Essential Guide to Premature and Early Menopause | Stella
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The essential guide to premature and early menopause

byDr Lucy Wilkinson

While menopause is generally seen as a rite of passage for older women, some will find it turns up much earlier than expected and as a shock. For those who go through early menopause, hot flushes, sleepless nights and unpredictable periods can appear alongside the other challenges of being in your 20s or 30s.

What age can menopause start?

Menopause happens when your ovaries stop releasing an egg each month and periods cease. A doctor will diagnose menopause once it has been 12 months since your last period, but symptoms can last for several years on either side of this date. 

Menopause happens due to a number of hormonal changes including reduced production of both oestrogen and progesterone.

The average age for menopause in developed countries is between 50 and 52, and slightly lower in the developing world. This is an average, meaning that some women will go through menopause later, and others earlier. Generally the decade between ages 45 and 55 is prime time for menopausal symptoms.

For a small number of women, things don’t go quite according to plan and menopause can happen years or even decades earlier.

How common is premature and early menopause?

You can go through menopause at any age after first getting your period, although the younger you are the less common this becomes. 

  • Around 1 in 20 women will naturally go through the menopause by age 45. This is known as early menopause
  • A smaller number – around 1 in 100 – will have gone through menopause by age 40. This is premature menopause, also known as premature ovarian insufficiency (POI)
  • It is estimated that 1 in 1000 women will go through menopause aged 30 or under

Read Isabel’s experience of premature menopause

For simplicity, in this article we will use the term early menopause to include all of these conditions unless otherwise specified.

Why does early and premature menopause happen?

For most women who go through early menopause, there is no clear cause (idiopathic). However, certain medical conditions and procedures can be responsible.

Causes of early menopause

Latrogentic (medical) menopause

Some medical treatments can make early menopause more likely:

  • Chemotherapy. Widely used to treat cancer and is often highly effective. However, in the same way that these agents damage and kill off cancerous cells, they can also damage the ovaries. In some cases this may lead to early menopause.
  • Radiotherapy. Especially when applied to the abdomen or pelvis can have similar effects as chemotherapy. If you are going through cancer treatment, your oncologist will be able to explain the possible side effects, including implications for your ovarian function and fertility.
  • Some types of surgery. Perhaps the most obvious is where the ovaries are removed surgically, a procedure known as oophorectomy. This can be done to remove cysts, tumours and ectopic pregnancies, as well as to reduce the risk of ovarian cancer if you are a carrier of a BRCA gene. If you have had this type of surgery, your doctors will discuss menopause and HRT around the time of your procedure. Other forms of surgery can also have an impact on your age at menopause. One study of women aged 46 and under found that removal of the womb (hysterectomy) while leaving the ovaries in place brought forward menopause by an average of 3.7 years. Similar effects have been observed in those who have had surgery for endometriosis, and in those who have had ovarian drilling for PCOS (polycystic ovary syndrome).

Read more about surgical or induced menopause

Autoimmune conditions

Around 1 in 20 cases of early or premature menopause are related to autoimmune conditions including type 1 diabetes, Addison’s disease, some types of arthritis and thyroid conditions among others. This is because the body’s immune system mistakenly attacks its own organs and tissues. 

In some cases, premature ovarian failure (POI) is considered an autoimmune condition in its own right, especially when it forms part of one of the so-called polyglandular autoimmune syndromes. These are rare genetic syndromes which cause clusters of autoimmune illnesses. 

While having an autoimmune condition does not necessarily mean you will go through menopause early, talk to your doctor if you notice menopause symptoms.”

Likewise, POI can be the first of a cluster of autoimmune conditions to present itself. If you have been through early or premature menopause and think you may be suffering from another autoimmune condition, talk to your doctor.

Genetics

Many different genetic causes of early and premature menopause have been identified. The most common of these is Turner syndrome, in which the affected person has only one X chromosome rather than the usual two. Of women who go through menopause before the age of 20, 50% are thought to have a genetic cause.

Is early menopause different from spontaneous menopause in any way?

Early and premature menopause can be slightly different from the menopause which occurs at a more usual time. Hormone levels tend to be more unstable, and even after diagnosis women may go through periods of relatively normal ovarian function, including having normal menstrual periods and even getting pregnant.Those who go through early menopause as a result of medical or surgical treatment tend to have more severe and longer-lasting symptoms than those who go through a ‘spontaneous menopause. This is thought to be due to the sudden decrease in hormone levels (as opposed to the slow decline seen in other types of menopause).

What are the signs?

Menopause symptoms can vary widely but are the same no matter what age you go through menopause. They include:

  • Irregular or absent periods, or change to bleeding pattern
  • Hot flushes
  • Night sweats
  • Poor sleep
  • Weight gain
  • Hair loss
  • Mood changes
  • ‘Brain fog’ or difficulty concentrating
  • Vaginal changes (especially itching, burning and painful sex)

These can also be signs of other conditions, particularly in younger women. It is therefore sensible to check in with your doctor for a full evaluation.

Find out more about the 34 most common menopause symptoms or take a look in our menopause symptoms library.

Is there an early menopause test?

Depending on your symptoms, your doctor may then examine you or order further tests to see if you are experiencing early menopause. These can include blood tests for the hormones FSH (follicle-stimulating hormone) and LH (luteinizing hormone) among others. 

If these are high and suggest menopause, they will usually be repeated after 4-6 weeks to confirm the result and to ensure that it is not simply the result of a normal hormonal fluctuation.

Should I talk to my doctor?

See your doctor if you have any symptoms of menopause, or if you are concerned about the possibility of early menopause for any other reason, including previous cancer treatment or family history. 

Your doctor will find it useful to have a record of your recent periods, which you may keep either on paper on an app.

They may also ask about any medications you use, any family history of early or premature menopause, and any other medical conditions which may be related.

How is early menopause treated?

HRT

Women with premature menopause may be able to be treated with hormone replacement therapy (HRT) depending on your medical history and lifestyle.Your doctor will be able to help you decide on the best type of HRT to suit your lifestyle and needs. When it comes to HRT, there is no one-size-fits-all solution and you may need to try a few different types before finding the best treatment for you. 

Read more about HRT risks and benefits

If you have gone through early menopause due to surgical treatment, you may need higher doses of oestrogen to control your symptoms. The best way to work out whether your HRT is adequate is to keep a log of your symptoms. You can do this either on paper or using an app, and share this information with your doctor who will be able to adjust your dose as needed.

Combined contraceptive pill

An alternative to HRT for some women is the combined contraceptive pill. This is especially useful if you are still at risk of pregnancy and would also like a reliable contraceptive. Again, your doctor will be able to advise if this is an appropriate choice for you.

Lifestyle changes 

These may also help with your symptoms. Common recommendations include maintaining a healthy diet, taking regular exercise and cutting down on alcohol and caffeine. 

What about my fertility?

If you have gone through menopause due to removal of the ovaries or womb, you will be unable to get pregnant. Your specialist will be able to discuss the implications of this and any alternatives to surgical treatment prior to the procedure.

If you go through a spontaneous premature menopause, you may still become pregnant. This is because hormone levels and ovarian health are variable in this condition, between 5% and 10% of women with POI become pregnant after diagnosis. This means that it is still important to use appropriate contraception if needed.

Read more about menopause contraception

If fertility is a worry for you, it’s important to seek help early on if you are hoping to have a baby. Although it is still theoretically possible to get pregnant, it is much more difficult if you have been diagnosed with early menopause. This is because your menstrual cycle is likely to be irregular, and your ovaries will be releasing eggs much less frequently.

If you have already been through menopause, it is generally thought that freezing eggs or embryos is less likely to be successful. It is, however, important that you are assessed properly by a fertility specialist as your options depend on a number of factors and can vary widely from person to person.

If you have not yet been through menopause but are at risk of POI – for example, if you are facing cancer treatment or have a strong family history of premature menopause – it  may be worth discussing your options with a fertility specialist. This may include freezing eggs or embryos. 

How does early menopause impact your long-term health?

While menopause is a normal part of life, early menopause comes with a few extra health considerations.

Mental health

Taking care of your mental health is especially important. While we know that hormonal changes can increase your risk of anxiety and depression, early menopause can be particularly difficult to deal with for other reasons too. 

You may find yourself coping not only with the physical aspects of menopause, but also fertility issues and the social implications of going through menopause at a much earlier age than expected. Who wouldn’t find this difficult?

You don’t need to feel alone and your doctor will be able to advise on treatment options including medications and talking therapies.”

Cardiovascular disease

There are physical health issues to take into consideration too. After the menopause, you are at greater risk of cardiovascular disease (including heart disease, stroke and blood clots) due to hormonal changes. Some studies have suggested that this risk is increased further in those who go through menopause early One large cohort study of over 140,000 women found that natural premature menopause increased the risk of cardiovascular disease by 36%. This figure was even higher in those who went through premature menopause due to surgery, with an 87% increased risk.

Although there has been fierce debate and mixed evidence about the role of Hormone Replacement Therapy (HRT) in preventing cardiovascular disease, current thinking is that it may help to reduce your risk. This is one of the reasons that HRT should usually be prescribed in cases of premature menopause. It is also sensible to pay attention to your wider cardiovascular health if you go through premature menopause. Your doctor will be able to advise on how to approach your own personal risk factors, which may include smoking, having high blood pressure or high cholesterol, and being overweight or obese. 

Bone health

Premature menopause in particular has been linked with thinning of the bones (osteoporosis and osteopenia) and a subsequent increased risk of fractures. If you are diagnosed with POI, your doctor will discuss bone density testing, as well as using HRT to help slow or prevent this process. It is also important to have a balanced diet with plenty of calcium and vitamin D, and to get plenty of weight-bearing exercise to strengthen the bones. 

Read more about bone health, osteoporosis and menopause

Cognitive impairment

Surgery to remove the ovaries before the usual age of menopause has been linked to an increased risk of cognitive impairment, dementia and Parkinson’s disease in later life. 

This surgery has also been linked with an increased risk of two conditions which affect the eye: macular degeneration and glaucoma. If you are concerned about symptoms of any of these conditions, see a doctor. It is thought that HRT may have a beneficial effect on this. 

Sexual health

Finally, don’t forget contraception! If you are under 50, you are still potentially fertile for two years after your last period. Your doctor will be able to help you choose the right contraceptive for you. Bear in mind that although HRT contains the same hormones as many contraceptives, it will not prevent pregnancy. 

Contraception is also important to protect your from sexually transmitted infections.

Can you prevent early menopause?

If you smoke, it is worth making a real effort to stop as soon as possible. Smokers have been found to go through menopause on average just under two years earlier than non-smokers.

Otherwise, there is not a great deal that you can do to prevent or delay menopause, although we would always recommend following a healthy diet and lifestyle.

Read more about menopause on our blog or in our symptoms library.