Premature ovarian insufficiency
Premature ovarian insufficiency (POI), refers to loss of ovarian activity that occurs before the age of 40. POI occurs in approximately 1% of the population but may differ between countries.
70–90% of the time the cause of POI is unknown. Occasionally it could be linked to genetics (X-linked), autoimmune, infectious, metabolic, toxin-related, and iatrogenic i.e chemotherapy, radiation. Family history, early menarche, cigarette smoking, low or nulliparity and low BMI, hysterectomy are all linked with POI.
Women usually present with secondary amenorrhoea or oligomenorrhea, subfertility, and estrogen deficiency symptoms. Some women have absolutely no symptoms and others can have severe symptoms worse than natural age of menopause.
Diagnosis is usually by history and blood tests. . Most guidelines recommend confirmation by two elevated FSH tests 4-6 weeks apart. Most utilised limit is >40IU/l. Some societies accept 30IU/l and even 25IU/l. . Anti-Mullerian hormone(AMH) produced from antral follicles is thought to be the most reliable measure of reduced ovarian reserve. Although no diagnostic level is established and AMH can be undetectable years before menopause ceases. Also it is cost precludes it use as a universal test.
Long-term health consequences
Women with premature ovarian insufficiency is a greater risk of: . Infertility . Cardiovascular disease . Osteoporosis . Psychological distress . Genitourinary and sexual dysfunction . Memory, learning problems and dementia.
Premature ovarian insufficiency (POI) once diagnosed requires multidisciplinary management.
Optimal management should involve a baseline assessment of insulin resistance, and bone health assessment(DXA scan). Frequency of the tests is based upon risk factors.
Lifestyle changes such as ceasing smoking, weight bearing exercise, healthy diet will reduce cardiovascular risk and maintain bone strength.
Hormone therapy (HT) at least until the average age of menopause is the first-line treatment unless contraindicated.
Replacement can be with the combination oral contraceptives(COC) initially if contraception is required or because of personal preference, but in the long term HT is recommended to optimise bone and metabolic health. (COC containing 17-B estradiol is preferred)
Hypertension, migraines, fibroids endometriosis, obesity are not contraindications to use HT for POI. Treatment should be personalised and discussed in detail in junction with your GP.
Premature ovarian Insufficiency (POI) and infertility
Premature ovarian Insufficiency(POI) Or Premature menopause is an extremely devastating news for a woman to receive when dealing with Infertility. Management usually involves:
When there are risk factors such as strong family history of premature menopause, genetics, smoking- early presentation to care providers and referral to fertility specialists is useful. Blood tests can be undertaken to assess baseline hormone levels and ovarian reserve. With recent advances in egg freezing. Egg freezing is an extremely viable option for women to preserve their eggs particularly when social circumstances don’t allow early family planning.
Medication- Once the diagnosis is made, there are no proven treatment to increase the rate of pregnancy for women using their own eggs . Some trials have used oestrogen +/- gonadotropins to induce ovulation although the success rates are extremely low.
Currently the best chance of achieving a pregnancy for women with POI is oocyte donation. The options in Victoria include
Known donor: This can be a sister, relative or friend who be willing to go through IVF procedure and donate eggs.
Clinic recruited donor: There is usually a waiting list as donors are altruistic. Monash IVF has 1-3 altruistic egg donors per year (and sometimes none). The clinic cannot find donors for patients.
The world egg bank(TWEB) : Monash IVF is in partnership with TWEB which means they can help import frozen donor eggs from the USA. The egg donors don’t get paid but provide the eggs altruistically. The details can be found on Monash IVF website.
Stem cell therapies, platelet-rich plasma, and primordial follicle activation all require further research and confirmation of efficacy and safety.