P R E M A T U R E O V A R I A N F A I L U R E (POF)

For most women, the occurrence of regular menses is something that is often taken for granted. The absence of the same has profound physiological and psychological implications, which include effects of the estrogen-depleted state.

A woman usually reaches menopause somewhere between the ages of 45 and 55 yrs. Currently, the average age at menopause is said to be around 51 yrs, a fact that may be attributed to the improving quality of life over the last few decades. Elevated serum gonadrotropin levels and low serum estrogen levels characterize the loss of ovarian function. The fine discrimination between premature menopause and premature ovarian failure must be acknowledged, as this will be important in diagnosis and management of the patient. Premature menopause is when the menopause occurs between 41 to 45 years of age, while premature ovarian failure is when the ovarian failure occurs before 40 years of age.

Premature ovarian failure is seen in approximately 1% of all women. POF can exist with a normal or abnormal chromosome pattern in the woman. Secondary sexual characteristics may be normal or absent or underdeveloped.

Cause of POF

The cause is unknown in a majority of cases. Of the remainder autoimmunity is responsible to a large extent. Studies show that almost 80-92% of women with premature ovarian failure have tested positive for autoantibodies, though only about 20% have actually been found to have symptoms and signs of immunological dysfunction - usually thyroid disorders. Irradiations, surgery compromising ovarian blood supply are other causes. The condition may be hereditary. Smoking is also believed to play a role.

Manifestations

Amenorrhea or oligomenorrhea may be an initial feature. The most common symptom is the acute onset of hot flushes followed by other symptoms of estrogen deficiency including night sweats, depression, anxiety, mood swings, decreased libido and dyspareunia. Women with premature loss of ovarian function have been found to be at an increased risk of developing cardiovascular disease and osteoporosis.

Diagnoses

Investigations in a patient with suspected premature ovarian failure must be aimed at not only confirming the diagnosis, but also at detecting the underlying cause. Elevated Serum Gonadotropins and low serum estradiol form the basis of identifying the presence of premature ovarian failure. However they must be measured on at least 2 occasions before a definitive diagnosis is made. Other tests include a chromosomal karyotyping and a pelvic ultrasound. Ovarian biopsy is not adopted as a means of investigation. Tests aimed at various autoimmune disorders have to be carried out.

Treatment

As there are no methods to restore ovarian function, treatment is directed towards preservation or substitution of ovarian function with hormone replacement therapy (HRT). This involves cyclical administration of estrogens and progestogens. Addition of progesterone will prevent the complications associated with exogenous estrogen administration, mainly endometrial hyperplasia. These women however may require higher doses of estrogens when compared to the usual postmenopausal women. Spontaneous pregnancy rates while the patient is on HRT are upto 5 - 10%. This is because estrogens may activate receptor formation in the follicles, and the high gonadotropins levels may stimulate follicular growth and ovulation. Assisted conception involving controlled ovarian hyperstimulation with gonadotropins is the method of choice in women with POF. If after 3 such cycles the woman does not get pregnant,the patient is advised oocyte donation.

Steroids have been proven to be effective in autoimmune ovarian failure, but have no role in idiopathic or any other type of ovarian failure. Pychological support is extremely essential and is a requisite at every step in management. Let us not write off women with premature ovarian failure. On the other hand, we should reassure them that their life is by no means over and they too can lead perfectly normal lives.