Premature ovarian insufficiency

Menopause usually happens in women over the age of 45 years, but if the ovaries stop working prematurely (i.e. before the age of 40 years), this is called ‘Premature Ovarian Insufficiency’ (POI).
Listen to our Hormones: The Inside Story podcast episode on menopause

Listen to our Hormones: The Inside Story podcast episode on menopause

Alternative names for premature ovarian failure

Previous terms include ‘premature ovarian failure syndrome’, ‘premature ovarian failure’ (POF).

What is Premature Ovarian Insufficiency (POI)?

Premature Ovarian Insufficiency (POI) is a condition in which the ovaries stop producing eggs unusually early (i.e. before the age of 40 years). The natural menopause generally occurs around the age of 51 years (usually between 45-55 years). Menopause before the age of 45 years can be described as ‘early menopause’.

What causes Premature Ovarian Insufficiency?

It is not always possible to identify the reason as to why POI has occurred.

However, some known causes include:

  • Genetic causes - such as Turner syndrome (whereby women have only one X chromosome), or changes in the gene responsible for Fragile X syndrome (called FMR1 gene premutation).
  • Autoimmune diseases - whereby the body treats some of its own tissues as foreign, and the immune system attacks them inappropriately. Some women with other autoimmune diseases such as type 1 diabetes mellitus, autoimmune thyroid disease, or Addison’s disease have an increased risk of POI.
  • Cancer Treatments - Chemotherapy, radiotherapy, and other cancer treatments can lead to damage to the ovaries and an increased risk of POI. The ovaries may also need to be surgically removed as part of cancer treatment which would bring on a sudden form of POI.
  • Toxins - Exposure to toxins that harm the ovaries, which can include smoking.
  • Other medical conditions - Rare inherited enzyme deficiencies e.g. galactosaemia, or infections like mumps or HIV can also increase the risk of POI.

What are the signs and symptoms of premature ovarian insufficiency?

The cessation of menstrual periods is the commonest symptom, and can be associated with other symptoms that can occur during menopause such as hot flushes, sweats, sleep disturbance and mood changes.

How common is premature ovarian insufficiency?

It is relatively uncommon, occurring in one in 1,000 women under the age of 30 years and 1-4% of women under the age of 40 years. Early menopause (less than 45 years) occurs in up to 12% of women.

Is premature ovarian insufficiency inherited?

Approximately 10% of patients with POI have a hereditary cause, such that most women with POI do not have an inherited cause. Genes can also influence the exact timing of menopause that does not occur prematurely.

How is premature ovarian insufficiency diagnosed?

Diagnosis is made by clinical assessment, with periods having stopped for at least 4 months, and by blood tests measuring hormone levels that suggest decreased function of the ovaries. In particular, a blood test for follicle stimulating hormone (FSH) levels, would be expected to show persistently elevated levels on at least two occasions more than 4-6 weeks apart. A medical practitioner may also request tests to look for causes of POI, such as antibody or genetic tests.

How is premature ovarian insufficiency treated?

Treatment is centred around replacing the hormones that the ovaries are no longer able to produce (in particular oestrogen, and additionally progesterone if the uterus is still present). Hormone replacement therapy (HRT, which is referred to as Menopause Hormone Therapy or MHT when treating women with menopause) can help with relief of menopausal symptoms, prevent bone loss, and reduce the risk of cardiovascular disease in younger women.

Premature ovarian insufficiency (POI) is usually permanent, however depending on the cause, it can wax and wane in some women soon after diagnosis, more so than after the natural menopause. With regards to fertility, in vitro fertilisation (IVF) has a low chance of success using a woman’s own eggs as POI indicates that the ovaries are not functioning well and are unlikely to respond to hormonal stimulation, but receiving donated eggs can help facilitate pregnancy.

Are there any side effects to the treatment?

HRT can cause tender breasts, water retention, weight gain, nausea, headaches and erratic vaginal bleeding. These symptoms depend on the type of HRT that is prescribed, and women should seek advice from their doctor if they have concerns about side effects of their treatment. Changing the type of preparation or adjusting the dose of hormone treatment can reduce unwanted side effects.

Longer-term use has been linked with a small increase in the risk of breast cancer discussed in more detail in the article on menopause. An increased risk of blood clots in the veins (known as venous thrombosis) and of stroke is associated with the tablet form of oestrogens in HRT, but not with other modes of administration such as patches or gels. The balance of risks vs benefits can vary for each individual woman according to her medical history and thus HRT is best discussed with a medical practitioner.

In general terms, some risks of HRT are reduced if started at a younger age (as is the case in women with POI), and sooner after the menopause has occurred. Therefore, it is usually beneficial for women with POI to take HRT until the age that the natural menopause would have occurred (usually at least 51 years).

What are the longer-term implications of premature ovarian insufficiency?

Premature ovarian insufficiency means that the ovaries are not functioning well, and therefore the chance of conceiving is much reduced. However, the function of the ovaries can wax and wane during the early years after diagnosis of POI, more so than after the natural menopause, such that spontaneous pregnancy can still occur even after the diagnosis of POI. Pregnancy is also possible through assisted conception treatments such as in vitro fertilisation (IVF) treatment, however, the success of IVF treatment is much reduced if the ovaries are not able to respond to hormonal stimulation very well, as is often the case in POI.

In the longer term, the loss of ovarian hormones, particularly oestrogens, if not replaced,  can result in osteoporosis and an increased risk of heart disease. Regular exercise is a good, general health measure that can help maintain bone health, as well as helping to protect against heart disease and stroke. Women with POI are also encouraged to stop smoking, reduce stress, and try to maintain a healthy weight to reduce the risk of heart disease.

Listen to our Hormones: The Inside Story podcast episode on menopause

Learn more about premature/early menopause at Ask Early Menopause


Last reviewed: Apr 2022