Premature ovarian failure (or insufficiency)

Premature Ovarian Failure

Premature ovarian failure (POF), also known as premature or primary ovarian insufficiency (POI), is the loss of function of the ovaries before the age of 40, most often for no definable reason. The loss of function results in reduced or no production of oestrogen and other hormones, and no ovulation, so infertility is the natural result. You may still get your period and even ovulate, however your ovaries may be sporadic in their action, making periods irregular and ovulation uncertain.

Premature ovarian failure is not the same as early menopause, since menopause shuts up your reproductive shop as a normal part of ageing, however the symptoms can be very similar. Premature ovarian failure causes the loss of eggs, which may be caused by genetic conditions (Turner’s syndrome, fragile X syndrome), toxic cancer treatments, an autoimmune disease, or for unknown reasons.

There are two classifications: primary and secondary causes of premature ovarian failure. Ovarian insufficiency is classified as primary if the ovary doesn’t function normally in concert with other hormones, however it is considered secondary if the hypothalamus and pituitary don’t produce the right hormones to set off this cascade. This means the issue is more with the hypothalamus and pituitary, than the ovary itself. Primary ovarian insufficiency results in a form of early menopause, but they are not the same thing, since a woman with ovarian insufficiency can still get pregnant and ovulate.

     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 the woman likely entering and exiting the various states, rather than staying in one state. This movement can be unpredictable, and ovaries may function normally for some periods of time without warning.

Some causes of primary ovarian insufficiency
  • No known cause
  • Genetic abnormalities
  • Autoimmune disease
  • Anatomical abnormalities
  • Caused through other channels, like surgery or accident
  • Tumours
Some causes of secondary ovarian insufficiency
  • Disordered eating or exercise
  • Psychiatric disturbances
  • Chronic disease
  • Drug or medication use
  • Tumours – pituitary, hypothalamic
  • Sheehan syndrome
  • Kallmann syndrome
Occult primary ovarian insufficiency

Unexplained infertility, normal follicle-stimulating hormone (FSH) levels, do not respond to FSH therapy when attempts are made to force ovulation. Reduced fertility.

Biochemical primary ovarian insufficiency

Unexplained infertility in women with higher FSH levels, but do not respond to FSH therapy when attempts are made to force ovulation. Reduced fertility.

Overt primary ovarian insufficiency

Also called premature menopause or premature ovarian failure, increased FSH levels, irregular periods. Reduced fertility.

Premature ovarian failure

Complete follicle depletion (run out of eggs), irreversibly, no periods or ovulation, infertility, increases in gonadotropin levels. Having no eggs left (primordial follicle depletion) is not able to be proved at this point.

     Secondary ovarian insufficiency

A lack of or inadequate supply of gonadotropin to stimulate the ovary, caused by various conditions such as pituitary tumours (like prolactinomas causing hyperprolactinaemia), Cushing syndrome, polycystic ovarian syndrome, congenital adrenal hyperplasia, or an adrenal or ovarian tumour. Gonadotropins that stimulate the ovaries are gonadotropin-releasing hormone (GnRH), from a pulse generator in the hypothalamus. The pulse generator requires signals from the nervous system to operate optimally, therefore nervous system deficiencies may cause a failure of GnRH pulse generation. This results in a lack of pituitary gonadotropin hormones.

Secondary ovarian insufficiency can also be caused by stress, anxiety, depression, over-exercising and eating disorders.

     Risk factors that increase your chances of developing 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 is a process of elimination, with several reasons for the symptoms of low oestrogen to occur. First, you’ll have a pregnancy test performed, to rule that out. Then, a test will look for follicle stimulating hormone levels (FSH), which is the hormone that starts the process of getting an egg out of your ovary to ovulate. 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. This doesn’t start your ovaries up again, and may cause bleeding. You may take oestrogen therapy until you are about 50, to coincide with your natural menopause timing.

Calcium and vitamin D may be recommended to help prevent osteoporosis, which can occur without oestrogen. You need oestrogen to keep calcium in bones, and you need vitamin D to absorb the calcium.

You can see naturopaths for herbs and supplements to try to restore your ovarian function if there is no known cause of your ovarian failure, because there is a chance it will be restored with the right combination of treatments. You will need nutritional support no matter what, so seek the help of the practitioners that you need to stay healthy, with healthy bones.

     Fertility outcomes

If your ovaries stop producing eggs, you can’t get pregnant naturally, as there is no egg to fertilise. Your uterus will still be functional, however, so you can carry a baby to term, theoretically, using a donor egg.

     Emotional support

Losing ovarian function early and unexpectedly can cause some huge emotional upheavals and grief, so make sure you get support while you adjust to the idea and seek any additional treatments you may want to try.