Managing Early & Surgical Menopause

For some women, the transition comes early–and sometimes abruptly. Here’s what you need to know.

Menopause is mainstream news these days, which is great. But the focus tends to be on women who hit the milestone during midlife, around the average age or 51 or so, which leaves women who come into menopause early, either naturally or by medical causes like surgery wondering if all the advice they’re reading applies to them. The answer is mostly, but there are strategies for managing these types of menopause that are unique.

First, let’s clear up some confusion. “Early menopause” (total cessation of periods before the age of 45) or “premature menopause” (total cessation of periods before the age of 40) are terms that are often used interchangeably, though the age difference is certainly meaningful for the women’s life experience. Menopause brought on by surgeries, chemotherapy or other drug treatments is often included under the umbrella or early/premature menopause, but for this blog I’d like to consider those separately, especially since these can happen at any age. 

What’s Behind Early/Premature Menopause? 

Early or premature menopause can happen naturally on its own for no clear reason, though there can be a genetic component. If your mother and/or other women in your family went through menopause early, there’s an increased likelihood you will as well. Smoking (which I hope doesn’t apply to anyone reading this) can also lead to an earlier menopause, as well as worse symptoms. 

Another common cause that deserves a closer look is Primary Ovarian Insufficiency (POI) which used to be known as Premature Ovarian Failure. With POI, many women usually have menopausal symptoms, such as hot flushes, night sweats, brain fog, fatigue, and so on, as well as irregular or a cessation of periods. 

When women with POI get their blood work done to test hormone levels, their blood results of follicle stimulating hormone (FSH) and estradiol will indicate postmenopausal levels. But, unlike later onset, natural menopause, POI does not mean your ovaries are egg-depleted, but rather, there is a lack of feedback and hormone stimulation for ovulation. 

With POI, because you do still have eggs, you may also keep producing estradiol, and may have irregular periods. In fact, 20 to 25% of women diagnosed with POI still do ovulate from time to time. What causes POI?  In up to 90% of women with spontaneous POI, the cause is unknown. In some cases, the condition can be associated with:

• Genetic conditions, such as Turner syndrome and carriers of Fragile X syndrome. A number of other genetic changes have been identified in research studies but these cannot be screened for at present
• Autoimmune conditions, such as autoimmune thyroid disease, type 1 diabetes, pernicious anemia, myasthenia gravis and connective tissue disorders. 
• Rare metabolic conditions, such as galactosaemia
• Certain chemotherapies and hormonal therapies associated with breast and ovarian cancers can slow down or stop the functioning of the ovaries. This type of POI may be temporary — that is, last while you’re in treatment and for some time afterwards, and then your periods return — or it may be permanent.

How women with POI experience menopause varies. You may experience a sudden onset of menopausal symptoms or a slow, gradual onset even with regular periods; which makes it difficult to diagnose. I have heard from many younger women (aged 30 to 35) who were misdiagnosed by their physicians and told it “was all in their heads”, which unbelievably in this day and age still happens. The longer term health concerns with POI are similar to natural, later onset menopause, but because of the duration of time without sex hormones is longer, there are greater implications and risks for infertility, cardiovascular disease, osteoporosis, psychological and mental health concerns, as well as memory, learning, and cognitive dysfunction. 

There are several treatment options. First and foremost, work with your physician to determine if using an oral contraceptive pill is an option for you (instead of menopause hormone therapy). Because there is still a chance of ovulation and pregnancy, using an OC can help stabilize the hormone profile, treat any menopausal symptoms, and at the same time, work to provide contraception. Unless, of course, you are wanting children, then working with a fertility specialist for your options works in your favor. 

It also helps to adapt your exercise and nutrition habits to fall more inline with what we recommend for menopausal women broadly:

• Heavy/power-based resistance training, 2 to 3 times per week.
• High intensity interval training (HIIT) or sprint interval training (SIT) 2 to 3 times per week.
• Increased protein intake (1.8-2.0grams per kg) spread evenly throughout the day.
• A wide variety of fibrous veggies and fruit (aiming for 25 to 30 grams of fiber) for your gut microbiome health.

Special Needs of Surgical Menopause

Surgical menopause is an abrupt start to menopause by the removal of both ovaries (bilateral oophorectomy or bilateral salpingo oophorectomy if the fallopian tubes are also removed). Women who only have their uterus removed (hysterectomy) but still maintain their ovaries will not go into surgical menopause. When both ovaries are removed, this removes the main source of estrogen, progesterone, and testosterone in the woman’s body. This means she will no longer have a menstrual cycle and is in surgical menopause. Removal of just one ovary (leaving the other) is called a unilateral oophorectomy. When just one ovary is removed, this does not result in surgical menopause and the remaining ovary continues to produce normal hormone cycling each month.  

The key factor that must be considered is that menopausal symptoms of surgical menopause are more severe and immediate than non-surgical menopause, especially during the first 6 months post-surgery. Following the surgical removal of the ovaries, you become postmenopausal immediately. There is no gradual lead up to the loss of ovarian hormones. That means there has been no time for the body to slowly downregulate estrogen and progesterone receptors, there has not been a lead up for gut microbiome changes, nor any neurotransmitter changes. Women who experience immediate post-surgical menopause will experience a sudden onset of menopausal symptoms including (but not limited to): 

• Vasomotor symptoms (e.g., hot flushes and sweats)
• Musculoskeletal symptoms (e.g., joint and muscle pain, significant and rapid body composition changes)
• Effects on mood or anxiety (e.g., feeling abnormally sad or worried)
• Urogenital symptoms (e.g., vaginal dryness, needing to urinate frequently)
• Sexual difficulties (e.g., low sexual desire, painful sex).

For women who are 45 years or younger who enter surgical menopause, Menopause Hormone Therapy (MHT) is a first plan of action when it is not contraindicated following surgery in order to protect bone, brain, and cardiovascular health. MHT is usually used until the age of 51 , the “normal” age of natural menopause onset; yet each individual is their own case and should work with their physician to fulfill a complete treatment plan.

For women who cannot take hormones, there are alternatives, such as SNRI/SSRIs, clonidine, gabapentin, cognitive behavioral therapies (CBT), and selective estrogen receptor modulators (SERMs). For vasomotor symptoms specifically, there is also the new drug Veozah (fezolinetant), which works by manipulating a special type of brain cell called KNDy neurons, which are located in the hypothalamus.

You’ll also want to follow the exercise and nutrition recommendations outlined above to help maintain muscle, metabolic health, and your gut microbiome.

Resources

• For further information and help, here are several recommended websites:
• Early Menopause: https://www.earlymenopause.com/
• POI: https://www.daisynetwork.org/  and  https://www.menopause.org.au/health-info/fact-sheets/menopause-before-40-and-spontaneous-poi
• Surgical Menopause and Cancer: https://www.breastcancer.org/treatment-side-effects/menopause