Nimra* still remembers the day eight years ago when she was sitting in the doctor’s waiting room. Nervous and stressed out because of the changes she had been experiencing in her body, she was not sure what to expect after meeting her gynaecologist. The then 29-year-old single woman was enjoying her job as a media professional when she realised that all was not right with her health.
‘It began when I started experiencing hot flushes a year earlier,’ says the Dubai resident. Nimra also found that she was gaining weight although she had been careful about her diet.
‘While my unreasonable mood swings baffled my family, severe backaches left me wondering what was happening to my system,’ she says. However when her menstrual cycle started becoming increasingly irregular, she – on the insistence of her mother and sister – decided to consult the doctor.
‘After listening to my symptoms, the Obs-Gyn prescribed a series of tests including LH (Luteinizing Hormone) and FSH (Follicle Stimulating Hormone) tests, along with an ultrasound. But what actually got me worried was the look on the doctor’s face which spelled that something was seriously not right with me,’ remembers Nimra.
Her instincts proved right; tests revealed that Nimra’s LH and FSH levels were so high that she had entered perimenopausal stage. At 29, Nimra was experiencing premature menopause.
Premature menopause – also known as premature ovarian failure – is an infertility issue that affects around 1:10,000 women by age 20 and 1:1,000 women below 30; the irreversible process is often discovered too late for any medical intervention. Traditionally, any woman whose menstrual cycle completely stops before the age of 35 is considered a premature menopausal case.
The symptoms for any menopause, whether it’s premature or not remain the same. The first sign usually is an irregular menstrual cycle which finally ceases; if there’s no menstruation in the last six months, it means that the woman has entered menopause. Other symptoms also start kicking in and these are usually related to the lack of estrogen hormone. Women suffer from severe hot flushes, a disturbed sleep pattern, anxiety, irritability and mood swings, decreased libido, more frequent urinary infection and a burning sensation while passing urine.
The Obs-Gyn, immediately put Nimra on a hormonal therapy of estrogen and progesterone to induce artificial periods and to offset or slow down any health issues such as osteoporosis, a common outcome of menopause, which occurs due to severe lack of estrogen in the body.
‘The primary target of these medications is to safeguard the reproductive and menstrual function of women suffering from this rare disorder,’ says Dr Amala Nazareth, Specialist Obsgyn, Prime Healthcare Group, Dubai. ‘But it is vital for the treating physician to understand that such allopathic preparations do tend to have some side effects, such as cardiovascular issues and a strain on the liver. Hence mandatory checkups every six months are essential in such cases,’ she cautions.
‘By then, I was beginning to figure out what was happening to me, but acceptance did not come as easily and my body’s shock absorbers refused to function. In retrospect, I could see the onset of menopause creeping on me for almost a year, at least sporadically, but to be honest I did not recognise it,’ recalls Nimra.
According to fertility specialists, it is difficult – almost impossible – to identify the causes of premature menopause. However, incidental evidence points towards family history of premature ovarian failure and diseases such as Fragile X syndrome (an X-linked genetic disorder caused by mutation) and Turner’s syndrome (a genetic defect where affected women have only one X chromosome, causing infertility). Other such causes include surgical removal of the ovaries or undergoing radiotherapy or chemotherapy which severely affects the quality and quantity of eggs to the point of depletion. Having said that, there’s no conclusive evidence which explains any definite cause.
‘But there’s a strong relationship between egg depletion and smoking and even the use of sheesha,” stresses Dr Pankaj Srivastav, fertility expert and founder of fertility clinic, Conceive, ‘A girl who smokes will reach menopause 4-5 years before she was destined to and if her husband is a smoker, then the age of menopause will be advanced by two years – such is the impact of second-hand smoking on fertility. There’s also the environmental factor. We see so many young girls coming to us with very low egg reserves and no obvious reason for it. But recent research points fingers at the toxins that are seeping into our water table and food chain. The plastic we use to store or heat our food, for example, releases harmful chemicals that are directly toxic for eggs.’
Not willing to accept the diagnosis, and hoping the doctor had been wrong, Nimra sought a second opinion, consulting a few other specialists. ‘I was hoping to hear a different answer. But it was not to be.’
Within a year Nimra was two sizes larger while the prescribed hormone replacement therapy (HRT) took her on an emotional roller coaster ride every month. ‘There were days when I was normal, there were days when I was thoroughly depressed, and then there were days when I would turn into a wailing banshee. I felt as if an essential part of my life had been forcefully amputated, like I had a hit a cul-de-sac of motherhood’.
In most premature menopausal cases, as the estrogen level declines rapidly, a number of health issues begin to rear their heads. And while problems are similar across all ages, for younger women the effect is far more devastating since they have to live with these chronic issues much longer. There’s also evidence that premature menopause can lead to premature ageing. Nimra’s case was no different and within a few years, her bone health started giving all the signs of ageing with arthritis making steady inroads. In fact, a full body examination just a few years down revealed vulnerable areas in her backbone, knees and feet.
While the HRT helped Nimra’s condition from worsening further, she was worried about the long-term effects of the medication. Despite tons of benefits, the HRT has proved to be a double-edged sword. Over the years, a debate has ensued over the potential risks of the prolonged use of such therapies and some of the risks include strokes, formation of blood clots and breast cancer. Yet the fact remains that young women running out of estrogen and progesterone need the therapy to replenish the crucial depletion in their bodies.
The question is, how long does one take it? Dr Srivastav suggests a probable timeline of 10 years. He is also quick to point out that there is insufficient evidence whether doctors should continue to give HRT for longer than 10 years. ‘So the basic principle that we work on is to give the therapy to someone who requires it for her symptoms, use the lowest dose possible and try and taper it off as soon as we can.’
‘The consensus of opinion is that the clock starts ticking on the side effects after the age of 50 which is the average age of the natural menopause as these hormones are naturally occurring in a woman’s body until then. Therefore, when counselling women they need to be made aware of the benefits and risks of HRT to be able to make informed choices that can affect their quality of life,’ advises Dr Bohaira Elgeyoushi, Reproductive Medicine & IVF Consultant at HealthPlus Fertility Center, Dubai.
For Nimra, these eight years have been fraught with twists and turns, disappointments and self-doubts. Yet, despite all these adversities her confidence brims with positivity, and the experience has left her a much stronger person.
‘In these few years I’ve learnt that life has a terrible timing irrespective of what we may have planned for it. And when things go wrong to a point that they can’t be fixed, we need to find inner strength to overcome those hurdles. I can honestly say that it was my firm faith in God and the immense love and support of my loved ones that pulled me through this ordeal. It does not happen overnight, but it’s a gradual process with each day bringing more courage. Most importantly, over the years I’ve restored my self-confidence, fully aware that this was neither my fault nor something to be ashamed of,” smiles Nimra.
Freeze your chance of motherhood?
Given that premature menopause is irreversible with life-changing repercussions, is there a way to preserve fertility or slow down the process before a woman loses her ability to conceive? Unfortunately, medical experts believe that there’s very little hope, if at all, especially in cases that are diagnosed late.
‘There is very little that can be done to slow down this condition,’ says Dr Bohaira Elgeyoushi, Reproductive Medicine & IVF Consultant at HealthPlus Fertility Center, Dubai, ‘The best way is early detection and preventative measures. The knowledge of similar conditions in the family, genetic or autoimmune disorders are the red flags. This is why it’s important to consult a doctor if there is a known family history of premature ovarian failure or infertility at a young age.’
However, young women who are at risk of ovarian failure as a result of a medical treatment such a chemotherapy or radiotherapy do have the option of freezing their eggs or embryos, but this has to be done well in advance.
‘The only treatment that can help such women when it comes to infertility is an early diagnosis which allows them the option of fertility cryopreservation of the oocytes,’ explains Dr Amala Nazareth, adding, ‘Otherwise they have to inevitably embark on a journey of donated oocytes and embryos or for adoption which can take its toll on their psychological state of mind.’
Focus on mental health is vital too
Besides addressing the physical repercussions of menopause, the need for mental health therapy is just as important, since there are very few people menopausal women can turn to for support. In Nimra’s case, for instance, not many people around her understood her situation, which was quite frustrating. The few among her peers who she was able to confide in were – although sympathetic – unable to relate to something that seemed impossible. ‘Are you sure you got the correct diagnosis?’ or ‘How’s that even possible, you’re so young’ were the common responses that she encountered.
‘Because there were no outward and apparent indications of suffering, nobody really understood what I was going through,’ she adds sadly.
Nimra’s state of mind, given the shock and grief she had experienced, was not unexpected and is quite common among younger women who have suffered ovarian failure, according to psychologists. Many women have great difficulty coming to terms with the loss of reproductive capacity and feel that they have been cheated out of motherhood. Coupled with a sense of helplessness to reverse the condition, the depressing situation take its toll both physically and psychologically. Often, the question of “Why Me” also crops up.
Experts suggest that premature menopausal women – and their partners in case they are married – should seek therapeutic help, especially if there are signs of depression and anxiety. For many women, motherhood is the most natural and fulfilling manifestation of being a woman and to suddenly wake up to their inability to conceive can be an emotionally traumatic experience. A shock such as this can have far-reaching consequences, particularly if it is coupled with a prevalent sense of failure and can affect her relationship with those around her.
The key word is support, whether it is professional, familial, among peers, or even as part of a larger group (including online communities) of people who have also experienced early/premature menopause.
‘It’s very important that each person has the time and space to process what they are experiencing, both individually and together,’ advises Dr. Sarah Rasmi, Licensed Psychologist & Managing Director of the Dr. Sarah Rasmi Wellness Centre, Dubai, ‘It is not easy to see someone we love go through a difficult time; as a result, many of us try to console them. However, it’s important to remember that our loved ones don’t always need our advice. Most of the time, they need us to simply be there and listen. Ask them how they are doing and let them know that you are there for them.
‘Partners can support one another by being open with what they are experiencing and how they would like the other person to support them. When they are ready, partners can discuss other options for expanding their family. Some might also wish to seek couples therapy,’ adds Dr Rasmi.
With the support of her family, Nimra was able to slowly come to terms with her condition and find the strength to move on. Eight years down, while a part of her still wishes there was some way to reverse her menopause, she is more at peace with life, constantly seeking new ways to keep herself occupied, and more importantly, contented.
*Name has been changed