Guernsey Women Health Information
- Reported, January 23, 2012
 The
condition characterized by elevated gonadotrophins (gonadotropins elevated into
the menopausal range), low sex steroids, and menstrual disorders was previously
termed Premature Ovarian Failure (POF). However, over the last two years an
effort has been made by many authors to have the term Primary Ovarian
Insufficiency (POI) exclusively applied. Irrespective of the term, the condition
concerns adolescent and young adult women under 40 years who experience
cessation of menstruation for more than 3 cycles (whereas these women in the
past had a rhythmic menstrual cycle) or amenorrhea for 4–6 months against the
background of a previously disturbed menstrual cycle. Determining the cause of
POI is difficult, and it is even harder to deal with problems arising from the
paucity of estrogen as well as to draw up the plan for long-term monitoring of
these patients. This paper presents long-term therapeutic management strategies
concerning emotional health, hormone replacement therapy, maintenance of bone
health, family planning, other associated disorders as well as possible research
options for the future.
An important problem in treating these patients is that it is difficult to
announce the medical situation to both the teenage girl and her parents. The
most common words young patients use to describe how they feel after receiving
the diagnosis are “shocked,” “confused,” and “devastated” .The family feel
themselves confronted by an immense problem that will affect their daughter's
capacity for fertilization while also creating in them a feeling of
“stigmatization” as well as an acute sense of anxiety and insecurity.
When parents have fully understood the problem of their teenage daughter, they
can help her emotionally and further provide her with support at different times
when the teenage experiences emotional swings. Parents must be aware that
talking about POI with their daughter is an ongoing process. Responses should be
short and clear. Dialogue must always be encouraged, and emotional feedback has
to be obtained periodically. Should the patient's questions seem irrelevant,
parents need to understand what the hidden message is. The patient's outlook
should be encouraged to be positive, and her emotional state must be
externalized. Parents must help their daughter develop a sense of herself and
her purpose beyond biological motherhood. Since the patient may become secretive
and withdrawn, both the adult adolescent patient and her parents need to seek
out resources for support. Patients' parents should share their faith or sources
of hope and understanding with the child . All the above-mentioned procedures
are long-lasting and have to form the basis for a peaceful environment in which
such teenagers will grow up in.
Hormone Replacement Therapy (HRT)
Contrary to the case of menopausal , teenagers need to treat POI via long-term
therapy, which not infrequently may be necessary even before puberty. The
combined hormone therapy (oestrogen + progestin) should not be administered
before the completion of puberty (full development of secondary sexual
characteristics). Previously there were no guidelines on dosage and styles of
hormones. However, recently the ACOG published a Committee Opinion (Number 502)
on Adolescent Health Care . Suggested doses and available routes in the
prepubertal patient are 25-microgram estradiol-17ß transdermal patch (or 0.3
milligram conjugated estrogen orally or 0.2–0.5 milligram micronized estradiol
orally) and 2.5–5 milligrams/day oral medroxyprogesterone acetate for 12–14 days
every 30–60 days (or 100 milligrams/day oral micronized progesterone for 12–14
days every 30–60 days).
In the postpubertal patient treatment options can include combined hormone
contraception or hormone replacement. Suggested doses and available routes in
this group are 100-microgram estradiol-17ß transdermal patch (or 0.625–1.25
milligrams/day oral conjugated estrogen) and 2 milligrams/day oral micronized
progesterone with 10 milligrams oral medroxyprogesterone acetate daily for 12–14
days every 30–60 days (or 200 milligrams oral micronized progesterone daily
for12–14 days every 30–60 days).
The dosage and route of administration of HRT is extremely complex because of
the chronicity (many years of treatment) and because during that period of time
many changes take place at both the physical and psychological level. There are
rare cases where the estrogen needs are greater in younger women than in
menopausal women because the first category is required to achieve peak bone
mass, while the latter simply seeks maintenance of bone health . The HRT for the
period before completion of secondary sexual characteristics should be the
smallest possible (estrogen alone) in order to achieve maximum height increase.
Progestogen compound must be added when breakthrough bleeding occurs, in order
to induce regular withdrawal bleeding.
In virtually all cases treatment should be individualized to the patient. It
must be borne in mind that oral administration of any estrogen exposes the liver
to higher concentrations than any other tissue. In contrast, a transdermal patch
provides estrogen as 17ß-estradiol allowing easy absorption, rapid metabolism,
and low bioavailability. Several studies have been conducted comparing use of
oral versus transdermal estrogens. Use of oral estrogens leads to suppression of
insulin-like growth factor I (IGF-I) concentration, while transdermal estrogen
did not have a negative effect on IGF-I. In case-control studies of
postmenopausal women, transdermal estradiol has been associated with a lower
risk of venous thromboembolism than has oral estrogen .
Despite the fact that the final decision for route of therapy remains between
any individual patient and her clinician, based on current data, transdermal HRT
should be the first choice for adolescent patients . On the other hand, there
are several regions around the world, such as the Mediterranean countries, where
the warm and humid climate does not allow the use of patches. To date, however,
few studies have actually examined whether HRT administration reduces the
long-term risks of POF and no evidence-based guidelines for management of POF
exist . Despite the fact that HRT is still a controversial topic as regards
menopausal women, there is no doubt among physicians that all women with POI
must replace their missing steroid hormones (both estrogens and progesterone)
for the time period until they reach the usual age of menopause . All patients
with POI who take HRT must be aware that they have a 5–10% possibility of
conceiving and for this reason they must use barrier contraceptive methods such
as a condom or intrauterine devices. The HRT should be discontinued in the event
of a positive pregnancy test and the woman must be advised by a fetal specialist
as concerns her possible new “needs” of estrogen and progesterone, this time for
the safer maintenance of the starting pregnancy. Although combined oral
contraceptives (COCs) appear to be an acceptable method for adolescents' HRT,
they provide more steroid hormone than is needed for physiologic replacement and
are therefore not recommended as first-line management. Alternative methods for
HRT, such as percutaneous estradiol gel and transvaginal progesterone gel, have
been introduced over the last few years and seem to be well tolerated, reducing
the incidence of the psychologic side effects (emotional lability, sleep
disorders, depression) of estrogen single therapy.
Family Planning and Sexual Function
In cases of POI, couples typically have the options of adoption or egg donation.
As mentioned above, women with POI may experience sporadic resumption of ovarian
function and spontaneous pregnancies can occur in 5–10% of those with idiopathic
POI . Currently, there are no known markers that are associated with an
increased rate of remission and there are no therapies that have been shown to
restore ovarian function and fertility. Evidence suggests that pregnancies might
occur if women with POI managed to suppress their high FSH concentrations,
either with ethinyloestradiol or with gonadotrophin-releasing hormone analogues,
and then followed ovulation induction protocols using low-dose gonadotrophins .
Recent results of cryopreservation techniques of ovarian tissue have raised
hopes of fertility preservation in women who are due to receive chemotherapy for
cancer treatment. An alternative to cryopreservation of ovarian tissue is
ovarian stimulation, provided that cancer treatment can be delayed . Oocytes or
embryos can be cryopreserved after stimulation. Although there may be future
developments in fertility treatment, such as in vivo maturation of oocytes from
stem cells or primordial follicles, in vitro fertilization using donor oocytes
remains the mainstay of treatment for POI women who wish to become pregnant.
However, according to several authors, these pregnancies are at increased risk
for first trimester hemorrhage, gestational hypertension, and/or preeclampsia,
the delivery of small for gestational age (SGA) neonates, and postpartum
hemorrhage, although these findings are controversial.
Since patients with POI have estrogen deficiency, it is expected that there will
be a degree of vaginal dryness. This leads to reduced arousal, less frequent
sexual encounters, and increased pain . The above-mentioned factors diminish the
sense of sexual well-being of young women with POI and, in the case of adult
patients who are embarking upon their first sexual experiences, can lead to
complex psychosexual impairment . Adequate dosage of estrogen replacement and
occasionally androgen replacement, along with sexual counseling, may be helpful
in the management of sexual dysfunction.
Maintaining Bone Health
Estrogens have important anticatabolic and anabolic effects on bone remodeling.
Consequently, estrogen deficiency among patients with POI results in an
imbalance between osteoclast and osteoblast activity and a progressive loss of
bone mineral density (BMD). Popat et al. reported that women with POI have lower
bone density compared to regularly menstruating women . The same research team
concluded that delay in diagnosis of POI contributes to reduced bone density by
delaying proper therapy. There are no reports that suggest increased likelihood
of fracture in patients with primary ovarian insufficiency.
Since HRT has not proven to be completely effective in prevention of
osteoporosis, additional preventive measures such as calcium and vitamin D
intake and weight-bearing exercises should be taken. Adult and young women with
POI should engage in a variety of exercises, such as walking, jogging, and stair
climbing, along with resistance exercises since these not only aid bone
acquisition but also contribute to improvement of cardiovascular circulation.
The North American Menopause Society guidelines for perimenopausal and
postmenopausal women recommend an intake of 1200mg of elemental calcium and at
least 800 to 1000IU of vitamin D3 per day.
There is uncertainty (i.e., no clear purpose) as regards the frequency of
dual-energy X-ray absorptiometry (DEXA) scanning in adolescents with estrogen
deficiency. In a recent Committee Opinion (no. 502), the American College of
Obstetricians and Gynecologists refers to the proposal made by a number of
experts for annual monitoring of bone density during early to midpuberty in
order to document peak bone accrual, and then every 2 years through late
adolescence. By contrast, other experts claimed that there is no need for an
annual DEXA scan, as the implications of a low bone mineral density result in
this population are unclear, given the low risk of fracture and the potential
for long-term treatment of osteopenia or low bone mass. Up to now, use of
bisphosphonates is not recommended in the young population because of uncertain
adverse effects and safety profiles, especially in cases of spontaneous
pregnancy.
Crofton et al. recently published a study stating that the type and profile of
hormone replacement are critical and can have considerable effects on the bone
health of women with POI . The author concluded that physiological sex steroid
replacement (transdermal estradiol, 100µg daily for week 1, 150µg for weeks 2–4;
vaginal progesterone, 200mg twice daily for weeks 3-4) has better effects on
bone mass acquisition and turnover compared with standard HRT (oral
ethinyloestradiol 30µg and 1.5mg norethisterone daily for weeks 1–3, week 4
“pill-free”). Further research in this area is needed.
Every prepubertal girl, teenager or young woman, who is diagnosed with primary
ovarian insufficiency should undergo extensive search by a group of specialists
in a referral center while, moreover, benefiting from special handling of her
case that will comprise affection and understanding. The followup, which of
necessity will be long term, needs to take place twice annually. The final
decision for mode of therapy will be one taken mutually between the individual
patient and her clinician. Health care providers who counsel these patients must
possess comprehensive knowledge of female reproductive biology as well as
special sensitivity to the emotional needs of these patients and their parents,
especially at the time of diagnosis. Further investigation must also be carried
out into the extent and severity of POI complications and due consideration
given to the taking of all necessary precautionary measures.
Credits: Tsimaris Pantelis, Vrachnis Nikolaos,Iliodromiti Zoe, and Deligeoroglou
Efthymios
More Information at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235457/?tool=pubmed
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WF Team
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