Primary Ovarian Insufficiency (POI) and its Treatment
- POI affects your fertility before you reach 40 years of age.
- Measures to take to overcome risks of POI.
- With POI, you can still get pregnant through IVF.
After you attain your puberty, your ovaries release an egg every month and this continues until you enter your menopausal (no more menstrual periods) stage. When your ovaries stop releasing eggs at a very earlier age i.e. before you are 40, then you may be having a rare condition known as Primary ovarian insufficiency. In a more simple way, POI is a condition when your menstrual periods stop long before you expect it to. POI affects 1% of young women with significant health complications .
If you have primary ovarian insufficiency, then you may have issues of irregular periods and reduced fertility before you are 40 years of age. With the help of treatments, it is still possible in some women having primary ovarian insufficiency to get pregnant.
Primary ovarian insufficiency is a disorder where ovaries stop producing eggs before you reach 40 years. The common age at which ovaries stop to produce eggs is around 50, which is known as menopause. However, many women experience reduced fertility levels as they reach 40 years. When ovaries stop working normally, eggs are not produced, and also estrogen and progesterone hormone levels are lowered causing more chances of a woman to develop certain health issues.
Primary ovarian insufficiency is also known to be a premature ovarian failure (POF). This condition is recently called “insufficiency” instead of “failure” because ovaries do work normally at irregular intervals to release eggs and even cause a successful pregnancy.
Prevalence of POI: Among women aged 15 to 29, POI is seen in 1 out of every 1000. Whereas POI affects, 1 out of every 100 women between 30 to 39 years.
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Causes of Primary Ovarian Insufficiency (POI)
The exact cause of primary ovarian insufficiency is not known in about 90% of cases. Research shows that POI is caused due to problems related to the follicles, which are small sac-like structures inside which your mature egg grows. One of these follicle problems is when your normally functioning follicle is reduced at a very earlier stage, while the other is when the follicles do not work properly. However, sometimes known causes include :
- Genetically inherited problems: Sometimes, people born with missing chromosomes or problems with chromosomes can have POI, like in
- Fragile X syndrome: This syndrome is caused by mutation or genetic changes in the Fragile X mental retardation gene FMR1 and this gene is located on the X chromosome. When POI is associated with this fragile X syndrome, it is known as Fragile X-associated POI, the smaller gene changes affect the ovaries and their function .
- Turner syndrome: This is a condition where you have no X chromosome or a part of the x chromosome. due to this deficient X chromosome, ovaries do nor develop normally at birth and the menstrual cycle is also not normal.
- Autoimmune disease: It is a disease in which your own immune system starts attacking your ovaries so that your ovaries do not work normally. Examples are thyroiditis, rheumatoid arthritis, and Addison disease.
- Less number of follicles: If you are born with a low number of follicles that may be insufficient to last 40 or more years.
- Metabolic disorders: It is a disorder where your actual body metabolism is disturbed by unwanted chemical reactions that occur in your body, as seen in Diabetes.
- Treatments that are related to curing cancer like chemotherapy and radiation therapy: During these treatments, your ovaries get damaged and will cause your periods to stop permanently or just for a while.
- Infections: Certain infections that are caused by viruses are linked to POI.
- Hysterectomy: Hysterectomy (where the womb of a woman is surgically removed) or any other kind of surgery of your pelvis. If a hysterectomy is done you will not have periods and not get pregnant.
- Exposure: Regular exposure to toxins like pesticides, industrial chemicals, and cigarette smoking are associated with POI.
Symptoms of Primary Ovarian Insufficiency (POI)
If you have POI, then you can notice an irregular or missed periods, as they are the most common symptoms. You may also have an on-and-off type of periods or periods that may restart after many years of your POI being diagnosed.
As there is a lowered estrogen level, you may experience normal menopausal-like symptoms, that include :
- Infertility- or inability to get conceived, and this is the main reason many women with POI think of visiting a healthcare provider.
- Night sweats
- Having warmth feeling all over your body, also known as Hot flushes
- Depression, anxiety, and irritability
- Inability to focus on work or other activities due to poor concentration or memory
- Reduced desire to have sex
- Dryness of vagina
- Pain when having sex
- Trouble to get into sleep
Signs of POI: If you have POI then your doctor observes the following signs during examination:
- Missed or irregularity of your periods for a duration of 4 months.
- Lowered estrogen levels
- Significantly increased follicle-stimulating hormone levels (FSH).
Other Health Risks Caused By Primary Ovarian Insufficiency (POI)
As POI results in reduced estrogen levels at an earlier age, you will be a greater risk of developing several health problems like:
- Heart disease: Lower estrogen levels due to POI causes abnormal storage of cholesterols in the inner lining of the arteries. Due to cholesterol build up in arteries they get hardened (atherosclerosis) and increases the risk of heart attacks as your age increases.
- Altered thyroid function: This is generally called as hypothyroidism. Your body’s metabolism and energy levels are controlled by the hormones released by your thyroid gland. When the thyroid is affected, it causes inadequate production of hormones that are needed for metabolism, thus alters your overall metabolic level and lowers your energy causing mental laziness. You may also have cold feet and constipation when thyroid function is lowered.
- Osteoporosis: Estrogen hormone helps to keep your bones healthy and strong and if you have POI, the estrogen level is reduced causing bone problems like osteoporosis . In a person of osteoporosis, bones tend to become weak, brittle and are easily broken or fractured.
- Depression and anxiety: The hormonal changes that you experience due to POI, can cause anxiety or even lead to depression state. You may be anxious or feel shy when in social gatherings, and show less self-esteem. The increased lifetime risk of depression is seen in association with POI .
- Infertility: When you have POI, there are very few chances for you to get pregnant naturally. In such a case, you can be able to achieve pregnancy by undergoing treatments like donor eggs and certain fertility medications.
- Dryness of eyes: Some of the women with POI have problems with dryness of eyes that may even lead to blurred vision. If left untreated, you may even have permanent damage to your vision.
Diagnosis of Primary Ovarian Insufficiency (POI)
If your age is less than 40 years and if you have problems of irregular periods or if your periods are missing for 4 months or more than that, then your doctor will perform the following tests to identify the cause of missed periods :
- Medical history: Your doctor may ask a few questions related to your medical history like:
- Do you have a blood relative with a diagnosed POI?
- Did you have ovarian surgery?
- Are you on cancer treatment, taking radiation or chemotherapy?
- Do you have a pelvic inflammatory disease or sexually transmitted disease?
- Have metabolic disorders like diabetes?
- Presence of family history with fragile X syndrome or any developmental disability?
- Pregnancy test: You are tested for any unexpected pregnancy which may be the cause for your missed periods.
- Physical exam: Your physician will look for the presence of signs of any other disorders that are causing your symptoms. If the doctor finds the presence of other disorders during your physical examination, then POI can be ruled out. Or, if other disorders that are present are linked to POI like Addison’s disease, then your doctor may doubt the presence of POI.
- Blood test: Your blood is collected and sent to a lab for checking of certain hormones like:
- Follicle-stimulating hormone FSH: Ovaries release the hormone called estrogen that is most essential for maintaining your overall health as well as to maintain your normal fertility levels. Estrogen is commonly referred to as “female hormone”. If you have POI, your ovaries will not function normally resulting in increased levels of your FSH in your blood. Your doctor may do two FSH tests, usually repeating with at least a 4 to 6 weeks gap before confirming POI diagnosis. High levels of FSH in your blood usually mean that you have POI.
- Luteinizing hormone: Your pituitary gland in the brain releases LH and this LH will trigger your ovulation process where your active follicles get matured to release eggs. When your LH levels are high, it can be due to the abnormal functioning of your follicles.
- Estrogen test: This is the principal female sex hormone released by your ovaries and promotes egg growth, and also crucial to maintain heart, bone, and brain health. If estrogen levels are less in your blood, it is evident that ovaries are functioning normally to release estrogen.
- Pelvic ultrasound: This test helps your doctor to look for any swelling or any presence of multiple follicles in your ovaries. Ultrasound uses sound waves to create and see the images of your pelvic organs.
- AMH levels: Anti-Mullerian hormone test is considered to be the most reliable test that is done to assess your ovarian reserve, but not used routinely to diagnose POI. As follicles are reduced in POI, the AMH hormone level is also decreased. Usually, your doctor will suggest this test if other diagnostic test results are not clear or if they are uncertain.
- Karyotype: This test helps to identify any kind of genetic changes seen in your chromosomal structure that may be related to POI and other health issues. All of your 46 chromosomes are tested to detect the presence of abnormalities.
Treatment of Primary Ovarian Insufficiency (POI)
There is no exact proven treatment for your restoring the lost function of your ovaries due to POI. But treatment for reducing POI symptoms and also the treatment and behavioural therapies for lowering POI associated health risks and complications are available.
Treatments for POI include the following:
- (HRT) Hormonal Replacement Therapy: This is the most common treatment that helps in giving your body the estrogen and other hormones that your ovaries stopped making. Your sexual health is improved following HRT and your risk of developing heart attacks and osteoporosis is decreased. Your doctor will keep you on HRT until you reach your 5o years of age, as after this your actual menopause begins.
- Calcium and vitamins: As POI increases your risk of getting fractured bones due to weakened bones, you should start taking 1,200 to 1,500 mg of elemental calcium and 1000 IU of vitamin D daily. Bone mineral density check may be advised for you to have a check on your bone loss.
- IVF Invitro-fertilization: With POI it is hardly possible for you to get pregnant naturally. There are fertility treatment options like IVF that are available if you wish to get pregnant.
- Exercise regularly: You can discuss with your doctor about the activities that suit you better. Regular exercises like jogging, walking, climbing stairs help to keep your muscles and bones strong.
- Eat healthily: Your risk of reducing heart diseases can be managed by having a good healthy diet.
- Treatment for other associated health risks: You can treat your other problems that are caused due to POI, by taking over-the-counter medicines as told by your doctor.
- Avoid tobacco: Avoid using products that contain tobacco or nicotine. These include keeping yourself away from cigarettes and e-cigarettes. Avoid places where people smoke around you.
- Increase melatonin: All kinds of electronic devices should be turned off a couple of hours before going to sleep. Your best way to increase melatonin levels is to read a book under a lamp.
Fertility Treatment Options Available For Women With POI
If you wish to have a baby then you can talk to your fertility specialist about fertility treatments that are available. Fertility treatments for having a baby when you are diagnosed with POI include:
IVF: If you have POI and the cause of your POI is unknown, then pregnancy is possible through IVF with donor eggs and it suits you better. This is a procedure where you will be donated eggs from another woman to get conceived. Your fertility doctor will then allow these donor eggs to get fertilized with the sperm of your partner and then put back the resulting embryo into your uterus. You can then carry and deliver your baby. For the IVF process, your donor will be given hormones to produce eggs for donation and you will have to take hormones to prepare your body for your baby.
The success rate of IVF depends on several factors, so a timed decision should be taken after discussing it with your doctor.
Egg freezing: Sometimes, more eggs may be fertilized into embryos, and you are given the option to freeze them for future use. This is called cryopreservation. This can help to plan for IVF again.
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List of ReferencesHide
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Clevelandclinic.org.“Primary Ovarian Insufficiency”.Clevelandclinic.org, 9 April 2019.
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Last updated on: : 28 Sep 2020
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