Let's Talk About Early and Premature Menopause
When your body's jolted into a physiological transition that shouldn't occur for another 10 to 20 years, it can be jarring as hell. Understanding what's going on is the first step to dealing with it and feeling better—emotionally and physically.
It’s hard to hear that you are going to experience menopause early, whether it occurs naturally or is the result of a potentially lifesaving medical intervention—surgery, say, to stop the spread of cancer. HealthCentral is here to help you figure out how to plan for what comes next: choosing the right docs and sorting through treatment options, answering your questions about fertility, symptoms, and potential health risks. And of course, how to live well and feel healthy in the years to come.
Our Pro Panel
We went to some of the nation’s top menopause experts to bring you the most up-to-date info.
Diana Bitner, M.D.
OB/GYN and author of "I Want to Age Like That! Healthy Aging Through Midlife and Menopause"
Monica Christmas, M.D.
Assistant Professor of Obstetrics and Gynecology and Director of the Menopause Program
Juliana Kling, M.D.
Associate Professor of Medicine and Associate Chair of Research in the Division of Women’s Health
Early and premature menopause come with an increased risk of osteoporosis, heart disease, and weight gain typically associated with aging. Weight-bearing exercises—such as walking, lifting weights, or Pilates—help build bone and prevent bone loss, while eating a healthy diet and exercising regularly can help to prevent menopause weight gain and promote cardiovascular health.
Primary Ovarian Insufficiency (POI) is a health condition that can affect women as young as their teens. It’s the result of a shortage of eggs in the ovaries, causing infrequent and spread-apart periods or no periods at all. Though POI can lead to primary ovarian failure (POF) and menopause, it is not the same as either. Young women with POI may still be able to ovulate and become pregnant, and should find an endocrine reproductive specialist in addition to a North American Menopause Society (NAMS) certified menopause practitioner to discuss options and treatment.
Many health insurance plans are more likely to pay for fertility consultations and treatments if you are about to undergo a life-saving medical intervention that is likely to induce premature or early menopause. But insurance isn’t standardized, so you’ll need to check what your plan covers. The condition where fertility treatments will most standardly be paid for by insurance is cancer. Many cancer treatment centers have also begun to include fertility consultations, reproductive endocrinologists, and fertility specialists onsite, so that patients who are already in the midst of difficult health decisions don’t have to make separate plans to discuss and learn about their fertility options before or after treatment.
Every doctor on our expert panel stressed the importance and benefit for women who are going through menopause at earlier ages to see a specifically NAMS certified menopause practitioner. Because you are not only experiencing symptoms but also at a higher risk for heart disease and osteoporosis, your menopause practitioner will know to do tests that a regular PCP or OB-GYN may not, such as preventative bone density scans to help you stop bone loss before it starts, rather than diagnose it after it has already caused a fracture. A NAMS certified menopause practitioner will also discuss treatment options to help deal with sex after menopause, such as localized hormone therapy with different estrogens and methods of application as options, as well as vaginal moisturizers that match the pH and osmolality of the vagina and the best lubricant for menopausal dryness (look for an osmolality of around 300 on the label and an absence of fragrance or chemical additives), taking the burden off of you as a patient to breach these topics yourself, and with an advanced understanding of how complex and important sexual health is in menopause at any age.
First, What Is Typical Menopause, Exactly?
Many people think they’re in menopause when they start developing the classic symptoms of period changes and hot flashes. That’s actually called perimenopause, the period of time before you actually hit true menopause, the definition of which is: when a woman has gone a full year without a period. No blood, no spotting, no nothing. If this is you, you’re in the company of more than 60 million women in the U.S.
A bit more background:
As you age, your ovaries, responsible for releasing functioning eggs—of which you have a finite number—begin to slow down.
At the same time, they begin to produce less and less of the reproductive hormones progesterone and estrogen.
First, you’ll probably notice that your periods become less frequent and lighter, or longer, closer together, and heavier.
As this happens, you will likely start to experience the symptoms that most associate with menopause.
All women experience the hormonal fluctuations of perimenopause uniquely, with some ovaries reacting by releasing gradually fewer hormones, while others can release them in spurts before ovulation ends altogether. When that happens, and you haven’t had a period in a year, that’s menopause.
The big M is always the result of ovarian failure (scary term, we know, but as explained, it simply describes the slowed process of the ovaries releasing eggs until they stop). This “failure” can occur early, prematurely, or within an average timeline. With typical menopause, ovarian failure happens naturally as you age. The average menopause age is 51, but any time after 45 is considered within the expected age range. Before that, you have either early menopause or premature menopause. Less than 5% of women go through early or premature menopause.
What Is Early Menopause?
Menopause is considered early when it occurs before age 45—assuming that there isn’t another medical condition (such as anorexia) that could be causing a temporary but long period of time without menstruation.
A diagnosis of early menopause often includes a family or genetic history of stopping ovulation early.
What Is Premature Menopause?
For your menopause to be premature, you must be under 40 (the one “40 under 40” list you aren't psyched to be on). About 1% of women go through menopause before they turn 40, and one in 1,000 women experience it before they are 30.
Menopause that happens before age 40 and is not induced by surgery, medical interventions, or other illnesses may initially be diagnosed as premature ovarian failure (POF), which is when the ovaries fail to produce and release eggs from ovarian follicles. In 90% of POF cases, there is not a clear cause that can be determined for why the ovaries are failing prematurely.
However, some women with POF do still have periods even if their ovaries are not regularly producing eggs; it is not the same as premature menopause, though it can eventually lead to it and is a main cause.
What Can Cause Early and Premature Menopause?
On average, women are born with about 2 million ovarian follicles, with around 300,000 to 400,000 left by the time they get their first period. During a normal menstrual cycle, estrogen drops, which alerts the hypothalamus in the brain to send a signal—via FSH, or follicle stimulating hormone—telling the ovaries to produce an egg from a follicle.
Once one of the follicles is stimulated to mature into an egg (not all of them do), estrogen rises, triggering the body to stop producing FSH. That is why, if you are having trouble conceiving or suspect you are in premature menopause or experiencing premature ovarian failure (POF) or having abnormal menstrual spacing with few or no periods, your doctor will likely check your FSH levels. If they are high, it can be an indicator that you are not ovulating regularly, which normally causes estrogen to rise and FSH to fall.
Though this can be a common precursor to premature menopause, it isn't the same thing. With menopause, there are no more follicles left to become eggs. With POF, some follicles may still remain, they just aren't becoming eggs or they're malfunctioning; with the help of fertility treatments, follicles may be able to mature into eggs. Once POF is advanced to a point where there are no eggs left for one whole year, you've officially entered meno.
Other possible causes of menopause at an earlier age can include:
Bilateral Oophorectomy (or removal of the ovaries) and hysterectomy (removal of the uterus) throw you into menopause because, without ovaries, there is no production of eggs. Both of these procedures are often done to prevent the spread of uterine or ovarian cancer or as treatments for other medical conditions such as endometriosis, noncancerous ovarian or uterine cysts, ovarian torsion, or reducing the risk of ovarian or breast cancer in women with an increased risk.
Medications and Treatments for Other Health Conditions
Specifically, radiation, chemotherapy, and some immunosuppressant drugs. These medications do not always cause menopause—that will depend on your course of treatment, including the length of time and the amount of medication you are receiving.
If you are going to be on an aggressive course of chemotherapy, radiation, or another substance that could induce menopause, your doctor should discuss that with you in advance so that you’re aware of the risks before you begin treatment.
In these conditions, the immune system mistakenly treats parts and systems of the body as if they are outside threats—and attacks them. In some cases, these frequent wars can cause inflammation in the ovaries, which can then lead to premature or early menopause.
In addition, in cases where radiation and chemotherapy medications are used to treat these disorders, they can also bring about early or premature menopause, though they do not always.
Turner Syndrome and Other Chromosomal Conditions or Mutations
Turner syndrome is caused when one of the two X chromosomes women are usually born with is absent or partially missing. It is one of the most prevalent chromosomal abnormalities and affects approximately 1 in every 2,500 women. Most women who have Turner Syndrome have ovarian insufficiency, which does usually lead to premature or early menopause.
Thyroid function is directly related to hormone regulation in women and can influence menstruation, ovulation, and activate premature or early menopause.
Undiagnosed symptoms of hypothyroidism can sometimes mimic menopausal symptoms, so if you are missing periods and having signs of menopause at 40 or thereabouts, make sure to get your thyroid hormone levels tested.
Whether for hypothyroidism or hyperthyroidism, receiving the right thyroid treatment can sometimes prevent early or premature menopause or at least stop symptoms brought on by imbalances in thyroid hormone.
Women who are very underweight from eating disorders for a long period of their lives are more likely to go into menopause early because estrogen is stored in fat, and not having an adequate amount of fat over many years can halt estrogen production, and even eventually lead to early menopause if left untreated.
Eating disorders can also launch you into amenorrhea, which is the temporary cessation of periods, in this case brought on because the body isn’t receiving an adequate amount of calories and fat to continue normal hormone function. Amenorrhae, however, is not permanent, which is what distinguishes it from early or premature menopause.
HIV and AIDS
When these conditions are not controlled with medication, they can cause early or premature menopause. Why? Untreated HIV and AIDS can accelerate aging, including menopause, as well as exacerbate menopause symptoms. One more reason to seek treatment immediately if and when you discover that you are HIV positive.
You didn’t think smoking was getting off the hook here, did you? Smokers are likely to experience menopause earlier than nonsmokers. Puffing has anti-estrogen effects and reduces estrogen circulation throughout the body.
What Are the Health Risks Associated With Going Through Menopause Early or Prematurely?
In addition to fertility concerns and the experience of having more intense menopausal symptoms—such as hot flashes, sleep disturbances, and mood swings—women who go through menopause early or prematurely are at higher risk of other health consequences due to the early and rapid estrogen dip.
When a body that is expecting to have estrogen for many more years suddenly has to adjust to its abrupt and early withdrawal—due to surgery or illness rather than the typical slow tapering of traditional menopause—it can experience other adverse effects.
These risks include:
Bone loss, osteoporosis, and fractures
Psychological symptoms and cognitive impairment normally associated with aging (estrogen is linked to memory and contentment, and has complex effects within the brain)
Why Is Hormone Therapy so Important for Most Younger Women Who Go Through Menopause Early?
We tend to think of ovarian function and menses as solely a reproductive issue, but reproduction is not the only function of the ovaries. They are also endocrine organs, and there are estrogen, progesterone, and androgen receptors throughout the entire female body.
This is why it is important to find a North American Menopause Society (NAMS) certified practitioner certified practitioner and start hormone therapy (HT) right away if you are in premature or early menopause and don’t have contraindications.
Literally every part of a woman’s body is anticipating those hormones until the age of regular menopause, and losing them early can cause health risks that are normally associated with old age in women—such as osteoporosis, heart disease, or dementia—to arrive early if hormone levels are left unchecked. HT is the recommended course of treatment for all women without contraindications (such as elevated cancer risk) who go through menopause early or prematurely.
There are as many ways to take HT as there are for taking hormones for birth control, from a patch to a vaginal ring, to gels, creams, and pills. Your NAMS certified practitioner can help you find the right FDA-approved dosage, type, and delivery method for you.
Though hormone therapy has not been proven to prevent heart disease in women in their sixties and is used mostly for symptom management in that age group, FDA-approved hormone therapy has been shown to tamp down symptoms for those who have gone through premature or early menopause, but also to prevent health risks.
This is, in fact, the most important distinction in treating early or premature menopause with HT in younger vs older women. So, in case we still haven’t been clear enough, get ye to a NAMS practitioner ASAP to start HT right away to mitigate and possibly prevent many of the potential long-term health consequences.
Of course, women who are in premature or early menopause as a result of radiation, chemotherapy, oophorectomy, or hysterectomy with ovarian removal as treatment for breast, ovarian, or uterine cancer are usually not recommended to go on HT. This is because in some cancers, cancerous cells receive their growth signals from the hormone estrogen. Use the NAMS search function to find a certified menopause practitioner in your area who can tailor your menopause treatment with your medical history in mind.
What Are Other Treatments for Early or Premature Menopause?
If you’re not able to go on HT because of estrogen, know that there are more safe and effective menopausal treatments not involving estrogen than ever before, so your NAMS practitioner can recommend a cocktail of treatments specifically to your needs.
Some of the most common include:
FDA-approved non-estrogenic medications, known as bioidentical hormones (bioidentical hormones generally refer to estrogen and progesterone (and sometimes other hormones like testosterone) that are made from plants and are usually available at compounding pharmacies. The common ones are Remifemin or Estroven which are found over the counter), which are made with plant chemicals (typically from yams and soybeans).
Lube! Make it your friend. It can help with vaginal dryness and pain during sex. Look for an over-the-counter lubricant or vaginal moisturizer whose label lists an osmalality of around 300 (this means it matches what’s naturally going on in your vagina). It should have no fragrance or chemical additives.
Antidepressants, such as SSRIs, and other mental health medications that have recently been approved specifically for the treatment of hot flashes and psychological symptoms
It's worth repeating: We know it can be scary to go through menopause before your body is supposed to. It’s not something you’d probably expected would happen, and the ramifications can throw certain life plans into a tailspin. But knowing what the heck is happening can help you feel less helpless and better prepped to find the right treatment—and get back to feeling like you again.
- Risk Factors: Maturitas, The European Menopause Journal. (2000). “Factors associated with early menopause.” maturitas.org/article/S0378-5122(00)00092-X/fulltext
- Treatments for Menopause Symptoms: The Journal of the North American Menopause Society. (2014). “The North American Menopause Society Recommendations for Clinical Care of Midlife Women.” menopause.org/docs/default-source/2014/nams-recomm-for-clinical-care.pdf
- Cancer and Premature Menopause: European Journal of Cancer. (2011). “Hormone replacement therapy and women with premature menopause—a cancer survivorship issue.” ncbi.nlm.nih.gov/pubmed/21561765