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Are you managing your menopause well?

Data suggests that around 1-4% of women stop ovulating and menstruating before the age of 40 and it is important for everyone to ensure that the health and potential risks are identified at the earliest.

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Premature menopause is a condition in which a woman stops menstruating completely before the age of 40. Sometimes this can occur as early as 30 years leading to various problems related to health and reproduction in the affected women. The ovaries have two functions, the first being to produce eggs for fertility and the second, to produce reproductive hormones. The ovaries make three types of steroid hormones: - testosterone, estrogen and progesterone. The ovaries are most active during the ages of 20-30 years.


Global statistics suggest that approximately 1-4% of women stop ovulating and menstruating before the age of 40 and are considered to have premature menopause


The causes of premature menopause may vary from person to person, the commonest causes being.

  •  Ovarian Surgery, anti-cancer drugs or radiation therapy for cancer
  • Genetic disorders like Turnors syndrome, Swyers syndrome
  • Infections like mumps, tuberculosis etc
  • Environmental toxins like tobacco etc
  • In 5-30% of cases, there may be a family history
  • In many cases, the cause remains unknown

Women who attain premature menopause at a relatively young age, face various problems.

  • They stop menstruating and ovulating at a young age, hence natural conception is hampered leading to infertility.
  • Due to lack of reproductive hormones, there are many long-term health issues.
  • Psychologically a woman gets disturbed because she is no longer menstruating as her contemporaries are, and it makes her feel older. Added to that she has various symptoms related to estrogen deficiency.

Infertility Due to the absence of good quality eggs, infertility becomes a major consequence of premature menopause. A very small percentage of women may spontaneously become pregnant, but there are no medical investigations to predict which of these women would conceive.

Health-related issues: Women with premature menopause are at increased risk of osteoporotic bone fractures, atherosclerotic heart disease, cancer of the colon, Alzheimers and Parkinsons disease. All these conditions are related to a low estrogen state. The risk is similar to that seen after natural menopause.

Symptoms: Due to the hormonal changes following premature menopause, a woman may get hot flushes, have mood swings, get irritable develop insomnia or may also go into severe depression.


Diagnosis


Clinical presentations:

  • The first symptom is the absence of periods.
  • Due to her low levels of estrogen, she may have mood changes in form of irritability, emotional lability, depression etc. She may also have hot flashes, decreased sex drive, fatigue, night sweats, vaginal dryness or palpitations. I have seen such women being treated by various specialists such as psychiatrists, cardiologists, neurologists etc. when all they need is an estrogen therapy.


Investigations:

  • Measurement of hormones is the key to the diagnosis.
  • Rise in serum follicle stimulating hormone (FSH) levels. A value >40u/l is suggestive of menopause.
  • Low levels of estrogen (<20pg/ml)
  • Low Serum Anti-Mullerian Hormone (AMH) levels suggestive of a poor ovarian reserve.
  • Serum prolactin and thyroid levels need to be done to rule out the common causes of amenorrhoea
  • Chromosomal analysis to rule out a genetic disorder.
  • The hormone profile needs to be repeated on three occasions at least one month apart, because in certain instances the ovaries may return to normal after a phase of low activity.


Ultrasound:

On ultrasound, the ovaries are smaller than normal, the ovarian volume being less than 3 ml. Hardly any follicles are seen in the ovaries and the endometrium is thin, less than 5 mm in thickness.


Management:

This depends on how the patient presents to her doctor. If she has a problem of infertility, then she is investigated further accordingly and counselled. If she has menopausal symptoms then the symptoms are attended to with the appropriate therapy. And if she has no problems, she is still advised for further management in order that she does not have a poor quality of life in her later years due to the ageing process starting prematurely. 


Management of Menopause and Prevention of long-term health risks:

Women who experience symptoms are managed with supplements and hormone replacement. A wide range of HRT preparations is available for estrogen replacement including oral, transdermal, subcutaneous and vaginal routes of administration. The choice of estrogen is made on an individual basis. These women will need hormone replacement at least till they reach an age of natural menopause (in order to avoid premature ageing).

Hormone replacement therapy is absolutely necessary for these young women, contrary to women who have reached natural menopause in whom it is optional. The benefits and risks of HRT are discussed in another chapter in this same issue. One must remember, that in cases of premature menopause the benefits of hormone therapy definitely outweigh the risks.

Intake of calcium and vitamin D, avoidance of smoking and alcohol abuse also help to prevent osteoporosis. Affected women are counselled to carry out weight-bearing exercises and to have a balanced nutrition.

Once a woman is found to be menopausal, whatever may be the cause or at whatever age, we advise her to undergo all the necessary investigation done in a postmenopausal woman.


Note: This is a guest article written by Dr. Duru Shah. She is the Director of Gynaecworld, and a panel consultant at many popular hospitals in Mumbai. This article has been written to ensure awareness, based on the experience of treating patients related to reproductive issues. 

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