As well as the immediate consequences of POI such as the symptoms of oestrogen deficiency and fertility problems, POI can have longer-term implications. Chronic estrogen deficiency can affect many different parts of the body and so long-term health has to be considered when you are making decisions about your treatment.
Bone health is a major concern in POI. In healthy bones, tissue is in a state of continuous turn-over, with old bone being resorbed and new bone being made. When there is a lack of oestrogen (as in POI), more bone is resorbed than is made, leading to bone loss. Over time, this loss of bone can result in osteoporosis – a condition where bones are weak or brittle – which is associated with increased risk of bone fractures in later life.
Bone density increases through childhood to reach a maximum at around the age of 30. Thereafter it declines gradually, but in women, a sharper rate of decline is seen around the time of menopause. The development of osteoporosis depends on 2 factors – the peak level of bone density reached (usually up to around 30 years of age) and the rate of later bone loss. In women with POI, bone loss occurs earlier, and so without treatment, bone density in later life could be well below average. Furthermore, if POI occurs before the age of 30, you may not have yet reached peak bone density, so further increasing the risk of osteoporosis.
As well as POI, other risk factors for osteoporosis include a low body mass index, steroid use, smoking, personal history of fracture, family history of osteoporosis.
When someone is diagnosed with POI, it is normally recommended that you have a bone scan to assess bone density. This is usually called a Dual Energy Absorptiometry (DEXA) scan. The test is similar to an x-ray and will take images of bone density at the lower spine and hip. It is painless and is usually completed in less than 15 minutes.
Following the scan your bone density will be classified into one of 3 categories: normal, osteopenia or osteoporosis. Low bone mass (osteopenia) is where bone density is reduced but not low enough to be osteoporosis. Your doctor should then talk through the results and how they may affect your management. The frequency of bone scans will depend on the initial values and whether you are taking oestrogen replacement or not, but they are usually repeated after around 3-5 years.
Prevention and treatment
Bone density can reduce quickly, particularly in the 4-5 years after menopause due to the lack of oestrogen and so prevention and early treatment are crucially important. The good news is that there are measures which can be taken to effectively prevent bone loss.
There are several lifestyle changes which you can make to keep your bones healthy.
Calcium and Vitamin D are both important for bone health so you should ensure you are eating a healthy, varied, well balanced diet incorporating foods which are rich in calcium and vitamin D. The recommended intake is to aim for around 1000mg calcium daily and 800IU of Vitamin D.
Getting calcium from your diet is preferable to taking supplements. Calcium is found in dairy foods (low-fat milk, yoghurt and cheese), oily fish, green leaf vegetables, and pulses. Some bread and cereals also have calcium added to them.
Most of our Vitamin D is made by our skin in response to sunlight exposure. This means that in winter and in people who do not get much sun exposure, there can be a risk of vitamin D deficiency. There are a few foods which contain Vitamin D such as oily fish (eg mackerel, tuna), dairy, eggs and some cereals.
Minimising caffeine and alcohol and avoiding smoking will be beneficial for bone health.
Exercise also helps prevent bone loss. Regular weight-bearing exercise such as fast walking is the most effective. Ideally you should do around 30 minutes of exercise on most days of the week.
In women with POI, oestrogen replacement is recommended to help prevent osteoporosis. Taking oestrogen replacement, in the form of HRT or the combined oral contraceptive pill, can help prevent bone loss and sometimes increases bone density.
In women who can’t or do not wish to take oestrogen replacement, and have been diagnosed with low bone density, there may be some other treatment options. However, few of these options have been studied in women with POI. The most commonly used group is the bisphosphonates (eg alendronate, risedronate, ibandronate). These medications are effective in reducing the risk of fracture in women with osteoporosis but there are some safety concerns about their long-term use. Furthermore, in women with POI who either conceive naturally or have fertility treatment, the safety of these treatments in pregnancy is not know and they can stay in the bones for a long time after use. Other treatments for osteoporosis would usually only be considered under the guidance of specialist Rheumatology doctors.
More information on bone health can be found in our leaflet on Osteoporosis and also on the following websites:
National Osteoporosis Society website www.nos.org.uk
International Osteoporosis Foundation www.iofbonehealth.org
POI is a risk factor for heart disease. Oestrogen affects many aspects of the cardiovascular system and long-term oestrogen deficiency is associated with a higher risk of heart attacks and stroke.
Lack of oestrogen has been associated with weight gain, insulin resistance (which can lead to type 2 diabetes) and adverse changes to cholesterol. These are all risk factors for cardiovascular disease.
Does HRT reduce the risk of heart disease in POI?
There are currently very few studies which have investigated whether HRT reduces the risk of heart disease in women with POI. A study showed an increased risk of mortality from heart disease in those with a menopause under the age of 40 years compared to those with menopause at 49–55 years. This risk of heart disease was higher in women who had never used oestrogens, which suggests a protective effect from HRT.
Furthermore, there are several reasons why HRT should be beneficial for the cardiovascular system in women with POI. We know that oestrogen replacement has positive effects on cholesterol by lowering LDL cholesterol (bad cholesterol) and increasing HDL (good cholesterol). Other studies have suggested a benefit from HRT on blood pressure, glucose metabolism and on the function of blood vessel walls. All these factors would be expected to have a beneficial effect on cardiovascular risk. In older women, the use of HRT around the time of the menopause has been shown to reduce the risk of cardiovascular disease. Unfortunately, there have not yet been similar studies done in women with POI.
In women with POI, oestrogen replacement is recommended to reduce future risk of cardiovascular disease, and it is advised that HRT is used at least until the average age of menopause (51 years).
What other things can I do to reduce the risk of heart disease?
There are also many lifestyle changes which can reduce your cardiovascular risk. Maintaining a healthy weight, eating a well-balanced diet and doing regular exercise will be very beneficial. Dietary measures to reduce the risk of cardiovascular disease include minimizing salt, sugar and saturated fat. A healthy diet should ideally contain 5 portions of fruit and vegetables per day. Omega-3 oils, found in oily fish are also thought to be beneficial. Smoking is a large risk factor for heart disease and so should be avoided.
At the time of diagnosis, your doctor should make an assessment of your cardiovascular risk factors and give you advice how to reduce your future risk. This should include checking your blood pressure, smoking status, weight and height. They may also offer to check your cholesterol levels and sugar levels depending on your personal and family history of cardiovascular disease and diabetes.
British Heart Foundation: www.bhf.org.uk
Brain and cognitive function
Another concern in POI is the long-term effect which oestrogen deficiency may have on the brain. There are few studies looking into this subject but the latest evidence suggests that POI can cause negative effects on brain function in later life.
A large study from France showed that compared to women who experienced menopause after the age of 50, those with POI had a higher risk of poor performance in tests that assess brain function such as memory, verbal fluency, coordination and overall cognitive function. Importantly however, the study also showed that there was no significant association with POI and risk of dementia.
Other studies in women who had a surgical menopause before the onset of natural menopause have shown an increased risk of cognitive impairment and dementia. This increased risk only occurred those who did not take oestrogen replacement after surgery and until at least age 50 years, therefore suggesting that oestrogen treatment may protect against this risk.
Although there are few studies directly investigating the effect of HRT on long-term brain function in women with POI, current guidelines recommend that oestrogen replacement should be considered at least up to the age of natural menopause to reduce the possible risk of cognitive impairment.
As with cardiovascular disease, there are also lifestyle measures which may help reduce the risk for cognitive impairment such as regular exercise, avoiding smoking, maintaining a healthy weight and eating a well-balanced diet.
Link to paper by Ryan et al. (2014). Impact of a premature menopause on cognitive function in later life. British Journal of Obstetrics and Gynaecology.
Sexual health is a complex process which can be influenced by many physical, psychological and social factors such as stress, relationship problems, menopause, drugs and other medical conditions
For women with POI there are many reasons why their sexual function may be affected. Hormonal fluctuations can result in physical changes to the genital tissues causing vaginal dryness and pain. POI can also have a significant emotional impact affecting your mood, self-esteem and relationship, which in turn may affect your libido and sex life.
Although sexual problems are common, women are often embarrassed or not given the opportunity to discuss this aspect of their life. It is important to understand that there are many things that can be done to help restore a fulfilling sex life.
Due to the complexities of sexual health, adopting a holistic approach is important. Many women will benefit from a combination of psychological and medical treatment.
- Psychological interventions/counselling
There are several different types of counselling which may be helpful.
Psychosexual counselling involves education about anatomy and normal sexual function and how this may be affected by POI. It also aims to help improve communication within the relationship to help you discuss your sex life more easily.
Cognitive behavioural therapy (CBT) may be helpful when there are more complex psychological issues, as CBT explores our thoughts and behaviours in more depth. Relationship counselling or body awareness education are other forms of counselling which may be beneficial depending on individual circumstances.
Your GP or hospital specialist may be able to refer you to a psychosexual therapist. Alternatively these websites have information about local therapists:
British Association for Counsellors and Psychotherapists (BACP) website www.bacp.co.uk.
The College for Sexual and relationship therapists
- Hormonal treatment
Estrogen plays a vital role in sexual health by maintaining healthy genital tissue. A lack of estrogen can cause vaginal dryness and pain on intercourse.
‘Systemic’ estrogen replacement (i.e. estrogen taken by tablet/patch/gel/implant) normally helps prevent these symptoms. However, in some women systemic estrogen is not enough and they are still symptomatic. In this situation it can be useful to use ‘local’ estrogen in addition – usually given as a vaginal tablet/cream/ring. This local estrogen only effects the nearby tissues and very little is absorbed into the blood stream, therefore it is very effective for vaginal symptoms, but on its own is not enough to help treat hot flushes or prevent bone loss.
Testosterone is another hormone which plays an important role in sexual function, particularly for sexual desire. Testosterone levels are low in women with POI, especially in those women who have undergone surgical menopause, as the ovary is an important site of testosterone production.
Testosterone replacement is sometimes considered for women who are suffering from a lack of interest in sex despite adequate estrogen replacement. There are currently no testosterone preparations designed for use in women available in the UK. Therefore, at present, testosterone should normally only be prescribed by a specialist and is usually given in the form of a gel. There used to be testosterone patches and implants, which were licensed for use in women, but unfortunately these were withdrawn from the market due to commercial reasons rather than due to any safety concerns.
- Non-hormonal treatments
- Vaginal moisturisers
Other treatments to help vaginal dryness include vaginal moisturisers such as Replens®. These do not contain any hormones and so can be used along with the other hormonal treatments discussed above. They can either be prescribed or bought over the counter in pharmacies.
- Vaginal lubricants
These are used at the time of intercourse and can be very helpful to reduce dryness and pain. There are many different types of lubricant including water, oil, silicone and petroleum based products. As well as working as a lubricant, the water-based products (e.g Sylk®, Yes® and Durex Play Feel®) can help vaginal dryness.
An in-depth article addressing the different types of sexual problems along with practical tips: