Premature ovarian failure — also known as primary ovarian insufficiency — refers to a loss of normal function of your ovaries before age 40. If your ovaries fail, they don't produce normal amounts of the hormone estrogen or release eggs regularly. Infertility is a common result.
Premature ovarian failure is sometimes referred to as premature menopause, but the two conditions aren't exactly the same. Women with premature ovarian failure may have irregular or occasional periods for years and may even become pregnant. Women with premature menopause stop having periods and can't become pregnant.
Restoring estrogen levels in women with premature ovarian failure helps prevent some complications, such as osteoporosis, but infertility is harder to treat.
Signs and symptoms of premature ovarian failure are similar to those experienced by a woman going through menopause and are typical of estrogen deficiency. They include:
- Irregular or skipped periods (amenorrhea), which may be present for years or may develop after a pregnancy or after stopping birth control pills
- Hot flashes
- Night sweats
- Vaginal dryness
- Irritability or difficulty concentrating
- Decreased sexual desire
When to see a doctor
If you notice that you've skipped your period for three months or more, see your doctor to help determine what may be the cause. You may miss your period for a number of reasons — including pregnancy, stress, or a change in diet or exercise habits — but it's best to get evaluated whenever your menstrual cycle changes.
Even if you don't mind that your periods have stopped, it's still wise to see your doctor and try to find out what's causing the problem. If your estrogen levels are low, bone loss can occur.
In women with normal ovarian function, the pituitary gland releases certain hormones during the menstrual cycle, which causes a small number of egg-containing follicles in the ovaries to begin maturing. Usually, only one follicle — a sac that's filled with fluid — reaches maturity each month.
When the follicle is mature, it bursts open, releasing the egg. The egg then enters the fallopian tube where a sperm cell might fertilize it, resulting in pregnancy.
Premature ovarian failure results from one of two processes — follicle depletion or follicle disruption.
Causes of follicle depletion include:
- Chromosomal defects. Certain genetic disorders are associated with premature ovarian failure. These include Turner's syndrome, a condition in which a woman has only one X chromosome instead of the usual two, and fragile X syndrome, a major cause of intellectual disability (intellectual development disorder), formerly called mental retardation.
- Toxins. Chemotherapy and radiation therapy are the most common causes of toxin-induced ovarian failure. These therapies may damage the genetic material in cells. Other toxins such as cigarette smoke, chemicals, pesticides and viruses may hasten ovarian failure.
Follicle dysfunction may be the result of:
- An immune system response to ovarian tissue (autoimmune disease). Your immune system may produce antibodies against your own ovarian tissue, harming the egg-containing follicles and damaging the egg. What triggers the immune response is unclear, but exposure to a virus is one possibility.
- Unknown factors. If you develop premature ovarian failure through follicular dysfunction and your tests indicate that you don't have an autoimmune disease, further diagnostic studies may be necessary. An exact underlying cause often remains unknown.
Factors that increase your risk of developing premature ovarian failure include:
- Age. The risk of ovarian failure rises sharply between age 35 and age 40.
- Family history. Having a family history of premature ovarian failure increases your risk of developing this disorder.
Complications of premature ovarian failure include:
- Infertility. Inability to get pregnant may be the most troubling complication of premature ovarian failure, although in rare cases, pregnancy is possible.
- Osteoporosis. The hormone estrogen helps maintain strong bones. Women with low levels of estrogen have an increased risk of developing weak and brittle bones (osteoporosis), which are more likely to break than healthy bones.
- Depression or anxiety. The risk of infertility and other complications arising from low estrogen levels may cause some women to become depressed or anxious.
Your first appointment will likely be with your primary care physician or a gynecologist. If you're seeking treatment for infertility, you may be referred to a doctor who specializes in reproductive hormones and optimizing fertility (reproductive endocrinologist).
What you can do
To get ready for your appointment, you can:
- Make a list of any symptoms you've had and for how long
- Track your menstrual cycles, or lack of menstrual cycles, noting particulars such as the dates when they start and stop or how long ago your last cycle was
- List your key medical information, including other conditions for which you're being treated and any medications, vitamins or supplements you're taking
- Take a family member or friend along, if possible, to help you remember all the information you'll receive
- List questions to ask your doctor, putting them in order of importance, in case time runs out
For premature ovarian failure, some basic questions to ask your doctor include:
- What's the most likely cause of my irregular periods?
- Are there any other possible causes?
- What tests do I need to find out why I'm having this problem?
- What treatments are available? What side effects can I expect?
- How will these treatments affect my sexuality?
- What do you feel is the best course of action for me?
- What are the alternatives to the primary approach you're suggesting?
- I have other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see a specialist? Will my insurance cover it?
- Do you have any printed material I can take with me? What websites do you recommend?
Questions your doctor may ask
To gain a better understanding of what you're going through, your doctor may ask you several questions, such as:
- Do you have occasional menstrual periods or no periods at all?
- Are you experiencing hot flashes, vaginal dryness or other menopausal symptoms?
- How long have you had your symptoms?
- Have you ever had ovarian surgery?
- Have you been treated for cancer?
- Do you or any family members have any systemic or autoimmune diseases, such as hypothyroidism or lupus?
- Have any members of your family been diagnosed with premature ovarian failure?
- How distressed do your symptoms make you feel?
- Do you feel depressed?
- Did you have any difficulties with previous pregnancies?
- Have you experienced unexplained weight gain or weight loss?
- What medications or vitamin supplements do you take?
Don't hesitate to ask questions during your appointment as they occur to you. It's important that you understand the reason for any tests or treatments that are recommended.
To make a diagnosis of premature ovarian failure, your doctor may ask about your signs and symptoms, your menstrual cycle, and a history of exposure to any toxins, such as chemotherapy or radiation therapy, which cause direct injury to follicles and eggs. Most women have few signs of premature ovarian failure, but you'll likely have a physical exam, including a pelvic exam.
Your doctor may also recommend one or more of these tests:
- Pregnancy test. This test checks for the possibility of an unexpected pregnancy in a woman of childbearing age who has missed a period.
- Follicle-stimulating hormone (FSH) test. FSH is a hormone released by the pituitary gland that stimulates the growth of follicles in your ovaries. Women with premature ovarian failure often have abnormally high levels of FSH in the blood.
- Estradiol test. The blood level of estradiol, a type of estrogen, is usually low in women with premature ovarian failure.
- Prolactin test. High levels of prolactin — the hormone that stimulates breast milk production — in your blood can lead to problems with ovulation.
- Karyotype. This is a test that examines all 46 of your chromosomes for abnormalities. Some women with premature ovarian failure may have only one X chromosome instead of two or may have other chromosomal defects.
- FMR1 gene testing. The FMR1 gene is the gene associated with fragile X syndrome — an inherited disorder that causes intellectual problems. The FMR1 test looks at both of your X chromosomes to make sure they appear to be normal.
Treatment for premature ovarian failure usually focuses on the problems that arise from estrogen deficiency. Your doctor may recommend:
Estrogen therapy. To help prevent osteoporosis and relieve hot flashes and other symptoms of estrogen deficiency, your doctor may recommend estrogen therapy to compensate for the estrogen your ovaries no longer produce. Estrogen is typically prescribed with another hormone called progesterone. Adding progesterone protects the lining of your uterus (endometrium) from precancerous changes caused by taking estrogen alone. The combination of hormones may cause vaginal bleeding again, but it won't restore ovarian function. Depending on your health issues and personal choice, you may continue taking hormonal therapy until around age 50 or 51 — the average age of natural menopause.
In older women, long-term estrogen plus progestin therapy has been linked to an increased risk of heart and blood vessel (cardiovascular) disease and breast cancer. In young women with premature ovarian failure, however, the benefits of hormone replacement therapy for heart health may outweigh the potential risks.
Calcium and vitamin D supplements. Both calcium and vitamin D are important for preventing osteoporosis. If you don't get enough of them through your diet, your doctor may recommend supplements. Your doctor may suggest bone density testing before starting supplements to get a baseline bone density measurement.
For women ages 19 through 50, the Institute of Medicine recommends 1,000 milligrams (mg) of calcium a day through food or supplements, increasing to 1,200 mg a day for women age 51 or older. Scientists don't yet know the optimal daily dose of vitamin D. A good starting point for adults is 600 to 800 international units (IU) a day, through food or supplements. If your blood levels of vitamin D are low, your doctor may suggest higher doses.
Infertility is a common complication of premature ovarian failure. There's no treatment proved to restore fertility in women with this condition. It's important to understand and grieve for this loss of ovarian function and to seek counseling if you need it.
Some women and their partners choose to pursue a pregnancy through in vitro fertilization using donor eggs. The procedure involves removing eggs from a donor and fertilizing them with your partner's sperm in a lab. The fertilized egg (embryo) is then placed in your uterus. During this process, you take medication that balances your hormones to support a pregnancy. Once the pregnancy is established, you stop taking the medication and the pregnancy proceeds naturally to the delivery.
Learning that you have premature ovarian failure may be emotionally difficult. But with proper treatment and self-care, you can expect to lead a healthy life.
- Learn about alternatives for having children. If you'd like to add to your family, talk to your doctor about options such as in vitro fertilization using donor eggs or adoption.
- Talk with your doctor about the best contraception options. A small percentage of women with premature ovarian failure do spontaneously conceive. If you don't want to become pregnant, consider using birth control.
- Keep your bones strong. Women who produce low levels of the hormone estrogen are at an increased risk of developing osteoporosis. Work on maintaining strong bones. To do that, eat a calcium-rich diet, ask your doctor if you need calcium and vitamin D supplements, do weight-bearing exercises such as walking and strength-training exercises for your upper body, and avoid smoking.
If you'd hoped for future pregnancies, a diagnosis of premature ovarian failure can bring on overwhelming feelings of loss — even if you've already been pregnant and given birth. Grief is a normal feeling during this time.
To better cope:
- Be open with your partner. Talk with and listen to your partner as you both share your feelings over this unexpected change in your plans for growing your family.
- Explore your options. If you wish to have more children, look into alternatives to expand your family such as donor-egg in-vitro fertilization or adoption.
- Seek support. Talking with others who are going through the same thing can provide valuable insight and understanding during a time of confusion and uncertainty. Counseling may be of particular benefit as you adjust to your circumstances and the implications for your future. Ask your doctor if he or she knows of any national or local support groups or seek out an online community as an outlet for your feelings and as a source of information.
- Give yourself time. Coming to terms with your diagnosis is a gradual process. In the meantime, take good care of yourself by eating well, exercising and getting enough rest.
- Find other ways to have children in your life. Consider mentoring a child at your local chapter of the Boys & Girls Club of America. Become more involved with nieces or nephews or with children of your close friends.
Feb. 12, 2014
- Shelling AN. Premature ovarian failure. Reproduction. 2010;140:633.
- Nelson LM, et al. Clinical manifestations and evaluation of spontaneous primary ovarian insufficiency (premature ovarian failure). http://www.uptodate.com/home. Accessed Aug. 27, 2013.
- Lentz GM, et al. Comprehensive Gynecology. 6th ed. Philadelphia, Pa.: Mosby Elsevier; 2012. http://www.clinicalkey.com. Accessed Aug. 27, 2013.
- Welt CK. Pathogenesis and causes of spontaneous primary ovarian insufficiency (premature ovarian failure). http://www.uptodate.com/home. Accessed Aug. 27, 2013.
- Rafique S, et al. A new approach to primary ovarian insufficiency. Obstetrics & Gynecology Clinics of North America. 2012;39:567.
- Nelson LM, et al. Management of spontaneous primary ovarian insufficiency (premature ovarian failure). http://www.uptodate.com/home. Accessed Aug. 27, 2013.
- Ross AC, et al. Dietary reference intakes for calcium and vitamin D. Institute of Medicine. http://www.nap.edu/openbook.php?record_id=13050&page=1. Accessed Aug. 26, 2013.
- Coddington CC (expert opinion). Mayo Clinic, Rochester, Minn. Sept. 16, 2013.
- Questions and answers about estrogen-plus-progestin hormone therapy. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/women/q_a.htm. Accessed Sept. 5, 2013.
- Schierbeck LL, et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: Randomised trial. BMJ. 2012;345:e6409.