What is Premature Ovarian Failure?
Premature Ovarian Failure (POF), also known as premature menopause or Premature Ovarian insufficiency, is defined as the pathological loss of function of the ovaries prematurely (before the age of 40), and the resulting amenorrhea, loss of fertility and decrease in oestrogen secretion. In general this is due to the depletion of the ovarian reserve and to the fact that in the absence of ovulation, the ovary does not produce any oestrogens or progesterone, causing menstruation to stop.
This pathology is preceded, in almost all cases, by so-called “occult ovarian failure” which consists of an ovarian insufficiency before the age of 40, without climacteric syndrome or amenorrhea, and which is diagnosed by determining blood levels of the hormones involved in the menstrual cycle.
Why does it happen?
At birth, a woman has a certain number of ova, and during each menstrual cycle approximately 30 of these ova begin to mature, although normally only one of these completes the process and descends into the Fallopian tube during ovulation. The rest of the eggs which begin the process are not released during ovulation and are lost in a process known as follicular atresia.
Some women experience a highly accelerated process of follicular atresia which causes their reproductive life to be shortened. Some factors which explain what may cause this accelerated process of follicular atresia are as follows:
- Following operations in which the ovaries have been partly or entirely removed.
- Due to genetic or chromosomal irregularities.
- Turner Syndrome
- Swyer Syndrome
- Androgen InsAndrogen Insensitivity Syndrome
- Fragile X Syndrome mily: the risk of developing POF increases if there is a direct family history
- Some autoimmune diseases are associated with premature ovarian failure. The body’s defence mechanism (autoimmune system) stops recognising the ovaries and produces antibodies against them, causing acceleration in the depletion of the ovarian reserve, or its destruction.
- Thyroid dysfunction
- Type I and II Polyglandular Failure
- Rheumatoid arthritis
- Idiopathic thrombocytopenic purpura (ITP)
- Pernicious anaemia
- Adrenal failure
- Systemic lupus erythematosus, also known as SLE or Lupus
- Some toxins: tobacco, pesticides, solvents, etc.
- Treatments using radiotherapy or chemotherapy, whether for cancer or for other benign illnesses, can cause destruction of the ovarian reserve. However, depending on age and on the doses administered, this may be reversible.
- Metabolic / enzymatic defects
- Thalassemia major treated with multiple blood transfusions
- Viral infections
Is it common?
It is seen in 1 in 100 women under the age of 40 and in 1 in 1000 women younger than 30.
What symptoms does it present?
The symptoms are not all that different to those that may be seen in women over the age of 40 when they stop menstruating, and symptoms are mainly due to a lack of oestrogen.
An absence of periods (amenorrhea) is the main cause for suspicion in a young woman and the main reason for checking for it, although there are other symptoms associated with low oestrogen levels, such as hot flushes, disturbance of sleep, mood swings, decreased sexual desire and dryness of the vagina, which can make sexual relations painful.
How is it diagnosed?
Diagnosis is based on:
- A detailed medical history, asking questions about a family history of POF
- A general and gynaecological physical examination
- A blood analysis measuring levels of estradiol (the most important hormone produced by the ovary) which will be reduced, and levels of follicle-stimulating hormone (FSH, produced by the hypophysis in the brain) which will be increasing in response to decreasing levels of ovarian estradiol. The tests are repeated more than once in order to confirm the diagnosis.
- When ovarian failure is spontaneous (without any apparent cause) a further blood analysis is recommended to study chromosomes (karyotype).
What repercussions does Premature Ovarian Failure have on fertility?
Owing to the absence of ovulation and to oestrogen levels being decreased, there is a greater risk of developing sterility. In these cases, treatments with ovulation stimulation are not effective. However due to the fact that in some cases the condition is not permanent and it is possible for the ovary to present a certain level of intermittent activity, around 5 – 10% of women manage to get pregnant spontaneously, although unfortunately there is no test that can indicate whether or not this will happen, nor whether or not treatment with ovarian stimulation will be effective.
To achieve pregnancy, the assisted reproduction technique used would be egg donation.
What other consequences does Premature Ovarian Failure have?
- Osteoporosis: this causes increased bone fragility resulting in a greater risk of breaks and fractures.
- Cardiovascular disease: low oestrogen levels at a young age can increase the risk of heart attacks.
- Depression: the unexpected loss of ovarian function can cause changes in women’s state of mind. Sometimes they require a visit to a psychologist in order to come to terms with this problem.
- Autoimmune diseases: in these women it is worth checking other glands periodically, such as the thyroid and the adrenal gland, in order to detect any deficiency which might be associated with ovarian failure.
What precautions can be taken?
- Maintaining a healthy lifestyle: regular moderate exercise, a diet rich in calcium, not smoking and avoiding being overweight diminish the risk of osteoporosis and coronary heart disease.
- Hormone Replacement Therapy (oestrogens and progesterone) is necessary and always recommended, and helps to avoid the symptoms and consequences mentioned above in the future. The sooner the treatment is started the better, and it should be continued until the age when menopause most frequently occurs (around the age of 50). Hormone therapy can be in tablet form, or even in the form of a patch or cream which are applied to the skin; contraceptives are not contraindicated.
- This treatment would only be contraindicated in cases where there is an existing thromboembolic disease, or following the diagnosis of a hormone-dependent cancer.
- Taking care of mental and emotional health: it is common for diagnosis with premature ovarian failure to cause varying levels of anxiety and depression, especially if the woman has not fulfilled her desire of becoming a mother. Professional help can allow them to find a place where they can work through and organise any feelings which emerge from this diagnosis.