Early menopause

Early menopause is menopause that happens between the age of 40 and 45 ¹, ², ³, ⁴, ⁵. Premature menopause is menopause before the age of 40 years ⁶, ⁵. In the Western world, the average age of menopause is between 46 and 55 years (the average age for menopause in the United States is 51) ⁷. About 10% of women naturally go through early menopause ⁸, ⁹, ⁶. Smoking, alcohol (alcohol 5-7 days/week), lack of physical activity, low body mass index (BMI < 18.5 kg/m²), obesity (BMI ≥ 35 kg/m²), a short period of oral contraceptives use (less than 1 year), lower number of pregnancies (less than 2 pregnancies), high intake of polyunsaturated fat and certain medicines or treatments can cause menopause to come earlier than usual ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵.

Early menopause can happen on its own for no clear reason or it can happen because of certain surgeries, medicines, or health conditions. Early menopause can be spontaneous such as primary ovarian insufficiency (premature ovarian failure) or induced due to cancer treatments including chemotherapy and radiation or surgical procedures such as surgery to remove the uterus (hysterectomy) or surgical removal of both ovaries (bilateral oophorectomy) ⁶, ²⁶, ²⁷, ²⁸. Primary ovarian insufficiency occurs from a premature loss of ovarian follicles, resulting in lower levels of female reproductive hormones. Regardless of cause, women who go through early menopause at an age well before the age of natural menopause may face emotional challenges and struggles with infertility. In general, the onset of menopause brings about an increase in certain risk factors such as osteoporosis, psychosexual dysfunction, heart and blood vessel disease (cardiovascular disease), cognitive impairment, dementia, decreased quality of life and increased all-cause mortality ²⁹, ³⁰, ³¹, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ³⁹, ⁶.

According to the World Health Organization (WHO), natural menopause is defined as “permanent cessation of menstruation resulting from the loss of ovarian follicular activity”, which is normally recognized as 12 months in a row without a period (amenorrhea) ⁴⁰. Hormonally, early menopause resembles natural menopause. Your ovaries produce very little or no estrogen. Ovulation completely or almost completely stops. And depending on the underlying cause of your early menopause, sometimes your ovaries may start functioning again for a short time and can release an egg, making pregnancy possible. The ovaries still contain thousands of eggs. Early menopause does not imply that a woman is aging prematurely. Early menopause means only that your ovaries are no longer functioning normally.

Early menopause has many causes ⁴¹:

• Primary ovarian insufficiency also called premature ovarian failure is a condition in which younger women skip many periods in a row or have no periods at all. In most cases, the exact cause of primary ovarian insufficiency is unknown ⁴², ⁴³, ⁴⁴.
• Genetic abnormalities: Chromosomes, including the sex chromosomes, may be abnormal. Sex chromosome abnormalities include Turner syndrome, disorders that result in having a Y chromosome (which normally occurs only in males), and Fragile X syndrome.
• Autoimmune disorder: Autoimmune disorder such as thyroiditis, vitiligo, myasthenia gravis, Addison disease (adrenal insufficiency) and rheumatoid arthritis. Although rare, the body’s immune system, which normally fights off diseases, may mistakenly attack the ovaries and keep them from making hormones.
• Metabolic disorders such as enzyme deficiencies
• Chemotherapy or radiation therapy for cancer
• Surgical removal of both ovaries (bilateral oophorectomy): Surgery to remove both ovaries (bilateral oophorectomy) ends menstrual periods and causes menopause.
• Surgical removal of the uterus (hysterectomy): Surgery to remove the uterus (hysterectomy) ends menstrual periods but does not cause most of the other symptoms of menopause as long as the ovaries are functioning.
• Women with mumps, chickenpox, malaria, shigella, and tuberculosis (TB) can destroy healthy ovarian tissue and substantially decrease the amount of functioning tissue that remains ⁴³, ⁴⁵, ⁴⁶, ⁴⁴.
• Toxins. Cigarette smoke, chemicals, nicotine, phthalates, polychlorinated biphenyls (PCBs), per- and polyfluoroalkyl substance (PFAS), bisphenol-A (BPA), dimethylbenzanthracene and pesticides can speed up ovarian follicle depletion.
• Viruse infections have been shown to affect follicle function ⁴⁶, ⁴³.
• HIV and AIDS. Women with HIV whose infection is not well controlled with medicine may experience early menopause ⁴⁷. Women with HIV may also have more severe hot flashes than women without HIV ⁴⁸.

Sometimes there’s no cause of early menopause. This is the case in up to 50% of women.

In early menopause, earlier loss of bone may lead to an earlier risk of bone fractures related to osteoporosis. Early menopause also may increase your risk of heart disease later in life. Because menopause appears to influence cognitive function (mental processes involved in the acquisition of knowledge, manipulation of information, and reasoning), this is an important consideration for women who experience menopause at a younger age. Estrogen has been shown to have protective effects on the brain. In addition, many of the same lifestyle habits used for heart health have been shown to be beneficial to memory and help protect the brain against dementia.

Just as important as the physical aspects of early menopause are the emotional ones. Early menopause can cause distress to a woman’s sense of self. For women who still want to have children, the effects may be particularly damaging. Early menopause may increase concerns about body image, sexuality, fertility, and the perception of growing old prematurely. For women with primary ovarian insufficiency (premature ovarian failure), a diagnosis may be delayed, which can be frustrating. Women going through early menopause also may need to cope with or continue treatment for the underlying condition that caused menopause to occur.

For women with induced menopause, especially when it results from treatment for a serious illness, a number of other fears and concerns may compound the challenges of early menopause:

• Pain and discomfort related to the disease or treatment
• Anxiety over additional treatments
• A sense of loss of control related to illness, treatments, hospitalizations, and adverse events
• Confusion over lack of information or a feeling of information overload
• Frustration over a lack of support
• Reduced self-esteem because of changes from surgery
• Embarrassment related to hair or skin changes caused by chemotherapy or radiation
• Feelings of resentment or guilt
• Apprehension about relationships, including sexual activity and intimacy
• A feeling of uncertainty or hopelessness
• Fear of not being cured or of death
• Fear of the disease coming back (recurrence)

If you believe you are going through early menopause and have concerns, see your doctor. Your doctor may order a blood test to check your hormone levels. Your doctor will check for estrogen as well as a follicle-stimulating hormone (FSH), luteinizing hormone (LH) and thyroid-stimulating hormone (TSH).

Symptoms of early menopause such as hot flashes, mood irritability, night sweats, sleep disturbance, vaginal dryness/irritation, and dyspareunia can be a nuisance for women. However, they are not life-threatening and can be improved by hormone replacement therapy (HRT) or birth control pills or a patch that contains both estrogen and progestin (combination oral contraceptives) ⁴⁹. Hormone replacement therapy (HRT) comes in two main types: estrogen-only and estrogen plus progestin. Estrogen therapy helps relieve symptoms and helps prevent other effects of menopause (such as vaginal dryness, and mood swings). It also helps maintain bone density (to prevent osteoporosis). Because taking estrogen alone increases the risk of cancer of the uterine lining (endometrial cancer), most women should also take a progestin or progesterone with the estrogen to help protect against this cancer. Women who have had a hysterectomy (removal of the uterus) do not need to take a progestin or progesterone. These treatments are typically taken until about age 51 (the average age for menopause). Then, doctors decide whether to continue the treatments based on a woman’s individual circumstances.

If you are interested in taking hormone replacement therapy (HRT), your doctor should discuss the benefits and risks with you before you start the treatment. This discussion should cover both the short-term (over the next 5 years) and the longer term (beyond the next 5 years) benefits and risks for you. You should also be informed about available alternatives to hormone replacement therapy (HRT) along with their benefits and risks.

Hormone replacement therapy (HRT) is delivered either systemically (meaning it is released into the bloodstream) or locally (only to the affected area). If used systemically, it can be delivered via pills, skin patches, gels, injections, and sprays; if used locally (for example, for women experiencing only vaginal dryness), it may be applied directly to the affected area by vaginal ring, cream, or tablet.

The delivery methods may have estrogen and progestin together, or progestin may be taken separately. Depending on the type of hormone replacement therapy (HRT), it may be taken daily or on certain days of the month. Systemic hormone therapy is usually not recommended for women who have had endometrial cancer, stroke, a heart attack, blood clots, or liver disease or for those who are pregnant.

A common post-pubertal hormone replacement therapy (HRT) regimen is 100 mcg of daily transdermal estradiol or 0.625 mg of daily oral conjugated estrogens, adding 200 mg of micronized oral progesterone daily for 12 days each month ⁵⁰, ⁵¹, ⁵². Transdermal estrogen may be associated with lower blood clot (venous thromboembolism) risk than oral formulations ⁵³. It is also reasonable to recommend 1,200 mg of calcium daily and 1,000 IU of vitamin D daily with regular weight-bearing exercises to maintain bone mineral density in accordance with guidelines for postmenopausal women ⁵⁴, ⁴³.

What is perimenopause?

Perimenopause also called the “menopausal transition” or “around menopause” is the time leading up to your last period or the transitional time to menopause ⁵⁵. Perimenopause is the gradual transition between your reproductive years and menopause (the cessation of menstrual periods). Menopause is when your periods stop permanently and you can no longer get pregnant. You have reached menopause only after it has been a full 12 months in a row since you have your last period. This means you have not had any bleeding, including spotting, for 12 months in a row. Perimenopause is a natural process when your ovaries gradually stop working. As your body transitions to menopause, your hormone levels may change randomly, causing menopause symptoms unexpectedly. During perimenopause, your ovaries make different amounts of the hormones estrogen and progesterone than usual. Your ovulation may become erratic and then stop. A common sign of perimenopause is a change in your menstrual cycle. Your menstrual cycle lengthens and flow may become irregular before your final period. Irregular periods happen during this time because you may not ovulate every month. Your periods may be longer or shorter than usual. You might skip periods a few months or have unusually long or short menstrual cycles. Your period may be heavier or lighter than before. Many women also have hot flashes and other menopause symptoms during perimenopause.

Perimenopause is generally a transition that is many years long and can be associated with shorter menstrual intervals, irregular periods, night sweats, and other symptoms. In some women, these symptoms are troublesome enough to need medical intervention.

Women start perimenopause at different ages. You may notice signs of progression toward menopause, such as menstrual irregularity, sometime in your 40s ⁵⁶. But some women notice changes as early as their mid-30s ⁵⁷.

• However, the perimenopause transition phase most often begins between ages 45 and 55 and may last for 4 to 8 years (usually lasts about 7 years), but can last as long as 14 years.
• Perimenopause begins with changes in the length of time between periods and ends 1 year after the final menstrual period. Once you’ve gone through 12 consecutive months without a menstrual period, you’ve officially reached menopause, and the perimenopause period is over.
  

The level of estrogen — the main female hormone — in your body rises and falls unevenly during perimenopause. Your menstrual cycles may lengthen or shorten, and you may begin having menstrual cycles in which your ovaries don’t release an egg (ovulate). You may also experience menopause-like symptoms, such as hot flashes, sleep problems and vaginal dryness.

No two women will experience perimenopause in the same way. Some women do not have any symptoms of perimenopause or have only a few mild symptoms. Others have many symptoms that can be severe.

These are the most common perimenopause symptoms ⁵⁸:

• Hot flashes. A hot flash is a sudden feeling of heat that rushes to your upper body and face. A hot flash may last from a few seconds to several minutes or longer. Some women have hot flashes a few times a month. Others have them several times a day. Hot flashes that happen at night (night sweats) may wake you up and cause you to feel tired and sluggish during the day.
• Sleep problems. You may have insomnia (trouble falling asleep), or you may wake up long before your usual time. Night sweats may disrupt your sleep.
• Vaginal and urinary tract changes. As your estrogen levels decrease, the lining of your vagina may become thinner, dryer, and less elastic. Vaginal dryness may cause pain during sex. Vaginal infections also may occur more often. The urethra can become dry, inflamed, or irritated. This can cause more frequent urination and increase the risk of urinary tract infections.

Other perimenopause symptoms include:

• Irregular periods. Your menstrual periods may not come as regularly as before. They also might last longer or be shorter. You might skip some months. Periods might stop for a few months and then start up again.
• Your periods might be heavier or lighter than before.
• You might experience mood swings or be irritable.
• Changes in sexual desire (libido). You may have less interest in sex. It may take longer for you to get aroused.
• Trouble concentrating or with memory
• Headaches
• Joint and muscle aches
• Heavy sweating
• Having to pee often
• Premenstrual syndrome (PMS)-like symptoms

Other possible changes are not as noticeable. For example, you might begin to lose bone density because you have less estrogen. This can lead to osteoporosis, a condition that causes bones to become weak and break easily. Changing estrogen levels can also increase your cholesterol levels and increase your risk for heart disease and stroke.

The symptoms of perimenopause may look like other health conditions. Always talk with your family doctor for a diagnosis.

Sometimes it’s hard to tell if you are having symptoms of perimenopause. Your symptoms, health history, age, and a physical exam may help your doctor with the diagnosis. You may also have blood tests to measure your hormone levels.

Perimenopause doesn’t need to be treated unless your symptoms are bothering you. Treatments are available to help ease perimenopause symptoms.

Perimenopause treatments may include:

• Find what triggers your hot flashes by keeping a record. For example, alcohol, coffee, or tea may be a trigger.
• Hormone therapy using estrogen or estrogen and progestins to level out hormone levels.
• Selective estrogen receptor modulators (SERMs)
• Antidepressants
• Gabapentin
• Clonidine
• Cognitive behavioral therapy (CBT)
• Plant-based therapies

Your family doctor may suggest healthy lifestyle changes:

• Eat a healthy diet with fruits and vegetables and whole grains.
• Get at least 1,000 mg to 1,200 mg of calcium each day through your diet or supplements.
• Exercise regularly.

Discuss other treatments for easing symptoms with your family doctor.

You may hear about herbal supplements that claim to help manage hot flashes. It’s important to remember that the FDA does not regulate these supplements. They are not tested like traditional medicines to prove that they work and are safe to take. Talk with your family doctor before using any herbal supplements.

When does perimenopause usually start?

Perimenopause, the transition to menopause, usually starts in a woman’s mid- to late 40s ⁵⁶. On average, women are in perimenopause for four years before their periods stop.

How will I know if I am in perimenopause?

Sometimes it can be hard for you and your doctor to tell whether you are in perimenopause, the transition to menopause:

• Symptoms: Tell your doctor about your symptoms such as hot flashes or trouble sleeping.
• Irregular periods: Track your periods. Irregular periods may be your first sign of menopause.
• Hormone levels: Your doctor may test the amount of hormones in your blood if your periods stopped at an early age (before 40). Doctors don’t usually recommend this test unless there is a medical reason to do so. This is because for most women hormone levels go up and down in an unpredictable way during perimenopause. So it is difficult to tell for sure whether you have gone through menopause or are getting close to it based on this blood test alone.

How long does perimenopause last?

Perimenopause can last between two and eight years before your periods stop permanently ⁵⁹. For most women, perimenopause lasts about 4 years. You will know you have reached menopause only after it has been a full 12 months in a row since your last period. This means you have not had any bleeding, including spotting, for 12 months in a row.

Should I continue using birth control during perimenopause?

Yes. You can still get pregnant during perimenopause even if you miss your period for a month or a few months ⁵⁹. During perimenopause you may still ovulate, or release an egg, on some months. But it is impossible to know for sure when you will ovulate ⁵⁹. If you don’t want to get pregnant, you should continue to use birth control until one full year after your last period. Talk to your doctor about your birth control needs.

What is menopause?

Menopause is when your periods stop permanently and you can no longer get pregnant. Menopause happens when you have gone 12 months in a row without a period. This means you have not had any bleeding, including spotting, for 12 months in a row. After menopause your ovaries make very little of the hormones estrogen and progesterone. These low hormone levels can raise your risk for certain health problems.

The average age of menopause in the United States is 51. The range for women is usually between 45 and 58. One way to tell when you might go through menopause is the age your mother went through it ⁶⁰.

Menopause may happen earlier if you:

• Never had children. Pregnancy, especially more than one pregnancy, may delay menopause ⁶¹.
• Smoke. Studies show smoking can cause you to start menopause up to two years earlier than women who don’t smoke ⁶².

Certain health problems can also cause you to start menopause earlier. Menopause usually happens on its own. However, you may enter menopause earlier than you normally would if you have had chemotherapy or surgery to remove both ovaries.

What is the earliest age for menopause?

Menopause can happen when a person is in their 20s, 30s or 40s. Premature menopause describes menopause that occurs any time before age 40. It’s rare for menopause to happen before age 30.

Can menopause start at 35?

Yes, starting menopause around age 35 is premature menopause.

What is the difference between early and premature menopause?

Early or premature menopause happens when ovaries stop making hormones and periods stop at a younger age than usual. This can happen naturally or for a medical reason, such as when both ovaries are removed in a hysterectomy.

Early and premature menopause can have the same causes. The only difference is the age at which it happens. Menopause that happens between the age of 40 and 45 is called early menopause. Menopause that happens before age 40 is called premature menopause.

Women who have gone through early or premature menopause cannot get pregnant.

How common are premature menopause and early menopause?

Early menopause (menopause between the age of 40 and 45) occurs in about 10% of women. Premature menopause (menopause before the age 40) happens in about 1% of women. It’s rare to experience menopause in your 20s. This happens in about 0.1% of women.

What is the difference between early menopause and premature ovarian failure?

Early menopause is not the same as premature ovarian failure, although some people use the terms interchangeably. Doctors now refer to premature ovarian failure as primary ovarian insufficiency (POI).

Table 2. HRT contraindications

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