Premature ovarian failure

What is premature ovarian failure?

Premature ovarian failure (POF) is defined as the cessation of ovarian function prior to the age of 40 years. It is diagnosed in women when ovarian function ceases, resulting in an end or pause in menstruation, the onset of menopausal symptoms, and a decline in the production of estrogen and eggs, resulting in infertility.  

It is not exactly the same as early menopause. There are many differences in the two conditions. Normal menopause occurs as a result of ageing, which results in follicle depletion and the onset of menopause with related symptoms. With POF, up to 50% of patients may ovulate once in any given year and 5-10% may become pregnant, leading to a theory that there is a follicular dysfunction rather than complete ovarian failure. POF actually affects one percent of women by the age of 40.

What are the symptoms?

The symptoms vary from patient to patient and the disorder may occur abruptly or spontaneously or it may develop gradually over several years. Women may experience infertility, hot flashes, absence of menses, night sweats, irritability, moodiness, sleep disturbance, decreased libido, hair coarseness and vaginal dryness.

Early indications of premature ovarian failure include menstrual cycles less than 21 days, very infrequent or light menstrual periods and the absence or cessation of menstruation.

What are the causes?

The causes of POF are idiopathic or unknown. Genetic, environmental, and autoimmune etiologies have been associated with POF. It is estimated that up to 40% of POF can be attributed to genetic causes, as the disorder has a tendency to be familial. Known environmental causes include pelvic surgery, cancer therapy such as chemotherapy and radiation, and viral oophoritis, all which affect ovarian function. Autoimmunity has also been shown to play a role, with the most common cause thought to be Hashimoto’s thyroiditis. Other secondary causes include disorders such as anorexia nervosa or chemotherapy treatments for various cancers.

How is it diagnosed?

Since the symptoms vary considerably from patient to patient, the diagnosis is often delayed. Women with symptoms of POF are best served by evaluation and treatment by a reproductive endocrinologist. The cessation of menstrual periods is often incorrectly attributed to a variety of conditions, such as stress, without appropriate testing or consideration, delaying the diagnosis even further.

In addition, many women who are affected by POF may have been incorrectly treated for irregular bleeding with oral contraceptives, which may have masked symptoms. All too often, POF is not diagnosed until the woman becomes interested in fertility and the oral contraceptives are stopped when the patient wants to conceive. The diagnosis of POF is made with a through medical evaluation that begins with a complete history and physical examination along with a simple blood test off hormonal therapy measuring an FSH level, or follicle stimulating hormone.  When this value is over 40 mIU/ml on at least two occasions over a four weeks period, the diagnosis can be made.

Chronic low levels of oestrogen can lead to a weakening of the bony skeleton, which can subsequently lead to osteoporosis, making bones more fragile and prone to fracture.

Other medical disorders that affect the heart, eyes, and neurologic systems can put POF patients at a greater risk for serious health problems such as cardiovascular disease, glaucoma, Parkinson’s disease, and Alzheimer’s disease.

Are there any complications?

Several conditions may result from premature ovarian failure:

Infertility - this is a troubling challenge for many women with premature ovarian failure.
Osteoporosis - the hormone oestrogen helps maintain strong bones. Women with low levels of oestrogen are at an increased risk of developing weak and brittle bones (osteoporosis), which are more likely to break than are healthy bones.
Addison's disease - this disorder results when adrenal glands, small hormone-producing glands located just above each of the kidneys, don't produce sufficient amounts of certain hormones that regulate body functions. Addison's disease can be fatal if it's not treated. Some types of premature ovarian failure may be associated with an increased risk of developing Addison's disease.
Depression or anxiety - the risk of infertility and other complications arising from low oestrogen levels may cause some women to become anxious or depressed.

What is the treatment?

Treatment for premature ovarian failure is usually tailored to address the problems that arise from oestrogen deficiency:

• Replacing the oestrogen that is normally produced by functioning ovaries is important to help prevent osteoporosis and relieve symptoms of oestrogen deficiency, such as vaginal dryness and hot flashes. Prescription oestrogen may be paired with another sex hormone, progesterone, to mimic the natural balance of hormones in the body.
  
• Calcium and vitamin D supplements when taken together, these supplements are important for bone health and help reduce the development of osteoporosis.
  
• Addressing infertility - infertility is a common complication of premature ovarian failure. There's no treatment proved to restore fertility in women with this condition. However, some women and their partners choose to pursue an alternative means of conception called in vitro fertilisation. This is a procedure in which a woman's eggs are removed, fertilised with her partner's sperm in a laboratory and then returned to the woman's uterus.