Premature Ovarian Insufficiency (POI)

By Dr. Bolanle Aderehinwo.

Introduction

A child is said to be Premature if it is born before 37 completed weeks of gestational life likewise is anything that happened before the time allotted for it.

Researches have shown that the average age for menopause is 51yrs and that complete cessation of flow before 40yrs is termed Premature Menopause of which the major causative factor is Ovarian insufficiency or failure even at that age.

Premature Ovarian Insufficiency also referred to as Premature Ovarian failure, Premature menopause, early menopause is when the ovaries stopped functioning before the age of 40.

The ovaries are both endocrine and reproductive organs, the stoppage of these 2 functions brings about Premature menopause or infertility. Most of the time, the ovary will regain its functionality intermittently hence the word insufficiency is used and preferred more than the word failure.

Premature Ovarian Insufficiency is more than just the ovaries stopping their functions and if we really want to understand it, we must get some medical knowledge. I will try to explain in clear terms below:

  1. The functions of the ovaries are regulated fully by hormones. Any imbalance in the hormones secreted by the brain to function at the ovaries will lead to delay functionality or absence of functions. 
  2. A lady at puberty has about 300,000-400,000 Ovarian in her ovaries, as against 2 million ova at birth due to the gradual decrease in their numbers as the female ages. The higher the age the more the numbers of ova decrease. 
  3. These ova (surrounded by fluid filled sac called follicles) are important for normal ovulation. One or two (one from each ovary) of them mature every month even though many of them are destined to die a natural death or shrink up. The follicles secrete hormones that help the brain and the ovaries by regulating their functions in relation to reproduction and menstruation. When these follicles get depleted untimely, their hormones will reduce significantly and there will be disruption in the normal processes that should lead to menstruation and fertility. 
  4. The endocrine (hormone secreting) function of the ovaries also regulates the lining of the womb, thins and thickened to be shed later as blood. Once this function is lacking, there will be no Menstrual flow or it will be very few. 
  5. The ovary releases ovum monthly which gets to be fertilized by the spermatozoon to become a zygote then a fetus which comes out as a baby. When the ovaries failed to release the ovum, usually due to reduction in Ovarian reserve, this is reproductive failure leading to infertility
  6. Reproduction is a great concern in POI as much as menopause. For example, a 35yr old newly married woman with POI will be greatly concern about the 2 problems (menopause and infertility)

Prevalence of POI

POI is highest in Caucasian, African American and Hispanic women. In a paper written in the year 2018 by the department of gynecological endocrinology, medical university of Warsaw in Poland, it was stated that the risk of having Premature Ovarian Insufficiency in a woman is 1%.

It’s prevalence according to age is 1 in 10,000 at the age of 18-25 years, 1 in 1000 at age 25-30 years and 1 in 100 in the age range of 35-40. With this, we can conveniently say it is rare in young adults and very rare in teenagers in that part of the world.

A research conducted in the University of Nigeria concluded that this condition is common in our environment affecting also 1% of women under the age of 40 years.

Causes Of POI

Imagine being diagnosed at a young age of this condition, the big question in the mind will be WHY. The following are various causes of Premature Ovarian Insufficiency.

  1. Unknown causes. Majority of cases are due to unknown causes so are termed spontaneous. This can  be used in cases of reduction in Ovarian reserves, that is, no more functioning follicle in the ovaries. 
  2. Genetic factors. Here the state of the ovary and its reduced functionality have been predetermined by the woman’s genetic composition. A normal female has 46XX but some women are 45X0, this severely manifests in the ovary disrupting its structure and function. Other genetic conditions like down syndrome or the ones due to mutations can result in Ovarian dysfunction. 
  3. Cells of the body attacking one another. This is called autoimmunity. Some diseases that involve the many cells of the immune system digesting the body cells including Ovarian cells can lead to POI. 
  4. Metabolic disorder. Some metabolic disorders involve deficiency of hormones that regulates the functions of the ovaries especially its endocrine functions and subsequently its reproductive functions. 
  5. Exposure to Radiation and dangerous chemicals. Radiation can affect cells of the ovaries likewise some medications especially those used in treatment of cancers. 
  6. Surgery. Surgery at the pelvis or surgery to remove the ovaries. Any pelvic surgery at all has a risk of affecting the blood supply to the ovaries which need blood, nutrients and oxygen to survive. 
  7. Infection: some viruses like cytomegalovirus and mumps virus have been associated with POI. 
  8. Environmental pollution: substances like hydrocarbons, pesticides and cigarette smoke have been found to be associated with POI. 
  9. Brain tumor. As said earlier, the brain controls Ovarian functions hence having a tumor or growth in the brain that affects its secretion of the hormones meant to stimulate the ovaries may cause POI. 
  10. Excessive bleeding at child birth to the extent that there is no blood flow to the part of the brain that controls the ovaries can cause POI. 
  11. Eating disorders like loss of appetite to the point of starvation. 
  12. Psychiatry disorders.

Symptoms of POI

There could actually be no symptoms at all for a while, functions of the ovaries may not totally cease but become intermittent and unpredictable. In cases of symptoms, you are likely to find the following. 

  1. Symptoms having to do with low estrogen like hot flashes, night sweats, vaginal dryness, sleep disturbances, mood changes e.t.c
  2. Lack of monthly flow. 
  3. Weak bones that can lead to fracture. 
  4. Infertility. 
  5. Symptoms of an underlying disease or genetic disorder. For example, those mentioned in the cause list above. 

Number 1 and 2 above may not be a permanent problem yet as the ovaries regain functions in between.

Treatment of POI

On noticing symptoms, if the woman will present to a gynaecologist for evaluation, she will be asked to run some tests like hormonal profiles, this is to rule out other conditions that look like POI. She may also be asked to do another test to know the specific cause in her so as to have a proper treatment plan.

 It is important that the doctor explain in detail the disease process so the woman can know that the ovaries can spontaneously recover. Young women can be devastated hearing that they have POI hence the service of a psychologist may be implored by the doctor. 

In cases of infertility, donor eggs for IVF or adoption are the available options. There’s usually no treatment once there’s infertility. 

Hormones lacking can be replaced, if not to restore Ovarian functions but at least to relieve bone symptoms and prevent fractures. 

It is recommended that women with POI should consume 1200-1500mg of calcium daily in diet or at least as a supplement with enough intake of vitamin D. 

All women with POI are advised to participate in sports and make adequate exercise a routine.

In conclusion, Premature Ovarian Insufficiency is not a mild disease as it can significantly reduce the woman’s quality of life both physiologically and psychologically. Anyone with this should be critically evaluated and cared for.

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