18th October marks World Menopause Day 2020. In its 16th year, the day aims to raise awareness of the different conditions and challenges related to menopause to help reduce the stigma around it as well as provide information about the options available for improving health and wellbeing. This year, the focus is on Premature Ovarian Insufficiency (POI), which is also sometimes referred to as Premature Ovarian Failure (POF).
Unfortunately, POI is a condition which isn’t widely talked about, despite its prevalence. It is estimated that POI occurs in around 1 in 100 women under the age of 40, 1 in 1,000 women under the age of 30, and 1 in 10,000 women under the age of 20. There is definite geographic and ethnic variation with 0.1% prevalence in Japan, 1% in Caucasians and 1.4% in African Americans and Hispanics.
There are far-reaching physical and emotional consequences for sufferers of POI. The condition can result in a lower quality of life, impacting on sex life, mental and cognitive health, fertility, bone health and cardivascular health.
Dr Ghazala Aziz-Scott, Consultant at Marion Gluck Clinic, explains: “Both underdiagnosis and misdiagnosis of POI is quite common, because women may experience irregular or missed periods and not seek medical advice. Figures show that 25% of patients say their diagnosis took more than five years, and 50% will see three or more specialists before a diagnosis. A proportion of younger patients with POI will visit their GP because periods have never started. Infertility or subfertility can also be a presentation. One of the other difficulties is that symptoms can also be masked by certain types of contraception, such as the contraceptive pill.”
Many women will experience the symptoms of menopause, but one in four women will not, which is another reason diagnosis can be delayed.
Is Premature Ovarian Insufficiency The Same As Menopause?
POI is often confused with early menopause, but the conditions are not the same. The average age at which women begin menopause in the UK is 51 and is defined as the absence of periods for 12 months. This also signifies the end of fertility and natural pregnancy is no longer possible. Around 5% of women will experience early menopause, which is when menopause begins between the ages of 41 and 45.
The British Menopause Society defines POI as ‘a combination of oligomenorrhoea/amenorrhoea of more than four months’ duration associated with elevated gonadotropins (FSH >40 iu/l) on at least two occasions measured four to six weeks apart in women under the age of 40’. POI results in decreased sex hormone production: Estrogen levels fall due to decreased ovulation. As ovulation is not occurring or is fluctuating, the body doesn’t produce adequate progesterone either. Low levels of estrogen and progesterone result in rising gonadotropins (FSH, LH) and as there is no cyclical variation of estrogen and progesterone, menstruation stops or becomes irregular. This usually results in patients experiencing various symptoms of the menopause. Although women with POI will generally find it difficult to get pregnant naturally, there is still a small risk of pregnancy for those with the condition. It is important that POI patients are aware of this and use suitable contraception if needed.
What Causes Premature Ovarian Insufficiency?
In most cases, the main reason for POI is unknown. However, there are several known causes, including oophorectomy (surgical removal of the ovaries) and hysterectomy. Even without oophorectomy, certain types of cancer treatment can damage the ovaries such as chemotherapy and pelvic radiotherapy. Another cause can be autoimmune conditions, where the body’s immune system attacks itself. There is an association of POI with other autoimmune conditions including diabetes, thyroid conditions and Addison’s disease. Genetics also plays a part and many women who experience primary ovarian insufficiency have a first-degree relative who is also affected.
Severe weight loss, whether due to an eating disorder or otherwise, can also cause the body to stop menstruating, which could lead to early menopause. In addition, there is a possibility that ethnicity could be a factor. This could be linked to variants in protein coding genes, for example mutations in the FSH receptor gene.
Symptoms Of POI
For many women, the most common symptom of POI is the cessation of regular periods. However, there are several symptoms that some women experience in addition to this:
- Hot flushes: These can occur suddenly and are associated with sweating and dizziness
- Low libido: Hormone levels, in particular androgens such as testosterone, fall lower than they do during normal menopause, which greatly impacts libido
- Loss of concentration and focus
- Joint pain: Falling estrogen levels means a lack of the hormone’s natural anti-inflammatory and lubricating properties for the joints
- Changes to the hair and skin: Falling estrogen levels also impact collagen and hair growth
- Depression and anxiety: These symptoms are much worse with POI due to severe hormone fluctuations. In addition, the diagnosis itself can cause low self-esteem and inadequacy especially concerning future fertility
- Memory loss
- Vaginal dryness: This can result in pain during intercourse
- Recurrent thrush or atropic vaginitis: POI can cause the skin around the vulva to become thin and itchy. The bladder wall can become thinner and less elastic, causing recurrent cystitis and stress incontinence. We can treat this with vaginal estrogen and systemic estrogen such as various forms of Biodentical Hormone Replacement Therapy (BHRT).
POI And Long-Term Health Issues
Due to the health issues and other conditions associated with POI, the life expectancy for women with POI is 2 years less than women without the condition.
This is a particularly high risk for women with POI. Estrogen, progesterone and testosterone all help keep bones strong and healthy. As hormone levels fall, bone breakdown occurs at a faster rate than bone build up resulting in decreased bone mass.This can lead to osteoporosis or brittle bones and even minor trauma can cause a fracture. Your doctor can order a DEXA or bone density scan to identify this and women with POI should have regular monitoring scans. BHRT can help those experiencing POI-related osteoporosis by restoring bone density to baseline levels.
Estrogen is very important for maintaining healthy blood vessels; those with POI have a higher risk of cardiovascular disease and an increased risk of heart attack, stroke, high blood pressure, and changes in cholesterol profile. Unfortunately, cardiovascular disease is the number one killer of women; therefore, monitoring heart health is essential.
POI can cause issues with conception. One treatment for this is Clomifene, an oral drug which stimulates ovulation from the ovaries. However, this is not always effective, and some women consider egg donation as an alternative. For women undergoing cancer treatment, they may be able to freeze their eggs or produce frozen embryos which can be used at a later date. There is also potential for genetic inheritance of POI to your children. The Human Fertilisation and Embryology Authority (HFEA) can be a useful source of information.
Mental health and wellbeing
POI can impact mental health and wellbeing. The incidence of depression, anxiety, poor body image, low self esteem and somatisation are much higher than average and supportive counselling can be helpful. The Daisy Network is a charity dedicated to providing information and support to women and girls diagnosed with POI.
Due to the fact that POI can cause vaginal dryness and decreased libido, this can affect sexual functioning. There are a number of solutions for this, including relationship or psychosexual counselling, using lubricant during intercourse, and BHRT with both local and systemic estrogen and testosterone replacement.
Treatment And Management Of POI
Some clinics offer birth control, specifically the pill, as a way of managing the symptoms of POI. However, this method is generally not a first-line treatment because it does not provide any benefits for cardiovascular or bone health.
BHRT is a much more effective alternative. When it comes to treating POI, the role of HRT extends beyond symptom relief to several levels of support: Bones, cardiovascular and sexual health. Each level can be treated specifically using different applications; for example, vaginal dryness can be treated with local estrogen in order to increase elasticity and lubrication, and reduce inflammation.
We treat each patient with POI individually, as it is experienced differently by each woman. Women with POI may need higher doses of estrogen than normal menopausal women to reflect the higher levels they would have had if still menstruating.
BHRT should be tailored to the individual until the natural age of menopause (around 51 or 52 for most women). We find that many women continue taking BHRT medication even after this age. However HRT discontinuation rates with POI are high, with 7% ceasing treatment within five years. In some cases, women stop taking BHRT due to a lack of information and support. For example, there is a stigma around the connection between BHRT and the risk of breast cancer; however, it has been found that there is no correlation between HRT treatment and breast cancer in young women with POI.
Dr Ghazala Aziz-Scott says, “Due to the complexity of POI, research and controlled clinical trials are currently in progress, with the aim of finding the best HRT regimen to treat the condition. The lack of research and funding is shocking, considering that this is not an insignificant problem – 1 in 100 women have POI at age 40 and 1 in 1000 under age 30.”
“It is important that women go to specialist clinics for comprehensive hormone treatment for POI and receive personalised holistic care, annual follow-ups, support for immediate problems plus monitoring of long-term health issues. We hope that more research and randomised controlled trials will take place in future to establish exact HRT regimes (including delivery methods and doses) and to explore the long term implications for women’s health. Fortunately, there is now a national and international database for cases of POI. ”
For up-to-date information and data on POI, please read this research paper from the International Menopause Society.
Get In Touch With Us To Speak To One Of Our Hormone Doctors
If you are looking for treatment after a diagnosis of POI, or you are concerned that you may have symptoms of this condition, get in touch with our friendly team at The Marion Gluck Clinic today. As an online clinic you can expect five-star care, anywhere in the UK.