‘Premature menopause’ is when the final menstrual period occurs before a woman is 40. ‘Early menopause’ is when the final menstrual period occurs between 40 and 45 years. Up to 8% of women have had their final period by the time they are 45. The number of women reaching menopause by this time may be increased in relation to treatment after cancer, or removal of the ovaries.
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.
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 at the expected age because there is a small possibility that ovarian function may spontaneously resume, whereas this does not happen after expected menopause. Spontaneous pregnancy may occur, especially after the diagnosis has been made, in up to one in 50 women.
Chemotherapy and radiotherapy treatments can cause the ovaries to stop functioning, which means periods stop, and this is usually described as ‘induced menopause’.
Surgical removal of the ovaries leads to menopause. Surgery can be with or without hysterectomy (removal of the uterus).
Causes of premature & early menopause
There are many causes of premature or early menopause. It is clear that surgery to remove the ovaries (oophorectomy) results in instant menopause, and chemotherapy and radiotherapy treatments cause ovaries to weaken, but the causes of POI are not always as clear. In about 60% of women, a cause cannot be found.
Other causes of premature and early menopause
|Genetic abnormality||Two functioning X chromosomes are needed for normal ovarian function. Some genetic conditions involve problems with X chromosomes, such as:
Women who have Turner’s syndrome type XO and those who are carriers for fragile X often have POI
There are other rarer genetic abnormalities, such as galactosaemia (a genetic condition that affects the body’s ability to process galactose), which are still under investigation
|Autoimmune disorders||These include Addison’s disease (adrenal insufficiency), thyroid disease, type 1 diabetes, Crohn’s disease, coeliac disease, or other autoimmune disorders|
|Metabolic disorders||These disorders are rare, but can include galactosaemia and aromatase deficiency (a problem in converting the hormone androgen to oestrogen)|
|Infection||Mumps can cause an infection in the ovaries called oophoritis|
|Idiopathic||This term describes the individual cases of women whose periods stop with no known cause found|
The following may put women at increased risk of premature and early menopause:
- early menarche – periods that start at 11 years or earlier
- family history – the risk is increased up to 12 times
- previous surgery on the ovaries, eg, in recurrent endometriosis.
Symptoms of premature & early menopause
Symptoms of premature or 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 (POI)
In premature or 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
- transient, intermittent, or 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:
- vaginal dyspareunia (pain with intercourse) and dryness
- sleep disturbance
- mood changes, including irritability, lowered mood, mood swings and poor concentration
- aches and pains
- urinary symptoms, including frequency
- low libido
- lack of energy
- premenstrual symptoms, including breast soreness and bloating when the cycles are irregular.
Diagnosis of Primary ovarian insufficiency (POI)
If you have irregular periods or have stopped your periods for more than three months, please see your doctor and make sure your doctor includes hormone tests to exclude early menopause.
Your doctor will need to do a full physical examination and investigate the cause of your symptoms.
The criteria for a diagnosis of POI are:
- at least three months without a period
- two blood tests to confirm whether the levels of follicle-stimulating hormone (FSH) are more than 40IU/l – the two tests need to be performed on the third day of your period (if you are still having cycles) and at least one month apart.
A doctor is likely to perform the following tests:
- pregnancy test, FSH and Oestradiol (E2)
- 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 testing, including fragile X syndrome
- blood sugar and cholesterol levels
- bone density (DXA)
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. This is a specialist area and usually, at least initially, an endocrinologist or gynaecologist with expertise in early or premature menopause should assess and advise you.
Your doctor should see you regularly over the years to reassess your health needs, including reviewing your medications and to test routinely for potential risks associated with POI. 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 & POI
Many women are unable to conceive a baby naturally after POI. There is still, however, a one in 50 chance of spontaneous pregnancy.
For a woman who has gone through premature or early menopause, her options for having children include:
- IVF using a donor egg[
- surrogacy with a donor egg
- foster care or 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
You will find information on fertility and chemotherapy on our webpages for ‘Menopause after cancer’.
Responses to loss of fertility
For some women, early or premature menopause can 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 can seem unfair. Early or premature menopause can mean the longed-for role of motherhood might not happen or, if it happens, it may not be in the way you anticipated. How this feels and the impact it has will depend on your individual circumstances, support networks and coping skills.
Some women with early or premature menopause feel they have to take on a role they did not expect until they were in their 50s – that of a menopausal woman. They might even experience menopause before their mother.
Sometimes we have many roles, which we overlook when we focus strongly on wanting to fulfil one particular one. Some women forget they are also partners, daughters, sisters, friends, aunties, granddaughters, workers, neighbours, caregivers. Thinking about these other roles does not necessarily take away all the pain of loss, but it can help to shift the focus.
There are also other constructive ways to think about your role in life. For example, if you think your role is to be a mother, explore the steps you can take to achieve this; perhaps donor eggs or adoption are options. It can be helpful to seek counselling to help you with your decision-making.
Risks of premature & early menopause
The risks of developing osteoporosis and cardiovascular disease are higher for women with premature or early menopause than for women reaching menopause at the expected age. For this reason, it is important that you seek advice and treatment from your doctor.
According to community studies, women who go through premature or early menopause without hormone treatment have a reduced life expectancy by about two years.
The advice below is based on current expert opinion, as there are no studies on women with premature or early menopause that establish which prevention strategies are effective.
Heart & cardiovascular health
Women experiencing a premature or early menopause may have an increased risk of heart disease, compared to women who reach menopause at the expected age, although this remains controversial.
A recent study suggested women with premature or 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.
There are also other cardiovascular disease risk factors, such as family history, high blood pressure and high cholesterol levels.
A healthy lifestyle can help reduce the risk of cardiovascular and heart problems. Stopping smoking, eating a healthy, balanced diet with plenty of fruit and vegetables, maintaining a healthy body weight and doing regular physical activity reduces the risk of heart disease in women of all ages.
There is some evidence that suggests menopausal hormone therapy, or MHT (formerly called hormone replacement therapy, or HRT) use in women with premature or early menopause reduces the risk of cardiovascular disease.
It is recommended that you have annual monitoring of blood pressure, weight, smoking status and cholesterol and sugar levels, as well as a discussion with your doctor, to help keep a check on your risks of cardiovascular disease.
Women who experience premature or early menopause can start to lose bone density at an earlier age than women who experience menopause in their 50s. This puts them at a greater risk of developing osteoporosis earlier in life than women who undergo menopause at midlife. Changing your lifestyle may help to maintain bone health.
Lifestyle changes include:
- 3-4 daily serves of calcium-rich dairy products
- regular physical activity, including supervised muscle strengthening and weight-bearing exercise
- maintaining good vitamin D levels. Sunlight exposure during the day helps 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
- regular assessment of bone mineral density is essential.
Visit our ‘Bone health’ webpages for more information on osteoporosis, calcium and/or vitamin D.
Women with POI untreated with hormone therapy have a possible risk of a negative effect on cognition and verbal memory functions. Some studies suggest there is an increased risk for dementia and Parkinson’s disease in these women.
Treatment with hormones, which may be menopausal hormone therapy (MHT) or the combined oral contraceptive pill (‘the pill’), is recommended at least until the expected age of menopause (about 50-52 years) to maintain health and wellbeing, including preventing osteoporosis and heart disease, and maintaining vaginal and urinary health.
Like any treatment, MHT or the pill can have side effects. Risks commonly associated with MHT or the pill include a small increase in the risk of thrombosis. Studies indicate breast cancer risks are not expected to increase until after the age of expected menopause.
There are circumstances where MHT or the pill should not be used (for example, in women with a strong history of breast cancer). Each woman’s treatment should be individualised with her health professionals, depending on her symptoms, risk factors and family history.
If a woman with POI does not wish to become pregnant, although the risk is very small, she is advised to use contraception. The combined oral contraceptive pill provides not only contraception, but hormone replacement. Speak to your doctor regarding the appropriate treatment for you.
Psychological wellbeing & emotions
The diagnosis of a premature or early menopause can bring many changes and challenges: when menopause does not come at the age and stage of life you expected it to, it can have a major impact on your wellbeing. Women who experience premature or early menopause can be at greater risk of depression, anxiety and mood changes.
It can be very upsetting for some women to experience menopause in their 20s or 30s when they expected it to happen in their late 40s or 50s. Often this is a time of feelings of loss, sadness and grief. These feelings are very common, along with the feelings of losing your body image, fertility, femininity and sexuality, and feeling old before your time.
It can take some time to diagnose a premature or 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’.
Associated illnesses, such as cancer and chemotherapy or surgery to remove ovaries, may also alter the course of your life. Plans, dreams and expectations must be re-thought and that can be very challenging and distressing.
During this time, women can experience 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 might not understand because they are not yet experiencing menopause, and, for some, mothers haven’t yet reached menopause either.
Women who have induced menopause with the sudden hormonal changes can experience symptoms that are often more severe and unpredictable, which can be distressing. They may also be coping with other illnesses at the same time, such as a cancer diagnosis.
There are many factors that contribute to the emotional wellbeing of a woman experiencing premature or early menopause. 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 – are your symptoms very distressing to you?, what are the effects they have on your daily living?
- other factors occurring at the same time as your diagnosis, such as a serious illness
- 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
- whether you have good support from family and friends
- your lifestyle, including your diet, level of physical activity and drug and alcohol use
- the stage you are at in your life, such as whether you have had children if you wanted to
- any earlier experiences of depression and/or anxiety.
It is important to have a network of family, friends and health professionals who will support you through the initial diagnosis of premature or early menopause, as well as beyond, depending on your age and stage in life.
A premature or early menopause, particularly when it is sudden, can mean a significant change in the way you view your body. The sudden drop in hormones with a surgical menopause for example may make you feel your body is out of your control.
Symptoms that are frustrating, annoying, confusing and distressing can cause you to think differently about your body. Hot flushes, dry skin, a dry vagina and an increased risk 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.
- Talk to someone you know and trust, such as a 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 being physically active, as this will help with physical and emotional symptoms of menopause.
For more information go to ‘Mental & emotional health’ and/or ‘Anxiety: learn, think, do’.
Sex and 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 affect 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 or early menopause are not yet in a committed relationship and this can provide another challenge. How do you tell a new partner you have already gone through menopause and that you might not be able to have children? Some women lose confidence that they will not be able to have an intimate relationship. Talking with a counsellor about how to approach new relationships can be helpful, even if it is just for a session or two.
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.
Exploring the best possible options and treatments for you as an individual, and using open communication with a partner, is absolutely vital. Taking your 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.
Management & treatment of premature & early menopausal symptoms
Seeking treatment and advice is recommended to reduce your risk of earlier onset of cardiovascular disease and osteoporosis, as well as to treat your symptoms.
Treatment with menopause hormonal therapy (MHT) or the pill 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 MHT or the pill.
Discuss these issues with your doctor so you can make the right decision for you.
It may be possible to reduce some symptoms of menopause with the following options:
- healthy diet and eating
- exercise and physical activity
- your environment
- natural and herbal therapies
- cognitive behavioural therapy or hypnotherapy for hot flushes.
Menopausal hormone therapy (MHT)
MHT or the pill is recommended for women diagnosed with premature or early menopause, in order to replace the hormones the body is missing. MHT and the pill both contain an oestrogen and a progestogen (type of progesterone) and differ by doses, methods of treatment delivery (oral or transdermal) and types of hormone in the product. Both an oestrogen and a progestogen are necessary if the uterus has not been removed (hysterectomy).
Either treatment 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 50 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. If your period doesn’t occur, then a pregnancy test should be performed if on MHT. Otherwise, a woman can be prescribed the oral contraceptive pill. Both of these therapies will normally give a monthly period.
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, especially after surgical menopause.
Long-term risks of MHT
Although there are no long-term studies of MHT in women experiencing a premature or early menopause, it is recommended that MHT should be taken until the expected age of menopause (50-52 years ). All the studies of long-term use of MHT published in recent years have been in women some years after the expected age of menopause, who have a much greater risk of heart disease, stroke and cancer because of their age.
Serious adverse effects in younger women are very rare.
Make regular appointments with your doctor, specialist or specialist clinic to:
- monitor your symptoms and therapy
- Menopausal vaginal changes can make important medical check-ups, such as cervical screening, uncomfortable. Talk to your doctor about available treatments.
- 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.