Primary Ovarian Insufficiency

What is primary ovarian insufficiency?

When the ovaries stop working as they should before the age of 40, it's called primary ovarian insufficiency (POI). With POI, the ovary doesn't release an egg each month as it should. POI has been called premature ovarian failure and premature menopause. But these terms are not as accurate. You may still have some function of your ovaries.

The ovaries are a pair of small, oval-shaped female reproductive organs in the lower part of the belly (abdomen). About once a month, one of the ovaries releases an egg. The ovaries also make the hormones estrogen and progesterone. These play roles in pregnancy, the menstrual cycle, and breast growth.

Someone with POI may have fewer eggs. Or the ovaries might not mature or release eggs correctly. The ovaries then don't make the normal amounts of hormones. This leads to the symptoms of POI.

POI is not the same as menopause. Menopause normally happens around age 50. In the time before menopause, the ovaries make smaller and smaller amounts of hormones. This time is called perimenopause. At the time of menopause, the ovaries run out of eggs to release each month. Menstrual cycles stop. In POI, you may have irregular or even normal menstrual cycles. You also may still have eggs in your ovaries.

POI isn't rare. But it can only happen if you're younger than age 40. It's more common in those in their 30s than those in their teens and 20s. It can affect both those who have had children and those who haven’t.

What causes primary ovarian insufficiency?

In most cases, the cause isn’t known. Researchers are working to understand the causes of POI. It can result from any cause that reduces the number of eggs in the ovaries. It can also happen if your ovaries don’t make enough hormones, even with a normal number of eggs.

Some of the known causes of POI include:

  • Autoimmune disease in which the body makes antibodies that attack the ovaries.

  • Eating disorders.

  • Genetic conditions, such as Turner syndrome, Fragile X syndrome, or galactosemia.

  • Infections that damage the ovaries, such as mumps.

  • Problems with hormones that regulate the ovaries, such as follicle-stimulating hormone (FSH).

  • Surgery on the ovaries.

  • Thyroid disease.

  • Toxins that affect the ovaries, such as from radiation or chemotherapy.

Who is at risk for primary ovarian insufficiency?

You may be more likely to have POI if you have thyroid disease, certain infections, or other conditions that sometimes cause POI. You may have a higher risk if you had certain cancer treatments. You also may be more likely to get POI if it runs in your family.

What are the symptoms of primary ovarian insufficiency?

It's common to have a normal puberty and have normal menstrual periods before symptoms start. Symptoms may include:

  • Decreased sex drive.

  • Hot flashes and night sweats.

  • Infertility.

  • Irregular periods or periods that completely stop.

  • Irritability.

  • Painful sex because of thinning and drying of the vagina.

These are many of the same symptoms of normal menopause.

You may have regular periods and not have any symptoms of POI. Or you may have symptoms that come and go.

How is primary ovarian insufficiency diagnosed?

Your primary doctor or your gynecologist may diagnose the condition. You will be asked about your health history and your symptoms. You may become aware of POI when your menstrual cycle doesn’t start again after a pregnancy or after stopping birth control pills. Or you may have had irregular menstrual cycles for several years before being diagnosed.

You will also have a physical exam, including a pelvic exam.

Many conditions can cause irregular periods. To diagnose POI, you may have your blood tested for follicle-stimulating hormone (FSH). FSH is higher in those who have gone through menopause and are no longer releasing eggs. FSH is also higher with POI. This test alone may be enough for you to be diagnosed.

Your gynecologist or primary doctor might do other tests to rule out other causes of your symptoms. These tests may include:

  • A pregnancy test.

  • Blood tests for prolactin and thyroid levels. These are other hormones that can cause POI symptoms.

  • Tests for adrenal autoantibodies to check for an autoimmune cause.

  • Genetic testing to check for genetic causes.

  • Bone density testing to check for osteoporosis caused by low estrogen.

How is primary ovarian insufficiency treated?

POI can be treated in different ways. Treatment may be done by a gynecologist who specializes in reproductive endocrinology. 

Most people with POI need hormone treatment with estrogen. This can help reduce bone loss and other symptoms of reduced estrogen, such as vaginal dryness.

Progesterone is also given to people who have not had surgery to remove their uterus (hysterectomy) and are receiving estrogen. Your gynecologist will probably advise estrogen and progesterone until you reach the natural age for menopause (around age 50).

Treatment of an underlying health problem may help treat POI. For example, treating thyroid disease or an eating disorder may reduce symptoms of POI.

Pregnancy rates for people with POI are low. If you have POI and want to get pregnant, your doctor may recommend:

  • Medicines to promote egg release, such as clomiphene.

  • Using a donor egg instead of your own egg.

Estrogen therapy may also increase your chances of getting pregnant. A small number of people with POI can get pregnant naturally. Talk with your primary doctor or gynecologist about birth control if you want to prevent pregnancy.

What are possible complications of primary ovarian insufficiency?

Thinned, weakened bones (osteoporosis) are one possible complication of POI. Osteoporosis can increase your chances of a broken bone. Your doctor may give you advice to help keep your bones healthy. This may include taking extra calcium and vitamin D, quitting smoking, and exercising more.

Some people are upset to learn that they have POI, especially if they want children. This can lead to depression and anxiety. Talking with a mental health provider may help.

When should you contact the doctor?

See your primary doctor or gynecologist if your menstrual cycle has been irregular for a few months or if you have other symptoms of POI.

Key points about primary ovarian insufficiency

  • Your ovaries stop working as they should before age 40.

  • It causes fewer eggs, or the eggs fail to release. In most cases, doctors don’t know why this happens.

  • Infertility, irregular menstrual cycles, vaginal dryness, and irritability are some possible symptoms. But you may not have any symptoms.

  • Estrogen therapy is the main treatment for the symptoms of POI.

Next steps

Tips to help you get the most from a visit to your doctor:

  • Know the reason for your visit and what you want to happen.

  • Before your visit, write down questions that you want answered.

  • Bring someone with you to help you ask questions and remember what your doctor tells you.

  • At the visit, write down the name of a new diagnosis and any new medicines, treatments, or tests. Also write down any new instructions your doctor gives you.

  • Know why a new medicine or treatment is prescribed and how it will help you. Also know what the side effects are.

  • Ask if your condition can be treated in other ways.

  • Know why a test or procedure is recommended and what the results could mean.

  • Know what to expect if you do not take the medicine or have the test or procedure.

  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.

  • Know how you can contact your doctor if you have questions.