Primary Ovarian Insufficiency (POI)

Background

• Primary ovarian sufficiency (POI) refers to hypergonadotropic hypogonadism in women before age 40 years.
• POI results from depletion or dysfunction of ovarian follicles due to genetic, iatrogenic, autoimmune, or idiopathic causes.
• POI presents with delayed or absent menarche or oligo/amenorrhea in addition to other symptoms of menopause, such as hot flashes and vaginal dryness.
• Untreated it results in a number of complications including osteoporosis, hypercholesterolemia, cardiovascular disease, impaired sexual function, and impaired well-being.

Evaluation

• Suspect diagnosis of primary ovarian insufficiency in adolescents with normal sexual characteristics who have not reached menarche by age 15 years, and women aged < 40 years with amenorrhea for ≥ 4 months or < 9 menses per year and symptoms of estrogen deficiency.
• Exclude pregnancy as a cause of amenorrhea (Strong recommendation).
• Measure follicle stimulating hormone (FSH) and estradiol twice, at least 1 month apart. Diagnosis is confirmed with the presence of FSH levels > 40 units/L and estradiol level < 50 pg/mL (Strong recommendation).
• Other tests to consider when primary ovarian insufficiency is suspected include thyroid-stimulating hormone (TSH), prolactin, luteinizing hormone (LH), karyotype evaluation to detect X chromosome abnormalities, and genetic screening to detect premutation of the FMR1 gene.
• For women who wish to become pregnant, consider ovarian reserve tests (ORT) to determine oocyte reserve and quality (Weak recommendation).

Management

• Offer either hormone replacement therapy or combination oral contraceptives until the typical age of natural menopause (Strong recommendation).
• Testosterone therapy can be considered to improve libido and sexual function in women with surgically-induced menopause, however androgen treatment is supported by limited data and women should be advised that long-term health effects are unclear (Weak recommendation).
• Use nonhormonal contraceptive methods (for example, barrier methods) for women who do not desire to become pregnant (Strong recommendation). Oral contraceptives will not prevent ovulation and pregnancy.