Early or Late Onset of Menopause

What counts as early or late menopause

Menopause is confirmed after 12 months in a row with no period, not caused by pregnancy, medicine or illness. The years of changing cycles and symptoms before that are perimenopause.

Your mother's and sisters' age at menopause is one of the best predictors of yours.

Early menopause: causes

Primary ovarian insufficiency

In primary ovarian insufficiency, the ovaries stop working normally before 40. Unlike natural menopause, function can fluctuate: some women still ovulate occasionally, and about 5 to 10 percent conceive naturally after diagnosis. In most women no cause is found. Known causes include:

• Genetic conditions: Turner syndrome and the fragile X premutation, a common inherited cause.
• Autoimmune disease: the immune system attacks the ovaries, often with thyroid disease, Addison's disease or type 1 diabetes.
• Infections: rarely, mumps or other infections damage the ovaries.

Medical treatments

• Surgery: removing both ovaries (bilateral oophorectomy) causes immediate menopause. A hysterectomy that leaves the ovaries stops periods but not hormones, though menopause may come a little earlier.
• Chemotherapy and pelvic radiation: can damage the ovaries temporarily or permanently. The risk rises with age at treatment.
• Medicines that suppress ovarian function, used for endometriosis or breast cancer, cause a temporary menopause.

Lifestyle factors

• Smoking brings menopause forward by about 1 to 2 years.
• Very low body weight and never having been pregnant are associated with earlier menopause.

Late menopause: causes

Late menopause is usually just the natural timing for that woman, often running in families. It is associated with:

• higher body weight, because fat tissue makes estrogen
• having had more pregnancies
• some conditions that cause high estrogen levels, such as estrogen-producing ovarian tumors (rare)

Uterine fibroids and endometrial polyps can cause bleeding that is mistaken for periods. Bleeding in your mid-50s should be assessed rather than assumed to be normal periods.

Symptoms

Early menopause causes the same symptoms as menopause at the usual age, but they can be more intense because the change is sudden, especially after surgery or chemotherapy:

• irregular or missed periods
• hot flashes and night sweats
• vaginal dryness and pain during sex
• mood changes, low mood, anxiety and poor sleep
• brain fog and poor concentration
• reduced sex drive
• difficulty getting pregnant

Health risks

Of early menopause

Estrogen protects bones, blood vessels and the brain. Losing it years early raises the risk of:

• osteoporosis and fractures
• heart disease and stroke
• possibly dementia and earlier death, mainly when not treated with hormone therapy
• infertility and the emotional impact of losing fertility unexpectedly

Of late menopause

Longer lifetime exposure to estrogen means:

• slightly higher risk of breast cancer
• higher risk of endometrial (womb) cancer and ovarian cancer
• but lower risk of osteoporosis and heart disease

Diagnosis

A doctor will ask about your cycles, symptoms, family history, surgery, cancer treatment and other health conditions.

• Under 45: blood tests are useful. A high FSH (follicle-stimulating hormone) level on two tests 4 to 6 weeks apart, with low estrogen, confirms POI. Doctors also check pregnancy, thyroid function and prolactin.
• POI tests: genetic testing (karyotype and fragile X) and screening for autoimmune adrenal and thyroid disease. A bone density scan is usually advised.
• Over 45: menopause is usually diagnosed from symptoms without blood tests.
• Late menopause or abnormal bleeding: a pelvic ultrasound and sometimes a sample of the womb lining (endometrial biopsy).

Treatment and management

Early or premature menopause

• Hormone therapy (HRT) until at least the average age of menopause is recommended for most women with POI or early menopause, unless there is a reason not to take it, such as certain breast cancers. At this age it replaces hormones the body would normally be making, and the benefits for bones and heart outweigh the risks. Combined birth control pills are an alternative for some.
• Vaginal estrogen for dryness.
• Bone health: calcium and vitamin D, weight-bearing exercise, no smoking, and limiting alcohol.
• Fertility: pregnancy is still sometimes possible with POI. Egg donation offers the highest success rates. Women facing cancer treatment can discuss egg or embryo freezing beforehand.
• Emotional support: counseling and support groups help with the sudden loss of fertility.

Late menopause

• Keep up with breast and cervical screening.
• Report any bleeding after menopause, or heavy or irregular bleeding in your 50s.
• Hormone therapy is not usually needed for late menopause itself.

Frequently asked questions

What is considered early menopause?

Menopause before age 45 is early menopause. Before 40, it is called premature menopause or primary ovarian insufficiency. The average age in the US is about 51 to 52, and anything from roughly 45 to 55 is considered normal.

What causes early menopause?

Common causes are surgery to remove the ovaries, chemotherapy or pelvic radiation, autoimmune disease, genetic conditions such as Turner syndrome and fragile X premutation, and smoking. In many women with primary ovarian insufficiency, no cause is found. Family history also plays a role.

Is late menopause good or bad?

It has trade-offs. Women with late menopause tend to have stronger bones and a lower risk of heart disease, but a somewhat higher risk of breast, womb and ovarian cancer. Regular screening and reporting abnormal bleeding are important.

Can you get pregnant with early menopause?

With primary ovarian insufficiency, about 5 to 10 percent of women conceive naturally, because ovarian function can return intermittently. After true menopause, natural pregnancy is not possible, but pregnancy with donor eggs and IVF is. Use contraception if you do not want to get pregnant until menopause is confirmed.

Should I take hormone therapy if I have early menopause?

Most experts recommend hormone therapy until at least the average age of natural menopause for women with premature or early menopause, unless there is a medical reason not to. It relieves symptoms and protects bones and the heart. Discuss your personal risks with your doctor.