Experiencing an earlier menopause can have medical and psychological consequences but help and treatment are available
• POI occurs when your ovaries no longer work properly when you are under the age of 40
• HRT and testosterone replace missing hormones
• Psychological support should be available if you would like it
The average age a woman experiences menopause in the UK is 51 years. However, many women have an earlier menopause. If you are under 45 years, then it is referred to as an early menopause. If you are under 40 years of age, then it is referred to as Premature Ovarian Insufficiency (POI).
What is Premature Ovarian Insufficiency (POI)?
POI occurs when your ovaries no longer work properly when you are under the age of 40 years. Your ovaries no longer produce normal amounts of oestrogen and therefore may not produce eggs. This means that your periods either stop or become irregular and you may experience symptoms of the menopause.
However, in most women with POI, your ovaries do not completely fail which is different to the natural menopause in middle age. This means that the function of your ovaries can fluctuate over time, occasionally resulting in a period, ovulation or even pregnancy, sometimes several years after diagnosis. This intermittent temporary return of ovarian function can result in around 5-15% of women with POI being able to conceive [1].
About four in 100 women under the age of 40 years in the UK have POI and it affects at least one in 1,000 women under 30 years [2]. Many women have POI without realising and it is really important that if you have irregular periods or your periods have stopped then you talk to your doctor about the possibility of POI.
RELATED: Am I too young to be menopausal?
What causes POI?
For most women with POI, the underlying cause is not known. The following, however, may cause POI:
• Having your ovaries removed during an operation (in which case the term Premature Surgical Menopause is technically more accurate as there can be no return of ovarian function).
• If you have radiotherapy to your pelvic area as a treatment for cancer or if you have received certain types of chemotherapy drugs that treat cancer.
• If you have had your womb (uterus) removed (an operation called a hysterectomy) even if your ovaries are not removed. Although your ovaries will still make some hormones after your hysterectomy, it is common that your levels of hormones will fall at an earlier age than average.
• In around 1 in 20 of women with POI, the condition is associated with severe autoimmune diseases [3], where your immune system mistakenly attacks healthy cells and organs in your body. There may be people in your family who have other autoimmune conditions – for example, type 1 diabetes, thyroid conditions or Addison’s disease.
Some women with POI have as a result of certain genetic conditions. The most common of these is Turner syndrome, in which one of the female sex chromosomes (the X chromosome) is missing. Chromosomes are found in every cell in your body and contain genetic information. Genetic conditions that cause POI are usually more common if you have other people in your family with POI or if you are under 20 years at the time of diagnosis.
RELATED: Will I have an early menopause like my mum?
How is POI or early menopause diagnosed?
The most common test is a blood test that measures a level of a hormone called follicle stimulating hormone (FSH). If this is raised, then it is very likely that you are menopausal. This blood test is often repeated 4-6 weeks later. However, although many guidelines write about this FSH test, in clinical practice it is not useful as women can have raised, normal or low FSH levels and be menopausal or perimenopausal. The most accurate way of making a diagnosis is by monitoring your symptoms. Often a blood test for your oestradiol and testosterone levels is undertaken, which can be useful.
You may also be advised to have other blood tests, for example some types of genetic tests. You may also be recommended to have a bone density test (DEXA scan) to determine the density of your bones as women with POI have a greater risk of developing osteoporosis.
What are the symptoms of POI?
For most women, the most common indication of having POI is that their periods stop. For around 14% of women with POI, their periods do not even start [4], and they present with POI at a very early age, usually under 20 years. Other women may notice that their periods become irregular.
Many women experience some symptoms of menopause. However, around one in four women do not have any of these symptoms.
Symptoms of menopause can often have a negative effect on your home and work life. It can be common for symptoms to come and go so you may have some months where you feel completely normal and then other times when you experience unpleasant symptoms which adversely affect the quality of your life.
Common symptoms of menopause can include:
Hot flushes and night sweats: hot flushes usually come on suddenly and spread through your body, chest, neck and face. They vary in length from a few minutes to much longer. They can be associated with symptoms such as sweating, dizziness, light-headedness and even heart palpitations. Many women find they wake up several times each night drenched with sweat and need to change their bed clothes and bed linen.
Tiredness and poor sleep: these can be related to disrupted nights’ sleep from night sweats, but many women find that they have more unsettled and less fulfilled nights’ sleep when they are perimenopausal. Even if your sleep is not affected, you may feel more tired than normal during the day.
Lack of libido: reduced or absent libido (sex drive) occurs when your hormone levels fall. It can also be related to low testosterone levels.
Brain fog: you may find it harder to concentrate or multi-task, or you may forget words, appointments, birthdays or do silly things (for example, put your car keys in the fridge!). Many women find that their brain does not feel as engaged as much as it used to, which can affect your ability to work and function.
Joint pains: your joints may feel stiff and achy.
Hair and skin changes: your skin may have less elasticity, become dry, itchy or become thinner and gain more fine wrinkles. Your hair can become thinner and less glossy.
Changes in mood: Some women experience mood swings or feel lower in themselves, while others can find that symptoms of depression, anxiety, panic attacks, anger and irritation worsen.
Genitourinary Syndrome of the Menopause (GSM): this is a collective term to describe symptoms that include vaginal dryness, discomfort or pain during sex, irritation or burning of the vulva or vagina, needing to go to the toilet more often and feeling very desperate to go, without much notice, and urinary tract infections such as cystitis. Your vulva may also become itchy and you may find you have episodes of thrush more frequently.
These are all common symptoms that affect most women at some time during perimenopause and menopause, but there are many more symptoms, some of which you might not be aware of.
RELATED: 10 surprising menopause symptoms
Long-term health considerations of POI
If you experience menopause at a young age there are potential associated health conditions you need to be aware of, including osteoporosis and cardiovascular disease.
Oestradiol (oestrogen), progesterone and testosterone help to keep your bones strong and healthy but when there are less hormones in your body, your bone breaks down at a faster rate than it builds up, resulting in a gradual loss of bone mass. Once this loss of bone reaches a certain point, osteoporosis develops. This leads to your bones becoming less dense and less strong.
People with osteoporosis have an increased risk of fractures occurring even with little or no trauma. This can mean that normal stresses on your bones from sitting, standing, coughing or even hugging can result in painful fractures. These fractures can occur in any of your bones, including your spine, hips and wrists.
Oestradiol, progesterone and testosterone also have positive effects on the inner layer of the walls of your blood vessels, which helps to keep your blood vessels flexible and healthy. When levels of these hormones are low, your risk of cardiovascular disease (diseases of your heart and blood vessels, including heart attack and strokes) increases. Other changes in your cardiovascular system can take place - your blood pressure is more likely to start to increase and bad cholesterol, or LDL cholesterol, levels may increase while good cholesterol, or HDL cholesterol, may decline or stay the same.
It is natural to feel anxious, worried or even have feelings of hopelessness after a diagnosis of POI has been made. Some women find they feel sad and even guilty, as having POI can affect your fertility, although not every woman with POI will be infertile.
Treatment options
Menopausal symptoms are due to a lack of hormones – oestradiol, progesterone and testosterone. Therefore, replacing the missing or low hormones will relieve symptoms. Taking the right dose and types of hormones will also reduce your future risks of diseases too.
NICE guidance states that women with premature menopause or POI should take HRT up to the average age of the natural menopause (51 years in the UK), after which the need for ongoing HRT should be reassessed [5]. Women usually continue taking HRT for ever due to the many benefits associated with taking HRT.
Early initiation with HRT is strongly recommended in women with POI to improve symptoms and also to reduce future risk of cardiovascular disease, to maintain bone health, and prevent osteoporosis [5]. Women with POI are at increased risk of developing heart disease, including coronary heart disease, heart failure and stroke. They are at increased risk of osteoporosis, cognitive problems and dementia and autoimmune diseases. Some women with POI also have low thyroid function (hypothyroidism), and are at higher risk of dry eye syndrome and mental health conditions such as anxiety and depression.
Your healthcare professional will work with you to determine the best dose and type of HRT for you, taking into account that women with premature menopause or POI may need high oestrogen doses for symptom relief [5].
NICE menopause guidelines also recommend vaginal oestrogen to help manage GSM in menopausal and postmenopausal women [5]. Vaginal DHEA (prasterone) can also help to alleviate symptoms. Vaginal hormones are different to HRT as they are very low dose and do not get absorbed into your body. They can be used with HRT.
RELATED: Vaginal hormones: what you need to know
A healthy lifestyle is really important for all women. Stopping smoking, eating a healthy, balanced diet and limiting alcohol can all be beneficial as well as participating in regular aerobic exercise.
To reduce your risk of osteoporosis, eat a diet rich in calcium and do regular weight-bearing exercise. It is important to have adequate vitamin D levels to help keep your bones healthy. Vitamin D is made in the skin following sun exposure and is found in very small amounts in some foods. Many women need to take vitamin D tablets to have normal levels in their bodies.
Some women find that they experience anxiety symptoms or even depression when they have an early menopause. It is really important to talk about any symptoms you may be experiencing with a healthcare professional who specialises in hormone health, who will be able to recommend the right support and treatment for you. This might include psychological support or, if relevant to you, fertility counselling. Some GP practices have links to counsellors and therapists who can offer support.
Resources
British Association for Counselling and Psychotherapy (BACP)
United Kingdom of Counsellors and Psychotherapists (UKCP)
British Infertility Counsellors Association (BICA)
