What is Early Menopause?

Menopause is a natural biological stage in a woman’s life. The term menopause is commonly used to describe any of the changes a woman experiences either before or after she stops menstruating and the cessation of her ovarian function. It simply means not having a period for 12 months and results in infertility, or the inability to conceive children. In the UK, the average age of natural menopause is 51 years, although this can vary between different ethnic groups.

Early menopause is when a woman experiences these biological changes earlier; she stops menstruating and her ovarian function ceases between the ages of 40 and 45 years. Around 5% of women in the UK will go through an early menopause, that is approximately 1 in every 100 women.

Experiencing menopause before the age of 40 years is called premature menopause, and a small number of women can go through this in their 30s or even as early as in their 20s.

As women commonly experience declining fertility during the 10 years leading up to natural menopause, for women with early or premature menopause, this may have substantial consequences for family planning, particularly as there is an increasing tendency to want to delay childbearing into the later reproductive years.

What is early menopause?

Menopause marks the end of a woman’s reproductive cycle, when the ovaries no longer produce eggs and she has her last menstrual cycle. The diagnosis of menopause is not confirmed until a woman has not had her period for six to twelve consecutive months.

When a woman experiences this under the age of 45, it is classified as an early or premature menopause, and is also known as primary ovarian insufficiency (POI) or premature ovarian failure.

The topic of early and premature menopause has started to be discussed more openly recently, with celebrities prepared to share their experiences:

The Hollywood star Angelina Jolie opted to have her ovaries and breasts removed to reduce her risk of getting the cancer that ran in her family. One side effect of this for the then 39-year-old was going into early menopause.

She described this for the New York Times in 2015, “I am now in menopause. I will not be able to have any more children, and I expect some physical changes. But I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared.”

Radio personality Lisa Snowden was also diagnosed with early menopause. She said, “In 2017, aged 44, I began to really pile on weight, around 3st over the next year or so, and I was having brain fog, anxiety, and real fits of rage. In 2018, I went to the doctor for blood tests, which was when I got the bombshell that I was perimenopausal. It all finally made sense, but it was hard to process.” The diagnosis came as a blow for Lisa, but it meant that she could finally get the help that she needed. She posts about menopause and her experiences on Instagram to help others.

Singer Michelle Heaton has opened up about her insomnia and bouts of rage as she battled early menopause aged 39. Speaking out to promote World Menopause Day, which is held every year on the 18th October, led by the International Menopause Society, she said: “We are too scared to talk about the menopause because it’s a non-sexy chat but every woman’s going to go through it, whether as early as me or late like my mum. Everyone has a different journey.”

What causes early menopause?

If you have had a hysterectomy, an operation to remove your womb, you might have had your ovaries removed at the same time. If this happens, you will immediately experience menopause. This is known as surgical menopause, and can happen to women of any age, often at a pre-menopausal age.

Early menopause can also occur for any number of other reasons, including:

• Surgery to remove ovaries because of cancer, endometriosis, or another condition.
• Certain breast cancer treatments.
• Chemotherapy.
• Radiotherapy.
• An underlying medical condition, such as in women with Addison’s disease or Down’s syndrome.
• Chromosome abnormalities, such as in women with Turner syndrome.
• An autoimmune disease, where the immune system starts attacking body tissues, such as hypothyroidism, Hashimoto’s thyroiditis, Graves’ disease, rheumatoid arthritis, Crohn’s disease, myasthenia gravis, multiple sclerosis (MS), and type 1 diabetes.
• Certain infections, such as tuberculosis (TB), malaria and mumps – this is very rare though.
• Early or premature menopause can run in families.
• Lifestyle factors such as smoking cigarettes and e-cigarettes have been observed to be related to the timings of menopause.

What are the symptoms of early menopause?

The symptoms of early or premature menopause are the same as for menopause at the typical age. Women may experience all, some or none of these symptoms at a variety of levels ranging from mild to severe as they go through the menopause.

Every woman’s experience will differ; however, many women will experience symptoms, and these can include but are not limited to:

• Menstrual cycle changes, including changes to the usual bleeding pattern such as missing periods, and particularly irregular bleeding.
• Hot flushes – The sudden feeling of warmth in the upper body, which is usually most intense over the face, neck and chest. Your skin might redden as if you are blushing. A hot flush can also cause sweating. If you lose too much body heat, you might feel chilled afterwards. You may also experience a rapid heartbeat during a hot flush.
• Sweats – Night sweats are hot flushes that happen at night, and they may disturb your sleep or may wake you from sleep.
• Sleep disturbance – Sleep issues are common in menopause, with sleep disorders affecting 39% to 47% of perimenopausal women and 35% to 60% of postmenopausal women.
• Urinary problems, such as increased frequency of urination, or incontinence, or pain when urinating.
• Vaginal dryness – With this condition, vaginal tissues become thinner and more easily irritated, resulting from the natural decline in your body’s oestrogen levels during menopause. Oestrogen is one of the main female sex hormones. While both women and men produce oestrogen, it plays a bigger role in women’s bodies.
• Mental fogginess – Brain fog is a very common symptom of the perimenopause and menopause, and many women say that their brains feel like “cotton wool”. You may become increasingly forgetful, can’t remember names, lose things, and find it hard to retain or recall information.
• Increase in mood changes – Irritability and feelings of sadness are the most common emotional symptoms of menopause. You may experience feelings of anxiety, stress or even depression. Menopausal symptoms may also include anger and mood swings.
• Increase or decrease in weight – The hormonal changes of menopause might make you more likely to gain weight around your abdomen than around your hips and thighs; muscle mass typically diminishes with age, while fat increases.
• Aches and pains – Oestrogen affects your cartilage which is the connective tissue in joints, as well as the replacement of bone, and so depletion plays a part in inflammation and pain. Stress can also cause muscle tension and pain.

About 75%–80% of women will have menopausal symptoms, and 25% of these women find the symptoms are severe, affecting their quality of life. Severe or persistent symptoms warrant consideration for HRT. Symptoms could be classified as acute, medium and long-lasting.

Diagnosing early menopause

If you are concerned that you may be experiencing early or premature menopause, in most cases, your first point of contact will be your GP or the practice nurse at your local surgery, although it is always worth asking if there is a healthcare professional who specialises in the menopause, and some areas have specialist menopause clinics.

Before your appointment, take a look at the symptoms list to record the menopausal symptoms that you are experiencing. Make a note of any changes to your periods and a list of any medications that you are taking, including over-the-counter medication (OTC) and any herbal supplements.

When you make your GP appointment, explain that you will need to have enough time to discuss your symptoms and concerns, so it might be advisable to book a double appointment if possible.

According to the 2015 NICE menopause guidelines, your doctor should discuss the following:

• The stages of menopause.
• Common symptoms of the menopause.
• How the menopause is diagnosed.
• Lifestyle changes that can help your health and wellbeing.
• Benefits and risks of treatment.
• How the menopause can affect your future health.

Early or premature menopause is diagnosed using your age and symptoms, as well as information about your family history and medical history, for example, whether you have had medical treatment that is known to trigger menopause.

Sometimes your GP may want to carry out blood tests to rule out other underlying issues, such as pregnancy, or an underactive thyroid. They will also check your blood pressure, and possibly conduct a physical examination, including a pelvic examination.

If you are under 40 and having none or very few periods, you should be offered blood tests to measure your levels of follicle-stimulating hormone (FSH). You should be offered two blood tests for FSH, which should be done 4–6 weeks apart; this is because your FSH levels change at different times during your menstrual cycle.

If your GP diagnoses early or premature menopause, they will probably refer you to a healthcare professional who specialises in menopause or reproductive medicine to confirm your diagnosis.

What are the health risks associated with early menopause?

When a woman experiences an early or premature menopause it poses some health risks.

Potential health issues that can arise include:

• Heart disease – Oestrogen helps a pre-menopausal woman’s body protect her against heart disease. Lower oestrogen levels can cause changes in the blood vessels and the heart, possibly leading to a higher risk of heart problems.
• Osteoporosis – Lower oestrogen levels can sometimes weaken bones and make them more susceptible to fractures. Women are more at risk of osteoporosis than men, particularly if the menopause begins early, before the age of 45, or if they have had their ovaries removed.
• Anxiety, depression and other mood changes – Hormone changes can also cause some significant emotional shifts; anxiety, depression and lower self-esteem are not uncommon.
• Eye conditions – Hormone changes can also cause changes in the oil and fluid producing glands in the eyelids, the eyelids can become inflamed, reducing tear production and tear quality, consequently leading to dry eyes. Around 79% of menopausal women develop dry eyes and other conditions that can affect the surface of the eye.
• Infertility – It is harder for people in early or premature menopause to become pregnant naturally. Working with a fertility specialist may help.
• Hypothyroidism – This is also known as an underactive thyroid. For some people, hormones produced by the thyroid gland drop after menopause, which can cause changes in metabolism and energy levels.
• Multiple sclerosis – Women who experience early menopause may be more likely to face an early onset of progressive multiple sclerosis (MS).

What are the treatments for early menopause?

There is no treatment available to make the ovaries start working again and to reverse an early menopause.

There are several different treatment options available to help you manage early menopause symptoms and the different treatments have different goals, such as:

• Reducing your menopause symptoms.
• Protecting your heart, bone and sexual health.
• Providing emotional support.
• Connecting you with fertility specialists if you want to become pregnant.

Women who experience early menopause have a long period of postmenopausal life, which means they are at increased risk of health problems such as those described above. For this reason, it is recommended that they take some form of hormone therapy until they reach the typical age of natural menopause, around 51 years old. This may be the combined oestrogen and progestogen oral contraceptive pill, or hormone replacement therapy (HRT).

The combined oral contraceptive pill (COCP) contains artificial versions of female hormones – oestrogen and progesterone – which are produced naturally in the ovaries. The COCP is easy to take; many women will have used it in the past as a contraceptive, so will be familiar with taking it. Generally, COCP can bring relief for many perimenopausal women experiencing hot flushes or irregular periods, or both.

The COCP is not an appropriate choice for every woman, and the following categories are not good candidates to be prescribed COCP:

• Women over age 35 who smoke, because smokers are at higher risk of a heart attack or stroke if they are aged over 35 and take COCP.
• Women with high blood pressure.
• Women who have had a blood clot in their leg, lung or pelvis.
• Women who have had breast cancer.
• Women who have liver disease.
• Women who did not tolerate COCP during their early reproductive years, may not tolerate it well in menopause.

Whilst there are benefits to taking COCP such as improvements to mood swings as well as providing some relief for the hot flushes, there can also be the typical side effects of oral contraceptives, such as irregular bleeding, especially in the first few months, nausea, puffiness, and weight gain, although many low-dose COCP are weight neutral. Occasionally, some women report depression as a side effect of COCP.

Hormone replacement therapy (HRT) is prescribed to make up for your hormones that are depleted through early or premature menopause. The dose, course and duration of HRT need to be individualised and there is no maximum duration.

For women who experience early or premature menopause, HRT is strongly recommended until the average age of menopause, around 51 years, unless there is a particular reason for a woman not to take it, and women experiencing early or premature menopause often need higher doses of HRT for symptom control.

Some women experience side effects during the early stages of HRT treatment, and depending on the type and dose of HRT, these may include:

• Bloating.
• Nausea.
• Breakthrough bleeding.
• Breast tenderness.

These side effects will usually settle within the first few months of treatment. HRT is not a form of contraception and it does not contain high enough levels of hormones to suppress ovulation, so pregnancy is still possible in women in the perimenopausal period. For women younger than 50, contraception is still recommended for at least two years after the final period.

HRT reduces the likelihood of some chronic, debilitating conditions that can affect postmenopausal women such as:

• Osteoporosis – HRT prevents further bone density loss, preserving bone integrity and reducing the risk of fractures, but it is not usually recommended as the first choice of treatment for osteoporosis, except in younger postmenopausal women, under the age of 60.
• Diabetes – Taking HRT around the time of menopause reduces a woman’s risk of developing diabetes.
• Colorectal (bowel) cancer – HRT slightly reduces the risk of colorectal cancer.
• Heart disease – HRT has been shown to reduce cardiovascular disease markers when used around the time of menopause.

Whilst HRT may reduce the likelihood of some conditions, it can conversely increase the risk of others, such as:

• Breast cancer – Women who use combined HRT for more than five years have a slightly increased risk. Women on oestrogen alone HRT have no increased risk up to 15 years of usage.
• Cardiovascular disease – Women over 60 have a small increased risk of developing heart disease or stroke on combined oral tablet form HRT. Although the increase in risk is small, it needs to be considered when starting HRT, as the risk occurs early in treatment and persists with time. Oestrogen used on its own increases the risk of stroke further if taken in tablet form, but not if using a skin patch.
• Venous thrombosis – Venous thromboses are blood clots that form inside veins. Women under 50 years of age, and women aged 50 to 60, face an increased risk of venous thrombosis if they take oral tablet form HRT. The increase in risk seems to be highest in the first year or two of HRT and in women who already have a high risk of blood clots.
• Endometrial cancer – The endometrium is the lining of the uterus. Use of the oestrogen-only HRT increases the risk of endometrial cancer, but this risk is not seen with combined continuous oestrogen and progestogen HRT.
• Ovarian cancer – The increased risk of ovarian cancer is very small and estimated to be one extra case per 10,000 HRT users per year.

HRT is not an appropriate choice for every woman, and the following categories need special consideration before being prescribed HRT.

These include women with:

• Liver disease.
• Migraine headaches.
• Epilepsy.
• Diabetes.
• Gall bladder disease.
• Fibroids.
• Endometriosis.
• Hypertension (high blood pressure).

Other treatments for menopausal symptoms

There are a number of natural treatments that can help with menopausal symptoms, and these include:

• Eating foods rich in calcium and vitamin D which are linked to good bone health.
• Achieving and maintaining a healthy weight may help alleviate menopause symptoms and help prevent disease.
• Certain foods may trigger hot flushes, night sweats and mood changes – these include, caffeine, alcohol and foods that are sugary or spicy.
• Regular exercise can help alleviate menopause symptoms such as poor sleep, anxiety, low mood and fatigue.
• Phytoestrogens are naturally occurring plant compounds that can mimic the effects of oestrogen in the body – foods such as soybeans and soy products, tofu, sesame seeds and beans are rich in phytoestrogens.
• During menopause, thirst is often an issue, which is likely caused by the decrease in oestrogen levels. Drinking 8 to 12 glasses of water a day can help with these symptoms.
• CBT is a type of talking therapy and is particularly useful as a treatment option for women who are experiencing mood swings, anxiety or depression as a result of the menopause.

Support groups

One woman in four with menopause symptoms is concerned about their ability to cope with life, and research from the independent Nuffield Health group discovered the following sobering facts.

• 1 in 4 women will experience severe debilitating symptoms.
• Almost half of menopausal women say they feel depressed.
• A third of women say they suffer from anxiety.
• Women commonly complain of feeling as though they are going mad.
• Approximately two thirds of women say there is a general lack of support and understanding.

Going through the menopause early can be difficult and upsetting, particularly as early menopause will affect your ability to have children naturally.

Counselling, advice and support groups may be helpful:

• Healthtalk.org – Provides information about early menopause, including women talking about their own experiences.
• The Daisy Network – A support group for women with premature ovarian failure.
• The Menopause Café – A charity offering events, support and information.
• Women’s Health Concern – Provides a confidential, independent service to advise, inform and reassure women about their gynaecological, sexual and post-reproductive health.
• Human Fertilisation and Embryology Authority (HFEA) – Provides information on all types of fertility treatment.
• Fertility friends – A support network for people with fertility problems.
• Fertility Network UK – Has online forums where you can find other people who have dealt with similar issues.
• Queermenopause for people who identify as LGBT+.

Currently there are only 29 NHS menopause clinics in the UK, and you can find your nearest NHS or private menopause specialist on the British Menopause Society website.

Final thoughts

Menopause is not an illness, it is a natural part of a woman’s life, although for some it may happen earlier than expected and that may be difficult to adjust to.

So, it is important to give yourself the time and space you need to work through these changes, and if the symptoms are particularly difficult to deal with, it is a good idea to seek medical advice to discuss the types of treatment options available to support you.