Management of Premature Ovarian Failure

Premature ovarian failure (POF) or premature ovarian insufficiency (POI) is defined by loss of ovarian activity before the age of 40 years. It is characterized by menstrual disturbance (absent or irregular menses) with increased follicle stimulating hormone (FSH) and low estradiol levels.

According to guidelines recently published by The ESHRE Guideline Group on POI, for diagnosis of premature ovarian failure, the absent or irregular menses should be present for at least 4 months and the FSH level should be elevated (greater than 25 mIU/mL) on two occasions, at least 4 weeks apart. Patients may have symptoms of estrogen deficiency such as hot flashes, vaginal dryness etc.

Premature ovarian failure affects approximately 1% of the population affects approximately 1% of the population. Efforts should be made to reduce the incidence of it. Modifiable factors include: 1) gynecological surgical practice. Especially in patients with ovarian cysts (endometriomas, dermoids) on both ovaries, it is important to try and conserve “normal” ovarian tissue in order to prevent premature ovarian failure. 2) Lifestyle changes e.g. smoking and 3) modified treatment regimens for cancers and chronic diseases. When radiation or chemotherapy is used to treat these conditions, it can lead to POF.

Other tests that can be done to determine the cause of POI include:

• Chromosomal analysis. Patients with Turner syndrome (45XO, where one X chromosome is missing) should be referred to an endocrinologist, cardiologist and a geneticist.
• Test for Y-chromosomal material. If a portion of the Y chromosome is present in these patients, then they are at risk for developing cancer. Removal of both ovaries should be discussed with these patients.
• Fragile-X. This is a fairly common cause of POI and has been discussed in a previous blog.
• Anti-adrenal antibodies (adrenocortical antibodies). If present, patient should be referred to an endocrinologist to rule out adrenal deficiency (Addison’s disease).
• Anti-thyroid antibodies (thyroid-peroxidase antibodies or TPO). If these are present, the patients thyroid (TSH) should be checked every year.

Fertility issues in patients with POI

• There is a small chance of spontaneous pregnancy.
• Women with established POI should use contraception if they wish to avoid pregnancy.
• There are no treatments that have been reliably shown to increase ovarian activity and natural conception rates.
• Egg donation is an established option for fertility in women with POI.
• There is an increased risk for cycle cancellation when a sister is considering egg donation.
• In patients with established POI, the opportunity for fertility preservation has been missed.
• For successful management of POI, patients should discuss with their doctor issues such as fitness for pregnancy, bone health, cardiac health, sexual health and hormone replacement therapy.

To see a fertility specialist who is a board-certified physician with high success rates, make an appointment at one of InVia’s four Chicago area fertility clinics.