With the recent news that a Birmingham-based clinic is offering a procedure to delay the menopause, we investigate the impact this could have on millions of women – and how effective it might really be.
By Sara Matthews
In recent weeks, the media has reported news of a medical procedure that claims it can help women delay the menopause by up to 20 years. The surgery, which is offered by Birmingham-based company ProFaM, costs between £7,000 and £11,000 and is being offered to women up to the age of 40. But what does it involve, will it actually work – and is it safe?
Sara Matthews, consultant in reproductive medicine, surgery and infertility at The Portland Hospital, part of HCA Healthcare UK, explores the efficacy of the groundbreaking procedure:
Signs and symptoms of the menopause
What we often consider to be symptoms of the menopause are in fact symptoms of the perimenopause. The menopause is the time at which all menstruation ends, whereas the perimenopause is the period of symptoms building up to this.
In the months, or even years, of perimenopause leading up to the menopause, there are various signs and symptoms that you may experience. Some of the most common physical symptoms include hot flushes, vaginal dryness, headaches and palpitations. You might also experience symptoms such as changes in your mood, including feeling more anxious or low, a reduced libido or difficulty sleeping.
The symptoms of the menopause vary considerably from woman to woman, with some women having very few symptoms lasting for only a short period of time and others having more severe symptoms. In some rare cases, symptoms can affect a woman for many years after her periods stop.
How do you delay the menopause?
In the procedure offered by ProFaM, Keyhole surgery is used to remove a small piece of ovarian tissue. This is then sliced up and frozen to preserve it. The operation takes 30 minutes (a pre-assessment consultation, ultrasound and blood test confirm whether ovarian reserve is good enough to merit taking the tissue). ProFaM claims they are happy to freeze tissue for women under the age of 40, but would also consider those over 40 with a good ovarian reserve.
Removal of a small piece of ovarian tissue carries little guarantee of success in reversing the menopause.
Once a woman enters the menopause, the frozen tissue can then be defrosted and transplanted back into the body. A second keyhole operation under general anaesthetic can be used to stitch the tissue onto the menopausal ovary. The tissue can also be grafted under the skin with the aid of a local anaesthetic somewhere with a good blood supply, such as the armpit. If the ovarian tissue has survived the process, the procedure works to halt the menopause by restoring falling hormone levels.
Does the ProFaM procedure work – and is it safe?
Removal of such a small piece of ovarian tissue carries little guarantee of success in reversing the menopause for any length of time. The limited worldwide previous experience with grafts that have been replaced after successful cancer treatments demonstrates that they can fail completely.
In all cases, the lifespan of a graft depends on myriad technical laboratory variables, but most importantly on both the age of a woman and the number of eggs she has at the time of freezing. Women are born with all the eggs they will ever have, but that number varies a lot between individuals, as does the rate at which the eggs are naturally lost from the ovary. The menopause happens when there are no functioning eggs left in the ovary. For most women, this is around 52 years of age, but one in three women will have their last period by the age of 45, and one in 100 by the age of 40. A handful of reports confirm that grafts can remain hormonally active in a very small number of patients for up to 10 years, but this company claims that the treatment can provide adequate hormone replacement for 20 years. This is rather preposterous, sensationalist and scientifically implausible.
Claiming that treatment can provide adequate hormone replacement for 20 years is sensationalist and scientifically implausible.
In addition, there have been no research studies to confirm that the tissue is not at increased risk of becoming malignant over time in a post-menopausal woman.
There is also no research to confirm that restoring a woman’s hormonal cycle is any more beneficial than giving a steady dose of daily (preferably bio-identical) hormone replacement therapy. There are a few studies underway to assess whether post-menopausal women really do benefit from a regular cycle where hormone levels in HRT vary over the month to mimic a younger woman, but absolutely no knowledge as to whether doing this might actually increase the risk of chronic illnesses, including dementia, cardiovascular disease and arthritis, or more significantly whether it could increase the risk of hormone-dependent cancers, such as breast and uterine cancer, or indeed of other types of cancer.
Can delayed menopause restore fertility?
ProFaM is promoting the treatment as a perimenopausal hormone replacement strategy, rather than a way to restore fertility. But it would be feasible that pregnancy could be achieved at advanced age if the graft is active and eggs grow.
Mothers at an ‘advanced maternal age’ (a mother aged over 35) are at increased risk of complications during pregnancy and birth. This includes increased risk of miscarriage, foetal abnormality and early birth. Older mothers may also experience complications related to maternal health concerns, such as high blood pressure or gestational diabetes, which can in turn put the mother at risk of premature delivery or need for an emergency delivery.
Mothers at an ‘advanced maternal age’ are at increased risk of complications during pregnancy and birth.
Once women enter their 50s, the risk of cardiac arrest during pregnancy is significant. Regardless of fitness levels, a 52-year-old who is pregnant is rarely able to maintain routine daily activities until the end of the pregnancy, having to stop work at an earlier stage to rest more and guard against pregnancy complications.
However, on the flip side, older women who plan this type of pregnancy are usually in a more stable financial situation, which enables them to leave work early and have additional help with childcare.
The future of ovarian transplant
In the future, if autologous transplantation (transplanting your own tissue) does prove to be safe long-term and the cycle of hormone production at advanced age is shown to be protective rather than detrimental to general health, then the much more effective option would be to remove a whole ovary to freeze in pieces or possibly whole (which has not yet been proven in humans) at a young age in women with a good ovarian reserve.
Removal of a single ovary decreases the age of menopause by approximately two years, as the remaining ovary compensates.
Removal of a single ovary only decreases the age of menopause by approximately two years, as the remaining ovary compensates. The ovary strips, or possibly the whole ovary (if cryobiology were to advance), could be replaced at the time of menopause. The increased volume of tissue, containing many more primordial follicles, would then theoretically be able to sustain hormone and egg production for 20 years or so. Multiple tissue grafts could be performed over time as required.
Alternative methods of preserving ovarian function, such as drugs to reduce the rate of egg loss or to stimulate the growth of dormant stem cells in the ovary, may provide safer, less invasive methods of maintaining ovarian function beyond the normal age of menopause in the future, without the need to remove the ovarian tissue at all.