Premature Ovarian Insufficiency
Premature Ovarian Insufficiency (POI)
1 in 100 women will experience menopause before they are 40
1 in 1000 will experience it before they are 30
Although the average age of menopause is 52, sometimes a woman’s ovaries stop working properly at a much younger age.
When this happens before the age of 45, it is called Early Menopause.
When it happens before the age of 40, it is called Premature Ovarian Insufficiency (POI)
POI used to be called “Premature Ovarian Failure/POF” or “Premature Menopause” – but we don’t tend to use those terms anymore. This is because the ovaries do not always completely ‘fail’ and periods do not always completely stop.
Instead, the ovaries decline and fluctuate; in a similar way as happens in Perimenopause – except it is happening years or even decades earlier than it should.
Around 1 in 10 women with POI are diagnosed under the age of 20
POI is often not recognised and it can sometimes take years before it’s diagnosed.
Some women do not have any obvious symptoms of POI and it is not until they start struggling to get pregnant that the diagnosis is made.
For other women, there are various symptoms that can happen because their ovaries are not working properly. Their periods can become either infrequent or they can stop altogether. In very young women, their periods may never start at all. Women with POI may also experience any of the classic symptoms of perimenopause and menopause such as hot flushes, mood changes, fatigue, sleep disturbances and reduced sex drive.
The reason POI is often missed, is that there are lots of other reasons why a woman under 40 may experience these sorts of symptoms and changes in her periods. Stress, too much exercise, some drugs, thyroid problems and polycystic ovary syndrome (PCOS) are just some of the things that can look similar to POI. All of these other causes need to be checked and ruled out.
Unfortunately, POI is not always at the front of doctors’ minds when they see their younger patients with these types of symptoms.
A diagnosis of POI is often devastating.
Being told that your ovaries are not working properly, with usually no reason to explain why and no treatment to reverse it – can be devastating. The chances of ever having a natural pregnancy are very slim.
Many women feel they have lost their womanhood.
This is why women with POI need more than just hormone replacement. They need to feel supported, informed and understood – so they can start to process what POI means for them and how it will impact their life going forwards.
How is POI diagnosed?
There are two things that doctors use to make a diagnosis:
SYMPTOMS: Infrequent or absent periods
BLOOD TESTS: High levels of FSH (follicle stimulating hormone) on two blood tests at least 4 weeks apart. If you are still having periods, this blood test should ideally be done on days 2-5 of your cycle. If you are not having periods, you can have the test at any time.
Infrequent Periods: The medical term for this is oligomenorrhea – this means you have longer than 35 days between each period for at least 4 months. This leads to you only having 4 to 9 periods in a year.
Absent Periods: The medical term for this is Amenorrhoea - it means a total lack of periods. To diagnose POI, periods must be absent for at least 4 months with no other explanation for the lack of periods. Some women with POI develop it so early in life that they never start their periods at all.
FSH: This is released by the pituitary gland in your brain. It stimulates the ovaries to produce follicles, which produce eggs and release hormones. It operates on what is called a ‘negative feedback mechanism’ – this means it is released when estrogen (estradiol) levels are low, to stimulate the ovaries to produce more.
In POI, when the ovaries aren’t working properly and estrogen levels are low, the pituitary releases high levels of FSH to try and stimulate the ovaries to produce estrogen again.
However, FSH levels can sometimes be erratic and fluctuate, which is why at least two high values are needed. Occasionally, a women can still be diagnosed with POI even with seemingly normal FSH levels.
Women diagnosed with POI often also have blood tests to check for thyroid or adrenal problems, as well as diabetes and coeliac disease. They should also be referred for a DEXA scan (bone density scan) to check their bones have not become thinner as a result of the lower estrogen levels.
Women who have POI can still sometimes get pregnant.
The ovaries do not always permanently stop working in women with POI. Instead, their function can fluctuate over time, so sometimes they can produce enough hormones to cause a period or to produce an egg. This temporary return of ovary function means that pregnancy is possible – with 3% to 10% of women with POI falling pregnant naturally.
Unfortunately, we have no way of predicting when or whether this will happen and no way of stimulating this reactivation. Even in women who still have eggs in their ovaries that can be seen on an ultrasound scan; these remaining eggs do not respond to current fertility treatments or hormonal stimulation.
The majority of women with POI never regain any cycles or ovulation and therefore never fall pregnant naturally. This means that at the present time, the only fertility treatment available to women with POI is egg donation (where donor eggs from another women are fertilised by the partners sperm and then implanted into the womb). This has a success rate of around 20-40%.
In 90% of cases, the cause of POI is unknown.
For most women with POI, the underlying cause is never discovered. It just comes out of the blue for no clear reason. This is known as Spontaneous or Idiopathic POI. For some women, it is possible to pin-point a cause. These include autoimmune diseases, genetic conditions and some infections. POI can also be the result of surgical or medical treatments that affect the function of the ovaries. This is known as Induced Menopause. See here for more information.
Women with POI have an increased risk of several health problems.
As well as the huge impact on a woman’s fertility, POI also brings with it many health implications. The loss of the ovarian hormones estrogen, progesterone and testosterone, put these women at an increased risk of fractures, osteoporosis, depression, dementia, stroke and heart disease.
The younger we are when we lose these hormones, the greater the risks for these health problems. For this reason, a big part of the management of POI should be focussed on healthy lifestyle habits, like good diet, regular exercise, stress management and quality sleep.
Hormone replacement is recommended for all women with POI
Unlike when menopause occurs at the usual age, in POI doctors always recommend some form of hormone replacement for women. This is because the younger female body is not yet ready to lose these hormones – and there is lots of evidence that replacing the lost hormones leads to better future health and a longer lifespan.
Women with POI are advised that it’s best to continue taking some form of hormone replacement until at least the usual age of menopause (around 51)
Women with POI can either take the oral combined contraceptive pill or conventional HRT to replace their hormones.
There is still not enough research to know for sure what is the best type and dosage of hormone treatment to give women with POI. It is usual though to give higher doses of estrogen replacement to younger women, to more closely mimic what their natural hormone levels would be, had the ovaries not stopped working properly.
Both the combined oral contraceptive pill and HRT are options. Many younger women prefer to take the pill, as it’s more familiar in their age-group and doesn’t carry the negative associations of being ‘menopausal’.
However, HRT can offer women with POI many additional benefits that the pill can’t.
HRT does not worsen fertility in women with POI and is safe to take even if a woman becomes pregnant.
Below is a summary of the main pros and cons of the contraceptive pill vs HRT in POI.
HRT use in POI has NOT been linked to any increased risk of breast cancer
Lots of research shows that the risks of HRT in younger women, are not the same as the risks in older women. This is probably because the hormones are just being replaced to the natural levels they would have been, had the ovaries continued to produce them.
Breast cancer risk is what most women worry about when they hear the term ‘HRT’ – but in the case of POI, all the evidence shows that taking HRT is not linked to any increased risk of breast cancer.
There is some great patient information and support available from the following websites:
European Society for Human Reproduction and Embryology (ESHRE) Guideline Group on POI, Webber L, Davies M, et al. ESHRE guideline: management of women with premature ovarian insufficiency. Hum Reprod. 2016;31(5):926-937.
Faubion SS, Kuhle CL, Shuster LT, Rocca WA. Long-term health consequences of premature or early menopause and considerations for management. Climacteric. 2015;18:483–91.
O’Donnell RL, Warner P, Lee RJ, et al. Physiological sex steroid replacement in premature ovarian failure: randomized crossover trial of effect on uterine volume, endometrial thickness and blood flow, compared with a standard regimen. Hum Reprod. 2012;27(4):1130-1138.
Wu X, Cai H, Kallianpur A, et al. Impact of premature ovarian failure on mortality and morbidity among Chinese women. PLoS One, 2014;9(3):e89597.