Early menopause

Early menopause is menopause that comes before 45. The Pakistan Menopause Society puts it between 40 and 44. Before 40 it has a different name, premature ovarian insufficiency, with guidance of its own.

For Pakistani women the line at 45 sits close to the average, which the Pakistan Menopause Society puts between 45 and 49. See age at menopause.

The main sign, the NHS website says, is periods becoming infrequent or stopping before 45. Alongside that it lists hot flushes and night sweats, vaginal dryness, difficulty sleeping, low mood or anxiety, a lower sex drive, and problems with memory or concentration.

There is often a feeling the lists leave out. Being told you are too young for this, by family, friends or even a doctor, and then finding out you are not. Some women feel relief at having a name for it. Some feel grief, especially if they had hoped for more children. Both are normal reactions, and NICE recommends psychological support for women who are distressed by an early menopause.

The NHS website says early menopause is more likely if it runs in your family, and if you started your periods early, smoke or are underweight. Treatment for other conditions can cause it too: radiotherapy, chemotherapy, certain hormone medicines and surgery to remove the ovaries. See menopause after chemotherapy and surgical menopause.

The European Menopause and Andropause Society (EMAS) adds endometriosis: it says the condition, or its treatment, may lead to an early menopause.

NICE NG23 adds that it can also happen for a reason nobody can find (1.2.1). Either way, it is not something you caused.

The Pakistan Menopause Society asks doctors to take early menopause seriously from the first appointment:

• Between 40 and 45, with symptoms and a change in your cycle, an FSH blood test can be considered if the result would change the advice (Table 3). NICE NG23 says the same for 40 to 45 (1.3.6). More in FSH.
• Early menopause with distress or a fertility concern is on its list of red flags that need evaluation or referral (section 2.3).
• When early menopause is suspected, doctors should refer to a clinician with menopause expertise (section 3.4).
• A bone scan, called DXA, where available, is listed for women with early menopause (Table 4).

The NHS website says early menopause is usually treated with the combined contraceptive pill or HRT, to replace the hormones that are low. The reason it gives is your bones and heart. The same page notes that women who have had certain types of breast cancer may not be able to have hormone treatment.

EMAS adds dementia to the list. It says an early menopause, left untreated, raises the risk of osteoporosis, heart disease and dementia. The British Menopause Society also names dementia among the later risks when menopause comes very early in South Asian women and goes untreated.

The Pakistan Menopause Society says hormone therapy is indicated and recommended in early menopause (section 5.1).

NICE NG23 asks doctors to explain that for women in early menopause, the benefits and risks of taking or not taking HRT are likely to sit somewhere between those for women with premature ovarian insufficiency and those for women of 45 and over (1.6.6). The Menopause Society adds that the results of the Women's Health Initiative, the large HRT trials in older women, do not apply to women with an early menopause. Whether HRT suits you is your doctor's call, made with your history in front of them.

If you are under 45 and your periods have become irregular or stopped, see a doctor. You do not need to wait a year to find out. The NHS says a GP may sometimes do blood tests if you are under 45.

If you are finding the diagnosis hard, say so. That is what NICE's recommendation on psychological support is for.

The British Menopause Society, writing about premature ovarian insufficiency in South Asian women, points out that many women finish having children young. With no more children planned, an early end to periods can seem not worth a doctor's visit. The same thinking can keep a woman of 42 from booking an appointment. But the worry is not only fertility: the NHS points to bones and heart, which is why the guidance still wants you seen.

For women still hoping for a child, early menopause can be one of the hardest diagnoses to carry, and the pressure from family can make it heavier. Questions about fertility treatment and faith come up often. Those belong with a qualified scholar you trust, and the medical options with a fertility specialist.