Physical Changes in Menopause: ​ the vagina and vulva, body weight, skin and hair

How will my body change?

The vagina and vulva:

The vaginal tissue is estrogen sensitive. When estrogen levels decrease in menopause, the vagina becomes more dry. The mechanism of vaginal lubrication is largely from fluid that comes from blood vessels in the vaginal wall. These blood vessels decrease with menopause, and lubrication declines. The tissue of the vagina can become thin, pale, smooth ad sometimes inflamed. Trauma to the vaginal wall, including intercourse, can cause bleeding, or tearing of the tissue. The caliber of the vagina may narrow. Many women notice dryness and pain with intercourse. Not all women experience these symptoms, but many do. Lubricants are helpful for many, and vaginal topical estrogen often reverses these changes.

There are normal bacteria that colonize the vagina, predominantly lactobacilli. The vaginal environment is acidic, with a pH of 3.5-4.5. After menopause, there are changes in the vaginal estrogen, and lactobacilli decline, and other types of bacteria are often more common. The pH of the vagina often increases. Although this environment is not abnormal, it is a change from pre-menopause. Because of this change in pH and bacteria, occasionally abnormal bacteria will predominate, causing vaginitis symptoms of discharge, odor, and vulvar burning. Vaginal estrogen can normalize the vaginal environment, promote a more normal epithelium, and make it less likely that abnormal bacteria will predominate. Evaluating vaginal secretions with a culture and visual inspection under a microscope can diagnose the type of vaginitis and which treatment will eliminate the symptoms.

Body weight:

Many women complain of weight gain that begins during peri-menopause and before cycles are actually ended. The average weight gain is about 5 lbs. Although it certainly might seem that menopause or hormone replacement may be responsible, scientific studies do not support this. The weight gain is most often related to changes in lifestyle. Women often lose lean body mass, muscle, as they age. Muscle is metabolically active tissue at rest. Therefore, your calorie requirements decrease, and if you do not decrease your intake, you will gain weight. This can be compounded by decreases in physical activity. If you have an injury that sidelines you for awhile, your caloric requirement decreases. There is now evidence that sleep deprivation is related to weight gain.

Studies have shown that women do redistribute fat body fat with menopause. Increased visceral fat, fat surrounding the abdominal organs, increases with menopause. Visceral fat is associated with an increased risk of diabetes, metabolic syndrome, and aortic plaque.

Many women think that hormone replacement causes weight gain, and studies do not prove this. Actually, the difference in weight gain between women taking hormones and those who do not is minimal, but tends toward less weight gain in women on hormone therapy.

Higher body weight and body fat are related to adverse health consequences such as diabetes, heart disease, hypertension, some cancers, osteoarthritis, and premature death. Breast cancer rates are higher in obese women. Hot flashes are worse with increased body weight, and weight loss can reduce these symptoms. Weight loss of just 10% can significantly reduce blood pressure.

So which diet is best? Scientific studies have compared diets that restrict either carbohydrates, fat, calories, or balance nutrients in a particular way (Zone diet). All of these diets worked, and all improved cardiac risk factors, but length of adherence was the key. One large analysis of data demonstrated that a high protein, low fat and low carbohydrate diet resulted in more weight loss, less body fat and lower triglycerides. One study did demonstrated that sustained weight loss, which of course is the key, was best obtained with daily caloric restriction of about 500 calories, low fat intake, and regular physical activity. Increased fruits and vegetables as substitutes for higher fat and carbohydrate choices were ideal. Self monitoring and behavioral support were helpful. Apps that track food intake and exercise are excellent ways to achieve self-monitoring. Regular exercise is key to decreasing weight gain in the menopause.

Resistance exercise, such as using weights, is best at decreasing body-fat ratios and increasing muscle mass. Muscle tissue is metabolically active at rest. But resistance exercise alone will not lead to weight loss unless calorie restriction is also included.

Do dietary supplements help? Chromium picolinate has been touted as a metabolic booster, but studies showed only about a one pound difference between groups who took the supplement vs. those who did not. Products containing ephedrine should be avoided since it can have adverse effects on blood pressure, heart rate, and the nervous system.

Skin changes:

Skin changes as we age. We all know this, and understand that sunlight is an important factor. Here is how that works. The skin is made of multiple layers. The outermost layer is the epidermis. It is made of layers of cells that are shed routinely. These cells contain keratin, which gives them strength. Melanin is produced in this cell layer. Melanin is produced in response to the sun, therefore a suntan. It also protects the cells beneath, the dermis. Collagen and elastic fibers are formed by cells in the dermis. This gives the skin its resilient nature. Because of skin exposure, the elastic fibers break down. Along with this is the loss of subcutaneous fat. These two factors lead to the skin becoming more relaxed.

Collagen is lost in skin after menopause because skin is responsive to estrogen. Studies have shown that 30% of collagen is lost in the first 5 years after menopause begins, then at a rate of about 2% yearly thereafter. The decrease in collagen leads to wrinkles. Many changes in the skin occur due to exposure to the sun. These changes include wrinkles, dry and rough skin, dark spots, and irregular pigmented skin color. Benign skin changes can be unsightly and include blood vessels that are visible on the skin, vascular spots or hemangiomas, and keratoses. Many women develop many keratosis that are raised rough spots on the skin, either skin colored or brown. If these lesions are dry and scaly they may be actinic keratoses which are pre-malignant. Smoking is a risk factor for wrinkles, vascular lesions, and squamous cell skin cancers.

Skin cancer is quite common and more often seen is women who are fair-skinned, sunburn easily, who have used a tanning bed, or who sustained a sunburn prior to the age of 20. Having a regular whole body skin exam with a dermatologist will help to find lesions at an early stage.

To prevent skin cancer, use a sunscreen with at least 30 SPF. Sunscreen, to be effective, should be reapplied at regular intervals. What about the efficacy of skin products? Topical retinoids such as tretinoin and tazarotene will repair skin and treat fine wrinkles and skin color irregularities. Many women will obtain injections of botulinum toxin. The safety data for this type of treatment is very good.

So, do hormones prevent skin aging? Systemic hormone replacement does impede collagen loss, maintains the thickness of the skin, improves moisture and elasticity, and decreases wrinkle depth. However, estrogen does not obviate the risks of sun exposure or smoking, and does not decrease the risk of skin cancer.

Dry skin becomes very common as we age. Topical products with an oily base are better than products with alcohol. Very hot water and abrasive soaps should be avoided. Oral hydration is helpful.

Acne is common in menopause, especially in women who had acne as teens. The cause is decreased estrogen, which allows testosterone in the system to be more dominant. Topical acne medications and antibiotics do not prevent production of sebum in the glands, but hormonal manipulation can be helpful. Oral contraceptives have been approved for prevention of acne. Spiroolactone is a diuretic that prevents the effects of testosterone on the hair follicles.

Hair

Hair loss in menopause is a common complaint, and can be extremely distressing. There are several different patterns. Telogen effluvium is a term that signifies that there is a more sudden loss of hair. Women will tell you that they see hair in the sink and on their brush. This can be related to sudden changes in hormone levels or stress. Often, no cause is found.

Female pattern hair loss occurs more gradually. Women will often note thinning in the crown of their scalp, and a widening part. Women rarely will actually become bald from this, but the loss can be very significant.

Male pattern hair loss is different. Regression of hair at the temporal areas of the scalp and in the crown of the scalp can be marked.

Another type of hair loss is called frontal fibrosing alopecia. Women will note that their frontal hair line and temporal hair regresses. The eyebrows can also become thin or absent.

Evaluation for types of hair loss can include the following blood tests tests: a complete blood count, , comprehensive metabolic panel, thyroid function tests, iron, ferritin, zinc, testosterone, DHEAS, and sex hormone binding globulin. A dermatologist may perform a scalp biopsy to determine the status of the hair follicle. Autoimmune tests may also be indicated. Despite testing, it is not often that blood work will be abnormal and lead to an obvious cause.

Treatments include a healthy diet with a high content of iron, zinc, and Vitamin D. Supplements with biotin and a multivitamin may correct nutritional deficiencies. Minoxidil at a concentration of 2% or 5% has been found to be helpful. Minoxidil 5% has not been approved by the FDA for women.

Spironolactone is a diuretic that decreases the effect of androgens (male hormones) at the hair follicle, and suppresses the production of androgens in the ovaries. It can have side effects and is not approved by the FDA for this use, although it is prescribed off-label. . Finasteride, which is used in men to prevent balding, has been used in women although, it is not approved. It can be effective in doses of 2.5-5.0 mg. Hormone replacement may be helpful. There are a number of treatments under investigation including latanoprost which is used for glaucoma, shampoos with zinc, and low energy laser combs.Researches are studying whether plasma rich protein may be helpful for hair regrowth

What about the opposite problem? Increased growth of coarse hairs on the upper lip and chin are common with menopause. In women who have problematic hair growth, there may be increased androgen production from the ovary such as in polycystic ovary syndrome, or increased production of androgens (male hormones) at the level of the hair follicle. Diagnostic tests include blood tests for androgens, thyroid, adrenal status, and diabetes. Treatment is multifactorial. Hormone treatment may be helpful, as well as topical products such as eflorninthine hydrochloride cream which decreases local hair growth. Many women utilize plucking, shaving, waxing, depilatories, laser treatments, and electrolysis. If androgen excess is determined, treatment for this should be instituted.