Menopause is a natural biological transition that typically occurs between ages 49 and 52, with a median age of 51. However, for some women, menopause can occur much earlier.
Premature menopause refers to menopause that occurs before the age of 40 and affects approximately 1% of women. Early menopause occurs between the ages of 40 and 45 and is experienced by around 5% of women.(1) Both conditions can happen spontaneously or as a result of medical or surgical interventions.
Since early and premature menopause share similar causes, symptoms, and management, and only the age at which menopause occurs differs, the terms will be used interchangeably in this article. The key distinction is that spontaneous premature menopause can be caused by primary ovarian insufficiency (POI).
POI is a condition where the brain sends increased signals to the ovaries to produce hormones, but the ovaries do not respond properly. As a result, hormone levels remain low, which can affect puberty, fertility, and overall hormonal balance.(1)
Estrogen plays an important role in supporting bone, heart, and brain health. Declining estrogen levels at a younger age caused by early or premature menopause may increase the risk of conditions like osteoporosis, cardiovascular disease, and cognitive decline. However, early intervention can make a significant difference. Hormone replacement therapy (HRT) and other medical strategies can help improve overall health and lower the risk of potential complications.(2)
Causes of Early and Premature Menopause
Early and premature menopause can occur spontaneously due to underlying biological factors or can be induced by medical treatments or surgical procedures.
Spontaneous Early and Premature Menopause
While spontaneous premature menopause can occur without a clear cause, several known factors contribute to ovarian dysfunction:(3)
Genetic Disorders: Chromosomal abnormalities and inherited metabolic disorders are common causes of early menopause.
Autoimmune Diseases: The immune system can mistakenly attack ovarian tissue, leading to early ovarian failure. Autoimmune conditions like rheumatoid arthritis, systemic lupus erythematosus, and type 1 diabetes are responsible for 30%–60% of spontaneous early menopause cases.
Infections: Certain infections like mumps and pelvic tuberculosis can cause ovarian damage to increase the risk of early menopause.
Smoking: Studies indicate that smoking can increase the risk of early menopause by 40%–60%. Heavy smoking can cause menopause to occur up to two years earlier than it might naturally.
Poor Health and Nutrition: Research suggests that malnutrition and low body weight can increase the risk of early menopause.
Induced Menopause
Induced menopause occurs due to medical interventions, including cancer treatments, radiation exposure, surgical removal of ovaries, and prolonged use of certain medications.(2)(3)
Cancer Treatments
Cancer treatments, particularly chemotherapy and radiation therapy, can damage ovarian function and lead to premature menopause. The risk of ovarian damage depends on the age at which treatment is received, as well as the type and dosage of the therapy.(2)(3)
Chemotherapy
The most harmful chemotherapy medicines that affect the ovaries are alkylating agents, which include cyclophosphamide, methotrexate, 6-mercaptopurine, actinomycin D, and adriamycin.
According to the Childhood Cancer Survivor Study (CCSS), 6% of cancer survivors experienced acute ovarian failure (AOF) during or shortly after treatment, while 8% retained ovarian function initially but later developed premature menopause. Childhood cancer survivors can also face an increased risk of miscarriages, low birth weight offspring, infertility, cardiovascular disease, and osteoporosis later in life.
For adult women, breast cancer treatments remain a leading cause of induced menopause. Breast cancer accounts for one-third of all cancers in reproductive-age women, with 25% of cases occurring in premenopausal women.
Chemotherapy used for managing breast cancer can significantly affect ovarian function, with approximately two-thirds of premenopausal women becoming amenorrheic after starting standard chemotherapy regimens.
Radiation
High-dose radiation therapy, typically 4,500–5,000 rads, often leads to permanent ovarian failure. Meanwhile, lower doses (less than 500 rads) may allow ovarian function to recover, with about 50% of women regaining normal function within one to two years. Among all radiation treatments, pelvic radiation carries the highest risk of ovarian failure due to its direct impact on reproductive organs.
Surgical Removal of Ovaries
Surgical menopause occurs when both ovaries are removed, typically through a bilateral oophorectomy, resulting in an abrupt loss of estrogen and an immediate onset of menopause. Among women aged 35 to 45, approximately 1 in 9 undergoes a hysterectomy (surgical removal of the uterus), and nearly 40% of these procedures also involve bilateral oophorectomy.
The frequency of prophylactic oophorectomy, often performed as a preventive measure against ovarian cancer, is also on the rise. However, it’s essential to understand the health consequences associated with prophylactic oophorectomy, including osteoporosis, cardiovascular disease, neurological disorders, and psychiatric symptoms.
Medications
Certain medicines can temporarily suppress ovarian function, like GnRH agonists (gonadotropin-releasing hormone agonists). However, normal ovarian function is restored when the medication is stopped. These medications are used to treat endometriosis and fibroids and work by shutting down estrogen production. These medications are also sometimes used before IVF to help reset and align a woman’s cycle in preparation for the treatment.
Signs and Symptoms of Premature Menopause
The symptoms of early menopause are similar to natural menopause but tend to be more severe in some women due to a longer duration of estrogen deficiency.(3)
Hot flashes and night sweats
Vaginal dryness and pain during intercourse
Urinary incontinence
Mood changes
Joint pain
Thin and dry skin
Risks and Health Implications of Early Menopause
While not all women with early menopause suffer long-term consequences, some may face increased health risks due to prolonged estrogen deficiency. The risks vary depending on the age at menopause and the use of HRT.(2)(3)
Cardiovascular Diseases
Women who experience menopause before the age of 40 have a 50% higher risk of coronary heart disease compared to those who reach menopause after 45. According to a 2019 analysis, the likelihood of experiencing a cardiovascular event before the age of 60 is nearly twice as high for women who undergo premature menopause and 1.4 times higher for those that experience early menopause. The risk appears to be more pronounced in women who do not receive estrogen therapy after surgical menopause.(1)
Neurological and Cognitive Decline
Some women who undergo early menopause may be at an increased risk of cognitive impairment and dementia. The risk is higher in women who experience menopause due to surgical removal of the ovaries and don’t pursue estrogen replacement.
Studies have also found that memory and cognitive function tend to decline more significantly in women who undergo menopause before 40, with lower cognitive scores observed within six months of surgical menopause.
Mood Changes
Women who experience early menopause may be more likely to report increased anxiety, depression, and mood instability compared to those who go through menopause at the typical age. The risk of new-onset anxiety symptoms is highest in women who undergo menopause before the age of 49.
Sexual Dysfunction
Sexual function can also be affected, with higher rates of vaginal dryness, pain during intercourse (dyspareunia), and loss of libido in women who undergo early menopause. Women younger than 50 who have both ovaries removed are twice as likely to experience low sexual desire compared to premenopausal women.
Osteoporosis
Earlier menopause is associated with faster bone loss and a higher risk of osteoporosis and fractures. Women who go through menopause before the age of 45 have a significantly lower bone mineral density later in life compared to those who reach menopause at a typical age.
The risk of osteoporotic fractures is particularly high for women who have had their ovaries removed before the age of 45, especially if they’re not given estrogen therapy. This same risk is also increased for women who undergo natural menopause before the age of 45.
Diagnosing Premature Menopause
There are no unique clinical signs that definitively diagnose premature menopause. In most cases, the diagnosis of premature menopause is based on a combination of three key factors: the absence of menstrual periods (amenorrhea), elevated gonadotropin levels, and signs of estrogen deficiency, such as hot flashes, vaginal dryness, or mood changes.
In women with suspected premature ovarian failure, FSH levels above 40 mIU/ml can suggest a lack of viable ovarian follicles. However, as ovarian function fluctuates, a single test may not be conclusive. Repeated FSH measurements, taken at two- to four-week intervals, are often required to confirm the diagnosis.
Is it possible to prevent early menopause?
Early menopause is primarily caused by factors beyond a person's control, such as genetic conditions, autoimmune disorders, metabolic diseases, and infections, with no known way to entirely prevent these underlying causes.
Smoking is the only modifiable risk factor linked to an earlier onset of menopause. Research shows that women who smoke are more likely to experience menopause one to two years earlier than non-smokers. The harmful chemicals in cigarette smoke accelerate ovarian aging and reduce estrogen production, increasing the likelihood of early menopause.
While preventing early menopause may not always be possible, maintaining a healthy lifestyle, managing underlying health conditions, and avoiding smoking may help support overall reproductive health. For women at risk of premature menopause, early medical intervention and hormone therapy may help mitigate some of its long-term effects.
Management of Early and Premature Menopause
The primary approach to managing early and premature menopause is to identify the underlying cause and tailor treatment accordingly.
Hormone Replacement Therapy (HRT)
HRT is widely recommended for women experiencing early or premature menopause, as it helps in replacing declining hormone levels, especially estrogen. Some benefits of estrogen for women with early menopause include the following:
Maintaining bone density and reducing the risk of osteoporosis
Lowering the risk of cardiovascular disease
Possibly reducing the risk of cognitive decline and dementia
Combining estrogen with progesterone is necessary for women with an intact uterus to protect against endometrial overgrowth.
The optimal timing of HRT is also crucial. Studies show that women who begin HRT within one year of early menopause have a lower risk of cardiovascular disease compared to those who delay treatment. Experts recommend continuing HRT until at least the average age of natural menopause (around 50–51) to minimize long-term health risks associated with early menopause.(4)
Bone Health and Osteoporosis Prevention
Getting enough calcium and vitamin D, along with regular exercise and healthy lifestyle habits, is essential for maintaining strong bones in individuals going through early menopause. Current guidelines recommend 1,200 mg of calcium daily for women over 51, along with 800–1,000 IU of vitamin D to support calcium absorption.(4)
Weight-bearing and muscle-strengthening exercises, such as walking, resistance training, and yoga, help maintain bone mass and reduce fracture risk. Avoiding smoking and limiting alcohol intake can further protect bone health.
Bone mineral density (BMD) testing is an important tool for monitoring bone health. Women who undergo menopause before the age of 45 should consider BMD screening due to the increased risk of spine and hip fractures later in life.(4)
Individuals who reach menopause due to breast cancer treatments may need earlier screening, with some guidelines suggesting BMD testing within three months of treatment-induced menopause and follow-up testing within two years if estrogen therapy is not initiated.
Mental Health and Emotional Well-Being
Early menopause can increase the risk of emotional and psychological challenges, including difficulty adjusting to changes in self-image, sexual function, and fertility loss. Talk therapy, counseling, or support groups can help women navigate these changes.(4)
Consulting a psychologist or sex therapist may be beneficial for women struggling with sexual dysfunction or loss of intimacy due to estrogen deprivation.
Fertility Preservation and Family Planning
For individuals experiencing POI or those undergoing chemotherapy or radiation, fertility preservation can offer hope if they wish to conceive in the future. Options like egg freezing, embryo cryopreservation, or ovarian tissue preservation can make pregnancy possible later in life through assisted reproductive technology. Talking to a fertility specialist early helps ensure the best choices and outcomes based on individual circumstances.(4)
Additional Considerations
Autoimmune-related premature menopause may be managed with corticosteroid therapy if antibodies to sex hormones are present.
Genetic testing, including karyotyping and FMR1 premutation analysis, may be recommended to rule out genetic causes of premature ovarian health.
Supporting Health Through Early and Premature Menopause
Experiencing early or premature menopause can feel overwhelming, but with proper care, it’s possible to manage symptoms and support overall health. Taking steps to protect bone, emotional, and heart health can make a significant difference. Fertility preservation, HRT, and other treatment approaches can help address symptoms and complications associated with early or premature menopause. A healthcare provider can help determine the most suitable options based on an individual's unique needs and health circumstances.
