The Change of Early Menopause

Menopause or skipping it altogether

/ Author:  / Reviewed by: Joseph V. Madia, MD

Menopause can be a challenging time for women, both physically and emotionally. It may be even more difficult for women with early menopause.

About 5 percent of women go through early menopause between the ages of 40 to 45, though the average age of menopause is 51, according to the North American Menopause Society (NAMS).

Most are not pleased to go through "the change" early for a combination of reasons ranging from loss of fertility to unpleasant symptoms and increased health risks.

"They are at an increased health risk. It's important to protect bone health and cardiovascular health," said Dr. Lauren F. Streicher, an assistant professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine and a certified NAMS menopause practitioner.

"If they choose not to take estrogen therapy, they may well be at risk of osteoporosis and early cardiovascular disease."

Defining menopause

By the age of 51, half of women have begun menopause, and by the age of 55 as many as 95 percent of women are in menopause, Dr. Streicher said.

A handful of women also go through premature menopause before the age of 40, though Dr. Streicher said this is uncommon. At most she sees one or two patients each year who have entered menopause before the age of 40.

The classic sign of menopause is when a woman has missed her period for 12 consecutive months. It is associated with reduced ovarian function and means the end of fertility. It also marks a period when women's bodies will begin producing less estrogen.

With those gradual hormone changes comes perimenopause, a transition phase into menopause that can last up to six years, according to NAMS. Common symptoms include hot flashes, mood swings and disturbed sleep.

Fertility is also low, though women who do not want to become pregnant should continue use of birth control, and women may notice vaginal dryness or a reduced sex drive.

Hormonal blood tests may be useful in diagnosing women under 40, though it is not traditionally used as a diagnostic tool for older women. The primary diagnostic tool used by physicians is a test for a follicle-stimulating hormone to confirm diagnosis.

Dr. Streicher said that about 80 percent of women have symptoms from menopause. The type often dictates how long the symptom will last. While hot flashes may last two or three years, some symptoms such as vaginal dryness generally last a lifetime.

Symptoms tend to be worse among younger women going through menopause, though they can vary in severity regardless of age of onset. It may be a necessary part of life, but most women are still disappointed when it happens.

"If someone is only having problems with vaginal dryness, the approach may be way different than someone with cognitive function issues," said Dr. Streicher.

Birth control and menopause

It may sound unbelievable, but some women aren't even aware that they are going through or already have entered menopause. That's because women who are taking oral contraceptives -- even at the lowest available dose -- when menopause begins don't experience symptoms such as hormonal imbalance or hot flashes.

About 30 percent to 40 percent of women taking contraception take it for benefits that are not related to avoiding pregnancy. Many of those women use it to balance hormones, and it's not uncommon for that group of women to still be taking the pill once menopause kicks in.

Most also are taking birth control in a way that ensures they never have a menstrual period, so it's not immediately obvious. The older method of taking birth control was to take it for three weeks, then take a week off, taking placebo-like pills during which a women would have her period. But now it is common for women to take birth control pills throughout the four week cycle, essentially eliminating periods in most women.

"If you stay on birth control pills and you go through early menopause, you're not going to have any of those effects such as hormonal swings," said Dr. Streicher. "So you're not going to notice even if you're on the lowest dose because that's still more (estrogen) than you make on your own."

She said that going through menopause without being aware of it is fairly common. The current NAMS guidelines suggests that women can remain on low-dose birth control until age 55 before being transitioned to hormone replacement therapy.

Unfortunately, not all gynecologists are aware of the recommendations. Dr. Streicher notes that up to 70 percent of patients seen by a traditional gynecologist/obstetrician are there for obstetrician services so they may seldom see patients going through menopause or might not be as interested in treating it.

"The more you know, the better you are at," she said. "Most doctors -- when patients ask about vaginal dryness -- they're not embarrassed, but they just don't know a lot."

The protection of estrogen

Most commonly, menopause symptoms are treated with hormone replacement therapy consisting of either only estrogen or a combination of estrogen and progestogen therapy.

Progesterone combined with estrogen is used to protect against uterine cancer in women that still have a uterus. Estrogen-only therapy is prescribed for women without a uterus following a hysterectomy.

Women who receive hormone replacement therapy often can successfully reduce or eliminate the side effects of menopause, while also protecting their health. Dr. Streicher said a great deal of scientific research suggests that women who take estrogen during the first five years after menopause receive a benefit in cognitive function, while also gaining protection against heart disease and decreasing the risk of osteoporosis and bone loss.

Women in menopause who take hormone therapy are not at an increased risk of osteoporosis or heart disease as compared to women who have not yet begun menopause. However, hormone replacement therapy does come with risks.

Taking oral estrogen alone or as a combined hormone therapy increases the risk of blood clots, heart attack and stroke, though the risk level returns to normal after hormone replacement is stopped.

Other risks include urinary incontinence, and dementia in patients over the age of 65 who take hormones, though most women tolerate the estrogen well.

"There are very few risks with taking estrogen," said Dr. Streicher. "For the majority of women, they do absolutely fine with hormone therapy. I have women in their 80s who are still happily on it."

Women who take estrogen combined with progestin also are at an increased risk of developing breast cancer. The breast cancer is more likely to be larger and have spread to the lymph nodes at the time it is diagnosed, the National Cancer Institute notes. Breast cancer risk increased with the length of time a woman takes hormone replacement therapy, though the risk declines after it is stopped.

"While many women are concerned about an increased risk of breast cancer, the risk is probably minimal if at all. WHI (The Women's Health Initiative) showed no increase in breast cancer in women who took estrogen alone. I prescribe estrogen for women with a family history of breast cancer," said Dr. Streicher, who noted that dementia is only a concern when hormone replacement is started after the age of 65.

She also noted that transdermal estrogen does not seem to have the increased risk of stroke heart disease or blood clots, which she expects will be backed by the KEEPS study to be released in the coming weeks.

Estrogen is available in several forms, ranging from an oral pill to transdermal patches that are placed on the skin. Other forms include gel, emulsion or spray used for treating symptoms such as hot flashes and night sweats, vaginal symptoms, and osteoporosis.

Localized creams, rings and tablets can aid women with specific concerns such as vaginal problems. For women without symptoms, skipping hormone replacement might be the best option.

One dilemma regarding hormone replacement therapy, however, is the current recommendation that women take the lowest dose for the shortest possible period of time.

"This can be meaningless," said Dr. Streicher. "If it helps their sex drive it might be needed until death. It it's just hot flashes, maybe it would be shorter."

Reviewed by: 
Review Date: 
December 16, 2011