A single copy of this article may be reprinted for personal, noncommercial use only.
Premature ovarian failureBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/premature-ovarian-failure/DS00843
Premature ovarian failure refers to a loss of normal function of your ovaries before the age of 40. If your ovaries fail, they don't produce normal amounts of the hormone estrogen or release eggs regularly. Infertility is a common result.
Premature ovarian failure is sometimes referred to as premature menopause, but the two conditions are not exactly the same. Women with premature ovarian failure — also known as primary ovarian insufficiency — may have irregular or occasional periods for years and may even become pregnant. Women with premature menopause stop having periods and can't become pregnant.
Restoring estrogen levels in women with premature ovarian failure helps prevent some complications, such as osteoporosis, but infertility is harder to treat.
The signs and symptoms of premature ovarian failure are similar to those experienced by a woman going through menopause and are typical of estrogen deficiency. They include:
- Irregular or skipped periods (amenorrhea), which may be present for years or may develop after a pregnancy or after stopping birth control pills
- Hot flashes
- Night sweats
- Vaginal dryness
- Irritability or difficulty concentrating
- Decreased sexual desire
When to see a doctor
If you notice that you've skipped your period for three months or more, see your doctor to help determine what may be the cause. You may miss your period for a number of reasons — including pregnancy, stress, or a change in diet or exercise habits — but it's best to get evaluated whenever your menstrual cycle changes.
Even if you don't mind not having your period, it's still wise to check in with your doctor and try to find out what's causing the problem. If your estrogen levels are low, bone loss can occur.
CLICK TO ENLARGE
In women with normal ovarian function, the pituitary gland releases certain hormones during the menstrual cycle, which causes a small number of egg-containing follicles in the ovaries to begin maturing. Usually, only one follicle reaches maturity each month. When the follicle is mature, it bursts open, releasing the egg. The egg then enters the fallopian tube, where a sperm cell might fertilize it, resulting in pregnancy.
Premature ovarian failure results from one of two processes — follicle depletion or follicle disruption.
Causes of follicle depletion include:
- Chromosomal defects. Certain genetic disorders are associated with premature ovarian failure. These include Turner's syndrome, a condition in which a woman has only one X chromosome instead of the usual two, and fragile X syndrome, a major cause of mental retardation.
- Toxins. Chemotherapy and radiation therapy treatments are the most common causes of toxin-induced ovarian failure. These therapies may damage the genetic material in cells. Other toxins such as cigarette smoke, chemicals, pesticides and viruses may hasten ovarian failure.
Follicle dysfunction may be the result of:
- An immune-system response to ovarian tissue (autoimmune disease). Your immune system may produce antibodies against your own ovarian tissue, harming the egg-containing follicles and damaging the egg. What triggers the immune response is unclear, but exposure to a virus is one possibility.
- Unknown factors. If you develop premature ovarian failure through follicular dysfunction and your tests indicate that you don't have an autoimmune disease, further diagnostic studies may be unnecessary. An exact underlying cause often remains unknown.
Factors that increase your risk of developing premature ovarian failure include:
- Age. The risk of ovarian failure rises sharply between age 35 and age 40.
- Family history. Having a family history of premature ovarian failure increases your risk of developing this disorder.
Complications of premature ovarian failure include:
- Infertility. Inability to get pregnant is the most troubling complication of premature ovarian failure.
- Osteoporosis. The hormone estrogen helps maintain strong bones. Women with low levels of estrogen are at an increased risk of developing weak and brittle bones (osteoporosis), which are more likely to break than are healthy bones.
- Depression or anxiety. The risk of infertility and other complications arising from low estrogen levels may cause some women to become anxious or depressed.
Preparing for your appointment
Your first appointment will likely be with your primary care physician or a gynecologist. If you're seeking treatment for infertility, you may be referred to a doctor who specializes in reproductive hormones and optimizing fertility (reproductive endocrinologist).
Because appointments can be brief, and it can be difficult to remember everything you want to discuss, it's a good idea to prepare in advance of your appointment.
What you can do
To make the best use of the limited time, plan ahead and make lists of important information, including:
- Detailed descriptions of all your symptoms and when they began. For instance, keeping track of the irregularity of your periods or lack of periods on a calendar provides your doctor useful information.
- Names and dosages of all medications you take, including nonprescription drugs and supplements.
Questions you might ask your doctor include:
- What's the most likely cause of my irregular periods?
- Are there any other possible causes?
- What tests do I need to find out why I'm having this problem?
- What treatments are available? What side effects can I expect?
- How will these treatments affect my sexuality?
- What do you feel is the best course of action for me?
- What are the alternatives to the primary approach that you're suggesting?
- I have other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see a specialist? What will that cost, and will my insurance cover it?
- Are there any brochures or other printed material that I can take with me? What websites do you recommend?
Don't hesitate to ask additional questions during your appointment.
Questions your doctor may ask
To gain a better understanding of what you're going through, your doctor may ask you several questions. Think about how you'll respond — and even write out some answers — in advance of your appointment so that you're fully prepared and don't forget any important details.
Questions your doctor may ask include:
- Do you have occasional menstrual periods or no periods at all?
- Are you experiencing hot flashes, vaginal dryness or other menopausal symptoms?
- How long have you had your symptoms?
- Have you ever had ovarian surgery?
- Have you undergone treatment for cancer?
- Do you or any family members have any systemic or autoimmune diseases, such as hypothyroidism or lupus?
- Have any members of your family been diagnosed with premature ovarian failure?
- How much distress do your symptoms cause you?
- Do you feel depressed?
- Did you have any difficulties with previous pregnancies?
- Have you experienced unexplained weight gain or weight loss?
- What medications or vitamin supplements do you take?
During your appointment, speak up if you don't understand something. It's important that you understand the reason for any tests or treatments that are recommended.
Tests and diagnosis
To help make a diagnosis of premature ovarian failure, your doctor may ask about your signs and symptoms, your menstrual cycle, and a history of exposure to any toxins, such as chemotherapy or radiation therapy, which cause direct injury to follicles and eggs. Most women have few signs of premature ovarian failure, but you'll likely have a physical examination, including a pelvic exam.
Several blood tests are important in making a diagnosis. These include:
- Pregnancy test. Pregnancy tests are often performed to rule out the possibility of an unexpected pregnancy in women of childbearing age who have missed a period.
- Follicle-stimulating hormone (FSH) test. FSH is a hormone released by the pituitary gland that stimulates the growth of follicles in your ovaries. Women with premature ovarian failure often have abnormally high levels of FSH in the blood.
- Luteinizing hormone (LH) test. Luteinizing hormone prompts a mature follicle within the ovary to release an egg. In women with premature ovarian failure, the level of LH is usually lower than the level of FSH.
- Serum estradiol test. The blood level of estradiol, a type of estrogen, is usually low in women with premature ovarian failure.
- Karyotype. This is a test that examines all 46 of your chromosomes for abnormalities. Some women with premature ovarian failure may have only one X chromosome instead of two or may have other chromosomal defects.
Treatments and drugs
Treatment for premature ovarian failure is usually tailored to address the problems that arise from estrogen deficiency:
Estrogen therapy. To help prevent osteoporosis and relieve hot flashes and other symptoms of estrogen deficiency, it's important to replace the estrogen your ovaries have stopped producing. Estrogen is typically prescribed with another hormone, progesterone. Adding progesterone protects the lining of your uterus (endometrium) from precancerous changes caused by taking estrogen alone. The combination of hormones may cause you to have vaginal bleeding again, but it won't restore ovarian function. You can take estrogen as a pill, a gel or patch applied to your skin, or a vaginal ring, which you replace every three months. You'll likely continue taking hormonal therapy until about the age of 50 or 51 — the average age of natural menopause.
In older women, long-term estrogen therapy has been linked to an increased risk of cardiovascular disease and breast cancer. In young women with premature ovarian failure, however, the benefits of hormone replacement therapy usually outweigh the potential risks.
Calcium and vitamin D supplements. Taken together, these supplements are important for preventing osteoporosis. Your doctor may advise you to have bone density testing done before starting supplements so that you'll have some idea of your baseline bone density measurement.
The Institute of Medicine recommends 600 international units (IU) of vitamin D a day for adults ages 19 to 70. For adults age 71 and older, the recommendation increases to 800 IU a day. For women ages 19 to 50, the calcium recommendation is 1,000 milligrams (mg) a day, increasing to 1,200 mg a day for women age 51 and older.
Infertility is a common complication of premature ovarian failure. There's no treatment proved to restore fertility in women with this condition. It's important to understand and grieve for this loss of ovarian function and to seek counseling if you need it.
Some women and their partners choose to pursue a pregnancy through in vitro fertilization using donor eggs. The procedure involves removing eggs from a donor and fertilizing them with your partner's sperm in a laboratory. The fertilized egg (embryo) is then placed in your uterus. During this process, you take medication that balances your hormones to support a pregnancy. Once the pregnancy is established, you stop taking the medication and the pregnancy proceeds naturally to the delivery.
Lifestyle and home remedies
Learning that you have premature ovarian failure may be emotionally difficult. But with proper hormone replacement therapy and self-care, you can expect to lead a healthy life.
- Learn about alternatives for having children. If you'd like to add to your family, talk to your doctor about options such as in vitro fertilization using donor eggs or adoption.
- Be aware of the best contraception options. A small percentage of women with premature ovarian failure do spontaneously conceive. If you don't want to become pregnant, consider using birth control.
- Keep your bones strong. Women who produce low levels of the hormone estrogen are at an increased risk of developing osteoporosis. Work on maintaining strong bones by eating a calcium-rich diet, taking calcium and vitamin D supplements, engaging in weight-bearing exercise such as walking, and refraining from smoking.
Coping and support
If you'd hoped for future pregnancies, a diagnosis of premature ovarian failure can bring on overwhelming feelings of loss — even if you've already been pregnant and given birth to children. Grief is a normal feeling during this time.
To better cope:
- Be open with your partner. Talk with and listen to your partner as you both share your feelings over this unexpected change in your plans for growing your family.
- Explore your options. If you wish to have more children, look into alternatives to expand your family such as donor-egg in-vitro fertilization or adoption.
- Seek support. Talking with others who are going through the same thing can provide valuable insight and understanding during a time of confusion and uncertainty. Counseling may be of particular benefit as you adjust to your circumstances and the implications for your future. Ask your doctor if he or she knows of any national or local support groups or seek out an online community as an outlet for your feelings and as a source of information.
- Give yourself time. Coming to terms with your diagnosis is a gradual process. In the meantime, take extra good care of yourself by eating well, exercising and getting enough rest.
- Find other ways to have children in your life. Consider mentoring a child at your local chapter of the Boys & Girls Club of America. Become more involved with nieces or nephews or with children of your close friends.
- Rebar RW. Premature ovarian failure. Obstetrics & Gynecology. 2009;113:1355.
- Do I have premature ovarian failure (POF)? National Institute of Child Health and Human Development. http://www.nichd.nih.gov/publications/pubs/pof/index.cfm. Accessed Nov. 16, 2010.
- Lobo RA. Menopause: Endocrinology, consequences of estrogen deficiency, effects of hormone replacement therapy, treatment regimens. In: Katz VL, et al. Comprehensive Gynecology. 5th ed. Philadelphia, Pa.: Mosby Elsevier; 2007. http://www.mdconsult.com/das/book/body/208746819-4/0/1524/0.html. Accessed Nov. 16, 2010.
- Welt CK. Pathogenesis and causes of spontaneous premature ovarian failure. http://www.uptodate.com/home/index.html. Accessed Nov. 15, 2010.
- Bulun SE, et al. The physiology and pathology of the female reproductive axis. In: Kronenberg HM, et al. Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa.: Saunders Elsevier; 2008. http://www.mdconsult.com/das/book/body/191205553-3/0/1555/0.html#. Accessed Nov. 16, 2010.
- Kalu E, et al. Spontaneous premature ovarian failure: Management challenges. Gynecological Endocrinology. 2008;24:273.
- Nelson LM, et al. Evaluation of spontaneous premature ovarian failure. http://www.uptodate.com/home/index.html. Accessed Nov. 15, 2010.
- Nelson LM, et al. Management of spontaneous premature ovarian failure. http://www.uptodate.com/home/index.html. Accessed Nov. 15, 2010.
- Coddington CC (expert opinion). Mayo Clinic, Rochester, Minn. Nov. 29, 2010.
- Dietary Reference Intakes for calcium and vitamin D. Institute of Medicine. http://www.iom.edu/vitamind. Accessed Dec. 10, 2010.