Related Subjects:
|Causes of abnormal Vaginal bleeding
|Vaginal Carcinoma
|Cervical cancer
|Endometrial (Uterine) Cancer
|Post Menopausal Bleeding
|Anatomy of the Uterus
|Anatomy of the Ovary
|Gynaecological History Taking
|Colposcopy
|Premature Menopause
|Polycystic Ovary syndrome
📖 Introduction
- Premature menopause, also termed Premature Ovarian Insufficiency (POI) or Premature Ovarian Failure (POF), is defined as loss of ovarian function before the age of 40.
- Spontaneous POI (non-iatrogenic) is a significant clinical challenge with implications for fertility, bone health, and cardiovascular risk.
- Epidemiology: ~1% of women under 40, ~0.1% under 30 are affected.
🔍 Definition
- Premature Ovarian Insufficiency: Intermittent or permanent loss of ovarian function before 40, characterised by amenorrhoea/oligomenorrhoea, hypoestrogenism, and raised gonadotrophins.
🧬 Aetiology
- Genetic: Turner syndrome (45,XO), fragile X premutation (FMR1 gene).
- Autoimmune: Autoimmune oophoritis, thyroid disease, Addison’s disease.
- Iatrogenic: Surgery, chemotherapy, radiotherapy (distinguish from spontaneous POI).
- Idiopathic: Most cases, with ovarian follicle depletion or dysfunction.
🩺 Clinical Features
- Primary or secondary amenorrhoea.
- Vasomotor symptoms: hot flushes, night sweats.
- Infertility.
- Genitourinary syndrome of menopause: vaginal dryness, dyspareunia.
- Long-term risks: osteoporosis, cardiovascular disease, mood disorders.
🧪 Investigations
- Hormonal profile: Low oestrogen, elevated FSH (in menopausal range, on 2 occasions ≥4–6 weeks apart).
- Anti-Müllerian Hormone (AMH): Usually low, reflects diminished ovarian reserve.
- Additional tests: Karyotype in young women (<30), fragile X premutation screen, autoimmune panel (thyroid, adrenal antibodies).
- Differentials: Hypothalamic amenorrhoea, hyperprolactinaemia, PCOS.
💊 Management
- Hormone Replacement Therapy (HRT): Cyclical oestrogen + progesterone until at least the natural age of menopause (~50) to relieve symptoms and prevent osteoporosis/CVD.
- Fertility: Spontaneous ovulation is rare but possible. Egg donation and assisted reproduction offer options.
- Lifestyle: Weight-bearing exercise, calcium/vitamin D, smoking cessation, healthy BMI.
- Monitoring: Regular bone mineral density (DEXA), cardiovascular risk assessment, psychological support.
- Psychosocial support: Counselling is vital for coping with infertility and diagnosis at a young age.
💡 Clinical Pearls
- Think of POI in any woman <40 with >4 months of amenorrhoea + menopausal symptoms.
- FSH in the menopausal range on 2 occasions is diagnostic.
- Key OSCE scenario: 28-year-old with amenorrhoea, hot flushes, and family history of early menopause.
✅ Conclusion
Premature ovarian insufficiency is a multifactorial disorder characterised by early ovarian failure.
Diagnosis rests on clinical features and confirmatory hormonal profile.
Management is multidisciplinary: HRT until natural menopause age, lifestyle and psychosocial support, fertility counselling, and long-term surveillance for bone and cardiovascular health.