Premature Ovarian Insufficiency
Classification and frequency by age
The average age of menopause is accepted as an average of 48 years in the world and in our country. 88% of women enter menopause after age 45. Up to 10% enter menopause at the age of 40-45, with the age range of 40-45 considered as early menopause. Early ovarian failure is the ovarian function of women under 40 years of age. 1-2% under 40 years old, one in a thousand under 30 years old and one in ten thousand under 20 years old.
In 90% the reason is not clear. However, chromosome anomalies (Turner Syndrome, trisomy X etc), premutations (Fragile X), radiotherapy, chemotherapy or autoimmune diseases (Addison’s disease, hypothyroidism), previous surgery (removal of endometrioma, removal of the uterus, etc.) can be found in 10%.
Decreased ovarian function under the age of 40 is defined as early ovarian failure. This definition should not be perceived as an early menopause. Because in half of the women who have early ovarian failure, ovarian functions continue at varying levels. Defining it as early menopause may cause anxiety and depression in women. 5-10% of women diagnosed with early ovarian failure can become pregnant after giving birth.
Findings and Reasons of Consulting
Menstrual irregularity is the most common complaint. However, irregularity can occur in many ways. The woman may state that her menstrual periods have stopped completely in her first application. However, before the menstruation was cut in about half of the women; Abnormal bleeding patterns such as infrequent (the time between two start days is longer than 35 days), frequent (between the two start times is less than 21 days) or intermediate bleeding can be encountered. In this process, catching early ovarian insufficiency may give the woman time to have a chance to have a child.
Sometimes, the woman who uses the pill for protection purposes may have irregular menstrual periods or not after the pill is stopped. In this process, birth control pills do not cause early ovarian failure. Only if they are used, the woman will have regular menstruation, and when the pill is left, menstrual irregularities will appear according to the degree of failure in the ovaries.
Early ovarian insufficiency is diagnosed in 4-18% of women who previously had menstruation regularly and who did not have menstruation later. Since the ovarian functions continue intermittently in half of the women, irregular menstruation will appear more often than not having menstruation. For menstrual periods, it is generally foreseen for diagnosis, even though 4 months are not clearly determined.
Since estrogen level is variable in women with early ovarian insufficiency; Complaints such as flushing, night sweats, and vaginal dryness and sleep disorders due to estrogen deficiency may not exist at all or may be seen at varying levels.
Regardless of the form, it is beneficial to perform hormone analysis on the 2nd day of menstruation if a complaint of menstrual irregularity occurs. Repeating hormone analysis twice at least one month apart is an important factor in making the diagnosis certain. Depending on the value of the increase in FSH, the degree of failure can also be determined. In this context, Anti-Mullerian hormone preservation is envisaged as the most sensitive test in determining fertility especially in young women. The Anti-Mullerian hormone is very sensitive in showing the egg pool.
It is useful in chromosome analysis, premutation screening and research of autoimmune diseases in women who are diagnosed.
The first step of the treatment is to inform the woman correctly. Information should be made face-to-face, especially in women who are young and without risk factors, and therefore do not expect the diagnosis, and the situation should be explained with full clarity but without fear. In this case, it is important to give the woman time to understand the situation first. The conditions for having a child can be shared after this time or it can be explained during the first meeting according to the woman’s wish.
There is no proven method for maintaining fertility here. However, we know that pregnancy can be achieved in 5-10% of women in early ovarian insufficiency. If the egg pool is completely exhausted, the solution will only be to try to conceive with someone else’s egg (illegal in our country) or adopt it.
The aim of long-term therapy is to prevent negative consequences that may be due to estrogen deficiency. All respected associations about menopause in the world recommend hormone replacement therapy up to 48-50 years of age, if there is no special obstacle. The aim here is to prevent osteoporosis, prevent coronary heart disease, flushing, sweating, mood disorders and fight vaginal dryness.
It is important to try to idealize the lifestyle with hormone therapy. If smoking is allowed, it must be quit, weight control must be ensured, adequate vitamin D and calcium must be taken and regular exercise must be done. Exercise should definitely include cardio selection, and ideal walking time should be tried, which is 150 minutes a week.
Women with early ovarian insufficiency are in the young population and the risk of coronary heart disease and breast cancer is relatively lower than women who enter menopause at normal time. However, as estrogen protection will end early, heart disease risks will be higher in the long term. Therefore, both the use of hormone therapy and the regulation of lifestyle according to these facts will reduce the risks.
During follow-up and treatment, gynecological examination, pap smear, blood biochemistry, mammography, breast ultrasonography, bone density measurements and tests specific to the condition of the woman should be repeated with the frequency exactly appropriate to the condition of the woman and clinical evaluation should be done at least once a year.