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Premature ovarian insufficiency — Clinical Guidelines

Overview

Premature ovarian insufficiency (POI) refers to the cessation of ovarian function before age 40, leading to amenorrhea, infertility, and increased risks for osteoporosis, cardiovascular disease, and cognitive decline 1 2.

Diagnosis

Clinical Criteria: Irregular menstrual cycles, elevated follicle-stimulating hormone (FSH) levels, and low estradiol levels 1.

Recommended Tests:

- Basal FSH ≥25 IU/L on two occasions ≥1 month apart 1. - Estradiol levels typically <50 pg/mL 1.

Additional Assessments: Antral follicle count (AFC) may provide supportive evidence 3.

Management

First-Line Treatment: Hormone replacement therapy (HRT) with estrogen and progestogen to mitigate symptoms and prevent complications 1.

Adjunctive Therapies:

- Vitamin D supplementation may be considered based on deficiency status 3. - Psychological support and counseling to address emotional impacts 1.

Special Populations

Pregnancy: Limited evidence; HRT should be carefully managed to avoid adverse outcomes 1.

Pediatrics: Not extensively covered in provided abstracts 1 2 3 4 5 6 7.

Elderly: Considerations for long-term HRT safety and efficacy are ongoing 1.

Comorbidities: Management of cardiovascular and bone health is crucial; tailored HRT and lifestyle modifications recommended 1.

Key Recommendations

Diagnose POI using elevated FSH levels and low estradiol levels confirmed on two separate occasions ≥1 month apart (Evidence: Strong 1).

Initiate hormone replacement therapy (HRT) with estrogen and progestogen to manage symptoms and prevent long-term health risks (Evidence: Strong 1).

Consider vitamin D supplementation in patients with deficiency to potentially support ovarian health (Evidence: Moderate 3).

Provide psychological support to address emotional well-being in women with POI (Evidence: Expert opinion 1).

Counsel healthcare providers on the gonadotoxic effects of iatrogenic treatments like chemotherapy and radiotherapy (Evidence: Moderate 4).

Enhance educational exposure to POI for obstetrics and gynecology trainees to improve clinical management (Evidence: Expert opinion 7).

References

1 Panay N, Anderson RA, Bennie A, Cedars M, Davies M, Ee C et al.. Evidence-based guideline: Premature Ovarian Insufficiency. Fertility and sterility 2025. link 2 Panay N, Anderson RA, Bennie A, Cedars M, Davies M, Ee C et al.. Evidence-based guideline: premature ovarian insufficiency. Climacteric : the journal of the International Menopause Society 2024. link 3 Karimi E, Arab A, Rafiee M, Amani R. A systematic review and meta-analysis of the association between vitamin D and ovarian reserve. Scientific reports 2021. link 4 Wang Y, Zou Y, Wang W, Zheng Q, Feng Y, Dong H et al.. Knowledge of iatrogenic premature ovarian insufficiency among Chinese obstetricians and gynaecologists: a national questionnaire survey. Journal of ovarian research 2020. link 5 Gong L, Ji HH, Tang XW, Pan LY, Chen X, Jia YT. Human papillomavirus vaccine-associated premature ovarian insufficiency and related adverse events: data mining of Vaccine Adverse Event Reporting System. Scientific reports 2020. link 6 Osuga Y, Akira S, Irahara M, Iwase A, Katagiri Y, Kugu K et al.. Annual report of Reproductive Endocrinology Committee, Japan Society of Obstetrics and Gynecology, 2019. The journal of obstetrics and gynaecology research 2019. link 7 Jarcevic R, Christakis MK, Wolfman W, Ye XY, Shirreff L. Survey of Canadian PGY-4 and PGY-5 Obstetrics and Gynaecology Residents on Knowledge of and Exposure to Premature Ovarian Insufficiency. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC 2018. link

Premature ovarian insufficiency