Premature ovarian failure

Premature ovarian failiure may occur due to auto-immune disease or as an isolated 'premature menopause'. The diagnosis is also known as primary ovarian failure or primary gonadal failure.

Discuss diagnosis and offer counselling

The implications of diagnosis, and possibilities for fertility should be discussed at or soon after diagnosis. Counselling should be offered at diagnosis if appropriate.

Fertility

Early discussion and referral for infertility is recommended.

It is important for patients desiring fertility to have a realistic understanding of their options. The chance of an unaided conception is low with complete ovarian failure and an elevated FSH. However, occasional ovulatory cycles may occur early in the disease, and multiple assisted conception techniques are available, particularly using donor ova.

Initiate treatment

Cyclical estrogen and progesterone replacement therapy should be considered in all patients.

The combined oral contraceptive pill is a convenient preparation and may be more socially acceptable at diagnosis and in young patients. However, there has been some doubt as to whether this offers sufficient bony protection unless taken continuously, with some authorities advising taking this 3 packs at a time. Combined oral contraceptive pills are also contraindicated in patients with a history of migraines with aura. Low dose HRT is more suitable in these cases.

Hormone replacement therapy is more appropriate in the long term, and should be tailored to suit the individual, for example by offering topical, depot or oral preparations. Choice will also depend on the age of the patient, presence or absence of a uterus, and history or family history of breast or endometrial cancer. A history of, or strong risk factors for cardiovascular or thromboembolic disease will also need to be considered.

Topical estrogen is particularly useful in patients at high cardiovascular risk, or with abnormalities of liver function. Combined patches are available, or if estrogen gel is used, low dose continuous progesterone will also be required to prevent endometrial hyperplasia eg 1x350mcg progesterone only pill daily.

Estrogen replacement therapy should be continued until the time of the natural menopause - typically to age 50. Vaginal dryness may be ameliorated by topical estrogen gels.

 

Monitoring and follow up

Estrogen replacement therapy requires no routine monitoring unless the patient is symptomatic, for example complaining of menstrual irregularity or hot flushes. 

Annual monitoring of TSH, free thyroxine, 9am cortisol and vitamin B12 levels should be initiated to screen for the development of other associated conditions.

Specialist follow up may not be required long term.

Bone densitometry

Consider assessing bone densitometry at diagnosis. Estrogen replacement therapy should be sufficient to improve bone densitometry. However, vitamin D levels should be checked, to determine whether supplementation is also necessary. 

Consider repeating bone densitometry after five years of treatment in those with severe osteoporosis, to determine whether additional treatment is indicated for example bisphosphonates.