Early menopause and premature menopause

Women typically menopause between 45 years and 55 years of age. Research shows that Indian women typically menopause around 46.2 years, give or take 4.9 years. By comparison, Caucasian women typically menopause around 51 years of age.

Early menopause is hitting menopause between 40 and 45 years and premature menopause means cessation of normal periods before the age of 40. A 2016 research by the Institute for Social and Economic Change (ISEC) in Bengaluru showed that 4% of Indian women menopause aged 29-34 years and 8% between 35 years and 39 years of age.

The signs of menopause and early or premature menopause overlap to a large degree. The following are some of the symptoms of early or premature menopause:

• Irregular periods: If you have always had a fairly regular cycle, then irregular periods may be a sign that your body is starting to experience perimenopause. You may start to bleed more or less. If your consecutive menstrual cycles start moving by more than seven days, it shows early menopause transition. Skipping more than two periods points towards a later stage of transition towards menopause. (Read more: Abnormal uterine bleeding)
  As per the National Institute of Aging, US, even though changes in menstruation are normal, you should consult your doctor if you notice symptoms like heavy bleeding, spotting, periods lasting more than a week and if your periods start suddenly after being absent for a year. 
• Hot flashes and night sweats: Hot flashes are one of the most known symptoms of menopause and early/premature menopause. Changing hormone levels or changes in the thermoregulatory centres in the brain are suggested to be the possible cause of hot flashes and for some women. Women experiencing hot flashes have a sudden feeling of heat, usually in the upper parts of their body including the neck, face and head. They may sweat profusely and have a slightly higher core temperature. These symptoms may show up for 30 seconds to 5-10 minutes once in a day or week, several times a day or several times an hour. Night sweats is the term used to describe hot flashes that happen at night—they typically leave the person drenched in their sweat during sleep, hence the name. Hot flashes may continue for many years past menopause.
• Difficulty sleeping: Women may sleep late or wake up early. Night sweats also cause insomnia and make it difficult to get a good night’s sleep.
• Vaginal atrophy and related symptoms: Low estrogen may cause the mucous membrane (lining) of the vagina to become thin, dry, and less elastic. As a result women notice itching, irritation and pain during sex.
• Bladder problems: These include urinary incontinence, frequent infections of the urinary tract or bladder infections, dysuria (painful urination), and urgent need to urinate.
• Low sex drive: Though a woman can no longer become pregnant after menopause, the reduction in estrogen levels contributes to a low sex drive. Even if you don’t notice your sex drive dipping by a lot, you will still be prone to STDs if you have multiple sex partners or if you have sex with someone who has more partners.
• Anxiety or mood disturbance: The exact cause of mood disturbances during menopause is not really known. Experts suggest that this may be due to general anxieties of life rather than hormonal changes.
• Other symptoms: Some other symptoms associated with menopause include reduced bone density, loss of muscle mass, increase in body fat, muscle stiffness and joint pain, poor concentration, and memory loss.
  In the postmenopausal period, symptoms like hot flashes and night sweats slowly decrease though they may continue for decades still.

There is a bit of confusion when it comes to the terms "premature menopause" and "primary ovarian insufficiency". Some use the terms interchangeably, while some say that the two are different. Both terms are used to talk about menopause before the age of 40. However, as per the US National Library of Medicine, women with primary ovarian insufficiency can still get pregnant as they do menstruate occasionally. Regardless, the following same causes are listed for both the conditions:

• Most cases of early menopause or primary ovarian insufficiency are idiopathic—they have no known cause. 
• Genetic conditions like Turner syndrome, fragile X syndrome, galactosaemia may cause early or premature menopause as well as primary ovarian insufficiency
• Autoimmune diseases like lupus, Crohn’s disease and rheumatoid arthritis are linked with both
• Cigarette smoking 
• Viral infections like cytomegalovirus infection are also thought to cause premature menopause in some women
• Induced menopause: Induced menopause occurs due to a surgery involving removal of ovaries or uterus or as a side effect of radiotherapy and chemotherapy. Menopause caused due to chemotherapy or drugs can revert a while after the therapy is stopped.

1. What happens in a normal menstrual cycle

There are advantages and risks associated with both early menopause and late menopause. 

• Early menopause can reduce the risk for some types of cancer; for example, breast cancer. On the other hand, women who go through early menopause and premature menopause are at higher risk of neurological problems like dementia, psychological distress, anxiety and sleeping problems, heart problems, lower bone density, osteoporotic fractures and early-onset osteoporosis, poorer sexual well-being and early death. Research has also linked health issues such as palpitations, constipation, pain, stiffness, osteoporosis and musculoskeletal disease with induced early menopause. The word “induced” is used to indicate early or premature menopause brought on by surgery.
• Late menopause provides prolonged protective effects of estrogen which promotes good (high-density lipoprotein) cholesterol and reduces bad (low-density lipoprotein) cholesterol in the body, and reduces the risk of heart disease in women who are still menstruating. On the other hand, it increases the risk of some types of cancer like breast cancer and ovarian cancer.

Premature menopause is typically treated with hormone replacement therapy for menopause. This is important because the advantages of taking hormonal therapy outweigh the risk in younger women who menopause.

However, not all women need treatment for early menopause.

That said, symptomatic treatment can be given to those who have particularly bothersome symptoms. Treatment of early menopause and menopause includes lifestyle modifications and medicines. Some also use alternative remedies. Let us have a look at all these treatment methods: 

• Lifestyle modifications: The following lifestyle modifications are suggested for various symptoms of menopause, early menopause and premature menopause:
  • Hot flashes: Healthy diet, regular workout, breathing exercises, wearing light and comfortable clothes, using fans or air-conditioning or staying in a cooler environment whenever possible, staying away from any triggers including spicy foods, extreme emotions and bright light.
  • Night sweats: Using an ice pack under the pillow and turning the pillow over in the middle of the night to keep yourself cool, drinking cold water, using many layers of bedsheets which you can change over the night can help.
  • Vaginal dryness and sexual discomfort: Regular intercourse can keep up the blood flow to the vagina. Use water-based lubricants to manage vaginal dryness. Prescribed vaginal moisturisers are said to be better than lubricants, though. Apart from reducing dryness and vaginal itching, they help maintain vaginal pH.
  • Urinary incontinence: Kegel exercises are a good way to manage and reduce urinary incontinence. Make sure to take enough water throughout the day and avoid drinking caffeinated beverages as they may irritate the bladder.
  • Difficulty sleeping: Having a good sleep schedule may help you with sleeping difficulties over time. Avoid using your phone or a screen right before bedtime and do not take caffeine at night. You can also try drinking milk at night, using relaxation techniques or relaxing music to help you fall asleep.
  • Mood swings: Regular exercise, yoga and tai chi are some ways to relieve stress and manage mood swings.
  • Weak bones: Vitamin D supplements along with calcium, healthy diet and exercise and spending some time in sunlight may help maintain bone strength. Make sure to talk to a doctor before taking any kinds of supplements.
• Alternative treatments: Several alternative therapies like mindfulness and acupuncture are said to be helpful in relieving some of the symptoms of menopause. Herbs including black cohosh, red clover, and evening primrose oil are used by some women for relieving hot flashes. Ginseng is suggested to be helpful in reducing mood swings and sleep disturbances and kava for anxiety. However, more studies are needed to confirm the benefits of most herbs in the management of menopausal symptoms.
  It is important to note that not all herbs suit every person. Some herbs interact (increase or decrease) the effects of medications. They may also worsen the symptoms of certain health conditions. For example, herbs with anticoagulant properties may increase bleeding problems for those with coagulopathy (difficulty clotting).
  It is always wise to talk to a healthcare practitioner before taking any herb or alternative medicine.
• Medicines: Various medicines are prescribed off-the-label for the management of early menopause and menopause symptoms. These include:
  • Gabapentin: Gabapentin is a drug used to control seizures. It is sometimes given for reducing the frequency and intensity of hot flashes. It also helps improve sleep quality. Nausea, dizziness, fatigue and weight gain are some side effects of this drug.
  • Clonidine: Clonidine is a medication that is normally used to lower blood pressure. It is also used (though less commonly) to relieve hot flashes. Low blood pressure, dry mouth and fatigue are some side effects of this medication.
  • Antidepressants: These drugs are helpful in reducing anxiety, mood swings and irritation.
  • Paroxetine: Paroxetine is a serotonin reuptake inhibitor that was approved by the US Food and Drug Administration (FDA) in the year 2013 for the treatment of hot flashes in menopause. Serotonin reuptake inhibitors are widely used for the treatment of depression. These drugs increase brain serotonin levels—serotonin levels in the brain tend to be low in depression. Experts have proposed two mechanisms through which serotonin reuptake inhibitors work. These include reducing blood flow to skin and lowering the core body temperature by countering skin vasodilation during hot flashes and central vasodilation due to narrowing of the thermoregulatory zone. That is, the medicine narrows certain blood vessels to cool the body down.
  • Duavee: This is a mixture of estrogen and bazedoxifene that was approved in the year 2013 by the FDA for the treatment of hot flashes in postmenopausal women with a uterus. It also prevents osteoporosis. Bazedoxifene functions in a similar way to progestin (synthetic progesterone).
  • Ospemifene: This is an estrogen agonist/antagonist that was approved by the US FDA in 2013 for the treatment of pain during sex (dyspareunia) in postmenopausal women. 
  • Prasterone: Prasterone is yet another FDA-approved drug for the treatment of postmenopausal dyspareunia.
  • Medicines like raloxifene and calcitonin are prescribed to treat osteoporosis
• Birth control pills: In the perimenopausal period, birth control pills are sometimes suggested for managing early menopause and menopause symptoms. These pills can be taken in the form of a skin patch or vaginal ring. However, these pills can increase your risk for high blood pressure and blood clots. Do not take birth control pills without talking to your doctor first.
• Menopausal hormone therapy: Menopausal hormone therapy or hormone replacement therapy was once considered to be highly effective in the management of menopause symptoms. This therapy includes the administration of hormones that a woman lacks during menopause—estrogen and progesterone.
  Estrogen and progesterone are usually given together. However, estrogen-only treatment may be given to women who have had their uterus removed. Hormone replacement therapy may or may not be given in cycles. Tablets, gels, vaginal rings, skin patches, and vaginal creams are some ways to administer hormone therapy. Women with premature menopause are typically given this therapy, to offset the disadvantages of hitting menopause so early in life.
  Keep in mind, though, that this therapy can have side effects: over the course of time several research studies have shown that this therapy may increase the risk of stroke and heart attack, and breast cancer, endometrial cancer and ovarian cancer. Hormone replacement therapy also has side effects like nausea, bloating, bleeding, and mood changes. Talk to your doctor about the potential benefits and side effects for you before starting the therapy.