Premature Ovarian Insufficiency – Causes, Symptoms, & Treatment

Premature ovarian insufficiency (POI) happens when your ovaries stop functioning correctly before age 40. In contrast to menopause occurring spontaneously, ovarian function can abruptly stop and resume unpredictably, such that women experience unpredictable cycles, fertility issues, as well as long-term complications for bone and heart health. Understanding the causes, symptoms, and treatments allows you to manage POI effectively and protect your long-term health.

What is Premature Ovarian Insufficiency?

Premature ovarian insufficiency is a reproductive condition where ovaries stop working efficiently in women under 40. Doctors clinically diagnose this after four months of missed or irregular periods. They also look for at least two blood tests, taken at least four weeks apart, which show increased follicle-stimulating hormone (FSH) and lowered estradiol levels.

POI is ovarian function loss before the age of 40, which results in low oestrogen, high gonadotropins, and absent/irregular periods. It causes menopausal symptoms and raises the risk of osteoporosis, cardiovascular disease, and reproductive problems. We recommend hormone therapy (HT) at least until the natural menopause age of 51 to reduce symptoms and avoid long-term health risks.

The potential longer-term complications of undiagnosed premature ovarian insufficiency (POI) are serious. Oestrogen deficiency is strongly related to reduced bone density, osteoporosis, and cardiovascular disease. Emergency red flags such as sudden bleeding, severe pelvic pain, or systemic disease should be accompanied by a prompt assessment to exclude alternative diseases.

Common Symptoms of Premature Ovarian Insufficiency

Early recognition is vital because Premature Ovarian Insufficiency (POI) signs are easily overlooked. Initial symptoms are typically menstrual changes like amenorrhoea (lack of menstrual period) or oligomenorrhoea (periods that are infrequent and irregular). Younger women rarely expect vasomotor symptoms, such as hot flushes or night sweats, which often delays the diagnosis.

Other typical symptoms include the following:

• Vaginal dryness and discomfort during intimacy.
• Recurrent urinary tract infections
• Changes in emotional state, including anxiety, depressed mood, or poor concentration
• Sleep disruption and lethargy
• Signs of chronic oestrogen deficit, which increase risks for bone and heart disease.

According to the British Menopause Society and the new ESHRE guideline, delays in the diagnosis of POI are the result of minimal clinical symptoms and relative unfamiliarity, and the long-term sequelae of early disruption of ovarian function increase the lifetime risk of skeletal fragility and cardiovascular and neurocognitive disease. Identifying the causes early and referring women to specialists prevents both immediate and long-term damage.

What are the Causes of Premature Ovarian Insufficiency?

Premature ovarian insufficiency may be the outcome of various factors, yet in 70 to 90 percent of cases, no definite cause is identified, making the condition idiopathic. Known contributors include genetic or chromosomal defects, autoimmune diseases, and medical procedures like chemotherapy, radiotherapy, or pelvic surgery.

Genetic & Chromosomal Defects

Chromosomal defects are responsible for the occurrence of premature ovarian insufficiency (POI). One of the strongest associations is that of Turner syndrome, which is the absence of part or all of an X chromosome. Therefore, doctors recommend a karyotyping analysis (a test to examine chromosomes) for women with POI.

FMR1 premutation is another concern. It is estimated that 20% of females carrying it go on to develop fragile X-associated primary ovarian insufficiency (FXPOI) and therefore account for the single-greatest gene-based explanation for POI.

Autoimmune & Medical Conditions

Autoimmune diseases, particularly thyroid and adrenal disease, are strongly associated with POI. Your doctor should screen you for thyroid antibodies and adrenal markers immediately, with repeat tests upon the development of new symptoms.

Radiation and chemotherapy can damage ovarian tissue, and pelvic surgery can reduce ovarian blood supply. Certain systemic infections and diseases can be atypical of POI and may complicate diagnosis.

Understanding these potential reasons is the first step; the next is to distinguish how premature ovarian insufficiency is diagnosed in clinical practice. Understanding these potential causes helps us navigate how we diagnose the condition.

How Premature Ovarian Insufficiency is Diagnosed

We diagnose POI by correlating your clinical history, a physical examination, and laboratory tests. The principal diagnostic clues are one elevated level of follicle-stimulating hormone (FSH) level >25iu , with concomitant reduced levels of estradiol. We may also use other hormone, imaging, genetic, and autoimmune tests to support the diagnosis.

POI can, in rare instances, be seen with viral causes, again emphasising the importance of meticulous taking of history, repetition of biochemical tests, and exclusion of reversible etiologies before the establishment of the diagnosis.

Timely intervention is only possible with an accurate premature ovarian insufficiency (POI) diagnosis, as ovarian activity can vary prior to total failure. A clear diagnosis allows us to start fertility counselling, track bone health, and address psychosocial needs.

What are the effects of POI on health?

POI can have an impact on different parts of the body.

Infertility

As the ovaries stop functioning properly, the chance of conceiving naturally is significantly reduced. However, there may be a small chance of spontaneous pregnancy, so your doctor should discuss the need for contraception with you.

Sex life

You may experience vaginal dryness, reduced libido, and pain during intercourse due to the low estrogen levels associated with POI, which may have a significant impact on your sex life, and relationships with your partner.

Bone, heart and brain.

Reduced estrogen levels do not only result in menopausal symptoms but can also affect the health of your:

Bones

POI is associated with reduced bone mineral density. Estrogen plays an integral part in bone density and helps your body equalise the balance between bone build up and bone break down. When estrogen production falls, bone breakdown occurs at a quicker rate than build up, leading to a condition called Osteoporosis. People with Osteoporosis are at increased risk of bone fractures.

Heart

POI is associated with an increased risk of developing heart disease. We also now know that POI leads to a higher rate of Cardiovascular disease, which is a disease of heart and blood vessels leading to a higher risk of strokes and heart attacks. Other changes, such as increased blood pressure or cholesterol, can also take place.

Brain

POI may have an impact on your memory. Some studies suggest that women under age 45 years who undergo bilateral oophorectomy and do not receive estrogen replacement are at increased risk for dementia and cognitive decline. 

A healthy lifestyle including exercise, cessation of smoking, limiting alcohol intake, maintaining a healthy diet, and weight can reduce the impact of POI on your bones, heart and brain. Your doctor can monitor the health of your bones and check on your bone density with a DEXA Scan if needed.

Available Treatments for Premature Ovarian Insufficiency

Management of premature ovarian insufficiency is aimed at hormone replacement of the lost hormones, protection of long-term health, and fertility advice. The recommended first-line treatment is usually Hormone Therapy (HT), and it is continued at least until the natural menopause age (approximately 51 years) unless contraindicated.

Hormone Therapy (HT)

HRT provides oestrogen and, for women with a uterus, progestogen to restore hormone levels and support bone, cardiovascular, and brain health. Combined Hormonal Contraception (CHC) may be suitable for younger women who require effective contraception as well.

HRT discontinuation is connected with increased risk of fracture, therefore underscoring its usefulness in long-term care.

Fertility & Childbearing

Women facing gonadotoxic treatment, like chemotherapy, should discuss fertility preservation options like freezing eggs or embryos before treatment starts. Contraception also needs to be considered as unpredictable ovarian function can occur.

As infertility is often emotionally devastating, psychosocial care is of first importance. Counselling, peer support groups, and specialist infertility clinics offer reassurance and advice, comfort to women as they deal with the medical and the personal aspects of Family Planning.

Lifestyle & Psychosocial Care

Lifestyle changes support medical management and are useful for chronic care. Weight-bearing exercise, sufficient vitamin D and calcium, avoidance of smoking, and alcohol in moderation all reinforce the skeleton and increase cardiovascular fitness. Sexual health can be compromised.

Peer support groups such as the Daisy Network reduce loneliness, and counselling services can help cope with depression or anxiety. Study or Workplace accommodations, like flexible hours, can reduce the impact of symptoms.

These methods reinforce compliance and give women more freedom to be in control of managing their disease more confidently.

ANDROGEN THERAPY (testosterone)

Androgen therapy can be very helpful in some women as a treatment for the effects of POI on sex life, bones and memory, but studies are limited, and the long-term side-effects of androgen treatment are unknown. If androgen therapy is commenced, the treatment effect should be reviewed after 3-6 months, and stopped if no benefit experienced.

When to Consult a Healthcare Provider

Knowing when to seek medical care is vital for women with possible early ovarian insufficiency.

Referral to specialists is recommended for women with higher needs, including those for whom hormone replacement is contraindicated, those with fertility issues, or those at risk for genetic diseases or autoimmune diseases. Those who received chemotherapy, irradiation, or pelvic surgery should be considered early to evaluate ovarian function and possible longevity risk.

Expert guidance is essential not only for diagnosis but for ongoing management, from hormone treatment and contraception to lifestyle support. If you are looking for a multidisciplinary approach, come to us at Hormone Health. Book a consultation with a hormone specialist today to ensure you receive evidence-based advice for every stage of your treatment.