A Biological Clock Gone Awry

VINITA Karlekar is 36, single, and works as a trade promotion officer with a TNC. She suffers from depression, is greying, has hot flashes and extreme mood swings. She hasn't menstruated in over two years now. According to her doctor, she's a victim of Premature Ovarian Failure (POF) or an early onset of menopause.

A subject of heated debates in the West but still largely ignored by the Indian medical profession, POF is a condition where the ovary runs out of follicles before the normal age associated with menopause. Unfortunately, there's no treatment for POF, since there are no drugs to stimulate the ovaries, and medicine is still floundering around for explanations. Most doctors today agree that there seems to be an increase in such cases but in the absence of serious research, all that exists is anecdotal evidence. With answers hard to come by, POF is a subject that is either ignored, taboo or shrouded in secrecy.

According to Vinita's doctor, her condition has been brought about by stress. That's all she knows and can only pray that there's a miraculous reversal, for she longs to raise a family. For the moment, her faith rests in homoeopathy and herbal remedies.

Unfortunately, with the beauty boom, as women discover the body beautiful, they are also discovering some unpleasant truths about themselves. "I'm 22 years old and was diagnosed with POF when I was 20," says Chandrika Sethi, a Delhi college student. "My ovaries have stopped working and there is no explanation as to why." One of the innumerable doctors Chandrika consulted told her with characteristic insensitivity that he could take her ovaries out, stomp on them, wring them... but no matter what he did, they would not work. "I was told that my body had already aged to that of a 50-year-old woman. That was the beginning of the end of my world."

 Chandrika suffers from genital atrophy, extreme dryness of skin and is on hormone replacement therapy to ward off the usual deterioration of bodily systems which comes with menopause, like osteoporosis or the loss of bone density and cardiovascular diseases. For, the body ceases to produce two main ovarian hormones, oestrogen and progesterone—the elixirs which make women hardier than men. The lack of oestrogen can have serious side-effects and accelerates the aging process. A hard fact for 22-year-old Chandrika to swallow.

In both Vinita's and Chandrika's cases, the respective doctors either misinformed them about the reasons for their condition or offered no explanation at all. Ranjana Gupta, 30, however, asked her doctor a direct question. Diagnosed with POF and suffering from hypothyroidism for the past 17 years, she wanted to know if the two were related. The answer was an evasive "maybe".

However, it's a subject which demands serious attention today because most doctors admit that between 1 and 3 per cent of the female population suffers from POF. The numbers could be higher. Says well-known Delhi gynaecologist Col M.R. Dutta: "About 5 per cent of women today between the ages of 35 and 40 are undergoing premature menopause and all the associated problems that come with it."

The mean age worldwide, says Dr Urvashi Jha of Indraprastha Apollo Hospitals, Delhi, is 51.2, give or take 5 years, with most Indian women experiencing the transition or perimenopause between ages 45 and 50. "And there certainly seems to be more visible cases of premature menopause these days," she adds. Says Dr Manju Gupta, vice-president, South Delhi Medical Association: "All of us get quite a number of POF cases, but putting a definite number to it will be dif-ficult. Let's say I get about four cases in a thousand with symptoms of POF."

 But she admits there could be more. Agrees gynaecologist Dr Manjeet Arora: "Though the average age of menopause has not changed over the centuries, it is a fact that we get many POF cases but our data maintenance is poor." Also, most Indian women accept it as a condition to be dealt with in private and hence never see a doctor. And since the child-bearing age is earlier than in the West, the problem is not accorded much importance.

Like in the case of Saheli Biswas, 31, a teacher in a Delhi school. Her doctor told her that she should consider herself lucky because she has at least one child. She was diagnosed with POF nine years ago and was never offered an explanation. The diagnosis came 10 months after her daughter was born. "I have so many unanswered questions," she says. "I also very foolishly hang on to the hope that one day my ovaries are going to start producing eggs again so that I can have another child."

THE reasons for POF, as explained by the doctors, could be manifold. Ranging from heredity and genetics to viral infections, auto-immune diseases, diabetes, environmental factors or simply idiopathic, that is, without any cause. Genetic factors affect about 5 per cent of women where there is a family history of premature menopause, sometimes affecting every female member of the family. Interestingly, infections like mumps which have so far been known to result in impotency in men, could also be a reason for the onset of POF. Auto-immunity is where the body's immune system mistakenly damages the ovaries, perhaps as a side-effect of trying to fight an infection. But the exact process by which they destroy the ovaries is unknown.

 "One factor that has been definitely identified as a POF-causing agent is smoking," says Dr Manjeet Arora. "It's been proved that smoking lowers the age of menopause." Studies in the West have shown that beginning to smoke as a teenager increases a woman's risk of early menopause threefold. That may be caused by a toxic effect on the ovaries by polyhydrocarbons or by the significantly lower levels of oestrogens noted among women smokers. Col Dutta points to other environmental factors. For instance, he says that women who work in radiation-related industries are in the high-risk category.

Dr Manju Gupta also attempts a sociological explanation. Says she: "A woman was supposed to produce children. We have today interfered with the natural process of fertility through contraception, medical termination of pregnancy. Women are becoming more independent and assertive and having children very late or opting to have no children at all. The factor of never having given birth may also account for early menopause."

Research could throw up more reasons. Dr Gupta draws a parallel with the rising cases of 'precocious puberty'. She and her colleagues all point out that there's a definite trend towards the age of menarche decreasing. Which in turn is related to socio-economic factors. It has been observed that while girls belonging to the lower socio-economic strata still attain puberty between 13 and 16, menarche among those belonging to the upper rungs of society commences any time between 10 and 11. It's dipping further with many attaining it at even 9 years of age. Better nutritional status and achieving a body fat level of 17 per cent earlier are the reasons cited universally. Similarly, POF could also be triggered by still-unknown sociological factors.

According to Dr Indu Bhushan, what is worrisome and requires sensitive management is that with increasing longevity, most women today spend one-third of their lives in a post-menopausal state and the major issue is how to give these women a better life. Dr Arora points out that during the Roman era only about 20 per cent of women reached menopause. In the Elizabethan era it was about 40 per cent. "But today," she says, "about 96.7 per cent women reach menopause and live for a good 20 years or more after that." And in the absence of awareness and knowledge, most women have to deal with serious physiological and psychosomatic disorders for the rest of their lives. "We do recommend hormone replacement therapy," says Arora, "but awareness is still low and not many come forward and ask for it." Adds Gupta: "It's a serious health issue today with cardiovascular and osteoporosis topping the list."

Ultimately, there seems to be an urgent need for the medical fraternity to collectively tackle an issue which is regarded as a natural process but seems to be affecting all women—young and old. There is the need for a definite database, research and some way of disseminating information so that a woman in the prime of her life undergoing premature menopause is not faced with despair and hopelessness for the rest of her life, unable to understand why she is aging so fast. She should be armed with the knowledge that there could be ways of slowing down the process, even if there's still no cure. Modern science provides more than hope, something that should be made available to all.

(Names of POF patients have been changed to protect their identities.)