Chapter 3

Fooling Mother Nature: Early Menopause

In This Chapter

Discovering the facts about early menopause

Understanding how your body can suddenly change

Getting ready for surgical menopause

Checking out hormone alternatives

Seeking and finding the support you need

Though it’s not something you think about a lot, you probably expected all along to go through menopause sooner or later. Mostly later. But if you’re one of the roughly 25 percent of women who experience early menopause because of surgery or some other health factors, you’re now facing a whole new game plan. You may be one of a significant number who find themselves experiencing menopause way too early, often without much warning. You find that the bookstore shelves aren’t exactly sagging under the weight of books on early menopause, and that your own physician may not even recognize the symptoms for what they truly are.

Early menopause isn’t just regular menopause with bad timing. If you’re already in early menopause, we don’t have to tell you that it’s far more complicated than menopause arrived at the old fashioned way — by aging. And if you’re facing this possibility now, the best thing you can do to protect your health and your lifestyle is to educate yourself (and your friends, and your family, and your doctor).

Which (blush) is why we’re here for you. We’re here so you can figure out what’s going on. And why. And what to do about it. In this chapter, we discuss some different ways in which menopause can sneak up on you and shout “Boo!” before you are even remotely ready for it. While your girlfriends are still stocking up on tampons and asking, “Is it hot in here, or was that my first hot flash?” you’re looking menopause in the face. We’ll help you here with an introduction to menopause — the early edition.

Understanding the Lingo

As if one kind of menopause isn’t enough to go around, there are actually several kinds, each with its own designation. And even though each one leads to more or less the same outcome (the end of menstruation and fertility), there are differences among them that will color your experience.

Here’s the obligatory “your mileage may vary” notice. Every case is different. One woman might breeze through chemotherapy and still be fertile, while a woman with a similar diagnosis experiences ovarian failure after such treatments. Keep in mind that no two people or sets of circumstances are exactly alike, so no two outcomes will be the same. So many variables are involved: your personal health history, your genes and your family’s health history, your age, body type, general level of health and fitness, environmental circumstances, lifestyle, and, of course, the nature, history, and extent of your medical problem.

Induced menopause

Induced menopause occurs when your periods end because of some kind of intervention that removes or damages your ovaries. In many cases this is the result of surgery (surgical menopause), but radiation therapy, chemotherapy, and some medications can also cause your ovaries to quit functioning (medical menopause).

Surgical menopause

Most cases of surgically induced menopause result from either the removal of both ovaries (oophorectomy) or from a hysterectomy (surgical removal of the uterus) that includes removal of the ovaries or results in the cutting off of the blood supply to the ovaries. After your ovaries are removed, you are immediately in menopause.

If you have just one healthy ovary, you can continue to produce estrogen and stave off menopause, at least for a while. Women who have had a hysterectomy but whose ovaries remain intact tend to go through natural menopause a few years earlier than they might have otherwise.

You can enter surgical menopause in a number of ways. Hysterectomy is the most typical cause of surgical menopause. Oophorectomy (ovary removal) may also be performed along with an elective hysterectomy in the case of conditions that are not necessarily life-threatening but that have not responded to any other medical treatments.

Fewer hysterectomies are performed these days for non-life threatening conditions than was the case in even the recent past. Certainly this surgery is an appropriate option under some circumstances. It is, however, an irreversible option with long-term consequences. Don’t assume that the first suggestion that you have a hysterectomy is the right decision for you. Get a second (and a third and a fourth) opinion. Be sure to weigh in the potential for early menopause when weighing up the costs and benefits of this procedure when it is genuinely an elective choice.

Don’t be afraid of offending your doctor by asking for a second opinion. If your doctor is truly looking out for your best interests, he or she should applaud you for investigating all your options before having major surgery.

Some surgeries intended to treat non-reproductive health conditions may also result in surgical menopause. Surgical treatment of colon cancer, for example, may involve removal of the uterus and ovaries. The ovaries may also be removed to treat disorders driven by or made worse in the presence of plentiful estrogen. These might include breast cancer or endometriosis.

Medical menopause

Medical procedures and treatments beyond those requiring surgery can also put you into menopause. These can include radiation therapy, chemotherapy, and certain medications.

The fact that radiation and chemotherapy have been associated with medical menopause in many cases doesn’t necessarily mean this will be true in your case. Understand the risks and possible outcomes, but don’t give up hope too soon. Every case is different.

Surgical removal of ovaries results in an immediate end to fertility. In cases in which ovarian functioning has been damaged by medications or radiation, fertility may decline more slowly and unpredictably. Be sure to talk with your healthcare provider about the best way to protect against unplanned pregnancy during this transitional time.

Premature ovarian failure

Premature ovarian failure (POF) can occur at almost any age prior to the time at which menopause would be considered natural. Finding out that you are in menopause in your 30s, even in your 20s, can be devastating, particularly because it means the end of your fertility.

POF not caused by one of the diseases or conditions described below affects about one out of 100 women. Sometimes the cause of premature menopause is never found, but it can be linked to a variety of conditions, among them:

Immune system disorders

Severe anorexia

Genetic disorders

Polycystic ovarian syndrome (PCOS)

Chronic, severe physical stress, such as that sometimes experienced by professional athletes or those with exercise anorexia

Nutritional deficits

Pituitary tumors

Because POF can occur so much earlier than you would expect to start identifying perimenopausal symptoms, those first hot flashes and skipped periods might not make you jump up and say, “Aha! This could be menopause!” Trouble is, it might not make your doctor say this, either. Although POF is rarely reversible, there are cases in which an early diagnosis and treatment of the underlying problem could mean the salvation of your ovaries — derailing that menopause train that’s pulled out of the station way ahead of schedule. If you even suspect that what you’re experiencing sounds similar to meno-pause, bring this concern to the attention of your healthcare provider, and do whatever gentle prodding (or jumping up and down) it takes to get the blood tests that could point you to a correct — and well-timed — diagnosis.

Coping with Sudden Change

After you pull the plug on estrogen production — either in one big whoosh or one prolonged trickle — unless you begin taking HT, your body is going to be subject to the same changes (see Chapter 4) and risks (see Chapters 11 through 14) that you’d experience in natural menopause. The biggest difference is in the timing: when it occurs, and how fast it happens. The younger you are when you experience early menopause, the greater the number of years you will have to cope with the consequences. Making decisions about your health and whether to take replacement HT early on, as well as continued monitoring of your hormone levels (see the next section “Knowing when you hit menopause”), are crucial.

Knowing when you hit menopause

We define menopause as reaching the one-year anniversary of your last period. But if your uterus is gone, you can’t have a period. How do you know when you clear that hurdle? The only way to know is by keeping an eye on your other symptoms — restless sleep, hot flashes, heart palpitations — the whole nine yards. If you experience the classic perimenopausal symptoms, you’re probably entering perimenopause and your hormones are dipping and cresting like waves in a storm. You’re probably menopausal when your symptoms settle down and the seas are calmer. If you’re not sure, ask your physician for a hormone test that can tell you what your menopause status is.

Women who have had hysterectomies but who still have one or both ovaries often go through menopause one to three years earlier than women who haven’t.

Getting the help you need for your body and mind

Estradiol (or E2), which your ovaries produce, is like a magic serum for your body. In addition to promoting breast development, bringing on your menstrual cycles, and helping you get (and stay) pregnant, estradiol has lots of other roles to play in promoting and protecting your health. It keeps your tissues (inside and out) moist and supple, helps you to grow strong bones (and you thought it was just the Wonder Bread), promotes normal sexual development, and plays many other roles throughout your body.

If the source (that is, your ovaries) of this wonderful stuff dries up — regardless of whether the cause is surgical, pharmaceutical, genetic, or something altogether different — then you may not even have achieved your peak health and strength by the time your hormones disappear. Not having had the full benefit of your hormones to start with can make it doubly hard to keep your whole body in its best working order when menopause begins to make demands on your bones, your sexual health, and your overall well-being.

Women in induced or premature menopause who are not taking hormone therapy are faced almost immediately with increased risk of a number of health problems. All these are associated with loss of estrogen, so hormone therapy does alleviate these risks. (We say more about these risks in Chapters 11 through 14.) Your caregiver can help you to cope with these sudden changes by working with you to find a medical regimen that minimizes menopausal symptoms while maximizing your overall health outlook.

Even if children (or more children) weren’t officially in your plans, losing your ability to conceive can be a shaker (for you and the people who care about you). Losing your options can be difficult, too. Seeing your periods come and go every month can also be a marker, a healthy part of your functioning. It’s okay to grieve this loss (and to get help in doing so), even if you are still figuring out what it means for you. Recognize your feelings and talk with a counselor or therapist about what’s happening to you.

Prepping for Surgical Menopause

If your physician anticipates that your ovaries will both be removed or damaged during your surgery, she knows that you’ll wake up in an uncomfortable state of hormone depletion. To help you make a slightly smoother transition to this new state of affairs, she may start you on hormone supplements prior to your surgery (if she’s not sure about what she’ll find during surgery, she may want to wait and start HT after your operation). Although every situation is different and most are more complex than this, the type of hormone therapy you are given depends largely — to put it bluntly — on what had to be removed during your surgery. If you still have a uterus, you will most likely be given combination hormone therapy (HT) with estrogen and progesterone balanced just for you to prevent cancer. If you’ve had a hysterectomy, then you will be given estrogen therapy (ET) because it can replace your missing estrogen with no increased risk of uterine cancer (the uterus now being gone, remember).

A hysterectomy with your ovaries left in place technically shouldn’t slow down the ovaries’ production of hormones. You should go through natural menopause (though perhaps a little sooner) if your ovaries are still intact and producing hormones.

While you are preparing for the hysterectomy you will have lots of questions for your surgeon and your general practitioner, internist, or gynecologist. Before surgery is a good time to talk about what to expect in the way of hormone-related effects, both immediately after surgery and in the long run. Because this is a very stressful time, especially if you only found out recently that you have a condition that requires surgery, you may find yourself a little rattled. Right near the list of the top 10 things that make you forgetful is having your doctor look up and say brightly, “Do you have any questions?” This is the universal signal for forgetting everything you wanted to ask, which is why it’s a good idea to keep a running list. No question is too small — or too large — to tackle. Questions to ask about menopause-related outcomes of your surgery might include:

How likely is it that my ovaries will still be functional after my uterus is removed? How great a risk is there that the ovaries will have to be removed, too?

If my ovaries are removed or damaged, how will that change how I feel after the surgery? What sorts of symptoms might I experience? How soon will these begin?

What kinds of decisions will I need to make about hormone therapy following the surgery?

Do you recommend that I begin any hormone therapy before my surgery?

I have concerns about some of the risks I’ve heard about from women taking hormone therapy. How do these apply in my case?

If your surgery is to treat a severe or life-threatening illness, don’t let anyone make you feel that you’re being petty or trivial worrying about menopause when all you “should” be worrying about is beating your breast cancer or curing that chronic infection. Certainly you will have questions about both the reasons for the surgery and the possible outcomes — that’s entirely normal. But if your doctor says, “We can talk about all that after your surgery,” be persistent. She may not be able to give you all the answers you need yet, but it’s entirely justifiable to want — and get — some sense of what you may be facing after the surgery.

Taking Advantage of Assisted Living

No, no, we don’t mean the kind your Great Aunt Natalie lives in, with the hot meals and the Bingo games on Saturdays. But under your new circumstances your doctor will most likely suggest very strongly that you go — and soon — on some form of hormone therapy. Hormones got you into this strange new place, by leaving you — literally — in the lurch. And hormones —administered with care and patience — can get you out again, or at least play an important role as you try to get a grip on the changes in your body and your mind that accompany induced or premature menopause.

As with natural menopause, whether you decide to take hormone replacement therapy is entirely your call. The difference that you need to factor in as you make this decision is all about the timing. Many women experiencing natural menopause take hormones for just a few years, until they are over the most bothersome of their menopausal symptoms. You will need to rely on hormone therapy indefinitely to ward off the effects of menopause until you reach the time at which you and your doctor feel you’d be postmenopausal even by natural menopause standards. At that point, you can work together to decide whether remaining on hormones is in your best interest, or whether it’s time to wean you off of them.

Estrogen alone

If you have had your uterus removed, you no longer need to fear that taking estrogen will contribute to uterine cancer. This means you can control your menopausal symptoms and reap the benefits of replacement estrogen as it wards off the health risks described above.

The especially good news for you (you knew there had to be some good news somewhere , right?) is that new findings coming out of the 15-year-long Women’s Health Initiative Study says that for women who have had a hysterectomy and who are between the ages of 50 and 59, and only for this group, estrogen therapy not only doesn’t damage the heart, but it can actually protect you from heart disease.

Combination therapy

With progesterone (and perhaps testosterone) added to the recipe to help balance the risks of uterine cancer, women who have had their ovaries removed but who still have an intact uterus can minimize their risk of other menopausal health problems.

It’s important to note that, especially with combination therapy, one size definitely does not fit all. What worked for your mother may not work for you. The balance of hormones that puts your best friend in the pink may leave you feeling bluer than blue. Be patient as your physician works with you to find the right balance — and the right dosage — of therapeutic hormones.

You may also hear a lot about the synthetic hormone DHEA if you surf the Internet or cruise the shelves of your local natural foods store. To listen to the manufacturer’s claims, you’d think that DHEA is the ultimate wonder drug, replacing or supplementing your body’s natural hormones to cure what ails you. Be very careful, though. Although there have been many claims about its symptom-relieving, vitality-giving qualities, no long-term studies have proven DHEA to be either effective or safe. Some of its known side effects (deepening of the voice, thickening of the skin, facial hair growth, and headaches) are as troublesome as the symptoms you’re trying to free yourself from. If you’re interested in learning more about this steroid hormone, ask your physician before you try it on your own.

If you do decide to use DHEA by itself or in combination with other forms of HT, do not use or suddenly discontinue its use without the supervision of a physician.

Got a uterus? Your hormone therapy will probably be a balanced mix of the hormones normally produced by the ovaries: estrogen and progesterone, or even estrogen, progesterone, and a bit of testosterone. If you’ve had a hysterectomy (no uterus), you can take estrogen-alone therapy (ET).

And your grandmother on your mother’s side?

If you experience induced or premature menopause at very nearly the age at which you would have expected to start natural menopause, you may have more leeway when it comes to deciding whether to take hormones. Here are some things you need to consider when making this decision:

Your age and general health

Any family history of DVT (deep vein thrombosis), pulmonary embolism (blood clots that have traveled to your lungs), or other blood clots; any family history of stroke (hormone therapy can increase the risk of these)

Any family history of breast cancer (estrogen therapy can promote the growth of breast cancer cells)

Whether you smoke (hormones and smoking are a time bomb combination, greatly increasing the risk of other dangers, such as that of stroke or blood clots)

Any family history of osteoporosis, which hormone therapy would help to prevent

Alternatives to HT

Certainly if you are still wary of hormone therapy, there are practical, situational remedies you can try. Some women find relief in simple approaches to symptom control:

Find fixes for your hot flashes. Sleep in a cool room with a window partly open, even in cold weather. Keep a pitcher of cool water on your nightstand, and sleep on 100 percent cotton sheets. If you find that alcohol or spicy foods contribute to your hot flashes, avoid them.

Get a good night’s sleep. Make your bedroom a calming place and don’t use it for work or exercise. Get plenty of exercise every day, but not within an hour or two of bedtime. A warm, caffeine-free drink before bed — warm milk, herbal tea, or hot lemonade — can help you relax. If you wake up for long periods during the night, get up and read quietly, or engage in a simple activity such as knitting or reading so that you don’t come to associate your bed with sleeplessness.

Calm your moods. Practice meditation or yoga and breathing exercises every day.

Take good care of yourself. Get plenty of rest, maintain a healthy weight, and don’t smoke.

Protect your bones. Do some weight-bearing exercise at least five days a week. Smoking also compromises bone health — if you smoke, stop.

Ask your physician for recommendations for herbal remedies to fight hot flashes and insomnia if you want to. Bear in mind, though, that few herbal preparations are regulated in the United States, so you may be getting more or less than the label indicates, and the product may not be as clean or free from additives as you’d like to think. Remember, too, that herbs aren’t necessarily any safer, or any more effective, than pharmaceutical hormones. Keep an open mind, but make sure your health and safety are your first concern, whether you rely on traditional medicines, alternative products, or a combination that balances the best of both.

Finding Support: Birds of a Feather

Taking care of yourself and getting support from people who understand your situation is especially important for women experiencing early menopause. Your issues, in many cases, are different from those of women who go through natural menopause at the expected time in their lives and you may need to go a little further out of your way than to the next cubicle at the office or your best friends to find women who know what you’re going through.

People who don’t “get” premature menopause are usually people who just haven’t been educated yet. Try to keep this in mind when people ask you questions about your situation or assume they know what you’re going through (when they don’t). Even people who care a great deal about you may say things to you that cause you pain or distress.

Ask your healthcare provider whether she knows of a support group in your area for women with early menopause. Or find a supportive message board online (feel free to lurk a while, or read the boards without becoming a member) until you find one that seems to offer genuine help and accurate information.

And don’t forget that the answers to your questions may be found in the upcoming chapters in this book. Although your situation may be different from that of most women, in many ways you are all going through the same things, even if you’re on different timetables.

As you’re making decisions about hormone therapy and your continuing care, try to find at least one woman to speak with who went into early menopause years ago. Get the benefit of her hindsight by asking whether she is happy with the decisions she made, and whether — given ongoing advances in our understanding of hormone therapy — she thinks she would make the same decisions today. Are there things she wishes she had done differently? What things were relatively easy to handle, and what were some that were the most difficult? What surprised her the most? Did she find any unexpected silver linings in this cloud?