Primary ovarian insufficiency

Primary Ovarian Insufficiency (POI) can occur spontaneously or be secondary to medical therapies. Spontaneous POI affects 1% of the population. A family history of POI is a risk factor for the development of POI, and smoking will also bring forward the timing of the menopause. In simple terms, in the setting of POI the ovaries no longer produce an egg regularly each month and the levels of oestrogen in the body decrease. Women usually see their doctor because they are unable to fall pregnant naturally or for complaints related to a low oestrogen level. Treatment is usually directed at correcting the oestrogen deficiency and assisting with conception. Women with primary ovarian insufficiency can still ovulate infrequently (10%), so there is possibility of spontaneous pregnancy. Signs of POI when present are like menopausal symptoms and include vasomotor instability (night sweats or hot flushes), abnormal uterine bleeding, subfertility, genital symptoms of menopause (GSM) and mood disturbance. Not all women with POI are symptomatic, apart from changes to their periods.

When you have missed three or more periods, you should see your doctor. Periods can stop for several other reasons, such as excessive stress, exercise and weight loss. Your doctor can order blood tests to establish the cause and menopausal hormone therapy (MHT) may be considered to protect your bones, heart, and alleviate symptoms. It is worth bearing in mind that there is still a risk of pregnancy with MHT as it does not suppress ovarian function, unlike the combined oral contraceptive pill (COCP). If pregnancy is desired, it is important to seek the advice of a fertility expert sooner rather than later. If pregnancy is not a concern, then the COCP will alleviate symptoms and act as a contraceptive. The contraceptive pill should be taken daily to avoid gaps in hormone levels. 

Reasons for POI include genetic predisposition, toxins (e.g. chemotherapy and radiotherapy) and autoimmune disorders. However, in most cases, a cause is not established. It is important not to miss this important diagnosis in young women.

Monitoring of bone mineral density (BMD) and metabolic profile (cholesterol/glucose) should be considered every 1-2 years. MHT is recommended until the average age of menopause (50-51 years) unless there are medical reasons.