to keep a record of signs and symptoms on a calendar or in a diary for at least two menstrual cycles. It is important to note the day that the first symptoms appear and disappear. Also it is important to be sure to mark the day the period started and ended.

Imaging tests: To rule out other causes of symptoms of menopause or PMS or to identify the cause of secondary dysmenorrhea, a doctor may request diagnostic tests, including imaging tests. These noninvasive tests enable a doctor to look for abnormalities inside the pelvis. The imaging tests most often used to diagnose the cause of secondary dysmenorrhea include ultrasound, computerized tomography (CT), and magnetic resonance imaging (MRI).

Laparoscopy: Laparoscopy is usually performed through a small (1 centimeter) incision into the belly button with the patient under general anesthesia in the operating room. A camera is mounted to a long tube about as big around as one's first finger, which is placed into the incision in the belly button and into the abdominal cavity. Once inside, carbon dioxide gas is used to expand the abdominal cavity so the internal organs can be visualized. A gynecologist (doctor specializing in female issues) either looks through the tube, or, more commonly, looks at a video monitor via the attached camera. A careful survey is made of the liver, appendix, the top layer of intestines, bladder, kidney tubes (ureters), and the gynecologic organs. Specifically, the gynecologist is able to fully visualize the uterus (womb), ovaries, fallopian tubes, rectum, and the bottom part of the cervix (the opening to the uterus) called the cul-de-sac.

Hysteroscopy: Hysteroscopy provides a way for a doctor to look inside the uterus. A hysteroscope is a thin, telescope-like instrument that is inserted into the uterus through the vagina and cervix. This tool often helps a doctor diagnose or treat a uterine problem. Hysteroscopy is minor surgery that is performed either in a doctor's office or in a hospital setting. It can be performed with local, regional, or general anesthesia--sometimes no anesthesia is needed. There is little risk involved with this procedure for most women.

Recording symptoms: Keeping a record to identify the triggers and timing of symptoms of PMS and menopause is recommended. This will allow the individual and doctor to intervene with strategies that may help to lessen them. PMS is often incorrectly diagnosed as another physical or emotional problem. The main characteristic that distinguishes PMS is the timing of the symptoms.

To diagnose PMS a record of symptoms needs to be kept on a calendar for two to three months. This calendar can help individuals see patterns in symptoms. A doctor will use the calendar along with a health history and physical exam to determine if the individual has PMS.

Use a calendar to record symptoms, such as hot flashes, mood swings, bloating, and heart palpitations. Rate each symptom on a scale of zero to three: zero (0) means the symptom is not present; one (1) means the symptom is mild; two (2) means the symptom is moderate; and three (3) means the symptom is severe and interferes with normal daily activities.

Start the calendar on the first day of the period (day 1) and use it every evening for one cycle. At the start of the next cycle (period), a doctor will help the individual calculate their scores and determine if PMS is present or if the symptoms of PMS are being caused by other health conditions, such as thyroid disorders, depression, or anxiety.

Complications

Menopause:

Several chronic medical conditions tend to appear after menopause. By becoming aware of the following conditions, women can take steps to help reduce their risk.

Cardiovascular disease: When estrogen levels decline, the risk of cardiovascular disease increases. Heart disease is the leading cause of death in women and men. Heart disease risk-reduction steps include stopping smoking, reducing high blood pressure, getting regular aerobic exercise, and eating a diet low in saturated fats and plentiful in whole grains, fruits, and vegetables.

Osteoporosis: During the first few years after menopause, women may lose bone density at a rapid rate, increasing their risk of osteoporosis. Osteoporosis is a condition that causes bones to become brittle and weak, leading to an increased risk of fractures. Postmenopausal women are especially susceptible to fractures of the hip, wrist, and spine. It is important during this time for women to get adequate calcium and vitamin D. It is recommended by healthcare professionals for postmenopausal women to have about 1,200-1,500 milligrams of calcium and 800 I.U. (international units) of vitamin D daily. It's also important to exercise regularly. Strength training and weight-bearing activities such as walking and jogging are especially beneficial in keeping the bones strong and healthy.

Urinary incontinence: Urinary incontinence is the loss of bladder control. As the tissues of the vagina and urethra lose their elasticity, postmenopausal women may experience a frequent, sudden, strong urge to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing, or lifting (stress incontinence).

Weight gain: Many women gain weight during the menopausal transition. Individuals may need to eat less, perhaps as many as 200-400 fewer calories a day, and exercise more just to maintain their current weight.

PMS:

PMS symptoms may become severe enough to hinder women from maintaining normal function. The incidence of suicide in women with depression is significantly higher during the latter half of the menstrual cycle.

Premenstrual dysphoric disorder (PMDD): PMDD is a condition where women suffer from many of the physical symptoms of PMS, often more severely than other women. In addition, they experience debilitating emotional symptoms such as feelings of hopelessness, isolation, and extreme mood swings. Researchers estimate that PMDD affects between 3-8% of women in their reproductive years. Major depression is common in women with PMDD, although PMDD can occur in women who do not have a history of major depression.

The complications of secondary dysmenorrhea depend on the underlying cause. For instance, pelvic inflammatory disease can scar fallopian tubes and compromise reproductive health. The scarring can lead to an ectopic pregnancy, in which the fertilized egg stays in the fallopian tube rather than traveling through the tube to implant in the uterus, or it implants somewhere else outside the uterus. Endometriosis, another possible cause of secondary dysmenorrhea, can lead to impaired fertility.

Treatment

Menopause, perimenopause, and postmenopause:

Calcium management: Adequate calcium intake is important to prevent osteoporosis and bone fractures. Daily calcium intake for postmenopausal women should be around 1,200 milligrams. Women should eat foods rich in calcium (such as dairy products, leafy green vegetables, tofu, calcium-fortified foods), as well as foods that promote calcium absorption. A glass of milk provides about 300 milligrams of calcium. Intake of foods that rob the bones of calcium, such as animal protein and salt, should be limited. Vitamin D helps the body absorb calcium. Fifteen minutes of sun exposure every day provides sufficient vitamin D. Foods such as fortified milk, liver, and tuna contain vitamin D. Women should ask their healthcare provider or nutritionist if they should take a vitamin D supplement.

Calcium supplements are available in several forms: amino acid chelate, calcium carbonate, calcium chloride, calcium lactate, calcium gluconate, bone meal, dolomite, hydroxyappetite, and calcium citrate. To maximize absorption, supplements containing amino acid chelate, calcium citrate, gluconate, or hydroxyappetite should be taken. Calcium supplements should be taken with food.

Exercise: Exercise is an important part of preventative healthcare for postmenopausal women. By increasing cardiovascular fitness and strengthening the bones, exercise helps prevent heart disease and osteoporosis. Low impact, weight-bearing exercises, such as walking, jogging, tennis, racquetball, and dancing are helpful. Women diagnosed with osteoporosis or cardiovascular disease should consult with their healthcare provider before initiating an exercise program.

Hormone replacement therapy: Hormone replacement therapy (HRT) uses man-made estrogens and progestin (synthetic progesterone) to ease the symptoms of menopause. The hormones are available in a variety of forms: pills, vaginal creams, vaginal ring inserts, implants, injections, and patches worn on the skin.

HRT has many short-term and long-term side effects. It is important to weigh all of the potential benefits and risks, preferences, and needs before beginning HRT. The benefits and side effects vary considerably from woman to woman. Women who take HRT should be closely monitored by a healthcare professional to ensure that they benefit as much as possible from the hormone therapy. Sometimes, changing the dosage or the way it is administered can help to control side effects.

Minor side effects include bloating, breast tenderness, cramping, irritability, depression, and menstrual bleeding for months or years following menopause. More serious risks include: breast cancer - women who have not had a hysterectomy and use estrogen supplements are at increased risk for invasive breast cancer and cardiovascular disease - HRT causes an increased risk for stroke (neurological damage caused by a lack of oxygen to the brain), heart attack, and cardiovascular disease.

Endometrial cancer has been linked to high-dose estrogen supplements. Women who have not had their uterus removed are prescribed low doses of estrogen with progestin (progestin protects against endometrial cancer).

Women who take HRT are at increased risk for deep vein thrombosis (DVT or blood clots).

HRT may help to prevent or delay the development of many diseases, including; osteoporosis; Alzheimer's disease; colon cancer; macular degeneration - the leading cause of visual impairment in persons over age 50; urinary incontinence; and skin aging.

Various types and dosages of estrogen and progestin are available and the type of HRT recommended often depends on particular symptoms. For example, women who experience vaginal dryness may opt for a vaginal cream or vaginal ring insert, both of which alleviate dryness. The vaginal ring insert can also help urinary tract problems. For women who suffer from hot flashes, pills or patches may be helpful.

Hormonal medications:

Estrogen therapy remains, by far, the most effective treatment option for relieving menopausal hot flashes. Depending on the individual's personal and family medical history, a doctor may recommend estrogen in the lowest dose needed to provide symptom relief for the individual.

Conjugated estrogens: Conjugated estrogens are a mixture of estrogens prescribed to treat menopausal symptoms. The conjugated estrogens in Premarin? and Premarin Vaginal Cream? are obtained from pregnant mare (female horse) urine. The conjugated estrogens in Cenestin? are synthetic.

Dienestrol: Dienestrol (Ortho-Dienestrol?) is a synthetic, nonsteroidal, estrogen vaginal cream used to treat atrophic vaginitis. Side effects include vaginal discharge, increased vaginal discomfort, uterine bleeding, vaginal burning sensation, breast tenderness, and swelling in the hands or feet.

Esterified estrogens: Esterified estrogens (Estratab?, Menest?) are estrogenic substances consisting of 75-85% natural estrogens and 15-25% equine (mare or female horse urine) estrogens. They are supplied in tablet form and are used to treat hot flashes and atrophic vaginitis and urethritis (infections due to thinning and drying of vaginal tissues).

Estradiol: Estradiol is one of the three major estrogens made by the human body and is the major estrogen secreted during the menstrual years. It is available as an oral pill (Estrace?), transdermal skin patch (Climara?, Estraderm?, Vivelle?), vaginal tablet (Vagifem?), and vaginal cream (Estrace Vaginal Cream?).

Estropipate (estrone): Estropipate is an estrogenic substance derived from estrone, one of the three major estrogens produced by the body. Estrone is produced from estradiol and is a less potent estrogen. It is available in pill form (Ogen?, Ortho-Est?) and prescribed to treat hot flashes and vaginal atrophy and to help prevent osteoporosis.

Ethinyl estradiol: Ethinyl estradiol (Estinyl?) is a synthetic nonsteroidal estrogen available as a tablet that is prescribed to treat hot flashes (vasomotor symptom). It is administered on a cyclical basis (such as three weeks on and one week off) with attempts to discontinue or taper at three to six month intervals.

Testosterone: Testosterone is one of the androgens or male hormones and is also produced by women. Testosterone contributes to muscle strength, appetite, well-being, and sex drive (libido). The level of testosterone falls rapidly after menopause, and some women take testosterone supplements in addition to estrogen and progestin as part of HRT. However, supplemental testosterone can produce side effects and has potentially serious risks. Common side effects include weight gain, acne, facial hair, and liver disease. Testosterone can exacerbate estrogen's carcinogenic effect on breast and uterine tissue.

Other medications:

Low-dose antidepressants: Venlafaxine (Effexor?), an antidepressant related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs), has been reported to decrease menopausal hot flashes. Other SSRIs can be helpful, including fluoxetine (Prozac?, Sarafem?), paroxetine (Paxil?), citalopram (Celexa?), and sertraline (Zoloft?). Side effects include drowsiness and fatigue

Gabapentin (Neurontin?): Gabapentin (Neurontin?) is approved to treat seizures, but it also has been reported to significantly reduce hot flashes. Side effects include drowsiness, sedation, blurred vision, nausea, vomiting, or tremor.

Clonidine (Catapres?): Clonidine (Catapres?) is typically used to treat high blood pressure. However clonidine may significantly reduce the frequency of hot flashes. Side effects include slow heart rate, low blood pressure, fatigue, dizziness, headache, constipation, nausea, vomiting, diarrhea, insomnia, or a dry mouth.

Bisphosphonates: Alendronate (Fosamax?), risedronate (Actonel?), ibandronate (Boniva?), and zoledronate (Zometa?) are approved by the U.S. Food and Drug Administration (FDA) for the prevention and treatment of osteoporosis in postmenopausal women. Alendronate has been approved for management of osteoporosis in men. Both alendronate and risedronate are approved for the prevention and treatment of steroid-induced osteoporosis in men and women. Bisphosphonates help slow down bone loss and have been shown to decrease the risk of fractures. All are taken on an empty stomach with water. Because bisphosphonates have the potential for irritating the esophagus, remaining upright for at least an hour after taking these medications is recommended by healthcare professionals. Alendronate and risedronate can be taken once a week, while ibandronate can be taken once a month. An IV form of ibandronate, given through the vein every three months, also has been FDA-approved for the management of osteoporosis. Another IV bisphosphonate being studied for osteoporosis is zoledronic acid or zoledronate (Zometa?). This form is injected once yearly.

Side effects, which can be severe, include nausea, abdominal pain, and the risk of an inflamed esophagus or esophageal ulcers, especially if the individual has had acid reflux or ulcers in the past. If individuals cannot tolerate oral bisphosphonates, the doctor may recommend the periodic intravenous infusions of a bisphosphonate.

Use of bisphosphonates in women who are pregnant or breastfeeding is not well studied. Blood calcium levels in women who take bisphosphonates during pregnancy are usually monitored. Individuals using Boniva? injection will have blood levels of creatinine measured prior to each dose to determine kidney function. Creatinine is measured using blood tests.

Selective estrogen receptor modulators (SERMs): Selective estrogen receptor modulators (SERMS) mimic the positive effects of estrogen on bones without some of the serious side effects such as breast cancer and stroke. Raloxifene (Evista?) decreases spine fractures in women. Hot flashes are a common side effect of raloxifene, and individuals with a history of blood clots should not use this drug.

Vaginal estrogen: To relieve vaginal dryness, estrogen can be administered locally in the vagina using a vaginal tablet (Vagifem?), ring (Nuvaring?), or cream (Premarin? vaginal cream). This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse, and some urinary symptoms.

PMS and related conditions of hormonal imbalances:

Studies have reported that women with PMS should consider treatment if they notice any of the following, especially one to two weeks before their period: poor performance at school or at work as a result of difficulty concentrating, irritability, or fatigue; disturbing physical symptoms, such as breast tenderness, bloating, hot flashes, and headaches; problems in social life, such as damaged relationships with spouses, friends, lovers, and colleagues; difficulty parenting; and suicidal thoughts - suicidal thoughts are common in women with severe PMS.

Diet and physical activity: Diet and physical activity changes are the preferred method for treating symptoms of PMS. Eating a healthy diet is important for general health and may also help relieve PMS symptoms such as bloating, breast tenderness, weight gain, irritability, and headaches. A healthy diet includes eating foods high in complex carbohydrates, like whole grains and fresh fruits and vegetables, and avoiding saturated fats. It may also help to avoid salt, sugar, caffeine, alcohol, red meat, and sometimes dairy products. Eating more small meals each day instead of three large meals may reduce food cravings and mood swings.

Most women report that exercise improves their PMS symptoms. It is especially helpful in relieving stress, improving mood, and preventing weight gain. Physically activity should include exercise for at least 30 minutes on most days of the week throughout the menstrual cycle. Walking or other moderate physical activity may be enough, but some women find they need more vigorous aerobic exercise, such as jogging, biking, swimming, or climbing stairs.

Anti-inflammatory drugs: Over-the-counter (OTC) drugs such as aspirin and nonsteroidal anti-inflammatory drugs (NSAID), such as ibuprofen (Advil?, Motrin?) or naproxen (Aleve?) may be used for symptoms of dysmenorrhea (painful menstruation) and associated headaches.

Progesterone: Progesterone can be delivered using suppositories (a suppository is a drug delivery system that is inserted either into the rectum, vagina, or urethra where it dissolves), an oral form (by mouth), or topically (applied to the skin). Progesterone products can be purchased from compounding pharmacies. Compounded progesterone creams usually contain pharmaceutical progesterone mixed with other natural progesterone sources, including plants.

Oral contraceptives: Oral contraceptives, or birth control pills, stop ovulation and stabilize hormonal swings, thereby offering relief from PMS symptoms. Yaz?, a newer type of birth control pill that is a combination of the hormones drospirenone and ethinyl estradiol, has been reported to be effective in reducing the physical and emotional symptoms of premenstrual dysphoric disorder (PMDD). Yaz? is the first oral contraceptive to be approved for this use. For severe cramping, a doctor might recommend low-dose oral contraceptives to prevent ovulation, which may reduce the production of prostaglandins and therefore the severity of cramping. Low-dose oral contraceptives (such as Loestrin?) may increase risk for heart attack or stroke (neurological damage due to lack of oxygen to the brain).

Antidepressants: Selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac?, Sarafem?), paroxetine (Paxil?), and sertraline (Zoloft?), have been successful in reducing symptoms such as fatigue, food cravings, and sleep problems. These drugs are generally taken daily, and may cause side effects such as sedation, insomnia, and weight gain. For some women with PMS, use of antidepressants may be limited to the two weeks before menstruation begins.

Medroxyprogesterone acetate (Depo-Provera?): Medroxyprogesterone (Depo-Provera?) is used for severe PMS or PMDD. Depo-Provera? is an injection that can be used to temporarily stop ovulation. However, Depo-Provera? may cause an increase in some signs and symptoms of PMS, such as increased appetite, weight gain, headache, and depressed mood.

Diuretics: Diuretic medications help relieve the body of excess fluid. Excess fluid causes symptoms of bloating and swelling (especially in the feet and ankles). Diuretics include hydrochlorothiazide (Hydroduiril?) and furosemide (Lasix?). Some diuretics may deplete the body of electrolytes, such as potassium. A healthcare professional will advise the patient if potassium supplements are needed. Often, adding potassium rich foods to the diet, such as bananas, is sufficient.

Anti-anxiety medicines: If antidepressant medications are not helpful for anxiety, anti-anxiety medicines can be used to relieve anxiety associated with PMS. The one most commonly used is alprazolam (Xanax?). It is in the class of medicines called benzodiazepines and increases the amount of the neurotransmitter GABA. Side effects include drowsiness, sedation, and blurred vision. It is recommended to use caution when driving an automobile or operating heavy machinery if taking benzodiazepines. Because benzodiazepines can be addictive, they must be used cautiously.

Another anti-anxiety medicine, buspirone (BuSpar?), may also help reduce anxiety and depression in PMS. It is not addictive and has less severe side effects than the benzodiazepines.

GnRH agonists: Gonadotropin-releasing hormones (GnRH) suppress the hormones that cause ovulation - follicle stimulating hormone (FSH) and luteinizing hormone (LH). GnRH agonists are drugs that cause a temporary menopause-like state (lack of menstruation). They are highly effective in treating PMS, including breast tenderness, irritability, and fatigue. However, GnRH agonists can also cause menopausal symptoms, such as hot flashes and vaginal dryness. In addition, long-term use (more than six months) is associated with bone loss (osteoporosis). Small doses of estrogen and progesterone can be given in addition to GnRH agonists to lessen these side effects and allow long-term use. GnRH agonists include goserelin (Zoladex?, available as an implant), leuprolide (Leupron?, available as an injection), and naferelin (Synarel?, available in a nasal spray).

Anti-infectives: If a vaginal yeast infection is present, drugs prescribed may involve antifungal creams and suppositories, antibiotics, and other prescription drugs. Vaginal creams and vaginal applications are often recommended first rather than oral medication. Common medications used include: the prescription antifungal medications metronidazole (Flagyl?) and fluconazole (Diflucan?); antibiotics including doxycycline (Doryx?, Vibramycin?) and azithromycin (Zithromax?); and over-the-counter (OTC) antifungal medications such as miconazole (Monistat?).

Some self-care techniques include vinegar douches or sitz baths in a solution of one teaspoon of vinegar for every gallon of water, and eating yogurt containing live acidophilus (probiotic) cultures. It is recommended by healthcare professionals to abstain from sexual intercourse until treatment is completed.

Hysterectomy: If the individual's menstruation (periods) are heavy, not regular, or last for many days each cycle and nonsurgical methods have not helped to control bleeding, a hysterectomy may bring relief. A hysterectomy is the complete removal of the uterus (womb). The ovaries and fallopian tubes may also be removed if necessary. Hysterectomies are very common. One in three women in the United States has had a hysterectomy by age 60. A hysterectomy will stop the menstruation (period) and the individual will no longer be able to become pregnant. Symptoms of menopause may also begin, such as hot flashes, irritability, and vaginal dryness. Individuals should discuss a hysterectomy carefully with a doctor, family members, and counselor if needed.

Hysterectomies are performed in a hospital. Hysterectomies involve a cut in the abdomen (abdominal hysterectomy) or the vagina (vaginal hysterectomy). Sometimes an instrument called a laparoscope is used to help see inside the abdomen during vaginal hysterectomy. The type of surgery that is done depends on the reason for the surgery. Abdominal hysterectomies are more common and usually require a longer recovery time. An abdominal hysterectomy may also cause greater discomfort than following a vaginal procedure and a visible scar on the abdomen may be present.

Recovery from a hysterectomy generally takes four to six weeks.

A hysterectomy is generally very safe, but as with any major surgery, there are risks of complications. Such complications include blood clots, infection, excessive bleeding, or an adverse reaction to the anesthesia. Other risks of hysterectomy are: damage to the urinary tract, bladder, or rectum during surgery, which may require further surgical repair; loss of ovarian function; or early onset of menopause.

Other reasons to perform a hysterectomy in women include: fibroids (tumors); endometriosis not cured by medicine or surgery; uterine prolapse or when the uterus drops into the vagina; cancer of the uterus, cervix, or ovaries; vaginal bleeding that persists despite treatment; and chronic pelvic pain. Surgery is usually a last resort.

Integrative therapies

Strong scientific evidence:

Calcium: Calcium is the nutrient consistently found to be the most important for attaining peak bone mass and preventing osteoporosis. Adequate vitamin D intake is required for optimal calcium absorption. Adequate calcium and vitamin D are deemed essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis. Multiple studies of calcium supplementation in the elderly and postmenopausal women have found that high calcium intakes can help reduce the loss of bone density. Studies indicated that bone loss prevention could be achieved in many areas, including ankles, hips, and spine. Although calcium and vitamin D alone are not recommended as the sole treatment of osteoporosis, they are necessary additions to pharmaceutical treatments. Treatment of postmenopausal osteoporosis should only be done under supervision of a qualified healthcare professional.

Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or irregular heartbeat. Talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

Vitamin D: Adults with severe vitamin D deficiency lose bone mineral content ("hypomineralization") and experience bone pain, muscle weakness, and osteomalacia (soft bones). Treatment for osteomalacia depends on the underlying cause of the disease and often includes pain control and orthopedic surgical intervention, as well as vitamin D and phosphate binding agents.

Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

Good scientific evidence:

Calcium: There is a link between lower dietary intake of calcium and symptoms of premenstrual syndrome (PMS). Calcium supplementation has been suggested in various clinical trials to decrease overall symptoms associated with PMS, such as depressed mood, water retention, and pain.

Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or irregular heartbeat. Calcium appears to be safe in pregnant or breastfeeding women. Talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

Lactobacillus acidophilus: Multiple human studies report that Lactobacillus acidophilus vaginal suppositories are effective in the treatment of bacterial vaginosis. Additional research is necessary before a firm conclusion can be reached. Patients with persistent vaginal discomfort are advised to seek medical attention.

Lactobacillus acidophilus may be difficult to tolerate if allergic to dairy products containing Lactobacillus acidophilus. Avoid with history of an injury or illness of the intestinal wall, immune disease or heart valve surgery. Avoid with prescription drugs, like corticosteroids. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus.Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids (like famotidine (Pepcid?), esomeprazole (Nexium?)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

Rose hip: Rose hips are the fruits that develop from the blossoms of the wild rose (Rosa spp.). They are typically orange to red in color, but some species may be purple or black. Estimates of the number of women who experience menstrual cramps with dysmenorrhea range from 50-93%. In 10-26% of women, this pain may be severe. Herbalists have recommended aromatherapy, the therapeutic use of essential oils from plants, as a treatment for menstrual cramps. The oils are absorbed into the body via the olfactory system and the skin. Lavender, clary sage, and rose are three of the oils traditionally used to treat dysmenorrhea.

Avoid in individuals with a known allergy/hypersensitivity to Rosa spp., rose hip dust, its constituents, or members of the Rosaceae family.

Sage: Sage (Salvia officinalis) may contain compounds with mild estrogenic activity. In theory, estrogenic compounds may decrease menopausal symptoms. Sage has been tested against menopausal symptoms with promising results.

Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use the essential oil or tinctures cautiously in patients with epilepsy. Avoid with previous anaphylactic reactions to sage species, their constituents, or to members of the Lamiaceae family. Avoid if pregnant or breastfeeding.

Soy: Soy (Glycine max) products containing isoflavones have been studied for the reduction of menopausal symptoms such as hot flashes. The scientific evidence is mixed in this area, with several human trials suggesting reduced number of hot flashes and other menopausal symptoms, but more recent research reporting no benefits. Overall, the scientific evidence does suggest benefits, although better quality studies are needed in this area in order to make a conclusion.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy supplementation.

Vitamin D: Without sufficient vitamin D, inadequate calcium is absorbed and the resulting elevated parathyroid (PTH) secretion causes increased bone resorption. This may weaken bones and increase the risk of fracture. Vitamin D supplementation has been shown to slow osteoporosis and reduce fracture, particularly when taken with calcium.

Unclear or conflicting scientific evidence:

Acupressure, Shiatsu: Based on initial research, acupressure may reduce symptoms of dysmenorrhea, pain medication use, and anxiety associated with menstruation. Further research is needed before a conclusion can be made.

With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Acupuncture: Although some studies report beneficial results, currently there is not adequate available evidence to recommend for or against the use of acupuncture in the treatment of symptoms of menopause such as hot flashes or in the treatment of dysmenorrhea. High quality clinical research is needed to make a conclusion.

There is preliminary evidence suggesting that electroacupuncture may increase ovulation in some women with polycystic ovarian syndrome (PCOS). However, available study is inadequate to recommend for or against electroacupuncture for this indication.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.

Aromatherapy: Abdominal aromatherapy massage with a combination of essential oils may reduce the intensity of menstrual cramps in women with dysmenorrhea. More research is needed in this area to identify the most effective essential oils.

Avoid with history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

Belladonna: Bellergal? (a combination of phenobarbital, ergot, and belladonna) has been used to treat premenstrual syndrome (PMS) symptoms as well as menopausal symptoms like hot flashes. However, in human studies belladonna supplements have not shown effectiveness. More studies are needed.

Avoid if allergic to belladonna or plants of the Solanaceae(nightshade) family (bell peppers, potatoes, eggplants). Avoid with history of heart disease, high blood pressure, heart attack, abnormal heartbeat (arrhythmia), congestive heart failure, stomach ulcer, constipation, stomach acid reflux (serious heartburn), hiatal hernia, gastrointestinal disease, ileostomy, colostomy, fever, bowel obstruction, benign prostatic hypertrophy, urinary retention, glaucoma (narrow angle), psychotic illness, Sj?gren's syndrome, dry mouth (xerostomia or salivary gland disorders), neuromuscular disorders such as myasthenia gravis, or Down's syndrome. Avoid if pregnant or breastfeeding.

Bilberry: Preliminary evidence suggests that bilberry may be helpful for the relief of dysmenorrhea, although more research is necessary before a firm conclusion can be drawn.

Avoid if allergic to plants in the Ericaceae family or to anthocyanosides (a component of bilberry). Avoid with a history of low blood pressure, heart disease, bleeding, diabetes, blood clots, or stroke. Avoid if pregnant or breastfeeding. Stop use before surgeries or dental or diagnostic procedures involving blood tests.

Black cohosh: Black cohosh (Actaea racemosa, formerly known as Cimicifuga racemosa) is popular as an alternative to hormonal therapy in the treatment of menopausal symptoms such as hot flashes, mood disturbances, diaphoresis, palpitations, and vaginal dryness. Several studies have reported black cohosh to improve symptoms for up to six months, although the current evidence is mixed. The mechanism of action of black cohosh remains unclear and the effects on estrogen receptors or hormonal levels (if any) are not definitively known. Recent publications suggest that there may be no direct effects on estrogen receptors, although this is an area of active controversy. Safety and efficacy beyond six months have not been proven, although recent reports suggest safety of short-term use, including in women experiencing menopausal symptoms for whom estrogen replacement therapy is contraindicated. Nonetheless, caution is advisable until better-quality safety data are available.

Use of black cohosh in high-risk populations (such as in women with a history of breast cancer) should be under the supervision of a licensed healthcare professional. Use cautiously if allergic to members of the Ranunculaceaefamily such as buttercups or crowfoot. Avoid if allergic to aspirin products, non-steriodal anti-inflammatories (NSAIDs, Motrin?, ibuprofen, etc.), blood-thinners (like warfarin) or if history of blood clots, stroke, seizures, or liver disease. Stop use before surgery/dental/diagnostic procedures with bleeding risk and avoid immediately after these procedures. Avoid if pregnant or breastfeeding.

Black tea: Preliminary research suggests that chronic use of black tea may improve bone mineral density (BMD) in older women. Better research is needed to more clearly determine the effects of black tea for osteoporosis prevention.

Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances and insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism and irritability.

Boron: Animal and preliminary human studies report that boron may play a role in mineral metabolism, with effects on calcium, phosphorus, and vitamin D. However, research of bone mineral density in women taking boron supplements does not clearly demonstrate benefits in osteoporosis. Additional study is needed before a firm conclusion can be drawn.

Inorganic boron (boric acid, borax) has been used as an antiseptic based on proposed antibacterial and antifungal properties. It is proposed that boric acid may have effects against candidal and non-candidal vulvovaginitis. A limited amount of poor-quality research reports that boric acid capsules used in the vagina may be effective for vaginitis. Further evidence is needed before a recommendation can be made.

Avoid if allergic or sensitive to boron, boric acid, borax, citrate, aspartate or glycinate. Avoid with history of diabetes, seizure disorder, kidney disease, liver disease, depression, anxiety, high blood pressure, skin rash, anemia, asthma, or chronic obstructive pulmonary disease (COPD). Avoid with hormone-sensitive conditions like breast cancer or prostate cancer. Avoid if pregnant or breastfeeding.

Calcium: Calcium supplementation above the normal daily dietary intake has not been shown to reduce stress fractures. Further studies are needed to better determine the role of calcium in bone stress injury prevention.

Rickets and osteomalacia (bone softening) are commonly thought of as diseases due to vitamin D deficiency; however, calcium deficiency may also be another cause in sunny areas of the world where vitamin D deficiency would not be expected. Calcium gluconate is used as an adjuvant in the treatment of rickets and osteomalacia, as well as a single therapeutic agent in non-vitamin D deficient rickets. Research continues into to the importance of calcium alone in the treatment and prevention of this condition. Treatment of rickets and osteomalacia should only be done under the supervision of a qualified healthcare professional.

Chamomile: Chamomile douche may improve symptoms of vaginitis with few side effects. Because infection (including sexually transmitted diseases), poor hygiene, or nutritional deficiencies can cause vaginitis, medical attention should be sought by people with this condition. Better research is needed before a conclusion can be drawn regarding the role of chamomile in the management of vaginitis.

Avoid if allergic to chamomile or any related plants such as aster, chrysanthemum, mugwort, ragweed, or ragwort. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.

Chasteberry: It remains unclear if chasteberry is an effective therapy in the management of irregular menstrual cycles. The use of chasteberry for corpus luteum deficiency also remains controversial. Additionally, most studies evaluating chasteberry for premenstrual syndrome (PMS) have been of poor study design, although one recent trial demonstrating benefit is of high quality. Further evidence is necessary before a firm conclusion can be drawn.

Avoid if allergic or hypersensitive to members of the Vitex (Verbenaceae) family or any chasteberry components. When taken in recommended doses, chasteberry appears to be well tolerated with few side effects. Use cautiously in patients taking oral contraceptives or hormone replacement therapy Use cautiously with dopamine agonists or antagonists. Avoid with hormone sensitive cancers or conditions (like ovarian cancer or breast cancer). Avoid if pregnant, breastfeeding or if undergoing in vitro fertilization.

Chiropractic: There is currently not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of dysmenorrhea or premenstrual syndrome.

Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, and migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid if taking drugs that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.

Chromium: There is currently a lack of evidence for or against the use of chromium for the treatment of bone resorption and bone loss in postmenopausal women.

Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

Copper: Supplementation with copper may be helpful in the treatment and/or prevention of osteoporosis, although early human evidence is conflicting. Further research is needed before clear conclusions can be drawn.

Avoid if allergic to copper. Avoid copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia. Avoid with genetic disorders affecting copper metabolism (e.g. Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis). Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6 milligrams/liter. Use cautiously with anemia, arthralgias, or myalgias. Use cautiously if taking birth control pills. Use cautiously if at risk for selenium deficiency. Doses that do not exceed the recommended dietary allowance appear to be safe during pregnancy and breastfeeding.

Creatine: Creatine is an amino acid that is found in the muscles. Early studies examining the effect of creatine in aging suggest that creatine may increase bone density when combined with resistance training. Further studies in which creatine alone is compared with placebo are needed.

Avoid if allergic or hypersensitive to creatine. Early research suggests that creatine may reduce muscle cramps that are often associated with hemodialysis. However, further studies are needed to confirm this claim. Avoid if taking diuretics (e.g. hydrochlorothiazide or furosemide). Use cautiously with asthma, diabetes, gout, kidney disease, liver disease, muscle problems, stroke, or with a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.

DHEA: DHEA (dehydroepiandrosterone) is a hormone made in the human body and secreted by the adrenal gland. DHEA serves as precursor to male and female sex hormones (androgens and estrogens). Many different aspects of menopausal disorders have been studied using DHEA as a treatment, such as vaginal pain, hot flashes or emotional disturbances such as fatigue, irritability, anxiety, depression, insomnia, difficulties with concentration, memory, or decreased sex drive (which may occur near the time of menopause). Additionally, the ability of DHEA to increase bone density is under investigation. Effects are not clear at this time.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or with anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Dong quai: There is limited poor-quality study of Dong quai as a part of herbal combinations used for amenorrhea. There are also unclear results of preliminary, poor-quality human research of Dong quai in combination with other herbs for dysmenorrhea.

Dong quai supplements may increase the risk of bleeding in sensitive individuals, such as those taking medications to reduce blood clotting, including aspirin and warfarin (Coumadin?). Although Dong quai is accepted as being safe as a food additive in the United States and Europe, its safety in medicinal doses is not known. Long-term studies of side effects are lacking. Avoid if allergic/hypersensitive to Dong quai or members of the Apiaceae / Umbelliferae family (like anise, caraway, carrot, celery, dill, parsley). Avoid prolonged exposure to sunlight or ultraviolet light. Use cautiously with diabetes, glucose intolerance or hormone sensitive conditions (like breast cancer, uterine cancer or ovarian cancer). Do not use before dental or surgical procedures. Avoid if pregnant or breastfeeding.

Echinacea: When echinacea is used at the same time as the prescription cream econazole nitrate (Spectazole?), vaginal yeast infections (Candida) may occur less frequently. However, further research is needed to confirm this.

Avoid if allergic to echinacea, its constituents, or any members of the Asteraceae/Compositae family (ragweed, chrysanthemums, marigolds, daisies). Use cautiously in patients prone to atopic reactions and in those with hemochromatosis and diabetes. Some natural medicine experts discourage the use of echinacea by people with conditions affecting the immune system, such as HIV/AIDS, some types of cancer, multiple sclerosis, tuberculosis, and rheumatologic diseases (such as rheumatoid arthritis or lupus). Use parenteral preparations of echinacea(no longer approved for use in Germany) cautiously. Use tinctures cautiously with alcoholic patients or in patients taking disulfiram or metronidazole. Avoid using echinacea in patients presenting for anesthesia. Use cautiously if pregnant or breastfeeding.

Evening primrose oil: Primrose oil has been suggested as a possible treatment for osteoporosis. Well-designed human trials are needed before primrose oil can be recommended for osteoporosis therapy.

Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

Fennel: Fennel has been used to treat dysmenorrhea. Although preliminary study is promising, there is currently insufficient evidence to recommend for or against this use of fennel.

Avoid if allergic or hypersensitive to fennel or other members of the Apiaceae family. Fennel is generally well-tolerated. However, serious allergic reactions may occur. Use cautiously with diabetes. Avoid with epilepsy. Avoid in infants and toddlers. Avoid if pregnant or breastfeeding.

Flaxseed: Flaxseed (Linum usitatissimum) and its derivative flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid, which is a biologic precursor to omega-3 fatty acids such as eicosapentaenoic acid. There is preliminary evidence from randomized controlled trials that flaxseed oil may help decrease mild menopausal symptoms. Additional research is necessary before a clear conclusion can be drawn.

Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with history of a bleeding disorder or with drugs that cause bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil?)), high triglyceride levels, diabetes, mania, seizures or asthma. Avoid if pregnant or breastfeeding. Avoid with breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods.

Gamma linolenic acid (GLA): Gamma linolenic acid (GLA) is a dietary omega-6 fatty acid found in many plant oil extracts. Limited available study has examined the effect of GLA on menopausal hot flashes. No improvement in the number of hot flashed was noted as compared with placebo. More clinical studies are required to better determine effectiveness.

A study using Efamol (containing GLA) suggests there may be benefit for premenstrual syndrome symptoms. More information is needed in this area before a firm recommendation can be made.

Some clinical evidence suggests that GLA and eicosapentaenoic acid (EPA) enhance the effects of calcium supplementation for osteoporosis. More clinical studies are required.

Use cautiously with drugs that increase the risk of bleeding like anticoagulants and anti-platelet drugs. Avoid if pregnant or breastfeeding.

Gamma oryzanol: Gamma oryzanol is a mixture of ferulic acid esters of sterol and triterpene alcohols, and it occurs in rice bran oil at a level of 1-2%, although it has been extracted from corn and barley oils as well. It is theorized that some of the health benefits from rice bran oil, namely its cholesterol-lowering effects, may be due to its gamma oryzanol content. Gamma oryzanol may reduce menopausal symptoms. However, these results must be viewed cautiously as a high placebo effect is associated with the treatment of menopausal symptoms. Additional study is needed in this area to better determine gamma oryzanol's effect on menopausal symptoms.

Avoid if allergic/hypersensitive to gamma oryzanol, its components, or rice bran oil. Use cautiously if taking anticoagulants (blood thinners), central nervous system (CNS) suppressants, growth hormone, drugs or herbs that alter blood sugar levels, immunomodulators, luteinizing hormone or luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering or thyroid drugs, or herbs or supplements with similar effects. Use cautiously with diabetes, hypothyroidism, hypoglycemia, hyperglycemia and high cholesterol. Avoid if pregnant or breastfeeding.

Ginkgo: Initial study in women with premenstrual syndrome (PMS) or breast discomfort suggests that ginkgo may relieve symptoms including emotional upset. Further well-designed research is needed before a recommendation can be made.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin?)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.

Ginseng: Although ginseng (Panax ginseng) has been used for menopausal symptoms, evidence from a small amount of research is unclear in this area. Some studies report improvements in depression and sense of well-being, without changes in hormone levels.

Avoid with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Grape seed: Little information is available for the use of grape seed extract in the treatment of premenstrual syndrome. Early study shows positive results but further research is necessary before a recommendation can be made.

There are reports of people with allergy to grapes or other grape compounds, including anaphylaxis. Individuals allergic to grapes should not take grape seed and related products. Use cautiously if taking anticoagulants. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Grape seed may interfere with the way the body processes certain drugs that use the liver's "cytochrome P450" enzyme system. Avoid if pregnant or breastfeeding.

Green tea: Green tea supplements are made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use, dating back to China approximately 5,000 years ago. Green tea, black tea, and oolong tea are all derived from the same plant. A study conducted in healthy postmenopausal women showed that a morning/evening menopausal formula containing green tea was effective in relieving menopausal symptoms including hot flashes and sleep disturbances. Further studies are needed to confirm these results.

Green tea supplements may increase the risk of bleeding in sensitive individuals, such as those taking medications to reduce blood clotting, including aspirin and warfarin (Coumadin?). Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease. Caffeine-free green tea supplements are available.

Hops: When used in combination with other products, hops may help alleviate menopausal symptoms, such as hot flashes and difficulty sleeping, because it has estrogen-like activity. However, until more well-designed studies are performed, a strong recommendation cannot be made.

Hops may cause drowsiness, therefore, caution is advised when operating an automobile or heavy machinery. Hops supplements are not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Horsetail: Silicon may be beneficial for bone strengthening. Because horsetail (Equisetum arvense) contains silicon, it has been suggested as a possible natural treatment for osteoporosis. Preliminary human study reports benefits, but more detailed research is needed before a firm recommendation can be made. People with osteoporosis should speak with a qualified healthcare provider about possible treatment with more proven therapies.

Avoid if allergic or hypersensitive to horsetail or nicotine. Avoid with a history of chronic alcohol abuse, malnutrition, and kidney disorders. Use cautiously with abnormal heart rhythms, diabetes, gout, neurological disorders, and osteoporosis. Avoid in children. Avoid if pregnant or breastfeeding.

Hypnotherapy: Early evidence shows that hypnotherapy may be beneficial in the treatment of hot flashes and may improve quality of life in women with menopausal disorders. Further research is needed.

Use cautiously with mental illnesses (e.g. psychosis, schizophrenia, manic depression, multiple personality disorder, or dissociative disorders) or seizure disorders.

Kudzu: Kudzu (Pueraria lobata) originated in China and was brought to the United States from Japan in the late 1800s. It is distributed throughout much of the eastern United States and is most common in the southern part of the continent. Kudzu contains chemicals called isoflavones, which are reported to have estrogenic activity. There is conflicting evidence regarding the effects of kudzu on menopausal symptoms. Additional study is needed to clarify these results.

Avoid if allergic or hypersensitive to Pueraria lobata or members of the Fabaceae/Leguminosae family. Use cautiously if taking anticoagulants/anti-platelet and blood pressure lowering agents, hormones, antiarrhythmics, benzodiazepines, bisphosphonates, diabetes medications, drugs that are metabolized by the liver's cytochrome P450 enzymes, mecamylamine, neurologic agents, or methotrexate. Well-designed studies on the long-term effects of kudzu are currently unavailable. Avoid if pregnant or breastfeeding.

Lactobacillus acidophilus: Lactobacillus acidophilus taken by mouth or as a vaginal suppository has not been adequately assessed for the prevention or treatment of vaginal candidiasis. More research is needed in this area a before a conclusion can be drawn.

Lactobacillus acidophilus may be difficult to tolerate if allergic to dairy products containing Lactobacillus acidophilus. Avoid with history of an injury or illness of the intestinal wall, immune disease, or heart valve surgery. Avoid with prescription drugs, like corticosteroids. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus.Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids (like famotidine (Pepcid?), esomeprazole (Nexium?)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

Licorice: Spironolactone is a synthetic steroid that is commonly used as a diuretic in women with polycystic ovary syndrome. Licorice has been used in combination with spironolactone to reduce side effects related to the diuretic activity of spironolactone.

Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid licorice with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.

Massage: Initial research of the effects of massage on mood in women with premenstrual dysphoric disorder (PMDD) is inconclusive. A recent study investigating abdominal meridian massage (Kyongrak) found positive effects for menstrual cramps and dysmenorrhea. Further study is needed before a recommendation can be made for premenstrual syndrome.

Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin?). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

Milk thistle: An herbal preparation containing milk thistle may be effective in decreasing menopausal symptoms. However, milk thistle alone has not been researched.

Use cautiously if allergic to plants in the aster family (Compositea or Asteraceae), daisies, artichoke, common thistle, or kiwi. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

Omega-3 fatty acids, fish oil, alpha-linolenic acid: Omega-3 fatty acids are found in fish oil and certain plant/nut oils. Fish oil contains both docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). There is preliminary evidence suggesting possible benefits of fish oil/omega-3 fatty acids in patients with dysmenorrhea. Additional research is necessary before a firm conclusion can be reached.

Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid, or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).

Peony: Traditionally, peony was used to treat menstrual problems and lack of a menstrual period. Preliminary research suggests that peony may have hormonal effects. More research is needed to support the use of peony for menstrual irregularities.

Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.

Phosphates, phosphorus: Early research shows that high amounts of phosphorus may have negative effects on bone density. This is because phosphorus decreases bone formation and increases bone resorption. Additional study is needed in this area.

Avoid if allergic or hypersensitive to any ingredients in phosphorus/phosphate preparations. Use phosphorus/phosphate salts cautiously with kidney or liver disease, heart failure, unstable angina (chest pain), recent heart surgery, hyperphosphatemia (high phosphate blood level), hypocalcemia (low calcium blood level), hypokalemia (low potassium blood level), hypernatremia (high sodium blood level), Addison's disease, intestinal obstruction or ileus, bowel perforation, severe chronic constipation, acute colitis, toxic megacolon, hypomotility syndrome, hypothyroidism, scleroderma, or gastric retention. Avoid sodium phosphate enemas with congenital or abnormalities of the intestine. Too much phosphorus may cause serious or life-threatening toxicity.

Physical therapy: Supervised or home-based physical therapy has been used in combination with resistance and endurance training in physically frail elderly women taking hormone replacement therapy to improve bone density. Although early study is promising, more studies are needed in this area.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Pomegranate: There is currently not enough evidence to support the use of pomegranate in the reduction of menopausal symptoms.

Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under supervision of a qualified healthcare professional. Use cautiously with liver damage or disease. Pomegranate supplementation can be unsafe during pregnancy when taken by mouth. The bark, root, and fruit rind can cause menstruation or uterine contractions. Avoid if breastfeeding due to a lack of scientific data.

Probiotics: Vaginal suppositories containing probiotics may be effective in the treatment or prevention of bacterial vaginosis. However, not all applications of probiotics show benefit. Probiotics have also not been adequately studied for the prevention or treatment of vaginal candidiasis. More research is needed in this area before a conclusion can be drawn.

Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

Propolis: Propolis may be an effective treatment for vaginitis. However, more research is needed.

Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, or balsam of Peru. Severe allergic reactions have been reported. There has been one report of kidney failure with the ingestion of propolis that improved upon discontinuing therapy and deteriorated with re-exposure. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.

Pycnogenol?: Preliminary human data shows that Pycnogenol? may have a potential analgesic (pain relieving) effect on dysmenorrhea. Further research is needed to confirm these results.

Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, or bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.

Qi gong: It has been suggested that regular Qi gong therapy may help to reduce symptoms of premenstrual syndrome (PMS). High quality human study is still needed in this area.

Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.

Red clover: Red clover (Trifolium pratense) is a legume, which like soy, contains "phytoestrogens" (plant-based chemicals that are similar to estrogen, and may act in the body like estrogen or may actually block the effects of estrogen). Laboratory research suggests that red clover isoflavones have estrogen-like activity. However, there is no clear evidence that isoflavones share the possible benefits of estrogens (such as effects on bone density). Red clover isoflavones are proposed to reduce menopausal symptoms (such as hot flashes) and to serve as a possible alternative to hormone replacement therapy (HRT). However, most of the available human studies are poorly designed and short in duration. As results of published studies conflict with each other, more research is needed before a clear conclusion can be drawn.

It is not clear if red clover isoflavones have beneficial effects on bone density. Most studies of isoflavones in this area have looked at soy, which contains different amounts of isoflavones, as well as other non-isoflavone ingredients. More research is needed to better understand the effects of red clover on osteoporosis.

Avoid if allergic to red clover or other isoflavones. Use caution with hormone replacement therapy (HRT) or birth control pills. Use caution with history of a bleeding disorder, breast cancer, or endometrial cancer. Use caution with drugs that thin the blood. Avoid if pregnant or breastfeeding.

Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. Currently, there is not enough evidence to support the use of reflexology for treating hot flashes and other menopausal symptoms, dysmenorrhea, or premenstrual syndrome. Further research is necessary.

Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. There is promising early evidence from human trials supporting the use of relaxation techniques to reduce menopausal symptoms,although effects appear to be short-lived. There is also early evidence that progressive muscle relaxation (PMR) training may improve physical and emotional symptoms associated with premenstrual syndrome (PMS). Further research is necessary before a conclusion can be drawn.

Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.

Soy: It has been theorized that phytoestrogens in soy (such as isoflavones) may prevent post-menopausal bone loss and reduce the risk of osteoporosis. However, more research is needed before a conclusion can be made.

St. John's wort: Extracts of St. John's wort (Hypericum perforatum) have been recommended traditionally for a wide range of medical conditions. The most common modern-day use of St. John's wort is the treatment of depression. Although St. John's wort supplements have been used with effectiveness in treating depression associated with menopause, there is a lack of high quality human studies supporting the use of St. John's wort for peri-menopausal symptoms or premenstrual syndrome (PMS).

St. John's wort interferes with the way the body processes many drugs using the liver's "cytochrome P450" enzyme system. As a result, the levels of these drugs may be increased in the blood in the short-term (causing increased effects or potentially serious adverse reactions) and/or decreased in the blood in the long-term (which can reduce the intended effects). Examples of medications that may be affected by St. John's wort in this manner include carbamazepine, cyclosporin, irinotecan, midazolam, nifedipine, birth control pills, simvastatin, theophylline, tricyclic antidepressants, warfarin, or HIV drugs such as non-nucleoside reverse transcriptase inhibitors (NNRTIs) or protease inhibitors (PIs). The U.S. Food & Drug Administration (FDA) suggests that patients with HIV/AIDS on protease inhibitors or non-nucleoside reverse transcriptase inhibitors avoid taking St. John's wort. Avoid if allergic or hypersensitive to plants in the Hypericaceae family. Rare allergic skin reactions like itchy rash have been reported. Avoid with organ transplants, suicidal symptoms, or before surgery. Use cautiously with history of thyroid disorders. Use cautiously with diabetes or with history of mania, hypomania (as in Bipolar Disorder), or affective illness. Avoid if pregnant or breastfeeding.

Tai chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility, and strength. Preliminary research suggests that tai chi may be beneficial in delaying early bone loss in postmenopausal women and preventing osteoporosis. Additional evidence and long-term follow-up is needed to confirm these results.

Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

Tea tree oil: In laboratory studies, tea tree oil has been shown to kill yeast and certain bacteria. However, at this time there is not enough information available from human studies to make recommendations for or against the use of tea tree oil for vaginal infections.

Avoid allergic or hypersensitive to tea tree oil (Melaleuca alternifolia), any of its constituents, balsam of Peru, benzoin, colophony (rosin) tinctures, eucalyptol, or other members of the Myrtle (Myrtaceae) family. Avoid taking tea tree oil by mouth. Avoid if taking antineoplastic agents. Use tea tree oil applied to the skin cautiously in patients with previous tea tree oil use. Avoid if pregnant or breastfeeding.

TENS: Transcutaneous electrical nerve stimulation (TENS) has been examined for the treatment of dysmenorrhea in several small studies. Research in this area suggests that the use of TENS may reduce short-term discomfort and need for pain medications.

Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

Traditional Chinese medicine (TCM): Traditional Chinese medicine (TCM) herbs are commonly used for menopausal symptoms such as hot flushes. TCM herbs have also been reported to increase pregnancy rates in women with polycystic ovary syndrome. More studies are needed to explore the possible contributions of TCM herbs for these indications.

Chinese herbs can be potent and may interact with other herbs, foods, or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ephedra (ma huang). Avoid ginseng if pregnant or breastfeeding.

Valerian: Valerian root (Valerian officinalis) has been used as a sedative and anti-anxiety treatment for more than 2,000 years. There is currently not enough available scientific evidence on the use of valerian for menopausal symptoms.

Caution is advised when taking valerian supplements, as numerous adverse effects including drowsiness and drug interactions are possible. Caution is also advised when operating heavy machinery or an automobile if taking valerian supplements. Valerian is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Vitamin B6: There is some evidence that taking vitamin B6 orally may improve symptoms of premenstrual syndrome (PMS) such as breast pain or tenderness (mastalgia) and PMS-related depression or anxiety in some patients. Further research is needed before a recommendation can be made.

Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA).

Vitamin C (ascorbic acid): Preliminary human study shows that vitamin C vaginal tablets given once a day may help patients suffering from non-specific vaginitis. Further research is needed to confirm these findings.

Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods, as well as in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding.

Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. A study of oral vitamin E reports a very small reduction in frequency of breast cancer-related hot flashes (approximately one less hot flash per day), but no preference among patients for vitamin E over placebo.

There is preliminary evidence of possible benefits of vitamin E supplementation to reduce dysmenorrhea and premenstrual syndrome, although additional research is necessary before a firm conclusion can be reached.

Vitamin E supplements may increase the risk of bleeding in sensitive individuals, such as those taking medications to reduce blood clotting, including aspirin and warfarin (Coumadin?). Avoid if allergic or hypersensitive to vitamin E. For short periods of time, vitamin E supplementation is generally considered safe if taken at doses lower than the recommended dietary allowance (RDA). Avoid with retinitis pigmentosa (loss of peripheral vision).

Vitamin K: Vitamin K appears to prevent bone resorption, and adequate dietary intake is likely necessary to prevent excess bone loss and for osteoporosis prevention. Elderly or institutionalized patients may be at particular risk and adequate intake of vitamin K-rich foods should be maintained. Unless patients have demonstrated vitamin K deficiency, there is no evidence that additional vitamin K supplementation is helpful.

Avoid if allergic or hypersensitive to vitamin K. Injection into the muscle or vein should only be done by a healthcare professional; many serious side effects have occurred after injection. Menadiol (type of vitamin K that is not available in the United States) should be avoided with glucose-6-phosphate dehydrogenase deficiency. Conditions that interfere with absorption of ingested vitamin K may lead to deficiency, including short gut, cystic fibrosis, malabsorption (various causes), pancreas or gall bladder disease, persistent diarrhea, sprue, or ulcerative colitis. Avoid if pregnant. Use cautiously if breastfeeding.

Wild yam: It has been hypothesized that wild yam (Dioscorea villosa and other Dioscorea species) possesses dehydroepiandrosterone (DHEA)-like properties, and acts as a precursor to human sex hormones such as estrogen and progesterone. Based on this proposed mechanism, extracts of the plant have been used to treat menopausal symptoms such as hot flashes and headaches. However, these uses are based on a misconception that wild yam contains hormones or hormonal precursors - largely due to the historical fact that progesterone, androgens, and cortisone were chemically manufactured from Mexican wild yam in the 1960s. It is unlikely that this chemical conversion to progesterone occurs in the human body. The hormonal activity of some topical wild yam preparations has been attributed to adulteration with synthetic progesterone by manufacturers, although there is limited evidence in this area.

Avoid wild yam if allergic or hypersensitive to wild yam or any member of the Dioscorea plant family. Use cautiously with a history of hormone-sensitive conditions (e.g. breast cancer or endometrial cancer), asthma, blood clots, stroke, or diabetes. Avoid if pregnant or breastfeeding.

Yoga: Early evidence showed mixed results regarding yoga's effect on menopausal symptoms. Although early results are promising, more research is needed in this area.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Fair negative scientific evidence:

Boron: It has been proposed that boron affects estrogen levels in post-menopausal women. However, preliminary studies have found no changes in menopausal symptoms.

Calcium: Stopping treatment with topical hormone replacement therapy and switching to treatment with calcium plus vitamin D made vaginal disorders, including vaginal atrophy and vaginal tissue thinning, worse in one study. Increases in painful or difficult intercourse and urinary leaks were reported. Menopausal complaints of hot flashes and night sweats were also worse than before calcium plus vitamin D therapy.

Dong quai: Dong quai (Angelica sinensis), also known as Chinese Angelica, has been used for thousands of years in traditional Chinese, Korean, and Japanese medicine. It remains one of the most popular plants in Chinese medicine, and is used primarily for health conditions in women. Dong quai is used in traditional Chinese formulas for menopausal symptoms. It has been proposed that Dong quai may contain "phytoestrogens" (chemicals with estrogen-like effects in the body). However, it remains unclear from laboratory studies if Dong quai has the same effects on the body as estrogens, blocks the activity of estrogens, or has no significant effect on estrogens.

Evening primrose oil: Available studies do not show evening primrose (Oenothera biennis) oil to be helpful with flushing or bone metabolism during menopause. Small human studies also do not report that evening primrose oil is helpful for the symptoms of premenstrual syndrome. Larger, well-designed study is needed.

Prevention

Fortunately, many of the signs and symptoms associated with women's hormonal imbalances are temporary. Take these steps to help reduce or prevent the unwanted symptoms of menopause and/or premenstrual syndrome (PMS):

Decreasing hot flashes: Hot flashes are caused by rapid decreases in estrogen levels. Although hot flashes cannot be prevented, they can be helped and made less uncomfortable. Techniques that can help individuals deal with hot flashes include: wearing loose clothing and dressing in layers so the layers of clothing can be peeled off during a hot flash; wearing fabrics that absorb moisture and dry quickly; avoiding foods that may trigger hot flashes, such as hot drinks and spicy foods; splashing the face with cool water at the start of a flash; and avoiding stress.

Decreasing vaginal discomfort: Using over-the-counter (OTC) water-based vaginal lubricants (Astroglide?, K-Y?) or moisturizers (Replens?, Vagisil?) can help relieve vaginal dryness associated with low estrogen levels that may accompany menopause. Staying sexually active also helps with dryness.

Optimizing sleep: Healthcare professionals recommend avoiding caffeine, especially in the evening and at night. Exercising during the day can also help improve sleep. Relaxation techniques, such as deep breathing, guided imagery, and progressive muscle relaxation, can be very helpful.

Strengthening pelvic muscles: Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence. The exercises consist of the regular clenching and unclenching of the sex muscles that form part of the pelvic floor (sometimes called the "Kegel muscles").

Diet: Eating a balanced diet that includes a variety of fruits, vegetables, and whole grains and that limits saturated fats, oils, and sugars is recommended by healthcare professionals. It is also recommended to consume 1,200-1,500 milligrams of calcium and 800 I.U. (international units) of vitamin D a day. Eating smaller, more frequent meals each day may reduce bloating and the sensation of fullness.

A high protein diet or high coffee consumption increases calcium excretion and may increase the calcium needs for the body. Fiber, oxalates (in rhubarb, spinach, beets, celery, greens, berries, nuts, tea, cocoa), and high zinc foods (such as oysters and red meats) decrease absorption, requiring more calcium as a dietary supplement. The plant estrogens found in soy help maintain bone density and may reduce the risk of fractures, particularly in the first 10 years after menopause.

It is recommended to limit salt and salty foods to reduce bloating and fluid retention, to choose foods high in complex carbohydrates, such as fruits, vegetables, and whole grains, and to choose foods rich in calcium. If the woman cannot tolerate dairy products or is not getting adequate calcium in the diet, a daily calcium supplement may be needed.

Excessive alcohol has been associated with osteoporosis due to the degenerative metabolic effects of alcohol. Alcohol excess may inhibit calcium absorption and bone formation.

Weight control: Being underweight is a risk factor for osteoporosis. Staying within a healthy weight for an individual is important. Extreme thinness is a risk factor for osteoporosis. The onset of anorexia nervosa frequently occurs during puberty, the time of life when maximal bone mass accrual occurs, thereby putting adolescent girls with anorexia nervosa at high risk.

Smoking cessation: Smoking increases the risk of heart disease, stroke, osteoporosis, cancer, and a range of other health problems. It may also increase hot flashes and bring on earlier menopause. It is never too late to benefit from stopping smoking. Smokers lose bone more rapidly than nonsmokers. Among 80 year olds, smokers have up to 10% lower bone mineral density, which translates into twice the risk of spinal fractures and a 50% increase in risk of hip fracture. Fractures heal slower in smokers, and are more apt to heal improperly.

Regular exercise: It is recommended by healthcare professionals to get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis, and other conditions associated with aging in women. More vigorous exercise for longer periods may provide further benefit and is particularly important if the individual is trying to lose weight. Exercise can also help reduce stress.

Regular checkups: A doctor can advise the individual about how mammograms, Pap tests, lipid level (cholesterol and triglyceride) testing, and other screening tests.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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Causes and risk factors

Menopause:

Menopause begins naturally when the ovaries start making less estrogen and progesterone, the hormones that regulate menstruation. The process usually begins in a woman's late 30s. By that time, fewer potential eggs are ripening in the ovaries each month, and ovulation is less predictable. Progesterone (the hormone that prepares the body for pregnancy) levels drop and fertility declines. These changes are more pronounced in the 40s, as are changes in menstrual patterns. The woman's period may become longer or shorter, heavier or lighter, and more or less frequent. Eventually, the ovaries shut down and there are no more periods. It is possible, but very unusual, to menstruate every month right up to the last egg is released, although a gradual tapering off is more common.

Early menopause is associated with the following factors: smoking; nulliparity - women who have never been pregnant; medically treated depression; exposure to toxic chemicals (such as pesticides); and treatment of childhood cancer with pelvic radiation or chemotherapy.

Menopause is usually a natural process. But certain surgical or medical treatments or medical conditions can bring on menopause earlier than expected. An oophrectomy (also called ovariotomy) is the surgical removal of the ovaries. Oophorectomies are most often performed in women due to diseases such as ovarian cysts or cancer, prophylactially to reduce the chances of developing ovarian cancer or breast cancer, or in conjunction with the removal of the uterus. A hysterectomy is a surgical procedure to remove the uterus, but not the ovaries. A hysterectomy usually does not cause menopause. Although women no longer have periods, their ovaries still release eggs and produce estrogen and progesterone. However, surgery that removes the uterus and the ovaries (called a total hysterectomy and bilateral oophorectomy) does cause menopause, without any perimenopausal phase. Instead, periods stop immediately and hot flashes and other menopausal signs and symptoms appear. Women that have their ovaries removed are at a decreased chance of developing breast cancer, ovarian cancer, and endometriosis.

Chemotherapy and radiation cancer therapies can induce menopause, causing symptoms such as hot flashes during the course of treatment or within three to six months.

Premature ovarian failure: Approximately one percent of women experience menopause before age 40. Menopause may result from premature ovarian failure, or when the ovaries stop working before age 40. This lack of ovarian function can stem from genetic factors or autoimmune diseases (such as lupus), but often no cause can be found.

PMS and related hormonal imbalances:

Premenstrual syndrome (PMS) is found in women all over the world. Up to 40% of women in their reproductive years experience some of the physical and emotional symptoms of PMS. Exactly what causes premenstrual syndrome is unknown, but several factors may contribute to the condition.

Mineralocorticoids: Mineralocorticoids are a group of hormones that regulate the body's fluids and electrolytes (such as sodium and potassium). Changing levels of mineralocorticoids may cause the bloated feeling that is common in women with PMS.

Prolactin: Prolactin stimulates breast development and the formation of milk during pregnancy and is associated with amenorrhea (abnormal absence of menstruation) and other gynecologic complications. Excess prolactin may cause the breast tenderness associated with PMS, although studies show that suppressing the secretion of excess prolactin does not relieve symptoms.

Prostaglandins: Prostaglandins are hormone-like substances that play a role in the luteal phase of the menstrual cycle, which occurs prior to bleeding. Changing levels of prostaglandins may be involved in PMS.

Neurotransmitters: Serotonin and gamma-aminobutyric acid (GABA) are chemicals in the brain that relay signals from one nerve cell to the next (called neurotransmitters). Low levels of serotonin have been linked to depression, and low levels of GABA are associated with anxiety, both symptoms of PMS.

Endorphins: Endorphins are neurochemicals that suppress pain and increase the threshold to painful stimuli. Low levels of endorphins may be involved in PMS.

Nutrition and exercise: Nutrition may play a role in PMS. Women can alleviate many symptoms by changing their diet. Eliminating certain foods or drinks often reduces symptoms to more tolerable levels. Imbalances in calcium and magnesium levels may trigger PMS symptoms. These two minerals affect nerve cell communication and blood vessel opening and closing, functions that may be involved in PMS symptoms (such as hot flashes). Other possible contributors to PMS include eating a lot of salty foods, which may cause fluid retention, and drinking alcohol and caffeinated beverages, which may cause mood and energy level disturbances. Those who eat a lot of simple sugars (such as found in candy, juices, and soft drinks), may be more susceptible to mood swings and fatigue.

Hypoglycemia (low blood sugar) afflicts many PMS sufferers. Some researchers speculate that hypoglycemia is a precursor to PMS. Controlling blood sugar levels may be important in decreasing the symptoms of PMS.

PMS can also be affected by the amount of exercise the individual participates in and their diet. Studies have reported that women who exercise regularly are less susceptible to negative moods and experience fewer and less severe physical PMS symptoms than women who do not exercise or who exercise infrequently. A healthy diet, including fresh fruits and vegetables, may help decrease the symptoms of PMS.

Depression: Because depression-related symptoms are prevalent in women who suffer PMS, there may be an underlying psychological condition that causes or contributes to PMS. Approximately 60% of women with psychological disorders (including depression) also have PMS. More than 30% of women who suffer chronic depression experience their first depressive episode during a time of significant hormonal change (such as pre-menstrual). Studies have found that women who have seasonal affective disorder (SAD), a form of depression characterized by annual episodes of depression during fall or winter that improves in the spring or summer, are likely to also have premenstrual dysphoric disorder (PMDD).

PMS can be caused or aggravated by: stress; genetics - PMS is more likely in a woman whose mother had PMS; age - PMS is most common in women between the ages of 25-40; the number of children a woman has had - women with more children are more likely to suffer from PMS than women with fewer children; alcohol, sugar, and caffeine intake; hypothyroidism - low thyroid hormone levels; and depression.

Female conditions related to hormonal imbalances

Menopause:

Menopause, also known as "the change," is when a woman's menstrual periods stop altogether. It signals the end of the ovaries releasing eggs for fertilization. A woman is said to have gone through menopause when her menses have stopped for an entire year. Menopause generally occurs between the ages of 45-55, although it can occur as early as the 30s or as late as the 60s. It can also result from the surgical removal of both ovaries. A woman may still get pregnant during menopause until she has gone at least 12 months without menstruating (a period).

Changes and symptoms include: a change in menstruation (periods) - periods may be shorter or longer, lighter or heavier, with more or less time in between; hot flashes and/or night sweats; trouble sleeping; vaginal dryness; mood swings; trouble focusing; and hair loss on the head but increased hair on the face. About 85% of women experiencing menopause will have hot flashes.

All women will experience menopause. Menopause is not considered a disorder and most women do not need treatment for it. However, if symptoms are severe, medications may be used to help alleviate symptoms.

Researchers have estimated that more than 1.3 million women in the United States and 25 million women worldwide experienced menopause. There are about 470 million postmenopausal women worldwide, a number that is expected to increase to 1.2 billion by the year 2030.

Perimenopause: During perimenopause, the woman may begin to experience menopausal physical and emotional signs and symptoms, such as hot flashes and depression, even though they still menstruate. The average length of perimenopause is four years, but for some women this stage may last only a few months or continue for 10 years. Perimenopause ends the first year after menopause, when a woman has gone 12 months without having her period. Periods (menstruation) tend to be irregular during this time and may be shorter or longer or even absent.

Despite a decline in fertility during the perimenopause stage, individuals can still become pregnant. If the individual does not want to become pregnant, they may continue to use some form of birth control until menopause is reached.

Postmenopause: Postmenopause is a time when most of the distress of the menopausal changes have faded. Hot flashes may seem milder or less frequent and energy, emotional, and hormonal levels may seem to have stabilized. During postmenopause, women are at a higher risk for developing osteoporosis (bone loss) and heart disease, due to the decrease in circulating estrogen. The postmenopausal phase begins when 12 full months have passed since the last menstrual period. After menopause (postmenopause), women are more vulnerable to osteoporosis (bone loss) and heart disease, in part due to estrogen imbalance.

Women may become pregnant during menopause.

Premenstrual syndrome (PMS):

Menstruation, commonly referred to as a period or menses, is the periodic discharge of blood and mucosal tissues from the uterus in non-pregnant women, usually occurring at four week intervals. Every month, a woman's body prepares for pregnancy. If no pregnancy (fertilization of the egg) occurs, the uterus sheds its lining. The menstrual blood is partly blood and partly tissue from inside the uterus, or womb. The blood passes out of the body through the vagina. Periods usually start around age 12 and continue until menopause (generally between the ages of 45-55). Most periods last from three to seven days.

Premenstrual syndrome, or PMS, is a group of symptoms that start one to two weeks before the period (called the luteal or secretory phase). Four out of 10 menstruating women suffer from PMS. There have been as many as 150 symptoms associated with PMS. Most women have at least some symptoms of PMS, and the symptoms go away after their periods start. The most common symptoms are: irritability, anxiety, depression, headache, bloating, fatigue or excessive tiredness, feelings of hostility and anger, and food cravings, especially for chocolate or sweet and salty foods. Breast tenderness is also common in women during PMS.

The exact causes for PMS are not known. One theory points to low levels of the hormone progesterone. Others link it to nutritional deficiencies, such as calcium and magnesium. To be classified as PMS, symptoms must occur between ovulation and menstruation - that is, anytime within two weeks before the menstrual period and disappear shortly after the period begins.

For some women, symptoms of PMS are minor and may last only a few days before menstruation. For others, they can be severe and last the whole two weeks before every period.

While not all women have PMS, it's estimated that 70-90% of women who menstruate experience premenstrual symptoms. And another 30-40% of individuals suffering from PMS have symptoms severe enough to disrupt their lives. Severe PMS is seen in 3-8% of women.

Other conditions due to hormonal imbalances:

Premenstrual dysphoric disorder (PMDD): Premenstrual dysphoric disorder (PMDD) is a condition where women suffer from many of the physical symptoms of PMS, often more severely than other women. In addition, they experience debilitating emotional symptoms such as feelings of hopelessness, isolation, and extreme mood swings. Women with family members (a mother or sister) who have PMDD may be genetically predisposed to experiencing PMDD.

Dysmenorrhea: Dysmenorrhea is a menstrual condition characterized by severe and frequent menstrual cramps and pain associated with menstruation. Dysmenorrhea may be classified as primary or secondary. Primary dysmenorrheal is severe and frequent menstrual cramping caused by severe and abnormal uterine contractions in women. Painful menstrual periods may be caused by another medical condition present in the body, such as pelvic inflammatory disease (PID) or endometriosis. Pelvic inflammatory disease (PID) is a general term that refers to infection of the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus), and other reproductive organs. It is a common and serious complication of some sexually transmitted diseases (STDs), especially chlamydia and gonorrhea. Endometriosis is when the tissue that lines the uterus is found to be growing outside the uterus, usually due to hormonal fluctuations. Secondary dysmenorrhea is caused caused by another medical condition, such as endometriosis (abnormalities in the lining of the uterus), adenomyosis (nonmalignant growth of the endometrium into the muscular layer of the uterus), pelvic inflammatory disease, uterine fibroids, cervical narrowing, uterine malposition, pelvic tumors, or an IUD (intra-uterine device). This condition usually occurs in older women.

Amenorrhea: Amenorrhea is a menstrual condition characterized by absent menstrual periods for more than three monthly menstrual cycles. Amenorrhea may be classified as primary or secondary. Primary amenorrhea is the absence of menstrual bleeding and secondary sexual characteristics (for example, breast development and pubic hair) in women during puberty or the absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 years. Secondary amenorrhea is the absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for three or more months in the absence of pregnancy, lactation (the ability to breastfeed), cycle suppression with systemic hormonal contraceptive (birth control) pills, or menopause.

Menorrhagia: Menorrhagia, also known as hypermenorrhea, is the medical term for excessive or prolonged menstrual bleeding and for periods that are both heavy and prolonged. Normal menstrual flow produces a total blood loss of 30-40 milliliters (about two to three tablespoonfuls). An individual's period may be regular or irregular, light or heavy, painful or pain-free, long or short and still be considered normal. Menorrhagia refers to losing 80 milliliteres or more of blood during the menstrual cycle.

Osteoporosis: Osteoporosis is a disease associated with a gradual thinning and weakening of the bones. It occurs most frequently in women who have gone through menopause. Declining estrogen levels during the first postmenopausal decadelead to rapid bone loss. Increased fracture risk maybe reversed by estrogen replacement therapy. The bone-protectiveeffects of estrogen may involve suppression of inflammatorychemicals called cytokines. Cytokines, such as interleukin-1 (IL-1) and tissue necrosis factor-alpha (TNF-?), promote bone loss and bone resorption. Without estrogen, such as in postmenopause, bones may become weak. As bones become thinner and weaker, they also become increasingly susceptible to fractures. Over the course of time, tiny bone fractures in the spine can lead to stooped posture and loss of height. If left untreated, postmenopausal osteoporosis can lead to constant back pain, disabling fractures, an increase in hip and leg fractures, and lost mobility.

Polycystic ovary syndrome: Polycystic ovary syndrome (PCOS) is a common condition characterized by irregular menstrual periods, excess hair growth, and obesity, though it can affect women in a variety of ways. A cyst is a closed sac- or bladder-like structure that is not a normal part of the tissue where it is found. Polycystic ovary syndrome affects about one in 10 women in the United States and is the leading cause of infertility in women. Early diagnosis and treatment of polycystic ovary syndrome can help reduce the risk of long-term complications, which include diabetes and heart disease.

Vaginitis (yeast infection): Vaginitis, or yeast infection, is irritation and/or inflammation of the vagina. Vaginitis is a very common disease affecting millions of women each year. The three most common vaginal infections are bacterial vaginosis (caused by the bacterium Gardnerella), Candida vaginitis (caused by yeast infection or Candida albicans), and Trichomonas vaginitis (caused by the protozoan Trichomonas vaginalis). Hormonal vaginitis is usually found in postmenopausal or postpartum (after childbirth) women. In these women, the estrogen support of the vagina is poor. Irritant vaginitis can be caused by allergies to condoms, spermicides, soaps, perfumes, douches, lubricants, and semen. Irritant vaginitis can also be caused by hot tubs, abrasion, tissue, tampons, or topical medications. Yeast infections are also common in women during menstruation.

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