When menopause occurs before the age of 40

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Most young women assume menopause is a distant event occurring way off in the future.  But this is not always the case for some.  A condition called primary ovarian insufficiency or POI (previously called premature ovarian failure or POF), affects approximately 1 out of every 1000 teens and adult women between 15-29 years of age.  Around the world, POI affects 1 to 2 percent of women.  There is some evidence this condition is underdiagnosed. 

POI, sometimes called “early menopause” is when the ovaries are not functioning normally in women under the age of 40.  Technically, POI is not completely synonymous with menopause as the ovaries have not totally shut down and a woman may still have a period occasionally.  What is happening is that the hormones naturally made by the ovaries (estrogen, progesterone, and testosterone) are no longer being produce in normal amounts.  This leads to the ovaries not releasing eggs or only releasing them just once in a while. 

Symptoms of women with POI

Besides the most common symptoms of infrequent or missed periods, POI can cause symptoms typically associated with menopause including the following:

·      Hot flashes

·      Vaginal dryness and lack of normal vaginal discharge

·      Pain during sexual intercourse due to thinning of the vaginal walls

·      Mood swings

·      Trouble sleeping

·      Night sweats

Causes of POI

 Generally, there is no specific cause of POI in a woman.  For some young women there may be a genetic abnormality such as from Turner Syndrome and Fragile X mutation, family history of premature menopause, exposure to certain medicines or radiation for cancer treatment, or an autoimmune disease.

How is POI diagnosed? 

A diagnosis of POI is usually based on missed or infrequent periods for at least four months and abnormal levels of a hormone called FSH (follicular stimulating hormone) on two separate tests at least a month apart.  High levels of FSH usually mean a woman has POI. 

Other hormones that may be checked include an “AMH” (Anti-Mullerian Hormone) level and genetic tests checking for a medical reason for POI.  AMH is made by the follicles within the ovaries and high levels of AMH usually mean there are healthy eggs in the ovaries. 

Risks of POI

When a woman enters menopause before the age of 40, there are two major long-term health risks associated with this – osteoporosis and heart disease.  Studies have found that women who developed POI for no apparent reason tend to have lower bone mineral density compared to women who were still menstruating before the age of 40.  These same women also tend to have higher rates of bone loss and a greater risk of bone fractures. 

The other long-term health risk of POI is possibly a higher incidence of cardiovascular disease.  Not only do these women face a higher risk of heart disease but also a possibly higher risk of stroke.  This is assumed to be due to the decline in estrogen which is heart-protective.  Women who have POI are also at a greater risk of developing type 2 diabetes than women with late-onset menopause.

Can a woman with POI get pregnant?

Studies have found that up to 5-10% of women with POI will eventually get pregnant either with help or on their own.  These are women who may spontaneously ovulate on occasion in which pregnancy can occur but it is quite rare.  Generally these pregnancies are more likely to happen if a woman is on estrogen replacement therapy.

Another consideration a woman can try is egg donation with in vitro fertilization (IVF). This can be a very effective therapy for women with POI that wish to become pregnant. 

How is POI treated? 

The treatment for POI is to replace the hormones the body is not making.  This type of treatment is called hormone replacement therapy or HRT.  The guidelines from the European Society of Human Reproduction and Embryology recommend that women with POI begin estrogen therapy along with progestin, a form of progesterone, not only to deal with menopausal symptoms such as night sweats but also to offset the potential health risks.

Women with POI usually continue HRT until around the age of 50 at which time it is gradually tapered off. 

Is POI permanent?

POI is an unpredictable condition.  But usually it is permanent especially if the ovaries have not worked for a long time or the reason is due to Turner syndrome or Fragile X mutation, or past radiation therapy.  However, up to 5-10% of women with POI will ovulate every once in a while making pregnancy a possibility.

In conclusion

Any woman, who is younger than the age of 40 and is having irregular or missed menstrual cycles, should see her gynecologist.  They should do a thorough health history including family history, a physical exam, and take blood tests to determine the cause.  If a woman is found to have POI she should discuss with her doctor about whether to start HRT and what steps she can take to reduce the risk of bone loss and cardiovascular disease