Premature Ovarian Insufficiency

Authored by , Reviewed by Dr Sarah Jarvis MBE on | Certified by The Information Standard

Premature ovarian insufficiency (POI) occurs when you are under 40 years and your ovaries stop working. It's sometimes called premature ovarian failure.

There are various causes. You may have no symptoms other than your periods stopping or you may develop symptoms of the menopause such as hot flushes and night sweats. It is important to have treatment which is usually in the form of hormones. Without treatment, there is an increased risk of 'thinning' of your bones (osteoporosis) and also of heart disease.

Uterus and ovaries

Women have two ovaries, one on either side of their womb (uterus) in the lower tummy (abdomen). Ovaries are small and round, each about the size of a walnut. Your ovaries make eggs. In fertile women, each month an egg (ovum) is released from one of their ovaries. The egg passes down the Fallopian tube into the womb where it may be fertilised by a sperm.

The female reproductive system

The organs and structures of the female reproductive system give women the ability to produce a ...

Your ovaries also make chemicals (hormones) including the main female hormones - oestrogen and progesterone. These hormones pass into your bloodstream and have various effects on other parts of your body, including regulating the menstrual cycle and periods. Oestrogen is also very important in protecting your body from heart disease and 'thinning' of the bones (osteoporosis).

Your ovaries produce oestrogen and progesterone in response to other hormones (follicle-stimulating hormone (FSH) and luteinising hormone (LH)) which are made in a part of your brain called the pituitary gland. All these hormones interact as part of your monthly menstrual cycle which results in the development of an egg in one of the ovaries.

POI occurs when your ovaries no longer work properly when you are under the age of 40 years. Your ovaries no longer produce normal amounts of oestrogen and therefore may not produce eggs. This means that your periods stop (or become irregular) and you may experience symptoms of the menopause.

In the majority of women, this occurs around the age of 51 years and is called the menopause. The term early menopause is usually used if you go through the menopause when you are between 40 and 45 years of age.

However, it is different from the menopause, as the natural menopause is irreversible. With POI your ovaries are not working properly and have stopped producing eggs early. In some women, however, this loss of function is temporary and their ovaries work and function again in the future. This means that you may find that your periods return at some stage in the future.

Around 1 in 100 women under the age of 40 years have POI. It occurs in around 1 in 1,000 women aged under 30 years and 1 in 10,000 women aged under 20 years. This condition can run in some families.

There are many different causes of POI. However, for the majority of women there is no underlying cause found.

Some of the underlying causes include:

Surgery

When your ovaries are removed following an operation, you will no longer have oestrogen in your body. It is common to experience a sudden onset of symptoms soon after surgery. Before your operation, it is important to discuss with your surgeon about receiving hormone replacement therapy (HRT) after your operation, as this will reduce the risk of having symptoms.

Cancer treatment

Some types of chemotherapy and radiotherapy can affect the function of your ovaries. For some women this may be a temporary affect but for others it may be permanent. If you think you are at risk of developing POI in the future due to any cancer treatment, talk with your doctor. It is important to do so before starting treatment, so that you can discuss possible options for fertility preservation.

Autoimmune disease

In around 1 in 20 of women with POI, the condition is caused by an autoimmune disease. This means that your immune system (which normally protects your body from infections) mistakenly attacks itself. There may be people in your family who have other autoimmune conditions - for example, diabetes, thyroid conditions or Addison's disease.

Genetic conditions

Genetic means that the condition is passed on through families through special codes inside cells called genes. Some women with POI have abnormalities with part of their genes. The most common of these is Turner syndrome, in which one of the female sex chromosomes (the X chromosome) is missing. Chromosomes are found in every cell in your body and contain genetic information. Genetic conditions causing POI are usually more common if you have other people in your family with POI or if you are very young (under 20 years) with POI.

Infections

Certain infections can very rarely be a cause of POI in some women. These include mumps, tuberculosis and malaria.

For most women, the most common symptom is that their periods stop. For around 1 in 10 women with POI, their periods do not start and they present with POI at a very early age, usually under 20 years. Other women may notice that their periods become irregular.

Many women experience symptoms of the menopause. These include hot flushes, night sweats, reduced energy, mood disturbances, loss of energy and loss of sex drive. Some women notice that their hair becomes thinner and they have some joint pains. However, around 1 in 4 women do not have any of these symptoms.

It can be very common to feel anxious, worried our even have feelings of hopelessness after a diagnosis of POI has been made. Some women find they feel very sad and even guilty, as having POI affects fertility.

The most common way of diagnosing this condition is by a blood test measuring the level of a hormone called follicle-stimulating hormone (FSH). This level is usually very high as your body produces high levels to try to stimulate your ovaries to produce FSH. You will usually have two of these blood tests several weeks apart.

Other blood tests - for example, other hormone tests and genetic tests - may also be undertaken.

You may have a DXA bone scan. DXA (formerly DEXA) stands for dual-energy X-ray absorptiometry. It is a scan that uses special X-ray machines to check your bone density. A DXA scan can confirm 'thinning' of the bones (osteoporosis).

The low level of oestrogen in your body can lead to 'thinning' of the bones (osteoporosis) developing which can then lead to fractures developing in your bones.

There is also an increased risk of heart attacks at a young age.

However, these increased risks are all reversed by taking hormone treatment.

You should receive treatment in the form of hormones to replace the hormones your body woluld be producing if you had not gone through POI. This will either be in the form of hormone replacement therapy (HRT) or a combined (oestrogen and progesterone) hormonal contraceptive. You should continue with treatment until you are at least  51 (the age of natural menopause), to give some protection from osteoporosis and other conditions that can develop after menopause.

The reported risks regarding HRT, such as an increased risk of breast cancer, are only relevant to those women who take HRT after the age of the natural menopause, which is around 51 years. These risks do not apply if you take HRT for POI. 

If you are also needing contraception then your doctor may suggest that you take an oral contraceptive pill instead. The levels of hormones are different to those in HRT and HRT is not a contraceptive. However, HRT may be better for your blood pressure than the combined contraceptive pill. 

There are many different types of hormone treatments. If one type does not suit you then it is important to talk with your doctor in order to be given an alternative treatment.

It is really important that you have a healthy lifestyle. This means that you should stop smoking if you smoke and you should eat a healthy, balanced diet. Many experts also recommend that you have adequate calcium in your diet or take calcium supplements and also take vitamin D supplements.

If you are experiencing any mood changes (for example, feelings of anxiety, low mood or anger), it is very important that you seek help from your doctor. Some women find joining a support group and talking to other women with POI really helpful.

Around 1 in 10 women with POI which occurs without a known reason become pregnant. This is because their ovaries start working again.

IVF with egg donation is usually undertaken for those women who are keen to become pregnant. Your doctor will be able to describe this to you in more detail.

With hormone treatment, the risk of both 'thinning' of the bones (osteoporosis) and heart disease reduces. Taking the correct dose and type of hormone treatment will also improve any symptoms you may be experiencing.

Further reading and references

  • ; British Menopause Society & Women’s Heath Concern recommendations on hormone replacement therapy, May 2013

  • ; NICE Guidelines (Nov 2015)

  • ; Management of Menopausal Symptoms. Obstet Gynecol. 2015 Oct126(4):859-76. doi: 10.1097/AOG.0000000000001058.

  • ; Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov22(11):1155-74. doi: 10.1097/GME.0000000000000546.

  • ; Faculty of Sexual and Reproductive Healthcare (August 2017)

  • ; The evidence base for HRT: what can we believe? Climacteric. 2017 Apr20(2):91-96. doi: 10.1080/13697137.2017.1280251. Epub 2017 Mar 10.

The truth about HRT
What is postmenopausal depression?

I was on HRT oral tablets for a couple of years due to early menopause at 45 years. I had unbearable sweats day and night and exhausted I went to my GP. I was told - recommended I stay on HRT until 5...

retsina