About Early Menopause

Premature Menopause: When menopause comes too early

By Dr Andrew Shelling, Auckland University

What is menopause, and what is premature menopause?

Simply put, menopause is when your periods stop, and when you stop ovulating. The onset is usually around the age of 50, although some women are earlier or later than this. You are technically considered in menopause after you haven’t had a period for six months to a year. Symptoms of menopause are associated with a reduction in the production of the female hormone, oestrogen. Symptoms include irregular periods, hot flushes, palpitations, decreased interest in sex and mood changes. Menopause refers to a single event in the reproductive life of a woman, and other terms describe the process associated with this stage in life, including the menopausal transition, the peri-menopause, and the climacteric. Most people use the word “menopause” however, to include the entire process leading up to and including menopause.

What is premature menopause

Premature menopause (also called premature ovarian failure or POF) is when menopause occurs before the age of 40. It can occur in very young women, even in teenagers. There is some debate about whether the symptoms experienced by women with premature menopause are the same as other women experiencing menopause at age 50. While physiologically there may be some similarities, there are some differences, and there are definite psychological differences.

What hormonal changes occur at menopause?

There are some significant hormonal changes at menopause. The decline in the number of eggs after the age of 40 leads to the alterations in the levels of some female hormones, menstrual periods become less regular, and eventually cease. During this time, the ovary begins to make less and less of the two female hormones, oestrogen and progesterone. Eventually when the monthly menstrual cycle ceases, eggs are no longer released, resulting in infertility.

What are the symptoms of menopause ?

For some women, menopause produces only mild symptoms and their lives continue relatively uninterrupted. For others, menopause can lead to severe changes in the body that cause a great deal of discomfort. Most women will experience some discomfort from a range of symptoms that are produced by the drop in oestrogen levels in the body.

Symptoms can include

  • hot flushes
  • night sweats
  • palpitations
  • decreased interest in sex
  • pain during sex
  • vaginal dryness
  • weight gain
  • urinary frequency or burning

Psychological changes include

  • mood swings
  • loss of memory or concentration
  • depression
  • anxiety and panic attacks
  • irritability
  • tiredness
  • insomnia

Is premature menopause common?

Premature menopause is surprisingly common, and occurs in one or two in every 100 women under the age of 40, and 1 in every 1000 women under the age of 30.

Is premature menopause becoming more common?

There is no evidence to suggest that premature menopause is becoming more common. However, it is certainly becoming more important, particularly as women are delaying having children until later in their lives. It also seems that it seems to be becoming more common, as modern women are happier to talk about menopause and particularly premature menopause, than older generations. It has also been suggested that women are more likely to visit their GP about premature menopause if they have seen or heard about improvements in infertility treatments in the media.

Why is premature menopause not always diagnosed straight away?

There are a number of reasons why a woman can lose her periods, and early menopause is probably not one of the first reasons that would come to mind for a medical doctor. They may wish to rule out some of those other possibilities first. There is still a lack of information about premature menopause, and there needs to be more awareness in society that premature menopause is a common condition.

What causes premature menopause?

For most women there is no explanation why their periods stop at such a young age. There are some known causes described below, however even for those, the exact process is not completely understood. More research is clearly needed in this area.

  • Permanent damage to the ovaries, such as during pelvic surgery, chemotherapy or radiotherapy
  • Autoimmune conditions are common, where the bodies immune system mistakenly damages the ovary, perhaps as a side effect of trying to fight an infection. However, the exact process by which this occurs is not clear, and is very difficult to measure.
  • Abnormal chromosomes have been identified in some women, and in some families. The X chromosome is frequently affected, and those with Turners syndrome (women who have only one X chromosome, instead of two) experience premature menopause.
  • Inherited genes have been shown to be important in some families. About 20–30% of women with premature menopause will be aware of someone else in their immediate family who also have premature menopause. We have seen that the defective gene can be passed down through a number of generations within a family, by either males or females, and that sometimes it skips a generation.

What health issues are important for women with premature menopause ?

  • Infertility. One of the most devastating consequences of the early loss of eggs and early menopause is the loss of fertility. At present there is no effective way of stopping the loss, or re-activating ovaries. If no eggs are left, there is little that can be done. It seems that some women do have eggs present, which can be seen by ultrasound, however, they do not seem to respond to the normal hormonal signals, and these women do not seem to respond to current medical treatments. About 5–10% of women with premature menopause will begin ovulating and get pregnant naturally. Most women with premature menopause will never regain their lost ovarian function and menstrual cycle. The mechanism of re-activation is unknown, and cannot be predicted. Hormone replacement therapy does not interfere with the re-activation process. At present, the only treatment for infertility in women with premature menopause is egg donation, whereby donor eggs are fertilised by the partners sperm in a test tube and the embryos are implanted into the womb. This procedure has a success rate of approximately 20–40% per attempt.
  • Bone loss (osteoporosis). The onset of menopause can affect the level of calcium in a woman’s bones. In women, oestrogen helps calcium to be efficiently absorbed by the body. As a woman’s oestrogen levels start to fall as she enters menopause, this leads to an even faster loss of calcium from the body. Osteoporosis resulting from a loss of bone density is a major cause of disability in later life, with fractures of the hip, wrist and spine. In women with premature menopause, risk of osteoporosis is even greater. There would be significant protection offered by a healthy diet and regular exercise. Regular monitoring of bone density is highly recommended. The use of oestrogen replacement therapy will replace the lost oestrogen, and slow or reverse bone loss and significantly reduce the risks of fractures in women. Taking calcium supplements is also recommended.
  • Coronary heart disease. Oestrogen is known to protect against the hardening of the arteries and other heart problems. After menopause and the resulting drop in oestrogen levels, a woman is at a greater risk of developing heart disease. In women with premature menopause, risk of coronary heart disease is increased. There would be significant protection offered by a healthy diet and regular exercise. The use of oestrogen replacement therapy will replace some of the lost oestrogen, and may offer some protection against heart disease, although there is no strong evidence for this.
  • Psychological issues. Premature menopause is emotionally distressing. Premature menopause and infertility is unexpected, unwelcome and interrupts planning of life’s goals. Some changes in mood are closely linked to menopause, probably related to the fall in oestrogen levels. Most of the emotional distress is related to infertility, and the grief at the loss of what is supposed to be one of the normal stages of a women’s life. Some women are also concerned at the perceived “loss of femininity” or “loss of youth” signified by the early menopause. Although premature menopause is a devastating diagnosis, it does not have to be a totally negative change. A recent book by Kathryn Petras “The Premature Menopause Book” states that “coping with premature menopause can help women emerge stronger, more confident and better able to handle the challenges that life tosses us”.