Losing fertile ground

Dr Pratibha Singhal

The number of women who experience early menopause related to premature ovarian failure is rising. Many patients feel devastated by their diagnosis of premature ovarian failure (PoF) or premature menopause.

What is premature menopause 

The World Health Organisation defines natural menopause as complete cessation of menses for more than a year in a woman resulting from the loss of ovarian function. Normal menopause occurs between 45 to 55 years of age, with mean age of 51 years. In India, the range of mean menopausal age has been reported as 41.9 to 49.4 years. However, menopause is said to be early if occurs between 40 to 45 years age whereas below 40 years is labelled as premature.  Menopause occurs when your ovaries stop producing estrogen, the hormone that controls the reproductive cycle. A woman is in menopause when she hasn’t had a period for more than 12 months. 

Indian studies, conducted on women between 15 to 49 years, revealed the incidence of premature menopause as 1.5 per cent. Some Indian surveys have also found that 18 per cent of married women between 30 to 49 years have reached menopause. The number of women who experience early menopause related to premature ovarian failure is rising worldwide, according to recent studies. The overall incidence of premature menopause worldwide is 1 per cent. Some surveys have reported the incidence as high as 8 per cent. 

Watch out for the signs 

Premature menopause has been associated with malnutrition, poverty , emotional stress, genetic factors and demographic variables Demographic studies reveal the lowest rate in Kerala (0.2 per cent)and highest in Odisha (2.4 per cent) Higher incidence has been found in poorest and lowest in richest. Female sterilisation at early age also leads to premature ovarian failure and subsequent premature menopause. 

 Auto-immune conditions like thyroid, adrenal insufficiency, rheumatoid arthritis are commonly associated with PoF leading to premature menopause. The increasing incidence of cancers at early age is an important cause of premature menopause due to surgical removal of ovaries, chemotherapy and radiotherapy. Above all, several studies have strongly associated premature menopause with rapidly changing dynamics of the Indian family, the increased stress upon women to be financially independent with reducing family support system leading to tremendous physical, emotional and mental strain on women. Add to these pressures, lack of proper nutrition and sedentary lifestyles and situation becomes more scary. Smoking, too, makes women more prone to premature menopause.

This unfortunate condition often affects self-esteem of affected young women and many of them think that they will never feel normal again. Aside from hormone replacement therapy (HRT), conventional medicine doesn’t help much when it comes to PoF. It is not possible to reassure women of regaining the normal function of ovaries. However, a complete understanding of the problem and its management does make life easier for the affected women. 

Seek medical help immediately

A premature menopausal woman has to face several concerns about infertility as well. PoF is usually permanent but ovarian activity can resume in 5 to 10 per cent of cases leading to return of menses and sometimes fertility. However, with complete menopause, use of donor eggs, IVF, surrogacy and adoption are the only means left for becoming parents in cases of premature menopause. 

The other clinical features of concern are the premature start of hot flushes, night sweats, mood swings, behavioural changes, lowered sex drive, vaginal dryness, repeated urinary infection, weight gain, sleep disorders etc. Apart from these, affected women are at greater risk of weak bones or osteoporosis due to low estrogen levels. Similarly, having lost the protective effect of estrogens for the heart at early age, these women are more prone to heart disease. Further, premature menopause often leads to some form of depression as a result of fluctuating hormones in the body, coupled with extremely anxious state of mind following the premature cessation of menses.

Line of treatment

Medical management of women suffering from premature menopause is aimed at regaining a normal life with specific therapies, life-style modifications, including regular exercise schedule. 

Some common treatments include hormone replacement therapy (HRT) or menopausal hormone therapy (MHT). Dietary changes also have important role. They should shun transfats and refined carbohydrates. Fresh fruits and vegetables should be included in diet processed foods avoided. Exercise, yoga and meditation provide some relief in this stressful condition and can lead to a more positive and happy life. Calcium, multivitamins and vitamin D supplements are advised on regular basis. Hormone replacement therapy, if advocated, has to be strictly monitored in view of proven increased risk of breast and uterine cancers. 

How is it diagnosed?

Tests aren’t usually needed to diagnose menopause. Most women can self-diagnose menopause based on their symptoms. But if you think you’re experiencing early menopause, it is recommended to visit a gynaecologist at the earliest.  The doctor would recommend a few hormone tests to help determine whether your symptoms are due to peri-menopause or another condition. These are the most common hormones to check:

  • Estrogen: In menopause, estrogen levels decrease.
  • Follicle-stimulating hormone (FSH): If your FSH levels are consistently above 30 mIU/mL, and you haven’t menstruated for a year, it’s likely that you’ve reached menopause. However, a single elevated FSH test can’t confirm menopause on its own.
  • Thyroid-stimulating hormone (TSH): Your doctor may check your levels of TSH to confirm diagnosis. If you have an underactive thyroid (hypothyroidism), TSH levels are too high. Symptoms are similar to the symptoms of menopause.
  • Infertility is often the biggest concern when you start menopause early. 

Causes

  • Genetic factors 
  • Lifestyle factors such as smoking and a high BMI 
  • Autoimmune diseases like thyroid, adrenal insufficiency, rheumatoid arthritis

Symptoms 

  • Reduced menstrual flow
  • Progressively delayed cycles
  • Vaginal dryness 
  • Trouble in sleeping 
  • Night sweats

— The writer is director, Department of Obstetrician and Gynaecology, Cloudnine Group of Hospitals, Noida