Premature menopause needs urgent policy attention: A piece published in Hindustan Times last month highlighted how menopause has long been neglected as a public health issue in India, with implications for health policy, healthcare systems and research. There is a need to focus attention on a group that has received little attention: women who experience menopause before the age of 40.
This article draws on data from the Longitudinal Ageing Study in India (LASI), a nationally representative survey of over 72,000 adults aged 45 and above, the largest such study conducted in India. Our analysis of more than 17,000 women in the LASI sample (2017–18) finds that over 5% had experienced premature menopause, defined here as natural menopause before the age of 40. Extrapolated to India’s older female population, this translates to an estimated eight million women living with the long-term health consequences of an early hormonal transition. Hysterectomy is treated as a separate outcome in our analysis.
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Premature menopause as a public health problem
A parallel study using NFHS-5 data puts the prevalence among currently married women aged 30–39 at nearly 5% in rural areas and 3% in urban areas, with a particularly high burden in Bihar, Andhra Pradesh and Telangana. In states such as Bihar, a significant share of this burden may be associated with hysterectomy among women with less education rather than natural ovarian decline (Saha et al., 2024).
The education gradient is striking, and sharper than earlier analyses suggested. Women with the lowest education levels are almost seven times more likely to experience premature menopause than those with the highest education: 6.85% compared with 0.94% (Saha et al., 2024). Decomposition analysis from the same study finds that 73% of this gap is explained by hysterectomy before the age of 40. The remaining gap is associated with poverty, early and repeated childbearing, and sterilisation, characteristics concentrated among women who undergo hysterectomy rather than necessarily independent causes of premature menopause.
These findings change how we understand premature menopause at the population level in India. It is commonly discussed as a spontaneous biological event. Yet the Indian evidence points to a substantial surgical component, raising questions about procedures performed on women in their 30s, often without adequate information about their long-term consequences. Hysterectomy does not necessarily cause immediate menopause when the ovaries are preserved, but it may affect subsequent ovarian function. The clinical governance of hysterectomy therefore deserves attention in any examination of premature menopause.
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What the body carries
International evidence on premature menopause is clear. Women who reach menopause before 40 face significantly higher risks of cardiovascular disease, osteoporosis, cognitive decline and overall mortality than those who reach menopause at the usual age (Shuster et al., 2010). Another study using LASI data found that women who experienced premature menopause through surgical methods had significantly higher odds of cardiovascular disease than those who reached menopause at the typical age (Agrawal & Khandekar, 2022). These risks compound over time. A woman who reaches menopause at 35 may spend fifteen more years with reduced oestrogen exposure than one who reaches it at 50.
In the LASI classification used here, premature menopause and hysterectomy are counted separately. The following findings refer to women whose menopause was natural and early, rather than surgical. Our analysis found that women who experienced premature menopause had mean depression scores of 18.58, comparable to the hysterectomy group (18.63) and notably higher than women who reached menopause in the normal window (17.77) or later (18.05). This association held in adjusted models controlling for age, education, residence, region, religion, caste and marital status.
One possible explanation is that premature menopause often arrives without clinical or mental preparation, or even a clear diagnosis. Unexpected physical symptoms, combined with a poorly understood health transition, may contribute to psychological distress. These are associations, however, and further longitudinal evidence is needed to establish whether the relationship is causal.
The experience can also carry a grief that goes beyond physical symptoms. For women who have not yet had children, or who wanted more, the loss can be devastating. As one participant in a qualitative study on women’s experiences of early menopause described it: “Around 35, 36 I started to skip periods. I just thought it was stress and overwork. It didn’t occur to me that I was going through menopause” (The Conversation, 2021). In a cultural context where a woman’s social standing is closely tied to her reproductive capacity, that loss carries additional weight.
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A burden that compounds at every step
The data reveal a consistent, troubling pattern. Premature menopause falls most heavily on women with the least education and the fewest economic resources, often in association with hysterectomy, which is more common among poorer women. These women also face greater barriers to specialist care, timely diagnosis and hormone therapy. Given the long-term cardiovascular and bone health consequences, an early and unmanaged hormonal transition can deepen disadvantages they already face.
A woman presenting at a primary health centre at 37 with irregular periods and fatigue may leave without an assessment for premature menopause. Without a diagnosis, access to hormone therapy, counselling, referral and follow-up remains limited or poorly defined. The health consequences may accumulate over the years that follow.
This invisibility reflects a health system that has given little attention to women experiencing menopause at an unusually young age. They are too young to fit the conventional understanding of menopause, while their symptoms may not receive adequate attention within reproductive healthcare. Their needs fall between established categories of care.
Invisible in the evidence, absent from policy
One reason premature menopause receives so little policy attention is that routine surveys often fail to collect enough information about the age at which women’s periods stopped. The difficulty goes beyond measurement. Menopausal status is frequently inferred from proxy questions that may miss important distinctions, particularly among women in their 30s and 40s.
The LASI Wave 1 data used in our analysis are cross-sectional, and the premature menopause group is small enough to limit subgroup analysis. The findings establish an association with higher depression scores, although they cannot determine causality. They also point to the need for closer examination of the care available to women experiencing menopause before 40.
A dedicated menopause module in a future national survey should ask about age at menopause and the circumstances surrounding it, including whether a woman underwent hysterectomy and whether her ovaries were removed. Without such information, aggregate data will continue to obscure the different experiences and health needs of women who reach menopause prematurely.
Premature menopause as a distinct challenge
Premature menopause in India is not a rare clinical curiosity. It affects a measurable share of women, falls disproportionately on those with the least education and the fewest resources, and carries consequences that can extend decades beyond the transition itself. The available evidence is sufficient to justify greater clinical and policy attention, even as important gaps remain in our understanding.
The most immediate starting point is clinical recognition. A woman who stops menstruating before 40 should be assessed, rather than having her symptoms dismissed. This means recognising premature menopause within primary care, improving awareness among frontline health workers and establishing referral pathways for women who need further investigation or treatment.
Clinical guidance must also translate into routine practice. ASHAs, ANMs and community health centres already provide points of contact through which symptoms could be identified and women referred for appropriate care. The challenge is to make recognition of premature menopause part of these encounters.
For women whose premature menopause reflects natural ovarian decline, early diagnosis and appropriate management are particularly important. For those who have undergone hysterectomy, the questions are different: whether the procedure was clinically warranted, what alternatives were considered, whether ovarian function was preserved, and whether the woman received adequate counselling about the possible consequences.
The link between hysterectomy and premature menopause warrants closer examination. Clinical guidance alone, however, will not address the conditions in which some women undergo surgery. Economic insecurity, social pressures and limited access to alternative treatment can influence these decisions. The experience of sugarcane workers facing the threat of job loss illustrates how working conditions and financial pressures can affect women’s choices about their reproductive health. The health system’s role in these decisions also requires scrutiny.
Evidence remains thin. There is limited quantitative research that tracks premature menopause as a distinct category, and relatively little qualitative work documenting what the transition means for women living through it. Both are needed. Population data can establish the scale and distribution of the problem, while women’s accounts can reveal how symptoms are understood, what care is available and how the experience affects their lives.
The consequences extend well beyond the years in which menstruation stops. Cardiovascular risks, bone loss and psychological distress may persist for decades, often following a transition that women have never been helped to understand. Counting these women, recognising their symptoms and learning from their experiences would be a start.
Abhishek Gautam is Director, Gender and Health at the International Centre for Research on Women, Asia office.