Early Menopause: Causes, Symptoms and Support

Early menopause is menopause between 40 and 44. Before 40, it is called premature ovarian insufficiency (POI). Recent studies suggest POI affects about 3.5% of women. It can follow surgery or cancer treatment, be linked to genetic or autoimmune conditions, or have no identifiable cause. Hormone therapy until around 51 is recommended to protect bone, heart and brain health.

What is early menopause?

Two terms are used, depending on age:

• Premature ovarian insufficiency (POI): loss of ovarian activity before 40. Periods become irregular or stop, estrogen is low and FSH is raised. It is sometimes called premature menopause or primary ovarian insufficiency.
• Early menopause: menopause between 40 and 44.

The distinction matters because POI is not always permanent. A 2024 international guideline from ESHRE, ASRM, the International Menopause Society and partners notes that ovarian activity can return intermittently, giving a chance of natural pregnancy. With early menopause after 40, periods are less likely to return.

For how early menopause compares with other ages, see menopause at 40, 45, 50 and beyond.

How common is early menopause?

According to the 2024 guideline, estimates of how many women have POI range from about 1% in older studies to 3.5% in recent ones, and may vary by ethnicity. Early menopause between 40 and 44 is more common. A UK study reports that around 10% of White women in high-income countries reach menopause before 45.

What causes early menopause?

Often, no cause is found. The 2024 guideline advises that clinicians explain the known causes and the limits of current testing, and that a cause may not be identified.

Known causes include:

• Surgery. Removing both ovaries causes immediate menopause. See surgical menopause.
• Cancer treatment. Chemotherapy and pelvic radiotherapy can damage the ovaries.
• Genetic conditions. These include chromosome differences such as Turner syndrome, and the fragile X (FMR1) premutation.
• Autoimmune conditions. The immune system can affect the ovaries, sometimes alongside adrenal or thyroid conditions.
• Lifestyle factors. The guideline lists smoking among modifiable risk factors.

Female relatives, such as sisters and daughters, of someone with POI without a known medical cause have a higher risk themselves. The guideline recommends they are told about the signs and offered support.

What are the symptoms?

Symptoms are similar to those of menopause at any age, but can feel more abrupt and more distressing when unexpected:

• Irregular, infrequent or absent periods. See irregular periods.
• Hot flashes (called hot flushes in the UK) and night sweats
• Sleep problems, low mood and anxiety
• Vaginal dryness and discomfort during sex
• Lower sex drive
• Difficulty concentrating

Some people have few symptoms and only notice that their periods have stopped. The guideline advises clinicians to consider POI in anyone under 40 with irregular or absent periods or symptoms of low estrogen.

How is early menopause diagnosed?

Under 40 (POI)

The 2024 international guideline recommends diagnosing POI when there are:

• Disordered periods, meaning absent or irregular periods, for at least 4 months, and
• A raised FSH blood test, above 25 IU/L

This is simpler than before: previous guidance required two raised FSH results. The FSH test can be repeated after four to six weeks if the result is unclear, and AMH testing may help in uncertain cases. Clinicians should also:

• Rule out pregnancy
• Consider whether hormonal contraception is hiding or causing changes to periods
• Not diagnose POI based on estradiol levels alone

If both ovaries were removed before 40, POI is diagnosed without further tests.

Between 40 and 45

NICE suggests an FSH blood test may be considered in people aged 40 to 45 with menopause symptoms, including changes to their cycle. See perimenopause tests. Other conditions can cause similar symptoms, so your clinician may also check for thyroid problems or pregnancy. See perimenopause or something else.

Tests after diagnosis

For POI without an obvious medical cause, the guideline recommends:

• Chromosome analysis for everyone with POI of unknown cause
• Fragile X (FMR1) premutation testing, with genetic counseling
• Screening for adrenal antibodies if the cause is unknown
• A thyroid function test, repeated about every five years or if symptoms arise
• A bone density scan (DXA) at diagnosis, where available
• A cardiovascular risk check, including cholesterol and diabetes screening, with at least yearly blood pressure checks

Why does early menopause matter for long-term health?

Estrogen protects many body systems. Losing it early means more years without that protection. The 2024 guideline highlights:

• Heart and circulation: increased risk of coronary heart disease, heart failure and stroke
• Life expectancy: reduced without hormone therapy, largely because of cardiovascular disease
• Bones: lower bone density and a possible increased risk of osteoporosis and fracture
• Muscles: possible reduced muscle mass and strength
• Brain: increased risk of cognitive impairment and dementia
• Emotional wellbeing and sexual health: often significantly affected

These risks are why treatment is recommended even for people without troublesome symptoms.

What treatments are recommended?

Hormone therapy until the usual age of menopause

The 2024 guideline strongly recommends hormone therapy for women with POI until the usual age of menopause, whether or not they have symptoms. The aim is to reduce the risk of heart disease, osteoporosis and dementia, and it may benefit muscle health too. The Menopause Society similarly recommends hormone therapy until at least the average age of menopause for people with POI or early menopause, unless there is a contraindication. Key points from the guideline:

• Breast cancer risk: there is no evidence that hormone therapy increases breast cancer risk for women with POI compared with women of the same age without POI.
• Doses: doses may be higher than those commonly used after natural menopause, to protect bones.
• Womb protection: people with a womb need a progestogen to protect it.
• Combined contraceptive pill: this can be an alternative. If used, a continuous or extended regimen is recommended to avoid gaps in estrogen.
• Compounded "bioidentical" hormones are not recommended, because data on their safety and effectiveness are lacking.
• Taking it consistently matters. Delayed starts and missed treatment should be avoided.

For people aged 40 to 44, NICE advises that the benefits and risks of HRT likely lie between those for POI and those for people over 45.

Other support

• Vaginal estrogen for vaginal and urinary symptoms, which can be used alongside HRT
• Testosterone may be considered for low sexual desire in some cases, particularly after surgery
• Healthy lifestyle: weight-bearing and resistance exercise, not smoking, a healthy diet and adequate calcium and vitamin D
• Psychological support, which NICE and the guideline both recommend offering

What about fertility and contraception?

POI substantially reduces the chance of natural conception, but the 2024 guideline notes that ovarian activity can return, giving a chance of pregnancy. It advises:

• Use contraception if you want to avoid pregnancy. HRT does not work as contraception.
• Egg donation is an established route to pregnancy after POI.
• No treatment has been reliably shown to restore ovarian function.
• Fertility preservation, such as egg freezing, can be considered before treatments known to cause POI, such as some cancer treatments.

Pregnancy after egg donation is higher-risk and needs specialist care. See pregnancy during perimenopause for general contraception guidance.

Finding emotional support

An early menopause diagnosis can bring grief, shock and worry, especially about fertility. The 2024 guideline recommends that the diagnosis is shared compassionately and that people are referred to support groups and mental health care. Patient organizations such as the Daisy Network, a UK charity for people with POI, offer information and community.

It is also worth telling your clinician if you are struggling. Support is part of treatment, not an extra.

Questions to ask your clinician

1. Is this premature ovarian insufficiency or early menopause, and how was that decided?
2. Do you know the cause, and should I have genetic or other tests?
3. What type and dose of hormone therapy do you recommend, and why?
4. Do I need contraception, and what are my options if I want a pregnancy?
5. When should I have a bone density scan and heart health checks?
6. Should my sisters or daughters be told?
7. What emotional support is available?

For more questions, see your first menopause appointment.

See a doctor if:

• Your periods stop for 4 months or more and you are under 40, after ruling out pregnancy
• You are under 45 and have menopause symptoms

Seek urgent help if low mood includes thoughts of harming yourself. Contact emergency services or a crisis line in your country straight away.

Frequently asked questions

Is premature ovarian insufficiency the same as early menopause?

Not quite. POI means loss of ovarian function before 40 and may not be permanent. Early menopause is menopause between 40 and 44.

Can you get pregnant with POI?

It is less likely, but possible. The 2024 international guideline notes that ovarian activity can return intermittently, so contraception is advised if you want to avoid pregnancy.

Do I need HRT if I don’t have symptoms?

International guidance recommends hormone therapy for people with POI until the usual age of menopause, even without symptoms, to protect bone, heart and brain health.

Does HRT increase breast cancer risk with POI?

According to the 2024 guideline, there is no evidence that hormone therapy increases breast cancer risk for women with POI compared with women of the same age without POI.

Will my sisters also have early menopause?

If POI has no known medical cause, female relatives have a higher risk. They should know the signs, and genetic counseling may be offered if a genetic cause is found.

References

1. ESHRE/ASRM/CRE-WHiRL/IMS: Evidence-based guideline on premature ovarian insufficiency, 2024 (Human Reproduction Open)
2. ESHRE POI guideline summary, Climacteric 2024
3. ASRM: Evidence-based guideline on premature ovarian insufficiency
4. NICE guideline NG23: Menopause, identification and management
5. Guideline Central: NICE NG23 summary (early menopause and POI recommendations)
6. The 2022 hormone therapy position statement of The North American Menopause Society
7. Let’s Talk Menopause: Summary of the NAMS 2022 position statement
8. Risk factors for natural menopause before the age of 45: two British birth cohorts
9. Prenatal maternal smoking and time to natural menopause: two UK birth cohorts
10. World Health Organization: Menopause fact sheet

Editorial status: evidence-based educational article. Last evidence check: September 10, 2026.