Premature Ovarian Insufficiency
Signs of the early menopause and what to do about it…
Written by Hormone Health Associate Dr Imogen Shaw Consultant in women’s health and the menopause.
What is POI?
POI stands for Premature Ovarian Insufficiency; you may also hear it referred to as premature menopause or premature ovarian failure. POI is a condition where the ovaries struggle to function correctly before the age of 40. The ovaries stop releasing eggs and stop producing hormones (estrogen, progesterone, testosterone).
The incidence of POI increases with age:
- 1 in 10,000 women in their teens
- 1 in 1,000 women in their twenties
- 1 in 100 for women in their thirties.
During perimenopause, which is the transition period before menopause occurs, the ovaries produce fewer and fewer hormones until they run out of eggs to release, and a woman’s periods stop.
The menopause (when your periods stop) happens at an average age of 51 years. However, POI occurs more than 10 years before this due to prematurely declining ovarian function.
POI can be diagnosed in women under 40 years with irregular cycles and follicle-stimulating hormone (FSH) concentrations in the postmenopausal range. Any woman who has had no periods for four months or only a few throughout one year should have two measurements of blood FSH levels, at least six weeks apart, which should show elevated levels of FSH.
The causes of POI:
The vast majority of cases (90%) are spontaneous, no underlying causes found (also referred to as idiopathic). While psychologically, this can be hard to accept, it is essential to remember that it should in no way affect the treatment you are offered.
Known causes of POI are:
- Autoimmune disease (5% of cases). This includes conditions such as underactive thyroid, type 1 diabetes, and Addison’s Disease. In these cases, the woman’s body makes antibodies that attack her ovaries.
- Genetic conditions, such as Turner syndrome, Fragile X syndrome, or galactosemia.
- Surgery to remove the ovaries
- Treatment for cancer, such as radiation or chemotherapy
- Infections such as mumps, TB, and malaria (although this is rare)
What are the symptoms?
Many women with POI experience normal puberty and have regular periods before symptoms start. The symptoms of POI are the same as those seen at the menopause and may include:
- Hot flushes
- Night sweats
- Tiredness and disrupted sleep
- Reduced sex drive (libido)
- Irritability or mood swings
- Poor concentration or memory
- Joint pain or stiffness
- Changes to skin and hair
- Painful sex because of the thinning and drying of the vagina
- Dry eyes
What are the effects of POI on health?
POI can have an impact on different parts of the body.
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.
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:
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.
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.
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.
What are the options for treatment?
HORMONE REPLACEMENT THERAPY (HRT)
In women with POI, the ovaries no longer produce hormones (estrogen, progesterone, testosterone), which are needed for a healthy body. HRT aims to restore the levels of these hormones in your body to a similar level as women of the same age without POI, so improving the typical symptoms of POI (hot flushes, night sweats). HRT may have a role in the prevention of heart disease and protecting your bones. In women with POI, HRT is safe and does not increase the risk of breast cancer above the normal level for this age group.
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.
LOCAL TREATMENTS (vaginal estrogen cream/pessaries, lubricants)
Some women with POI experience significant sexual problems, either uncomfortable or painful intercourse from vaginal dryness or sexual changes such as altered libido and arousal. HRT may improve these symptoms. Lubricants are useful for the treatment of vaginal discomfort and painful sex due to vaginal dryness, whether HRT is being used or not.
What support is available?
The leading UK charity supporting women with POI is The Daisy Network.
Your GP may also be able to provide you with details of NHS support groups or forums. For contact details of national patient organisations for infertility, you can ask your doctor, or contact fertilitynetworkuk.org