Premature ovarian insufficiency (POI) occurs when the ovaries no longer work effectively in women under the age of 40. Different terms are used interchangeably for POI, such as ‘premature menopause’ and ‘primary ovarian failure’. It is a fairly common condition, affecting around 1% of people and can sometimes be a cause of fertility problems.
What exactly is POI?
The ovaries are a part of the female reproductive system and have two main functions when it comes to fertility: (1) production of eggs, (2) production of hormones. There are four important hormones involved in the menstrual cycle which interact to allow an egg to develop and be released with every cycle – this is known as ovulation. The table shows each hormone and its role:
|FSH||Pituitary gland||Stimulates the growth of eggs in the ovaries|
|LH||Pituitary gland||Releases the egg from the ovary|
|Oestrogen||Ovary||Repairs and thickens the lining of the womb|
|Progesterone||Ovary||Maintains the lining of the womb|
When the ovaries stop producing normal levels of oestrogen, it can lead to an egg no longer being matured or released. This is a normal finding in people aged 45 and above when going through menopause. When this occurs in younger people, particularly those below 40, this is known as premature ovarian insufficiency. If you are between 40 and 45, then the term ‘early menopause’ is used. It is important to note that the natural menopause is irreversible, but for those with POI the loss of ovarian function can be temporary.
What symptoms might I experience?
The most common symptom associated with POI is having irregular or no periods. Around 1 in 10 women with POI will not have any more periods and they may receive a diagnosis at a very early age.
Alongside this, there are many other symptoms that occur when you have low oestrogen levels in your body. These include symptoms typically associated with menopause, such as hot flushes and night sweats. You may also notice that you are experiencing a lower sex drive, vaginal dryness, and painful intercourse. POI can also be a very emotive diagnosis, and it is common for people to feel anxious, worried, or low at times. If you are experiencing any of these symptoms, speak to your GP about any concerns you may have. The Daisy Network is a charity dedicated to providing information and support to women diagnosed with POI.
A more comprehensive list of symptoms of POI and menopause can be found on the NHS website.
What might be causing my POI?
There are multiple potential causes for POI. However, for most people there is no identifiable reason – this is known as ‘idiopathic’ POI.
Surgery to remove the ovaries will mean there is no oestrogen being made in your body and you are not able to release an egg each month.
Cancer treatments such as radiotherapy and chemotherapy can reduce the function of the ovaries. This may be something that you only experience temporarily, but it can be permanent. It is worth discussing fertility options with your doctor before starting treatment if you are hoping to get pregnant in the future.
Autoimmune diseases like diabetes and thyroid problems affect roughly 1 in 20 women diagnosed with POI. These conditions lead to your immune system attacking itself and can affect the ovaries.
Genetic conditions are passed through families. This may be the cause of your POI if there are lots of members of your family who share the diagnosis, or if you are very young (20s or early 30s). The most common genetic condition to cause POI is Turner’s syndrome, where one of the X chromosomes (female sex chromosomes) is missing.
Infection including tuberculosis, malaria and mumps may rarely be a cause of POI.
How is POI diagnosed?
If you have had your ovaries removed, your doctor will not recommend any tests for a diagnosis. Otherwise, the most used way to achieve a diagnosis is by a blood test. The hormone FSH is measured. FSH will be raised in POI as the body is trying to work overtime to stimulate the ovaries to produce oestrogen. You will provide a blood sample twice, 4-6 weeks apart. This should be able to be done at your GP. Prior to doing the test, the doctor should establish whether you are still having periods as this will affect when the tests need to be done. Other hormones in your blood may also be tested as these can help to aid the diagnosis. The results of the blood test, plus any symptoms you are experiencing, will be able to provide a good indication as to whether you have POI.
To try and find an underlying cause of your POI, you will be offered a blood test to check for any diabetes and thyroid problems. If you are very young (under 30), then you may also be offered some genetic testing to look at your chromosomes.
Sometimes people with POI can have thinning of their bones, known as osteoporosis. This is because of the reduced oestrogen levels. For this reason, a DXA scan of your bones will be offered which will check the density of your bones.
What can be used to treat POI?
Women with POI are advised to take a hormone replacement to provide what your body would have otherwise been producing. Oestrogen is an important hormone in your body and prevents bone thinning and helps cardiovascular health. Taking hormones can also help with the symptoms associated with POI.
The main methods for replacing oestrogen are by using either the combined oral contraceptive pill (COCP), or hormone replacement therapy (HRT). This medication can be prescribed to you by your GP, who will most likely recommend you continue taking this until around the age of typical menopause (on average 51 years of age). There are lots of different variations of hormone treatments and people are suited to different ones more than others. A discussion with a healthcare professional can help you decide which might be the best option for you.
As with many physical health conditions, a healthy lifestyle can be hugely beneficial. Cutting out smoking and excessive alcohol, as well as maintaining a balanced diet can help with POI. There is an emphasis on getting plenty of calcium and vitamin D, it may be recommended that you take supplements to help with this.
What are my fertility options?
POI significantly decreases the chance of getting pregnant naturally, however it is not impossible. Around 5-10% of people who have POI for an unknown reason will get pregnant without needing any assistance over their lifetime. Should you wish to get pregnant in the future, then it is important to discuss this with your doctor as it may alter the kind of treatment they recommend.
Unfortunately, fertility treatments like in vitro fertilisation (IVF) and egg freezing are unlikely to be successful for those diagnosed with POI. This is due to the low reserve of eggs, which do not respond well to the medications that try to stimulate the ovaries.
One option is using eggs from a donor. Donor eggs can be fertilised with either a partner’s sperm or donor sperm to create an embryo. In vitro fertilisation (IVF) is then carried out, with a much higher success rate, to implant the embryo into your womb. If this is something that you’d like to consider, talk to your GP about a referral to a fertility specialist.
Not everyone wishes to go down this route and there is no right or wrong answer. Some people with POI decide to adopt or foster children. Considering your options and discussing it with your partner, healthcare professionals and a counsellor is recommended to ensure you are empowered to make the right choice for you.
Take Home Messages
- Premature ovarian insufficiency is when the ovaries are no longer working in people under the age of 40.
- The most common symptom for POI is irregular or missed periods.
- There are many different causes of POI, but most often the cause is unknown.
- POI is usually diagnosed using a blood test.
- People will usually need to take hormones to treat their POI.
- It is still possible to get pregnant with POI, but there are routes to go down if you are concerned about your fertility.
- The Daisy Network – support network for women with premature ovarian failure
- Human Fertilisation and Embryology Authority (HFEA) – information about the types of fertility treatment available
- European Society of Human Reproduction and Embryology (ESHRE) Guideline on the management of premature ovarian insufficiency.