Premature Ovarian Insufficiency (POI) is defined as ovarian failure under the age of 40years. Prevalence is estimated to be 1%. Women in this group are at increased risk of cardiovascular disease, osteoporosis and cognitive impairment. Untreated, women will have a reduced life expectancy.
HRT until the age of 51 (average age of menopause) is cardioprotective, improves bone density, and does not increase breast cancer risk above the baseline risk of a woman of the same age with ovarian function. Therefore, HRT should be discussed with and offered to all women with POI (regardless of symptoms), as well as appropriate lifestyle interventions.
Consider repeating FSH level if one normal and one abnormal result in the context of on-going symptoms or concerns, or risk factors present.
Refer all women with a new diagnosis of POI to an appropriate specialist service for review. This may be a specialist in Primary Care, Complex Menopause clinic, Reproductive Medicine clinic, Fertility clinic or Paediatric Adolescent Gynaecology, dependent on patient factors.
Hormone replacement in the form of hormone replacement therapy (HRT) or the combined oral contraceptive pill (COC) should be recommended for all women (unless contra-indicated) up until the age of 51. This should be started at the time of referral.
There is on-going national research to determine whether HRT or COC is a better management strategy for POI (Home - Poise)
Hormone Replacement Therapy (HRT) |
Combined Oral Contraception (COC) |
Physiological hormone replacement Likely to sustain long-term health benefits (bones, cardiovascular) Beneficial effect on BP Different oestrogen formulations may have different risks and benefits Not contraceptive Cost implications – HRT pre-payment certificate available (cost of 2 prescriptions for 1y supply) |
Offers contraception Free May be more socially acceptable by younger women May reduce stigma asc. with menopause Consider tricycling to reduce frequency of hormone free interval (off license) |
Qlaira ® (estradiol valerate, dienogest) (TLS Amber Specialist Recommended) is an option for patients with premature ovarian insufficiency requiring contraception and HRT cover where standard oral contraceptives are not suitable and patients have completed puberty.
Lifestyle advice
As with all women established on HRT, those with POI should have an annual review to include – effectiveness of treatment, side effects, bleeding pattern, type and dose of hormone replacement, risk factors for bone health, and to assess ongoing risk vs benefit. Routine BP and BMI should be documented annually.
Women with POI can have intermittent ovarian activity and have a small chance of spontaneous pregnancy, estimated to be 5-10%. For women wishing to pursue fertility outcomes, it is beneficial for them to have a regular bleed and therefore they should be advised to use sequential HRT or COC.
Contraception should be discussed and offered as appropriate. HRT is not contraceptive. The COC can be used as an alternative to HRT and offers both hormone replacement and contraception.
Women wishing to discuss their fertility options can be referred to the Reproductive Medicine clinic for advice, or advice can be sought via the Advice and Guidance service. Those actively trying to conceive should be referred in line with local policy ( Infertility Assessment and Treatment Policy.docx). As per the policy women with proven POI would be eligible for immediate referral for fertility assessment and treatment once fertility is desired (and do not have to have been trying for 2 years), providing they meet all other criteria. As success with IVF with a woman’s own eggs in the context of POI is extremely low, those with a POI diagnosis would be eligible for IVF with egg donation but not for treatment with their own eggs.
Please refer all women with suspected or confirmed POI for specialist review in the most appropriate service. Referrals should be made via eRS to gynaecology or menopause clinic, or if fertility is a concern, reproductive medicine as indicated.
Please do start hormone replacement therapy in the meantime.
At time of referral please arrange the following investigations, if not already done, and manage as appropriate
TEST |
POSITIVE RESULT |
2 x FSH |
For diagnosis |
Estradiol |
(For those using transdermal HRT) |
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 (Vitamin B12 (Remedy BNSSG ICB)) |
Assess bone health |
Please include any risk factors in the referral and request imaging if indicated (see above) |
Patient Information
Charity for Women with POI | The Daisy Network
BRITSPAG HRT in Young Women - HRT-BritSPAG-Information-Leaflet-2019.pdf
ESHRE Patient information leaflets – 2 leaflets available Iatrogenic and Non-iatrogenic Recommended patient information (eshre.eu)
Food for healthy bones - NHS (www.nhs.uk)
Exercise - NHS (www.nhs.uk
19-WHC-FACTSHEET-Osteoporosis-Bone-NOV2022-B.pdf (womens-health-concern.org)
References
BMS Premature Ovarian Insufficiency Consensus Statement - Premature ovarian insufficiency - British Menopause Society (thebms.org.uk)
ESHRE Guidelines – Management of Premature Ovarian Insufficiency Guideline on the management of premature ovarian insufficiency (eshre.eu)
FRAX calculator - frax.shef.ac.uk/FRAX/tool.aspx?country=1
PCWHF_A-guide-to-managing-POI-in-primary-care_v2.pdf
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