Premature menopause and its management           

Premature menopause is a condition in which a woman stops menstruating before the age of 40. Sometimes this can occur as early as 30 years of age, leading to various problems, related to health and reproduction in the affected women

Premature Menopause and its Management
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The ovaries have two functions, first is to produce eggs for fertility and the second to produce reproductive hormones. The ovaries make three types of steroid hormones – testosterone, estrogen, and progesterone. The ovaries are most active during the age between 20 and 30.

Global statistics suggest approximately 1-4 per cent of women stop ovulating and menstruating before the age of 40, and these women, who reach menopause before 40, are considered to have premature menopause.

The causes of premature menopause may vary from person to person, the common causes being:

  • Ovarian Surgery, anti-cancer drugs or radiation therapy for cancer
  • Genetic disorders like Turners syndrome, Swyers syndrome
  • Infections like mumps, tuberculosis etc.
  • Environmental toxins like tobacco etc.
  • In 5-30 per cent of cases, there may be a family history
  • In many cases, the cause remains unknown

Women, who attain premature menopause at a relatively young age, face various problems.

They stop menstruating and ovulating at a young age, hence natural conception is hampered leading to infertility.

Due to lack of reproductive hormones, there are many long-term health issues.

Psychologically, a woman gets disturbed as she is no longer menstruating as her contemporaries are, and it makes her feel older. In addition to this, she has various symptoms related to estrogen deficiency.

Infertility: Due to the absence of good quality eggs, premature menopause may result in infertility. A small percentage of women may spontaneously become pregnant, but there are no medical investigations to predict which of these women would conceive.

Premature menopause and its management
Dr Duru Shah

Health-related issues

Women with premature menopause are at increased risk of osteoporotic bone fractures, atherosclerotic heart disease, cancer of the colon, Alzheimer’s and Parkinson’s disease. All these conditions are related to a low estrogen state. The risk is similar to that seen after natural menopause.

Symptoms

Due to the hormonal changes following premature menopause, a woman may get hot flushes, have mood swings, get irritated, develop insomnia or may also go into severe depression.

Diagnosis

Clinical presentations:

The first symptom is the absence of periods.

Because of the low estrogen levels, a woman may have mood swings like irritation, emotional liability, depression, etc. She may have hot flashes, decreased sex drive, fatigue, night sweats, vaginal dryness or palpitations. I have seen such women being treated by various specialists, such as psychiatrists, cardiologists, neurologists, etc. when all they need is a little estrogen therapy.

Investigations

Measurement of hormones is the key to the diagnosis.

Rise in serum follicle stimulating hormone (FSH) levels. A value >40u/l is suggestive of menopause.

Low levels of estrogen (<20pg/ml)

Low Serum Anti-Mullerian Hormone (AMH) levels suggestive of the poor ovarian reserve.

Serum prolactin and thyroid levels need to be done to rule out the common causes of amenorrhoea

Chromosomal analysis to rule out a genetic disorder.

The hormone profile needs to be repeated on three occasions at least one month apart, because, in certain instances, the ovaries may return to normal after a phase of low activity.

Ultrasound: In ultrasound, the ovaries look smaller than normal as the ovarian volume is less than three ml. Hardly any follicles are visible in the ovaries, and the endometrium is thinner than five mm in thickness.

Management

Management depends on how the patient presents herself to her doctor. If she has a problem of infertility, then she is investigated further and counselled accordingly. If a woman has the menopausal symptoms, then they can be attended with appropriate therapy. If she does not have any problems, then she is advised for further management that she does not have to lead a poor quality of life in future, due to the aging process starting prematurely.

Management of symptoms of menopause and prevention of long-term health risks:

Women experiencing above symptoms can be managed with supplements and hormone replacement. A wide range of HRT preparations is available for estrogen replacement, including oral, transdermal, subcutaneous, and vaginal routes of administration. The choice of estrogen is made on an individual basis. These women will need hormone replacement, at least till they reach the age of natural menopause (in order to avoid premature aging).

Hormone replacement therapy is necessary for these young women, contrary to women who reached natural menopause. The benefits and risks of HRT are discussed in another chapter in this same issue. One must remember that in case of premature menopause, benefits of hormone therapy outweigh the risks.

Intake of calcium and vitamin D, avoidance of smoking and alcohol abuse also help prevent osteoporosis. Affected women are counselled to carry out weight-bearing exercises, and to consume a balanced diet.

Once a woman is found to be menopausal, whatever may be the cause, or at whatever age, we advise her to undergo all necessary investigation done in a postmenopausal woman.

The author is the Director of Gynaecworld Center for Assisted Reproduction and Women’s health and Panel Consultant – Breach Candy Hospital and Jaslok Hospital