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Menopause before 40 and spontaneous premature ovarian insufficiency

Menopause before 40 and spontaneous premature ovarian insufficiencyMAIN POINTS

  • Premature ovarian insufficiency (POI) is a loss of function of the ovaries in women who are less than 40 years old. 
  • Spontaneous POI affects 1% of women less than 40 years and in most cases the cause is not identified. 
  • Irregular/no menstrual periods or menopausal symptoms may be the only sign of POI and blood tests are needed for diagnosis.  
  • POI can cause infertility and increase the risk of long-term health problems such as heart disease, osteoporosis and memory problems. 
  • Hormone replacement therapy is recommended until the natural age of menopause (51 years) to reduce the long-term risks. 
  • Speak with your doctor about treatments and other options to manage any infertility and health consequences.

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Premature ovarian insufficiency (POI) is a loss of function of the ovaries in women who are less than 40 years of age. The ovaries do not release eggs regularly and do not produce typical amounts of oestrogen.

Women with spontaneous POI have irregular or no periods. Women may or may not have menopausal symptoms such as hot flushes. Approximately one in every 100 women will spontaneously have POI and enter menopause before the age of 40. Spontaneous early menopause (menopause between 40 and 45 years) affects approximately five in every 100 women.

POI can affect your short- and long-term physical and mental health. Speak with your doctor about emotional support and lifestyle and treatment options to manage your health.

Symptoms and consequences of premature ovarian insufficiency

POI has a number of symptoms and long-term health problems, but your doctor can advise you about treatment and other options to manage your symptoms and health (see below). Signs and symptoms of POI can include:

  • loss of menstrual periods – one of the first or only symptom of POI and can be preceded by longer or irregular periods
  • menopausal symptoms such as hot flushes and sleep disturbance, aching joints, vaginal dryness or poor lubrication during sexual arousal

mood changes, depression and anxiety, feelings of confusion and sadness. These symptoms can come on suddenly or gradually and can occur while you are still having periods. Long-term health consequences of premature ovarian insufficiency can include a greater risk of:

  • infertility
  • cardiovascular disease
  • osteoporosis
  • psychological distress
  • memory and learning problems and dementia.

Causes of premature ovarian insufficiency

In up to 90 per cent of women with spontaneous POI, the cause is unknown. In some cases, the condition can be associated with:

  • genetic conditions – in women with Turner syndrome and in women who are carriers of Fragile X syndrome
  • autoimmune conditions – such as autoimmune thyroid disease, type 1 diabetes, pernicious anaemia, myasthaenia gravis and connective tissue disorders
  • rare metabolic conditions such as galactosaemia
  • chemotherapy and radiation therapy (see AMS fact sheet – Early menopause – chemotherapy and radiation therapy).

Risk factors for spontaneous POI include:

  • age – although younger women can have POI, the risk increases between 35 and 40 years of age
  • family history of early menopause
  • never having given birth
  • hysterectomy
  • HIV infection
  • smoking.

Diagnosis of premature ovarian insufficiency Diagnosis of POI is difficult and can be delayed because women and their doctors might not consider the possibility of menopause in younger women. A process of elimination of other potential causes for the loss of your period will be needed. Criteria for a diagnosis of POI include:

  • more than four months without a menstrual period
  • follicle stimulating hormone (FSH) levels in the menopausal range on two occasions at least 4–6 weeks apart.

A diagnosis of POI can be distressing and you will need to plan for your future health. Make sure you are comfortable with your healthcare team because you will need followup support and management options.

Treatment and other options for managing your health

Women with POI should discuss with their doctor the possibility of using hormone therapy.

In women more than 50 years of age, hormone therapy is called menopausal hormone therapy (MHT). In women who are aged less than 50, similar hormone therapy can be called hormone replacement therapy (HRT) because the treatment is replacing hormones that would otherwise be produced in younger women. If you choose to use HRT, international guidelines recommend that you continue HRT until the typical age of menopause (51 years) to reduce your risk of long-term health problems. Oestrogen therapy is not suited to everyone and is best avoided if you have breast or endometrial cancer. In these cases, non-hormonal options are available to help manage hot flushes and other symptoms. HRT options include (see AMS fact sheet – What is MHT and is it safe?):

  • oestrogen tablets, patches, gels and topical vaginal treatments – if you have had a hysterectomy
  • oestrogen plus progesterone – if you have not had a hysterectomy
  • combined oral contraceptive pill as a replacement hormone – if you have no significant risk factors (such as a clotting tendency, past clots or if you are a current smoker).

If contraception is required, hormonal options include the oral contraceptive pill or an intrauterine device plus oestrogen (usually as a patch or gel). If hormones are not recommended for your situation, discuss non-hormonal contraceptive options with your doctor.

Managing fertility issues

There is a very small chance that some women with POI can become pregnant. If you do not want to become pregnant, you should use contraception. Losing fertility at an early age can cause emotional distress. The support of a partner, family, friends and your healthcare team can help you manage fertility issues. Women can manage their infertility in a number of ways including:

  • choosing not to have children
  • adopting or fostering children
  • trying in vitro fertilisation (IVF) or medications to stimulate egg production – these have a low chance of success
  • using donated eggs
  • using donated embryos from another couple.

Managing health risks associated with premature ovarian insufficiency

Adopting healthy lifestyle changes (see AMS fact sheets – Lifestyle and behaviour changes for menopausal symptoms and Weight management and healthy ageing) can reduce the risk of some of the health impacts associated with POI. Long-term health risks include:

  • osteoporosis or bone loss
  • cardiovascular/heart disease
  • learning and memory disturbances
  • emotional disturbances.

It is widely known that regular physical activity, a healthy diet and healthy sleep patterns can improve these problems, no matter what the cause. In addition, regular check-ups (including blood tests and bone scans) with your doctor can help you to manage your health. Osteoporosis Osteoporosis in women with POI can be caused by:

  • low levels of oestrogen
  • low levels of calcium in the diet
  • smoking
  • low levels of physical and weight-bearing activity
  • some types of chemotherapy and medications.

In addition to lifestyle changes (quitting smoking, engaging in regular weight-bearing activities, and ensuring adequate dietary intake of calcium and vitamin D) women should have regular bone density scans every one or two years. Use of HRT can help to maintain bone health.

Cardiovascular or heart disease

POI can result in an earlier increase in the risk of heart disease in women. Taking HRT early and continuing treatment until the age of a natural menopause (51 years) can reduce the risk of heart disease. Regular check-ups for high blood pressure, diabetes and fats in the blood will help you manage your heart health.

Learning and memory problems

There is only limited evidence that low levels of oestrogen affect memory. Taking HRT early and continuing treatment until the age of a natural menopause (51 years) might reduce the risk of any potential learning and memory problems.

Emotional issues

A POI diagnosis means women have the stress of having to cope with potential menopause, infertility and the related long-term consequences. It is only natural to feel some psychological distress and some women might have anxiety and depression. Women can feel confused, sad, old before their time and have mixed feelings about other women’s pregnancies. Psychological counselling can ease this distress. Support from the woman’s partner, family and friends is important.

Support groups

In addition to the support of family, friends and a healthcare team, some women find it useful to talk to other women in the same situation. Available support groups include: ACCESS Australia (Australia’s National Infertility Network) – www.access.org.au The Daisy Network Premature Menopause Support Group – www.daisynetwork.org.uk NZ Early Menopause Support group – www.earlymenopause.org.nz

Where can you find information about other treatment options?

If your symptoms are bothering you, your doctor can help. Your doctor can tell you about the changes in your body and offer options for managing your symptoms. Other fact sheets about treatment options include:

If you have any concerns or questions about options to manage your menopausal symptoms, visit your doctor or go to the Find an AMS Doctor service on the AMS website.

AMS Empowering menopausal women

NOTE: Medical and scientific information provided and endorsed by the Australasian Menopause Society might not be relevant to an individual’s personal circumstances and should always be discussed with their own healthcare provider. This Information Sheet may contain copyright or otherwise protected material. Reproduction of this Information Sheet by Australasian Menopause Society Members, other health professionals and their patients for clinical practice is permissible. Any other use of this information (hardcopy and electronic versions) must be agreed to and approved by the Australasian Menopause Society.

Content updated November 2018

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