Early menopause (EM) can be caused by medical treatment, including
chemotherapy, radiotherapy, bone marrow/stem cell transplants, or
surgical removal of both ovaries (
bilateral oophorectomy ). In some cases, surgical removal of the uterus (without removing the ovaries) or ovarian surgery (for example to remove cysts) can lead to EM. Reasons for having a bilateral oophorectomy or
hysterectomy include cancer,
endometriosis,
fibroids, or to reduce cancer risk in women with particular gene mutations including BRCA 1/2 or
Lynch Syndrome. Women who still have their ovaries and are undergoing ovarian suppression therapy with monthly gonadotrophin releasing hormone (GnRH) agonist injections (e.g. goserelin) for breast cancer or endometriosis usually experience menopausal symptoms; but they are not considered to have EM because ovarian suppression is reversible when therapy is stopped.
To learn more about ovarian suppression therapy, please see the Box at the end of this Talking Point.
Women’s accounts of cause of medically-induced early menopause
Compared with women who experienced spontaneous EM or premature ovarian insufficiency (POI) (Causes of spontaneous early menopause: Women’s accounts), women with medically-induced EM were in general more able to identify the reason they had experienced EM. However, their ability to link medical treatments to EM varied according to the type of medication or procedures they experienced. This reflects the fact that some medications or procedures are certain to cause EM, while other treatments may or may not cause EM, or may cause menopausal symptoms rather than EM.
Women who had both their ovaries surgically removed (for cancer treatment, to reduce cancer risk, or to treat endometriosis) identified their surgery as causing EM. As Louise, who had both ovaries removed after being diagnosed with ovarian cancer, said, ‘…anyone that knows what an ovary’s job is in your body knows that that equals menopause, once they’re removed.’
Linda attributed her EM to a hysterectomy and oophorectomy in her early 30s for endometriosis.
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So this is when I was in my early 20s, and I was diagnosed with endometriosis. I had severe endometriosis; not only on my ovaries and my pouch of Douglas, but also on my bowel, my bladder and the lining of my stomach. So it was fairly extensive. So I had that removed and I was good.
The pain had decreased for a couple of months and then it would just come back again. So it was incredibly frustrating. Tried a number of different medical options, so a range of drug options, drug therapies as well further laparoscopies. So this continued on for another 10 years and in 1997, I was lucky enough to get pregnant to my daughter, [daughter’s name], and back then I was told that pregnancy could be a cure or that the endometriosis might kind of go into remission, if you like, after a pregnancy.
Well, that didn’t happen with me so in 2002 by that stage, after giving birth to [daughter’s name] in October 1997, I’d had further laparoscopies, operative for further diagnosis that had recurred. And in 2002 I decided that was enough. I was around 33 at the time and I had a hysterectomy and an oophorectomy, so removal of both ovaries as well. And that was designed to cure the endometriosis if you like. I also had eggs frozen at that stage in case I wanted to explore further conception options down the track. I was then pain free, which was awesome, for the first time in years and years and years. Yeah, so that was a really good outcome for me.
What perhaps wasn’t so good was the symptoms that went along with menopause, so things like hot flushes and dryness and all of those sorts of things. I went onto HRT not long after I had my hysterectomy and oophorectomy and they decreased the symptoms of the hot flushes and that sort of stuff, so that was great.
A radical hysterectomy
Alex had at 32 as part of her ovarian cancer treatment caused early menopause.

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So that was a horrendous operation. I had everything removed in my pelvic region excluding my lymph nodes. I’m very lucky I got to keep them. Cancer was even on my bowel and scraped off my bowel so it was pretty horrendous. I have a huge scar. It is gigantic. It’s like an old-school hysterectomy, like, old school all the way down my stomach, all the way down to my pelvis and the recovery from that surgery was the most horrible thing I’ve endured until chemo. [laughs] It was so painful.
The stomach muscles just being – I was quite fit and healthy before that, like the night before my first surgery I was doing, you know, sit-ups and yoga in the lounge room, and then I just couldn’t move or walk. I stayed in hospital for five days until I was sent home and I was given one month to recover before chemo started which is very cruel because after a radical hysterectomy, you need at least six weeks before you start doing things. That’s what they call mine, a radical hysterectomy, because everything is taken out. I don’t have a cervix anymore either – that freaked me out when the doctor told me that. But I guess that’s good because it means the cancer, you know, is all gone. So the first time we talked about menopause was in the meetings leading up to this very rushed surgery and I didn’t care about menopause at all. It was the lowest concern on my list. But the surgeons and the oncologists were quite insistent about it being something I needed to think about. They wanted me to think about you know, what hormone replacement therapy I was going to do and the side effects I was going to experience straight after surgery.
A couple of women who had chemotherapy, radiotherapy or a bone marrow/stem cell transplant for Hodgkin’s Lymphoma linked EM directly to chemotherapy (see Finding out about medically-induced early menopause).
Julia explained how treatment for Hodgkin’s Lymphoma led her to experience early menopause.
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Hodgkin’s lymphoma is a blood disease and it doesn’t have any links to your hormones at all. It’s not to do with oestrogen dominance or anything like that, or any of the breast cancers where you need to have certain drugs afterwards. It’s just that the high dose chemotherapy that is needed in a stem cell transplant is so strong, that it actually kills your entire immune system and kills off… well in 99% of cases really, kills off your ovarian function because the chemo is so strong.
For women with oestrogen sensitive breast cancer, chemotherapy and radiotherapy typically occurred after lumpectomies or mastectomies, and before other follow-on treatments to reduce their oestrogen levels (e.g. bilateral oophorectomy and/or hormone/adjuvant endocrine therapy). Disentangling which treatments had caused menopausal symptoms and which had caused EM was not easy. Women who had had a bilateral oophorectomy attributed EM to this surgery.
Maree explained the different effects of chemotherapy, bilateral oophorectomy, and hormone (adjuvant endocrine) therapy (anastrazole).
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I had a bilateral mastectomy with immediate reconstruction and during the chemo my periods had stopped and I experienced some symptoms of menopause, even though they didn’t officially diagnose me with that because chemo can bring on things like the hot flushes, the mood swings, no period at all. My official diagnosis of early menopause came after I had my oophorectomy. After the first operation, I had radiotherapy for five weeks and then once I had recovered from that I had the oophorectomy which was in May. Once I had that, of course, I was diagnosed with early menopause.
The reason I had my oophorectomy is mainly to prevent ovarian cancer. My mother had ovarian cancer and she had gene testing done when she was going through that. And it was discovered that she had the BRCA1 gene and I also had testing done whilst I was in treatment and it was discovered that I have the BRCA1 gene as well. So I felt that the likelihood of myself getting ovarian cancer was very high and, to be frank, even though it was low I would have wanted to be sure. I wanted to make sure that there wasn’t a chance that that was going to happen to me.
And I had already had my two children. We didn’t plan on having any more children. So for me I wasn’t worried at all about having an oophorectomy and the doctors had discussed the fact that this would bring on early menopause. And they had talked about the symptoms and what I would experience, which I was quite prepared for. I just basically wanted the worry gone. I wanted to do everything I could in my power to make sure I didn’t have to go through this again, everything within my power. So there’s no guarantees but this is an excellent way of ensuring [laughs] that there’s a big risk factor gone.
Also I take medication now, I take anastrozole which stops – as far as I understand [laughs] it stops the oestrogen production. And that actually increases – one of the side effects is it increases the symptoms of menopause. So the hot flushes and things like that, they can increase basically [laughs].
Women who had not had a bilateral oophorectomy and were undergoing ovarian suppression therapy with monthly GnRH agonist injections (see Box at the end of this Talking Point) were aware the medication caused them to be in a ‘menopausal state.’ However some indicated that they had received unclear information about the difference between early menopause and ovarian suppression.
Kate described having ‘no idea’ if her periods would return after stopping ovarian suppression therapy in future, but recalled the term ‘menopause’ being used to explain her symptoms during chemotherapy and radiotherapy, then later ovarian suppression therapy.
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After I finished chemo, I noticed that my hot flushes and my night sweats and my joint aches were intense. I couldn’t work out whether it was just sort of chemo-based and radiation – I was still going through radiation. So I couldn’t work out, if it was that but then I was told that, because I’d had chemo, my ovaries had kind of gone into shut down and that it was probably likely that I was going through early menopause.
I think it was after the chemo when I started getting the physical symptoms. After a little while, they probably thought that – the chemo would have been out of my system so it wouldn’t be because of that. And then they told me that obviously starting ZOLADEX [goserelin] injections, which shut down your ovaries, and also I’m on an Aromatase Inhibitor, exemestane, which does the same thing, and that’s when you are kind of told, “Well this is probably menopause.”
See that’s the type of stuff that I don’t know. I have no idea and I think it will just be – I’ll have to find out but – and I’m not sure whether anyone would know that either. So I suppose it could happen, but, like I said, I’ll be early forties so I’m not sure whether it will or it won’t. And that’s just the unknown as well and then obviously that comes into a whole new thing of you’re probably fertile again. And if that does happen, I don’t want to get pregnant because the idea of having cancer again. So I guess there’s a whole lot of unknowns as well to do with early menopause and being on this medication.
I don’t think it will happen but I think my body is just – like, 10 years of this medication, of shutting it down. I just think that’s – it’s over. [Laughs].
Eden reflected on the meaning of being in a ‘menopausal state’ as a result of undergoing ovarian suppression therapy as opposed to having ‘real menopause.’
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Only fairly recently. Like, with ZOLADEX [goserelin], since I’ve been taking – that’s been two and a bit years. I think I’ve been interpreting it or they’ve been saying, I’m not sure, but more like, “You’ll be in a menopausal state,” but sort of implying if I stop taking the drug maybe my body would return to not being menopausal. So, maybe I’m technically, or maybe I am but only because of medicine. I don’t think I had thought through the boundaries of those terms.
In the lived experience of what I go through, I think it’s like what I would have gone through had none of this happened to me ten years – I think it is real menopause whether or not it counts or however it gets classified. Certainly there are concerns about bone density, about vitamin D, so I take vitamin D as well as the other drugs. They’re very concerned, but I’m happy to run and lift weights anyway, but they want me to do that sort of thing. I think I must be seen through a medical lens as being menopausal and I think that term has been used sometimes but I don’t remember it being used early on.
Several women had repeated ovarian or uterine surgeries to remove tumours (cancerous and benign), cysts or fibroids, or for endometriosis-related problems. Most reported that they were diagnosed with EM after a hysterectomy with oophorectomy, or removal of any remaining ovarian tissue. However, they described noticing changes in their menstrual cycles, menopausal symptoms, or feeling as though they were in ‘perimenopause’ before ‘final’ surgeries or before formal diagnosis (Finding out about medically-induced early menopause). A few suggested that their ovaries had ‘shut down’ or been ‘damaged’ as a result of either disease (e.g. cancer, cysts, endometriosis) or treatment (e.g. surgery).
Naomi had repeated ovarian surgeries for ovarian cancer. She recalled experiencing menopausal symptoms before her final ovarian surgery (after which she was diagnosed with early menopause) but wasn’t sure why.
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My periods have always actually been a bit irregular, which is kind of genetic because my mum’s the same. So I’ve always, I’ve never had the four week thing. It’s always been longer between periods for me. And, so there hasn’t really been a [laughs] normal thing to go on. But, I was still having periods. That was because I was on the pill actually at that point. [laughs] Sorry, I neglected to say that before [laughs] – so much is going on and it’s been a while since I stopped taking that.
After my initial diagnosis, they actually put me on the pill because at that point, they’d found that it seemed to have a bit of a protective effect. I was having quite regular periods because of that. But, then they, obviously when I had that surgery in 2013 we stopped the pill as well because there seemed to be a hormone thing involved and we thought it was better if we stopped that.
So, you know – and I mean, I’ve sort of said this to my specialist and he looks at me funny. But even though I was on the pill, I almost felt, like, in the lead up, when I had that last tumour growing – I almost felt like I had some menopausal symptoms. But I was on the pill. [laughs] So I don’t know whether that was in my head or whether something funny was going on and that ovary had shut down then, and the pill wasn’t fully compensating.
Because I was getting sort of some hot flushes and stuff then which was a bit weird. But yeah, when I say that to my specialist, he goes, “Oh, no, but you were taking the pill.” [laughs] I’m like, “Well, I don’t know.” [laughs] I haven’t brought it up for a while. It was just at the time and I think I only ever said it once and he was like, “Okay. Whatever.” [laughs
Women’s perceptions
Some women had different views from their doctors about the cause of their EM. Natalie was diagnosed with EM after a hysterectomy for endometriosis. However, she recalled experiencing menopausal symptoms two years beforehand following removal of a fibroid, and noted that her sister had experienced spontaneous EM. She reflected that, ‘[i]t just happened to be everything on top of each other, and that kicked [EM] off.’
Mary, who had a history of surgeries for ovarian cysts and benign tumours, shared her thoughts on why she experienced early menopause at age 39.
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I was experiencing these menopausal symptoms with periods all over the place and hot flushes and that kind of stuff. Again I had another laparoscopy because I had a lot of pain on the left side again. The – I can’t remember the guy’s name; [doctor’s name] something, I went to the gynaecologist. When I said to him, “I think I’m going through menopause, early menopause,” he was just very dismissive and said, “You’re too young to be going through that.”
I said, “Yeah, but I was 25 when I got breast cancer so this whole too young to get these kind of things it doesn’t wash with me because anything can happen really. And why wouldn’t it be? I’ve only got one ovary.” So I was kind of – at this point I’m Googling stuff of course. And people say “Don’t do that,” but when you don’t get answers and the doctors are dismissive, of course you do. And I’d read somewhere that if you’d only ever had one ovary it does the job of two, of course – and from the age of 14 I’d only ever had one ovary and it did the job of two ovaries – until I was 37.
And so it seemed to me that that, that ovary had just completely conked out, or the surgery I’d had in February 2008 had caused some damage to the ovary and had cut off the blood supply or whatever. And that’s what prompted it – prompted the early menopause. This gynaecologist was very dismissive and said, “Oh, you’re not going through menopause. No, I’ve just operated and I’ve seen you had just ovulated, you know, a few weeks before anyway,” because he’d looked at the ovary and you can tell. But, like, I was still getting periods but it was just very on off, on off, all the time.
They wouldn’t come for months or they’d not show up at all for months, or then I’d get them and it was really heavy, then I’d get another one a week later. It was just completely all over the place. But when he was saying that it wasn’t menopause I just got more and more angry and frustrated. And then – he finally said, “Oh, I’ll do a blood test,” and he did a blood test just to shut me up basically. “All right, I’ll do a blood test,” he said rolling his eyes. And the blood test came back and I rang the office to get the results and I spoke to the receptionist and she said, “Oh, yes, you’re postmenopausal.”
What is Ovarian Suppression Therapy?
Ovarian suppression therapy refers to any treatment that lowers or stops the amount of oestrogen made by the ovaries. It includes chemotherapy, radiotherapy, bilateral oophorectomy, and the use of certain drugs. Ovarian suppression can be permanent or temporary. Bilateral oophorectomy before the age of 45 causes early menopause (EM). Chemotherapy and radiotherapy before age 45 may cause EM. Women undergoing ovarian suppression therapy with gonadotrophin-releasing hormone (GnRH) agonists such as goserelin (ZOLADEX) for breast cancer or endometriosis usually experience menopausal symptoms; but they are not considered to have EM because the ovarian suppression is reversible when therapy is stopped. If women have chemotherapy followed by ovarian suppression therapy, they may develop EM due to chemotherapy, but EM may be hidden until their ovarian suppression is stopped and they find that their menstrual periods do not return.
Tamoxifen may cause menopausal symptoms as it has an anti-oestrogen effect on some parts of the body (breast and brain temperature regulation) but does not cause menopause itself. Aromatase inhibitors (e.g. exemestane, letrozole, anastrozole) block the chemical pathway producing oestrogen, causing very low oestrogen levels and thus menopausal symptoms, but do not cause menopause itself.
Terminology
Therapy involving GnRH agonists, tamoxifen or aromatase inhibitors, may also be referred to as “hormone therapy” or “adjuvant endocrine therapy”. The term “hormone therapy”, used to describe treatments where the aim is to block or lower oestrogen in the body, can be confusing as it is similar to the term “hormone replacement therapy” (HRT). However, HRT is designed to increase oestrogen levels to relieve menopause symptoms.
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