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, this will not offer sufficient bony protection unless taken continuously. Hormone replacement therapy is therefore more appropriate and should be tailored to suit the individual, for example by offering topical, depot or oral preparations. Vaginal dryness may also be a problem, which can be aleviated by local application of estrogen gels.
The age of the patient, presence or absence of a uterus, desire or not for withdrawal bleeds, and a family or personal history of breast cancer or endometrial cancer should all influence the choice of treatment.
Individualised risk of cardiovascular or thromboembolic disease should also be taken into account.
Estrogen replacement therapy should then be continued until the time of the natural menopause - typically to age 50.
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.