Your Guide to Primary Ovarian Insufficiency

Primary ovarian insufficiency (POI) occurs when the ovaries stop working normally before age 40. The exact cause is often unknown.

Symptoms may include:

• Hot flashes

• Vaginal dryness

• Night sweats

This condition can also lead to infertility and may increase the risk of other health concerns. 

The following guide provides information on symptoms, causes, risk factors, diagnosis, and treatment options for POI.

What is POI?

Primary ovarian insufficiency (POI), also known as premature ovarian insufficiency, occurs when your ovaries stop working normally before age 40. Previously, healthcare professionals called this “premature ovarian failure.”

In POI, the number of ovarian follicles — known as your ovarian reserve — is reduced, and the remaining follicles don’t work as they should. Follicles are small, fluid-filled sacs in the ovaries that hold immature eggs. 

Typically, one follicle matures each menstrual cycle and releases an egg during ovulation. 

In POI, this process is disrupted, and ovulation may not occur regularly.

Ovarian follicles are also the main source of estrogen during your reproductive years. When follicles don’t work properly, estrogen levels drop, which can affect your overall health and menstrual cycles.

Primary ovarian insufficiency often causes missed or irregular periods. Difficulty getting pregnant is also common.

But POI doesn’t always lead to early menopause. Many women with POI still ovulate at times, and pregnancy is still possible for some.

Other symptoms are related to low estrogen levels and may include:

• Hot flashes and night sweats (vasomotor symptoms)

• Vaginal dryness or irritation, which can cause discomfort during sex

• Sleep problems

• Mood changes, including depression or anxiety symptoms

• Decreased sexual desire

• Difficulty with concentration or memory

Low estrogen can also increase the risk of osteoporosis and heart disease.

POI often has no identifiable cause. This is called idiopathic primary ovarian insufficiency. 

One possible cause of POI is genetics. Changes in genes related to hormones like follicle stimulating hormone (FSH) and luteinizing hormone (LH) may affect ovarian function. 

Certain chromosome abnormalities, including Turner Syndrome and fragile X syndrome, also have links to POI. About 20 percent of women with the FMR1 permutation in fragile X syndrome develop POI. Other genetic disorders, such as galactosemia and ataxia-telangiectasia, may also play a role in POI.

Autoimmune diseases can lead to POI if the immune system attacks the ovaries. Conditions associated with POI include:

• Hashimoto’s thyroiditis (autoimmune hypothyroidism)

• Addison’s disease

• Lupus

• Celiac disease

• Rheumatoid arthritis

Other possible causes of POI include:

• Surgical removal of the ovaries

• Cancer treatments such as chemotherapy or radiation therapy

• Certain infections, including mumps, tuberculosis, or malaria

• Exposure to environmental toxins or pollutants

Certain factors can increase the risk of primary ovarian insufficiency. These include:

• Family history of POI in close female relatives

• Genetic or chromosomal conditions

• Autoimmune diseases

• Previous ovarian surgery, chemotherapy, or radiation therapy

While POI can happen at any age, it’s rare in women under 30. The highest incidence is seen in women between ages 35 and 39.

If you’re under 40 and experience irregular periods or haven’t had a period for four months or more, make an appointment with your healthcare provider. Your primary care provider or your local gynecology and obstetrics (OBGYN) practice are good places to start.

The diagnostic process for POI typically includes:

Medical History and Physical Exam

Your provider might ask about:

• Your symptoms and how long you’ve been having them

• If you have any relatives with POI

• Other medical conditions you’ve been diagnosed with, including genetic conditions, autoimmune diseases, or endocrine diseases

• Whether or not you’ve had pelvic surgery or gone through chemotherapy or radiation therapy

Laboratory Tests

Your healthcare provider will also do a pregnancy test. This helps rule out pregnancy as a cause for missed periods.

They’ll also order blood tests to check:

• Follicle-stimulating hormone (FSH) (usually elevated in POI)

• Luteinizing hormone (LH) (usually elevated)

• Estrogen (often low)

• Anti-mullerian hormone (often low)

Blood tests might also check the following to rule out other conditions:

• Androgens

• Prolactin

• Thyroid hormones

Genetic Testing

Your healthcare provider may also suggest genetic testing or karyotyping to look for genetic causes of POI. A karyotype looks at all of your chromosomes and can help detect chromosomal abnormalities

Imaging

Pelvic ultrasound can help assess the ovaries and other reproductive organs. If you have POI, your ovaries might appear smaller or more compact on an ultrasound.

There’s currently no treatment for POI that can restore ovarian function. 

However,  several options can help manage symptoms, lower the risk of health issues, and support fertility.

Hormone Replacement Therapy (HRT)

Healthcare providers often recommend hormone replacement therapy to replace estrogen until at least the natural time of menopause (usually 50-52 years old) regardless of symptoms. HRT can:

• Relieve symptoms such as hot flashes and night sweats

• Slow bone loss and lower the risk of osteoporosis

• Reduce the risk of heart disease

• Increase life expectancy

Estrogen therapy may involve medications such as estradiol or conjugated equine estrogens, taken by mouth or through skin patches or gels. Some HRT regimens also include progestin to protect the uterus. 

Local Estrogen Therapy

Topical estrogen treatments can help with POI symptoms like vaginal dryness. These include creams, vaginal rings, or suppositories that deliver estrogen directly to the vagina. 

Emotional Support

POI can increase the risk of depression and anxiety. Treatment may involve talk therapy, medication, or both to help manage emotional symptoms.

Lifestyle Changes

To reduce the risk of osteoporosis and heart disease, your provider might suggest:

• Eating a balanced diet with enough vitamin D and calcium

• Engaging in regular cardio exercise and strength training

• Maintaining a healthy weight 

• Getting enough sleep

• Finding effective ways to cope with stress

• Limiting alcohol intake

• Quitting smoking

POI and Pregnancy

Women with primary ovarian insufficiency may still ovulate occasionally, so spontaneous pregnancy is possible. The chance of becoming pregnant without treatment is about 5 to 10 percent. 

Contraception and POI

Your healthcare provider will likely recommend birth control if you don’t want to get pregnant, since pregnancy can still happen in people with POI.

HRT doesn’t prevent pregnancy. If you want to avoid getting pregnant, opt for nonhormonal methods, such as a copper IUD or barrier methods like condoms. 

Fertility Options With POI

If you do want to become pregnant, it’s a good idea to consult with a reproductive endocrinology specialist. This specialist can discuss fertility treatment, including in vitro fertilization (IVF).

IVF involves fertilizing an egg with sperm in a laboratory and transferring the embryo to the uterus. Women with previously frozen eggs can use them for IVF. But donor eggs often have the highest success rates. Studies show that the cumulative pregnancy rate after four IVF cycles with donor eggs is 70 to 80 percent.

There’s no way to prevent POI. But if you have a higher risk, you may want to reach out to a healthcare provider about fertility preservation. This involves saving eggs or fertilized embryos for potential future use.

You might go this route if you have:

• A family history of POI

• An upcoming pelvic surgery

• Upcoming chemo or radiation therapy

POI causes a decline in ovarian function before age 40, affecting fertility and reducing estrogen levels. This can lead to symptoms similar to menopause. It can also increase the risk for early heart disease and osteoporosis.

If you’re concerned about POI, consult a healthcare provider. They can assess your risk for POI, perform diagnostic tests, and discuss your treatment and fertility preservation options.

How common is primary ovarian insufficiency?

Researchers estimate that POI impacts 3.7% of women worldwide.

Is primary ovarian insufficiency the same as premature ovarian failure?

Yes, but premature ovarian failure is an outdated term.

At what age does primary ovarian insufficiency happen?

While POI can affect teens and young women, it’s rare. It’s more likely as you approach age 40.

How can I tell I have primary ovarian insufficiency?

Irregular or absent periods are one of the main signs of POI. You may also notice menopause-like symptoms like hot flashes, night sweats, vaginal dryness, and mood changes.

When should I see a healthcare provider?

It’s a good idea to talk to your healthcare provider if you’re under 40 and have irregular periods or haven’t had a period for four months or more. 

Can women with primary ovarian insufficiency get pregnant?

Yes, some women with POI may ovulate periodically. That means that they can still become pregnant during that time.