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Missed Periods - Premature Menopause?

As a reader of this blog you probably know that missed periods, very late, and erratic periods usually can be attributed to missed ovulations. Yet when hot flashes or night sweats are also present many younger women wonder “Could I have premature menopause?” After reading this post you should have the information needed to work with your GYN to get a definitive answer.

Is there a difference between early menopause, premature menopause, and premature ovarian failure?

Overall, menopause means the failure of ovaries to produce estrogen. Estrogen builds up the lining of the uterus so that there is something to shed as a period. Technically, if your uterus is removed with a hysterectomy you will have no more periods. Yet if the ovaries are still in place and working, a woman is not yet in menopause. If ovaries are taken out that is considered “surgical menopause.”

According to the North American Menopause Society, early menopause is when the last, natural menstrual period occurs before age 45, while premature menopause indicates a woman aged 40 or less. Premature ovarian failure (POF), like premature menopause, also is linked to being age 40 or younger. Among researchers who study POF, a term used first by the French “Ovarian Insufficiency” may become the new standard term for POF. I’ll explain why that is the most appropriate term in a moment.

How common is POF?
Overall the incidence in the USA is reported to be 1-4% of women. While POF can be triggered by medical interventions such as chemotherapy, radiation, or surgery, the greatest number of women will not have an observable cause. The majority of woman with POF will have had prior menstrual periods.

The exceptions to these generalizations are in teenagers, who have not yet had a first period. In this specific group there is a 50% incidence of an abnormal, genetic karyotype. If this is suspected specialized testing is done, along with genetic counseling.

Is it true that POF can reverse back to normal?
The answer here is both “yes” and “no”. About half of younger women (age less than 40) with a clear diagnosis of POF will experience normal function of the ovary that can come and go. That’s why the term “Ovarian Insufficiency” may end up as the new standard name for POF. Insufficiency suggests the status quo might return – it is not permanent as implied by the idea of “menopause.”

Does that mean I COULD get pregnant after a diagnosis of POF?
The data suggests that 5-10% of POF women will conceive unexpectedly. That is good news if women are trying to conceive. But the majority of women with POF will usually have a family via donor eggs, or adoption. There have been numerous studies of ovulation induction treatments (eg. Clomid, estrogens, GnRH, FSH, etc.) for women with POF. Alas, the best designed studies have failed to show ovulation rates any better than in untreated POF women (Sinha, 2007).

What if I don’t want to get pregnant?
Among women who become menopausal at around age 50, we suggest some type of birth control should be used for one year after the last period. For women with POF, contraception should be used for a minimum of two years. Because of the intermittent, and unpredictable, ovulations in some women there are reports of POF women conceiving 8-15 years after there diagnosis of POF! For birth control, barrier methods (eg condoms/spermicide, diaphragm) or birth control pills (BCPs) can be used. BCPs have the additional benefit of adding needed estrogen if a woman’s ovaries are not producing their own estrogen. One study (Buckler, 1993) found that BCP use did not enhance the return of normal ovary function.

What should I ask of my GYN if I want them to check for POF?
There is no completely standardized evaluation for POF. Generally, the following four elements need to be present to make a diagnosis of POF:

  • Absent periods for 4, or more, months
  • Age 40 or less
  • Evidence of low estrogen (eg vaginal dryness, hot flashes, etc)
  • FSH blood test results of more than 40mIU on two tests taken a little over a month apart

Probably the most important part of the work up for POF is for the GYN to consider it as a possibility. One study of 48 women with POF found age 25 to be the average age of symptom onset, but it took two years to get the correct diagnosis. Almost two thirds of the women had to see three or more MDs before getting the correct diagnosis (Alzubaidi, 2002).

Where can I learn more?
Of all the internet sites I reviewed, I believe that these two have some of the best information.

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