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Primary Ovarian Insufficiency

(Premature Menopause; Hypergonadotropic Hypogonadism; Premature Ovarian Insufficiency; Premature Ovarian Failure)

By JoAnn V. Pinkerton, MD, University of Virginia Health System

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In primary ovarian insufficiency, ovaries do not regularly release eggs and do not produce enough sex hormones despite high levels of circulating gonadotropins (especially follicle-stimulating hormone [FSH]) in women < 40. Diagnosis is by measuring FSH and estradiol levels. Typically, treatment is with combined estrogen/progestogen therapy.

In primary ovarian insufficiency, the ovaries stop functioning normally in women who are < 40. This disorder used to be called premature ovarian failure or premature menopause; however, these terms are misleading because women with primary ovarian insufficiency do not always stop menstruating and their ovaries do not always completely stop functioning. Thus, a diagnosis of primary ovarian insufficiency does not always mean that pregnancy is impossible. Also, this disorder does not imply that a woman is aging prematurely; it means only that her ovaries are no longer functioning normally.

In primary ovarian insufficiency, the ovaries

  • Stop releasing eggs or release them only intermittently

  • Stop producing the hormones estrogen , progesterone , and testosterone or produce them only intermittently

Etiology

Primary ovarian insufficiency has various causes (see Table: Common Causes of Primary Ovarian Insufficiency), including the following:

  • The number of ovarian follicles present at birth is insufficient.

  • The rate of follicular atresia is accelerated.

  • The follicles are dysfunctional (as occurs in autoimmune ovarian dysfunction).

  • Certain genetic disorders are present.

Genetic disorders that confer a Y chromosome can cause primary ovarian insufficiency. These disorders, which are usually evident by age 35, increase risk of ovarian germ cell cancer.

Common Causes of Primary Ovarian Insufficiency

Cause

Examples

Enzyme defects

Galactosemia

17α-Hydroxylase deficiency

17,20-Lyase deficiency

Genetic defects

Accelerated ovarian follicular atresia (idiopathic)

Certain autosomal defects

FMR1 premutation (Fragile X syndrome)

Gonadal dysgenesis secondary to genetic defects (eg, Turner syndrome [45,X], pure [46,XX or 46,XY] or mixed gonadal dysgenesis)

Idiopathic hypogonadotropic hypogonadism

Kallmann syndrome

Myotonic dystrophy

Reduced germ cell number

Trisomy X with or without chromosomal mosaicism

Immune-mediated disturbances

Autoimmune disorders (most commonly, thyroiditis, Addison disease, hypoparathyroidism, diabetes mellitus, myasthenia gravis, vitiligo, pernicious anemia, and mucocutaneous candidiasis)

Congenital thymic aplasia

Isolated ovarian failure

Sarcoidosis

Other causes

Addison disease

Adrenal insufficiency

Chemotherapeutic (especially alkylating) drugs

Cigarette smoking

Diabetes

Irradiation of the gonads

Surgical extirpation of the gonads or adnexa

Viral infections (eg, mumps)

Symptoms and Signs

In women with occult or biochemical primary ovarian insufficiency (see Classification, below), the only sign may be unexplained infertility. Women with overt primary ovarian insufficiency or premature ovarian failure typically have amenorrhea or irregular bleeding and often symptoms or signs of estrogen deficiency (eg, osteoporosis, atrophic vaginitis, decreased libido).

The ovaries are usually small and barely palpable but occasionally are enlarged, usually when the cause is an immune disorder. Women may also have symptoms and signs of the causative disorder (eg, dysmorphic features due to Turner syndrome; intellectual disability, dysmorphic features, and autism due to Fragile X syndrome; rarely, orthostatic hypotension, hyperpigmentation, and decreased axillary and pubic hair due to adrenal insufficiency).

Unless women receive estrogen therapy, the risk of dementia, Parkinson disease, and coronary artery disease is increased.

If primary ovarian insufficiency is caused by an autoimmune disorder, women are at risk of potentially life-threatening primary adrenal insufficiency.

Diagnosis

  • FSH and estradiol levels

  • Thyroid function tests, fasting glucose, electrolytes, and creatinine

  • Sometimes genetic testing

Primary ovarian insufficiency is suspected in women < 40 with unexplained infertility, menstrual abnormalities, or symptoms of estrogen deficiency.

A pregnancy test is done, and serum FSH and estradiol levels are measured weekly for 2 to 4 wk; if FSH levels are high (> 20 mIU/mL, but usually > 30 mIU/mL) and estradiol levels are low (usually < 20 pg/mL), ovarian insufficiency is confirmed. Then, further tests are done based on which cause is suspected.

Because antimüllerian hormone is produced only in small ovarian follicles, blood levels of this hormone have been used to attempt to diagnose decreased ovarian reserve. Normal levels are between 1.5 and 4.0 ng/ml. A very low level suggests decreased ovarian reserve.

Genetic counseling and testing for the FMR1 premutation are indicated if women have a family history of primary ovarian insufficiency or have intellectual disability, tremor, or ataxia. Karyotype is determined if women with confirmed ovarian insufficiency or failure are < 35.

If karyotype is normal or if an autoimmune cause is suspected, tests for serum adrenal and anti-21 hydroxylase antibodies (adrenal autoantibodies) are done.

If an autoimmune cause is suspected, tests to check for autoimmune hypothyroidism are also done; they include measuring thyroid-stimulating hormone (TSH), thyroxine (T4), and antithyroid–peroxidase and antithyroglobulin antibodies.

Bone density is measured if women have symptoms or signs of estrogen deficiency.

Ovarian biopsy is not indicated.

Classification

Primary ovarian insufficiency can be classified based on clinical findings and serum FSH levels:

  • Occult primary ovarian insufficiency: Unexplained infertility and a normal basal serum FSH level

  • Biochemical primary ovarian insufficiency: Unexplained infertility and an elevated basal serum FSH level

  • Overt primary ovarian insufficiency: Irregular menstrual cycles and an elevated basal serum FSH level

  • Premature ovarian failure: Irregular or occasional periods for years, the possibility of pregnancy, and an elevated basal serum FSH level

  • Premature menopause: Amenorrhea, permanent infertility, and complete depletion of primordial follicles

Treatment

  • Estrogen/progestogen therapy

Women who do not desire pregnancy are given cyclical estrogen/progestin therapy ( combination hormone therapy) until about age 51 unless these hormones are contraindicated; this therapy relieves symptoms of estrogen deficiency, helps maintain bone density, and may help prevent coronary artery disease, Parkinson disease, and dementia.

For women who desire pregnancy, one option is in vitro fertilization of donated oocytes plus exogenous estrogen and a progestogen, which enable the endometrium to support the transferred embryo. The age of the oocyte donor is more important than the age of the recipient. This technique is fairly successful, but even without this technique, some women with diagnosed primary ovarian insufficiency become pregnant. No treatment has been proved to increase the ovulation rate or restore fertility in women with primary ovarian insufficiency.

Other options for women who desire pregnancy include cryopreservation of ovarian tissue, oocytes, or embryos and embryo or oocyte donation. These techniques may be used before or during ovarian failure, especially in cancer patients. Neonatal and adult ovaries possess a small number of oogonial stem cells that can stably proliferate for months and produce mature oocytes in vitro; these cells may be used to develop infertility treatments in the future.

To help prevent osteoporosis, women with primary ovarian insufficiency should consume an adequate amount of Ca and vitamin D (in the diet and/or as supplements).

Women with a Y chromosome require laparotomy or laparoscopy and bilateral oophorectomy because risk of ovarian germ cell cancer is increased.

Key Points

  • Suspect primary ovarian insufficiency in women with unexplained menstrual abnormalities, infertility, or symptoms of estrogen deficiency.

  • Confirm the diagnosis by measuring FSH (which is high, usually > 30 mIU/mL) and estradiol (which is low, usually < 20 pg/mL).

  • Unless contraindicated, prescribe cyclic estrogen/progestogen therapy to be taken until about age 51 to maintain bone density and relieve symptoms and complications of estrogen deficiency.

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