When Jenny Richards came to my office for the first time she was crying, but she refused to tell Nancy, my receptionist, what the problem was. Nancy asked me if I could fit Jenny in between my other scheduled patients. When I spoke with Jenny in the waiting room, she told me that she’d suddenly felt weak and dizzy while passing the sign for my office. I am an internist, and I agreed to see her immediately.
Jenny appeared to be in her mid-twenties, though the age stated on her patient intake form was 35. She said she was an artist. Her blue denim shirt and khaki pants were stained with red and yellow blotches, and her long hair was also speckled with paint. She sat far forward on the examining table, kicking her feet back against the metal and biting her lower lip. When I asked her what the problem was, she said she had been feeling fatigued and stressed. As I asked more questions, I discovered that Jenny had been experiencing irregular menstrual periods for most of the past year. She said she sometimes missed her period altogether; at other times it was either early or late. Some months she had even had an extra period.
Jenny showed no embarrassment or shyness in talking about her problems. She said that she thought the stress of being an artist was somehow causing the menstrual irregularities. Things always got worse, she explained, just before her paintings were due to appear in a gallery. I agreed that this was a possibility. The hormones that regulate the menstrual cycle, estrogen and progesterone, fluctuate widely and may be affected by changes in mood as well. Conversely, mood may be altered by rapid or extreme fluctuations in the hormones, which can occur when the menstrual cycle is out of whack. I also believe that toxins from paints may interfere with hormone regulation. I mentioned this to Jenny, but added that this had not been proved.
Jenny’s physical examination was normal. I suggested that she see a gynecologist about her irregular periods.
What about the dizziness? she asked.
It could be related to the stress, I said. Let’s see what the lab work shows.
Two days later, the results came back. They showed no signs of anemia, dehydration, or any metabolic problems that indicate disease. When I called Jenny to tell her the blood work was normal, she blurted out that she had been seeing a psychotherapist for some time.
Do you think this could all be in my head? she asked.
I don’t think so, I said. Let’s see what the gynecologist says.
I hadn’t ordered hormone levels on Jenny, figuring that the gynecologist would order them as part of a routine workup. When Jenny skipped her follow-up appointment with me and Nancy was unable to reach her by telephone, I assumed the gynecologist was taking care of her problem.
Five months later, Jenny suddenly reappeared, again without an appointment, and again Nancy fit her into my schedule. In the examining room, Jenny looked very anxious and angry. She handed me a folder of test results from the gynecologist, and I read that the gynecologist had entertained several possibilities for the irregular menses, including ovarian cysts, uterine polyps, and fibroids. Such growths on the ovary or within the uterus can cause irregular periods. But when he performed an ultrasound and a biopsy of the uterine lining, he found no signs of disease. Reviewing the blood tests, I noticed that he hadn’t checked Jenny’s hormone levels.
How are your periods? I asked. Are they still irregular?
Tears began streaming down Jenny’s face. She told me that the gynecologist had put her on a birth control pill. After that, said Jenny, her cycles became regular for a few months. But when she stopped taking the pills, her periods had stopped altogether.
Today’s birth control pills consist largely of progesterone; they prevent pregnancy by interfering with the normal hormonal surges in a menstrual cycle that induce ovulation--the release of a mature egg from a follicle, or small sac, in the ovary. Normally estrogen levels rise at the midpoint of a woman’s menstrual cycle. That rise prompts a maturing egg to burst out of the ovarian follicle and enter the fallopian tube for a three- day journey to the uterus. During the two weeks following ovulation, the ruptured follicle produces progesterone. That surge in progesterone helps prepare the uterine lining to receive a fertilized egg, but it also suppresses maturation of an egg in the other ovary.
By taking birth control pills, a woman artificially boosts the level of progesterone throughout most of her cycle, thus preventing eggs from maturing in both ovaries. If an egg doesn’t mature, it doesn’t leave the ovary and the woman doesn’t ovulate.
The controlled dosage of progesterone in birth control pills also makes menstrual cycles extremely regular. For seven days of the cycle, the pills contain no progesterone. That drop in progesterone prompts the uterus to shed its lining, causing menstruation. In Jenny’s case, taking the pills had made her cycles regular, but she was still having problems.
In my consultation room, Jenny told me that her husband was eager to start a family. She had resisted becoming pregnant for the five years of her marriage in order to pursue her career. Now that her periods had stopped, she said that she realized for the first time just how much she wanted to have children.
It’s the first time in my life I’ve ever looked forward to my period, she said.
I drew blood from Jenny to check her hormone levels. Two days later, the results came back. Jenny seemed to be in menopause. Her estrogen level was very low, and the level of follicle-stimulating hormone (fsh)-- the hormone that the brain’s pituitary gland produces to spur egg maturation and estrogen production in the ovary--was high. In normal premenopausal women, these hormones are regulated in a classic feedback loop: low levels of estrogen stimulate fsh production, while high levels of estrogen inhibit fsh production.
But in Jenny’s case, the ovaries had somehow become impervious to the fsh coming from her pituitary gland. Her eggs were not maturing, and estrogen was not being produced. More and more fsh was produced, but to no avail.
Menopause usually occurs in middle age, when the ovaries run out of eggs and cannot produce estrogen. Although a female baby is born with several million eggs, nearly half will have atrophied by the time she reaches puberty. After that, eggs compete each month within the ovary to mature; the winning egg is released into the fallopian tube, and the losing eggs atrophy. By the age of 45 or 50, a woman has usually exhausted her supply of viable eggs. In cases of premature menopause, though some eggs may remain, they are for some unknown reason unable to function or mature.
I now thought that Jenny’s recent mood shifts and anxieties were partly due to low estrogen. It was also possible that the dizziness and fatigue she’d experienced were the physiological effects of menopause. Jenny hadn’t experienced the hot flashes--the intermittent rapid dilation of blood vessels--that typically ensue as estrogen levels fall during menopause, but not every woman entering menopause does.
Reporting bad news is probably the worst part of being a doctor. Jenny began to weep and pound on my desk when I told her that she might be entering menopause early. I tempered the news by saying that there is some chance that premature menopause can be reversed, but Jenny would have to see a hormone expert for a workup.
Could this be from the birth control pills? Jenny asked.
No. They’ve definitely worn off by now.
I referred Jenny to Joan Wirth, a fertility specialist and gynecologist with a subspecialty in hormones. She agreed that Jenny probably still had eggs, but she also thought the chances of reversing the menopause were very slight.
Dr. Wirth explained to Jenny that she could take estrogen to see if it would somehow stimulate normal ovarian function. But the treatment, she stressed, carried no guarantee. Sometimes periods resume--with or without estrogen. Much more often, however, they never return in women experiencing premature menopause. If Jenny’s ovaries remained dormant, she would be advised to remain on estrogen. For reasons that are still not clear, estrogen helps protect menopausal women from the early onset of heart disease and osteoporosis.
Menopause in a woman of 35 is rare. What had caused it? Stress? Toxins?
Dr. Wirth said that for some reason more women are being diagnosed with premature menopause than ever before. Perhaps, she added, it is being detected more often because more women are delaying childbearing into their thirties. She also agreed with me that today’s stresses and environmental toxins might be contributing to the problem.
But that hypothesis has never been proved, she said.
When I next saw Jenny, she had been taking estrogen for two months. She reported feeling calmer, though she still hadn’t had her period. She smiled as she told me that her husband had remained supportive throughout the entire ordeal.
I now know that he really loves me, she said.
I saw that her hair and clothes were no longer streaked with paint. When I asked her about her work, she said that she was unable to concentrate on her painting. I told her I didn’t really know if paint toxins had contributed to her problem. She said she understood, but she needed a break from her work anyway.
Jenny told me she’d always considered it her right to choose whether or not to have children. She’d never really considered the possibility that this choice might be taken away from her prematurely. Now that she was finally succeeding as an artist and her paintings were being shown in major galleries, she was feeling more ready to have a child. But she felt cheated by nature, unfairly punished with infertility for having devoted herself to her art. At the same time, she was also angry with herself for not having decided on motherhood sooner.
I feel so helpless. I feel like time has run out on me.
Maybe there’s still time, I said.
A month later, Jenny stopped by my office to tell me that her period had resumed. She said she was working closely with Dr. Wirth.
She thinks I may be ovulating again, Jenny added. A hormone test showed that Jenny’s progesterone levels had risen at midcycle. Because the ovary releases progesterone after ovulation, rising progesterone levels were a strong sign that Jenny’s ovaries were functioning normally again. To confirm this, Dr. Wirth had taken her off estrogen.
Jenny said she was going to try to conceive. While smiling over the news, I couldn’t help noticing that the streaks of paint had returned to her clothes.
You’re painting again, I said.
Jenny leaned across the desk, her shoulders and chin communicating her determination. She said she had rented a studio so she no longer had to work at home. Now she was going to pursue both children and a career. I have to paint, she said. It’s what I do.