Primary ovarian insufficiency

The signs and symptoms of POI can be seen as part of a continuum of changes leading to menopause. Hormonally, POI is defined by abnormally low levels of estrogen and high levels of FSH, which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. The ovaries will likely appear smaller than normal. The age of onset can be as early as 11 years. POI can be seen as part of a continuum of changes leading to menopause that differ from age-appropriate menopause in the age of onset, degree of symptoms, and sporadic return to normal ovarian function. A contrasting problem can be when a girl never begins menstruation due to a genetic condition causing primary amenorrhea. ==Causes==

The cause of POI is idiopathic in 39-67% of cases. Hashimoto thyroiditis, Addison disease, type I diabetes mellitus, pernicious anemia, genetic disorders such as Turner syndrome, Trisomy X, and Fragile X syndrome, metabolic defects, and enzyme defects. Chemotherapy and radiation treatments (especially radiation to the pelvis) for cancer can sometimes cause POI. The effect of chemotherapy or radiation is variable and in a mouse model, with results consistent with observations in humans, cyclophosphamide can result in an 87% reduction in primordial follicles 72 hours after administration. ==Mechanism==

The pathogenic mechanisms of POI are highly heterogeneous and can be divided into four major categories: follicular migration defect early in embryogenesis; an early decrease in the primordial follicles; increased follicular death; and altered maturation or recruitment of primordial follicles. Genetic causes such as Turner syndrome have initial ovarian development but then ovaries degenerate rapidly during prenatal life, often leading to gonadal dysgenesis with streak ovaries. In those cases where POI is associated with adrenal autoimmunity, histological examination almost always confirms the presence of an autoimmune oophoritis in which follicles are infiltrated by lymphocytes, plasma cells, and macrophages that attack mainly steroid-producing cells and eventually result in follicular depletion. (Since the serum Anti-Müllerian hormone (AMH) level is correlated with the number of remaining primordial follicles some researchers believe the above two phenotypes can be distinguished by measuring serum AMH levels. Genetic associations include genetic disorders, DNA repair deficiency BRCA1 protein plays an essential role in the repair of DNA double-strand breaks by homologous recombination. Women with a germline BRCA1 mutation tend to have premature menopause as evidenced by the final amenorrhea appearing at a younger age. BRCA1 mutations are associated with occult POI. Impairment of the repair of DNA double-strand breaks due to a BRCA1 defect leads to premature ovarian aging in both mice and humans. In addition to BRCA1, the MCM8-MCM9 protein complex also plays a crucial role in the recombinational repair of DNA double-strand breaks. In humans, an MCM8 mutation can give rise to premature ovarian failure, as well as chromosomal instability. MCM9, as well as MCM8, mutations are also associated with ovarian failure and chromosomal instability. The MCM8-MCM9 complex is likely required for the homologous recombinational repair of DNA double-strand breaks that are present during the pachytene stage of meiosis I. In women homozygous for MCM8 or MCM9 mutations, failure to repair breaks apparently leads to oocyte death and small or absent ovaries. ==Diagnosis==

The diagnosis is based on age less than forty, amenorrhea, and two elevated serum follicle-stimulating hormone (FSH) and decreased estrogen measurements at one-month intervals. The anterior pituitary secretes FSH and LH at high levels to try to increase the low estrogen levels that are due to the dysfunction of the ovaries. Typical FSH in POI patients is over 40 mlU/ml (post-menopausal range). The evaluation of amenorrhea for other common causes includes checking a blood pregnancy test, checking the prolactin level, as prolactinomas or certain medications can increase prolactin levels and lead to amenorrhea, and checking the thyrotropin (thyroid hormone) level, as hypothyroidism can cause amenorrhea. A karyotype (to evaluate for Turner's Syndrome) and a Fragile-X premutation carrier analysis is also recommended, with additional genetic testing possibly being warranted based on family history of amenorrhea or early menopause or signs and symptoms of a genetic disorder. ==Treatment==

Fertility Between 5 and 10% of women with POI may become pregnant with no treatment. Results from studies on DHEA in 2010 indicated that DHEA may increase spontaneously conceived pregnancies, decrease spontaneous miscarriage rates and improve IVF success rates in women with POI. This includes women referred for donor eggs or surrogacy in 2009. In 2018, there was no significant improvement in ovarian function by 12-month on DHEA supplementation in women with POI. In 2013, Kawamura in Japan and his collaborators at Stanford University published treatment of infertility of POI patients by fragmenting ovaries followed by in vitro treatment of ovarian fragments with phosphatidylinositol-3 kinase activators to enhance the AKT pathway followed by autografting. They successfully promoted follicle growth, retrieved mature oocytes, and performed in vitro fertilization. Following embryo transfer, a healthy baby was delivered. A 2020 review covered variations including phosphatidylinositol-3 kinase activators to enhance the AKT pathway, fragmentation of ovarian cortex, combining those two into in-vitro activation (IVA), and drug-free IVA. Two laparoscopies are needed in conventional IVA and one with drug-free IVA. The transdermal estradiol patch also provides the replacement by steady infusion rather than by bolus when taking daily pills. There is also an increased risk with valvular heart disease and cardiomyopathy. To avoid the development of endometrial cancer, young women taking estradiol replacement need to also take a progestin in a regular cyclic fashion. The most evidence supports the use of medroxyprogesterone acetate daily for days 1-12 of each calendar month. This will induce regular and predictable menstrual cycles. It is important that women taking this regimen keep a menstrual calendar. If the next expected menses is late, it is important to get a pregnancy test. If this test is positive, the woman should stop taking the hormone replacement. Approximately 5-10% of women with confirmed POI conceive a pregnancy after the diagnosis without medical intervention. In observational studies, hormone replacement therapy in women with primary ovarian insufficiency and other causes of early menopause was associated with a lower risk of cardiovascular disease, increased bone density, and a reduced mortality. ==Prognosis==

Primary ovarian insufficiency is associated with co-morbidities associated with menopause including osteoporosis (decreased bone density), which affects almost all women with POI due to an insufficiency of estrogen. There is also an increased risk of heart disease, Emotional health The most common words women use to describe how they felt in the two hours after being given the diagnosis of POI are "devastated", "shocked," and "confused." The diagnosis is more than infertility and affects a woman's physical and emotional well-being. Some have advocated formation of a patient registry as well as a community-based research consortium with integrative care to better understand the etiology and treatment of the condition, including treatment of its psychological effects. Women with POI perceive lower social support than control women, so building a trusted community of practice for them would be expected to improve their well-being. Also, when having that social support, it often helps with reducing stress and having better coping skills. It is important to connect women with POI to an appropriate collaborative care team because the condition has been clearly associated with suicide related to the stigma of infertility. ==Epidemiology==

The prevalence increases with age and is approximately 1 in 10,000 women under age 20, 1 in 1,000 women under age 30, and one percent by age of 40. It occurs in 3.7% of women worldwide and 1% of women in the United States. In the United States, the incidence is 1% in White women, 1.4% in Black and Hispanic women, with lower rates seen in Chinese and Japanese women, at 0.5% and 0.1% respectively. ==History==

Fuller Albright et al. in 1942 reported a syndrome with amenorrhea, estrogen deficiency, menopausal FSH levels, and short stature. They used the term "primary ovarian insufficiency" to distinguished POI from ovarian insufficiency secondary to a primary failure of pituitary FSH and other hormonal secretion. POI has been described as a more accurate and less stigmatizing term than premature ovarian failure == References ==