Introduction:
Menopause is the natural cessation of ovarian function when estrogen production decreases and menstruation ceases. Normally, menopause occurs between 42 and 56 years of age. However, approximately one per cent of women under the age of 40 develops early menopause, also called premature ovarian failure (POF).
The Female Reproductive System:
The monthly menstrual period is the result of an intricate process that prepares a woman’s body for pregnancy. The hypothalamus and pituitary glands, located in the brain, help orchestrate the events leading to ovulation. The hypothalamus stimulates the pituitary to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). These hormones are secreted into the bloodstream and stimulate the growth and maturation of eggs (oocytes) and the ovaries. The ovaries are two small glands, each about one-and-one-half to two inches long and three-fourths to one inch wide, located in a woman’s pelvic cavity. They are attached to the uterus one on each side, near the fimbriae or finger-like openings of the fallopian tubes. About once a month, a mature egg is released by one of the ovaries. The fimbriae of the fallopian tubes sweep over the ovary, pick up the egg, and send it travelling down the tube toward the uterus. If fertilization occurs, which usually happens in the tube, the resulting embryo (fertilized egg) continues travelling to the uterus and can implant in the endometrium (uterine lining).
As menopause approaches, the ovaries become less and less responsive to FSH and LH. To compensate for this lack of ovarian response, the pituitary secretes much higher levels of both FSH and LH into the bloodstream. In early menopause, as in normal menopause, the ovaries produce little estrogen, and the levels of FSH and LH in the bloodstream are consistently high.
Causes Of Early Menopause:
Early menopause may occur due to genetic factors, autoimmune disorders, or destruction of the ovaries by radiation therapy, chemotherapy, surgery, toxins, or unknown factors. Each of these situations results in depletion of eggs and reduction of estrogen and progesterone production by the ovaries. For more information on chemotherapy and radiation therapy’s effect on reproductive function, refer to the ASRM patient information booklet titled Fertility After Cancer Treatment.
Genetic Factors:
Females have two X chromosomes. Males have one X chromosome and one Y chromosome. The X and Y chromosomes are called the sex chromosomes. If a female is missing all or part of an X chromosome, a normal ovarian function may be disrupted. A karyotype is a blood test that examines and detects abnormalities in the chromosomes. In Turner’s Syndrome, the female is born with only one X chromosome. The ovaries are small, do not contain eggs, and do not produce estrogen. Women with Turner’s Syndrome usually need to take estrogen to develop breasts, have menstrual periods, and maintain normal bone strength, preventing osteoporosis. In rare cases, women with Turner’s Syndrome may ovulate and menstruate spontaneously, but eventually, they will all develop early menopause. In addition to Turner’s Syndrome, early menopause may be caused by an extra X chromosome or other sex chromosome abnormalities.
Autoimmune Disorders:
The immune system is the body’s defence against foreign substances such as bacteria and viruses. The body produces antibodies and specialized immune cells which try to destroy harmful foreign substances that enter the body. Occasionally, the immune system mistakenly attacks its own cells. This is called an autoimmune disorder. Some of the autoimmune diseases that may be associated with early menopause include Addison’s disease, Myasthenia Gravis, Rheumatoid arthritis, Systemic Lupus Erythematosus, and certain types of disease of the thyroid and parathyroid glands.
Destruction of the Ovaries:
The ovaries may be damaged or destroyed by radiation therapy, chemotherapy, surgery, or certain reproductive tract infections. The amount of radiation normally associated with diagnostic x-rays that a woman receives during the course of her life will not cause early menopause. Very high amounts of radiation used to stop the growth of cancer cells can destroy the ovaries and result in early menopause. In some types of cancers, it may be possible to shield or move the ovaries during radiation treatments to preserve ovarian function. Many of the chemotherapeutic medications used to destroy cancer cells may also destroy normal cells, such as eggs within the ovaries. For more information about radiation and chemotherap’s affect on the ovaries, refer to the ASRM patient information booklet titled Fertility After Cancer Treatment. Extensive ovarian surgery to remove large cysts or tumors may also damage the ovaries and cause early menopause. Rarely, infections that affect the ovaries, such as tuberculosis, can cause severe damage to eggs and result in early menopause.
Unknown Factors:
In up to half of all women with early menopause, no clear cause is identified. This is called idiopathic early menopause.
Symptoms of Menopause:
Menopause is different for each woman. Some women may only experience a few mild symptoms, while others may have more. Symptoms may include:
i) Changes in period: The time between periods or flows may be different than what are used to.
ii) Hot flushes: The most common symptom of menopause is hot flushes. As many as 75% of menopausal women will experience them. A hot flush is a feeling of heat that spreads over the body (usually face, neck, and chest). It is thought to be caused by a rapid loss of estrogen. Hot flushes can be mild or severe.
iii) Night sweats and sleeping problems: This can affect mood, health and ability to cope with daily activities. Hot flashes are the main cause of lack of sleep, causing “ night sweats”.
iv) Vaginal and urinary tract changes: These changes are a result of estrogen loss. The vaginal lining can become thin and dry. These changes can make sexual intercourse painful and make the vagina more prone to infection. Some women also have a greater risk of bladder infections after menopause.
v) Thinning of bones: This thinning puts women at a much greater risk for developing osteoporosis. Bone loss is a normal part of aging. But with menopause and the decrease of estrogen (which protects bone), the rate of loss increases quickly. Osteoporosis, a condition of thin, frail bones, puts women at risk for hip fractures and broken bones.
vi) Emotional changes: Menopause can be troublesome to some women. But, it does not cause sudden mood swings. It is lack of sleep and hot flushes that can leave women feeling tired, irritable, and nervous. Excess stress may make the symptoms of menopause harder to deal with.
Lifestyle Changes to Stay Healthy:
- Quit smoking.
- Eating a low-fat, low-cholesterol, high-fiber diet.
- Maintaining a healthy weight.
- Avoiding caffeine and foods that trigger hot flushes such as spicy foods.
- Breast exam and mammogram (breast x-ray) regularly.
- calcium and vitamin D supplements for bone health.
- Exercising regularly. Drink alcohol only in moderation.
- Blood pressure, cholesterol, and blood sugar checked regularly.
- Counseling.
Treatment Options After Menopause:
i) Hormone replacement therapy (HRT) to relieve menopausal symptoms
- a.i.1.a.i.1. Estrogens.
- a.i.1.a.i.2. Progesterones/ progestins.
ii) Osteoporosis prevention
- 1,200 to 1,500 mg (milligrams) calcium per day and multi- vitamin containing vitamin D.
- Bisphosphonates.
- Selective Estrogen Receptor Modulators (SERMS)
iii) Cholesterol medicine if cholesterol levels are high
iv) Over the counter remedies to relieve symptoms (i.e., vaginal dryness) such as vaginal lubricants, soy protein, or nutritional supplements.
Diagnosis of Early Menopause (High Fsh & Low Amh):
To confirm the diagnosis of early menopause, the physician will take a detailed medical and family history, perform a complete physical exam, and obtain blood tests, including tests to check FSH levels. In early menopause, FSH is elevated (> 20miu/ml). Because the levels can fluctuate, the FSH level may be observed over several weeks or months before a conclusive diagnosis of early menopause can be made. Extremely low AMH levels are found (<0.1 ng/ml). If the diagnosis of early menopause is confirmed, the physician may order blood tests to rule out autoimmune problems of the thyroid, parathyroid, and adrenal glands. A karyotype is also frequently performed to diagnose a chromosomal problem.
Early Menopause And Fertility:
Women diagnosed with early menopause seldom have spontaneous ovulation. Although some women with early menopause have become pregnant while on estrogen treatment, spontaneous pregnancy is rare. The use of fertility drugs, such as clomiphene citrate or human menopausal gonadotropins (hMG), to stimulate the ovaries is unsuccessful.
Donor Egg IVF:
An assisted reproductive technology known as In Vitro Fertilization (IVF) with donor eggs can allow women diagnosed with early menopause to bear children. Eggs donated by a woman with normal ovarian function are fertilized in the laboratory with sperm. The resulting embryos are then placed into the uterus of the woman with early menopause, who is given hormones to prepare her endometrium (uterine lining) to receive the embryos. This procedure allows women with early menopause to carry a pregnancy. It is important to understand that a child born through a donor egg procedure will not be genetically related to the woman with early menopause. It is important to discuss and carefully consider the issues of raising a child resulting from egg donation. Seeing a counselor or therapist who is familiar with the issues surrounding donor conception can be helpful. Consulting an attorney who is familiar with the ramifications of donor egg is also suggested.
Effects Of Early Menopause:
The effects of early menopausal estrogen deficiency are identical to those seen in normal menopause. Short-term effects may include hot flashes, mood swings, vaginal dryness, and loss of libido. Long-term effects are an increased risk of heart disease and osteoporosis.
The symptoms of menopause can be relieved, and the risks of heart disease and osteoporosis reduced, by the use of hormone replacement therapy(HRT). This can be given as estrogen/progesterone replacement for women with a uterus, or as estrogen alone for women without a uterus. Women who use HRT may resume menstrual periods, but their ovaries will not develop eggs or ovulate. Regular exercise and adequate calcium intake, combined with HRT, will help prevent bone loss.
Emotional Response To Early Menopause:
Early menopause can be emotionally intense. Few women expect that their fertility will end prematurely. Feelings of shock, anger, depression, and loss are common. Young women may feel distressed that they are experiencing a condition that is usually reserved for older women. They may find that other people do not understand their grief.
Summary:
Early menopause may mean experiencing the symptoms of menopause earlier than expected, but medical advances, combined with adequate diet and exercise, can treat these symptoms and help patients maintain good health. With the aid of today’s assisted reproductive technologies, many women with early menopause can experience the joys of pregnancy and childbirth.