Menopause | PDF
By William Pfeffer, MD
Department of Reproductive Medicine
Some women go through menopause in their early 40s or younger. These
women, whether it is a natural menopause or brought about by surgery or
medication, face special challenges. Dr. William Pfeffer reviews some of
the causes and how women can manage what can be an unexpected change. —
Beverly Vaughn, MD, Medical
Coordinator, Menopause and You Program
It is a fact of life that most women will stop menstruating sometime
between their 45th and 54th birthdays. This process signals loss of
fertility, changing sexuality, spiritual growth and, inevitably, aging.
To successfully weather unpredictable menstrual cycles, hot flashes,
medical concerns and sexual changes is a daunting undertaking for the
average 50-year-old undergoing her change of life. Menopause that
appears unexpectedly early in life (before age 40) presents an enormous
challenge to a younger woman’s life plans and self-esteem. Let’s
consider why some women have early menopause, how we recognize this
condition, and how women may cope with premature menopause.
Causes of Premature Ovarian Failure
Women are born with hundreds of thousands of eggs stored within their
ovaries. The supply of eggs is usually exhausted around age 50. In the
absence of eggs, the ovary cannot produce estrogen. Periods cease.
Symptoms of estrogen deficiency arise (hot flashes, vaginal dryness,
mood change, etc.).
The precise age of the last period varies from one woman to another.
Family history has some influence. A woman who started her periods at a
young age tends to have a later menopause. Ninety percent of women will
be 45 or older when it happens. Between 40 and 45 we call menopause
“early”. Only one in a hundred women who are younger than 40 will go
through what we term premature ovarian failure (POF). Some cases of POF
seem totally unprovoked while others may be linked to surgery,
chemotherapy or irradiation. In my medical practice the most common
reason for POF is cancer treatment.
Survivors of childhood cancers, such as leukemia, will often have
received chemotherapy. Depending on the particular combination and
dosage, these drugs may temporarily or permanently damage the ovaries.
Radiation treatment aimed at the pelvis may have similar results. In
these cases the ovaries are “innocent bystanders” whose function is
sacrificed for the sake of saving a life.
In other cancer situations, the ovaries are intended targets. Obviously,
ovaries get removed surgically in most cases of when cancer originates
in the ovary. The elimination of ovarian hormone production is also a
desired goal in treating the hormone-responsive breast cancers that are
so prevalent in our society. Whereas replacement of lost hormones and
pursuit of pregnancy are allowable goals for survivors of most childhood
tumors, these treatments are contraindicated when they might stimulate
the recurrence of a hormonally responsive tumor such as breast cancer.
Rarely, a woman will have had both of her ovaries removed surgically for
non-cancer disease. The most frequent of these conditions is
endometriosis. Whether for cancer or benign conditions, surgical removal
of both ovaries will precipitate a sudden menopause. The severity of hot
flashes and other symptoms is worse when menopause is sudden, compared
with the more gradual course that accompanies natural menopause. In
these situations, women lose not only estrogen, but progesterone and
testosterone. Loss of each of these hormones can have an effect.
Several times a year I’ll be referred a patient who has developed POF in
the absence of surgery, radiation or chemotherapy. The younger this
woman is the more likely she has a genetic abnormality such as the
absence of all or part of an X chromosome. As techniques in diagnosis
evolve, I suspect we will be able to offer more genetic explanations to
our patients. Another group of women have POF because their immune
systems have mounted an inappropriate attack, destroying their ovarian
tissue much in the same way the immune system destroys the pancreas in
juvenile diabetes. Unfortunately, in most cases the reason for POF
Signs of an Early Menopause
Be suspicious if your period has stopped, especially if you have never
had menstrual problems in the past. Hot flashes are also an important
clue, but don’t jump to the conclusion that you will have an early
menopause just because you experience flashes. Many women sense these
flashes and continue to have their period for years. If you have doubts,
schedule an appointment with your gynecologist. Blood tests that measure
estrogen and the hormone that stimulates ovulation (FSH) can confirm the
Coping with POF
In our fertility patients we look for a tendency towards POF in women
who still have their periods by measuring these same hormones on the
second or third day of the menstrual cycle. We will investigate this
possibility in our fertility patients who are as young as 30 years old.
Knowing a woman’s menopausal status is critical to successful treatment
Although most women who have been diagnosed with POF will not become
pregnant with their own eggs, spontaneous conception will occasionally
occur. The use of low-dose estrogen supplementation may increase this
likelihood. The younger the woman with POF, the more likely she is to
spontaneously become pregnant. Therefore, the diagnosis of impending
menopause in a women who is younger than 35 is a true “fertility
emergency” requiring aggressive action. If a woman with POF is
determined to carry a pregnancy, we might recommend she consider donated
eggs (fertilized with the sperm of her husband). These pregnancies are
created through in vitro fertilization techniques.
When fertility is not the main concern, we focus our attention on
hormone replacement. A 35-year-old woman with POF will have more years
to live in an estrogen-deficient state than a woman experiencing the
usual timing of menopause. We have particular concerns about bone loss
(osteoporosis) that accompanies estrogen deficiency. On the other hand,
a younger woman on estrogen therapy has more time for the possible
complications of hormone therapy (breast cancer, stroke) to occur. The
effects of long-term estrogen therapy in younger women, however, is not
clear. Proper treatment for each case must be individualized.
Should we use herbal, natural or synthetic hormones? How much and what
kind of progesterone must be added to the estrogen to protect the lining
of the uterus? At what age should the hormone supplementation be
stopped? Non-hormonal supplements (calcium, vitamins) and medications
(bone strengtheners such as Fosamax or Actonel, alternative hot-flash
relievers such as Effexor) may be used alone or with estrogen to help
with flashes or bone health.
Nutrition and exercise, important to all of us, has a particular
significance for those with POF. POF challenges our coping mechanisms.
Lifelong-held plans for childbearing will need to be adjusted. Unwanted
symptoms and/or medications must be tolerated. Drawing on their natural
strength and resilience, and perhaps with the help of a sympathetic
physician, most women confronted with POF will successfully have the
family and quality of life they desire. Those of us at Main Line Health
Hospitals are ready to help.
This article is part of the Menopause and Youlibrary,
a web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own health care practitioner with your
specific concerns and questions.
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