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Considerations for Pre-Mature, Early, & Surgical Menopause

Updated: Nov 21, 2023

Most of my blog posts have talked about menopause that occurs naturally in women over 45. But some women experience menopause earlier in life and shouldn't be left out of the conversation. About 5% of women experience menopause between ages 40-45, and they are said to have "early menopause." Another 1% of women are diagnosed with "primary ovarian insufficiency (POI)" before they are 40 years old. Women of any age can have a surgically-induced menopause. (If they are younger than 45, they are referred to as having "premature menopause" since, unlike those with POI, they can no longer make estrogen in their ovaries.) I'll discuss considerations for women who have or had breast cancer at a later date.

POI is the condition wherein a woman under 40 stops producing enough estrogen for her menstrual cycle to function normally. A women with POI may produce virtually no estrogen or some estrogen; as a result, she may experience infertility or have an unwanted pregnancy. POI can be caused by genetics, an autoimmune disease, exposure to radiation or chemotherapy, or unknown reasons (so-called idiopathic POI). The key signs of POI in women under 40 are missed or irregular periods for more than 3 months, low levels of estrogen, and high levels of follicle-stimulating hormone (FSH). Of course, there are many reasons why a woman might stop having a period - pregnancy, stress, change in diet, excessive exercise, hypothyroidism, etc. - so women under 45 should see a doctor any time they stop having their period for several months in a row. Risk factors for POI include having a relative with POI or Fragile X Syndrome, previous ovarian surgery, a history of radiation or chemotherapy, a history of pelvic inflammatory disease (PID) or sexually transmitted infections (STIs), particularly gonorrhea or chlamydia, or a current endocrine disorder like diabetes. Women with POI who are interested in having children should seek assistance from a specialist in reproductive endocrinology. Women with POI who do not wish to have additional children should use birth control since they may still become pregnant.

Surgical menopause occurs when a woman has a bilateral oophorectomy (i.e., she has both of her ovaries removed), often along with her fallopian tubes (salpingo-oophorectory) and/or uterus (hysterectomy). One study found that more than 2/3 of women who had both ovaries removed surgically in 2013 were under 54. Women who undergo surgical menopause experience a rapid decline in estrogen instead of a slower decline seen in typical menopause. In fact, menopause for these women is defined as 6 weeks post surgery. As a result, their symptoms can be more severe. Removal of both ovaries also causes a decrease in a woman's testosterone level, which may cause a drop in libido. Removal of only one ovary typically does not cause menopausal symptoms or increase health risks because the other ovary can produce enough estrogen. Surgical removal of ovaries is done for a variety of reasons, including some cancers and cancer prevention in women with known genetic risk factors, as well as for treatment of benign diseases like borderline ovarian tumors, symptomatic large ovarian cysts, ovarian torsion (twisting of the ovary), or large abscesses that are unresponsive to antibiotics. Some women may choose to have their ovaries removed for conditions like endometriosis or chronic pelvic pain. In the management of endometriosis, often doctors will try "chemical menopause" before they operate. For example, gonadotropin-releasing hormone (GnRH) agonists like Lupron Depot work to stop production of estrogen to prevent endometriosis from getting worse. Interestingly, GnRH antagonists like Elagolix also are used to treat endometriosis and, albeit by a different mechanism, have the same effect of inducing chemical menopauseas GnRH agonists . (You can find a good review of endometriosis, treatment options, mechanisms of action for GnRH agonist and antagonist drugs, and avenues for future research here.)

Whether a woman experiences premature surgical menopause or POI, early menopause, or typical menopause around the average age of 51-52, she is at risk to suffer from menopause symptoms. All women during menopause or POI can have hot flashes, mood disorders, vaginal atrophy (GSM), sleep distruption, sexual dysfunction, and others. Menopausal women are at higher risk of heart disease, osteoporosis, and dementia than they were during their premenopausal yers. In general, women who experience menopause younger have an even higher risk of heart disease, osteoporosis, and dementia. For women who experience POI or surgical menopause before they are 40, these risks are significant. For example, in women under 40 with POI or surgical menopause, their risk of cardiovascular disease increases by 50%. There is strong evidence that menopause, occurring at 45 years or younger, is associated with a risk of fracture that is 1.5–3-fold higher than the risk for women who experience menopause after age 50. Pre-menopausal women who started estrogen therapy within 5 years of their surgical menopause (bilateral oophorectomy) and continued for 10 years had 13.5% less decline in cognition, episodic memory, semantic memory, and visuospatial ability compared with those who did not use estrogen therapy.

So, what are the treatment options for women under 45 with POI, surgical menopause, or early menopause? Since the risk of serious health conditions like heart disease, osteoporosis, and dementia are so significantly increased with menopause in younger women, the current recommendation is that women under 45 be treated preventatively with menopause hormone therapy (MHT), unless there are other contraindications to using MHT, until they are the average age of typical menopause. Menopausal and women with POI who are younger than 45 should take MHT preventatively even if they don't have any menopause symptoms. At age 50-52, those women, like the women who experience a typical age of menopause, should discuss with their doctor whether any menopause symptoms that they are experiencing justify continued use of MHT.

Women with POI can be prescribed combined oral contraceptives (that is, those containing an estrogen and a progestin) instead of MHT until they reach the age of typical menopause, but oral contraceptives are a higher dose of hormones than MHT and, therefore, may increase the risk of blood clots. use contraception to prevent unwanted pregnancy . As an alternative, women who want contraception that does not include estrogen can be prescribed a progestin-releasing IUD like Mirena. ACOG notes that progestin-only oral contraceptives are not recommended. Barrier methods also can be used for contraception.

The current recommendation for women younger than 45 who had their ovaries removed to manage endometriosis is that they should use MHT. They should use progesterone/progestin in addition to estradiol regardless of whether they have a uterus because endometriosis can exist outside the uterus and be reactived by unoppsed estrogen. (Women without a uterus who don't have endometriosis can use estradiol without a progesterone/progestin.)

Women who are diagnosed with POI or early menopause or who have their ovaries surgically removed should pay close attention to their lifestyle choices and see their doctors regularly. Eating a diet full of fruits, vegetables, and lean proteins and getting daily exercise are more important than ever. A focus on good bone and heart health may reduce some of the risk of the early appearance of low estrogen. These women should have their Vitamin D levels, as well as glucose and lipid levels checked regularly. Bone Density (DXA) scans should be performed every 2 years on women who experience menopause before age 45. In addition, there are many hormonal and non-hormonal treatment options available to women to help ameliorate their menopause symptoms.

Menopause (and POI) in women under 45 pose significant increases in health risks for cardiovascular disease, dementia, and osteoporosis. As a result, it's important that those women use MHT preventatively until they are of average age of menopause (~51 years old.) Additionally, extra attention should be paid to clinical indicators of serious disease so that they can be addressed before the disease progresses. At 51-52 years old, the use of MHT should be reassessed to treat symptoms (not preventatively) and consider whether the risks continue to outweight the benefits.

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