What is premature ovarian insufficiency (POI)?

Premature ovarian insufficiency is the loss of ovarian function before the age of 40 years. It is also referred to as ‘primary ovarian failure’ or ‘premature menopause’. POI affects 1 in the 100 women under the age of 40 years.

 

 

What do ovaries normally do?

The ovaries have 2 functions  – to produce eggs needed for pregnancy and to produce hormones.

Women are born with enough eggs in the ovaries so that they ovulate one each month from puberty until the menopause. Something happens in women with POI, resulting in a premature loss of egg number or function.

The main hormones produced by the ovaries are called oestrogen, progesterone and testosterone. The reproductive cycle is controlled by 2 hormones made by the pituitary gland – follicle-stimulating hormone (FSH) and luteinising hormone (LH).  These hormones interact to allow ovulation and if pregnancy does not occur, monthly periods. 

FSH is a good marker of the health of the ovary. When the ovary begins to fail the level of FSH in the bloodstream rises. A higher FSH measurement is found when the ovaries stopped working, such as after the menopause.

In premature ovarian insufficiency, the ovaries do not produce normal levels of hormones and do not produce enough functioning eggs. However the function of the ovaries can return intermittently and some women may even start to have periods or become pregnant years later, although this is rare.

 

What are the symptoms?

The most common symptom is infrequent or absent periods. 

Other symptoms include:

• Hot flushes and night sweats
• Low energy levels
• Poor sleep
• Vagina dryness and painful intercourse
• Loss of interest in sex
• Mood changes

 

What effect will premature ovarian insufficiency have on my long-term health?

• Women with POI have an increased risk of osteoporosis (thinning bones)  and bone fractures as a result of oestrogen deficiency.
• Oestrogen deficiency can also increase the risk of heart disease.
• The diagnosis of POI in a young woman can be difficult to come to terms with. Women may suffer low mood, low self-esteem and depression.

 

What are the causes of premature ovarian insufficiency (POI)?

There are many different causes of POI which include:

Genetic conditions. It can occasionally be due to chromosomal or genetic abnormality such as Turner’s syndrome.

Familial POI. Between 5 and 30% of women with POI have another affected female relative.

Autoimmune disease. In some women, the body’s immune system attacks the ovaries causing them to stop working.  10-30% of women with POI have another autoimmune disease such as Type 1 Diabetes or thyroid disease.

Cancer treatments. Some chemotherapy and radiotherapy treatments can stop your ovaries from working.

Surgery. Removal of your ovaries will obviously cause ovarian failure.

Infections very rarely mumps and other viral infections are associated with premature ovarian insufficiency.

However, for the majority of women, no underlying cause is found.

 

How is POI diagnosed?

A blood test is taken to measure FSH and oestrogen levels. Women with POI  usually have high FSH levels and low oestrogen levels.  You will usually have 2 blood tests for FSH at least 4 weeks apart.

If you are not having periods you can have the test on any day but if you are, try to have the blood test done on day 2-4 of your period.

If POI is confirmed then you may be offered other blood tests looking for the cause, such as tests to check for autoimmunity and your chromosomes.

You may also have a DXA scan to measure your bone density and exclude osteoporosis.

 

What treatments are available?

Oestrogen replacement is the mainstay of treatment. It will improve the many symptoms of POI and reduce the risk of osteoporosis and heart disease. Oestrogen replacement is advised until you are at least 51 years of age (the average age of the natural menopause).

Oestrogen replacement can be given as hormone replacement therapy (HRT) or the combined oral contraceptive pill (COCP). There are many different types of HRT and COCP and your doctor will be able to provide you with more information. The choice of oestrogen in the formulation should be made on an individual basis. If one type does not suit you then it is important to talk with your doctor in order to be given an alternative treatment. If pregnancy is something you are looking for then HRT may be a better choice.

As women with POI do not produce many eggs the chances of pregnancy are low. However, studies have shown that 5-10% of women will become pregnant over their lifetime. Unfortunately, there is no particular feature that can predict who will be able to conceive. There also does not appear to be any medical treatment that makes fertility more likely. 

Most women with POI who achieve pregnancy have IVF using donated eggs. 

 

For more information and support

The Daisy Network – A patient run support group based in UK.

 www.daisynetwork.org.uk

 

By Dr Mohgah Elsheikh