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Premature ovarian failure

Overview

Premature ovarian failure — also known as primary ovarian insufficiency — is a loss of normal function of your ovaries before age 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 aren't the same. Women with premature ovarian failure can have irregular or occasional periods for years and might 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, that occur as a result of low estrogen.

Symptoms

Signs and symptoms of premature ovarian failure are similar to those of going through menopause and are typical of estrogen deficiency. They include:

  • Irregular or skipped periods (amenorrhea), which might be present for years or develop after a pregnancy or after stopping birth control pills
  • Difficulty conceiving
  • Hot flashes
  • Night sweats
  • Vaginal dryness
  • Irritability or difficulty concentrating
  • Decreased sexual desire

When to see a doctor

If you've missed your period for three months or more, see your doctor to help determine the cause. You can 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 periods, it's advisable to see your doctor to find out what's causing the change. Low estrogen levels can lead to bone loss.

Causes

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 one or two follicles — tiny sacs filled with fluid — reach maturity each month.

When the follicle matures, it opens, releasing an egg. The egg enters the fallopian tube where a sperm cell might fertilize it, resulting in pregnancy.

Premature ovarian failure results from the loss of eggs (oocytes). This might happen because of:

  • Chromosomal defects. Certain genetic disorders are associated with premature ovarian failure. These include mosaic Turner's syndrome — in which a woman has only one normal X chromosome and an altered second X chromosome — and fragile X syndrome — in which the X chromosomes are fragile and break.
  • Toxins. Chemotherapy and radiation therapy are the most common causes of toxin-induced ovarian failure. These therapies can damage the genetic material in cells. Other toxins such as cigarette smoke, chemicals, pesticides and viruses might hasten ovarian failure.
  • An immune system response to ovarian tissue (autoimmune disease). In this rare form, your immune system produces antibodies against your 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. It's possible to develop premature ovarian failure, but have no known chromosomal defects, toxin exposure or autoimmune disease. Your doctor might recommend further testing to find the cause, but in most cases, the cause remains unknown (idiopathic).

Risk factors

Factors that increase your risk of developing premature ovarian failure include:

  • Age. Risk rises between the ages of 35 and 40, although younger women and adolescents can develop the condition.
  • Family history. Having a family history of premature ovarian failure increases your risk of developing this disorder.
  • Multiple ovarian surgeries. Ovarian endometriosis or other conditions requiring repeated surgeries on the ovaries increases the risk of premature ovarian failure.

Complications

Complications of premature ovarian failure include:

  • Infertility. Inability to get pregnant may be the most troubling complication of premature ovarian failure, although in rare cases, pregnancy is possible until the eggs are depleted.
  • Osteoporosis. The hormone estrogen helps maintain strong bones. Women with low levels of estrogen have an increased risk of developing weak and brittle bones (osteoporosis), which are more likely to break than healthy bones.
  • Depression or anxiety. The risk of infertility and other complications arising from low estrogen levels causes some women to become depressed or anxious.
  • Heart disease. Early loss of estrogen might increase your risk.
  • Dementia. Lack of estrogen can contribute to this in some people.

Diagnosis

Most women have few signs of premature ovarian failure. Diagnosis usually involves a physical exam, including a pelvic exam. Your doctor might ask questions about your menstrual cycle, exposure to toxins, such as chemotherapy or radiation therapy, and previous ovarian surgery.

Your doctor might recommend one or more of these tests:

  • Pregnancy test. This checks for an unexpected pregnancy in a woman of childbearing age who has 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.
  • Estradiol test. The blood level of estradiol, a type of estrogen that comes from the ovaries, is usually low in women with premature ovarian failure.
  • Prolactin test. High blood levels of prolactin — the hormone that stimulates breast milk production — can lead to problems with ovulation, including irregular or absent menstrual periods.
  • Karyotype. This test examines your 46 chromosomes for abnormalities. You could have only one X chromosome instead of two or other chromosomal defects.
  • FMR1 gene testing. The FMR1 gene is the gene associated with fragile X syndrome — an inherited disorder that can cause intellectual problems. The FMR1 test looks at both of your X chromosomes to make sure they appear normal.

Treatment

Treatment for premature ovarian failure usually focuses on the problems that arise from estrogen deficiency. Your doctor might recommend:

  • Estrogen therapy. Estrogen therapy can help prevent osteoporosis and relieve hot flashes and other symptoms of estrogen deficiency. Your doctor typically prescribes estrogen with the hormone progesterone, especially if you still have your uterus. Adding progesterone protects the lining of your uterus (endometrium) from precancerous changes caused by taking estrogen alone.

    The combination of hormones can cause vaginal bleeding again, but it won't restore ovarian function. Depending on your health and preference, you might take hormone therapy until around age 50 or 51 — the average age of natural menopause.

    In older women, long-term estrogen plus progestin therapy has been linked to an increased risk of heart and blood vessel (cardiovascular) disease and breast cancer. In young women with premature ovarian failure, however, the benefits of hormone therapy outweigh the potential risks.

  • Calcium and vitamin D supplements. Both are important for preventing osteoporosis, and you might not get enough in your diet or from exposure to sunlight. Your doctor might suggest bone density testing before starting supplements to get a baseline bone density measurement.

    For women ages 19 through 50, the Institute of Medicine recommends 1,000 milligrams (mg) of calcium a day through food or supplements, increasing to 1,200 mg a day for women age 51 and older.

    Scientists don't yet know the optimal daily dose of vitamin D. A good starting point for adults is 600 to 800 international units (IU) a day, through food or supplements. If your blood levels of vitamin D are low, your doctor might suggest higher doses.

Addressing infertility

There's no treatment proved to restore this common complication of premature ovarian failure. 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 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 lab. The fertilized egg (embryo) is then placed in your uterus.

Preparing for an appointment

Your first appointment will likely be with your primary care physician or a gynecologist. If you're seeking treatment for infertility, you might be referred to a doctor who specializes in reproductive hormones and optimizing fertility (reproductive endocrinologist).

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as fasting before having a specific test. Make a list of:

  • Your symptoms, including missed periods and how long you've been missing them.
  • Key personal information, such as major stresses, recent life changes and your family medical history.
  • our health history, especially your reproductive history, any past surgeries on your ovaries and possible exposure to chemicals or radiation.
  • All medications, vitamins or other supplements you take, including doses.
  • Questions to ask your doctor.

Take a family member or friend along, if possible, to help you remember all the information you're given.

For premature ovarian failure, some questions to ask your doctor include:

  • What's the most likely cause of my irregular periods?
  • What other possible causes are there?
  • What tests do I need?
  • 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?
  • I have other health conditions. How can I best manage them together?
  • Should I see a specialist?
  • Do you have printed material I can have? What websites do you recommend?

Don't hesitate to ask other questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask questions, such as:

  • When did you start missing periods?
  • Do you have hot flashes, vaginal dryness or other menopausal symptoms? For how long?
  • Have you had ovarian surgery?
  • Have you been treated for cancer?
  • Do you or any family members have systemic or autoimmune diseases, such as hypothyroidism or lupus?
  • Have members of your family been diagnosed with premature ovarian failure?
  • How distressed do your symptoms make you feel?
  • Do you feel depressed?
  • Have you had difficulties with previous pregnancies?

Lifestyle and home remedies

Learning that you have premature ovarian failure may be emotionally difficult. But with proper treatment 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.
  • Talk with your doctor about 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. Eat a calcium-rich diet, do weight-bearing exercises such as walking and strength-training exercises for your upper body, and don't smoke. Ask your doctor if you need calcium and vitamin D supplements.
  • Keep track of your menstrual cycle. If you miss a period while taking hormone therapy that causes you to have a monthly cycle, get a pregnancy test.

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 given birth. Grieving is normal.

  • 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 don't have children and want them, or if you want 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 might help you adjust to your circumstances and the implications for your future. Ask your doctor about national or local support groups or seek an online community as an outlet for your feelings and a source of information.
  • Give yourself time. Coming to terms with your diagnosis is a gradual process. In the meantime, take good care of yourself by eating well, exercising and getting enough rest.

Last updated: October 27th, 2016

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