Hair Loss

What does the hair loss specialist need to know? — Donovan Hair Clinic

Identifying Incipient Early Menopause and Primary Ovarian Insufficiency: Key Learning Points for the Hair Specialist

The average age of menopause in much of the western world is between 51 and 52 years of age. “Early menopause” is defined as menopause between age 40-45. This occurs in about 5 % of women age 40-45. “Premature menopause” is menopause that occurs before age 40. This occurs in about 1 % of women under age 40. 1 in 1000 women have menopause before age 30.

The term “primary ovarian insufficiency” (POI) refers to declining ovarian function before age 40 without a complete cessation of menstrual cycles. Women with POI may have irregular cycles but POI does not necessarily correlate with an inability to become pregnant. In fact, 5-10 % of women with POI can become pregnant naturally. The ovaries in patients with POI, however, are not producing normal amounts of hormones and are not producing follicles and eggs in the same manner as before.

In my opinion, the definition of POI really matters. POI is somewhat different than premature menoapuse. The exact definition of POI is still not agreed upon by everyone. The ‘classical’ definition had been 4 months of not having a period together with high menopausal level FSH tests (ie above 35-40 mIU/L). However, this is probably not the best definition given that many women with POI have intermittent periods. A better definition is 3 or more months or irregular periods (either no periods, long duration between periods, heavier periods) together with high FSH lab tests on two different occassions)

In 90 % of cases of POI, the cause is not known. There may be certain genetic and autoimmune links. Women with POI are at increased risk to develop autoimmune conditions like hypothyroidism, adrenal insufficiency, type 1 diabetes, pernicious anemia, myasthenia graves, connective tissue dissorders and hypothyroidism. POI was once referred to as premature ovarian ”failure” (POF) but this term is not used any more.

Early menopause and premature menopause are easier to diagnose than Primary Ovarian Insufficiency (POI) – at least if exact and precise definitions are used. This is because menopause is associated with a complete cessation of menstrual cycles for 12 months or more and POI is not. If periods have completely stopped for more than 1 year, there is a good chance the patient has menopause (assuming they are not taking hormone based medications like birth control). If the patient is 40-45 years of age, we call this early menopause and if she is under 40 we call it premature menopause. There are other reasons for periods to cease besides menopause, but this is a common reason for a cessation of periods longer than 12 months. women with POI are under 40 but don’t meet the criteria for complete cessation of periods. They have cycles intermittently.

It is a valuable skill for the hair specialist is to be able to recognize the possibility of POI and get patients connected to the right specialists who can help. POI is challenging to recognize because symptoms are not always very specific. A 33 year old female patient with fatigue, poor sleep, weight gain and changing periods may have primary ovarian insufficiency but the symptoms are not specific and most 33 year olds with fatigue, poor sleep and weight gain and changing periods will not have primary ovarian insufficiency. It’s important to know when the condition is a “possibility” even if a remote possibility. Many lives have been changed by the consideration that POI could at least be possible.

Risk Factors for Early Menopause and POI.

Several factors are known to increase the risk of early menopause and POI. The age that one enters menopause is thought to be highly inherited so the age of menopause in the patient’s mother is very very relevant. Other factors that affect the age of menopause include oophorectomy (surgery to remove the ovaries), hysterectomy (surgery to remove the uterus), smoking, chemotherapy, a family history of early menopause and chromosomal abnormalities (Turner syndrome, Fragile X). In addition. some autoimmune diseases are associated with early menopause including rheumatoid arthritis, thyroid disease and inflammatory bowel diseases. Chronic fatigue syndrome may be associated with early menopause as well. Frontal fibrosing alopecia is an autoimmune disease that is seen in the hair clinic that is also associated with early menopause.

See: FFA in Women Under 40: The Importance of Diagnosis

Signs and Symptoms of Early Menopause.

If can be challenging sometimes to recognize the very earliest signs of the menopausal transition – especially in the hair clinic when one is focused mainly on – hair loss. However, the two can be closely linked given that the hormonal changes of early menopause sometimes prompt hair loss and acceleration of an androgenetic alopecia-like picture. Also, I am always on the lookout for possible immune mediated hair disease in patients with early menopause. Frontal fibrosing alopecia as mentioned above is the main one, but lichen planopilaris should be considered.

The first clue to prompt me to consider the possibility of possible incipient early/premature menopause or primary ovarian insufficiency is a change in menstrual cycles. This is very non specific but shorter periods or longer heavier periods can both be seen. Periods may become irregular and further apart. When this has been occurring for at least consecutive 3 months, it’s worth checking an FSH level in the patient.

For example, a female patient under 40 years of age who once had periods lasting 5-7 day but now has 3 day lighter periods for many months must be evaluated further by the doctor for possible incipient premature menopause or primary ovarian insufficiency. Other symptoms include hot flashes, vaginal dryness and dyspareunia (pain during intercourse), dry skin, mouth, eyes, decreased libido, increasing number of urinary tract infections or UTIs, urinary frequency (need to urinate frequently), headaches, poor sleep (insomnia), changing mood, breast tenderness, heart racing, weight gain, problems concentrating, muscle and joint pains and infertility. Finally, hair loss can be a sign of primary ovarian insufficiency (POI) as well, especially an acceleration of an androgenetic alopecia like picture. Hair shedding occurs along with a thinning of hair in the central scalp and sometimes diffusely.

Besides the changes in menstrual cycles noted above, it is important to point out that about 20 % of patients who enter into premature menopause have minimal to no symptoms. So we must take note to ask about menstrual cycles and how they are changing.

Primary Ovarian Insufficiency and Hair Loss

Not all patients with POI or early menopause experience hair loss just like not all women experience hair loss with transition to menopause. However, some patients with POI will experience an acceleration of their underlying androgenetic alopecia (if they have AGA to begin with) and some will experience a shedding phenomenon consistent with a telogen effluvium. In addition, some women will first notice AGA-like hair thinning at the time that a POI is having effects on the rest of the body. I always evaluate for possible POI in women age 30-40 with hair shedding or dramatic changes in their underlying AGA who also report significant shortening of the menstrual cycles or lengthening of the duration between cycles. In my practice, this is most often women ages 30-40 who note that their periods are much shorter (5 or 6 days down to 2 or 3) or much lighter than in previous years. The second group of women who I see are women with longer duration between periods and occasional months with no period at all. These symptoms raise concern for possible POI.

The Importance of Recognizing Early Menopause

Every year, I diagnose primary ovarian insufficiency in a few patients who did not know this was even a concern. There are so many reasons that specialists of all backgrounds need to recognize and ultimately confirm a diagnosis of primary ovarian insufficiency, premature menopause and early menopause. First, many patients I see with a diagnosis of primary ovarian insufficiency have had children and have completed their families. Fertility issues are not key issues for these patients. However, some of my patients with POI would like to have children or would like to have additional children. If we can recognize POI and incipient premature menopause as early as possible, patients who wish to become pregnant can be referred to a gynaecologist for further evaluation and help with plans for future pregnancy. But there are many other reasons that getting the diagnosis is so important. Women with premature menopause or early menopause are at increased risk for cardiovascular diseases, osteoporosis, cognitive issues, type 2 diabetes, Parkinson’s diseases and glaucoma. I encourage patients to see a gynaecologist or endocrinologist and get connected with the latest and most up to date approaches to optimize health.

Evaluation of Early/Premature Menopause/POI.

When I see a patient who I feel might have early or premature menopause or concerns of primary ovarian insufficiency, I make sure they get connected with a gynaecologist as soon as possible. I generally will perform a good history asking about symptoms and family history and then order some basic tests that I know will be helpful to the gynaecologist. These include tests such as estrogen, LH, FSH, testosterone, DHEAS, TSH, Prolactin, B12, glucose and hemoglobin A1c. Sometimes a pregnancy test (beta HCG) is ordered as well in the event that recent cessation of periods is actually due to pregnancy. Menopause is associated with low estrogen (less than 30 pg/mL or 110 pmol/L) and high FSH (above 40 mIU/L). The perimenopausal period is associated with estradiol and FSH numbers somewhere in between.

The AMH Test

When discussing primary ovarian insufficiency and possible early or premature menopause, it’s helpful to know about the AMH test. AMH may become increasingly important in the evaluation of early POI.

AMH is a protein that is made by the ovary. Specifically, it is made by granulosa cells of primary follicle. The AMH is a test that I sometimes will order to better assess the possibility of primary ovarian insufficiency (POI) as I wait for my patient to be referred to a gynaecologist for further evaluation of this possible diagnosis. I generally order AMH if the patient is hoping to have additional children and I want them to see a gynaecologist. This is because the AMH test measures “ovarian reserve” – or the number of follicles remaining in the ovary. Some refer to this test as a measure of “ovarian aging”.

It’s important to keep in mind that there are other ways of measuring “ovarian reserve” besides the AMH but the AMH is among the best ways. These other methods include measuring FSH and estradiol blood tests on the third day of the menstrual cycle and using ultrasound to measure the number of antral follicles that are 2-10 mm in the early follicle phase. All these give some measure of ‘ovarian reserve’. An FSH above 10 IU/L on day 3 is thought to be consistent with “reduced ovarian reserve”.

AMH measurements, however, are currently viewed as one of the best measures of ‘ovarian reserve’ and that is why it’s important to know about the AMH test. Even if FSH and estradiol levels are normal and even if menstrual cycles are regular, a low AMH test result indicates reduced ovarian reserve. That is really important information.

Technically speaking, AMH is actually a measure of the number of AMH producing antral follicles that have been recruited in any given menstrual cycle to produce an egg. But that’s a bit complicated so AMH is most often simply viewed as a measure of the number of eggs remaining in the ovary. As a woman ages, the number of eggs in her ovaries decreases over time – and so does her AMH lab test result. We’ll talk more about how AMH declines in a moment.

AMH declines with age and become undetectable in menopause. AMH levels can also be reduced with a number of other factors like smoking, autoimmune disease, low vitamin D and birth control pills. AMH levels are fairly constant across the menstrual cycle in older women but in younger women they are highest in the follicular phase (first 14 days after menstruation). The key parameter, however, that affects AMH is age. Young patients have higher AMH and more eggs In the ovary and older patients have lower AMH and less eggs in the ovary.

What is a normal AMH Level … and what is considered low?

When a patient asks me “what do you consider to be a normal AMH level” I usually reply by saying “I would just need to know the age of the patient you are referring to first and then I can tell you what the normal AMH level would be for a patent of that age.”

This is because AMH levels vary by age. A normal AMH for a woman in her 20s is above 5 ng/mL (38.5 pmol/L). This would not be considered a normal AMH level for a woman in her late 30s. A woman in her late 30s would typically have a an AMH around 1.5 ng/ml (10.7 pmol/L)

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You can follow a few hair hygiene tips to make your hair less likely to fall out: Avoid hairstyles that pull on the hair - Avoid high-heat hair styling tools - Don't chemically treat or bleach your hair - Use a shampoo that's mild and suited for your hair - Use a soft brush made from natural fibers - Try low-level light therapy.

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