Early Menopause & Surgical Menopause

This article aims to offer the latest updates on early and surgical menopause. To start, let’s delve into some definitions.

Menopause: no period for 12 months. The average age is 51.

Early menopause: menopause younger than age 45.

Premature menopause: menopause younger than age 40. This can be due to premature ovarian insufficiency, removal of ovaries, chemotherapy, radiation or other medical problems.

Surgical menopause: menopause due to the removal of ovaries. Symptoms tend to be abrupt and more severe.

Perimenopause: the period of time in which your body is transitioning to menopause. This is marked by irregular cycles, fluctuating levels of estrogen and the beginning of “menopause symptoms “ for many like hot flashes, sleep problems, vaginal dryness and mood changes.

What are some health concerns of early menopause?

What often goes overlooked but holds immense clinical significance is early menopause, regardless of its cause. It carries notable health implications that women should be aware of, enabling them to take proactive measures. In comparison to women who undergo menopause after the age of 46, early menopause exhibits more pronounced health effects across various aspects.

Hot Flashes
Hot flashes, also known as vasomotor symptoms, affect approximately 80% of women and typically persist for an average of seven years. They are often linked to a decline in quality of life. Hormone therapy continues to be regarded as the primary treatment for hot flashes.

Bone Density Changes
Low estrogen adversely affects skin, muscle, and bone health. It leads to collagen thinning and skin dryness, often accompanied by increased body aches and pains in women. Menopause accelerates bone resorption while slowing bone formation, resulting in decreased bone density. Numerous landmark studies have concluded that hormone therapy reduces the rate of bone loss.

Cognitive Changes
Our brains contain estrogen receptors, and estrogen plays a crucial role in nerve growth. Menopausal women often report difficulties with recall and concentration. Women who undergo ovary removal before experiencing natural menopause have a higher incidence of dementia. Hormone therapy (referred to as “HT” from hereon) and its impact on memory are currently areas of intense research, with preliminary findings suggesting that HT may prevent memory loss.

Mental Health Concerns
Perimenopausal women report more depression symptoms compared to premenopausal women. There is a 2-4 times increased risk of depression in early menopause. Women who undergo surgical menopause also have a higher incidence of new anxiety and depression. While antidepressants remain the first-line treatment, estrogen has been found to have an antidepressant effect in perimenopausal women. This represents a new and important clinical treatment change.

Earlier Sexual Problems
With hormonal changes comes a higher incidence of sexual dysfunction. Perimenopausal and early menopausal women report sexual dysfunction more often than premenopausal women. For most women, decreased estrogen results in vulvar and vaginal dryness/irritation, collectively known as genitourinary syndrome of menopause (GSM). Estrogen acts as a natural lubricant for the vulva, vagina, and urethral regions, promotes stretch/elasticity of the tissues, as well as muscle/skin integrity. Therefore, when estrogen decreases with menopause, the majority of women note progressive irritation, some discomfort with vaginal intercourse, burning, and other symptoms. Fortunately, this is very treatable—options abound, but the gold standard is vaginal estrogen. The perimenopause years as well as early menopause are common timeframes for women to note less sexual desire. While hormone therapy (HT) can help with sexual desire, it may not be enough. Testosterone helps libido. Testosterone gradually decreases with age and declines dramatically after ovaries are surgically removed. Testosterone supplementation in a patch or gel/cream form is now part of the recommended treatment for postmenopausal women with low desire (when other outlier causes have been ruled out like medicine side effects, relationship issues, severe depression, and some medical conditions).

Sleep Problems
About half of women in perimenopause feel that their sleep quality declines. Hot flashes are often part of the problem, but not always. Anxiety and depression also negatively impact sleep. Getting to the root cause with a good history provides the best-focused treatment.

Heart Disease
Low estrogen results in weight gain, increased cholesterol, more fat deposited around the waist, and early thrombotic changes in blood vessels. What’s the good news? Yes, there is good news. Now we know that hormone therapy (HT) can help reduce these changes. There is a lot of important information on this topic—there is a separate article on this website (please see “Cardiovascular Health in Women and a Word About Menopause”). The main “take-home message” is that estrogen helps to deposit fat in “healthier areas”—primarily the bottom and hips. Estrogen in early menopause also acts as a vasodilator, meaning it helps to keep our blood vessels open.

The BRCA mutation is a genetic anomaly found in approximately 0.2-0.3% of the population. Typically, women with this mutation have a significant family history of ovarian and breast cancer. Due to the mutation’s impact on the likelihood of developing these cancers, obtaining a comprehensive family history and initiating appropriate screening tests are crucial. Those with a strong family history are offered genetics consultations. For individuals positive for the BRCA mutation, it is recommended to undergo ovary removal between the ages of 35-40, with mastectomies being offered as an option. The use of birth control pills before this age range does not increase the risk of breast cancer and helps reduce the incidence of ovarian cancer in these individuals.

What about healthy women with early menopause?

The primary “take-home” message of this article is that offering hormone therapy (HT) to women experiencing early menopause (and who have no contraindications to HT) is the standard of care until at least the average age of natural menopause (around 51 years old). Beyond age 51, it is often advisable to consider continuing HT based on individual symptoms.

What’s the bottom line?

Women have received and continue to receive very mixed and confusing messages about hormone therapy (HT) from popular media sources. At the forefront of this confusion is the 2002 study headlines from the Women’s Health Initiative (WHI). This study made everyone stop HT. Headlines abounded with the gist being “Study Shows Hormones Cause Breast Cancer and Blood Clots”. Unfortunately, the average age of women in that study was 63 years old. That is NOT the population we are talking about starting HT on. When the study looked at HT in younger menopausal women (those younger than 60 or less than 10 years out from menopause), the overall benefits of HT in many health areas were noted compared to the no-HT group. The overall survival in the HT group was greater than the no-HT group. Why was this not a headline? I have no idea, but the ramifications have left a lot of women to needlessly suffer. Please see our separate article and video. In summary, HT is the gold standard and most effective treatment for menopause symptoms and quality of life improvement for women who otherwise have no contraindications to HT. For those patients with contraindications, there are a lot of very good treatment options tailored to one’s individual symptoms, and their symptoms DO NOT need to be dismissed.