Premature ovarian failure is not the same as premature menopause. While menopause is an irreversible condition, premature ovarian failure is characterised by intermittent and temporary ovarian failure with periodic episodes of normal follicular activity and ovarian function. The estimated prevalence of premature ovarian failure is 1/1000 in women aged 15-29 years and 1/100 in women aged 30-39 years.
This complaint is diagnosed if a woman of less than 40 years of age has the following signs and symptoms:
- Amenorrhoea for four months or more
- Low oestrogen levels
- An elevated FSH (confirmed by two to three FSH levels of >40 IU/1 at least one month apart)
There is a depletion of the primordial ovarian follicles and ovulation occurs sporadically. Physical changes that occur when a woman has premature ovarian failure include a thinning of the endometrium, which can be detected on ultrasound. Bone density is severely compromised if the oestrogen levels remain low over a long period.
Most of the time, premature ovarian failure appears to begin spontaneously and its origin is elusive or unknown. Some of the identified causes include auto-immune disease, particularly if related to hypo-thyroidism, or auto-immune oophoritis. Specific genetic defects have been identified as a cause, as have infections such as mumps, shigella, malaria and varicella; and enzyme deficiencies such as galactosaemia, although these are less common. Chemotherapy for breast cancer leads to premature ovarian failure in approximately one-third of all women treated — women approaching menopause are more likely to be affected, but younger, fertile women can develop persistent amenorrhoea and should be counselled accordingly.
Despite the high levels of gonadotrophins, women with premature ovarian failure will produce oestrogen and ovulate intermittently, and can achieve a spontaneous pregnancy. However, the probability of this occurring is very low, being estimated to be in the region of 5-10 per cent.
The medical approach
If pregnancy is not a desire, women with premature ovarian failure are prescribed the Pill as a type of hormone replacement to protect their bones from the prolonged absence of oestrogens. As ovulation can occur spontaneously and with no warning, the Pill also provides contraceptive protection for those women who need it.
When the woman wants to become pregnant, the first step is oestrogen replacement for one month to check ovarian reserve. If this is satisfactory, FSH levels will drop and drugs are then prescribed to stimulate ovulation. In many cases, however ovulation induction rates do not change and continue to be much the same as the spontaneous ovulation rate seen in untreated women. Medically, the proven method of achieving pregnancy in women with premature ovarian failure is fertilisation of a donor egg.
The natural therapist’s approach
Contraception and protection of bone density is difficult to achieve successfully for these women. Details on bone density protection and treatment are outlined in section ‘Osteoporosis’. Natural family-planning methods may be acceptable for some women, and will need to be taught by those trained in this area, but the sporadic nature of ovulation is likely to create some difficulty. Natural therapists should ensure that bone monitoring is undertaken regularly.
Some women respond to hormone modulating treatments such as Vitex agnus-castus or Paeonia lactiflora in conjunction with female tonic herbs and the steroidal saponin-containing herbs. Usual treatment would involve a single morning dose of Vitex combined with a pulsed prescribing regime of the tonic herbs, usually for two weeks of every month until a cycle is re-established and then for the first two weeks during and following menstruation after that. When menstruation can be re-established, the positive effects have been short lived for some women, and may be apparent for no more than 3-6 months. Other women have achieved successful pregnancies where medical treatment has failed, but numbers of women treated herbally have been limited and it is not possible to make firm predictions about outcomes.
Over the centuries, traditional medicine developed an understanding of the actions of blood by observing people during and after blood loss. Those who looked as though they had lost blood and were pale, weak, tired and vague were said to have ‘weak’ blood; those who were red-faced, overstimulated, irritable and energetic were said to have an excess of blood.
A large number of women’s complaints were attributed to blood because women not only lose blood every month and during childbirth, but also were believed to lose the essence of blood when they breastfed. (Many early cultures thought of breast milk as blood with the redness taken out.)
A relatively modern name for weak blood, dating from around Shakespeare’s time until the turn of this century, was ‘chlorosis’. Chlorosis means ‘greenish colour’ and was a common diagnosis of young menstruating women. The symptoms were fatigue; a yellowish face with dark rings around the eyes; and menstrual symptoms such as amenorrhoea or menorrhagia.26
The opposite condition, ‘plethora’, indicated an excess of blood. It was characterised by over-indulgence generally and of alcohol in particular, irritability, headaches and a red face. It was a condition common to the older generation, usually men, and was believed to be the precursor to strokes.
A diagnosis of either chlorosis or plethora was cast aside when it became possible to test for anaemia. Technically, anaemia means a lack of iron in the red blood cells or insufficient numbers of red blood cells. The common causes are lack of dietary iron or excessive blood loss. The term is commonly used (incorrectly) to describe a number of symptoms including tiredness, inability to concentrate, paleness, dizziness or a lacklustre attitude to life.
A natural therapist’s diagnosis of poor blood quality (also known as ‘blood deficiency’ in traditional Chinese medicine, and ‘anaemic’ or ‘nutritionally depleted’ by naturopaths) is not the same as anaemia. It is a rather more complex syndrome characterised by:
- frequent exhaustion and poor stamina
- unusual debility around the time of menstruation, and especially afterwards
- an increased tendency to infection around the period, especially thrush and recurrent viral infections such as herpes
- frequent headaches, often with or after the period
- pale face and tongue
- dry skin and unhealthy lank hair
- menstrual irregularities, especially amenorrhoea or infrequent periods, occasionally menorrhagia
The aim of the treatment is to improve the overall quality and activity of the blood. Iron, though important, is not the end of the story.
- The quality of blood is corrected with appropriate dietary changes, nutritive herbs and supplements as required.
- The general energy levels are improved with the female tonic herbs.
- Where infrequent periods or amenorrhoea occur, hormonal regulatory herbs are used.
- Assimilation of nutrients is assisted with the Warming digestive herbs and foods.
- Circulation is enhanced with circulatory stimulants and Warming herbs.
Many of the common herbs used to treat abnormal bleeding are also nutritive herbs and are high in the blood-building and anti-haemorrhagic nutrients iron, vitamins A, K and C, and folic acid. Some important examples are Rubus idaeus and Petroselinum crispum.
Aletris farinosa and Angelica sinensis, as well as Rubus idaeus, are general female tonics and assist with regulation of all aspects of the menstrual cycle.
Anaemia is related to blood quality and is a common complaint affecting menstruating women. The iron-containing foods, and information on iron and anaemia.
Selections from the book: “ Women, hormones and the menstrual cycle. Herbal and medical solutions from adolescence to menopause”. Edited by Ruth Trickey, 2004.