Current Concepts in Premature Ovarian Insufficiency

Premature ovarian insufficiency - hormone replacement therapy and management of long-term consequences

Premature ovarian insufficiency (POI) correlates with increased risk of cardiovascular diseases, osteoporosis, genitourinary syndrome, and other symptoms of prolonged oestrogen deprivation. Properly selected therapy improves the quality of women's lives and reduces the risk of mortality. There is a wide spectrum of available oestrogen and progestogen formulations restoring proper levels of serum sex steroid hormones. The treatment should be implemented at recognition of the POI and continued to at least the age of natural menopause. Transdermal oestradiol and oral or vaginal progesterone administration provide the most physiological sex steroid replacement therapy. Patients' views and individual preference according the route, dose, and regimen of hormonal treatment have to be taken into consideration in order to achieve high compliance rates. Women with POI should be managed by a multidisciplinary team, such as a gynaecologist, endocrinologist, dietitian, and psychologist.

Consequences of premature ovarian insufficiency on women's sexual health

Premature ovarian insufficiency (POI) is defined by amenorrhoea and decreased serum levels of oestrogens associated with increased serum gonadotropins concentrations before the age of 40 years. Patients suffering from POI present with irregular menses, either secondary or (less common) primary amenorrhoea, and subfertility. POI affects approximately 1 in 100 women by the age 40 years and 0.1% by 30 years of age. Both spontaneous and iatrogenic causes may induce POI, although up to 90% of POI cases are idiopathic. Impairment of sexual function is a common problem affecting women suffering from POI. Premature loss of gonadal function is particularly traumatic in young women and affects many aspects of physical and social life. POI patients suffer from genital pain due to vaginal dryness and diminished sexual arousal. Additionally, POI patients report increased anxiety, depressed mood, and have impaired interactions with their peers, which leads to feeling less feminine and having decreased self-esteem. Moreover, they have significantly decreased physical and psychological well-being when compared to age-matched controls. Systemic hormonal replacement therapy and topical oestrogen therapy as well as vaginal moisturisers may be used in the treatment of POI patients’ sexual impairment.

A lowered probability of pregnancy in females in the USA aged 25-29 who received a human papillomavirus vaccine injection

Birth rates in the United States have recently fallen. Birth rates per 1000 females aged 25-29 fell from 118 in 2007 to 105 in 2015. One factor may involve the vaccination against the human papillomavirus (HPV). Shortly after the vaccine was licensed, several reports of recipients experiencing primary ovarian failure emerged. This study analyzed information gathered in National Health and Nutrition Examination Survey, which represented 8 million 25-to-29-year-old women residing in the United States between 2007 and 2014. Approximately 60% of women who did not receive the HPV vaccine had been pregnant at least once, whereas only 35% of women who were exposed to the vaccine had conceived. For married women, 75% who did not receive the shot were found to conceive, while only 50% who received the vaccine had ever been pregnant. Using logistic regression to analyze the data, the probability of having been pregnant was estimated for females who received an HPV vaccine compared with females who did not receive the shot. Results suggest that females who received the HPV shot were less likely to have ever been pregnant than women in the same age group who did not receive the shot. If 100% of females in this study had received the HPV vaccine, data suggest the number of women having ever conceived would have fallen by 2 million. Further study into the influence of HPV vaccine on fertility is thus warranted.

Preservation of gonadal function in women undergoing chemotherapy: a systematic review and meta-analysis of the potential role for gonadotropin-releasing hormone agonists

PURPOSE

To evaluate the available randomized controlled trials (RCTs) in the literature investigating the use of gonadotropin-releasing hormone agonist (GnRHa) co-treatment for ovarian preservation in women receiving chemotherapy.

METHODS

A systematic review of the literature was performed from 1960 through 2017 to identify relevant RCTs. Included patients had lymphoma, ovarian cancer, or breast cancer. The primary outcome was the proportion of women who retained ovarian function after chemotherapy. Extracted data points included study design, patient characteristics, and proportion of women who developed premature ovarian failure (POF). A risk of bias assessment was performed according to the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The pooled odds ratio was calculated, and outcomes of individual studies were compared using the random-effects model with the inverse-variance method and the DerSimonian-Laird estimator.

RESULTS

Twenty-nine RCTs were identified, and 10 met criteria for inclusion in the meta-analysis. An analysis of patients who did not develop POF after chemotherapy revealed eight studies supporting the use of GnRHa (OR 1.83; 95% CI 1.34-2.49). The duration of benefit of GnRHa is unclear. An analysis of three studies with outcome data at 2 years revealed a non-significant OR of 0.53 (95% CI 0.22-1.30) for the preservation of ovarian function with GnRHa treatment.

CONCLUSION

GnRHa may have a protective effect against the development of POF after gonadotoxic chemotherapy; however, the duration of benefit is unclear and requires further study.

[Low-intensity pulsed ultrasound promotes repair of cyclophosphamide?induced ovarian injury in rats]

OBJECTIVE

To study the effects of low?intensity pulsed ultrasound (LIPUS) in promoting repair of cyclophosphamide (CTX)?induced ovarian injury in female rats.

METHODS

Fifty female SD rats were subjected to intraperitoneal injection of cyclophosphamide at 30 mg/kg for 5 consecutive days to induce premature ovarian failure. Successful modeling was achieved in 43 rats, which were then randomized into model group (21 rats) and treatment group (22 rats), with another 13 rats without any injections serving as the normal control group. The rats in the treatment group received low?intensity pulsed ultrasound treatment, and those in the other two groups received no interventions. The estrous cycle of the rats was monitored during the experiment, and all the rats were sacrificed 7 days after the treatment for analysis of serum estradiol (E₂), follicle stimulating hormone (FSH), anti?Mullerian hormone (AMH), morphological changes of the ovary and the number of follicles.

RESULTS

Compared with those in the normal control group, the rats in the model group showed disorders in the estrous cycle, reduced number of follicles at all levels, significantly decreased serum E₂ and AMH, and increased serum FSH following CTX injection (P=0.01). Ultrasound treatment obviously promoted the recovery of estrous cycle, significantly increased the number of follicles and serum E₂ (P=0.01), and decreased FSH (P=0.01) in the rats with CTX?induced ovarian injury, but AMH showed no significant changes after ultrasound treatment (P=0.50).

CONCLUSION

Low?intensity pulsed ultrasound can promote the repair of the CTX?induced ovarian injury in SD rats.

Estrogen treatment in infertile women with premature ovarian insufficiency in transitional phase: a retrospective analysis

PURPOSE

During the transitional phase of premature ovarian insufficiency (POI), sporadic resumption of ovulation is possible because of fluctuation of hormonal levels but the chance of spontaneous pregnancy is low, and the main perspective of childbearing in these women is egg donation or adoption. The purpose of the study was to verify whether treatment with estrogens in POI patients in transitional phase could reduce FSH levels and to evaluate if this pre-treatment could improve reproductive outcomes of in vitro fertilization (IVF).

METHODS

Study patients (26) were administered with valerate estradiol 2 mg daily adding dihydrogesterone 10 mg daily during luteal phase for 3 months before IVF. Control group (26 patients) did not receive any pre-treatment. Ovarian stimulation was conducted in both groups with the same short GnRH-antagonist protocol. Clinical and laboratory data of patients were retrospectively analyzed.

RESULTS

In the study group, 4/26 POI patients became spontaneously pregnant during pre-treatment. In the remaining patients, the mean level of FSH after the pre-treatment was significantly reduced compared with baseline. Levels of circulating estradiol on the day of hCG administration were significantly higher in the study group. The total number of MII oocytes retrieved and fertilized oocytes was significantly higher in the study group, as well as the number of embryos transferred for pickup and clinical pregnancy rate.

CONCLUSIONS

Treatment with estrogens in infertile POI patients in transitional phase reduces circulating FSH levels, hence causing potential spontaneous conception. Moreover, in these patients, estrogen pre-treatment seems to improve IVF outcomes in a GnRH-antagonist short protocol compared to no pre-treatment.

Standard hormone therapy is inadequate for bone density in premature ovarian insufficiency

To assess standard dose hormone therapy (HT) and bone mass in premature ovarian insufficiency (POI), 239 women with POI, 132 using standard estrogen dose HT and 107 women without HT, were evaluated. All underwent bone mineral density (BMD) evaluation in the lumbar spine (LS) and total femur (TF). Mean age, age at last period and body mass index (BMI) for the untreated and for the HT groups were 38.1 ± 6.1 and 36.8 ± 7.3 years; 31.4 ± 7.3 and 30.7 ± 7.2 years; 26.6 ± 7.1 and 25.8 ± 4.6 kg/m², respectively, (p=NS). The women taking standard dose HT started treatment at the age of 33.8 ± 6.3 years and had been on hormone treatment for 3 years at the time of the bone densitometry examination. The BMD in LS was 1.06 ± 0.15 and 1.00 ± 0.17 g/cm² (p = 0.003); the BMD in TF was 0.92 ± 0.19 and 0.91 ± 0.13 g/cm² (p = 0.039), respectively, for the untreated and HT groups. A 45% altered BMD (osteopenia/osteoporosis) in LS was verified in women without treatment and 60.1% in those using the standard dose TH (p = 0.01). The BMD in TF was altered in 32.3% in those without HT and 36.4% in the HT users (p = 0.34). In conclusion, standard dose HT was not adequate to reduce impaired bone mass in the spine and femur of women with POI.

Preservation of gonadal function in women undergoing chemotherapy: a review of the potential role for gonadotropin-releasing hormone agonists

A cancer diagnosis in women of reproductive age has unique medical and psychosocial ramifications, especially with treatments that are known to cause gonadal toxicity. For patients who undergo chemotherapy, a multidisciplinary team approach is essential to ensure that the patients' reproductive wishes are addressed. Currently, embryo and oocyte cryopreservation are the standard of care for those who wish to preserve their fertility. The use of gonadotropin-releasing hormone agonists has been a source of debate with numerous studies that have investigated the efficacy on both fertility and ovarian function preservation. This review evaluates the current literature on the use of gonadotropin-releasing hormone agonists for preservation of gonadal function. Assisted reproductive technology is excellent for preservation of fertility but will not protect gonadal function. Protection of gonadal function is critical for the broader issues of health and quality of life as a result of a hypogonadal state. At this moment, gonadotropin-releasing hormone agonists are the only drug class available to protect gonadal function.

Occult form of premature ovarian insufficiency

Premature ovarian insufficiency (POI) is a life-changing diagnosis, with profound physical and psychological consequences. Despite the description of different genetic, immune and iatrogenic factors of POI, the etiology of most cases of this disease are unexplained, and optimal management strategies are still unclear. Recent data showed that POI may have a long period of oligomenorrhea before the fully developed form (complete ovarian failure stage), with the occurrence of amenorrhea and climacteric symptoms. The main problem in the recognition of early stages of POI is the lack of proper diagnostic criteria. Patients with an undiagnosed occult form of POI may present with menstrual irregularities, unexplained infertility or repeated IVF failures. We evaluated 23 patients with unexplained oligomenorrhea and/or infertility. After a proper evaluation of these patients, a low ovarian reserve was identified, and an occult form of POI was diagnosed.