4 Things to Know About Early and Premature Menopause

The experience of menopause can vary widely. Some women have debilitating hot flashes, among other symptoms, that interfere with sleep, work, and everything else in life. Others sail through this life change—the end of menstruation and, thus, fertility, marked by a full year without a period—with hardly a complaint. Still others fall somewhere in between.

But in addition to having potentially unbearable symptoms, women going through menopause are at risk of experiencing detrimental health consequences, such as an increased risk of heart disease, stroke, dementia, and osteoporosis (a condition in which bones become weak and break easily). That’s because at and after menopause, a woman’s ovaries have few remaining eggs and no longer produce hormones, causing her estrogen levels to drop.

Ovarian estrogen plays crucial roles in the body, including protecting bones and keeping the vagina, heart, and brain healthy. As a result, the earlier a woman reaches menopause (particularly before age 45), the more exposure she has to the negative health effects mentioned above.

In the United States, the average age of menopause is 51. Menopause between ages 40 and 45 is considered “early menopause,” and before 40 is called “premature menopause.” About 5% of women experience early menopause, and roughly 1% of women go through premature menopause. Early or premature menopause can have the same causes; the only difference between the two is the age at which it starts.

“There are certain genetic reasons and autoimmune conditions that can lead to early or premature menopause, but sometimes we never really quite know why it happens,” says Hugh Taylor, MD, chair of Yale Medicine Obstetrics, Gynecology & Reproductive Sciences. “But premature or early menopause can be devastating because that means a woman has lost her fertility, and she may still want to complete her family.”

It’s also true that some medical treatments, including chemotherapy for cancer, may cause a woman to go into menopause early. In these cases, she may be able to preserve fertility by freezing her eggs or even ovarian tissue. However, the normal effects of menopause, including burdensome symptoms, will remain.

A woman who is in menopause before age 45, especially if she has uncomfortable symptoms, should consider hormone therapy to make up for the extra years of lost estrogen and to relieve discomfort, Dr. Taylor says. Hormone therapy is often now called menopausal hormone therapy (MHT), an update to the term hormone replacement therapy (HRT).

“If there are no contraindications to taking hormones [more on that below], we know that estrogen prevents hot flashes [a sudden feeling of heat in your face, neck, and chest]. It helps with sleep, preserves bone, and it may have some cardiovascular benefits if you're younger and still have healthy blood vessels,” Dr. Taylor says.

The use of hormone therapy for menopause symptoms became controversial after the landmark Women’s Health Initiative (WHI) study was stopped early in 2002. At that time, data suggested that postmenopausal women taking hormones were at increased risk of breast cancer, stroke, pulmonary embolism, and cardiovascular disease.

However, since then, a major limitation of the study has been pointed out—the women in the study were mostly over age 60, which meant they were already at higher risk of cardiovascular disease and other health problems. A recent review in JAMA Network exploring the WHI study concluded that women younger than 60 in the WHI hormone therapy trials had more benefits than risks compared to women between ages 60 and 79.

“It’s highly individualized, but hormone therapy is a very safe strategy for the right patient. It wasn’t so much the WHI data that was an issue, but how it was interpreted and applied broadly to young women, not the older women who were studied,” says Lubna Pal, MBBS, MS, a Yale Medicine reproductive endocrinologist and infertility specialist.

We talked more with Yale Medicine physicians about what women who go through premature or early menopause should know.

Early or premature menopause can occur for unknown reasons, or it can be the result of medical treatments or procedures, including chemotherapy or pelvic radiation for cancer, surgical removal of the ovaries, and removal of the uterus (hysterectomy).

Women with a family history of early or premature menopause are more likely to go through the transition early. “We don’t know why this happens, but if mom has gone through menopause at a very early age, we encourage her to talk to her daughters about it because that can figure into their family planning in terms of when they might lose fertility,” says Mary Jane Minkin, MD, a Yale Medicine gynecologist.

Other factors that increase the chance of early or premature menopause include having an autoimmune condition or certain other diseases (such as thyroid disease, rheumatoid arthritis, or HIV/AIDS) and specific genetic conditions (such as Turner Syndrome). Additional associations have been reported, but there is nothing definitive.

In addition to the many uncomfortable symptoms that can accompany menopause, ranging from vaginal dryness and pain during sex to memory problems to incontinence, it’s even harder for women who are younger, Dr. Minkin notes. “We know the consequences of menopause are more significant the earlier you go through it,” she says.

There is bone loss, for instance, at a young age, which might put women at a higher lifetime risk of fracture, says Dr. Taylor. “That is tough because these are often active women who want to be engaged in sports,” he says. “And they are also likely sexually active and need to prevent vaginal atrophy, which is another symptom.”

Early or premature menopause might be especially difficult for women who experience it suddenly as a result of surgery or a medical treatment.

That sudden drop in hormone levels can feel dramatic, Dr. Taylor explains, because most women first go through perimenopause, which is the time leading up to menopause when the ovaries slow down, periods become irregular, and hormone levels fluctuate.

“It’s not that one day the ovaries shut off and you're in menopause. Often, it's a slow, gradual transition, and it can last several years,” Dr. Taylor says. “But if a woman enters menopause suddenly from having her ovaries removed surgically, for example, it can feel like they are falling off a cliff, and they can suffer significantly.”

Estrogen is a natural hormone mostly produced in the ovaries that is important for building and maintaining bone. In young women, it can also prevent vascular damage. However, after menopause, the ovaries do not produce much estrogen, Dr. Taylor says.

Notably, women who experience premature or early menopause have a higher risk of heart disease and osteoporosis because they will spend more years of their lives without the benefits of estrogen.

“If you have healthy blood vessels, estrogen tends to keep them healthy by allowing them to be relaxed and open, and by helping the body maintain a healthy balance of good and bad cholesterol. However, if you have damaged blood vessels, such as from aging or diseases like obesity, having supplemental estrogen around may be a risk. If you have atherosclerotic plaques, for instance, it may make them more likely to rupture,” Dr. Taylor explains. “If they do, estrogen causes an increase in clotting, so it's more likely to clot off that blood vessel and cause a heart attack or stroke. If you're 80 and have damaged blood vessels with some atherosclerosis, taking estrogen can be risky for the heart. But if you're 30, you really need it to preserve cardiovascular benefits.”

Because of this, women who are going to use MHT should do so within six to 10 years of their last menstrual period, Dr. Minkin says.

“The timing is very important. If you don’t give estrogen early but wait 12 years after menopause, which was the average incidence when estrogen was given in the WHI study, we know it’s too late, and it won't protect against heart disease,” Dr. Minkin says. “That’s why I do my best to educate patients who go through menopause early on the benefits of estrogen—it can protect your heart, your brain, your bones, and your vagina.”

Unless there’s a reason a woman can’t safely take hormones, medical experts recommend menopausal hormonal therapy for women going through premature or early menopause. One reason a woman shouldn’t receive MHT is if she had breast cancer in the past, because studies have shown that breast cancer survivors who took MHT were more likely to have new or recurrent breast cancer than women who were not taking hormones.

For a woman who does not have a personal history of breast cancer, certain forms of MHT can raise the risk of breast cancer, but that risk is very small and has more to do with therapy that includes progestin, a synthetic form of the natural hormone progesterone, Dr. Taylor says.

MHT comes in two main types: estrogen-only and estrogen plus progestin. Estrogen-only therapy thickens the uterus lining, which raises the risk of uterine cancer. Progestin is a hormone that reduces this risk. If a woman doesn’t have a uterus, she doesn’t need progestin.

MHT is delivered either systemically (meaning it is released into the bloodstream) or locally (only to the affected area). If used systemically, it can be delivered via pills, skin patches, gels, injections, and sprays; if used locally (for example, for women experiencing only vaginal dryness), it may be applied directly to the affected area by vaginal ring, cream, or tablet.

The delivery methods may have estrogen and progestin together, or progestin may be taken separately. Depending on the type of MHT, it may be taken daily or on certain days of the month. Systemic hormone therapy is usually not recommended for women who have had endometrial cancer, stroke, a heart attack, blood clots, or liver disease or for those who are pregnant.

The risks of MHT are very small for younger, healthy women who don’t have contraindications against taking it and are experiencing bothersome menopause symptoms, Dr. Pal says.

“It’s only when aging accelerates, when the risk of stroke and clotting go up, when obesity is present—when all of these things add up—that adding estrogen, for some patients, may not be the best choice,” she says.

The U.S. Food and Drug Administration (FDA) recommends that women take MHT at the lowest dose that works for them and for the shortest time needed.

This, doctors say, can be extremely variable. According to The Menopause Society, "the benefit-risk ratio is favorable for women who initiate hormone therapy close to menopause (ages 50-59, typically) but becomes riskier with time. Women with early menopause before age 40 without a history of breast cancer risk can take hormone therapy until the typical age of menopause at 51 if there is no reason not to take it. Clinicians will recommend an individualized plan for each woman. There is no ‘one-size-fits-all’ therapy.”

Dr. Minkin agrees. “As long as a woman is healthy and feels well on her estrogen, I keep her on it; this is a shared decision-making event between me and my patient,” she says.

There are also nonhormonal options, including a pill approved by the FDA last year for hot flashes sold under the brand name Veozah®, with other new medications on the horizon. While such a pill will offer comfort for that symptom, it won’t provide all the health benefits of estrogen, Dr. Taylor notes. Additionally, some women take anti-depressants for menopause symptoms, but none of them are nearly as effective as hormonal options, he adds.

Ultimately, the decision to take MHT is a woman’s, Dr. Minkin says.

“A woman needs to make an informed decision based on risk factors and what she’s interested in,” she says. “We talk about everything together. I present the data, meet them where they are—in terms of their level of understanding—and encourage them to think about it. It’s always their decision.”