Premature ovarian failure (or insufficiency)

Premature ovarian failure (POF), also known as premature or primary ovarian insufficiency (POI), is the loss of function (or insufficient function) of the ovaries before the age of 40, most often for no definable reason.^​1​

The loss of ovarian function results in reduced or absent production of oestrogen and other hormones and often a lack of ovulation. Infertility is a common outcome. Menstruation and ovulation may still occur; however, the ovaries may be sporadic in their action, making periods irregular and ovulation uncertain.^​2​

Premature ovarian failure is not the same as early menopause since menopause ceases menstruation and ovarian function as a normal part of ageing. But, the symptoms of premature ovarian failure or insufficiency can be very similar since there is a loss of oestrogen.

Premature ovarian failure causes the loss of ovarian follicles (eggs), which may be caused by genetic conditions (Turner’s syndrome, fragile X syndrome), toxic cancer treatments, an autoimmune disease, or for unknown reasons.

Primary and secondary ovarian insufficiency

There are two classifications of ovarian insufficiency: primary and secondary.

Primary ovarian insufficiency

Ovarian insufficiency is classified as primary if the ovary doesn’t function normally and in concert with other hormones.

Secondary ovarian insufficiency

However, this condition is considered secondary if the hypothalamus and pituitary don’t produce the right hormones to set off the hormonal cascade. The issue is a lack of instruction from the brain to to the ovary to produce hormones than with the ovary itself.

Primary ovarian insufficiency can result in early menopause, but it’s not always straightforward since someone with ovarian insufficiency can still get pregnant and ovulate (although the chances are reduced).

Secondary ovarian insufficiency, therefore, is not premature ovarian failure but a problem with ovulation and hormone production and signals. It is important to seek support to find the underlying causes of the dysfunction and work towards correcting it.

Symptoms of premature ovarian failure

• Irregular periods or periods stop (secondary amenorrhoea)
• Infertility due to lack of ovulation
• May occur after stopping hormonal birth control or a pregnancy
• Hot flashes
• Night sweats
• Dry, irritated vagina
• Problems concentrating
• Irritability
• Low libido

Causes of premature ovarian insufficiency or failure

A loss of function of the ovaries is divided into four states, with each person likely entering and exiting the various states, rather than staying in one state. Function or dysfunction can be unpredictable, and ovaries may function normally for some periods of time.

Some causes of primary ovarian insufficiency^​3​

• Genetic abnormalities
• Autoimmune disease
• Anatomical abnormalities
• Caused through other channels, like surgery or accident
• Tumours

Often, the cause of a loss of ovarian function can not be found.

Risk factors for premature ovarian failure

• Aged between 35 and 40 (though it can happen to teenagers and younger women)
• Family members with the condition
• Repeated ovarian surgeries

Diagnosing premature ovarian failure

Diagnosis of premature ovarian insufficiency or failure is a process of elimination, with several possible reasons for the symptoms of low oestrogen to occur.

First, a pregnancy test will be performed.^​4​

A blood test of follicle-stimulating hormone levels (FSH) is taken. FSH is the hormone that starts the process of ovulation. Other hormone tests will include oestrogen and prolactin.

Genetic testing may be warranted if nothing else can be found.

Treatment for premature ovarian failure

Your doctor may prescribe oestrogen therapy, either on its own or in combination with progesterone. If you have a uterus, progesterone therapy is more likely. Hormone therapy doesn’t restart ovarian function, and may cause bleeding.^​5,6​

Hormone therapy, calcium and vitamin D may be recommended to help prevent osteoporosis. Bones rely on oestrogen to retain bone. Vitamin D helps the body absorb calcium. Nutritional and hormonal support are important, to optimise bone health.^​7​

Primary ovarian failure cannot be reversed, as it results in a loss of follicles in the ovary that cannot be recovered.

Fertility outcomes

If ovulation ceases and the ovarian follicles are lost, it’s not possible to become pregnant without assistance. There is no egg to fertilise.

Pregnancy is a slim possibility if some ovarian follicles remain and ovulation is sometimes occurring. In vitro fertilisation (IVF) and other assisted reproduction treatments are usually recommended.

Ovulation induction (where your ovaries are stimulated by drugs to release an egg) may be recommended, but the main alternative is to use an egg donor. ^{​8,9​​7​}

The uterus still functions normally, so a full-term pregnancy is an option.

Emotional support

Losing ovarian function early and unexpectedly can be a huge loss. Everyone responds differently, but please seek emotional support if needed.

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