Primary ovarian insufficiency

Dr Sagarika Agarwal
Somya, at the age of 38 had menstrual irregularities for the past 8 months. When she didn’t have period for 3 months, she was excited about pregnancy. The tests were negative, so she thought it to be menopause, but had cycle the next month itself. Confused, she made a visit to  a hospital wherein with several tests she was diagnosed for Primary Ovarian Insufficiency.
She was educated that she still has chances to get pregnant as POI is different from pre-menopause. A blood test was done in order to study the complete study, with levels of Follicle stimulating Hormone (FSH) found high which are responsible for generating estrogen. This also indicated low levels of estrogen, responsible for fertility. Luteinizing hormone, which signals a mature follicle to release egg, was also on the high side. These tests were enough to confirm that the follicles are not functioning normally.
Follicle Dysfunction being her major cause for POI, She was told for Hormone Replacement Therapy (HRT). HRT is usually a combination of an estrogen and a progestin which gives the body the estrogen and other hormones that the ovaries are not making. She started having regular periods again and her luteinizing hormone levels were found to be reduced, which indicates better ovulation.
Primary Ovarian Insufficiency (POI) Vs Menopause
In the past, POI used to be called “premature menopause” or “premature ovarian failure,” but those terms do not accurately describe what happens in a woman with POI. Many women naturally experience reduced fertility when they are around 40 years old. This age may mark the start of irregular menstrual periods that signal the onset of menopause. A woman who has gone through menopause will never have another normal period and cannot get pregnant.
A woman with POI may still have periods, even though they might not come regularly, and she may still get pregnant. For women with POI, irregular periods and reduced fertility occur before the age of 40, sometimes as early as the teenage years.
How to identify if you have POI?
Sudden menstrual irregularities or missing periods for atleast 3 months are the first signs of POI. For many women with POI, trouble getting pregnant or infertility is the first symptom they experience. Some women may experience symptoms of natural menopause, which should not be ignored, and immediate consultation is required. The following symptoms should not be ignored if you are under 40:-
* Hot flashes leading to night sweat – a quick feeling of heat and sometimes a red, flushed face due to changes in blood circulation when the blood vessels near the skin surface dilate to cool. This usually leads to sweating in the night.
* Irritability and poor concentration – hormonal fluctuations during menopause are often the prime cause of irritability. With estrogen levels fluctuating, they directly have an effect on brain’s regulation of mood and emotions leading to irritability and poor concentration.
*    Loss of Libido – medically termed “hypoactive sexual desire disorder,” is a reduction or lack of interest and desire in sexual activity. This is due to hormonal changes.
* Pain during sex due to Vaginal dryness – Estrogen plays a vital role in female sexuality by increasing sensations, assisting in the production of vaginal lubrication, and maintaining the health of vaginal tissue. And with low levels of Estrogen, vaginal dryness occurs which leads to pain during sex.
What causes POI?
POI is related to problems with the follicles – small sacs in the ovaries in which eggs grow and mature. Normally a woman is born with 2 million primordial follicles (microscopic seeds which grow into follicles), which may get depleted or not function properly to cause POI-
* Follicle depletion – If a woman runs out of working follicles before her natural menopause.
* Follicle dysfunction – a woman has enough follicles in her ovaries but is not working properly.
The reasons for follicle depletion or dysfunction may be –
* Idiopathic
* Genetic and chromosomal disorder – Disorders such as Fragile X syndrome and Turner syndrome can cause follicle depletion.
* Low number of follicles – Some women are born with fewer primordial follicles, so they have a smaller pool of follicles to use throughout their lives. Even though only one mature follicle releases an egg each month, less mature follicles usually develop along with that mature follicle and egg. If these extra follicles are missing, the main follicle will not mature and release an egg properly.
*Autoimmune diseases – the immune system may damage the developing follicles in the ovaries and glands that make hormones needed for the ovaries and follicles to work properly.
* Toxins – Cigarette smoke, chemicals, and pesticides can speed up follicle depletion.
* Cancer chemotherapy recipients.
What are the treatments for POI?
Though the functions of a woman’s ovaries cannot be restored to normal but chances of getting pregnant can be increased. There are only 5% chances for a woman (under the age of 40 years) with POI to get pregnant without medical intervention ( ‘Spontaneous Remission’; the ovaries may begin to function on their own, restoring fertility).
To restore the estrogen level, Hormone Replacement Therapy is useful along with IVF treatment for a woman to get pregnant after diagnosed for POI.
Hormone Replacement Therapy – It is the most common treatment for POI. It gives the body the estrogen and other hormones that ovaries are not making. HRT is usually a combination of an estrogen and a progestin (form of progesterone.) available in these forms – pills, creams, gels, patches that stick onto the skin, an intrauterine device, or a vaginal ring.
If a woman with POI begins HRT, she will have  periods again , which would also improve her sexual health and decrease the risks for cardiovascular disease. Progesterone is taken along with estrogen to balance out its effect on the lining of the womb,which even decreases risk of endometrial cancer.
As women with POI are at a higher risk of osteoporosis, calcium and vitamin supplements are also prescribed, along with Bone mineral density check for bone loss.
(The author is INVF Exper, Indira, IVC Centre New Delhi)

LEAVE A REPLY

Please enter your comment!
Please enter your name here