What is premature menopause?

Premature menopause (also called premature ovarian failure or POF) is when menopause occurs before the age of 40, though very young women can also be affected, even teenagers. Menopause means the end of periods and of ovulation, and usually occurs around age 50. The cause of early menopause is not always known, but can include damage to the ovaries, autoimmune conditions, and chromosomal or genetic abnormality.

What is 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 reach menopause earlier or later than this. You are technically considered to be in menopause after you have not 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.

Are premature menopause symptoms the same as for menopause?

There is some debate about whether the symptoms experienced by women with premature menopause are the same as for 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 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 one in every 1000 women under the age of 30.

Is premature menopause becoming more common?

There is no evidence to suggest 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 appears as if it is becoming more common because 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 it 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 causes, where the body's 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 Turner's 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 had 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 in premature menopause?

Main health issues for early menopause:

• infertility
• bone loss
• heart disease
• psychological issues.

These are discussed in detail below.

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 therapy (HT) [see further below] 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 partner's 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 hardening of the arteries (atherosclerosis) 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 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”.

Treatment

Hormone therapy (HT/HRT)

Women with premature menopause may be advised to take hormone therapy (HT), also referred to as hormone replacement therapy (HRT), until the age of 50 for the treatment of menopausal symptoms, and for long-term protection against osteoporosis. Women who are concerned about avoiding pregnancy are often advised to take the combined oral contraceptive pill. [However, some studies have shown that HT in older women can lead to a slight increase in risk for health problems, including some cancers, blood clots and stroke - similar research is not available for HT in younger women with early menopause]. 

This is a very difficult area, and there is divided opinion among the medical profession regarding the best way of dealing with hormone therapy for women with premature menopause. It is difficult to make statements about what all women should do, as there will be individual issues for each person [and some women will have existing risk factors that make HT inadvisable for them]. You should discuss this with your health professional. Also see our topic on Hormone therapy

Lifestyle measures

Stop smoking

Smoking is very significant to women's health at menopause. It has the direct effect of decreasing the amount of active oestrogen, and contributes to earlier menopause. It is also a major risk factor in heart disease and osteoporosis. Smoking has a multitude of effects on fertility at a number of different levels, and limits fertility in a significant number of women. Women with premature menopause would significantly improve their health by stopping smoking.

Good diet and exercise are essential

There is substantial evidence that a well-balanced diet and regular exercise are going to improve your health and alleviate the long term effects of oestrogen deficiency. Some foods can interfere with your ability to absorb calcium, such as tea, salt and alcohol. Most importantly, you can increase the amount of calcium in your diet. Vitamin supplements may help, but won’t replace the benefits of a well-balanced diet.

Regular, sensible exercise, at least 30 minutes three times a week, will offer some protection against coronary heart disease and osteoporosis. Weight-bearing exercise is the best type of exercise, as it helps to maintain bone strength. Walking, running, tennis, aerobics and dancing are all good forms of weight-bearing exercise. Swimming, cycling and yoga are less useful for building bone strength.

Original material provided by Dr Andrew Shelling, Auckland University. Reviewed and edited by everybody, March 2011.