As a woman ages, she begins to notice signs of menopause as estrogen levels start to decrease with the cessation of ovarian function. Her monthly cycle becomes erratic, hot flashes and vaginal dryness may occur, and she may start to notice extra weight around her middle. As true menopause occurs, these symptoms – along with sleeping difficulties and mood swings – may intensify and become major issues for 50 percent of all women, according to Dr. Jimmy Sparks, an ob/gyn with Sparks & Favor at Brookwood. "We define menopause as permanent cessation of menses associated with a loss of ovarian activity," Sparks said. "Physicians can confirm the diagnosis by testing for an increase in both the follicle stimulating hormone and the lutenizing hormone levels. When both are elevated, it indicates a decrease in ovarian activity." Managing Weight Estrogen levels can also play a role in fat deposition, changing where the fat goes on the body. "There is ongoing research to determine how estrogen guides fat," said Beth Kitchin, UAB assistant professor of nutrition sciences and a registered dietician. "Loss of estrogen affects the fat, making it more prevalent around the middle which can increase the risk for a heart attack." Kitchin said doctors can evaluate that risk by determining if the woman has intra-abdominal obesity. "A simple tape measurement test is the best way to check for intra-abdominal fat," she said. "A woman should measure less than 35 inches and men less than 40." Kitchin also suggested that physicians talk to their patients about their weight and refer them to a registered dietician. "Patients trust and respect their doctors. If the doctor is concerned about weight, that means a lot. A physician professing concern can have a tremendous impact on a patient, but he must have resources for referral," she said. Exercise is also important and doctors can refer patients to an exercise physiologist to learn the proper way to exercise, Kitchin added. She also recommends weight training to build muscle. "There's a myth about metabolism dropping as we age, but a lot of researchers feel that weight gain is linked to lack of muscle mass," Kitchin said. A recent study by the American Heart Association supported that fact when 164 overweight and obese women age 24 to 44 found that strength training with weights dramatically reduced the increase in abdominal fat in premenopausal women. Managing Symptoms While physicians diagnose menopause the same way in all women, the way they help patients manage symptoms will vary from woman to woman. Half of all women go through menopause without significant symptoms while others have significant problems, Sparks said. "The only medicine that effectively controls symptoms is estrogen treatment, so given the spectrum of symptoms – from none to severe – a physician should look at each patient. It is a mistake for physicians to paint all menopausal women with the same brush. We must manage them individually," he said. Hormone replacement therapy continues to be controversial both inside and outside the medical community, but after weighing both risks and benefits, many physicians feel that hormone therapy is beneficial for treating menopausal symptoms. "However, we recommend the smallest dose for the shortest time," Sparks said. "For some women, that may be one to five years. For others symptoms are lifelong and treatment will be required indefinitely to provide the quality of life benefit. Risk versus benefit must be weighed individually as the balance differs for each patient." Hormone therapy was once thought to benefit cardiovascular health, but a Women's Health Initiative study showed that it offers no benefit to the heart and slightly increases the risk of breast cancer, stroke and thrombosis. As a result, Sparks said, hormone therapy is generally not recommended for asymptomatic patients after menopause. "The summary of the large study was that hormone therapy should not be used in menopausal women for the sole purpose of preventing heart disease," he added. Sparks added that animal data indicates hormone therapy can offer protection to cardiovascular health if it's begun prior to the development of atherosclerotic disease. "There's a question about the window of opportunity for menopausal women without heart disease of any kind," he said. "If we begin hormone therapy, will it offer protection? Data supports the possibility, but there are few prospective randomized studies to support it. Studies need to determine timing and who would benefit. We need more research but we also should be aware of these early findings. There's more data to come, but for now we should use hormone therapy for the purpose of controlling menopausal symptoms."