Premature ovarian failure: an update

Premature ovarian failure and dehydroepiandrosterone

Since the first successful birth at our center following treatment with DHEA in a patient with premature ovarian failure (POF), all subsequent patients with POF underwent the same treatment protocol. Receiving very encouraging results (FSH level was decreased in the first five patients and all achieved pregnancy), it was decided to study the action of DHEA for a reasonable length of time and in a larger number of patients to confirm the effectiveness of this particular therapeutic regime.

Evaluation of different markers of the ovarian reserve in patients presenting with premature ovarian failure

Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or the follicles. Based essentially on animal models, these mutations are associated with various ovarian histological phenotypes, from a complete absence of to a partial follicular maturation. The aims of our work were in one hand to determine if ovarian histology, compared to pelvic ultrasonography, would be helpful either in identifying which patients display an impaired follicular growth or in the orientation of the POF etiology; on the other hand, since developing follicles up to the antral stage are reported in POF and that Anti-Müllerian hormone (AMH) might be a good indicator of follicular presence, we decided to determine whether AMH should be a better marker to determine the presence of an ovarian reserve in POF patients. To try to answer to the first question, we studied first 166 patients suffering from POF with a normal karyotype. Vaginal ultrasonography (US) was performed in 134 patients and an ovarian biopsy was obtained in 67 women. The presence of follicles suggested at US was confirmed at histology in only 56% of the patients. Ovarian histology led to the distinction of two phenotypes (a) small-sized ovaries, deprived of follicles, and (b) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women have been studied, confirming that ovarian biopsy at random allow reliable assessment of follicular activity. To try to answer to the second question of our work, a cross sectional study analyzing serum AMH, ovarian histology and AMH immunoexpression in 48 POF patients, was performed. Serum AMH was significantly higher in women with more than 5 follicles at ovarian histology. Ovarian AMH immunostaining revealed a normal AMH expression in POF preantral follicles but a decrease expression at the early antral stages. In conclusion, ovarian histology appears to be a reliable tool to appreciate the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in order to orient the search for various genetic causes of POF syndrome. Finally, AMH levels in POF patients could identify women with persistent follicles.

Detection of antizona pellucida antibodies in the sera from premature ovarian failure patients by a highly specific test

OBJECTIVE

To develop a highly specific test for the detection of antizona pellucida (ZP) antibodies in the sera from premature ovarian failure (POF) patients.

DESIGN

Laboratory study.

SETTING

University hospital.

PATIENT(S)

Twenty-seven idiopathic POF patients, 30 control women, and 30 healthy males.

INTERVENTION(S)

Anti-ZP antibodies were detected by the microdot assay using a very small amount of human ZP or porcine ZP. The effect of anti-ZP antibodies on sperm-ZP binding was examined by hemizona assay.

MAIN OUTCOME MEASURE(S)

Results from the microdot assay and hemizona assay.

RESULT(S)

By the microdot assay using human ZP, the sera from POF patients reacted significantly stronger than those of control women and healthy males. However, no obvious difference could be found by the same assay using porcine ZP among these three groups. Anti-ZP antibodies against sera from some POF patients showed significant blocking effects on sperm-ZP binding assessed by hemizona assay. Anti-ZP antibodies were detected in 7 of 27 POF patients, while none were detected in control women and healthy males.

CONCLUSION(S)

Some idiopathic POF patients have anti-ZP antibodies in their sera, which were detected with high specificity by a newly developed microdot assay using a very small amount of human ZP.

Specificity of the requirement for Foxo3 in primordial follicle activation

Primordial follicles are long-lived structures assembled early in life. The mechanisms that control the balance between the conservation and the activation of primordial follicles are critically important for fertility and dictate the onset of menopause. The forkhead transcription factor Foxo3 serves an essential role in these processes by suppressing the growth of primordial follicles, thereby preserving them until later in life. While other factors regulating primordial follicle growth have been described, most serve multiple functions at several stages of female germ cell or follicle development, and corresponding mouse mutants exhibit pleiotropic phenotypes with disruption of multiple stages of follicle assembly, development, or survival. To investigate the possibility that Foxo3 also functions in other aspects of ovarian development beyond its known role in primordial follicle activation (PFA), we performed detailed analyses of mouse ovaries including electron microscopy to study primordial follicle structure, assembly, and early growth. These analyses revealed that the timing of primordial follicle assembly, early oocyte survival, and the expression of early germ line markers were unaffected in early Foxo3 ovaries. Taken together, these studies demonstrate that the phenotype associated with Foxo3 deficiency is remarkably specific for PFA and further support the placement of Foxo3 in a unique phenotypic class among mammalian female sterile mutants. Lastly, we discuss the implications of the specificity of this mutant phenotype with regard to the hypothesis that oocyte regeneration may occur in adults and serves as a means to replenish oocytes lost via natural physiological processes.

Falência ovariana prematura: aspectos atuais

A falência ovariana prematura (FOP) acomete aproximadamente 1:1000 mulheres antes dos 30 anos, 1:250 em torno dos 35 anos e de 1:100 aos 40 anos. Manifesta-se como amenorréia primária ou amenorréia secundária, não podendo ser considerada definitiva em todas as pacientes, uma vez que a concepção espontânea pode ocorrer em até 5-10% das FOP. Na maioria dos casos apresenta-se na forma esporádica, pois apenas 5% apresentam história familial. Entre as causas conhecidas estão as alterações cromossômicas, dos genes ligados ao cromossomo X e cromossomos autossômicos, doenças autoimunes, alterações tóxicas e iatrogênicas. Com relativa freqüência, a causa etiológica não é obtida, sendo então denominada de idiopática. O diagnóstico da FOP é feito baseado na história clínica e níveis elevados do hormônio folículo estimulante (FSH), sendo posteriormente investigadas as causas mais específicas. O manejo clínico visa o suporte emocional, o tratamento hormonal com estrogênios e progestogênios, a abordagem da infertilidade e a prevenção de co-morbidades como a osteoporose e potencial maior risco cardiovascular.

Androgen receptor function in folliculogenesis and its clinical implication in premature ovarian failure

The action of estrogen in the female reproductive organs is well known in terms of the expression pattern and gene regulation of the estrogen receptor (ER). The significance of ERs in female reproduction is undisputed. The role of the androgen receptor (AR) is less clear. Clinical hyperandrogenism, a typical feature of polycystic ovary syndrome (PCOS), highlights pathological androgen production by the ovary. By contrast, the physiological impact of androgen action in female reproductive organs remains elusive. Androgens affect folliculogenesis in a variety of experimental approaches and ARs are expressed in developing follicles. Recent observations have discovered that inactivation of ARs in female mice results in premature ovarian failure (POF), indicating that normal folliculogenesis requires AR-mediated androgen action. Moreover, these results imply that POF might be caused by impairment of AR-mediated androgen action.

Antiovarian antibodies in primary Sjogren's syndrome

Our study aimed at screening patients with primary Sjogren's syndrome (pSs) for the presence of antiovarian antibodies (AOAs). Detection of AOAs in patients' sera was achieved by ELISA, using bovine ovarian extract for coating. Western blot analysis and immunohistochemistry were used to characterize the antibody targets in the extract and to determine their locus on the bovine ovary, respectively. Specific AOAs were detected in 27% of 37 patients (two with premature menopause) and in none of the controls. Immunoreactivity mainly resided in five proteins of the extract with molecular masses 42, 49, 55, 64 and 72 kDa, and it might be attributed to their carbohydrate components. The antibody targets were mainly located in the granulosa and theca interna cells of the follicle, and in the endothelial cells and fibroblasts of corpus luteum. The detection, for the first time, of AOAs in a significant percentage of patients with pSs may suggest autoimmune oophoritis, clinical or subclinical.

Premature ovarian failure

The diagnosis of premature ovarian failure is based on the finding of amenorrhoea before age 40 associated with follicle-stimulating hormone levels in the menopausal range. Screening for associated autoimmune disorders and karyotyping, particularly in early onset disease, constitute part of the diagnostic work up. There is no role for ovarian biopsy or ultrasound in making the diagnosis. Management essentially involves hormone replacement and infertility treatment, the most successful being assisted conception with donated oocytes. Embryo cryopreservation, ovarian tissue or oocyte cryopreservation and in vitro maturation of oocytes hold promise in cases where ovarian failure is foreseeable as in women undergoing cancer treatments.

Premature ovarian failure

Premature ovarian failure (POF) is gonadal failure before the age of 40 years. Several rare causes have been discovered yet we still fail to identify the cause in many cases. Although it was once thought to be a permanent condition, a substantial number of patients experience spontaneous remissions and even pregnancy. HRT remains the cornerstone of treatment and the only proven method of achieving pregnancy in these patients is by ovum donation. New alternatives to HRT and fertility preservation are under development. Basic understanding of ovarian physiology and pathogenesis of POF is necessary for the development of newer therapies.

Premature ovarian failure: a review

OBJECTIVES

To present an updated review on the etiology, consequences and management of premature ovarian failure.

DESIGN

A search of the English language literature using the Cochrane Library database and Medline 1966-2006, with a hand search of the references.

CONCLUSION

Premature ovarian failure is defined as the occurrence of amenorrhea, hypergonadotropinemia and estrogen deficiency in women under the age of 40 years, with the prevalence being 0.9-1.2%. In the majority of cases, the etiology is unknown, but known causes include chemotherapy, radiotherapy, surgery, genetic disorders, particularly involving the X chromosome, associations with autoimmune diseases, infections, smoking and other toxins. The three critical issues of management in these women are the effect of the diagnosis on the psychological health of the patient, the consequent infertility and the long- and short-term effects of estrogen deficiency arising from ovarian decline. Promising methods of screening for premature ovarian failure are being developed.

Epigenetic control of the critical region for premature ovarian failure on autosomal genes translocated to the X chromosome: a hypothesis

Chromosomal rearrangements in Xq are frequently associated to premature ovarian failure (POF) and have contributed to define a POF "critical region" from Xq13.3 to Xq26. Search for X-linked genes responsible for the phenotype has been elusive as most rearrangements did not interrupt genes and many were mapped to gene deserts. We now report that ovary-expressed genes flanked autosomal breakpoints in four POF cases analyzed whose X chromosome breakpoints interrupted a gene poor region in Xq21, where no ovary-expressed candidate genes could be found. We also show that the global down regulation in the oocyte and up regulation in the ovary of X-linked genes compared to the autosomes is mainly due to genes in the POF "critical region". We thus propose that POF, in X;autosome balanced translocations, may not only be caused by haploinsufficiency, but also by a oocyte-specific position effect on autosomal genes, dependent on dosage compensation mechanisms operating on the active X chromosome in mammals.

Effects of pretreatment with estrogens on ovarian stimulation with gonadotropins in women with premature ovarian failure: a randomized, placebo-controlled trial

OBJECTIVE

To evaluate the hypothesis that pretreatment with estrogens in women affected by premature ovarian failure (POF) may improve the results of ovarian stimulation.

DESIGN

Double-blind, randomized, placebo-controlled study.

SETTING

Outpatient department in an academic research environment.

PATIENT(S)

Fifty women with POF seeking pregnancy.

INTERVENTION(S)

Before starting ovarian stimulation, group 1 received 0.05 mg ethinyl-E(2) (EE) three times a day for 2 weeks, while group 2 received placebo. Ovarian stimulation was carried out with recombinant FSH (r-betaFSH), 200 IU/day/SC. Both EE and placebo were administered during ovarian stimulation. Human chorionic gonadotropin (10,000 IU/IM) was added when the follicle exceeded a mean diameter of 18 mm.

MAIN OUTCOME MEASURE

Rate of ovulation in women with POF.

RESULT(S)

Levels of FSH before stimulation were significantly lower in group 1 than in group 2. The rate of ovulation in group 1 (8/25; 32%) was significantly higher than in group 2 (0/25; 0%). Notably, induction of ovulation was successful only in patients whose FSH levels after EE treatment were < or =15 mIU/mL.

CONCLUSION(S)

Our data suggest that pretreatment with EE improves the success of rate of ovulation induction with exogenous gonadotropins in patients with POF. A threshold of FSH < or =15 mIU/mL should be achieved before starting ovarian stimulation.

Skewed X-chromosome inactivation is associated with primary but not secondary ovarian failure

Premature ovarian failure (POF) is the occurrence of menopause before the age of 40, and may present with either primary or secondary amenorrhea. Numerous cases of POF in women with X-chromosome deletions or translocations have been reported; thus, it is possible that smaller rearrangements undetectable by conventional cytogenetics may contribute to POF in some patients. In females with an abnormal X chromosome, cells with inactivation of the normal X may be selected against, causing skewed X-chromosome inactivation (XCI). We therefore assessed XCI by methylation sensitive restriction digestion and PCR amplification at the androgen receptor (AR) locus, in 4 primary and 55 secondary POF patients and 109 control women. In samples heterozygous at AR and therefore informative for the skewing assay, the frequency of skewed XCI among the women with secondary amenorrhea was identical to that in control women, with 4 out of 48 (8.3%) secondary ovarian failure patients and 8 out of 97 (8.2%) control women having > or =90% skewing. Notably, all three primary amenorrhea patients that were informative at AR had skewed XCI > or =90% (P = 0.001 vs. control women; Fisher's exact test). To investigate whether X-chromosome copy number alterations were responsible, DNA from selected patients with skewed XCI was examined by high resolution DNA microarray, however no potential regions of DNA addition or deletion were confirmed by FISH or PCR. X-chromosome abnormalities undetectable by array, or reduced follicular pool due to an early trisomic rescue event, may explain the skewed XCI observed in POF patients presenting with primary amenorrhea.

Menopause: evidence-based practice

Menopause is a physiologic transition and is assuming an increasing importance as the demographic bulge moves through this phase. The transition takes place over several years. It is characterized by depletion of the ovarian follicles, decreasing inhibin leading to increases in follicle-stimulating hormone and loss of the menstrual cycle, accompanied by decreased estradiol production and typical symptoms. The role of hormone therapy in menopause has shifted from preventive use to a limited role in symptom management, for which it remains the most effective intervention. There is good evidence from observational and randomized trials of an increased risk of breast cancer in women on estrogen plus a progestin, compared with those on estrogen alone. There are insufficient data to be able to determine if there are clinically important differences between various progestins and progesterone with respect to breast cancer risk, nor between different regimens. Even relatively short-term exposure to unopposed estrogen will increase the risk of atypical endometrial hyperplasia or cancer; women who have their uterus should be using a progestational agent. Lifestyle changes at menopause are important and effective for preventive health. Recent evidence suggests that the discordance between epidemiologic studies with respect to cardiovascular outcomes and the Women's Health Initiative randomized controlled trial (WHI RCT) data might be attributable in large part to the older age of women enrolled in the WHI.

Serum anti-Müllerian hormone expression in women with premature ovarian failure

BACKGROUND

Premature ovarian failure (POF) is generally irreversible. However, developing follicles up to the antral stage are reported in POF and anti-Müllerian hormone (AMH) might be a good indicator of follicular presence. This study analysed serum AMH, ovarian histology and AMH immunoexpression in POF patients.

METHODS

A cross-sectional study of 48 POF patients in an Endocrinology Department setting. Patients had an ovarian biopsy simultaneously with serum AMH sampling and/or ovarian AMH immunostaining.

RESULTS

Mean serum AMH was 1.04 +/- 1.66 ng/ml. Serum AMH was significantly higher in women with 15 or more follicles at ovarian histology (P = 0.001). Comparison of ovarian AMH immunostaining from POF patients and 10 normal controls revealed a normal AMH expression in POF pre-antral follicles, but a decreased expression at the early antral stages. Serum AMH was undetectable in 77% of the patients with 0-5 AMH immunopositive follicles and detectable in 100% of the patients with more than 15 AMH immunopositive follicles.

CONCLUSIONS

AMH levels in POF patients could identify women with persistent follicles. The decrease of AMH immunoexpression in POF antral follicles could suggest a defect of antral development.

Treatment-related premature ovarian failure as a long-term complication after Hodgkin's lymphoma

BACKGROUND

One of the medical sequelae that chemo- and radiotherapy may cause is premature ovarian failure (POF). The scope of this study was to investigate the risk of developing POF as a long-term complication in young women treated for Hodgkin's lymphoma.

PATIENTS AND METHODS

The 99 women included in the study were treated between 1975 and 1992 at the Norwegian Radium Hospital. All patients received radiotherapy and 67 of the women also received chemotherapy.

RESULTS

POF was found in 37.4% of the patients. The risk of developing POF was significantly higher if the patient received chemotherapy in addition to radiotherapy. Furthermore, the risk increased if chemotherapy included alkylating agents. Long-term follow-up revealed that women who at the time of treatment were under 30 years of age developed POF later, but with the same cumulative risk as women above 30 years of age.

CONCLUSIONS

The risk of developing POF after radio- and chemotherapy is higher than earlier estimates suggest. After an observation time of 15 years the cumulative risk is 38% independent of age at the time of treatment. Age below 30 years at the time of treatment delays the development of POF, but does not decrease the life-time risk.

Age at menopause and mortality in Japan: the Jichi Medical School Cohort Study

BACKGROUND

Although several studies have reported increased mortality risk with early menopause, there were no studies examining the relationship between age at menopause and mortality in Japan. The goal of this analysis is to investigate the relationship between age at menopause and all-cause mortality among the Japanese.

METHODS

Study subjects were 4,683 postmenopausal females in the Jichi Medical School Cohort Study, a population-based prospective study. Baseline data were obtained by questionnaire and health checkups between April 1992 and July 1995 in 12 rural areas in Japan. Main outcome measures were all-cause mortality derived from death certificates up to December 31, 2002. Cox's proportional hazard models were used to analyze the association of age at menopause with mortality.

RESULTS

A total of 215 deaths were observed during the average of 9.2 year follow-up period. After adjusting for age, systolic blood pressure, serum total cholesterol level, serum high density lipoprotein cholesterol level, history of diabetes mellitus, body mass index, smoking habits, alcohol drinking habits, marital status, study area, and types of menopause, the hazard ratios (95% confidence intervals) of all-cause mortality were 2.10 (1.07-4.11), 0.68 (0.36-1.26), 0.94 (0.68-1.30), and 1.17 (0.63-2.20) for females with a menopause at ages younger than 40 years, 40-44, 50-54, and 55 or older, respectively, relative to those with menopause at age 45-49 years.

CONCLUSIONS

Our data suggest that menopause aged younger than 40 years increases the risk of death from all causes among the Japanese.

Corticosteroids in patients with antiovarian antibodies undergoing in vitro fertilization: a prospective pilot study

OBJECTIVE

Antiovarian autoantibodies (AOA) have been associated with reproductive failure, especially in in vitro fertilization (IVF) patients. Thus, the success rate of IVF might be improved by the use of corticosteroids. However, therapeutic trials with these drugs have yielded conflicting results, particularly because of heterogeneous inclusion criteria. Among women with previous IVF failure, we selected those who presented with a positive serum AOA assay, and analysed the efficacy of corticosteroids in improving the IVF outcome in these patients.

METHODS

One hundred patients with serum AOA detected by ELISA and at least two previously failed IVF attempts were selected. These patients underwent a further IVF cycle with 0.5 mg/kg prednisolone, started on the first day of the treatment cycle. In patients who became pregnant, corticosteroids were administered until the end of the first trimester of pregnancy and then progressively discontinued. AOA were assessed before and after oocyte retrieval. Clinical data of the corticosteroid-treated cycle were compared with data from the preceding IVF cycle for each patient.

RESULTS

No adverse effects resulting from corticosteroids were observed. Post oocyte retrieval antiovarian IgG were significantly lower in corticosteroid-treated attempts when compared with the preceding cycles. Twenty-six pregnancies resulted in the birth of 30 healthy children. The pregnancy rate, implantation rate, and live birth rate were 38.8%, 17.8%, and 26.5% respectively in prednisolone-treated cycles.

CONCLUSION

This study confirms the usefulness of corticosteroids in improving the success rate in a subset of patients with previous IVF failure and significant serum AOA levels.

Accelerated ovarian failure induced by 4-vinyl cyclohexene diepoxide in Nrf2 null mice

Genetic and biochemical analyses have uncovered an essential role for nuclear factor erythroid 2-related factor 2 (Nrf2) in regulating phase II xenobiotic metabolism and antioxidant response. Here we show that Nrf2 protects against the ovarian toxicity of 4-vinylcyclohexene diepoxide (VCD) in mice. Nrf2-/- female mice exposed to VCD exhibit an age-dependent decline in reproduction leading to secondary infertility accompanied by hypergonadotropic hypogonadism after 30 weeks of age. VCD is shown to selectively destroy small ovarian follicles, resulting in early depletion of functional follicles. Treatment with VCD induces apoptotic death in cultured cells and in ovarian follicles, suggesting apoptosis as a mechanism of follicle loss. Loss of Nrf2 function blocks the basal and inducible expression of microsomal epoxide hydrolase, a key enzyme in the detoxification of VCD, and increases the oxidative stress in cells that is further exacerbated by VCD. Foxo3a, a repressor in the early stages of follicle activation, displays reduced expression in Nrf2-/- ovaries, causing accelerated growth of follicles in the absence of exposure to exogenous chemicals. Furthermore, Foxo3a is degraded through the 26S proteasome pathway in untreated cells and is induced by VCD via both Nrf2-dependent transcription and protein stabilization. This study demonstrates that Nrf2 serves as an essential sensor and regulator of chemical homeostasis in ovarian cells, protecting the cells from toxic chemicals by controlling metabolic detoxification, reactive oxygen species defense, and Foxo3a expression. In addition, these findings raise the possibility that exposure to environmental or occupational ovotoxicants plays a role in the premature ovarian failure commonly associated with infertility and premature aging in women.

Idiopathic Premature Ovarian Failure in 63 Young Women

BACKGROUND

Premature ovarian failure (POF) in adolescents is defined as primary or secondary amenorrhea associated with high follicle-stimulating hormone (FSH) levels. In normal 46,XX patients, its etiology is most often unknown. We have evaluated the clinical, hormonal and ovarian phenotypes in patients with a normal karyotype who were diagnosed with POF before the age of 18.

METHODS

Sixty-three patients were included in this retrospective study.

RESULTS

The mean patient age was 20.4 years. The patients presented with three clinical patterns: lack of pubertal development (n = 23), primary amenorrhea with interrupted puberty (n = 18), and secondary amenorrhea with normal puberty (n = 22). Ten patients had a familial history of POF and 6 presented with hypothyroidism. The FSH, estradiol and inhibin B levels were not statistically different in the three clinical groups. Fifty percent of the patients presented small ovaries (length <2 cm) at ultrasonography. The presence of follicles was found at histology in only 7 of the 27 patients who underwent an ovarian biopsy.

CONCLUSION

46,XX patients presenting with early POF rarely presented a specific, identifiable disorder. We discuss the clinical management and different diagnosis strategies to improve our current knowledge of this syndrome.

Ovarian Biopsy in Infertile Patients With Ovarian Dysfunction

Evaluation of ovarian histology is feasible by obtaining ovarian tissue through laparoscopy; however, the role of an ovarian biopsy in an infertility workup is not widely accepted. To gain insight into the role of ovarian biopsy in reproductive medicine, we conducted a cross-sectional study in infertile patients with ovarian dysfunction and correlated follicle stimulating hormone (FSH) and estradiol serum concentrations with ovarian follicular counts. Fifty women were recruited and classified into four groups: premature ovarian failure (POF), chronic anovulation, diminished ovarian reserve, and ovulatory patients (control group). Ovarian endocrine function was assessed by the determination of FSH, luteinizing hormone, and estradiol serum concentrations and correlated with the number of follicles present in the ovarian biopsies obtained by laparoscopy. The number of ovarian follicles observed for each individual biopsy varied extensively. Patients with POF presented significantly lower counts of primordial, primary, and secondary follicles. No significant differences were found in the other groups. In the total sample, primordial follicle counts correlated inversely with serum FSH levels (r = -0.4, p = 0.003) and directly with serum estradiol levels (r = 0.5, p = 0.001) however, such associations no longer remained after adjusting by group. We conclude that ovarian biopsies do not provide additional information to the clinical-hormonal criteria previously established in the workup of infertile patients. Therefore, its use cannot be generalized in the study of infertile patients with ovarian dysfunction. In contrast, ovarian biopsies may be useful to identify patients with POF when the ovarian reserve is likely altered.

An update: spontaneous premature ovarian failure is not an early menopause

OBJECTIVE

To update clinicians regarding the management of women with spontaneous premature ovarian failure (POF).

DESIGN

Literature review and consensus building among three clinicians with experience in caring for women with spontaneous POF.

CONCLUSION(S)

Clearly the ovarian "failure" in this disorder is not permanent in all women. Approximately 5%-10% may conceive spontaneously and unexpectedly after the diagnosis. An integrated approach to management is best, and there is a need to first address physical and mental health issues before addressing plans for family building. Women with spontaneous POF are at increased risk of adrenal insufficiency, which should be detected and managed appropriately, especially before proceeding to ovum or embryo donation procedures. Young women with POF experience pathologically low serum E2 levels at least intermittently. Despite the absence of controlled evidence for this specific population, physiologic replacement of ovarian steroid hormones seems rational until the age of normal menopause. The disorder may be associated with other conditions that require evaluation and management, including hypothyroidism, dry eye syndrome, abnormal karyotype, or a premutation of the FMR1 gene. Finally, clinicians need to be sensitive to the emotional aspects of this disorder when delivering the diagnosis and during subsequent management.

Heterozygosity mapping by quantitative fluorescent PCR reveals an interstitial deletion in Xq26.2-q28 associated with ovarian dysfunction

BACKGROUND

Deletions of Xq chromosome are reported for a number of familial conditions exhibiting premature ovarian failure (POF) and early menopause (EM).

METHODS AND RESULTS

We describe the inheritance of an interstitial deletion of the long arm of the X chromosome associated with either POF or EM in the same family. Cytogenetic studies and heterozygosity mapping by quantitative fluorescent PCR revealed a 46,X,del(X)(q26.2-q28) karyotype in a POF female, in her EM mother, and also in her aborted fetus with severe cardiopathy. Applying a microsatellite approach, we have narrowed the extension of an identical interstitial deletion located between DXS1187 and DXS1073. These data, in line with other mapped deletions, single out the proximal Xq28 as the region most frequently involved in ovarian failure. We also propose that other factors may influence the phenotypic effect of this alteration. Indeed, skewed X inactivation has been ascertained in EM and POF to be associated with different X haplotypes.

CONCLUSION

Our analysis indicates that Xq26.2-q28 deletion is responsible for gonad dysgenesis in a family with EM/POF. The dissimilar deletion penetrance may be due to epigenetic modifications of other X genes that can contribute to human reproduction, highlighting that ovarian failure should be considered as a multifactorial disease.

Follicle-stimulating hormone receptor gene mutations are not evident in Greek women with premature ovarian failure and poor responders

BACKGROUND/AIMS

This clinical and molecular study aimed to investigate the presence of follicle-stimulating hormone (FSH) receptor gene mutations in women with premature ovarian failure (POF) and poor responders to in vitro fertilization treatment.

METHODS

DNA was extracted from blood samples for subsequent polymerase chain reaction (PCR). PCR was followed by restriction fragment length polymorphism and direct sequencing.

RESULTS

No inactivating mutations reported so far were identified in exons 6, 7, and 10 in women with POF and poor responders.

CONCLUSION

FSH receptor gene mutations are not frequent in Greek patients with POF as is the case in the rest of the world except for cases with ovarian dysgenesis in Finland.

Premature ovarian failure

Premature ovarian failure (POF) causing hypergonadotrophic hypogonadism occurs in 1% of women. In majority of cases the underlying cause is not identified. The known causes include: (a) Genetic aberrations, which could involve the X chromosome or autosomes. A large number of genes have been screened as candidates for causing POF; however, few clear causal mutations have been identified. (b) Autoimmune ovarian damage, as suggested by the observed association of POF with other autoimmune disorders. Anti-ovarian antibodies are reported in POF by several studies, but their specificity and pathogenic role are questionable. (c) Iatrogenic following surgical, radiotherapeutic or chemotherapeutic interventions as in malignancies. (d) Environmental factors like viral infections and toxins for whom no clear mechanism is known. The diagnosis is based on finding of amenorrhoea before age 40 associated with FSH levels in the menopausal range. Screening for associated autoimmune disorders and karyotyping, particularly in early onset disease, constitute part of the diagnostic work-up. There is no role of ovarian biopsy or ultrasound in making the diagnosis. Management essentially involves hormone replacement and infertility treatment, the only proven means for the latter being assisted conception with donated oocytes. Embryo cryopreservation, ovarian tissue cryopreservation and oocyte cryopreservation hold promise in cases where ovarian failure is foreseeable as in women undergoing cancer treatments.

Novel X-chromosomal defect associated with abnormal ovarian function

Abstract Premature ovarian failure (POF) may be idiopathic or may be associated with genetic or autoimmune disorders. It is well known that chromosomal defects can impair ovarian development and its function. It is estimated that X-chromosome abnormalities occur in 10-25% of women with abnormal ovarian function. Of these, the common chromosome defects reported are either true Turner's karyotype or its variants. We describe a novel X-chromosome aberration in a woman with primary amenorrhea. Cytogenetic and fluorescence in situ hybridization analysis revealed a short-arm deletion of X-chromosome as a Turner's variant [mos,45,XO/46,Xdel(X)(p11.1-p22.3)]. This interesting and rare case with unique X-chromosome defect reveals an additional mechanism for the cause of POF.

Down syndrome and precocious menopause

PURPOSE

To determine whether women who had children with Down syndrome (DS) had precocious menopause.

METHODS

We selected 104 mothers of children with DS and 121 normal women who had children with no genetic problems. We conducted an interview and compared their mean age at menopause.

RESULTS

We did not detect a statistically significant difference in mean age at menopause. When we stratified into women who had conceived when younger or older than 35 years of age, we found a statistically significant difference only for women who had conceived at the age of 35 years or older. We observed three cases of previous unilateral ovarian surgery in the study group and one case in the control group.

CONCLUSIONS

We cannot conclude that mothers of children with DS will have precocious menopause. Nevertheless, our findings do not exclude the theory of reduced ovarian reserve as a primordial factor in the genesis of DS.

Uterine prolapse in a young nulligravida with scleroderma and premature ovarian failure

We report a case of pelvic organ prolapse quantification (POPQ) stage III uterine prolapse in a 25-year-old nulligravida. Premature ovarian failure was diagnosed after 1 year of amenorrhea. Localized scleroderma was noticed on her thigh and lower back. We discuss the possible role of scleroderma and ovarian failure on the occurrence of uterine prolapse in light of the literature.

Menopausal symptoms and psychological distress in women with and without tubal sterilization

Data from self-administered mailed questionnaires were used to examine the relationship between menopausal and psychological/psychiatric factors in women age 45-50 years with and without tubal sterilization. In multivariate logistic regression analysis, tubal sterilization was associated with current flushing (odds ratio = 8.78, 95% confidence interval [CI] = 1.58-48.67) and current symptoms of psychological distress (odds ratio = 3.37, 95% CI = 1.27-8.95); psychological distress was associated with tubal sterilization (odds ratio = 3.28, 95% CI = 1.28-8.42) and with being perimenopausal (odds ratio = 3.93, 95% CI = 1.08-14.34). Sterilization was marginally associated with a history of physician-diagnosed depression (univariate age-adjusted odds ratio = 2.24, 95% CI = 0.90-5.60). The menopausal and psychological symptoms of women with tubal sterilization should be taken seriously and treated appropriately.

Significance of ovarian histology in the management of patients presenting a premature ovarian failure

BACKGROUND

Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or follicles. Based essentially on animal models, these mutations are associated with various ovarian phenotypes, from a complete absence of follicles to a partial follicular maturation. The aim of the present study was to determine whether ovarian histology, compared to pelvic ultrasonography, would be helpful in identifying which patients display an impaired follicular reserve and/or growth, and in orientating the search for POF aetiology.

METHODS AND RESULTS

We studied a cohort of 61 patients suffering from POF with a normal karyotype. Their median age (range) at diagnosis was 26 years (15-39). The FSH plasma level was high, 67.0 IU/l (13-155). Estradiol and inhibin B plasma levels were low: 18.5 pmol/l (18.5-555) and 5 pg/ml (5-105) respectively. Both pelvic ultrasonography and ovarian biopsies were performed in each patient. The presence of follicles suggested at ultrasonography was confirmed at histology in 56% of the patients. Ovarian histology led to the distinction of two phenotypes: (i) small-sized ovaries, deprived of follicles; and (ii) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women were studied. These demonstrated that ovarian biopsy at random enables reliable assessment of follicular presence, especially when their size is <2 mm.

CONCLUSION

Ovarian histology appears to be a reliable tool in evaluating the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in orienting the search for the various genetic causes of POF syndrome.

[What are the antigenic targets in the ovary?]

The ovary can be the target of an autoimmune disease involving many different autoantigens. The clinical feature of this disease often results in premature ovarian failure or infertility and may be either isolated or associated with other autoimmune pathologies, especially with adrenal autoimmunity. The diagnosis of an autoimmune mechanism relies on the presence of anti-ovarian antibodies, whose prevalence is quite variable according to the different methods used to detect them, and to the different stages of the disease. In addition, their clinical significance is not always clear, as to their pathologic or epiphenomenal nature. However, the study of these autoantibodies has led to the identification of some of their antigenic targets which have to be known for a better understanding of the pathologic mechanisms involved. This paper reviews anti-steroid producing cells, anti-gonadotrophin receptor, anti-gonadotrophin, anti-corpus luteum, anti-zona pellucida and anti-oocyte antibodies.

Age-related decline in fertility

A progressive decline in fecundity with advancing age is a reality, attributed primarily to the detrimental impact of various aging processes on female gametes. Despite medical advances that have dramatically prolonged the female life span, declining numbers and deteriorating quality of oocytes, and an increasing incidence of meiotic errors and aneuploidy of gametes and embryos, reduce clinical pregnancy rates and escalate pregnancy wastage. Increased fetal aneuploidies in ongoing pregnancies and an increased predisposition to obstetric morbidities further contribute to the diminishing reproductive successes associated with advancing age. The age of male partners, despite the decline in semen parameters and sexual performance with aging, does not appear to have a major impact on the eventual fertility of the aging couple. The contributions of age-related impaired sexuality and ejaculatory problems, although slight albeit significant, to declining fertility in the aging should be appreciated in appropriate cases. With the realization of the age-related detriment on fertility potential and the limitations of available therapeutic interventions, management of subfecundity in women beyond their mid-30s should be approached aggressively. Success of ovulation induction with clomiphine citrate or gonadotropins is marginal in women aged older than 40 years; a case can be made to proceed directly with ART in women in this age group, especially when there is coexisting male factor or pelvic disease. Except for the use of donor oocytes, the outcome of various therapeutic interventions to optimize reproductive performance in women aged older than 44 years remains dismal. A broader application of PGD techniques may contribute to improved live birth rates in reproductively aging women. The greater likelihood of obstetric complications in pregnancies resulting from donor oocytes and an increased prevalence of age-related medical problems complicating pregnancy should prompt a thorough medical evaluation before proceeding with ART.

Female carriers of fragile X premutations have no increased risk for additional diseases other than premature ovarian failure

Carriers of fragile X premutations were previously considered phenotypically normal but are now known to be at risk for premature ovarian failure (POF). This prompted us to investigate whether premutation carriers (PC) have an increased risk for other diseases. We approached 306 women out of 84 fra(X) families of whom 264 (86.3%) participated in this study. A medical history was taken of these women. Whenever possible, the anamnestic data were verified with medical records. We first evaluated the occurrence of diseases that are commonly associated with menopause in PC and compared this to that in women with either a normal FMR-1 gene or a full mutation. We found no statistically significant differences in the occurrence of diseases known to be associated with menopause, such as cardiovascular diseases and osteoporosis. However, lower bone mineral density was observed only in PC. Subsequently, we compared the occurrence of other medical problems between the two groups by estimating relative risks. PC did not demonstrate other diseases more commonly compared to non-PC from the same families. These findings are important for the counseling of PC. Carriership of the premutation may affect the ovaries, but does not substantially increase the risk for additional medical problems. Once a PC does experience POF, she is at risk for early estrogen deprivation, which may lead to a premature decrease in bone density, when not treated.

[Premature ovarian failure in galactosaemia: pathophysiology and clinical management]

Classic galactosaemia is a rare aetiology of premature ovarian failure. It is caused by galactose-1-phosphate uridyltransferase deficiency and leads to a severe disease in the newborn. This acute toxic syndrome will completely regress under a galactose-free diet, but some long-term complications, particularly hypergonadotropic hypogonadism in female patients, are frequently observed. Ovarian toxicity could be due to intracellular accumulation of galactose metabolites or to deficient glycosylation reactions. Moreover, the tremendous follicular decrease in the galactosaemic ovary could also involve programmed cell death (apoptosis). As the exact mechanisms of this ovarian injury are still unknown, there is no prevention of follicular loss, thus clinical management especially includes hormonal replacement therapy in order to prevent bone loss and cardiovascular risks and sometimes to allow patients to become pregnant.

Premature menopause in a multi-ethnic population study of the menopause transition

BACKGROUND

Premature menopause, also termed premature ovarian failure (POF), is characterized by cessation of menstruation before the age of 40 years. Little information is available on the general prevalence of POF or on the prevalence by ethnic group. There is also a lack of information on the association of POF with health indicators.

METHODS

A cross-sectional survey of women aged 40-55 years was conducted at seven sites in the USA to determine eligibility for a community-based, multi-ethnic longitudinal study of the peri-menopause (The Study of Women Across the Nation, SWAN). Interview data were used to (i). determine the prevalence of self-reported POF overall and by ethnic group, and (ii). assess the association of POF with selected self-reported variables related to health. Cases of POF included only women with no discernible cause for POF.

RESULTS

POF was reported by 1.1% (126/11 652) of women. By ethnicity, 1.0% (95% CI, 0.7-1.4) of Caucasian, 1.4% (95% CI, 1.0-2.1) of African American, 1.4% (95% CI, 0.8-2.5) of Hispanic, 0.5% (95% CI, 0.1-1.9) of Chinese and 0.1% (95% CI, 0.02-1.1) of Japanese women experienced POF. The differences in frequency across ethnic groups were statistically significant (P = 0.01). Only Caucasian, African American and Hispanic women were included in further analyses since too few Asian women had POF. In a multivariate model, POF was independently associated with osteoporosis, female hormone use (excluding oral contraceptives), higher body mass index (BMI) and current smoking after adjustment for education level, ability to pay for basics, site and age at interview. In Caucasian women, use of female hormones, osteoporosis, severe disability and smoking were significantly associated with POF. In contrast, POF in African American women was associated with higher BMI and female hormone use, but not osteoporosis.

CONCLUSIONS

The prevalence of POF appears to vary by ethnicity. Health factors associated with POF also vary by ethnicity but because of the cross-sectional study design, it is not possible to determine cause and effect relationships. Health risks of POF would benefit from further study.

Sex-specific gene expression during meiotic prophase I: Xlr (X linked, lymphocyte regulated), not its male homologue Xmr (Xlr related, meiosis regulated), is expressed in mouse oocytes

The Xmr (Xlr related, meiosis regulated) gene product is abundantly expressed in primary spermatocytes and is notably associated with nonrecombining segments of sex chromosomes in the XY body. Here we determined whether Xmr was expressed in meiotic oocytes. This was done by reverse transcription-polymerase chain reaction and cDNA sequencing, Western blot analysis, and immunocytochemistry. Unexpectedly, no Xmr message was detected in mouse fetal oocytes. Instead, Xlr (X linked, lymphocyte regulated), a closely related gene expressed in fetal thymus cells at the time of antigen-receptor gene rearrangement, was expressed in oocytes throughout meiotic prophase I. These findings indicate a sex-specific expression of two closely related members of the Xlr gene family during meiotic prophase I. The XLR protein may provide a useful marker for studies on chromatin condensation or DNA recombination in oocytes. In addition, because of the localization of the Xlr sequence family on the mouse X chromosome, the human equivalent of Xlr is a candidate gene for premature ovarian failure.

Age at menopause and prevalence of its different types in contemporary Greek women

OBJECTIVE

This study attempted to estimate the mean age at menopause and also characterize and quantify its types and frequencies in Greek women who have recently become postmenopausal.

DESIGN

A retrospective analysis of hospital records was used to record the frequency of natural, spontaneous or induced premature, and delayed natural menopause; the mean age at menopause of each group; and their possible interrelationships with major events of reproductive history in 1,747 women visiting an endocrine clinic 1 to 5 years after menopause. A group of 438 postmenopausal women drawn from 4,000 cases from the nongynecological clinics of this hospital comprised the control group.

RESULTS

Natural menopause was found in 1,333 (76.3%) women with a median age of 51 (95% CI, 50.8-51.2) and mean +/- SD of 48.7 +/- 3.8 years. Medically induced menopause after the age of 40 was recorded in 204 women (11.7%), spontaneous premature in 127 (7.1%), medically induced premature in 60 (3.7%), and delayed menopause in 26 (1.5%), with mean ages of 43.6 +/- 1.7, 35.1 +/- 3.3, 37.2 +/- 1.6, and 59.6 +/- 2.1 years, respectively. No significant differences in mean age at menopause or its types were noted between the two groups. Furthermore, no significant correlations among the parameters examined could be demonstrated except between smoking and age at menopause in the spontaneous premature menopause subgroup (P < 0.05). Finally, ovarian autoantibodies were found in 6.7% of the tested women with premature menopause.

CONCLUSIONS

Natural menopause occurred at a mean age of 48.7 years in Greek women, who displayed an unexpectedly high prevalence of spontaneous or induced premature cessation of menstruation.

Genes and translocations involved in POF

Changes at a single autosomal locus and many X-linked loci have been implicated in women with gonadal dysgenesis [premature ovarian failure (POF) with deficits in ovarian follicles]. For the chromosome 3 locus, a forkhead transcription factor gene (FOXL2) has been identified, in which lesions result in decreased follicles by haploinsufficiency. In contrast, sporadic X; autosomal translocations are distributed at many points on the X, but concentrate in a critical region on Xq. The association of the breakpoints with genes involved in ovarian function is thus far weak (in four analyzed cases) and has not been related to pathology in other POF patients. While many more translocations can be analyzed in detail as the human genome sequence is refined, it remains possible that translocations like X monosomy (Turner syndrome) lead to POF not by interrupting specific genes important in ovarian development, but by causing aberrations in pairing or X-inactivation during folliculogenesis. It is noted that the critical region has unusual features, neighboring the X-inactivation center and including an 18 Mb region of very low recombination. These suggest that chromosome dynamics in the region may be sensitive to structural changes, and when modified by translocations might provoke apoptosis at meiotic checkpoints. Choices among models for the etiology of POF should be feasible based on studies of ovarian follicle development and attrition in mouse models. Studies would prominently include gene expression profiling of developmental-specific pathways in nascent ovaries with controlled levels of Foxl2 and interacting proteins, or with defined changes in the X chromosome.

Premature ovarian failure (POF): discordance between somatic and reproductive aging

Premature ovarian failure (POF) is a unique example of isolated organ senescence, with a population prevalence of approximately 1%. Though the phenotypic expression of POF is similar to that of age-appropriate natural menopause, the underlying pathophysiological mechanisms are diverse and not entirely clear. The impact of POF on the patient is profound, with myriad ramifications, ranging from psychological devastation to multi-system implications of estrogen deprivation and its sequelae. The hastening of degenerative changes noted in these patients however, are not entirely ameliorated with estrogen replacement and POF may indeed represent an acceleration of the aging process.

Successful pregnancy after transient ovarian failure following treatment of symptomatic leiomyomata

OBJECTIVE

To report a case of transient ovarian failure after treatment of symptomatic leiomyomata and review other iatrogenic causes of transient ovarian failure.

DESIGN

Case report and literature review.

SETTING

University-affiliated private practice.

PATIENT(S)

A 35-year-old woman with symptomatic leiomyomata.

INTERVENTION(S)

Bilateral uterine artery embolization with subsequent abdominal myomectomy to treat unchanged regular heavy menstrual flow.

MAIN OUTCOME MEASURE(S)

Ovarian function.

RESULT(S)

Because medical therapy failed to control her menorrhagia, the patient proceeded with uterine artery embolization. She had persistent menorrhagia after bilateral uterine artery embolization and underwent exploratory laparotomy and myomectomy. After surgery, she had amenorrhea, hot flushes, and elevated FSH levels for 3 months. Ovarian function recovered after a short course of oral contraceptives, and the patient conceived without assistance.

CONCLUSION(S)

Several interventions can affect normal ovarian function and can lead to permanent or transient ovarian failure. Possible causes of transient ovarian failure are radioactive iodine treatment, radiation, chemotherapy, pelvic surgery, stress, and uterine artery embolization. Before these interventions are applied, the possibility of ovarian failure and available preventive measures should be discussed with the patient.

Heterotopic autotransplantation of the ovary with microvascular anastomosis: a novel surgical technique

OBJECTIVE

To test the feasibility of transplanting an entire ovary with anastomosis of the ovarian vascular pedicle.

DESIGN

Long-term survival study.

SETTING

Biological Resources Unit, Cleveland Clinic Foundation.

ANIMAL(S)

Five adult, nonpregnant ewes.

INTERVENTION(S)

Laparoscopic bilateral oophorectomy was performed. Ovaries were autotransplanted into the abdominal wall, and microsurgical vascular anastomosis of the ovarian to the inferior epigastric vessels was performed. The transplant was removed and evaluated after 7 +/- 1 days.

MAIN OUTCOME MEASURE(S)

Blood flow, serum E2 and FSH levels, and histologic characteristics.

RESULT(S)

At follow-up three transplants were viable; they showed no signs of necrosis, and patency of the vascular anastomosis was confirmed. Serum E2 levels did not change significantly after transplantation in the patent vessel group (155.3 +/- 46.1 vs. 125.7 +/- 44.6 pg/mL) or the nonpatent vessel group (99 vs. 158 pg/mL). Serum FSH level in the patent vessel group did not change significantly from before to after transplantation (70.6 +/- 37.2 ng/mL vs. 95.1 +/- 17.7 ng/mL), whereas a large increase in FSH level was observed in the nonpatent vessel group (52.3 ng/mL vs. 522 ng/mL). The patent vessel group had significantly more follicles after transplantation than did the nonpatent vessel group (6 +/- 1 vs. 1 +/- 1).

CONCLUSION(S)

In conjunction with improved protocols for cryopreservation, ovarian autotransplantation with vascular anastomosis may be superior to current ovarian tissue banking and grafting techniques.