Primary Ovarian Insufficiency

What is primary ovarian insufficiency?

When the ovaries stop working normally in women younger than age 40, it's called primary ovarian insufficiency (POI). With POI, the ovary doesn't release an egg each month as it should. POI has been called premature ovarian failure and premature menopause. But these terms are not as accurate. A woman with POI may still have some function of her ovaries.

The ovaries are a pair of small, oval-shaped organs in the lower part of a woman’s belly (abdomen). About once a month, one of the ovaries releases an egg. The ovaries also make the hormones estrogen and progesterone. These play roles in pregnancy, the menstrual cycle, and breast growth.

A woman with POI may have fewer eggs. Or the ovaries might not mature or release eggs correctly. The ovaries then don't make the normal amounts of hormones. This leads to the symptoms of POI.

POI is not the same thing as menopause. Menopause normally happens around age 50. In the transition time before menopause, the ovaries make smaller and smaller amounts of hormones. This time is called perimenopause. At the time of menopause, the ovaries run out of eggs to release each month. The menstrual cycles stop. In contrast, women with POI may have irregular or even normal menstrual cycles. They also may still have eggs in their ovaries.

POI isn't rare. But it can only happen to women younger than age 40. It's more common in women in their 30s than those in their teens and 20s. It can affect both women who have had children and those who haven’t.

What causes primary ovarian insufficiency?

Researchers are working to fully understand the causes of POI. It can result from any cause that reduces the number of eggs in the ovaries. It can also happen if your ovaries don’t make enough hormones, even with a normal number of eggs.   

Some of the known causes of POI include:

  • Autoimmune disease in which the woman makes antibodies that attacks her ovaries
  • Eating disorders
  • Genetic conditions, such as Turner syndrome, Fragile X syndrome, or galactosemia
  • Infections that damage the ovaries, such as mumps
  • Problems with hormones that regulate the ovaries, such as follicle-stimulating hormone (FSH)
  • Surgery on the ovaries
  • Thyroid disease
  • Toxins that affect the ovaries, such as from radiation or chemotherapy

In most cases, the cause of the condition isn’t known.

Who is at risk for primary ovarian insufficiency?

You may be more likely to have POI if you have thyroid disease, certain infections, or other conditions that sometimes cause POI. You may have a higher risk for POI if you had certain cancer treatments. You also may be more likely to get POI if the condition runs in your family.

What are the symptoms of primary ovarian insufficiency?

Most women with POI have a normal puberty and have normal menstrual periods before symptoms start. Symptoms may include:

  • Decreased sex drive
  • Hot flashes and night sweats
  • Infertility
  • Irregular periods or periods that completely stop
  • Irritability
  • Painful sex because of thinning and drying of the vagina

These are many of the same symptoms of normal menopause.

Some women with POI have regular periods and don’t have any symptoms of POI. Some women may have symptoms that come and go.

How is primary ovarian insufficiency diagnosed?

Your healthcare provider or gynecologist may diagnose the condition. You will be asked about your health history and your symptoms. Some women first become aware of POI when their normal menstrual cycle doesn’t start up again after a pregnancy or after stopping birth control pills. Many women have irregular menstrual cycles for several years before being diagnosed.

You will also have a physical exam, including a pelvic exam.

Many conditions other than POI can cause irregular periods. To diagnose POI, your gynecologist may have your blood tested for follicle stimulating hormone (FSH). FSH is higher in women who have gone through menopause and are no longer releasing eggs. FSH is also higher in women with POI. This test alone may be enough for you to be diagnosed.

Your gynecologist or healthcare provider might do other tests to rule out other causes of your symptoms. These tests may include:

  • A pregnancy test
  • Blood test for prolactin and thyroid levels. These are other hormones that can cause POI symptoms.
  • Adrenal autoantibodies to check for an autoimmune cause
  • Genetic testing to check for genetic causes
  • Bone density testing, to check for osteoporosis caused by low estrogen

How is primary ovarian insufficiency treated?

POI can be treated in different ways. Treatment may be done by a gynecologist who specializes in reproductive endocrinology. 

Most women with POI need hormone treatment with estrogen. This can help reduce bone loss and other symptoms of reduced estrogen, such as vaginal dryness.

Progesterone is also given to women who have not had surgery to remove their uterus (hysterectomy) and are receiving estrogen. Your gynecologist will probably advise estrogen and progesterone until you reach the natural age for menopause (around age 50).

In some women, treatment of an underlying health problem may help treat POI. For example, treating thyroid disease or an eating disorder may reduce symptoms of POI.

Pregnancy rates for women with POI are low. Many women with POI would like to have more children. If you have POI and still want to get pregnant, your gynecologist may recommend:

  • Medicines to promote egg release, such as clomiphene
  • Using a donor egg instead of your own egg

Estrogen therapy may also increase your chances of getting pregnant. A small number of women with POI can get pregnant naturally. Talk with your gynecologist about birth control if you want to prevent pregnancy.

What are possible complications of primary ovarian insufficiency?

Thinned, weakened bones (osteoporosis) is one possible complication of POI. Osteoporosis can increase your chances of a broken bone. Your healthcare provider may give you advice to help keep your bones healthy. This may include taking extra calcium and vitamin D, quitting smoking, and exercising more.

Some women are upset to learn that they have POI, especially if they still want children. This can lead to depression and anxiety. Talking with a mental health provider may help.

When should I call the healthcare provider?

See your healthcare provider or gynecologist if your menstrual cycle has been irregular for a few months, or if you have other symptoms of POI.

Key points about primary ovarian insufficiency

  • In POI, your ovaries stop working properly before age 40.
  • A woman with POI has fewer eggs, or the eggs fail to release properly. In most cases, healthcare providers don’t know why this happens.
  • Infertility, irregular menstrual cycles, vaginal dryness, and irritability are some possible symptoms of POI. Some women with POI don’t have any of these symptoms.
  • Estrogen therapy is a main treatment for the symptoms of POI.
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