Most women go through the changes associated with menopause between 47 and 53 years of age and generally don’t seem to panic when this happens, but for younger women it seems to be a devastating experience, especially if they are below 40 years of age. Menopause is the total cessation of bleeding for 12 months. If it occurs before the age of 40 years it is referred to as premature menopause or premature ovarian failure. I am not sure that I like the latter term as it denotes an illness rather than simply a natural physiological process for that woman. The question of what is normal for each person is problematic as it is based on statistical formulations and averages.
Menopause begins because the ovary runs out of eggs (this is the common story told to women but not all researchers concur) and no longer responds to hormonal signals. This transitional period is called ‘peri-menopause’ and can last from 2 to 6 years. Many women go through this period without any symptoms, suggesting that the symptoms some women complain of may not be due solely to hormones but rather to a whole complex of changes of which the hormones are just one reflection.
PREMATURE OR EARLY MENOPAUSE
This occurs before the age of 40 years and is usually associated with missed and irregular periods and other symptoms of the peri-menopausal phase, including hot flushes, night sweats, weight gain, breast tenderness, hair loss, changes in body odour, insomnia and a range of emotional symptoms including irritability, mood swings, anxiety and feeling emotionally detached.
Again please note that probably the majority of women go through the peri-menopause without any symptoms at all and land in menopause without even being aware that their hormone levels have fallen dramatically.
CAUSES OF PREMATURE MENOPAUSE
- Probably one of the most common causes of premature menopause is surgery, usually associated with hysterectomy. Either both ovaries are removed together with the uterus, or as a result of surgery the blood supply to the ovaries is disturbed, leading to ovarian failure. The ovaries may also be damaged in other ways such as during surgery, for example when having tubes tied or when cysts are removed.
- Radiation therapy and/or chemotherapy may also cause premature menopause, and less commonly treatment with tamoxifem, a drug that interferes with oestrogen receptors.
- According to JR Lee, an expert on progesterone therapy, the most common cause of premature menopause is stress.1
- Auto-immune disorders are regarded as a common cause. The body develops anti-bodies that mistakenly attack the ovarian tissue or even the ovarian hormones. There is often a history of other auto-immune disorders. A family history may suggest a possible chromosomal irregularity as the cause.
- Viral infections contracted by the mother during the early part of pregnancy may affect the ovaries of the unborn child and it is thought that mumps contracted by the child may also affect the number of eggs in the ovary.
While this may be the only way to be sure what is going on, laboratory tests are not always that easy to interpret, for the following reasons:
- Each woman is different and has her own standard of what constitutes normal.
- Hormones fluctuate in a rhythmic way between one cycle and another.
- The female hormones may be protein-bound or unbound (free). Protein-bound hormones are less active; this is the part measured by the lab when a blood test is requested. Free hormones ride around in the bloodstream on red blood cells; these are the more active hormones. According to Dr Lee natural progesterone creams are not protein-bound but ride on red blood cell membranes and other fat-soluble components of the blood. This means that measuring progesterone in the blood when using natural progesterone cream is not a good measure of what is available. He advises women to request a salivary hormone test instead. Saliva contains mucins in which the non-protein-bound progesterone is soluble and is a better measurement than blood assays for the progesterone in hormone creams.
Because of the fluctuation of hormone levels between cycles a random specimen sent to the laboratory is not useful on its own. If a woman is menstruating then the specimen should be taken on day 3 of her cycle. This should be repeated at exactly the same time for 2 or even 3 periods in order to really understand what is going on. A few hot flushes and missing a few periods don’t mean that menopause has started. Many women may have a ‘false menopause’ because of severe stress or other stress factors on the body.
The various hormones tested include the following:
- Follicle-stimulating hormone (FSH): This is the hormone secreted by the pituitary gland to stimulate the movement of an egg towards the surface of the ovary. It is affected by the level of oestrogen in the blood. The level of this hormone will begin to rise if no egg emerges monthly from the ovary and oestrogen begins to fall and signals the beginning of peri-menopause. Please remember that one abnormal test is not enough to make an absolute diagnosis of menopause.
- Oestrogen: This begins to fall during the peri-menopausal period.
- Progesterone: If you are using progesterone creams then salivary tests are indicated. Progesterone levels tend to fall even before oestrogen declines because many periods in the peri-menopausal phase are not associated with ovulation, leading to a relative oestrogen excess in relation to serum oestrogen.
- Testosterone: This is an important hormone even in women and may need to be supplemented, especially in women with a lack of sex drive and excessive fatigue.
- Other tests: Thyroid function tests are important as there is often an association between early menopause and thyroid problems and many symptoms may overlap with those of menopause. A DHEA test is sometimes useful in older women only.
IMPORTANT PHYSIOLOGICAL CONSIDERATIONS
Hormones are one part of the menopausal cascade of events. Let us consider the other parts of the process. Hormones are messengers and are one of the ways the body communicates with the cells, tissues and organs. In order for this to be effective these messenger hormones (or keys) must have receptor sites (or locks) into which they fit. These receptor sites are spread throughout the body and often define the way the hormones function. Receptor sites are on the membranes of cells and are living dynamic places of activity. They can increase in number or become fewer in response to the need of the organism. Clearly the effectiveness of hormones is also dependent on the number and health of the receptor sites. Essential fatty acids and other nutrients are a key to membrane health (I will discuss this later).
A second key understanding with regard to the efficiency of the hormones is what Professor Ali likes to call the ‘bowel-blood- liver ecosystem’ (Professor Ali is a multiple specialist in medicine that seeks to reverse chronic disease and preserve health using non-pharmacological molecular protocols of nutrition, allergy and chemical sensitivity, self-regulation and fitness. He is based in the USA).
The third consideration is how the female hormones actively influence and are influenced by all hormones produced by the pituitary, thyroid, pancreas, adrenals, hypothalamus and other body organs. In dealing with premature menopause therefore it is essential to have a holistic overview of each woman coming for treatment. The body is highly intelligent and is constantly making decisions to up-regulate or down-regulate systems. One therefore needs to be very careful when deciding to prescribe powerful hormones even in what appears to be ovarian failure without checking that other physiological functions are working well and asking the following questions:
- Are the receptor sites plentiful and healthy?
- Are the liver and other organs functioning optimally?
- Is the relationship between all hormonal glands healthy?
The receptor sites on the membranes are not fixed and each cell membrane increases or decreases the number of receptor sites according to need. So there may be enough hormones but not enough receptor sites for optimum activity. Receptor sites are very specific in their activity and a progesterone or oestrogen receptor site will only respond to that particular molecule.
A biologically identical hormone will fit perfectly onto its specific receptor site. The less perfect the fit the more inefficient the response and the possibility of damage and distortion to that receptor site must be considered. Xeno-oestrogen (environmental oestrogens) and synthetic hormones that are not bio-identical, damage and occupy these receptor sites, distorting them and preventing the body’s own hormones from functioning well. Receptor sites can also be damaged by free radicals and other pollutants such as pesticides. Receptor sites may also be damaged by poor food choices, especially refined carbohydrates. The key (hormone) needs to fit the lock (receptor site) perfectly for the best response.
The liver is another key to hormonal problems or health. It is the key site for detoxification of the system and the breakdown of hormones.
The exact reasons for early menopause vary from woman to woman. Generally a combination of factors is involved. My personal feeling is that a combination of emotional-mental factors and hormone disruption due to xeno-oestrogens in the environment are the main factors. Xeno-oestrogens function like oestrogen and may shut down the signals to the pituitary to release luteinising hormones (LH) to stimulate the ovaries to release an egg and to make progesterone. There will still be oestrogen released by the ovary but without the corpus luteum (released from the ovary during ovulation) no progesterone is released, starting a process of hormonal imbalance. Stress comes in at the level of the hypothalamus and through its controlling influence on the pituitary it can also influence hormone production.
Editor's note: See Dr Brom's article where he answers frequently asked questions around early menopause: Frequently asked Question around Early Menopause