PREMATURE OVARIAN INSUFFICIENCY (POI)

Premature ovarian insufficiency is defined when the ovaries fail to function before the age of 40.  This can happen very young, when a young girl fails to show the signs of puberty, or any time in her life before the age of 40. There are different names given to this problem, but the internationally accepted name is POI.  There is no ovulation and hormones, oestrogens, progesterone and testosterone are not produced. Besides reproduction these hormones are required for many functions in the human body, so the body suffers. I will explain this as we go along.

POI happens in 1% of women and 1 in 1000 women between the ages of 15 to 28. This is caused by chromosomal disorders, one of commonest being Turner’s syndrome. These women have only one X chromosome instead of two. These women have a fairly normal life when treated, except for fertility; the other chromosomal disorder is Fragile X mutation. The other causes are autoimmune diseases as in when the antibodies destroy the ovarian follicles, previous cancer treatments, metabolic disorders, toxins and viral infections. The special test required when these women or girls present to us are follicular hormone, oestrogens, chromosomes, genetic testing, thyroid function test, and antibodies. It is often very traumatic when women come to you hoping that they are pregnant and it is found that they have POI. In the management of young girls, once the diagnosis is established for sure; hormones are given in increasing doses to bring a period on and help with breast development. If they are really young growth hormones can be tried especially in girls with Turners Syndrome as they are short in height. This may help them to gain some height. Girls with Turners Syndrome need to be seen by a cardiologist who can look after any congenital heart lesion, as they often have them. Pregnancy can be tried with an Oocyte donation (a young egg from a donor) but this requires great care both during pregnancy and labour.  They are maintained on HRT at least until the age of menopause. These women with POI should be advised on general life style factors such as weight, cholesterol, smoking, as they have a higher risk of CVD due to lack of oestrogens. They can also try to get pregnant with an Oocyte donation. The age of the donor should be considered and screening should be carried out for any foetal abnormalities. If a woman is lucky to have a spontaneous pregnancy with POI, there are no special risks. Osteoporosis is another risk factor in women with POI; again due to lack of oestrogens, they should be having HRT, or a combined oral contraceptive pill, which will prevent any unexpected pregnancy if they do not want to be pregnant. If they have osteoporosis and require special treatment besides HRT, calcium, vitamin D and sunshine, it is best for them to be seen by an osteoporosis expert. HRT has not been shown to increase the risk of breast cancer under the age of 50. If any of these women are positive for BRCA12 (increased risk of breast cancer, and ovarian cancer) and there is no personal history of breast cancer they can have HRT but only after removal of both ovaries and tubes. Migraine headaches, fibroids, endometriosis, and blood pressure are not a contraindication of HRT in women with POI.  If obese it is better to use transdermal HRT. These women require a fair bit of psychosexual, psychological, cognitive, and life style intervention advice. Because of risks of CVS there life expectancy is shorter in women with POI. If they need help with genitourinary syndrome, they can be offered, local oestrogen creams, moistures and lubricants. They can read my previous posts on HRT and genitourinary syndrome. In short POI is perhaps a very premature menopause.

However it can be made very comfortable with all the modern treatments and in future we can achieve even more with regards to pregnancy.