Premature Ovarian Insufficiency (POI)

The average age of the menopause in the UK is 51 years. However, many women have an earlier menopause. If you are under 45 years then it is referred to as an early menopause. If you are under 40 years of age then it is referred to as Premature Ovarian Insufficiency (POI).

What is Premature Ovarian Insufficiency (POI)?

POI occurs when your ovaries no longer work properly when you are under the age of 40 years. Your ovaries no longer produce normal amounts of oestrogen and therefore may not produce eggs. This means that your periods either stop or become irregular and you may experience symptoms of the menopause.

However, in most cases of POI, your ovaries often do not completely fail which is different to the natural menopause in middle age. This means that the function of your ovaries can fluctuate over time, occasionally resulting in a period, ovulation or even pregnancy, sometimes several years after diagnosis. This intermittent temporary return of ovarian function can result in around 5-10% of women with POI being able to conceive.

Around one in a hundred women under the age of 40 years in the UK have POI and it affects around one in a thousand women under 30 years. Many women have POI without realising and it is really important that if you have irregular periods or your periods have stopped then you talk to your doctor about having a test for POI.

What causes POI?

For most women with POI, the underlying cause is not known. The following, however, may cause POI:

• Having your ovaries removed during an operation (in which case the term Premature Surgical Menopause is technically more accurate as there can be no return of ovarian function).
• If you have radiotherapy to your pelvic area as a treatment for cancer or if you have received certain types of chemotherapy drugs that treat cancer.
• If you have had your womb (uterus) removed (an operation called a hysterectomy) even if your ovaries are not removed. Although your ovaries will still make some oestrogen after your hysterectomy, it is common that your level of oestrogen will fall at an earlier age than average.

In around 1 in 20 of women with POI, the condition is caused by an autoimmune disease. This means that your immune system (which normally protects your body from infections) mistakenly attacks itself. There may be people in your family who have other autoimmune conditions – for example, Type 1 Diabetes, thyroid conditions or Addison’s disease.

Some women with POI have as a result of certain genetic conditions. The most common of these is Turner syndrome, in which one of the female sex chromosomes (the X chromosome) is missing. Chromosomes are found in every cell in your body and contain genetic information. Genetic conditions causing POI are usually more common if you have other people in your family with POI or if you are under 20 years at the time of diagnosis.

How is POI or early menopause diagnosed?

The most common test is a blood test measuring a level of a hormone called follicle stimulating hormone (FSH). If this is raised, then it is very likely that you are menopausal. This blood test is often repeated 4-6 weeks later. You may also be advised to have other blood tests, for example some types of genetic tests. You may also be recommended to have a bone density test (DEXA scan) to determine the strength of your bones.

Symptoms

For most women, the most common symptom is that their periods stop. For around one in ten women with POI, their periods do not even start and they present with POI at a very early age, usually under 20 years. Other women may notice that their periods become irregular.

Many women experience symptoms of the menopause. However, around one in four women do not have any of these symptoms.

It can be very common to feel anxious, worried or even have feelings of hopelessness after a diagnosis of POI has been made. Some women find they feel very sad and even guilty, as having POI can affect your fertility.

Symptoms of the menopause can often have a very negative effect on your home and work life. It can be common for symptoms to come and go so you may have some months where you feel completely normal and then other times when you experience unpleasant symptoms which adversely affect the quality of your life.

Common symptoms usually include:

Hot flushes

These are the most common symptoms of the menopause and occur in around 3 out of 4 women. They usually come on very suddenly and spread through your body, chest, neck and face. They vary in length from a few minutes to much longer. They can be associated with symptoms such as sweating, dizziness, light-headedness and even palpitations of your heart. They usually occur spontaneously but can come on after drinking certain types of food or drinking alcohol, especially wine.

Night sweats

These are also very common and can be very troublesome. Many women find they wake up several times each night and are “drenched” with sweat and need to change their bed clothes and bed linen.

Mood swings

Not all women experience mood swings but for other women they can be very disruptive to their lives.

Tiredness and poor sleep

These can be related to disrupted nights’ sleep from the night sweats but many women find that they have more unsettled and less fulfilled nights’ sleep when they are perimenopausal. Even if your sleep is not affected, you may find that you are more tired than normal during the day.

Lack of libido

Reduced or absent libido (sex drive) occurs when your hormone levels fall. This can also be related to low testosterone levels in your body.

Poor concentration

It is common to find that you do not concentrate as well as you used to. Many women find that it is harder to multi-task and this can be very frustrating.

Joint pains

Oestrogen is very important at providing lubrication in your joints and can also reduce any inflammation in your joints. Low levels of oestrogen can lead to many of your joints feeling stiff and aching.

Hair and skin changes

Oestrogen is important at building collagen, the protein that supports the structure of your skin. Lower levels of oestrogen can lead to skin changes such as reduced elasticity of your skin, dry skin, fine wrinkling of the skin and your skin becoming thinner. Some women find their skin becomes itchier too.

Oestrogen is very important for your hair growth so you may notice that your hair becomes thinner and less glossy.

Depression, anxiety, panic attacks and irritability

Some women find that symptoms of depression, anxiety, panic attacks, anger and irritation worsen so much that they really interfere with the quality of their life. These symptoms can affect your emotional well-being and really add to the stress of life in general.

Poor memory

It can be common to forget words, appointments, birthdays and even doing silly things (for example putting your car keys in the fridge!). Many women find that their brain does not feel as engaged as much as it used to and this can really affect your ability to work and function.

Vaginal Dryness and Urinary Symptoms

Vaginal dryness or atrophy, also called atrophic vaginitis, is a change of your vagina which develops when there is a significant decrease in oestrogen levels. Oestrogen is important at acting as a natural lubricant in your vagina and helps to keep this area moist.

The lack of oestrogen tends to cause the tissues around your vagina to become thinner, dryer and inflamed. These changes can take months or even years to develop and vary between women.

Your vagina may shrink a little and expand less easily during sex making sexual intercourse more painful or uncomfortable. Your vulva may become thin, dry and itchy. You may find you have episodes of thrush more frequently.

The low levels of oestrogen in your body can also cause your bladder to become thinner and less elastic. This can lead to symptoms of recurrent urinary infections such as cystitis or result in you needing to pass urine more frequently.

They are very common symptoms that affect the vast majority of women at some time after the menopause. These kind of symptoms can be treated very easily. As the problem is usually due to lack of oestrogen, the usual treatment is replacing the oestrogen in your vagina and the surrounding tissues. A cream, vaginal tablet or ring containing oestrogen is often prescribed and they work really well.

Vaginal lubricants and moisturisers can be used either with hormones or on their own and are usually also very effective. These are available either from your doctor or to buy from chemists.

Long term health problems which can arise from a premature menopause

Osteoporosis

Oestrogen helps to keep your bones strong and healthy. Your body has cells which build new bone and other cells which break down old bone. When there is less oestrogen in your body then your bone breakdown occurs at a faster rate than your bone buildup, resulting in a gradual loss of bone mass. Once this loss of bone reaches a certain point, osteoporosis develops. This leads to your bones becoming less dense and less strong.

People with osteoporosis have an increased risk of fractures occurring even with little or no trauma. This can mean that normal stresses on your bones from sitting, standing, coughing or even hugging can result in painful fractures. These fractures can occur in any of your bones, including your spine, hips and wrists.

Cardiovascular Disease

This means diseases of your heart and blood vessels, so includes heart attacks and strokes. Oestrogen is very important at keeping your blood vessels healthy as it seems to have a positive effect on the inner layer of the walls of your blood vessels. This helps to keep your blood vessels flexible and healthy. With the low levels of oestrogen in your body, your risk of cardiovascular disease increases.

Other changes in your cardiovascular system can take place. Your blood pressure is more likely to start to increase. In addition, bad cholesterol, or LDL cholesterol, levels may increase and good cholesterol, or HDL cholesterol, may decline or stay the same.

Treatment

A healthy lifestyle is really important. Stopping smoking, eating a healthy, balanced diet and limiting alcohol can all be beneficial as well as participating in regular aerobic exercise. To reduce your risk of osteoporosis, eat a diet rich in calcium and partake in regular weight-bearing exercise. It is important to have adequate vitamin D levels as this is important at keeping your bones healthy. Vitamin D is made in the skin following sun exposure and is found in very small amounts in some foods. Many women need to take vitamin D tablets to have normal levels in their bodies.

Many women find that they experience anxiety symptoms or even depression when they have an early menopause. You should not be ashamed if you have these symptoms. It is really important to talk about any symptoms you may be experiencing as there is effective treatment available to help you.

Support

The Daisy Network is a charity dedicated to providing information and support to women and girls diagnosed with POI.

Last updated: January 2018