Premature menopause (PM) should be considered in any woman presenting with a history of secondary amenorrhoea (see Table: Causes of secondary amenorrhoea) or menstrual disturbance regardless of whether they have menopausal symptoms. Although the clinical presentation of premature menopause may be similar to that of a woman in the perimenopause at the usual age, the diagnosis is often not thought of and may be delayed because the woman is considered to be too young. The median time to diagnosis of premature ovarian failure (POF) was 2 years in one study; however, in 25% of women it took longer than 5 years to establish the diagnosis. 61% of women consulted 3 or more different clinicians prior to the diagnosis being made. The diagnosis of premature menopause following oophorectomy is obvious. A high index of suspicion should be maintained in women with a past history of hysterectomy, chemotherapy or irradiation.

Clinical assessment including history (see Table: History) and examination (see Table: Examination) provides information regarding aetiology, assessment of hormone deficiency and related complications. In the majority of cases, physical examination will be normal. Turner's syndrome is the most common cause of an abnormal phenotype. Other causes of secondary amenorrhoea (see Table: Causes of secondary amenorrhoea) should be excluded.

Table: Causes of Secondary Amenorrhoea

Pregnancy

Systemic Thyroid disease Polycystic ovary syndrome Chronic renal failure Adrenal disease

Ovarian POF/premature menopause

Uterine Ascherman's syndrome

Anterior pituitary Pituitary tumours Hyperprolactinaemia Empty sella syndrome Sheehan's syndrome Lymphocytic adenohypophysis

Hypothalamic weight loss exercise stress drugs (via altered prolactin secretion) CNS disorders including tumors, trauma, irradiation

Table: History

Presenting symptoms Menstrual Menopausal Pregnancy / infertility Galactorrhoea

Gynaecolgical history Pubertal development Menarche Menstrual history Parity Previous gynaecological surgery including surgery for endometriosis, hysterectomy and oophorectomy

History or symptomatology of autoimmune disorders especially adrenal or thyroid dysfunction

Past history History of inherited conditions such as Turner's syndrome Previous cancer and treatment including radiotherapy or chemotherapy History of viral infections including mumps and cytomegalovirus Eating disorder Cardiovascular disease risk factors Osteoporosis

Exclude causes of secondary amenorrhoea

Medication For example OCP, chemotherapy, antipsychotics

Family history of premature menopause, autoimmune disorders, cardiovascular disease, osteoporosis

Lifestyle assessment Smoking Alcohol intake Diet Exercise pattern

Table: Examination

Assessment of secondary sex characteristics / pubertal development

General physical examination including Body mass index, waist circumference Breast and cardiovascular examination

Examination of genitalia and vaginal examination where appropriate

Evidence of specific genetic disorders Stigmata of Turner's syndrome

Content Updated November 21, 2007