This is the second part of our series about the menopause based on our booklet “Fast Facts for Patients: Menopause”, which is freely available online. This article deals with other reasons for the menopause, such as surgical menopause, endometriosis, premature ovarian insufficiency, and chronic diseases.

Some women will experience menopause for reasons other than natural ageing. These include premature ovarian insufficiency or a chronic health condition that causes early menopause, or removal of their ovaries to reduce their risk of certain cancers or to alleviate pain associated with endometriosis.

Surgical Menopause

Women who have their ovaries removed as part of a subtotal or radical hysterectomy (removal of the womb and some associated tissues) can experience an abrupt onset of menopausal symptoms. Your healthcare professional should discuss ways to manage these symptoms before you have surgery and put in place an individualised treatment plan, guided by your medical history.

Most women can start hormone replacement therapy (HRT) immediately after surgery. This is best delivered through the skin to prevent any increase in the risk of blood clots in the legs or lungs. Oestrogen-only HRT is most common, but you may also need a progestogen for the first 12 months or longer if you have endometriosis or if your cervix was not removed as part of your surgery.

Ovaries that are not removed during a hysterectomy often fail early. You can consider using HRT as soon as you experience symptoms.

If you are over 45 years of age when your ovaries stop producing hormones reliably, you will not need a blood test and you can start HRT without delay after consulting your healthcare professional. Again, if you have endometriosis or you still have your cervix, you may also need a progestogen.

Endometriosis

Endometriosis arises when tissue that is similar to the tissue that lines the womb (endometrium) grows in other places in the body.

Common sites include:

• the ovaries, resulting in “chocolate” cysts
• the Fallopian tubes, where it can cause fertility problems
• the lining of the abdominal cavity (this is called the peritoneum; it covers, supports and protects the organs inside the abdomen and pelvis)
• the muscle of the womb (in this location the condition is known as adenomyosis).

Less common sites include the belly button (which will bleed monthly), nose (monthly nose bleeds), lungs (monthly coughing of blood) and caesarean section scars (monthly pain).

Laparoscopy (keyhole surgery) is used to diagnose endometriosis. A small telescope is inserted into the abdomen via small incisions to look inside the body. The condition can be treated medically (often with hormones) or the deposits of endometriosis can be removed and/or scar tissue (adhesions) released during laparoscopy.

It is important that your healthcare professional considers your history of endometriosis when discussing your menopause management. If you have had surgical treatment, there may still be deposits of tissue in your body and you will need a progestogen to reduce the risk of hyperplasia (excess thickening of the tissue, which is a risk factor for cancer).

You may be eligible for a Mirena IUS (intrauterine system) if you have an intact uterus (that is, you have not had a hysterectomy). The progestogen released by the IUS will stop the endometrial tissue from thickening, no matter where in the body it is growing.

There are no clear guidelines on how long you will need a progestogen. Many clinicians recommend long-term use to reduce risk.

Premature Ovarian Insufficiency

Premature ovarian insufficiency (sometimes referred to as POI) occurs when the ovaries fail early (or are surgically removed) in women under the age of 40. There is usually no recognisable cause and it is particularly devastating in younger women who have not yet had children.

Women with POI are at increased risk of osteoporosis and cardiovascular disease (CVD).

Following an individualised risk assessment, you may be offered either combined hormonal contraception – pill, patch or vaginal ring – or HRT.

Fertility treatment using a donor egg is an option for women who wish to become pregnant.

Chronic Diseases

The menopause sometimes starts early in women with long-term (chronic) diseases, such as kidney failure, underactive thyroid, rheumatoid arthritis, epilepsy and migraine. Blood tests are recommended in women below the age of 40 (follicle-stimulating hormone (FSH) should be checked on two separate occasions, 2–6 weeks apart). HRT is not completely off limits to women with underlying health issues, but it is best delivered through the skin as a patch, gel or spray rather than taken orally.

Women with asthma may notice a change in symptom control around the menopause transition. HRT can also affect symptom control: sometimes it helps, but sometimes control deteriorates. It is important that you discuss any problems with your healthcare professional.

Please check out the previous and the next post of our series here:

• What Is the Menopause?
• How Will The Menopause Transition Affect Me?

Information based on Fast Facts for Patients: Menopause (Karger, 2021).