Premature Ovarian Failure
Loss of ovarian function is generally a progressive process that occurs over a number of years and culminates with menopause. Premature ovarian failure is defined as loss of ovarian function before age of 40 years. This condition occurs especially in young women aged between 15 and 29, but may also appear in women who have exceeded this age. Women who suffer from premature ovarian failure have fewer or no eggs, or the eggs can not develop normally. Depending on the cause, premature ovarian failure can appear early, in adolescence. Due to the relatively young age of appearance and because of the nature of this unexpected event, the patient may require both psychological support, and hormone replacement therapy. Although, most physicians are not adequately trained to provide fully psychological support, the right approach of the disease and a specialized service recommandation can be helpful.
Premature Ovarian Failure Causes
The exact causes of premature ovarian failure are not fully understood. It was observed that premature ovarian failure is more frequent associated with the following conditions:
- Enzymatic or metabolic defects:
- Galactosemia, thalassemia major treated with multiple blood transfusions and hemochromatosis;
- Chemotherapy – drug castration;
- Surgery – surgical castration;
- Viral infections;
- Abnormal secretion of gonadotropins or defects in their function;
- Genetic and chromosomal disorders :
- Turner Syndrome. Normally, female karyotype is 46, XX – meaning there are 46 chromosomes, of which two X chromosomes, the sex chromosomes. When there are only 45 chromosomes and one X chromosome is missing, then we talk about Turner syndrome. In moast cases, girls who suffer from Turner syndrome did not menstruate due to the fact that the follicular reserve is exhausted before they reach puberty;
- Androgen resistance syndrome;
- Familial predisposition.
- Autoimmune diseases:
- Thyroid disorders;
- Poliglandular failure;
- Rheumatoid arthritis;
- Autoimmune thrombocytopenic purpura;
- Pernicious anemia;
- Lupus erythematosus.
Premature Ovarian Failure Risk Factors
- Heredity: it was observed that in families where the mother or grandmother suffered from premature menopause (synonym for premature ovarian failure) the incidence of the disease is much higher;
- Age: as women get older, the risk for developing premature ovarian failure is greater, for eg. at the age of 20 years, the incidence is 1 in 1.000 women, at the age of 35 years, the incidence is 1 in 250 women and at the age of 40 years the incidence increases to 1 in 100 women;
- Disease of pituitary gland that are decreasing the secretion of hormones like LH (luteinizing hormone) and FSH (follicle stimulating hormone).
Premature Ovarian Failure Symptoms
Premature ovarian failure is characterized by irregular menstrual cycles or the absence of menstrual cycles, problems with fertility and menopause-like symptoms. It is, therefore, very difficult for women with premature ovarian failure to become pregnant.
The clinical manifestations of premature ovarian failure are similar to menopause symptoms:
- Night sweats;
- Hot flashes;
- Vaginal dryness and decreased vaginal secretion;
- Nervousness and decreased ability to concentrate;
- Decreased libido;
Paraclinical investigations in premature ovarian failure:
Gynecological examination can detect small impalpable ovaries (this is a highly subjective examination) or can suggest a pregnancy (due to amenorrhea – that lack of menstruation), which is certainly confirmed by ultrasound examination. On the other hand, transvaginal ultrasound examination can confirm or not a pregnancy, but also can detect the disappearance of the ovarian follicles (this is a sign of premature ovarian failure).
Testing the level of estrogen (estradiol) in the blood – low levels of this hormone may indicate the cessation of ovarian activity. Moreover, when the rate of estradiol falls below 36, menopause is likely to be already installed.
The dosage of follicle stimulating hormone from pituitary origin, is the most conclusive test which can indicate the installation of menopause (the role of this hormone is to stimulate the ovaries to produce estrogen). FSH over 30 indicate severe impairment in the ovarian unit.
Premature Ovarian Failure Complications
- Infertility – many women with premature ovarian failure are diagnosed with infertility.
- Osteoporosis – can cause fractures due to decreased bone density and strength. Many studies show that bone loss is faster after menopause, when estrogen levels decrease. This decrease of bone density and strenght can be slowed by taking estrogen. The most common are hip fractures. 85% of hip fractures occur in women and 10-20% of patients die due to the complications. Other effects of osteoporosis are deviations of the spine and back pain due to vertebral fractures.
- Endometrial cancer – There is a small risk of endometrial cancer in women who take estrogen. This risk can be virtually eliminated by adding progestin (synthetic progesterone). For these reasons, women should take estrogen and progesterone substitutes. Hysterectomised women should not take progestin for endometrial cancer, because they have no risk for developing this type of cancer.
- Heart disease – are the first cause of death in women, and is recorded two times more deaths from cardiac causes, than of all cancers combined. Estrogen improves serum cholesterol levels by increasing HDL cholesterol (“good” cholesterol) and lowering levels of LDL cholesterol (“bad” cholesterol). There is a reason to believe that estrogen reduces the risk of myocardial infarction, but this is not sure yet. On the other hand, there are other ways to reduce the risk of heart attack, such as a low-fat diet, exercise and medications. Women at high risk for cardiovascular disease, should talk with their cardiologist for treatment options.
- Breast caner – most problems in recent years are related to the possibility of a link between hormone replacement therapy and breast cancer. Studies show a 30% increase in the risk of breast cancer after 10 years of hormone replacement therapy. For example, a woman with risk of 9:100 for breast cancer, will have a risk of 12:100 after 10 or 15 years of hormone replacement.
- Dementia or Alzheimer’s disease – For women with early Alzheimer’s disease, estrogen appears to improve the disease. At this point, we do not know if estrogen replacement decreases the risk of Alzheimer’s disease.
Premature Ovarian Failure Treatment
Treatment for premature ovarian failure is generally hormonal. Usually, this therapy is associated with calcium and vitamin D.
Estrogen therapy in premature ovarian failure is used to optimize the level of estrogen in the blood so that the pituitary function to be normal and to be sufficient to stimulate the follicles. Normal level of estrogen also prevents the risk of osteoporosis.
There is no known treatment for the stimulation of the ovaries in premature ovarian failure. The gynecologist may prescribe a treatment based on hormones, antidepressants or other drugs to treat hot flashes and other symptoms. Some women may wish to become pregnant using donor eggs.