The purpose of this article is to provide the newest updates about early and surgical menopause. First, let us begin with 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 is not commonly discussed, but is of enormous clinical importance is early menopause (regardless of the cause ) has big health effects that women need to know about so that they can be proactive. Some of the significant health aspects of early menopause compared to women with menopause after age 46 include more pronounced:
- Hot flashes
- Bone density changes
- Cognitive changes
- Mental health changes
- Earlier sexual problems
- Sleep problems
- Heart disease
- Hot flashes (aka vasomotor symptoms):effects 80% of women, lasts for about 7 years on average and is commonly associated with worsening quality of life. Hormone therapy remains the gold standard treatment for hot flashes. The much misunderstood Women’s Health Initiative (WHI) study does not apply to women in early menopause.
- Bone density changes: Low estrogen is no friend to skin, muscle and bone health. Low estrogen causes collagen to thin and skin to dry. Women oftentimes note more body aches and pains. Menopause results in faster bone resorption and slower bone formation which results in a lower bone density. The conclusion of a lot of landmark studies is hormone therapy decreases rate of bone loss.
- The brain: our brain has estrogen receptors and in fact estrogen helps nerves to grow. Menopausal women oftentimes note problems with recall and concentrating. Women who have ovaries removed before natural menopause have a higher incidence of dementia. Hormone therapy ( we will refer to this as “HT” from here on out)and its effect on memory is a hot area of research currently but early findings suggest that HT can prevent memory loss.
- Mental health: perimenopausal women report depression symptoms more than premenopausal women. There is a 2- 4 times increased risk of depression in early menopause. Women with surgical menopause also have a higher incidence of new anxiety and depression. While antidepressants remain first line treatment, estrogen for perimenopausal women has an antidepressant effect. This is a new and important clinical treatment change.
- Sexual problems: With hormonal changes comes 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. Perimenopause years as well as early menopause are common timeframes for women to note less sexual desire. While 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 outlying causes have been ruled out like medicine side effects, relationship issues, severe depression, and some medical conditions).
- Sleep: about 1/2 of women in perimenopause feel 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 HT can help reduce these changes. There is a lot of important information in 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 bottom and hips. Estrogen in early menopause also acts as a vasodilator, meaning helps to keep our blood vessels open.
A word about BRCA mutation: this is a genetic mutation found in about 0.2-0.3 % of the population. Typically these women have a strong family history of ovarian and breast cancer. Because this mutation impacts a person’s likelihood of developing breast and ovarian cancer, getting a family history and initiating proper screening tests are critical. Those identified with a strong family history are offered genetics consultation. If a person is positive for BRCA mutation, removing ovaries by age 35-40 years old is recommended and mastectomies offered. Birth control pill use before age 35-40 does NOT increase risk of breast cancer and helps to decrease incidence of ovarian cancer in these women.
What about healthy women with early menopause?
The main, “take home” message of this article is that offering HT for women with early menopause ( who have no contraindications to HT) is the standard of care until at least the average of natural menopause (age 51). After age 51, in many cases ,it is a great idea to continue on HT depending on their symptoms.
What’s the bottom line?
Women have received and continue to receive VERY MIXED AND CONFUSING MESSAGES ABOUT HT from popular media sources. At the forefront of this confusion is the 2002 study headlines from the Women’s Health Initiative (WHI). This was the study that 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 (younger than 60 or less than 10 years out from menopause) the overall benefits of HT in many health areas were noted compared to 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, 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.