Premature menopause: What are the signs and the treatment options?

Premature and early menopause can have a devastating effect on women and their families. Here, Gynaecologist Vikram Talaulikar from The Menopause Clinic London, talks us through the signs to look out for and the treatment options for symptom relief and fertility available to women.

Fact file:

• Menopause is the cessation of periods
• Premature menopause or Premature Ovarian Insufficiency (POI) is menopause that occurs under the age of 40 and it affect 1-3% of women
• Early menopause is menopause that occurs under the age of 45 and it affects between 5-10% of women
• Premature and early Menopause puts you at a higher risk of heart disease, osteoporosis, depression, cognitive decline.

Many women who experience menopause symptoms under the age of 40 or even under 45 are often told they are too young to be heading toward menopause, but Mr Talaulikar says any symptoms that go on for more than 3-6 months should be investigated.

Common symptoms include:

• night sweats
• hot flushes
• vaginal dryness
• painful sex
• loss of libido
• mood swings
• low mood
• anxiety
• insomnia (difficulty sleeping)
• fatigue (tiredness)
• difficulty concentrating
• difficulty getting pregnant.

It’s easy to put these things down to stress, kids, busy lifestyle and work life but they shouldn’t be ignored and the cause should be investigated.

If the symptoms are due to declining oestrogen (estrogen) levels there are treatments that involve taking oestrogen and progesterone to restore levels to where they would normally be. Mr Talaulikar says, it is important if you want to have a family in the future and look after your long term health.

Oestrogen has a protective effect on the heart, brain, and bones and may even play a role in our immune system, so it’s vital to make sure it is at optimal levels.

Menopause usually occurs around the age of 51 in the UK, so if you go through it in your 20’s, 30’s or early 40’s you are without it’s protective influence for longer than the average women, and as a result, your risk of xdeveloping heart disease, brittle bones or cognitive problems such as dementia are higher.

Because of this the current advice it to take some form of hormone replacement therapy.

What are the causes of premature menopause?

1.Low amount of eggs

“If it happens naturally, it is believed that the woman may have started with a lower store of eggs. If she has been born with a lower store the will eventually run out and a few years after the eggs have run out the hormones will run out too.”

2. Medical conditions or interventions

That’s the physiological explanation but there are pathological ones too. Surgery is one example, such as removing the ovaries because of cyst or tumours. Other reasons include cancer treatments like chemotherapy or radiotherapy or some of the medications used in immunotherapy.

There’s also a genetic element he says. Two examples of this are Fragile X Syndrome and Turners Syndrome, where one of the X chromosomes doesn’t function.

But he says there are still more being discovered as we learn more about about genetics.

Immune disorders is also linked if they are in overdrive. “We often test for anti-bodies and we often find that women have high levels of anti-bodies which indicates that their bodies are in some form of overdrive and are targeting certain organs in the body, Mr Talaulikar says.

So far there is no treatment for this. He says people have tried steroid treatments but they haven’t managed to kick start the ovaries into producing eggs again as yet.

3. Lifestyle

Lifestyle may have an impact too, he says, although it’s a controversial topic. “Smoking and high  BMI may increase the risk although some studies contradict this, but overall there is an agreement that smoking, high BMI, stress and extremes of nutritional status [being too thin] have been linked to premature menopause,” he says.

If you are very underweight, ovulation will be irregular or stop – which again means you’re missing out on the protective effects of oestrogen. He says it’s best to maintain a healthy weight.

Why is oestrogen protective?

“The female body needs oestrogen, and not just for sexual function,” he says. “Oestrogen plays a keep role in bone reproduction. It stimulates the cells that produce bone and inhibits the cells that resorb bone from the skeleton. So, if you don’t have enough the bones will start to be resorbed and over 2-3 years you will see the result.

“The first stage is osteopenia which is a little bit of loss of bone density and if that’s not corrected it will go into osteoporosis within a year or so where there is definitely brittle bones and this is where we see fractures of the spine or hips which can be critical.”

The heart also reaps the benefit of oestrogen and is one of the reasons why women have lower rates of heart disease than men.

“It helps reduce bad cholesterol, keeps the arteries more supple and helps prevent the deposition of plaques into the arteries and blood vessels. So all of those protective effects will be lost if there is no longer enough oestrogen,” Dr Talaulikar says.

So could it be premature menopause?

If you’re under 45 having some blood tests is a good idea. This is no longer a requirement if you are over 45 unless there is a reason to rule out any other underlying conditions.

One red flag he says it irregular periods or if you’re periods have stopped for 3-6 months. “If so, something is wrong,” he says. “And you may start to notice some of the other symptoms – whether it’s night sweats, hot flushes or low moods.”

Periods may change in terms of flow and may become irregular and if this goes on for more than a few months it’s worth seeing your GP who may do a set of blood tests – Follicle Stimulating Hormone (FSH), Luteinising Hormone (LH) and oestrogen.

“If the oestrogen is not doing its job the brain will tell the body to increase the FSH to try and push the ovaries along and that usually tells you that something is not right.”

He says the blood test should be repeated after 3 months as hormone levels can fluctuate, and if the results are the same on the second test that’s usually an indication that the ovary has stopped functioning or isn’t functioning properly.

Not all women have all symptoms or the same symptoms, adding to the difficulty in diagnosing early or premature menopause, but some symptoms to keep an eye out for are hot flushes and night sweats, low libido, insomnia and vaginal dryness.

“If it’s not something you’d commonly experience, and it hasn’t gone away in 3-4 months, then it’s worth getting it checked out,” he says.

You can ask your GP to refer you to a clinic that specialises in premature menopause.

Fertility and making use of the remaining eggs

Difficulty getting pregnant is also an indication. If it is ‘sub-fertility’ where the ovary hasn’t completely stopped producing eggs then this is a “crucial time,” Talaulikar says.

“This is when you need to make the best use of those last remaining eggs. If you’ve still got some eggs, generally the best advice is to keep trying naturally, but also start the process of IVF.”

Usually about ten eggs are collected, if possible, which can be fertilised and frozen for future use.

If the ovaries have stopped producing eggs completely then egg donation IVF is a possibility.

This could be from a friend, family member or an egg donation bank.

Interestingly he says that research is showing the mother does have an influence on the genetic make up of the developing feotus from a donor egg, with signals or ‘crosstalk’ sent between the mother and the baby via the placenta.

“It’s showing that it can influence which genes are switched on or switched off in the baby, so you are not a passive carrier,” he says.

Many families worry that they are not going to bond with the baby and that it’s not their DNA, but he says: “I’ve seen many families go through this process and they’re very happy with the outcome.”

It can, however, be a costly process. And with many clinics offering these services it pays to do your homework to see which get good results and will be the right fit for you.

He says seeking help from support groups can help with this process as well as managing what can be an emotional rollercoaster. (links below)

Symptom relief

HRT is the gold standard and if you have early or premature menopause you must take it help prevent issues with your heart, brain or bone health later on, Mr Talaulikar says. But if there are medical reason why you can not take HRT, such as certain types of hormone dependent cancers or tumours or blood clots, there are other alternatives.

Red clover, black cohosh and bio-identical hormones don’t have reliable evidence on their long term safety so he doesn’t not recommend those.

There are some medications such as certain types of  anti-depressants that can help with vasomotor symptoms like hot flushes, but they can have a number of unwanted side effects such as tiredness or a dry mouth – and it is important to note they don’t help your brain, bones or heart health.

Some women have found relief from some symptoms through cognitive behavioural therapy (CBT) and as well as yoga, mindfulness, exercise and acupuncture, he says.

“Realistically, unless you have a serious contraindication you really should be taking HRT until around the age of 50 when you’d normally experience menopause,” he says. “It’s vital for protecting your long term health.”

This involves replacing oestrogen to a normal level for a pre-menopausal woman and, if you have a uterus,  you must have progesterone, he adds.

When do you stop taking HRT?

Once you get to 50 you’ll have to decide whether or not you want to continue taking it because at this stage your risk profile changes and there is a slightly higher risk of developing breast cancer. (See HRT: The Risks Explained)

“It’s here where we’ll have a conversation about minimising these risks but giving the lowest doses or safest types of oestrogen or progesterone. And then they can continue to take it for as long as they feel they need it.”

Testosterone is also an option to add in. It is naturally produced by women and also declines in levels as we ages. It can help restore libido and boost energy levels and is also important for bones and muscle strength.

There are also vaginal pessaries or creams that can help with vaginal dryness with low dose localised HRT, and there is a new drug called Ospemifene which can also help, as well as one called Intrarosa which is based on DHEA – a precursor androgenic steroid. These are considered safe for women who can not take oestrogen.

Support networks who could be helpful for you:

• The Daisy Network – a support group for women with premature ovarian failure
• The Turner Syndrome Support Society – a support group for people with Turner Syndrome
• healthtalk.org – information about early menopause plus women talking about their own experiences
• Fertility friends – a support network for people with fertility problems
• Human Fertilisation and Embryology Authority (HFEA) – provides information fertility treatments
• NHS – info on early menopause

You can read more about Vikram Talaulikar here and make a booking as well.