When menopause comes too early

Ayeema* sat forlornly across from me, biting her nails, a habit she had refused to drop since childhood. She was nervous but pretending to be all right. I had known Ayeema since she was born. This is one habit her mum had lost the fight on. 

Ayeema’s mother, Hawa*, sat next to Ayeema and literally took over the conversation. This was the Hawa I grew up knowing; she hadn’t changed a bit! Hawa would speak on behalf of everyone, like the predestined spokesperson, even when she had no business talking. 

Today, however, she was just a worried mother. Ayeema had not had periods for a whole year. Though Ayeema did not seem to mind her situation, Hawa made it her business to seek help. Ayeema started her period when she was 15. For the next decade, she had a fairly normal flow but at 25, her periods became lighter and irregular until they altogether disappeared. It had been over a year since she had last bled. What got mum concerned was when Ayeema started manifesting symptoms that were all too familiar. 

Hawa was going through menopause, with the classical symptoms of hot flashes, poor sleep patterns, change in appetite, anxiety and mood swings. She was quite startled to find the same symptoms, albeit a little subdued, in Ayeema. She was worried. She wanted to see her grandchildren before she died. 

Ayeema noted that her periods had never been remarkable. They came a little later than most of her peers but she had always been a tiny one, so she thought it was expected. The longest she ever bled was three days, but most times she would have periods for a day or two. The periods were light and she only got mild period pains. 

Three years back, she noted the periods becoming irregular. She would get a period every two to three months, which progressed to just twice in the year and then ceased completely for almost a year now. 

A thorough examination revealed that Ayeema’s adolescent transition had taken  place appropriately, with normal breast development, normal body hair distribution a normal female habitus. She did not demonstrate any signs of other hormonal problems and save for her menses going on strike, she was otherwise in perfect health. 

Medical tests done on Ayeema revealed that she did not have any chromosomal abnormalities. Her reproductive hormones were at menopausal levels. An ultrasound of her pelvis noted that her ovaries were present but abnormally small. Her uterus was quite small, the size of a pre-adolescent girl’s. 

It was heartbreaking to inform Ayeema and Hawa of the diagnosis. Ayeema had suffered premature ovarian insufficiency (POI), or premature menopause as better described in simpler terms. If I thought Ayeema had taken the news hard, I hadn’t quite comprehended what this would do to Hawa. 

Hawa went into denial. She quickly dragged Ayeema off to the United States where part of the family resided, for a second and third opinion. The upside was that Ayeema was further able to be screened for multiple possible causes of POI, which we hadn’t yet done as the sample specimen would require to be shipped abroad.

Thankfully all the screens for the rarer autoimmune disorders were negative. Having eliminated all known causes of POI, Ayeema joined the 70 per cent of women with the condition, categorised as idiopathic premature ovarian insufficiency. For these patients, the fact that there is no identifiable cause of the condition means that we are not able to modify its outcomes by treating the cause. 

The first order of business was to confront Ayeema’s reality regarding her fertility. POI meant that she had a less than negligible possibility of conception as her ovaries had  no more viable eggs left. A few patients with POI, especially those whose POI is caused by autoimmune diseases, being able to tame the autoimmune disease may result in a slight improvement in ovarian function, which may result in a conception. Unfortunately for Ayeema, this was not the case. She would have to be content with the fact that she would never be able to sire her own biological children.  Aside from that, the early decline in the female reproductive hormones has a direct impact on multiple systems in the body. A decline in oestrogen levels directly results in osteoporosis. This is why elderly post-menopausal women make up the majority of patients with osteoporosis. This puts them at high risk of fractures, even from low-impact forces. For a person with POI, the risk sets in way too early, compromising the quality of life. 

Further, their cardiovascular risk index disproportionately rises, putting them at risk of events such as stroke and heart attacks. As if that’s not enough, there is a marked impact on their cognitive function, resulting in earlier onset, more severe forms of conditions such as Alzheimer’s disease. The condition further predisposes to obesity, insulin resistance, and inappropriate cholesterol synthesis, increasing the risk for diabetes and high cholesterol levels.  Walking Ayeema through all these complications was important for her to understand the justification for proposing long-term hormone replacement therapy as part of her treatment plan. Further, she is more conscious of her lifestyle, making informed choices in order to keep undesired outcomes at bay.  Unfortunately, by virtue of being a practising Muslim, her religion does not permit the practice of using donor eggs for in-vitro fertilisation, hence the dream of ever becoming a mum is currently quashed.  Both Ayeema and Hawa were referred to a couns
elling psychologist.  It was important for Ayeema to go through the healing journey and accept herself.  

It was even more important for Hawa to accept her daughter and be able to provide Ayeema with the necessary support. 

Today, Ayeema finds fulfilment in the early childhood development center she opened a year ago. It allows her to experience children from a different perspective and find her joy. Hawa, well, she will always be Hawa! We love her as she is.

Dr Bosire is an obstetrician/ / gynaecologist