Premature Ovarian Insufficiency (POI)

What is POI?

Menopause is normally something that happens after the age of 45. Premature menopause, premature ovarian failure/insufficiency are all interchangeable. The term ‘premature ovarian insufficiency’ is more accurate as this reflects the difference between ‘normal’ menopause which occurs at an average age of 51.

Early menopause refers to menopause occurring between the ages of 40 and 45 whereas POI is when it occurs below the age of 40.

Essentially POI means the ovaries are not working normally and they stop producing eggs well before they should. As a result, the ovaries cannot produce normal levels of oestrogen and progesterone which have significant roles in ensuring a woman’s well-being and health.

How common is POI?

Around 1 in every 100 women <40, 1 in every 1000 women <30 and 1 in every 10,000 women under 20 have POI. Early menopause affects around 5% of the population (i.e. starts before 45).

It is worth remembering that as well as those women having a spontaneous early menopause, increasing numbers of women become menopausal far earlier than anticipated as a result of surgery/treatment for cancer, this is referred to iatrogenic POI. It is extremely common to feel anxious, worried or feel hopeless after a diagnosis of POI has been made.

Why does POI happen?

There are many different causes of POI, however, for many women, no underlying cause is found.

Here are some of the underlying causes:

  • Surgery – when the ovaries are removed following an operation, you no longer have normal levels of oestrogen. It is common to experience a sudden onset of symptoms following surgery. It is important to discuss hormone replacement therapy (HRT) prior to surgery
  • Cancer treatment – some types of chemotherapy and radiotherapy can affect the normal function of the ovaries. Sometimes this is a temporary issue, but for others it can be permanent. If you are undergoing cancer treatment, do discuss the risk of developing POI with your doctor.
  • Autoimmune disease – around 1 in 20 women have an autoimmune disease which causes POI. This means that the immune system (your body’s natural defence against infection) mistakenly attacks itself.
  • Genetic conditions – these are 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 this condition one of the female sex chromosomes (the X chromosome) is missing. Genetic conditions causing POI are more common if you have relatives with POI or if you are very young (under 20) with POI.
  • Infections – some infections can rarely be a cause of POI in some women, these include malaria, tuberculosis, and mumps.

How is POI diagnosed?

The easiest way to diagnose POI is by taking a blood test which checks the level of a hormone called follicle-stimulating hormone (FSH). This level is usually very high in POI as your body is trying to stimulate the ovaries. This test is normally performed twice, several weeks apart. Other blood tests such as hormone or genetic tests, may be undertaken. It may be necessary to have a DXA bone scan, this is a scan that uses special x-ray machines to check your bone density. The san can confirm ‘bone thinning’ (osteopaenia and osteoporosis).

Symptoms of POI

For most women, the most common symptom is that their periods stop. For around 1 in 10 women with POI, periods never start and so they present at a very early age, usually under the age of 20. Other women notice that their periods become irregular. In addition, many women experience typical menopausal symptoms which include, hot flushes, night sweats, low energy, mood changes and low libido (reduced sex drive). In addition, some women notice dry skin, hair thinning and joint pains. Around 1 in 4 women do not have any overt symptoms.

POI can affect fertility, so it is common to feel sad and even guilty after diagnosis.

Low levels of oestrogen in the body can lead to bone thinning (osteoporosis) which increases the risk of fractures developing in your bones. There is also an increased risk of heart attacks occurring at a young age.

All these risks are reversed by taking hormone treatment.

Treatment of POI

Treatment for POI consists of hormones which replace those that your body would be producing naturally otherwise. This can be in the form of hormone replacement therapy (HRT) or a combined hormonal contraceptive (oestrogen and progestogen). We recommend that women with POI continue to take treatment until the age of at least 51 (which is when the average age of natural menopause in the UK occurs), this protects you from osteoporosis and other conditions that can develop after the menopause.

Risks regarding HRT such as breast cancer, only apply to women using HRT after the natural age of menopause, these risks do not apply if you have POI and are using HRT prior to the age of 51. If you require contraception, your doctor may suggest you use an oral contraceptive pill.

There are lots of different types of hormone treatments, it is important to explore any issues with your doctor who can advise about an alternative if needed.

It is important that you have a healthy lifestyle. This includes stopping smoking, eating and healthy, balanced diet, minimising alcohol and ensuring an adequate amount of calcium in your diet or taking calcium supplements and taking vitamin D supplements.

Mood disturbance is a common issue in women with POI, do seek help from your doctor. Joining a support group can also be helpful as talking to other women with POI can be beneficial.

But what about fertility/pregnancy?

Around 1 in 10 women with POI without a clear underlying cause become pregnant. This is because the ovaries start working again. In women who are keen to become pregnant IVF using donor eggs can also be undertaken. You should discuss this with your doctor in more detail.

Resources for further information

www.jostrust.org.uk (cervical cancer)

www.daisynetwork.org (charity for women with POI)

www.womens-health-concern.org