Premature Ovarian Failure (POF) is defined as the cessation of ovarian function prior to the age of 40. It is diagnosed in women under age 40 when ovarian function ceases, menstruation stops, the onset of menopausal symptoms, estrogen levels falling to a menopausal range (less than 20 pg/ml) and resulting infertility.
Premature Ovarian Failure (POF) is not the same as menopause, although it is often synonymous with, and many physicians call it premature menopause or an "early menopause". Although the symptoms are often similar and Premature Ovarian Failure (POF) was once thought to be a form of premature menopause, there are differences in the two conditions.
Normal menopause occurs as a result of aging (average age in the US is 51.3), which results in follicle depletion or "running out of eggs".
With Premature Ovarian Failure (POF), up to 50% of patients may ovulate once in any given year and 5% may become pregnant, leading to a theory that there is a follicular dysfunction rather than complete ovarian failure.
A syndrome known as Resistant Ovary Syndrome (ROS) is a medical condition that presents, clinically, identical to Premature Ovarian Failure (POF); but the ovary has the normal amount of eggs, and it is thought to be secondary to a receptor block on the surface of the ovary to FSH, antibodies to gonadotrophins (FSH and LH) or a post receptor defect, that prevents the ovary from responding.
The only way to distinguish between the two diagnoses is to do an ovarian biopsy and have pathology look for the presence of a normal amount of egg follicles. If no eggs are found, than the diagnosis is Premature Ovarian Failure (POF); on the other hand, if eggs are present in normal amounts, than the diagnosis is Resistant Ovary Syndrome (ROS).
Although, there is no treatment for Resistant Ovary Syndrome (ROS), it is clinically treated similarly to Premature Ovarian Failure (POF). Rarely Resistant Ovary Syndrome (ROS) can reverse itself and a woman will spontaneously conceive, always in disbelief because she thought and was told she was "menopausal". There is current research looking at the possibility of maturing and recovering eggs in-vitro (outside the body in a dish) from portions of ovary that have been stimulated with FSH. At the present time, this technology is not available for clinical use.
Although often considered a rare disorder, Premature Ovarian Failure (POF) actually affects 1% of women by the age of 40.
Premature Ovarian Failure (POF) occurs in 0.1% (1 in a 1000) women between the ages of 15 and 29, and 1% (1 in 100) women between the ages of 30 and 39.
The average age of onset of Premature Ovarian Failure (POF) is 27 years.
Withdrawal from hormonal contraception in order to pursue fertility, without the return of menstrual function by 6 months, is a common time to diagnose Premature Ovarian Failure (POF). Masking symptoms of Premature Ovarian Failure (POF) with birth control pills in young woman may be a contributing factor to the underestimation of the actual incidence of Premature Ovarian Failure (POF).
The symptoms can vary considerably from patient to patient and the syndrome may occur abruptly or spontaneously or it may develop gradually over several years. Although, in retrospect, women will say that their period started getting irregular 6-12 months before the diagnosis of Premature Ovarian Failure (POF).
Women may experience infertility, hot flashes, irregular or even the absence of menses for one to two months at a time, night sweats, irritability, moodiness, sleep disturbance, decreased libido, hair coarseness, and vaginal dryness.
These symptoms, however, can be caused by a number of clinical conditions. Unfortunately, in the majority of cases, the causes of Premature Ovarian Failure (POF) are idiopathic or unknown.
Causes of Premature Ovarian Failure (POF)
It is estimated that up to 40% of Premature Ovarian Failure (POF) can be attributed to genetic causes, as the disorder has a tendency to be familial. If a woman's mother or maternal grandmother or even maternal aunts had an "early menopause" but was not necessarily diagnosed as Premature Ovarian Failure (POF), that woman is at increased risk of having an "early menopause" herself; and may want to think about having children sooner than later.
Autoimmunity has also been shown to play a role, with the most common cause thought to be Hashimoto's thyroiditis.
Since the symptoms can present as a number of medical or gynecologic disorders, a woman can be shuttled from physician to physician before a correct diagnosis is made. Many physicians do not always consider Premature Ovarian Failure (POF) in their differential diagnosis, it often takes months or years to make the correct diagnosis of Premature Ovarian Failure (POF). The cessation of menstrual periods is often attributed to stress, excessive weight gain or weight loss, or extreme physical activity; without appropriate testing or consideration of Premature Ovarian Failure (POF), delaying the diagnosis. In addition, many women who may have Premature Ovarian Failure (POF) may have been treated for irregular bleeding with oral contraceptives which would mask the symptoms. Premature Ovarian Failure (POF) is usually not diagnosed until the woman becomes interested in fertility and the oral contraceptives are stopped.
The diagnosis of Premature Ovarian Failure (POF) is made with a thorough medical history and physical examination along with a simple blood test measuring FSH level, or follicle stimulating hormone, any time in the cycle. When the value is over 40 mIU/ml on two separate occasions, the diagnosis can be made. Premature Ovarian Failure (POF) can be associated with failures or disorders of other endocrine systems, known multiple endocrinopathies (involving more than one endocrine system). Thyroid failure is most commonly associated with Premature Ovarian Failure (POF), and any patient with Premature Ovarian Failure (POF) should also have a complete evaluation of their thyroid function.
Once the diagnosis of Premature Ovarian Failure (POF) is made, additional diagnostic testing is important to evaluate for genetickaryotyping, assessment of other endocrine systems such as thyroid and parathyroid, myasthenia gravis (a muscle weakness disorder), idiopathic thrombocytopenia purpura (a platelet disorder), and antibody testing to search for signs of autoimmune disease; such as Hashimoto's thyroiditis, which can be a common cause of Premature Ovarian Failure (POF).
The diagnosis of Premature Ovarian Failure (POF) can be emotionally devastating to patients, especially for women looking forward to their childbearing years. Since the diagnosis can have such long-reaching physical and emotional circumstances, Arizona Center for Fertility Studies believes strongly, it is important that elevated FSH levels are confirmed by repeat testing and the patient should never be told over the phone or by anyone other than her physician; who will have the time to answer all her questions and give her reassurances that having children, now or in the future, is possible. Besides endocrine and reproductive issues, emotional support is paramount in treating this condition.
Chronic low levels of estrogen, needed for bone health, increase the risks of osteoporosis, leading to an increased risk of bone fractures and resulting complications. Other medical disorders that affect the heart, eyes, and neurologic systems can put Premature Ovarian Failure (POF) patients at a greater risk for serious health problems such as cardiovascular disease, glaucoma, Parkinson's disease, and Alzheimer's disease. Treatment for Premature Ovarian Failure (POF) is based on the needs of the particular patient. If pregnancy is currently not an option, then the woman should be started on a combination of estrogen and progesterone to alleviate the menopausal symptoms and to protect her bones and heart. All the available treatment options should be discussed, as well as the pros and cons, risks and complications and long term concerns. Some patients may consider alternative or herbal therapies as a type of hormone replacement therapy (HRT) but current data does not show any significant benefit for long term use. Autoimmune and other medical conditions need to be evaluated.
If the couple desires having children, although she will not be able to use her own eggs, In-Vitro Fertilization (IVF) using donor eggs is a great option to allow her and her partner to experience pregnancy and childbirth. Adoption is also an option but many times takes an average of 2-5 years and can have many disappointments along the way.
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