In 65% of women with premature ovarian insufficiency no cause can be determined. For these women the psychological grief becomes even greater when looking for potential treatment.
The authors of the research paper offer a medically based explanation of premature menopause (PM), also known as premature ovarian insufficiency (POI). The authors Shah and Nagarajan define POI as lack of menstruation, changes in hormones, and a decrease in sex steroids all occurring prior to the age of 40. The study discusses some known causes, possible risks for disease associated with POI, and includes suggestions for management of the POI regarding fertility and other issues associated with the condition.
How many women are affected by POI?
- 1 in 10,000 by the age of 20
- 1 in 1000 by the age of 30
- 1 in 100 by the age of 40
What are the known causes of POI?
Spontaneous POI is mainly due to depletion of the number of ovarian follicles. The cause can be either due to early degeneration or reduced numbers of follicles formed during development. Some know causes for reduced follicle density include genetic, chromosomal, autoimmune or metabolic conditions.
- Turner’s syndrome (defect in the female sex chromosome) can lead to ovarian failure and is the most common form of genetic abnormality found in PM.
- Other genetic problems are possible causes of PM but are rare.
- 10-15% of spontaneous PM have a first degree relative, indicating a genetic component. Detailed patient history is important.
Autoimmune ovarian damage
- The inflammation contributed by these conditions can affect the ovaries in about 30% of all PM cases.
- Examples include:
- Addison’s disease
- Pernicious anaemia
- Rheumatoid arthritis
- Thyroid disease
- Chemicals in cigarettes can affect ovarian function
- Anecdotal reports exist of PM following illnesses such as:
Otherwise known as ‘induced’ menopause can be due to the surgical removal of ovaries due to cancer. Induced menopause can also be the result of cancer treatments that aims to improve the rate of survival but interrupts ovarian function causing menopause.
Other factors with chemotherapy include:
– Patient’s age at chemotherapy treatment
– Level of exposure
– Type and dosage of drugs used
Other factors with radiation include:
– Location of radiation
– Dosage of radiation
– Patient’s age (prepubescent more resistant to damage leading to PM)
Hysterectomy (womb, tubes and ovaries removed)
Bilateral salpingo-oophorectomy (tubes and ovaries removed)
One or both ovaries removed
Treatment for ectopic pregnancy
Removal of large ovarian cysts
Treatment for polycystic ovarian disease
What are the signs and symptoms of PM?
Often there are no signs or symptoms prior to menstruation stopping. PM can develop gradual changes in periods and slow onset of symptoms, if any. The absence of menstrual cycles or irregular cycles are often caused by estrogen deficiency. Symptoms of estrogen deficiency include:
- Heat intolerance
- Hot flushes
- Night sweats
- Emotional lability
- Urinary symptoms
- Vaginal dryness
- Pain during sex
- Decreased libido
- Sexual dissatisfaction
- Sleep disturbance
- Joint pain
- Mood change
Diagnosis and evaluation
Women will often see several doctors before her concerns are taken seriously. Unfortunately it leads to delayed diagnosis and treatment, including fertility support.
- 50% of patients see at least 3 physicians before diagnosis made
- 25% of patients do not receive a diagnosis until after 5 years
- Hormone levels of FSH and LH should be measured at least twice, 4-6 weeks apart.
- Rule out hypothyroidism and hyperprolactinemia (high levels of the hormone prolactin in the blood)
- Screen for antibodies related to thyroid, parathyroid, adrenal and ovary after diagnosis of PM
- Chromosomal analysis in women with family history of PM
Management of PM
Young women will need individualised treatment and support in the management of their symptoms and the psychological impact. The goal for health professionals is to prevent long-term complications such as cardiovascular disease and osteoporosis, and to treat hormone deficits. A multidisciplinary approach is required to include:
– Psychosexual counsellor
- Lifestyle changes
– Avoid smoking, excessive alcohol and caffeine
– Weight bearing exercises
- Menopausal hormone therapy
– Aim to replace to within the physiological range
– Provide until natural age of menopause around 50
– Dosage and duration should be individualized
– Possibility of spontaneous pregnancy exists and hormone therapy does not prevent ovulation. Use contraception
- Fertility management
– 5-10% of women with PM spontaneously ovulate and conceive
– Ovulation induction combined with timed intercourse or insemination can work
– Use of donor eggs is the treatment of choice; IVF with donor eggs has the highest success rate.
– Preserving fertility before surgical PM
The authors of the staudy recommend attempting ovarian stimulation
The medical and personal situations of women experiencing young menopause, whether it is naturally occurring, due to surgery or as a result of disease, vary considerably from woman to woman. There is increasing recognition that personalised treatment is vital to assist women at their different stages from diagnosis to treatment plans, fertility support and important advice on long term health needs.
Shah D. & Nagarajan N. (2014) Premature Menopause – Meeting the Needs. Post Reproductive Health; 20(2): 62-68