Primary Ovarian Insufficiency: Get the Facts About Treatment

December 4, 2013

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What is primary ovarian insufficiency (POI)?

Health care providers use the term POI when a woman’s ovaries stop working normally before she is 40 years of age.^1,2

Many women naturally experience reduced fertility when they are around 40 years old. This age may mark the start of
irregular menstrual periods that signal the onset of menopause. For women with POI, irregular periods and reduced fertility occur before the age of 40, sometimes as early as the teenage years.^3,4

In the past, POI used to be called "premature menopause" or "premature ovarian failure," but those terms do not accurately describe what happens in a woman with POI. A woman who has gone through menopause will never have another normal period and cannot get pregnant. A woman with POI may still have periods, even though they might not come regularly, and she may still
get pregnant.^2,4

What are the symptoms of primary ovarian insufficiency?

The first sign of POI is usually menstrual irregularities or missed periods,² which is sometimes called amenorrhea (pronounced ey-men-uh-REE-uh or uh-men-uh-REE-uh).

In addition, some women with POI have symptoms similar to those experienced by women who are going through natural menopause, including:

Hot flashes
Night sweats
Irritability
Poor concentration
Decreased sex drive
Pain during sex
Vaginal dryness^1,5

For many women with POI, trouble getting pregnant or infertility is the first symptom they experience and is what leads them to visit their health care provider. This is sometimes called
"occult" (hidden) or early POI.⁶

How many women are affected by or at risk for primary ovarian insufficiency?

Estimates suggest that about 1% of women and teenage girls in the United States have POI.¹ Researchers estimate that, categorized by age, POI affects:

1 in 10,000 women by age 20
1 in 1,000 women by age 30
1 in 250 women by age 35
1 in 100 women by age 40⁸

Several factors can affect a woman’s risk for POI:

Family history. Women who have a mother or sister with POI are more likely to have the disorder. About 10% to 20% of women with POI have a family history of the condition.⁸
Genes. Some changes to genes and genetic conditions put women at higher risk for POI. Research suggests that these disorders and conditions cause as much as 28% of POI cases.⁹ For example:
- Women who carry a variation of the gene for Fragile X syndrome are at higher risk for Fragile X-Associated POI (FXPOI). ¹⁰ Fragile X syndrome is the most common inherited form of intellectual and developmental disability, but women with FXPOI do not have Fragile X syndrome itself. Instead, they have a change or mutation in the same gene that causes Fragile X syndrome, and this change is linked to FXPOI.
- Most women who have Turner syndrome develop POI. Turner syndrome is a condition in which a girl or woman is partially or completely missing an X chromosome. Most women are XX, meaning they have two X chromosomes. Women with Turner syndrome are X0, meaning one of the X chromosomes is missing.
Other factors. Autoimmune diseases, viral infections, chemotherapy, and other treatments also may put a woman at higher risk of POI.⁸

What causes primary ovarian insufficiency?

In about 90% of cases, the exact cause of POI is a mystery.^4,6,11

Research shows that POI is related to problems with the follicles (pronounced FOL-i-kulz)—the small sacs in the ovaries in which eggs grow and mature.⁶

Follicles start out as microscopic seeds called primordial (pronounced prahy-MAWR-dee-uhl) follicles. These seeds are not yet follicles, but they can grow into them. Normally, a woman is born with approximately 2 million primordial follicles,¹² typically enough to last until she goes through natural menopause, usually around age 50.⁴

For a woman with POI, there are problems with the follicles:¹

Follicle depletion. A woman with follicle depletion runs out of working follicles earlier than normal or expected. In the case of POI, the woman runs out of working follicles before natural menopause occurs around age 50. Presently there is no safe way for scientists today to make primordial follicles.
Follicle dysfunction. A woman with follicle dysfunction has follicles remaining in her ovaries, but the follicles are not working properly. Scientists do not have a safe and effective way to make follicles start working normally again.⁶

Although the exact cause is unknown in a majority of cases, some causes of follicle depletion and dysfunction have been identified:

Genetic and chromosomal disorders. Disorders such as Fragile X syndrome and Turner syndrome can cause follicle depletion.^6,8,12
Low number of follicles. Some women are born with fewer primordial follicles, so they have a smaller pool of follicles to use throughout their lives. Even though only one mature follicle releases an egg each month, less mature follicles usually develop along with that mature follicle and egg. Scientists don’t understand exactly why this happens, but these “supporting” follicles seem to help the mature follicle function normally. If these extra follicles are missing, the main follicle will not mature and release an egg properly.
Autoimmune diseases. Typically, the body’s immune cells protect the body from invading bacteria and viruses. However, in autoimmune diseases, immune cells turn on healthy tissue. In the case of POI, the immune system may damage developing follicles in the ovaries. It could also damage the glands that make the hormones needed for the ovaries and follicles to work properly. Recent studies suggest that about 20% of women with POI have an autoimmune disease.^4,13
- Thyroiditis (pronounced thahy-roi-DAHY-tis) is the autoimmune disorder most commonly associated with POI.¹³ It is an inflammation of the thyroid gland, which makes hormones that control metabolism, or the pace of body processes.
- Addison’s disease is also associated with POI. Addison’s disease affects the adrenal glands, which produce hormones that help the body respond to physical stress, such as illness and injury; the hormones also affect ovary function.¹⁴ About 3% of women with POI have Addison’s disease.¹⁵
Chemotherapy or radiation therapy. These strong treatments for cancer may damage the genetic material in cells, including follicle cells.^2,6,11
Metabolic disorders. These disorders affect the body’s ability to create, store, and use the energy it needs. For example, galactosemia (pronounced guh-lak-tuh-SEE-mee-uh) affects how your body processes galactose (guh-LAK-tohs), a type of sugar. More than 80% of women and girls with galactosemia also have POI.¹³
Toxins. Cigarette smoke, chemicals, and pesticides can speed up follicle depletion. In addition, viruses have been shown to affect follicle function.^4,12

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How is primary ovarian insufficiency diagnosed?

The key signs of POI are:

Missed or irregular periods for 4 months, typically after having had regular periods for a while
High levels of follicle-stimulating hormone (FSH)
Low levels of estrogen^4,6,13

If a woman is younger than age 40 and begins having irregular periods or stops having periods for 4 months or longer, her health care provider may take these steps to diagnose the problem:

Do a
pregnancy test. This test will rule out an unexpected pregnancy as the reason for
missed
periods.⁴
Do a physical exam. During the physical exam, the health care provider looks for signs of other disorders. In some cases, the presence of these other disorders will rule out POI. Or, if the other disorders are associated with POI, such as Addison’s disease, a health care provider will know that POI may be present.⁴
Collect blood. The health care provider will collect your blood and send it to a lab, where a technician will run several tests, including:
- Follicle-Stimulating Hormone (FSH) test. FSH signals the ovaries to make estrogen, sometimes called the “female hormone” because women need high levels of it for fertility and overall health. If the ovaries are not working properly, as is the case in POI, the level of FSH in the blood increases. The health care provider may do two FSH tests, at least a month apart. If the FSH level in both tests is as high as it is in women who have gone through menopause, then POI is likely.⁴
- Luteinizing (pronounced LOO-tee-uh-nahyz-ing) hormone (LH) test. LH signals a mature follicle to release an egg. Women with POI have high LH levels, more evidence that the follicles are not functioning normally.¹
- Estrogen test. In women with POI, estrogen levels are usually low, because the ovaries are not functioning properly in their role as estrogen producers.^1,6
- Karyotype (pronounced KAR-ee-uh-tahyp) test. This test looks at all 46 of your chromosomes to check for abnormalities. The karyotype test could reveal genetic changes in the structure of chromosomes that might be associated with POI and other health problems.^1,4
Do a
pelvic ultrasound. In this test, the health care provider uses a sound wave (sonogram) machine to create and view pictures of the inside of a woman’s pelvic area. A sonogram can show whether or not the ovaries are enlarged or have multiple follicles.^4,11

The health care provider will also ask questions about a woman’s medical history. He or she may ask about:

A blood relative with POI or its symptoms
A blood relative with Fragile X syndrome or an unidentified intellectual or developmental disability
Ovarian surgery
Radiation or chemotherapy treatment
Pelvic Inflammatory Disease or other
sexually transmitted infections
An endocrine disorder, such as diabetes⁴

If they do not do tests to rule out POI, some health care providers might assume missed periods are related to
stress.⁴ However, this approach is problematic because it will lead to a delay in diagnosis; further evaluation is needed.⁴

Are there associated disorders or conditions associated with primary ovarian insufficiency?

Because POI results in lower levels of certain hormones, women with POI are at greater risk for a number of health conditions, including:

Osteoporosis. The hormone estrogen helps keep bones strong. Without enough estrogen, women with POI often develop osteoporosis. Osteoporosis is a bone disease that causes weak, brittle bones that are more likely to break and fracture.¹
Low thyroid function. This problem also is called hypothyroidism (pronounced hahy-puh-THAHY-roi-diz-uhm). The thyroid is a gland that makes hormones that control your body’s metabolism and energy level. Low levels of the hormones made by the thyroid can affect your metabolism and can cause very low energy and mental sluggishness.
Cold feet and constipation are also features of low thyroid function. Researchers estimate that between 14% and 27% of women with POI also have low thyroid function.⁴
Anxiety and depression. Hormonal changes caused by POI can contribute to anxiety or lead to depression.¹⁶ Women diagnosed with POI can be shy, anxious in social settings, and may have low self-esteem more often than women without POI.⁴ It is possible that depression may contribute to POI.¹⁶
Cardiovascular (heart) disease. Lower levels of estrogen, as seen in POI, can affect the muscles lining the arteries and can increase the buildup of cholesterol in the arteries. Both factors increase the risk of atherosclerosis (pronounced ath-uh-roh-skluh-ROH-sis) – or hardening of the arteries – which can slow or block the flow of blood to the heart. Women with POI have higher rates of illness and death from heart disease than do women without POI.^1,6,11
Dry eye syndrome and ocular (eye) surface disease. Some women with POI have one of these conditions, which cause discomfort and may lead to blurred vision.⁴ If not treated, these conditions can cause permanent eye damage.

Addison’s disease is also associated with POI. Addison’s disease is a life-threatening condition that affects the adrenal glands, which produce hormones that help the body respond to physical stress, such as illness and injury. These hormones also affect ovary function.¹⁴ About 3% of women with POI have Addison’s disease.¹⁵

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What are the treatments for primary ovarian insufficiency?

Currently, there is no proven treatment to restore normal function to a woman’s ovaries.^1,2 But there are treatments for some of the symptoms of POI, as well as treatments and behaviors to reduce health risks and conditions associated with POI.

It is also important to note that between 5% and 10% of women with POI get pregnant without medical intervention after they are diagnosed with POI. Some research suggests that these women go into what is known as “spontaneous remission” of POI, meaning that the ovaries begin to function normally on their own. When the ovaries are working properly, fertility is restored and the women can get pregnant.

Hormone replacement therapy (HRT)

HRT is the most common treatment for women with POI. It gives the body the
estrogen and other hormones that the ovaries are not making. HRT improves sexual
health and decreases the risks for cardiovascular disease (including
heart
attacks, stroke, and high blood pressure) and osteoporosis.¹⁷

If a woman with POI begins HRT, she is expected to start having regular
periods again. In addition, HRT is expected to reduce other symptoms, such as
hot flashes and night sweats, and help maintain bone health.^1,13,17,26 HRT
will not prevent pregnancy, and evidence suggests it might improve pregnancy
rates for women with POI by lowering high levels of luteinizing hormone – which
stimulates ovulation – to normal in some women.¹⁹

HRT is usually a combination of an estrogen and a progestin. A progestin is a
form of progesterone. Sometimes, the combination might also include
testosterone, although this approach is controversial.¹¹ HRT
comes in several forms: pills, creams, gels, patches that stick onto the skin,
an intrauterine device, or a vaginal ring.¹⁴ Estradiol
is the natural form of human estrogen. The optimal method of providing estradiol
to women with POI is by a skin patch or vaginal ring. These methods are linked
with a lower risk of potentially fatal blood clots developing. Most women
require a dose of 100 micrograms of estradiol per day. It is important to take a
progestin along with estradiol to balance out the effect of estrogen on the
lining of the womb. Women who do not take a progestin along with estradiol are
at increased risk of developing
endometrial cancer. The progestin with the best
evidence available to support use in women with POI is 10 mg of
medroxyprogesterone acetate by mouth per day for the first 12 calendar days of
each month.

A health care provider may suggest that a woman with POI take HRT until she
is about 50 years old, the age at which menopause usually begins.

After that time, she should talk with her health care provider about stopping
the treatment because of risks associated with using this type of therapy in the
years after the normal age of menopause.⁴

Is it safe for women with POI to take HRT?

In general, HRT treatment for women with POI is safe and is associated with
only minimal side effects. Women with POI take HRT to replace hormones their
bodies would normally be making if they didn’t have POI.

The HRT taken by women with POI is different from the hormone therapies taken
by women who are going through or have gone through natural menopause, which are
often called menopausal or post-menopausal hormone therapy (PMHT).

A large, long-term study – called the Women’s Health Initiative – examined the
effects of a specific type of PMHT, taken for more than 5 years, by women ages
50 to 79 who had already gone through menopause. This study showed that PMHT was
associated with an increased risk of stroke, blood clots, heart disease, heart
attacks, and breast cancer in these women.²⁰

These results do not apply to young women with POI who take HRT.^4,14
The type and amount of HRT prescribed to women with POI is different from the
PMHT taken by older women.⁴

A woman should talk to her health care provider if she has questions about
HRT as a treatment for POI. Also, she should tell her health care provider about
any side effects she experiences while taking HRT. There are many different
types of HRT. Women should work with their health care providers to find out the
best type of treatment.

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Calcium and vitamin D supplements

Because women with POI are at higher risk for osteoporosis, they should get
at least 1,200 to 1,500 mg of elemental calcium and 1000 IU (international
units) of vitamin D, which helps the body absorb calcium, every day.²¹
These nutrients are important for bone health.¹⁴
A health care provider may do a bone mineral density test to check for bone
loss.¹⁹

Regular physical activity and healthy body weight

Weight-bearing physical activity, such as walking,
jogging, and stair
climbing, helps build bone strength and prevents osteoporosis.¹⁴
Maintaining a healthy body weight and getting regular physical activity are also
important for reducing the risk of heart disease. These factors can affect
cholesterol levels, which in turn can change the risk for heart disease.²²

Treatments for associated conditions

POI is associated with other health conditions, including (but not limited
to) Addison’s disease,
Fragile X permutation, thyroid dysfunction, depression, anxiety, and
certain other genetic, metabolic, and autoimmune disorders.

Women who have POI as well as one of these associated conditions will require
additional treatment for the associated condition. In some cases, treatment
involves medication or hormone therapy. Other types of treatments might also be
needed.

Emotional support

For many women who experience infertility, including those with POI, feelings
of loss are common. In one study, almost 9 out of 10 women reported feeling
moderate to severe emotional distress when they learned of their POI diagnosis.^14,

26 Several organizations offer help finding these types of professionals.

POI in teens

Receiving a diagnosis of POI can be emotionally difficult for teenagers and
their parents. A teen may have a similar emotional experience as an adult who
receives the diagnosis, but there are many aspects of the experience that are
unique to being a teenager. It is important for parents, the teenager, and
health care providers to work closely together to ensure that the teenager gets
the right treatment and maintains her emotional and physical health in the long
term. There are resources to provide advice and support for parents, teenagers,
and health care providers.²⁵

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