Premature & early menopause

Last updated 26 April 2014 — Last reviewed 03 March 2014

Menopause that happens earlier than the expected age of around 50 years is called premature or early menopause.  This may be due to primary ovarian insufficiency where the periods spontaneously stop, as a result of chemotherapy treatment for cancer or surgically induced menopause when the ovaries are removed.  The impact on physical health, emotions, mood, body image and relationships can be significant, but there are treatment options and ways to manage premature and early menopause, which can help.

What is premature menopause?

‘Premature menopause’ is when the final menstrual period occurs before a woman is 40.

This may happen because:

  • periods stop spontaneously – due to primary ovarian insufficiency (POI) – this affects up to 1% of women
  • menopause is induced by a secondary cause such as:
    • surgery – when ovaries are removed surgically (oophorectomy)
    • chemotherapy or radiotherapy treatment for cancer

What is early menopause?

‘Early menopause’ is when the final menstrual period occurs before a woman is 45.

Again, this may be because periods stop spontaneously or because menopause is induced by surgery or chemotherapy or radiotherapy.

Up to 8% of women may have early menopause.

Terminology

Primary Ovarian Insufficiency (POI)

When periods stop spontaneously, either prematurely or early, this is referred to as ‘primary ovarian insufficiency’ (POI).

POI is not the same as ‘menopause’ because there is the small possibility ovarian function may spontaneously resume and this does not happen after ‘menopause’.

Induced menopause

Chemotherapy and radiotherapy treatments can cause the ovaries to stop functioning which means periods stop and this is usually described as “induced menopause”.

Causes of premature & early menopause

There are many causes of premature/early menopause. While it is clear surgery to remove the ovaries (oophorectomy) results in instant menopause, and chemotherapy and radiotherapy treatments cause ovaries to weaken, the causes of ‘primary ovarian insufficiency’ are not always as clear. 

Genetic abnormality

Two functioning X chromosomes are needed for normal ovarian function. Some genetic conditions involve problems with X chromosomes such as:

  • Turner syndrome (one of the X chromosomes is missing or abnormal)
  • Fragile X syndrome (where the bottom of the long arm of the X chromosome is broken or fragile)
Women who have Turner’s syndrome type XO and those who are carriers for fragile X often have POI.
Autoimmune disorders Examples include thyroid disease, Type 1 diabetes, Crohn’s disease, coeliac disease, chronic candidiasis (thrush).
Metabolic disorders These disorders are rare but may include galactosaemia and aromatase deficiency (a problem in converting the hormone androgen to oestrogen).
Infection Such as the mumps.
Idiopathic Idiopathic describes the individual cases of women whose periods stop with no known cause.

The following may put women at increased risk of premature and early menopause:

  • Family history – the risk is increased up to 12 times
  • Smoking
  • Epilepsy

Symptoms of premature & early menopause

Symptoms of premature/early menopause are basically the same as for menopause at the expected age of 51-52, however, they are often more severe.

Primary ovarian insufficiency

In premature/early menopause not induced by surgery or cancer treatment, the first symptoms may be:

  • some irregularity of periods
  • no periods after stopping the oral contraceptive pill
  • inability to get pregnant
  • or there may be no symptoms except for the menstrual periods stopping

Further symptoms may be experienced while you are still having periods and they may fluctuate and get worse as periods become less frequent. You may feel:

  • hot
  • irritable
  • anxious
  • as if you are having premenstrual symptoms
  • breast soreness
  • bloating

In young women, premature/early menopause is not always recognised as a possible cause of infrequent periods or why periods may have stopped altogether.

The diagnosis of POI often takes time to make or confirm

Diagnosis of Primary Ovarian Insufficiency

If you are worried you might have POI, see your doctor and explain all of your symptoms, especially if your periods are irregular and if you are experiencing any of the symptoms suggestive of menopause.

Your doctor will need to do a full physical examination and investigate the cause of your symptoms.

The criteria for a diagnosis of primary ovarian insufficiency are:

  • at least 4 months without a period
  • 2 blood tests to test whether the levels of Follicle Stimulating Hormone (FSH) are more than 40mu/ml – the 2 tests need to be performed on the 3rd day of your period (if you are still having cycles, and at least 1 month apart)

A doctor is likely to run the following tests: 

  • Pregnancy
  • Prolactin – this is the hormone usually involved with breastfeeding, but when raised, it causes periods to stop
  • Transvaginal ultrasound – this is an internal ultrasound of the vagina and uterus to check for evidence the ovary is functioning by:
    • counting the number and size of the follicles or eggs in the ovary
    • measuring the volume of the ovaries
    • assessing the thickness of the lining of the uterus or endometrium
  • Checking for any blockage that is stopping menstrual blood flow

Post diagnosis tests

After POI is diagnosed other tests may be recommended to check for some of the possible causes and associated conditions. These might include tests for:

  • thyroid function and thyroid antibodies
  • adrenal antibodies
  • chromosomal and genetic make up
  • blood sugar and cholesterol levels
  • bone density (dexa)
  • fragile x syndrome  

In about 60% of women, the cause of POI is never found. 

What to expect after a diagnosis

If possible find a supportive and sympathetic doctor to help you adjust to the diagnosis of early menopause. Your doctor will help to counsel you, prescribe appropriate treatments and refer you to relevant specialists when necessary. 

Your doctor should see you regularly over the years to reassess your health needs including reviewing your medications.  Often it is necessary to have a team of health professionals monitor you through the years after you have been diagnosed. 

You may need to seek out a specialist early menopause clinic or individual practitioners such as infertility specialists, endocrinologists (hormone specialists), psychologists or psychiatrists for support. 

Fertility & primary ovarian insufficiency

Many women are unable to conceive a baby naturally after primary ovarian isufficiency. There is a 2-5% lifetime chance of spontaneous pregnancy.

For a woman who has gone through premature/early menopause, her options for having children include: 

  • a donor egg
  • surrogacy with a donor egg
  • adoption

To explore the best option for you, ask your doctor for a referral to a fertility specialist who is a member of one of the in vitro fertilisation (IVF) clinics.

Fertility & chemotherapy

Information on fertility and chemotherapy is on our webpages for menopause after cancer.

Complications of premature & early menopause

The risks of developing osteoporosis and cardiovascular disease are higher for women with premature/early menopause than for women reaching menopause at the expected age. For this reason it is important that advice is sought from your doctor.

The advice below is based on current expert opinion as there are no studies in women with premature/early menopause establishing which prevention strategies are effective.

Bone health

Women who experience premature/early menopause, may start to lose bone density at an earlier age than women who experience menopause in their fifties. This puts them at a greater risk of developing osteoporosis earlier in life than women who undergo menopause at midlife.

Lifestyle changes

Changing your lifestyle may help reduce the risk of osteoporosis. Lifestyle changes include:

  • 3-4 serves of calcium-rich dairy products each day
  • regular physical activity, including supervised muscle strengthening exercise
  • maintaining good vitamin D levels:
  • 5-15 minutes of sunlight before 11am and after 3pm will provide the necessary daily requirement (this varies depending on location and season)
  • a vitamin D supplement may be required if the blood level of vitamin D is below the normal range

Hormonal treatment

Treatment with hormone replacement therapy (HRT) is recommended at least until the usual age of menopause (about age 50 years) as it may assist in preventing osteoporosis.

Like any treatment, HRT may have side-effects. Risks commonly associated with its use, such as a small increase in the risk of breast cancer, are not expected to appear until after the age of normal menopause.

There are circumstances where HRT should not be used (for example in women with a strong history of breast cancer).

Heart and cardiovascular health

Women experiencing a premature/early menopause may have an increased risk of heart disease compared with women who reach menopause at the usual age, although this remains controversial.

Recently, one study suggested women with premature/early menopause may also be at greater risk of stroke. This might be because of the loss of the beneficial effects of oestrogen on the blood vessels and the lipid (blood fat) profile of younger women. Further understanding in this area is still needed.

How to reduce your risk

A healthy lifestyle can help reduce the risk of cardiovascular/ heart problems. Stopping smoking, eating a healthy, balanced diet with plenty of fruit and vegetables, maintaining a normal body weight and doing regular physical activity, reduces the risk of heart disease in women of all ages.

Also, be aware of other cardiovascular risk factors, for example family history, high blood pressure and high cholesterol levels.

It is still unknown whether HRT use in women with premature/early menopause reduces the risk of cardiovascular disease. Regular check-ups and discussion with your doctor can help to keep a check on your risks of cardiovascular disease.

Mental health and emotions

The diagnosis of a premature/early menopause can bring many changes and challenges. Women who have premature/early menopause can be at greater risk of depression, anxiety and mood changes.

For women who have induced menopause this may be because of the sudden hormonal changes causing symptoms that are often more severe and unpredictable. It may also be because of the reason for the induced menopause – such as a cancer diagnosis or illness.

Women who experience primary ovarian insufficiency may also find they are more moody and sad.

Being at greater risk of anxiety and depression is also likely because of a range of other physical, psychological and social influences. Some of these include:

  • your diagnosis – the time it took, how distressing it was, how it came about, how it was communicated
  • your individual physical changes and symptoms – if your symptoms are very distressing to you and their affects on your daily living
  • other factors occurring at the same time such as illness like cancer
  • your ways of coping – sometimes the way we used to cope with things, such as stress, stop working and we need to find new ways to cope
  • whether you are in a relationship and your partner is supportive
  • the support you have from family and friends
  • your lifestyle including your diet, level of physical activity and drug and alcohol use
  • the stage you are up to in your life such as whether you have had children if you wanted to
  • any earlier experiences of depression and/or anxiety

How early menopause impacts on each woman is likely to be different as each woman deals with her diagnosis and its meaning over time.

Life stages, loss and grief

When menopause does not come at the expected age and stage of life it can have a major impact on your wellbeing.

When you experience something in your 20s or 30s that usually happens to women in their late 40s and 50s it can be very upsetting. Associated illnesses, such as cancer and chemotherapy or surgery to remove ovaries, may also alter the course of one’s life. Plans, dreams and expectations have to be re-thought and that can be very challenging and distressing.

Often this is a time of loss and with it comes sadness and grief. Not only can there be a sense of loss of control, loss of ability to plan and loss of self-image, but often there is no one with whom to share the grief. Girlfriends may not understand because they are not yet experiencing menopause, and for some, mothers haven’t reached menopause either.

It may take some time to diagnose a premature/early menopause. Not knowing what is wrong, having no control over symptoms and not knowing what the future holds can be frightening. Some women with early menopause talk of ‘loss of womanhood’, and ‘loss of dreams’.

Role

Premature/early menopause may mean the roles you expected to have must change. Even just being aware of the ‘roles’ you have can be helpful in dealing with these challenges.

It may take away the possibility of becoming a mother. Some women have said ‘I wasn’t sure if I even wanted children’ or ‘I didn’t know if I wanted more children’ but when the power to make that decision is taken away, it seems unfair. A role that was longed for may not happen and if it happens it may not be in the way you anticipated. How this feels and the impact it has will depend on individual circumstances, support networks and coping skills.

Other women feel they have to take on a role not expected until they were in their 50s – that of a menopausal woman. They may even experience menopause before their mother.

Sometimes we have many roles, which we overlook when we focus strongly on wanting to fulfill one role and can’t. Some women forget they are also partners, daughters, sisters, friends, aunties, granddaughters, workers, neighbours, caregivers. This doesn’t necessarily take all of the pain of loss away but it can shift the focus.

And there are other constructive ways to think about your role:

  • If you think your role is to be a mother, explore the steps that can be taken to make this role a reality – maybe donor eggs or adoption are options.
  • Seek counselling to talk about the loss of a role 

Body image

A negative body image occurs when someone thinks, feels and/or pictures their body in a negative way.

A premature/early menopause, particularly when it is sudden, can mean a significant change in your view of your body. The sudden drop in hormones with a surgical menopause for example may make you feel your body is out of your control.

The reason for a premature/early menopause such as through chemotherapy or surgery because of cancer, can also impact on your view of your body.

Symptoms that are frustrating, annoying, confusing and distressing cause you to think differently about your body. Hot flushes, dry skin, a dry vagina and increased risks of osteoporosis are significant changes to experience in your 20s or 30s.

It is not surprising women talk of not being able to trust their body and seeing their body in a negative way, not feeling as attractive or desirable. A young body is not supposed to behave like this and women often say ‘I am a young woman in an older woman’s body’.

If you are thinking more negatively about your body and it is distressing, you should discuss your feelings with your doctor or a psychologist.

What helps

  • Talk to someone you know and trust such as close friend and/or health professional
  • Express your thoughts and feelings in a journal or diary
  • Drawing your feelings or expressing yourself in creative and artistic ways is known to help with mood
  • Seek some counselling
  • Make sure you are eating well and physically active as this will help with physical and emotional symptoms of menopause

Sex and relationships

Relationships

Feeling stressed, self-conscious about your body, depressed or anxious about intimacy can make sex uncomfortable, and even painful.

Sometimes, dyspareunia (painful sex) begins as a physical problem, but then has a flow-on effect to your psychological wellbeing and relationships, causing stress and anxiety.

Apart from understanding how the physical symptoms may impact on you and your relationships, it is helpful to understand how mood and emotions affect your relationship. It might be that, as a couple, you need to re-think dreams and plans.

Dealing with fertility issues can be difficult for both of you and seeking help at the earliest time can be good for both of you.

Some women who have premature/early menopause are not yet in a committed relationship and this can provide another challenge. How do you tell a new partner you went through menopause at 20 years of age and that you might not be able to have children? Some women lose confidence that they will be able to have an intimate relationship and this can be very distressing. Talking with a counsellor about how to approach new relationships can be helpful even if it is just for a session or two.

Sex

It can be distressing to have hot flushes and sweats at a young age and even more distressing to have a dry, thin vagina, which makes sex and intimacy painful. Your sexual relationship may be new or sex may never have been a problem in the past and now it is. Some women find it both frustrating and embarrassing to explain what is going on to a partner.

A vicious cycle can develop where past experiences of painful sex cause anticipatory fear of more pain. This fear creates stress, tension and reduces libido and arousal. As a result, sex becomes painful.

As always, exploring the best possible options and treatments for you as an individual and using open communication with partners is absolutely vital. Taking a longer term partner to a gynaecologist’s or doctor’s appointments can be helpful.

If early menopause has caused problems with your sex life, there are many treatments that can be helpful it might just be about finding the right one for you.

Menopausal vaginal changes can make important medical procedures, such as Pap smears uncomfortable. Talk to your doctor about how even short-term vaginal oestrogen replacement can make Pap smears more comfortable.

Management & treatment of premature & early menopause symptoms

Deciding whether you seek treatment or not depends on how much your symptoms interfere with your daily life and your need to reduce your risk of earlier onset of cardiovascular disease and osteoporosis. 

Treatment with hormone replacement therapy (HRT) is recommended to reduce severe symptoms and to reduce the long-term health risks associated with early menopause, such as osteoporosis. However, other therapies may be recommended for moderate to severe symptoms or if there are reasons, such as breast cancer, for not being able to take HRT. 

Discuss these issues with your doctor so you can make the right decision for you.

It is possible to reduce some symptoms of menopause with changes to your lifestyle, changes to your environment and you may also like to follow up on some information on natural and complementary therapies along with hormone replacement therapy.

  • Healthy diet and eating
  • Exercise and physical activity
  • Your environment
  • Natural and herbal therapies
  • Relaxation and paced respiration for hot flushes and mindfulness therapy

Hormone replacement therapy (HRT)

HRT is recommended for women diagnosed with premature/early menopause in order to replace the hormones the body is missing. It is recommended to:

  • ease menopausal symptoms
  • maintain bone density and reduce the risk of osteoporosis
  • reduce the risk of early onset of cardiovascular and heart disease   

For one in 10 women, pregnancy occurs spontaneously after the diagnosis of primary ovarian insufficiency. If a woman wants this chance of spontaneous pregnancy, the hormone therapy consists of continuous oestrogen with cyclic progestin therapy.  Otherwise, a woman can be prescribed the oral contraceptive pill.  Both of these therapies will normally give a monthly period.  If your period doesn’t occur then a pregnancy test should be performed.

Higher doses of hormones are often prescribed because younger women require more hormones to maintain quality of life and wellbeing. Testosterone, which is also a female hormone, may be considered an appropriate treatment.

Long-term risks of hormone therapy

Although there are no long-term studies of HRT in women experiencing a premature and early menopause, it is recommended that HRT should be taken to the expected age of menopause (45-50 years of age).  All the studies of long-term use of HRT published in recent years have been in women some years after the expected age of menopause, who have much greater risks of heart disease, stroke and cancer because of their age.

Serious adverse effects in younger women are very rare.

Ongoing management

Make regular appointments with your doctor, specialist or specialist clinic to:

  • monitor your symptoms and therapy
  • monitor for the development of any heart disease risks
  • check your bone density
  • continue surveillance to exclude the development of other conditions such as problems with your thyroid or an increase in your risk of developing diabetes risk

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at March 2014.

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