Suspected premature menopause

A 34 year old woman who attends your surgery has a 12 month history of irregular periods (increasing cycle length). She has never been pregnant. Her mother’s menopause began in her late 30s, and your patient is worried about her own current and future fertility.

What issues you should cover

• Discuss the possibility of premature ovarian failure, but tell her this is uncommon at age 34 and that other causes of menstrual irregularity—the most common of which would be polycystic ovary syndrome (PCOS) with anovulation—can usually be treated successfully. However, premature ovarian failure does have a familial component, so it is important to exclude this important possible diagnosis, as it has major implications for her future fertility.

• Ask about her menstrual history: age at menarche, dysmenorrhoea or menorrhagia, cycle length in the past.

• Ask about signsof PCOS (weight gain, hirsutism, acne, acanthosis nigricans) and family history of diabetes.

• Consider other causes of oligomenorrhoea and their symptoms, such as pituitary adenoma with hyperprolactinaemia (galactorrhoea, tunnel vision, headache), hypothalamic disorder (weight loss, excessive exercise, eating disorder), and recent stress in her life. Also consider thyroid disease. Has she had any radiotherapy or chemotherapy?

• Ask whether she has had any symptoms that indicate onset of menopause, such as hot flushes, night sweats, or vaginal dryness.

• Take a general gynaecological history. Has she had intermenstrual or postcoital bleeding, vaginal discharge, pelvic pain, urinary symptoms, abdominal pain or swelling, or a previous pelvic infection or sexually transmitted disease (such as chlamydia)? Also consider her smear test and contraception history.

• Is she in a sexual relationship and planning or trying to get pregnant? If so, assessment of her partner’s fertility may be appropriate.

• Don’t forget psychosocial issues. Explore concerns she may have about delaying pregnancy and the effects this may have on her career. Also cover lifestyle issues, such as smoking and alcohol intake.

Useful resources

• Meskhi A, Seif MW. Premature ovarian failure. Curr Opin Obstet Gynecol 2006;18:418-26

• Nikolauo D, Templeton A. Early ovarian ageing: a hypothesis. Hum Reprod 2003;18:1137-9

Internet resources for patients

• www.daisynetwork.org.uk—UK site for patients with premature menopause

• www.pofsupport.org—US site with multilingual support for patients with premature ovarian failure

• www.infertilitynetworkuk.com—For patients with infertility

• www.bica.net—British Infertility Counselling Association

• www.hfea.gov.uk—Human Fertilisation and Embryology Authority (has information on infertility and its treatment)

• www.ngdt.co.uk—National Gamete Donation Trust (for patients in need of oocyte donation)

• www.nos.org.uk—National Osteoporosis Society

What you should do

• Measure her body mass index. Examine her for hirsutism, acne, and acanthosis nigricans. Do an abdominal and pelvic examination if her symptoms warrant it—for example, if she has had pelvic pain, vaginal discharge, or postcoital or intermenstrual bleeding.

• Check her rubella immunisation status; organise immunisation if she has no history of it.

• Premature ovarian failure will be shown by raised concentrations of follicle stimulating hormone (FSH) (>20 IU/l) and luteinising hormone at day 2 of the menstrual cycle. This test should always be repeated in at least two separate menstrual cycles. An FSH concentration of >10 IU/l may have adverse implications for her future fertility.

• If she is trying to conceive, you may measure her luteal phase progesterone concentration to check for ovulation. However, in women with irregular periods the day of testing would have to be adapted to cycle length, or serial measurement of progesterone concentrations may be needed.

• If her history indicates, the blood tests can be combined with testing of thyroid function, prolactin and, if PCOS is suspected, testosterone and free androgen index.

• An FSH of <10 IU/l is not diagnostic of ovarian failure. Further investigation of oligomenorrhoea should be carried out. Given the family history, a repeat test in 12 months may be reassuring if she wishes to defer pregnancy. However, explain that the number and quality of eggs decline steadily as women age and that beyond the age of 35 fertility declines more rapidly.

• Explain the implications of a diagnosis of premature ovarian failure: loss of fertility and possible need for donor eggs. Psychological counselling regarding the implications of this diagnosis may be appropriate, and you may wish to refer her to a specialist centre for further support in managing her.

• Consider hormone replacement therapy (combined) for a menopausal woman aged <40, to protect against osteoporosis and maintain cardiovascular health. This should be continued to age 50, the mean age of natural menopause.