Many women pay close attention to their gynecological health during their younger years and start to ignore it after menopause. Your wellness plan after menopause should include at minimum annual visits to a health care professional. As part of those visits, the following tests should be done:

• Annual breast examinations by a health care professional

• Annual mammograms

• An annual gynecologic exam and a Pap test every one to three years, depending on your personal health history; HPV testing (human papillomavirus DNA testing) may be offered if your Pap results are abnormal.

Recommendations regarding how frequently Pap test screening should occur after age 65 vary. The U.S. Preventive Services Task Force (USPSTF) recommends against routine Pap test screening for women older than age 65 if they "have had adequate recent screening with normal Pap smears and are not otherwise at increased risk for cervical cancer." It also recommends against routine Pap screening for women who have had a total hysterectomy for benign disease.

The American Cancer Society (ACS) recommends that beginning at age 30, women who have had three normal test results in a row get screened every two to three years. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HPV or HIV infection, or a weakened immune system due to organ transplant, chemotherapy or chronic steroid use should continue to be screened annually.

If the Pap test is combined with a screening HPV test and both are normal, the Pap may be deferred for three years, although you should continue to see your gynecologist annually for a full gynecologic exam.

Women who are age 70 or older, and who have had three or more normal Pap tests in a row and no new sexual partners or abnormal Pap test results in the last 10 years may choose to stop having cervical cancer screening, according to ACS.

• Annual fecal occult blood test, which checks for blood in your stool (a symptom of colon cancer); this test is recommended beginning at age 50. This is done by testing three bowel movements at home and sending the occult blood cards back to the physician's office or laboratory.

• Colon cancer screening with colonoscopy every 10 years beginning at age 50 unless you or someone in your family has had benign colon polyps or colorectal cancer or an inflammatory bowel disease, such as ulcerative colitis, irritable bowel syndrome or Crohn's disease. African Americans are at higher risk than other groups for getting colon cancer and dying from the disease. The American College of Gastroenterology recommends that African Americans begin screening for colon cancer at age 45.

• Blood pressure check at least every two years (more often if it's chronically high), and blood cholesterol screening every five years; ask your health care professional for guidance.

• Bone density screenings, such as a DEXA-scan (dual-energy x-ray absorptiometry) if you are over age 65, or at a younger age if you are at risk for developing osteoporosis; ask your health care professional about how often you should have this test; in some parts of the country, peripheral screening for bone density is available using PIXA (peripheral DEXA) or ultrasound of calcaneus (heel).

• Annual screenings for diabetes (again, your health care professional may tell you this test is needed less frequently, depending on your risk factors)

• Some sources recommend thyroid function testing every five years

Discuss any unusual or uncomfortable symptoms with your health professional. Keep track of medications that you take and ask your health care professional or pharmacist about potential drug interactions, if you are told to take a new medication. Be sure to discuss with your health care professional any alternative medical treatments or herbal products you use or may wish to use.

The Menopause Transition

As your body transitions into menopause (a process that typically lasts about five years) you may notice some physical and emotional changes. The most common include:

• Irregular menstrual periods
• Hot flashes
• Vaginal dryness
• Urinary tract infections
• Stress incontinence
• Night sweats
• Insomnia
• Headaches
• Heart palpitations
• Forgetfulness
• Mood changes
• Anxiety and irritability
• Diminished concentration

There are a variety of options available to relieve these symptoms, if you find they interfere with your lifestyle. Discuss your symptoms and your concerns with your health care professional to determine which options make the most sense for you.

The following tips may be recommended to relieve the most common menopausal symptoms:

Hot flashes: Although no one knows for sure what causes hot flashes, they're believed to be the result of a narrowing of the temperature range that normally tells the brain to adjust your internal temperature. The pituitary gland in your brain increases the amount of follicle stimulating hormone (FSH) and luteinizing hormone (LH) aimed at the ovaries. Falling estrogen levels and the increase in FSH and LH levels disturb your body's internal temperature. This creates instability in your vasomotor balance and results in a hot flash.

About 75 out of every 100 women approaching or going through menopause have hot flashes, which may start intermittently in your late 30s or early 40s. Hot flashes may get more intense and more frequent around your last menstrual period and then taper off, usually stopping altogether after two to five years. Approximately nine percent of women continue to have hot flashes past age 70.

During a hot flash, you may experience a sudden sensation of heat in your face, neck and chest. You may sweat profusely and your pulse may become more rapid. Some women get dizzy or nauseous. A hot flash typically lasts about three to six minutes—which can seem like an eternity. For some women hot flashes are intolerable, occurring at inconvenient moments or at night, disrupting sleep.

There are a variety of strategies for coping with hot flashes, ranging from short-term hormone therapy (estrogen alone or estrogen plus progesterone for approximately three to five years) and other medical options to herbal remedies (see further down in this article), but lifestyle strategies may be the easiest and quickest changes to try first:

• Dressing in layers that may be removed if you find you're getting too warm

• Sleeping in a cool room

• Drinking plenty of water

• Avoiding hot foods, like soups, spicy foods, caffeinated foods and beverages and alcohol, which can trigger hot flashes

• Trying to decrease stress

• Exercising

• Breathing deeply and slowly, if you feel a hot flash starting; rhythmic breathing may help to "turn down" the heat of a hot flash or prevent it from starting altogether

• Using a hand-held fan

Insomnia: Sleep is often a casualty of menopause, whether it is interrupted by hot flashes (called night sweats when they occur at night) or difficulty falling or staying asleep. Hormonal ups and downs are partly responsible. Plus, as you age, your sleep patterns may change. Older people may sleep less, awaken earlier and go to sleep sooner or later than they did at younger ages.

Lifestyle changes for coping with insomnia include:

• Sleep in a cool room to help relieve hot flashes that may be disturbing your sleep
• Exercise regularly
• Set and keep a regular routine and hour for going to sleep
• Take a glass of warm milk but no other food right before bedtime
• Avoid alcoholic beverages or smoking before sleep
• Avoid watching TV in bed (some programs are anything but relaxing!)
• Practice relaxation techniques like deep breathing
• Review any medications you are taking to see if they may cause sleeplessness

Mood swings: For reasons still not well understood, declining and fluctuating estrogen levels during the menopausal transition can cause emotional highs and lows and irritability. Lack of sleep due to night sweats may also contribute to feeling irritable and depressed. Though your periods are coming to an end, you may continue to experience the symptoms of premenstrual syndrome (PMS). In fact, emotional symptoms may become worse for a time for some women as they approach menopause. You may also notice that you've lost interest in sex. Declining estrogen and changes in estrogen/testosterone ratios in women at this time may lower your sex drive.

Lifestyle strategies for coping with mood swings and sexuality concerns include:

• Making physical activity part of your schedule; exercise can improve mood and make you feel better about yourself
• Trying relaxation exercises such as meditation or massage which can be calming and reduce irritability
• Discussing your symptoms with your partner and what may be causing them; try new and different approaches to intimacy

Vaginal dryness and frequent urinary tract infections: Estrogen, a natural hormone produced by the body, helps keep the vagina lubricated and supple. Following menopause, as estrogen levels decline, the vagina becomes drier and the vaginal wall thins. Sex may become painful. The wall of the urethra becomes thinner, too, as estrogen levels fall, and increases the risk of more frequent urinary tract infections. Urine leakage may become a problem as muscle support for the bladder and urethra weakens. (This may also occur from strain on tissues as a result of childbirth).

Strategies for coping with vaginal dryness and frequent urinary infections include:

• Vaginal creams or gels (prescription or nonprescription). Vaginal estrogen (a prescription medication) is available as creams, rings or tablets if moisturizers and lubricants are not enough

• Drinking plenty of water to help your body stay hydrated

• Using moisturizing lotions

• Exercising to maintain muscle tone

• Kegel techniques to strengthen the pelvic floor muscles that support the bladder and urethra. Kegel exercises help firm up the vaginal canal, control urine flow and enhance orgasm. Just tighten and relax the muscles you use to stop urination at least five times in a row, several times a day:

  Tighten a little—count to five.
  Tighten a little more—count to five.
  Tighten as hard as possible—count to five.
  Relax in reverse steps, counting to five at each step.

• Telling your health care provider about any medications you're taking. Some may make vaginal dryness worse. Also, if you have a urinary tract infection, you may need antibiotics.

Heart palpitations. Some women in their late 40s are frightened by their hearts pounding in their chests for no apparent reason. This symptom, called a heart palpitation, is caused by the heart beating irregularly or missing one or two beats. Though this symptom can be associated with several types of serious heart-related conditions, it is also common during the transition to menopause and typically is not related to heart disease. For example, a woman's heart rate can increase eight to 16 beats during a hot flash, according to the North American Menopause Society.

If you think you are experiencing heart palpitations:

• See your health care professional immediately if you have shortness of breath, pounding or irregular heartbeat, dizziness, nausea, pain in the neck, jaw, arm or chest that comes and goes or tightness in the chest. Any could be a sign of a more serious heart condition.

• Ask your health care professional to rule out conditions that may cause heart palpitations, such as thyroid disorders.

• Ask your health care professional about appropriate options for relieving heart palpitations, such as decreasing caffeine, and whether any medications are needed.

Forgetfulness and/or difficulty concentrating. During and after the menopause transition, many women are troubled to find they have difficulty remembering things, experience mental blocks or have trouble concentrating. Not getting enough sleep or having sleep disrupted can contribute to memory and concentration problems. Stress associated with major life changes—such as children leaving home and caring for aging parents—can also interfere with sleep. More research is needed, experts say, to determine the cause of these symptoms during the transition to menopause. However, although they can be upsetting, memory-related issues at this time in your life are rarely associated with serious medical conditions such as Alzheimer's disease.

Strategies for coping with memory problems and lack of concentration include:

• Recognizing that these symptoms may be caused by menopausal changes and aging and not putting pressure on yourself.
• Relying on strategies for remembering things, such as developing daily reminder lists or messages to help get you through periods of forgetfulness.
• Practicing stress-reduction techniques, such as deep breathing exercises, yoga and meditation, and trying to be physically active on a regular basis.

If you find the strategies you've tried don't relieve your discomfort, ask your health care professional about medical options. Medical strategies to relieve various menopausal symptoms include:

Oral contraceptives (OCs): Oral contraceptives can help ease symptoms associated with early menopause, including irregular periods and mood swings, among others. Typically, OCs are recommended to women who are still having periods. For many women in their 40s, OCs provide the added benefit of preventing pregnancy. Still, taking OCs close to menopause can make it difficult to determine when you have stopped menstruating. Women who smoke, have high blood pressure, experience migraines associated with aura or have diabetes, a history of gall bladder disease or blood clotting disorders should not use OCs. Discuss your health history with your health care professional and ask for guidance on this treatment option.

If you're considering taking hormones other than oral contraceptives to manage menopausal symptoms, be aware that the doses of estrogen and progesterone typically taken to manage menopausal symptoms are not adequate to provide protection against an unwanted pregnancy. A woman who is still fertile must use contraceptives containing higher levels of hormones or use additional birth control methods in addition to hormone replacement.

Antidepressant medication. Studies find that low doses of some medications used to treat depression and anxiety may relieve hot flashes in up to 70 percent of women. These include venlafaxine (Effexor), fluoxetine (Prozac) and paroxetine (Paxil).

Cardiovascular medication. Low doses of the blood pressure drug Catapres (Clonidine) may also relieve hot flashes in some women.

Menopausal Hormone Therapy

Menopausal hormone or estrogen therapy . Once prescribed as the first choice for the long-term prevention of osteoporosis and heart disease as well as for the short-term relief of menopausal symptoms such as hot flashes, the safety of hormone therapy for both short-term and long-term use is now under intense study.

Hormone therapy comes in several forms: synthetic or bioidentical estrogen, either alone or combined with progesterone or with a synthetic progestin. When combined with progesterone, it is called hormone therapy (HT). It is typically given to women who still have their uterus because progesterone reduces the risk of uterine cancer that comes with supplemental estrogen.

When given as estrogen alone, hormone therapy is called estrogen therapy (ET). It is typically given to women who no longer have a uterus.

Postmenopausal hormone therapy comes in a variety of applications: pills, creams, skin patches, vaginal rings and injections.

Some hormones are called "bioidentical," meaning they are chemically, i.e., molecularly, identical to the substance as it occurs in your body. These hormones don't come from your body (or another woman's body) however. Most bioidentical estrogens and progesterone come from soy (estrogen) or yams (progesterone).

They are also not "natural," or in their natural state when you take them. To create a hormone women can use, the plant or animal-based hormones are synthesized, or processed, through a several-step process.

The difference between a bioidentical hormone and a synthetic hormone is that the synthetic hormone is a patented molecular compound created in the laboratory to mimic the action of naturally occurring hormones and mass produced. Prempro, for instance, is a combination of two synthetic hormones.

Synthetic and bioidentical hormones work in the same way: by binding in a kind of lock-and-key process to special proteins on cell surfaces called receptors. Once a hormone—whether synthetic or bioidentical—locks onto these receptors, the messages from that hormone can be transferred to the cell.

There are two main types of bioidentical hormones: those that are FDA-approved and commercially available with a prescription, such as Estrace, Climara, Vivelle, EstroGel, and Estrasorb, as well as those that are produced on an individual basis for women in compounding pharmacies.

Estrogen products produced via compounding are typically called "bi-estrogen" or "tri-estrogen," since they contain varying amounts of the two or three types of estrogen. The individual prescription is typically created based on a saliva test that identifies the forms of estrogen in which a woman is deficient. Keep in mind that saliva tests do not accurately reflect the amount of circulating estrogen, and are not clinically useful for determining estrogen dosing.

The U.S. Food and Drug Administration (FDA) now advises health care professionals to prescribe postmenopausal hormone therapies at the lowest possible dose and for the shortest possible length of time to achieve treatment goals.

This recommendation was made after findings from major studies of postmenopausal women with and without heart disease, conducted as part of the landmark federal Women's Health Initiative (WHI), found that while estrogen and progestin are effective for short-term relief from hot flashes and night sweats, they have no significant impact on general health or quality of life factors, such as energy, mental health, symptoms of depression or sexual satisfaction.

Among other findings:

• The National Cancer Institute found a very significant drop in the rate of hormone-dependent breast cancers among women, the most common breast cancer, in 2003. In a study published in late 2006, researchers speculated that the drop was directly related to the fact that millions of women stopped taking hormone therapy in 2002 after the results of a major government study found the treatment slightly increased a woman's risk for breast cancer, heart disease and stroke. The researchers suggested that stopping the treatment prevented very tiny cancers from growing into tumors large enough to be identified by mammogram or touch because they didn't have the additional estrogen required to fuel their growth.

• A study on the link between breast cancer and estrogen therapy published in the Journal of the American Medical Association in April 2006 found that women who do not have a uterus and take estrogen only have no increased risk of developing breast cancer for at least seven years after starting estrogen. In contrast, findings from the estrogen plus progestin study found that women with a uterus who took both hormones had an increased risk of breast cancer at or before five years.

• HT does not appear to help women with heart disease and may even make their existing heart condition worse. ET does not affect (either increase or decrease) the risk of heart disease.

• ET appears to increase the risk of stroke, but decrease the risk of hip fracture. However, the increased risk of stroke with ET outweighed any possible benefits for disease prevention.

• There is a small but statistically significant increase in the risk of invasive breast cancer with HT, a risk that translates into one new case of breast cancer for every 1,250 women taking the therapy.

• Older women taking HT have a higher risk of developing dementia, including Alzheimer's disease, and the combination therapy did not protect against the development of mild cognitive impairment, a form of cognitive decline less severe than dementia.

Discuss the individual risks and benefits of hormone therapy for you with your health care professional. If you are considering hormone therapy, you may want to consider one of two low-dose HT preparations now available.

Alternatives to Hormone Therapy

For heart protection. Lifestyle strategies for cardiovascular health include exercise, not smoking, maintaining a healthy weight and limiting salt and alcohol. A balanced diet rich in vegetables, fruits and fish, and low in saturated fat, can also provide some heart-health benefits.

Your health care professional may also prescribe medication to reduce cholesterol and blood pressure levels, and reduce your risk of heart disease.

For more information about high cholesterol and heart disease, visit the "Cholesterol" and "Heart Disease" topics at this Web site.

For reduced sex drive. Testosterone is a hormone that plays an important role in women's bodies. Often thought of incorrectly as exclusively a male sex hormone, testosterone is secreted by the ovaries and adrenal gland, and is natural to the female body. Surgical menopause (removal of the ovaries) may have a negative effect on sex drive, and testosterone therapy is sometimes prescribed to help.

Testosterone is not FDA approved for the treatment of low libido, however, and we don't know what doses are appropriate for women. Too much testosterone may not help with sexual desire but may, instead, make you feel agitated, overly aggressive and/or depressed. Higher doses can cause masculinizing side effects (that may not go away after stopping therapy) such as facial and body hair growth, acne, an enlarged clitoris, a lowered voice and muscle weight gain.

Testosterone may also be associated with adverse heart-related conditions, such as increased risk for atherosclerosis. There are currently no FDA-approved testosterone-alone preparations for women, although it is often prescribed "off-label" for women. The only FDA-approved androgen is Estratest, a combination of estrogen and methyl-testosterone.

Since the safety of taking testosterone for extended periods of time has not been established, women should be very cautious when considering this type of hormone treatment.

Osteoporosis. Lifestyle changes shown to improve bone density in young women and prevent fractures in older women include dietary calcium and avoiding smoking and excessive alcohol consumption.

Additionally, several prescription drugs are available to treat and/or prevent osteoporosis.

Herbal Remedies

Some women report that vitamin and herbal supplements are helpful in managing menopausal symptoms. For instance, phytoestrogens—naturally occurring compounds in certain plants, herbs and seeds—are similar in chemical structure to estrogen and produce estrogen-like effects.

Soy products (tofu, tempeh, soy milk, soy burgers and roasted soy nuts), certain herbs (red clover) and legumes (chick peas, lentils and various kinds of beans) contain specific types of phytoestrogens called isoflavones. These are healthy foods that are excellent sources of protein and calcium, and can be added to your diet.

Good scientific research is limited on the effects of isoflavones on menopausal symptoms, however, and ideal doses for specific symptoms have not been established. Some research suggests that a serving of soy foods and/or legumes eaten daily may help relieve hot flashes. Other studies, such as a clinical trial that compared the effectiveness of two red clover products (Promensil and Rimostil) suggest they are no more effective than placebo.

Other research suggest that black cohosh supplements may also help relieve hot flashes, but it may take several weeks before you see any benefit. A review investigating the use of black cohosh for menopausal symptoms conducted at the Center for Complementary and Alternative Medicine Research in Aging and Women's Health at Columbia University College of Physicians and Surgeons concluded that "black cohosh and foods that contain phytoestrogens show promise for the treatment of menopausal symptoms."

Some women report vitamin E helps reduce hot flashes. However, there is limited scientific evidence to support its use. There is also no scientific evidence to support the effectiveness of evening primrose oil, flaxseed oil and dong quai root, although some women report improvements in reducing menopausal symptoms.

Discuss any herbal or vitamin supplements you are considering taking with your health care professional. Bear in mind that studies related to their effectiveness are sparse and that the FDA doesn't oversee the production of supplements, nor does it require manufacturers to prove their products are safe. Also be aware that high doses of certain vitamins and herbal supplements can be dangerous. For example ephedra used in some weight loss products has potential serious side effects. Mixing herbal supplements with some prescription drugs can also be dangerous. So again, be sure to tell your health care provider everything you take.