Understanding Premature Ovarian Insufficiency

Majority of women go through ‘the change’ in their lives around the age of 51 to 52 years. However, for some women, ‘menopause’ may knock on their doors significantly early before they even reach their 40th birthday. Premature ovarian insufficiency (previously referred to as ‘premature menopause’ or ‘premature ovarian failure’) is a loss of ovarian function before the age of 40 years and it affects up to 3% of all women.

The ovaries primarily do two things for women – they mature and release eggs, and make female hormones called oestrogen and progesterone. Their activity is controlled by other hormones (FSH and LH) which are made by the ‘pituitary gland’ which lies behind the bridge of the nose. All these hormones interact as part of the monthly menstrual cycle. In premature ovarian insufficiency, the ovaries stop producing normal levels of oestrogen and may not produce eggs.

POI may be caused by chemotherapy or radiotherapy, or if the ovaries are removed during an operation. Removal of the ovaries due to cysts, tumours or in conjunction with a hysterectomy will often cause an abrupt menopause. POI can occasionally be due to chromosome or gene problems, which are found in one in 20 women with POI. On chromosomal testing, an abnormal X chromosome may be identified – the most common form is Turner Syndrome where one X chromosome is missing (normally women have 2 X chromosomes).

POI may be associated with autoimmune diseases such as diabetes or thyroid disease. In autoimmune conditions, body’s immune system mistakenly fights and damages the ovary. Some metabolic conditions such as galactosaemia and infections like mumps or tuberculosis are associated with POI.

However, most of the time, no cause is found for POI. This is known as ‘idiopathic’ or ‘unexplained’ POI.

Symptoms associated with premature menopause

With POI, periods become infrequent or stop. There may be other symptoms such as hot flushes (sudden feeling of heat), night sweats, palpitations, decreased energy levels, lack of concentration, poor sleep, lack of interest in sex, vaginal dryness and painful sexual intercourse. Majority of women with POI experience significant symptoms that negatively impact on their quality of life. The erstwhile formidable company board chair suddenly finds that she is self-conscious of the hot flushes that she now frequently experiences during crucial meetings – “surely everybody can see my sweating and red face” – and the clouding of her memory and decline in concentration powers. The relationship with her husband is not great, and she could not care less if they were never intimate again – which saddens her, because she still loves him, just not interested in the sex thing. She wakes up tired rather than refreshed as her sleep was interrupted by the cycles of heat and cold, and waking up several times to empty her bladder. The woman whose hair was once her pride and joy now finds that she fills the sink with dropping hair every time she shampoos her now dry and coarse hair. She now needs gallons of moisturizing cream for her skin, and her nails break all the time. Her energy levels have declined so much she feels she could sleep for England, and she feels so bad at how easily she snaps at her teenage children for the slightest of misdemeanours – and sometimes for no good reason at all. She watches a movie of an afternoon and finds herself in floods of tears, something she never used to – become sentimental with time? There is also this feeling of global anxiety for no obvious reason, and a loss of self-confidence – she no longer feels able to stride boldly into a room full of people, and does not feel able to express her opinions as publicly as she used to be able to.

Mary Buchan has depicted the main menopausal symptoms in terms of the SEVEN Dwarves who have “mutated from the fabulous 7 little guys who help Snow White escape from the curse of her wicked stepmother into gremlins on a mission to haunt the woman going through the change” [see http://marybuchan.com/wp-content/uploads/th1.jpg].

Itchy. Women can find that their skin becomes itchier and drier, particularly on the vulva, after premature menopause. The vaginal and vulval tissues become thinner and more fragile without oestrogen and this can make them become irritated or more prone to infections and skin conditions.
Bitchy. Dropping levels of oestrogen can have an effect on the level of endorphins (or feel good chemicals) in your brain. Many women will feel snappy or irritable with those around them during the menopause. Lack of sleep, depression and adapting to changes in your life can be the cause of this just as much as the menopause though.
 
Sweaty. Most of us have heard of, or experienced, hot flushes. That overwhelming tidal wave of heat, flushing and sweating that comes out of the blue. This is because of changes in the part of the brain that regulates temperature. The good news is that they do eventually settle although this does vary between women.

Bloaty. Hormone changes can cause some women to retain water or produce more gas than before the menopause. Becoming less active can also make bloating worse. Women often blame the menopause for weight gain, but most cases of weight gain are actually due to decreasing activity levels and changes in diet. 

Sleepy. Many women report that they struggle to get to sleep during or after premature menopause. Hot flushes are often the cause of this. Insomnia or lack of sleep may mean that you feel tired and sleepy throughout the day.

Forgetful. Although lots of women report that they started to become forgetful after their periods stopped, there isn’t actually any evidence to link memory problems with premature menopause. However, there is a link between getting older and not being able to remember things as well. If you are preoccupied with lots of other symptoms, then this will also make you more likely to become forgetful.
Psycho. The familiar stereo-type is of the knife wielding woman who has experienced an early change. Contrary to popular opinion, women do not turn into axe wielding maniacs once they stop needing to buy Tampax, and there is much than can be done to help cope with the irritability and mood swings that some women experience.

There are other symptoms associated with premature menopause which people do not generally recognise are part of the effects of the decline in oestrogen levels. These include flatulence, aching in muscles and joints, aches in back of neck or head, decrease in physical strength and stamina, weight gain, increased facial hair, involuntary urination on laughing or coughing, being dissatisfied with one’s personal life, feelings of wanting to be alone, and being impatient with other people, and feeling depressed, down or blue.

What happens to these symptoms over time, if left untreated? In some women the symptoms do burn out, while in others they may persist for decades. Unfortunately, it is not possible to predict what will happen in any given woman. What is evident is that no woman has to put up with debilitating symptoms just because she has experienced the premature menopause. Most, if not all of the symptoms can be controlled or eradicated. Conventional HRT is the most effective weapon, but where it may be contra-indicated, such as in women with a history of breast cancer, there are other weapons in the armamentarium.

Premature menopause and long-term health

The low oestrogen levels over a prolonged time (due to POI) can cause osteoporosis (bone thinning), which can lead to fractures. Low bone density can be diagnosed by a bone density scan (known as a DEXA), which is a simple and painless test using a low dose of X-rays. This can be repeated every few years to monitor the bone strength. The risk of osteoporosis is also influenced by smoking, exercise, calcium and vitamin D intake.

POI probably also causes an increase in cardiovascular risk (the risk of having a heart attack or stroke), which is also influenced by many other factors including smoking, diet, exercise and weight.

The good news is that both the osteoporosis and the cardiovascular risks can be prevented by regular use of hormone replacement therapy along with a healthy lifestyle.

POI can be a very difficult diagnosis to come to terms with and many women have feelings of anxiety and low mood following the diagnosis for a long period of time. Some women feel inadequate and may feel they have ‘failed’ their partners or parents. Many feel embarrassed or left out when their friends are talking about periods and having babies. Getting information about the condition and meeting others who have it can help you come to terms with it and help develop a positive attitude to life with POI. It is important to seek help if you feel like this or feel that you are unable to cope. Talking to friends or family and having counselling can help most women.

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