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 of Primary Ovarian Insufficiency
Primary ovarian insufficiency has various causes (see table Common Causes of Primary Ovarian Insufficiency Common Causes of Primary Ovarian Insufficiency 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... read more ), including the following:
The number of ovarian follicles present at birth is insufficient.
The rate of follicular atresia is accelerated, as occurs when the ovaries are damaged during surgery, chemotherapy, or radiation therapy.
The follicles are dysfunctional (as occurs in autoimmune ovarian dysfunction).
Certain genetic disorders are present.
Genetic disorders that can cause premature ovarian insufficiency include
Genetic disorders that confer a Y chromosome can also cause primary ovarian insufficiency. These disorders, which are usually evident by age 35, increase risk of ovarian germ cell cancer.
Symptoms and Signs of Primary Ovarian Insufficiency
In women with occult or biochemical primary ovarian insufficiency (see Classification Classification 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... read more , below), the only sign may be unexplained infertility. Women with overt primary ovarian insufficiency or premature ovarian failure typically have amenorrhea Amenorrhea Amenorrhea (the absence of menstruation) can be primary or secondary. Primary amenorrhea is failure of menses to occur by age 15 years in patients with normal growth and secondary sexual characteristics... read more or irregular bleeding and often symptoms or signs of estrogen deficiency (eg, osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more , atrophic vaginitis, decreased libido). They may also have changes in mood, including depression.
The ovaries are usually small and barely palpable but occasionally are enlarged, usually when the cause is an immune-mediated 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 until about age 51 (the average age for menopause), the risk of osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more , dementia Dementia Dementia is chronic, global, usually irreversible deterioration of cognition. Diagnosis is clinical; laboratory and imaging tests are usually used to identify treatable causes. Treatment is... read more , Parkinson disease Parkinson Disease Parkinson disease is a slowly progressive, degenerative disorder characterized by resting tremor, stiffness (rigidity), slow and decreased movement (bradykinesia), and eventually gait and/or... read more , depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , and coronary artery disease Overview of Coronary Artery Disease Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more is increased.
If primary ovarian insufficiency is caused by an autoimmune disorder, women are at risk of potentially life-threatening primary adrenal insufficiency (Addison disease Addison Disease Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex. It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis... read more ).
Diagnosis of Primary Ovarian Insufficiency
Follicle-stimulating hormone (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 weeks; 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. Reproductive endocrinologists use antimüllerian hormone levels to help predict which women may respond poorly to fertility drugs and generally which couples are less likely to be successful with fertility treatment. Antimüllerian hormone can be drawn at any time during the menstrual cycle.
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 or if the FMR1 premutation is suspected.
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.
If adrenal insufficiency Testing Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex. It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis... read more is suspected, measurement of a morning cortisol level or an adrenocorticotropic hormone (ACTH) stimulation test can confirm the diagnosis.
Other tests for an autoimmune dysfunction should be done; they include a complete blood count with differential, erythrocyte sedimentation rate, and measurement of antinuclear antibody and rheumatoid factor.
Bone density is measured if women have symptoms or signs of estrogen deficiency.
Ovarian biopsy is not indicated.
Primary ovarian insufficiency can be classified based on clinical findings and serum FSH levels:
Occult primary ovarian insufficiency (diminished ovarian reserve): 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 of Primary Ovarian Insufficiency
Estrogen/progestogen therapy (combination hormone therapy or hormone replacement therapy)
In vitro fertilization
Women who have primary ovarian insufficiency and do not desire pregnancy may be treated with oral contraceptives (cyclical or extended cycle) or estrogen/progestin therapy (cyclical or continuous).
Cyclical combination hormone therapy Hormone Therapy Menopause is physiologic or iatrogenic cessation of menses (amenorrhea) due to decreased ovarian function. Manifestations may include hot flushes, night sweats, sleep disruption, and genitourinary... read more is given until about age 51 (the average age for menopause) unless these hormones are contraindicated (1 Treatment references 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... read more ); this therapy relieves symptoms of estrogen deficiency, helps maintain bone density, and may help prevent coronary artery disease, Parkinson disease, mood changes (including depression), atrophic vaginitis, and dementia. Once women reach the average age of menopause, whether to continue hormone therapy depends on the woman's individual circumstances (eg, severity of symptoms, risk of fractures).
For women who desire pregnancy, one option is in vitro fertilization In vitro fertilization (IVF) Assisted reproductive techniques (ARTs) involve manipulation of sperm and ova or embryos in vitro with the goal of producing a pregnancy. ARTs may result in multifetal pregnancy, but risk is... read more 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 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. Ovarian tissue transplantation has been successful and,in the future, may become an option for women who are no longer fertile (2 Treatment references 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... read more ).
About 5 to 10% of women with primary ovarian insufficiency eventually become pregnant on their own, without fertility treatments.
Unless contraindicated, hormonal therapy or oral contraceptives are recommended rather than other bone-specific treatments (eg, bisphosphonates) to prevent bone loss in women with premature ovarian insufficiency; these treatments are given until women reach the average age for menopause (about age 51), when treatment may be reassessed.
To help prevent osteoporosis Preserving bone mass Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more , women with primary ovarian insufficiency should consume an adequate amount of calcium and vitamin D (in the diet and/or as supplements).
Women with a Y chromosome require bilateral oophorectomy via laparotomy or laparoscopy because risk of ovarian germ cell cancer is increased.
1.Committee on Gynecologic Practice: Committee Opinion No. 698: Hormone therapy in primary ovarian insufficiency. Obstet Gynecol 129 (5):e134–e141, 2017. doi: 10.1097/AOG.0000000000002044
2. Sheshpari, S., Shahnazi, M., Mobarak, H. et al: Ovarian function and reproductive outcome after ovarian tissue transplantation: A systematic review. J Transl Med 17:396, 2019.
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).
Measure the antimüllerian hormone level to help predict which women may respond poorly to infertility treatments.
If an autoimmune cause is identified, test for other autoimmune disorders.
Unless contraindicated, prescribe cyclic estrogen/progestogen therapy (combination hormone therapy) to be taken until about age 51 (the average age for menopause) to maintain bone density and relieve symptoms and complications of estrogen deficiency.