Primary Ovarian Insufficiency

Primary ovarian insufficiency (POI) is when the ovaries stop working normally in women younger than age 40. With POI, the ovary does not 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 do not produce 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 is not rare. But it can only happen to women younger than age 40. It is 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.

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.

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 of POI if you had certain cancer treatments. You also may be more likely to get POI if the condition runs in your family.

Most women with POI have a normal puberty and have normal menstrual periods before symptoms begin, such as:

• Decreased sex drive
• Hot flashes and night sweats
• Infertility
• Irregular periods or periods that completely stop
• Irritability
• Painful sex due to 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.

Your healthcare provider or gynecologist may diagnose the condition. You will be asked about your medical history and your symptoms. Some women first become aware of POI when her 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. This will likely include a pelvic exam.

Many conditions other than POI can cause irregular periods. To diagnose POI, your gynecologist may have your blood tested for 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 might have you take other tests to rule out other causes of your symptoms. These tests may include:

• A pregnancy test
• Blood test for prolactin and thyroid levels (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

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 medical problem may help treat POI. For example, treatment of 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.

 

Thinned, weakened bones, called 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.

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.

In POI, your ovaries stop working properly before age 40.

• In women with POI, the ovaries do not release an egg each month, and do not produce hormones as they normally would. This leads to similar symptoms as menopause.
• POI is when a woman has fewer eggs, or the eggs fail to release properly. In most cases, doctors 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.
• A blood test of your FSH level can help diagnose your POI.
• Estrogen therapy is a main treatment for the symptoms of POI.
• Some women with POI do get pregnant, especially with the help of assistive reproductive technologies.

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your healthcare provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your healthcare provider if you have questions.