Posted under Fertility Treatment by Dr. Rajeev Agarwal



Understanding Premature Ovarian Insufficiency

Understanding Premature Ovarian Insufficiency

Menopause is defined as when a woman experiences no menstrual period for 12 months with no other medical explanation. The ovaries stop releasing eggs and the monthly bleed does not occur.

The average age that this takes place is 51 years.

Menopause under 40 is premature and is now more commonly known as Premature Ovarian Insufficiency (POI).

How common is Premature Ovarian Insufficiency (POI)?

It affects 1% of the population.

1 in 10,000 women before the age of 20 years

1 in 1000 before the age of 30

What are the symptoms of Premature Ovarian Insufficiency (POI)?

The most common symptom experienced is the absence of monthly bleeds or having infrequent l periods. However, you may also experience a range of physical, psychosexual symptoms

Physical: Hot flushes, night sweats, Palpitations (awareness of heartbeat), Changes to skin and hair (dryness, thinning), Headaches, Breast tenderness

Psycological: Mood changes and irritability, Lethargy, Difficulty concentrating, Depression, Sleep disturbance

Sexual: Reduced sex drive, Vaginal dryness, Pain during sexual intercourse

What causes Premature Ovarian Insufficiency (POI)?

In most cases of POI, no specific cause is found.

This can often be upsetting and frustrating for the women affected.

However, POI can also be attributed to causes such as:

Genetic reasons e.g. Turners syndrome.

Autoimmune conditions (when the body develops an intolerance to its own cells such as the ovary).

Surgical removal of the ovaries.

Radiotherapy and/or chemotherapy.

Why does POI matter?

Oestrogen is the main hormone that is secreted by the ovaries, along with progesterone and small amounts of testosterone. Oestrogen is important for fertility and egg production, it also plays an important role in keeping bones strong and the heart and blood vessels healthy.

In POI, this decline happens earlier so the young woman experiences a long period of time with estrogen deficiency. This can lead to  some long-term health issues


  1. osteoporosis (brittle bones) which can break easily
  2. heart disease, including heart attacks and strokes
  3. dementia may be more common too


How can we prevent the complications?


Hormone Replacement Therapy (HRT)

Hormone replacement therapy (HRT) has been proven to be effective, for not only reducing symptoms like hot flushes and night sweats experienced in POI but also it preventive for long term complications such as heart disease, stroke, brittle bones. It replenishes the hormones you are missing due to premature cessation of ovarian function. This treatment is recommended until at least the average age of menopause, which is 51 years.

Oestrogen hormone is given with progesterone-like hormone when your womb is still present. Oestrogen is not given alone because this increases the risk of abnormal changes in the womb lining which can become cancerous. Progesterone like hormone effectively protects the womb lining from this side-effect.

Is Hormone Replacement Therapy (HRT)  safe for me?

In recent years, there have been studies claiming to have found a link between HRT and an increased risk of breast cancer and heart disease. This has led to women worrying about the safety of HRT. However, these studies do not apply to women with POI as they involved women who were much older. Here are some concerns and facts regarding HRT:


  • Does HRT increase my chance of getting breast cancer?

No, your risk of breast cancer is no different to a pre-menopausal woman of the same

  • Will I have an increased risk of cardiovascular problems?

Again there is no increased risk to a woman under 51 years taking HRT. Studies that suggested this were carried out on women over 51 years and some of the original research has now been deemed inaccurate.

  • Deep Vein Thrombosis (DVT) (blood clot in the leg veins

There is a slightly increased risk (as with the contraceptive pill) compared to women not taking hormones. The risk of blood clots with patches/gels at a standard dose is not increased compared with women not using them.

  • Endometrial cancer (cancer of the womb lining)

Women with a womb should take combined HRT (progestogen and estrogen) to minimize the risk.


What other treatment options are available?

  • The use of estrogen by vaginal route works well for vaginal and bladder symptoms.
  • Wiping with a cold flannel or having a shower when experiencing hot flushes.
  • Psychosexual advice and support e.g. using a lubricating gel


None of these are substitutes for HRT and they will not protect you against the long term health implications discussed above.

What lifestyle changes should I make?

Stop smoking - smoking reduces the effectiveness of HRT and is a risk factor for cardiovascular disease and osteoporosis.

Decrease alcohol intake - excess alcohol can further reduce bone strength leading to osteoporosis. It also increases your risk of falling which could cause bone fractures.

Regular exercise - aerobic exercise helps to reduce cardiovascular risks whilst weight-bearing exercise protects against osteoporosis.

Eating a balanced diet - this provides important sources of calcium and other essential vitamins and minerals. Dietary supplements such as calcium and vitamin D may be recommended.


Can I still have children?

A very distressing consequence of premature ovarian insufficiency is infertility. This does not necessarily mean you will not be able to have children; You may request a referral to see a fertility specialist to talk about your options.

In vitro fertilization (IVF) - is necessary to use an egg from another woman (donor egg) to fertilize with your partner’s sperm, in order for you to carry the pregnancy and birth your baby. This may not suit every woman but it can be very successful (about half of the women who try will have a baby but it may take more than one treatment attempt).

What about contraception?

In POI, some women’s ovaries go through waves of activity. They can have a few periods and then a gap.  Having a period can be a sign that ovulation has happened. HRT is not contraceptive so if you want to avoid an unplanned pregnancy you must take the contraceptive pill and it can also be used as a form of HRT with the same protective benefits of oestrogen.

About the author

The author, Dr. Rajeev Agarwal is a Fertility Consultant at Care IVF Kolkata. For an appointment with the doctor, call +91-33-66-398-600. You can also book a Skype Consultation here.


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