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Premature Ovarian Insufficiency (POI)

Checked: 23-01-2022 by Vicky Ryan Next Review: 23-01-2024

Overview

Premature Ovarian Insufficiency (POI) is defined as the loss of ovarian function before the age of 40 and has a prevalence of 1%. It is important to recognise the 5% chance of pregnancy so contraception should be discussed, if appropriate.

Causes of POI include:

Idiopathic (largest group)
Chromosomal/Genetic defects (10%) including Turner’s syndrome and Fragile X
Autoimmune disease
Chemotherapy
Radiotherapy
Surgery

Untreated, women with POI have a reduced life expectancy due to cardiovascular disease, as well as a reduction of bone mineral density. HRT until the age of 51 (average age menopause) is cardioprotective, improves bone density, but does NOT increase breast cancer risk up to this age.

Diagnosis

Oligo/amenorrhea for at least 3 months
*FSH > 30IU/l on 2 occasions > 4 weeks apart
+/- menopausal symptoms which may fluctuate

*FSH not to be taken on combined oral contraceptive pill – needs at least 3 months off this before testing.

Who to refer

Please refer ALL women with suspected or confirmed POI to Gynaecology via ERS.

Before referral

The following investigations should be requested prior to referral:

TEST	POSITIVE RESULT
TSH	Manage according to Hypothyroid pathway
Thyroid antibodies	Annual TSH monitoring
Adrenal antibodies	Highlight within referral letter
HbA1c	Manage according to CKS Type 2 Diabetes Guidelines
Lipids	CVD risk score for all at diagnosis
FBC/B12/folate/ferritin	Intrinsic Factor antibody if low B12

Management in Primary Care

Hormone replacement therapy should be actively encouraged in women with POI, to prevent cardiovascular disease and offer bone protection. There is no increased risk of breast cancer before the average age of menopause.

Estradiol, either orally or transdermally, is the oestrogen of choice. This is usually required at higher doses in the region of 75 – 100mcg transdermally or 2-4mg orally. This should be combined with progesterone in women with an intact uterus.

If contraception is required, or a woman chooses this treatment instead of HRT, then Qlaira is the preferred option, as it contains estradiol and offers a reduced hormone-free interval. However, it is important to recognise that it may not offer the same level of bone protection as HRT.

Women with POI often suffer more severe urogenital symptoms and may require a combination of vaginal oestrogen and systemic HRT.

Referral

Referrals should be made to Gynaecology via e-RS

St Michael’s Hospital, Paediatric and Adolescent Gynae service will see adult patients with Turner Syndrome.

Resources

Please also see the Menopause page of Remedy.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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