In July 2020, when I was 35, my period changed dramatically. What had long been a regular four-day event was suddenly a four-hour waterfall of viscous blood clots before it stopped abruptly. During those hours I changed my tampon every 20 minutes—sometimes it was hard to keep up. When my husband saw me scrubbing my jeans in the sink, he said, “My God, it looks like a murder scene.”
We had just moved across the country for my husband’s job, and while he worked long hours, I cared for our 2-year-old son. I was so stressed about all those life changes that my physical health was the last thing on my mind, so for the next several months I simply endured these four-hour waterfall periods. Then, in April 2021, I borrowed my father-in-law’s truck to move a piece of furniture, and while I sat in traffic I felt my period start, then leak onto the driver’s seat. Mortified, I wiped away tears as I cleaned the seat, and I promised myself, if these stains come out, I will seek help.
I cleaned the truck successfully and soon afterward found a gynecologist who ordered blood tests and ultrasounds. When the results came back normal, she ordered progesterone to reset my period to normal. But before I had even taken the progesterone, I got my period, and this time it was mild; the next month, it was mild again. The gynecologist told me my waterfall periods might have been due to postpartum hormonal fluctuations—even two years after my son’s birth—and I felt relieved that the crisis had passed.
Worry becomes anxiety
Not long after that, though, I developed anxiety and started doing some strange things—when I read about an accident on a bridge we drove over regularly, I stopped driving to activities on the other side of it. In 2022 I was seeing a therapist to help me cope, and she told me that my anxiety was environmental and that managing full-time child care had left me overwhelmed. Given that my son was about to return to preschool, she encouraged me to find part-time work as something else to focus on. I found freelance writing assignments, but my anxiety loomed, and I felt like a failure for not magically feeling better.
In June 2023 I missed a period, then another the next month. I knew I wasn’t pregnant but took a pregnancy test anyway. We had changed insurance providers, so I made an appointment with a new general practitioner. The nurse who checked me in at that office urged me to ask about menopause, which surprised me: At 38, wasn’t I too young for that? Still, while waiting for the doctor, I googled “menopause in your 30s,” and the results alarmed me: I read that early menopause could increase the risk of other health issues such as heart disease and osteoporosis. I expected my doctor to be concerned, but when I brought it up she chuckled and said I was too young, insisting, “A missed period or two is no big deal.” I trusted her, but after I missed two more periods, she told me to take another pregnancy test and gave me the number for the gynecology office.
Six months later, I spoke with a gynecologist who prescribed progesterone to try to reset my period once again as well as a blood test to be done on the second day of a bleed, but she didn’t tell me what she was looking for. Then, a week later, she retired! For two weeks, I was frustrated and scared, and when I got the lightest trace of a period, I took the blood test.
A new gynecologist called with the results: My FSH levels were high, at menopausal levels. I didn’t know what any of this meant (though I learned later that FSH is short for “follicle-stimulating hormone,” which stimulates the growth of follicles in the ovary each month). All I heard was “menopause,” the very word my previous doctor had brushed off. “This can’t be right,” I insisted. I told her about the postpartum waterfall periods the year before and my GP’s insistence that a missed period was no big deal. She listened politely, then explained that I was of perimenopausal age. The heavy periods were likely early symptoms of perimenopause, and I was now probably near menopause and needed to wait it out.
I asked about the risks of early menopause, but the gynecologist said that at 38, I was “basically 40 and wouldn’t need any different treatment.” After our call, I burst into tears. I trusted the test results, but I felt that she was ignoring my concerns.
From diagnosis to self-empowerment
Determined not to be brushed off, I learned all I could on my own. I felt sick thinking about how anxiety had begun controlling me when my son was small. I worried that if I waited out perimenopause, anxiety could permanently alter my brain. Then I read that perimenopause symptoms could be treated with hormone replacement therapy (HRT) and that HRT was crucial for menopausal women under 40. I wanted to start HRT, but the gynecologist wanted me to wait until I was fully in menopause, reasoning that there wasn’t yet enough research on the use of HRT in perimenopause. I found a new gynecologist, who diagnosed me with primary ovarian insufficiency (POI): My ovaries had stopped working normally years before I should have expected to enter menopause. She prescribed HRT consisting of an estradiol patch I was to change twice weekly, along with a progesterone IUD. Two months later, my anxiety finally subsided. My periods came back irregularly, but it is now unclear whether they are true periods or I have them because of the HRT.
I turned 40 this year. Since I still bleed occasionally, I don’t know whether I am officially in menopause, but when I asked, my new gynecologist told me, “What matters most is how you feel.” I feel content, though I sometimes wish I could relive the years when my son was small. He is still young enough that people ask if we’ll have more children. I explain that we won’t, but that I love what we have: one beautiful child and a beautiful life.
What Is Primary Ovarian Insufficiency?
Around 3% of women experience primary ovarian insufficiency (POI), in which their ovaries stop working normally before they turn 40, causing their estrogen levels to plummet; they may go months without a period. Scientists don’t know what causes most cases of POI, though in some women it results from an autoimmune attack on ovarian tissue or damage from chemotherapy, radiation, or exposure to certain viruses or chemicals. Because those with the diagnosis may still get a period on occasion, POI is not the same as premature menopause, which requires going without bleeding for a year before age 40. Women with a family history of POI or who have had ovarian surgery are at increased risk.
The symptoms of POI are generally the same as those for women nearing menopause; they just happen earlier than usual. These may include:
- Irregular and skipped periods
- Hot flashes and/or night sweats
- Vaginal dryness
- Anxiety, depression, irritability, and brain fog
- Decreased libido
- Difficulty conceiving
How is POI diagnosed?
If you are under 40 and miss three or more periods, see a health care provider (take a test first to rule out pregnancy). “If it’s not pregnancy and not thyroid issues, we need to think about perimenopause,” says Mary Jane Minkin, M.D., a clinical professor of obstetrics and gynecology at Yale School of Medicine. There are other possible causes, such as polycystic ovary syndrome (PCOS), but unfortunately many primary care doctors (and even some gynecologists) overlook the possibility of POI. “They think women this age are too young,” Dr. Minkin says. Your doctor will do physical and pelvic exams and test your levels of hormones, especially estrogen (levels of it drop close to menopause) and FSH (as you approach menopause, FSH levels increase as your body attempts to push your ovaries to release an egg).
How does it impact fertility?
Women with POI can get pregnant, though they have less than a 10% chance of doing so naturally (still, use birth control if you don’t want to conceive). For women who wish to have a baby, “the sooner you talk to an infertility specialist, the higher your chance of success,” Dr. Minkin says.
The health impact of POI
All women experience increased health risks from losing estrogen, which typically happens during menopause. But these are amplified when low levels persist for many years. See “Here’s the scoop on HRT for POI” on below for more information.
—Meryl Davids Landau
Here’s the scoop on HRT for POI
When a woman has POI or enters full menopause prematurely (before age 40), hormone therapy (HRT or HT) is crucial for long-term health. “Women in this situation should be on hormone therapy, ideally bioidentical,” says Bruce Dorr, M.D., an ob/gyn in Colorado and senior adviser to Biote, a hormone pellet provider. Boosting estrogen and progesterone protects the heart, bones, and brain and reduces bothersome menopause symptoms, he says. Like menopause, POI can increase the risk of weakened bones, fractures, and heart or blood vessel disease, and the longer you go without enough estrogen, the greater the risk. Some women worry that HRT may up breast cancer and heart disease risk, but properly administered HRT does not increase these risks, Dr. Minkin says, adding that in younger women with POI the much greater health risk is in not taking hormones.
Whether to stay on HRT when you reach your 50s is your choice. Dr. Dorr says many patients continue taking hormones to prevent the hot flashes, night sweats, and sleep issues that can otherwise come roaring back. —M.D.L.
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