The idiopathic forms of premature menopause and early menopause show the same genetic pattern

Primary ovarian insufficiency: update on clinical and genetic findings

Primary ovarian insufficiency (POI) is a disorder of insufficient ovarian follicle function before the age of 40 years with an estimated prevalence of 3.7% worldwide. Its relevance is emerging due to the increasing number of women desiring conception late or beyond the third decade of their lives. POI clinical presentation is extremely heterogeneous with a possible exordium as primary amenorrhea due to ovarian dysgenesis or with a secondary amenorrhea due to different congenital or acquired abnormalities. POI significantly impacts non only on the fertility prospect of the affected women but also on their general, psychological, sexual quality of life, and, furthermore, on their long-term bone, cardiovascular, and cognitive health. In several cases the underlying cause of POI remains unknown and, thus, these forms are still classified as idiopathic. However, we now know the age of menopause is an inheritable trait and POI has a strong genetic background. This is confirmed by the existence of several candidate genes, experimental and natural models. The most common genetic contributors to POI are the X chromosome-linked defects. Moreover, the variable expressivity of POI defect suggests it can be considered as a multifactorial or oligogenic defect. Here, we present an updated review on clinical findings and on the principal X-linked and autosomal genes involved in syndromic and non-syndromic forms of POI. We also provide current information on the management of the premature hypoestrogenic state as well as on fertility preservation in subjects at risk of POI.

Primary ovarian insufficiency has strong familiality: results of a multigenerational genealogical study

OBJECTIVE

To determine the familiality of primary ovarian insufficiency (POI) at population level through examination of multigenerational genealogical information linked to electronic medical records.

DESIGN

Case-control study.

SETTING

Not applicable.

PATIENT(S)

Women with POI were identified using International Classification of Disease 9 and 10 codes in electronic medical records (1995-2021) from 2 major health care systems in Utah and reviewed for accuracy. Cases were linked to genealogy information in the Utah Population Database (UPDB). All included POI cases (n = 396) were required to have genealogy information available for at least 3 generations of ancestors. The risk of POI in relatives was compared with population rates for POI matched by age, sex, and birthplace.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Relative risk of POI in first-, second-, and third-degree relatives.

RESULT(S)

We identified 396 validated cases of POI with an associated 2,132 first-degree relatives, 5,245 second-degree relatives, and 10,853 third-degree relatives. We found an increased risk of POI among the extended relatives of cases. Specifically, first-degree relatives demonstrated an 18-fold increased risk of POI compared with controls relative risk ([RR],18.52 95% confidence interval [CI], 10.12-31.07), second-degree relatives demonstrated a 4-fold increase (RR, 4.21; CI, 1.15-10.79), and third-degree relatives demonstrated a 2.7-fold increase (RR, 2.65; CI, 1.14-5.21]).

CONCLUSION(S)

This is the first population-based study to assess the familial clustering of POI. The data demonstrate excess familiality, familial clustering of POI in excess compared with matched population rates of disease, among first-, second-, and third-degree relatives. These findings support a genetic contribution to POI.

TMEM150B is dispensable for oocyte maturation and female fertility in mouse

Premature ovarian insufficiency (POI) refers to severe decline of ovary function in females which usually leads to infertility. It has been reported that the TMEM150B gene is mostly associated with age at natural menopause, early menopause and POI, but its role in female reproduction remains unknown. In this study, we found Tmem150b was highly expressed in mouse oocytes, but its deletion had no obvious effect on meiotic maturation of oocytes indicated by first polar body emission and spindle morphology. There were also no obvious differences in follicle development and corpus luteum formation between knockout and wild type mice. Finally, knockout of Tmem150b did not affect female fertility and sexual hormone levels. In summary, our results suggest that TMEM150B is not essential for female fertility in mice.

What Every Gynecologist Should Know About Perimenopause

Perimenopause often represents a physiologically challenging phase in women's lives. The clinical presentation of the perimenopause includes infertility, irregular menstrual cycles, menorrhagia, and new onset of or worsening of mood disorders. Unlike menopause, which is characterized by low levels of estradiol and progesterone, the hallmark of perimenopause is highly variable levels of estradiol and progesterone with abrupt increases and decreases that are often described as a hormonal roller coaster. This chapter invites general gynecologists to understand the hormonal basis of the common complaints of perimenopause and offers information about the physiology of these issues and helpful treatment options.

Trends of Premature and Early Menopause: a Comparative Study of the US National Health and Nutrition Examination Survey and the Korea National Health and Nutrition Examination Survey

BACKGROUND

While evidence shows a tendency toward delays in menopause worldwide, whether prevalence of premature (< 40 years) or early menopause (40-44 years) is also reduced in different ethnic groups is uncertain. The aim of this study was to explore birth cohort effect in the prevalence of premature and early menopause in United States (US) and Korea.

METHODS

This is a retrospective study using the National Health and Nutrition Examination Survey (NHANES, 1999-2014) and the Korea NHANES (KNHANES, 2007-2012). We analyzed prevalence of premature and early menopause in three ethnic groups of US and Korea. We restricted our analysis to women aged ≥ 45 years at the time of the survey born between 1920 and 1969. The data of both eligible 9,209 US women and 9,828 Korean was included in final analysis. We calculated odds ratios (OR) for each outcome adjusting for biological and socioeconomic factors, respectively.

RESULTS

Prevalence of premature menopause was 1.7% in US, 2.8% in Korean women. Early menopause occurred in 3.4% and 7.2% of US and Korean, respectively. In US women, prevalence of premature and early menopause did not change and did not differ across three ethnicities. Korean women showed highest and consistently decreasing prevalence (P < 0.001). When we adjusted for covariates, birth lower risk for premature menopause was evident in US Non-Hispanic black born in 1950s and in Korean born between 1940s and 1960s compared to those born in 1920s. In the analysis of early menopause, excluding premature menopause patients, lower risk of more recent generation (born in 1940s and later) was evident in Korean women.

CONCLUSION

The trend and birth cohort effect in occurrence of premature and early menopause among the US and Korea women are different. Prevalences of premature and early menopause decrease only in Korean.

Mutational analysis of theFAM175A gene in patients with premature ovarian insufficiency

RESEARCH QUESTION

The family with sequence similarity 175 member A gene (FAM175A; also known as ABRAXAS1, CCDC98 and ABRA1), a member of the DNA repair family, contributes to the BRCA1 (BRCA1 DNA repair associated)-dependent DNA damage response and is associated with age at natural menopause. However, it remains poorly understood whether sequence variants in FAM175A are causative for premature ovarian insufficiency (POI). The aim of this study was to investigate whether mutations in the gene FAM175A were present in patients with POI.

DESIGN

A total of 400 women with idiopathic POI and 498 control women with regular menstruation (306 age-matched women and 192 women over 40 years old) were recruited. After Sanger sequencing of FAM175A, functional experiments were carried out to explore the deleterious effects of the identified variation. DNA damage was subsequently induced by mitomycin C (MMC), and DNA repair capacity and G2-M checkpoint activation were evaluated by examining the phosphorylation level of H2AX (H2A histone family, member X) and the percentage of mitotic cells, respectively.

RESULTS

One rare single-nucleotide polymorphism, rs755187051 in gene FAM175A, c.C727G (p.L243V), was identified in two patients but absent in the 498 controls. The functional experiments demonstrated that overexpression of variant p.L243V in HeLa cells resulted in a similar sensitivity to MMC-induced damage compared with cells transfected with wild-type FAM175A. Moreover, after treatment with MMC, there were no differences in DNA repair capacity and G2-M checkpoint activation between the mutant and wild-type genes.

CONCLUSION

Our results suggest that the p.L243V variant of FAM175A may not be causative for POI. The contribution of FAM175A to POI needs further exploration.

Variation analysis of theTMEM150B gene in Chinese women with premature ovarian insufficiency

RESEARCH QUESTION

The TMEM150B gene, which promotes cell survival under stress conditions by modulating autophagy, is closely associated with age at natural menopause, early menopause and premature ovarian insufficiency (POI) in European women. However, whether gene variants of TMEM150B contribute to the pathogenesis of POI needs to be determined.

DESIGN

A case-control genetic study in 408 Han Chinese women with non-syndromic POI, in which all exons and exon-intron boundaries of the TMEM150B gene were screened by Sanger sequencing; the results were analysed by statistics and bioinformatics.

RESULTS

Two novel variants located in the 3' untranslated region of the TMEM150B gene were identified, but bioinformation analyses showed that neither was potentially disease-causing. Six known single-nucleotide polymorphisms (SNP) were found, and they were not potentially causative for POI. The intronic SNP rs11668344 was also detected in the POI patients; no significant differences were found in either genotype or allele frequencies compared with the control population.

CONCLUSION

The results suggest that the perturbations in the TMEM150B gene are not a common explanation for POI in Chinese women. The role of autophagy in the pathogenic mechanism of POI needs further exploration.

Advances in the Molecular Pathophysiology, Genetics, and Treatment of Primary Ovarian Insufficiency

Primary ovarian insufficiency (POI) affects ∼1% of women before 40 years of age. The recent leap in genetic knowledge obtained by next generation sequencing (NGS) together with animal models has further elucidated its molecular pathogenesis, identifying novel genes/pathways. Mutations of >60 genes emphasize high genetic heterogeneity. Genome-wide association studies have revealed a shared genetic background between POI and reproductive aging. NGS will provide a genetic diagnosis leading to genetic/therapeutic counseling: first, defects in meiosis or DNA repair genes may predispose to tumors; and second, specific gene defects may predict the risk of rapid loss of a persistent ovarian reserve, an important determinant in fertility preservation. Indeed, a recent innovative treatment of POI by in vitro activation of dormant follicles proved to be successful.

Genetics of primary ovarian insufficiency

Primary ovarian insufficiency (POI) is characterized by a loss of ovarian function before the age of 40 and account for one major cause of female infertility. POI relevance is continuously growing because of the increasing number of women desiring conception beyond 30 years of age, when POI prevalence is >1%. POI is highly heterogeneous and can present with ovarian dysgenesis and primary amenorrhea, or with secondary amenorrhea, and it can be associated with other congenital or acquired abnormalities. In most cases POI remains classified as idiopathic. However, the age of menopause is an inheritable trait and POI has a strong genetic component. This is confirmed by the existence of several candidate genes, experimental and natural models. The variable expressivity of POI defect may indicate that, this disease may frequently be considered as a multifactorial or oligogenic defect. The most common genetic contributors to POI are the X chromosome-linked defects. Here, we review the principal X-linked and autosomal genes involved in syndromic and non-syndromic forms of POI with the expectation that this list will soon be upgraded, thus allowing the possibility to predict the risk of an early age at menopause in families with POI.

Variation analysis of PRIM1 gene in Chinese patients with primary ovarian insufficiency

Insights into common genetic susceptibility between primary ovarian insufficiency (POI) and natural or early menopause have delivered an innovative way of assessing the genetic mechanisms involved in POI. PRIM1 plays a crucial role in DNA replication by synthesizing RNA primers for Okazaki fragments. It is closely associated with age at natural menopause, early menopause and POI in European women. In this study, we aimed to investigate whether mutations in PRIM1 contribute to POI in Chinese women. All exons and exon-intron boundaries of PRIM1 gene were sequenced in 192 Han Chinese women with non-syndromic POI. No plausible mutations were identified. The results suggest that the perturbations in PRIM1 gene are not a common explanation for POI in Chinese women.

Autosomal Translocation Patient Who Experienced Premature Menopause: A Case Report

Premature ovarian failure (POF) is a condition in which the ovarian functions of hormone production and oocyte development become impaired before the typical age for menopause. POF and early menopause are present in a broad spectrum of gonad dysgenesis, from a complete cessation of ovarian function to an intermittent follicle maturation failure. Actually POF has been identified as a genetic entity (especially chromosome X), but data on genetic factors of premature menopause are limited. Until now, several cases revealed that inactivation of X chromosomes has an effect on ages of premature menopause and females with balanced or unbalanced X-autosome translocations can have several reproductive problems. On the other hand, there have been a few data that was caused by autosome-autosome translocation can lead. Therefore we report a relevant case of POF with translocation between chromosomes 1 and 4. She had her first menstrual period at the age of 12, and after 7 years she stopped menstruation. Chromosomal analysis showed 46, XX, t (1;4) (p22.3;q31.3). While evaluating this rare case, we could review various causes (especially genetic factors) of POF. To remind clinicians about this disease, we report a case of POF caused by autosome-autosome translocation with a literature review.

The screening of HELQ gene in Chinese patients with premature ovarian failure

HELQ, a member of DNA repair gene family, is an enzyme required for DNA strands cross-links repair and closely related to age at natural menopause. It also possesses a critical role in the germ cell maintenance, and loss of HELQ gene leads to subfertility. The aim of the present study was to investigate whether mutations in HELQ contribute to premature ovarian failure (POF) in Chinese women. A cohort of 192 patients with POF was enrolled. All exons and exon-intron boundaries of genomic DNA were amplified and sequenced. Six known single-nucleotide polymorphisms were identified in both POF and control groups, including rs1494961, rs13141136, rs7665103, rs11099600, rs2047210 and rs12645412. No mutation was identified. Our study indicates for the first time that mutations in the coding sequence of the HELQ gene may not be responsible for premature ovarian failure in Chinese Han population.

Sex hormone replacement in ovarian failure - new treatment concepts

Premature ovarian failure is associated with decreased bone mass and fractures, and an increased risk of premature death from cardiovascular disease. There is also fertility compromise associated not only with the loss of ovarian function but, in those with pre-pubertal POF, inadequate uterine morphology. A wide variety of hormone replacement regimes are reported, but there is no clear evidence of best practice. Hormone replacement therapy (HRT) and the combined oral contraceptive pill (COCP) will suppress menopausal symptoms; however neither is designed to achieve physiological replacement of oestrogen and progesterone. There is evidence that physiological sex steroid replacement is superior to standard hormone replacement, in improving uterine volume as well as an improved blood pressure profile and bone mineral density. Sex steroid replacement therapy is long-term in these women, and therefore it is essential that the risk benefit ratio is optimal to maximise longer term health.

Translocation t(X;11)(q22;q25) in a woman with premature ovarian failure

Genetic, autoimmune, environmental, iatrogenic, and idiopathic factors are known to cause premature ovarian failure (POF). This report describes an X;11 translocation, t(X;11)(q22;q25), in a woman diagnosed with POF. The FSH level was found to be elevated. Menstrual cycle was regular initially, and she had a spontaneous abortion at the 5th month of gestation at 16 years of age. Her mother was karyotypically normal while her father was not investigated. Male carriers of X;autosome translocations are mostly infertile, and hence the translocation is presumed to be of de novo origin. Fluorescence in situ hybridization using whole chromosome paint probes confirmed the rearrangement.

Investigating the role of X chromosome breakpoints in premature ovarian failure

The importance of the genetic factor in the aetiology of premature ovarian failure (POF) is emphasized by the high percentage of familial cases and X chromosome abnormalities account for 10% of chromosomal aberrations. In this study, we report the detailed analysis of 4 chromosomal abnormalities involving the X chromosome and associated with POF that were detected during a screening of 269 affected women. Conventional and molecular cytogenetics were valuable tools for locating the breakpoint regions and thus the following karyotypes were defined: 46,X,der(X)t(X;19)(p21.1;q13.42)mat, 46,X,t(X;2)(q21.33;q14.3)dn, 46,X,der(X)t(X;Y)(q26.2;q11.223)mat and 46,X,t(X;13)(q13.3;q31)dn. A bioinformatic analysis of the breakpoint regions identified putative candidate genes for ovarian failure near the breakpoint regions on the X chromosome or on autosomes that were involved in the translocation event. HS6ST1, HS6ST2 and MATER genes were identified and their functions and a literature review revealed an interesting connection to the POF phenotype. Moreover, the 19q13.32 locus is associated with the age of onset of the natural menopause. These results support the position effect of the breakpoint on flanking genes, and cytogenetic techniques, in combination with bioinformatic analysis, may help to improve what is known about this puzzling disorder and its diagnostic potential.

ESR1, HK3 and BRSK1 gene variants are associated with both age at natural menopause and premature ovarian failure

Background

Premature ovarian failure (POF) is a complex and heterogeneous disorder that is influenced by multiple genetic components. Numerous candidate gene studies designed to identify POF susceptibility loci have been published, but most positive findings have not been confirmed in follow up studies. We sought to determine if sequence variants previously associated with age at natural menopause (AANM) or early menopause (EM) contribute as well to genetic susceptibility to POF.

Methods

Our study was performed on 371 unrelated idiopathic women with POF and 800 women controls, all Chinese Han. Thirty six SNPs from previous genome-wide association studies (GWAS) responsible for AANM or EM and 3 additional SNPs in ESR1, and 2 additional SNPs in PTHB1 were tested using the Sequenom MassARRAY iPLEX platform for genotyping.

Results

Three SNPs - rs2278493 in HK3, rs2234693 in ESR1 and rs12611091 in BRSK1 - showed nominally significant association with POF. Thus, a plausible relationship could exist between ESR1, BRSK1, HK3 and POF.

Conclusions

This largest association study undertaken to determine correlation between POF and AANM/EM revealed three significant SNPs (rs2278493, rs2234693, and rs12611091). All are associated with not only AAWM and EM but also POF. Insights into shared genetic susceptibility between POF and AANM/EM will provide novel entry points for unraveling genetic mechanism involved in ovarian reserve and oocyte aging processes.

A family with Xq22.3q25 interstitial deletion and normal ovarian function

OBJECTIVE

To investigate genomic changes in a family with deletion of X chromosome q22.3-q25 associated with normal constitutional and reproductive phenotypes.

DESIGN

Case report.

SETTING

Academic district hospital genetic laboratory.

PATIENT(S)

A family incidentally found to have deletion of X chromosome q22.3-q25.

INTERVENTION(S)

Cytogenetic analysis and array-based comparative genomic hybridization for amniotic fluid and peripheral blood lymphocyte of family members.

MAIN OUTCOME MEASURE(S)

Ovarian function and menstrual cycles.

RESULT(S)

The proband and two daughters showed deletion of Xq22.3q25. This region spans 17.4 Mb and contains 121 genes.

CONCLUSION(S)

Female subjects with deletion of Xq22.3q25 may present with normal constitutional and reproductive phenotypes.

Genes involved in initial follicle recruitment may be associated with age at menopause

CONTEXT

Timing of menopause is largely influenced by genetic factors. Because menopause occurs when the follicle pool in the ovaries has become exhausted, genes involved in primordial follicle recruitment can be considered as candidate genes for timing of menopause.

OBJECTIVE

The aim was to study the association of 23 tagging single nucleotide polymorphisms in five genes [Anti-Müllerian hormone (AMH), AMH type II receptor (AMHR2), bone morphogenetic protein 15 (BMP15), forkhead transcription factor L2 (FOXL2), and growth differentiation factor-9 (GDF9)] involved in recruitment of the primary follicle pool, including the AMHR2 gene, which has recently been associated with age at menopause.

DESIGN

We conducted a cross-sectional association study.

SETTING AND PARTICIPANTS

We studied a population-based sample of 3616 Dutch women with natural menopause.

MAIN OUTCOME MEASURE

We measured age at natural menopause.

RESULTS

Both studied AMHR2 tagging single nucleotide polymorphisms (rs2002555 and rs11170547) in the AMHR2 gene were associated with age at natural menopause in interaction with parity. Parous rs2002555 G/G carriers had menopause 1 yr later compared with A/A carriers (P = 0.01). For rs11170547, each minor allele (T) was associated with a 0.41-yr later onset of menopause in parous women (P = 0.01). Additionally, rs6521896 in BMP15 was associated with later menopause (β = 0.41; P = 0.007). Variants in the AMH, FOXL2, and GDF9 genes were not associated with timing of menopause.

CONCLUSIONS

The present study confirms an earlier finding that variation in the AMHR2 gene modifies the relation between parity and age at natural menopause. In combination with the association of BMP15 with menopausal age, we find that there is evidence that genes involved in primary follicle recruitment influence timing of menopause.

Cytogenetics of premature ovarian failure: an investigation on 269 affected women

The importance of X chromosome in the aetiology of premature ovarian failure (POF) is well-known but in many cases POF still remains idiopathic. Chromosome aneuploidy increase is a physiological phenomenon related to aging, but the role of low-level sex chromosome mosaicism in ovarian function is still undiscovered. Standard cytogenetic analysis was carried out in a total of 269 patients affected by POF: 27 chromosomal abnormalities were identified, including X chromosome and autosomal structural and numerical abnormalities. In 47 patients with 46,XX karyotype we performed interphase FISH using X alpha-satellite probe in order to identify X chromosome mosaicism rate. Aneuploidy rate in the patient group was significantly higher than the general population group. These findings underline the importance of X chromosome in the aetiology of POF and highlight the potential role of low-level sex chromosome mosaicism in ovarian aging that may lead to a premature onset of menopause.

Optimizing hormone therapy for future reproductive performance in women with premature ovarian failure

With increasing success in treatment of childhood cancer there is a growing population of women with premature ovarian failure (POF) seeking fertility treatment. Various preparations of estrogen and progestogen are prescribed for young women with POF. While the dose and duration of hormone therapy (HT) is usually adjusted according to the patient's height and the Tanner's stage of development for young pre-pubertal women, the optimal effective HT regimen to maximise the reproductive potential for young as well as for the older age group remains unclear. Furthermore, there is a paucity of evidence to support the preferential effectiveness of the different regimens used. Assisted reproduction using donated gametes or embryos remains the only realistic option to enable women with POF to conceive. Successful outcomes are primarily dependant on successful implantation and placentation. Consequently, the success of assisted reproduction is determined by uterine and endometrial development, which is largely influenced by the modality of HT as well as the age at which it is commenced. In this review, we critically appraise the current practices and published data for management of women with POF. We aim to focus on the effect of HT on uterine development in women with primary and irreversible POF.

Similar phenotype characteristics comparing familial and sporadic premature ovarian failure

OBJECTIVE

Premature ovarian failure (POF) is characterized by secondary amenorrhea before the age of 40 years, along with repeated increased follicle-stimulating hormone and low estrogen concentrations. POF is considered a complex genetic disease with a familial presentation in 12% to 50% of cases. POF may originate from different genes and various gene-environment interactions. The aim of this study was to identify possible differences in phenotype comparing women with familial and women with sporadic POF.

METHODS

A multicenter study was initiated in the Netherlands using standardized phenotyping. For each woman, medical history, menstrual cycle, and fertility and smoking status were assessed and a standardized examination was performed. Based on a detailed three-generation family history, women were identified as having either familial (defined as having at least one relative with POF) or sporadic POF.

RESULTS

A total of 58 familial cases and 142 sporadic cases of POF were identified. Maternal age at menopause was significantly lower in the women with familial compared with the women with sporadic POF (41.0 +/- 7.5 and 49.7 +/- 2.6 y, respectively; P < 0.001). Sex hormone-binding globulin concentration was significantly higher in the women with familial than in the women with sporadic POF (73.6 +/- 37.1 and 55.2 +/- 26.9 nmol/L, respectively; P = 0.002). All other characteristics, such as parity, bone mineral density, and serum follicle-stimulating hormone and lipid levels were similar, as was the incidence of autoimmunity and cytogenetic abnormalities.

CONCLUSIONS

Familial and sporadic POF do not differ in phenotype except for maternal menopause age and sex hormone-binding globulin concentration. Future studies are needed to unravel the genotype-phenotype interactions in POF.

Premature menopause is associated with increased risk of cerebral infarction in Japanese women

OBJECTIVE

: Few epidemiological studies have examined the relationship between age at menopause and stroke incidence, and none have done so in Japanese women. Here, we investigated the relationship between age at menopause and stroke incidence in a large group of Japanese women.

METHODS

: The study participants were 4,790 postmenopausal women aged 36 to 89 years enrolled 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. The incidence of all strokes and stroke subtypes was monitored.

RESULTS

: Mean (SD) participant age was 61.0 (6.7) years, and mean (SD) age at menopause was 48.3 (4.8) years. A total of 185 strokes were observed during a mean follow-up of 10.8 years. On adjustment for age, systolic blood pressure, total cholesterol, body mass index, smoking habits, and alcohol drinking habits, hazard ratios (95% CIs) of stroke for women who underwent menopause before age 40 years, at 40 to 44 years, at 45 to 49 years, and at 55 years or after relative to those who underwent menopause at age 50 to 54 years were 1.56 (0.78-3.12), 1.59 (1.00-2.51), 1.28 (0.92-1.78), and 0.83 (0.38-1.81), respectively. However, hazard ratios (95% CI) of cerebral infarction for women who underwent menopause before age 40 years, at 40 to 44 years, at 45 to 49 years, and at 55 years or after relative to those who underwent menopause at age 50 to 54 years were 2.57 (1.20-5.49), 1.49 (0.80-2.78), 1.06 (0.67-1.68), and 1.08 (0.43-2.74), respectively.

CONCLUSIONS

: Our data suggest that Japanese women who undergo menopause before age 40 years are at an increased risk of cerebral infarction. Premature menopause should be considered an indicator of the need for more aggressive medical intervention aimed at the prevention of cerebral infarction.

Premature ovarian failure from current perspective

Premature ovarian failure (POF) is a syndrome characterised by amenorrhoea, hypoestrogenism and hypergonadotropinism before the age of 40. It is a disorder affecting approximately 1% of women <40 years, 1/1,000 women by the age of 30 and 1/10,000 women by the age of 20. POF is not merely an early menopause. Up to 50% of the patients with POF will have intermittent and unpredictable ovarian function which may persist for some years. Heterogeneity of POF is also reflected by the variety of possible causes, including autoimmunity, toxics, drugs, radiation, infectious as well as genetic defects. HRT remains the cornerstone of treatment and the only proven method of achieving pregnancy in these patients is by ovum donation.

Human studies on genetics of the age at natural menopause: a systematic review

BACKGROUND Timing of natural menopause has great implications for fertility and women's health. Age at natural menopause (ANM) is largely influenced by genetic factors. In the past decade, several genetic studies have been conducted to identify genes in ANM, which can help us unravel the biological pathways underlying this trait and the associated infertility and health risks. After providing an overview of the results of the genetic studies performed so far, we give recommendations for future studies in identifying genetic factors involved in determining the variation in timing of natural menopause. METHODS The electronic databases of Pubmed and Embase were systematically searched until September 2009 for genetic studies on ANM, using relevant keywords on the subject. Additional papers identified through hand search were also included. RESULTS Twenty-eight papers emerged from our literature search. A number of genetic regions and variants involved in several possible pathways underlying timing of ANM were identified, including two possible interesting regions (9q21.3 and chromosome 8 at 26 cM) in linkage analyses. Recent genome-wide association studies have identified two genomic regions (19q13.42 and 20p12.3), containing two promising candidate genes (BRKS1 and MCM). In the candidate gene association studies on ANM, very few consistent associations were found. CONCLUSION A number of genetic variants have been discovered in association with ANM, although the overall results have been rather disappointing. We have described possible new strategies for future genetic studies to identify more genetic loci involved in the variation in menopausal age.

Mother's menopausal age is associated with her daughter's early follicular phase urinary follicle-stimulating hormone level

OBJECTIVE

Early follicular phase follicle-stimulating hormone (FSH), a marker of ovarian reserve, has been used to predict time to menopause. A mother's age at menopause is related to her daughter's age at menopause, possibly because of genetic factors. In this study we sought to determine the relationship between maternal age at menopause and early follicular phase FSH of premenopausal daughters.

DESIGN

The Uterine Fibroid Study enrolled women randomly selected from a prepaid health plan, collected questionnaire data, and obtained early follicular phase urine samples for a subset of participants. For this secondary analysis, premenopausal women between the ages of 35 and 46 years, who provided a urine sample on cycle day 2, 3, 4, or 5 and their mother's age at natural menopause (n = 182) were selected from the original cohort. Initially bivariate analysis and subsequently regression modeling were performed to assess the independent relationship between maternal age at menopause and urinary creatinine-corrected FSH.

RESULTS

Unadjusted analyses and those adjusting for age (mean +/- SD, 40.5 +/- 3.2 y), smoking status (16% current smokers), and body mass index (26.8 +/- 6.9 kg/m) showed a significant association between maternal age at menopause and daughter's urinary FSH level (P < 0.04). Women whose mothers experienced earlier menopause had higher urinary FSH levels.

CONCLUSIONS

The significantly increased FSH values among women whose mothers experienced early menopause is consistent with previously reported associations between mother's and daughter's age of menopause. FSH, a marker of ovarian reserve, is influenced by both genetic and environmental factors. Future epidemiologic studies on FSH should include collection of information on maternal age at menopause.

Spontaneous premature ovarian failure: management challenges

Premature ovarian failure (POF) generally describes a syndrome consisting of amenorrhea, sex steroid deficiency, and elevated/menopausal levels of ganadotropins in a woman aged more than two standard deviations below the mean age at menopause estimated for the reference population. Numerous questions relating to this condition remain unanswered, and several important management issues are yet to be addressed. The challenges posed by this important condition range from difficulties with nomenclature to the absence of standardized diagnostic criteria and management guidelines. In the present paper we discuss the management of spontaneous premature ovarian failure, highlight the challenging issues, review the current literature and propose a practical management outline based on our local practice. Women with POF have unique needs that require special attention. There is an urgent need for a more suitable terminology and evidence-based guidelines on which to establish the diagnosis and manage this difficult condition.

Premenopausal factors influencing premature ovarian failure and early menopause

OBJECTIVES

We conducted this study to examine premenopausal risk factors associated with premature ovarian failure (POF) and early menopause (EM) among Korean women.

METHODS

A 73% of total women aged 30-69 at four districts in the KMCC (Korean Multi-center Cancer Cohort) was participated in this study during 2002-2003. We selected 137 POF and 281 EM cases who had menopause before age 40 and at age 40-44, respectively, and 1318 normal menopause (NM) controls that experienced menopause at age 45-60, and among them, selected idiopathic POF (n=84) and EM (n=261) after excluding surgical/medical menopause. We collected the information of premenopausal lifestyle and reproductive risk factors. Multivariate and polytomous logistic regression were used to estimate POF and EM risk and to differentiate POF and EM risk using ordinal and nominal scale.

RESULTS

Cigarette smoking was associated with an increased risk of idiopathic POF (OR=1.82 [1.03-3.23]), whereas oral contraceptive use was associated with a reduced risk of natural EM (OR=0.62 [0.43-0.90]). Idiopathic POF risk by both factors differed from idiopathic EM risk (p-nominal<0.05). Factors related to ovulation, such as later menarche, irregular menstruation and longer breast feeding cumulatively reduced the risk of natural EM and POF (p-ordinal<0.05). In analysis including medical and surgical menopause, lung tuberculosis, hysterectomy, past cancers, and lower number of deliveries before menopause were associated with POF.

CONCLUSIONS

Our findings indicate that etiology in POF development may partly differ from that in EM.

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.

Acceptance of fragile X premutation genetic screening in women with ovarian dysfunction

OBJECTIVE

The purpose of this study was to assess patient perception of fragile X premutation genetic testing (FRAX).

STUDY DESIGN

This was a cross-sectional survey of women with elevated follicle stimulating hormone levels with (premature ovarian failure or early menopause [POF/EM], n = 20) or without (diminished ovarian reserve [DOR], n = 20) amenorrhea. Seventy-five percent participated.

RESULTS

Seventy-five percent of the DOR group and 43% of the POF/EM group desired FRAX testing. Eighty-three percent wanted to assist the scientific knowledge of FRAX, even if they did not want to know their own results. POF/EM women were more concerned than DOR women about paying out-of-pocket (P = .001) and maintaining confidentiality insurance-wise (P = .07). Primary motivations for women who wanted testing were the desire to know if they have FRAX, and wanting to determine if FRAX is the cause of their ovarian dysfunction. The primary decision factor for those declining testing was unwillingness to pay out-of-pocket (75%).

CONCLUSION

Women with ovarian dysfunction are interested in FRAX testing. Cost, confidentiality, and the implications for relatives are their key concerns.

The differences in panoramic mandibular indices and fractal dimension between patients with and without spinal osteoporosis

OBJECTIVES

The aims of this study were to evaluate the relationship between osteoporosis, oral signs, body mass index and age; and to assess the possibility of using these parameters as an indicator of post-menopausal osteoporosis. The oral signs were panoramic-based mandibular indices, such as cortical width, cortical index, panoramic mandibular index and mandibular crest resorption degree; the number of teeth and fractal dimension analysis.

METHODS

Forty-eight post-menopausal women between the ages of 40 years and 64 years were evaluated. Mandibular indices and the number of mandibular teeth were measured and evaluated from panoramic radiographs and fractal dimension was calculated from the direct digital periapical radiographs of the mandibular premolar-molar region in box-counting method. Weight, height, menopausal status and age of the patients were recorded by questionnaire. Bone mineral densities of the patients were measured with dual energy X-ray absorptiometry.

RESULTS

In this study there were no statistically significant differences between the osteoporotic and non-osteoporotic patients for cortical width, panoramic mandibular index, alveolar crest resorption degree, fractal dimension and the number of mandibular teeth, but there was a difference for cortical index. Binary logistic regression analyses demonstrated that age (P = 0.015) was an important risk factor for osteoporosis.

CONCLUSION

The results of this study demonstrated that osteoporotic patients were more likely to have altered inferior cortex morphology than non-osteoporotic patients and age is an important risk factor for osteoporosis.

Genetic studies to identify genes underlying menopausal age

Menopausal age is important as a retrospective marker for ovarian senescence, an early menopausal age is associated with an increased risk of cardiovascular diseases and osteoporosis, whereas a later menopausal age has been associated with an increased risk of breast cancer. The worldwide average for age at natural menopause is approximately 51 years and is more or less normally distributed with a range roughly between 40 and 60 years. Environmental factors explain only a small part of the variance and it has been proposed that genetic factors are the main source of variation. Menopausal age may be considered a continuous complex trait. Complex traits are defined as traits that are influenced by both multiple genetic and environmental factors. A category of complex traits comprises those that are measured on a continuous scale. The genomic loci that make up the genetic component are called 'quantitative trait loci' or QTLs. The first linkage study on menopausal age suggests that the involvement of the X-chromosome may not be limited to premature ovarian failure (POF), but may influence the broader spectrum of menopausal age. A potentially new locus for variation in menopausal age was allocated to chromosome 9. Further studies need to identify new candidate genes to help unravel the pathophysiology of menopausal age. It is becoming increasingly clear that, in any speciality, it should be acknowledged that genetic factors are involved in many traits and that uncovering these factors may provide insight into pathogenesis and ultimately advance prevention and treatment of disease. In this review we discuss methods and basic principles of gene finding for such traits, exemplified by menopausal age as phenotype. Furthermore, we give an overview of the state of the art of candidate gene studies and linkage studies.

Mutation analysis of two candidate genes for premature ovarian failure, DACH2 and POF1B

BACKGROUND

Balanced X;autosome translocations interrupting the 'critical region' of the long arm of the human X chromosome are often associated with premature ovarian failure (POF). However, the mechanisms leading to X-linked ovarian dysfunction are largely unknown, as the majority of the X chromosome breakpoints have been mapped to gene-free genomic regions. A few genes have been found to be interrupted, but their role has never been clarified.

METHODS AND RESULTS

By fine mapping of the X chromosome breakpoint of an X;autosome balanced translocation, we identified a new interrupted gene, POF1B. We performed a mutation analysis of POF1B and of another gene previously identified, DACH2, localized approximately 700 kb distal in Xq21, in a cohort of >200 Italian POF patients. Rare mutations were found in patients in both genes.

CONCLUSIONS

Our findings could not demonstrate any involvement of POF1B, but suggest that rare mutations in the DACH2 gene may have a role in the POF phenotype.

Age at natural menopause is not linked with the follicle-stimulating hormone receptor region: a sib-pair study

OBJECTIVE

Studies have shown that age at natural menopause is heritable. Mutations in the FSH-receptor have been identified in women with premature ovarian failure (POF) and the FSH-receptor gene may, therefore, be considered a candidate gene for (early) menopausal age. This study investigates whether there is linkage between genetic markers in the FSH-receptor region and (early) age at menopause using a sib-pair design.

DESIGN

Sib-pair based linkage analysis.

SETTING

Sister pairs and their first-degree family members from The Netherlands.

PATIENT(S)

The inclusion criteria for a family were natural menopause in upper or lower tail of the distribution of menopausal age in at least two sisters. A total of 126 families with at least one sib-pair were included in this study. Six polymorphic markers encompassing the FSH-receptor gene were genotyped.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Single point and multipoint logarithm of the odds (LOD) scores.

RESULT(S)

None of the markers showed evidence in favor of linkage with overall age at natural menopause or early age at natural menopause.

CONCLUSION(S)

Possibly, age at natural menopause in the more or less normal range is not part of the spectrum of phenotypes determined by mutations in the FSH-receptor gene. Alternatively, our results might be explained by genetic heterogeneity in the left tail of the distribution of menopausal age. This can limit the chance of finding a genetic locus, especially if this factor has a modest contribution to the phenotype.

Linkage analysis of extremely discordant and concordant sibling pairs identifies quantitative trait loci influencing variation in human menopausal age

Age at natural menopause may be used as parameter for evaluating the rate of ovarian aging. Environmental factors determine only a small part of the large variation in menopausal age. Studies have shown that genetic factors are likely to be involved in variation in menopausal age. To identify quantitative-trait loci for this trait, we performed a genomewide linkage study with age at natural menopause as a continuous quantitative phenotype in Dutch sister pairs, through use of a selective sampling scheme. A total of 165 families were ascertained using extreme selected sampling and were genotyped for 417 markers. Data were analyzed by Haseman-Elston regression and by an adjusted variance-components analysis. Subgroup analyses for early and late menopausal age were conducted by Haseman-Elston regression. In the adjusted variance-components analysis, 12 chromosomes had a LOD score of > or =1.0. Two chromosomal regions showed suggestive linkage: 9q21.3 (LOD score 2.6) and Xp21.3 (LOD score 3.1). Haseman-Elston regression showed rather similar locations of the peaks but yielded lower LOD scores. A permutation test to obtain empirical P values resulted in a significant peak on the X chromosome. To our knowledge, this is the first study to attempt to identify loci responsible for variability in menopausal age and in which several chromosomal regions were identified with suggestive and significant linkage. Although the finding of the region on the X chromosome comes as no surprise, because of its widespread involvement in premature ovarian failure, the definition of which particular gene is involved is of great interest. The region on chromosome 9 deserves further consideration. Both findings require independent confirmation.

Mutation analysis of the inhibin alpha gene in a cohort of Italian women affected by ovarian failure

BACKGROUND

Premature ovarian failure (POF) is a secondary hypergonadotrophic amenorrhoea affecting 1-3% of females, whose aetiology is almost unknown. However, inhibin alpha gene (INHalpha) has recently been indicated as candidate in POF pathogenesis.

METHODS

We analysed patients affected by POF (n = 157) for the missense mutation (769G-->A transition) in the exon 2 of the INHalpha gene. The same analysis was carried out on early menopause (EM) (n = 36) and primary amenorrhoea (n = 12) patients.

RESULTS

The incidence of the mutation was significantly more frequent within both POF (7/157, 4.5%) (Fisher's exact test, P = 0.030) and primary amenorrhoea (3/12, 25%) (Fisher's exact test, P < 0.001) patients, compared with the control population of women (0/100), who experienced physiological menopause. No mutation was found in EM patients. Furthermore, the likelihood of finding the mutation was statistically significant in familial (5/65; 7.7%) (Fisher's exact test, P < 0.01) but not in sporadic (2/92; 2.2%) (Fisher's exact test, P = not significant) POF, compared with the control group. The analysis of pedigrees showing the inheritance of the 769G-->A mutation and POF strengthens the concept of the disease heterogeneity, since the POF phenotype was not always associated with the mutation. Moreover, a higher prevalence of the C allele of a single nucleotide polymorphism (129C-->T), located in the 5'-UTR of the INHalpha gene, was observed in POF patients (80.3%) than in the control group (66.7%) (Fisher's exact test, P = 0.014).

CONCLUSION

These data strengthen the concept of the INHalpha gene as a candidate for ovarian failure.

Associations with age at natural menopause in Blackfeet women

This study seeks to determine the age at natural menopause and factors that may predict that age for Blackfeet women living on the reservation in Montana. Data were obtained from a probability sample of 150 women. Rates of surgical menopause among women who had experienced menopause were similar to those found in NHANES I for U.S. women. Median age at natural menopause by the status quo method (51.2 years) was comparable to that determined for other populations. Within the group of women who already had experienced natural menopause, age at menopause was associated in bivariate models with age at menarche (b = -0.83 +/- 0.44 years, P = 0.07), household income (b = 1.85 +/- 0.71 years, P = 0.01), "ever use" of birth control (b = 4.52 +/- 1.58 years, P = 0.008), "ever use" of oral contraceptives (b = 5.48 +/- 1.91 years, P = 0.007), current or recent unemployment (b = 4.75 +/- 1.97 years, P = 0.02), having been breastfed (b = -6.93 +/- 2.67 years), and educational attainment (ANOVA by tertiles of menopause age, mean 10.0 +/- 3.6 years of education for earliest, 13.0 +/- 2.2 years for latest, P = 0.04). In multivariate models, "ever use" of oral contraceptives, household income, and age at menarche remained significant predictors of age at menopause (R2 = 0.33-0.35, P = 0.002-0.004), with household income modifying the effect of age at menarche (analysis ofjoint effects). The findings are discussed in the context of cohort experiences, examining implications for both early and later-life influences on menopause age.

Implications of the FMR1 gene in menopause: study of 147 Spanish women

OBJECTIVE

To evaluate the relationship between the FMR1 premutation and premature ovarian failure (POF) in the Spanish population and the possible incorporation of this test in gynecological procedures for women with POF or early menopause (EM).

DESIGN

Clinical and molecular genetic study. Ninety-eight premutated and six full-mutated carriers of fragile X syndrome and 43 women with POF were studied by polymerase chain reaction and Southern blot analysis for the CGG repeat expansion in the FMR1 gene.

RESULTS

Among premutated carriers, 12.2% (12 of 98) presented with POF, and 15.3% (15 of 98) presented with EM. Neither POF nor EM was observed in any of the six full-mutated women. Two women of 43 from the POF population (4.65%) were carriers for the CGG premutation in the FMR1 gene. No correlation between CGG expansion size and age at menopause was found. A biased paternal origin of the premutation and a high twinning incidence was found in all premutated women, whether they had POF or not.

CONCLUSIONS

Our data support the hypothesis that the FMR1 gene is one of the genes associated with POF and EM. Analysis of the CGG expansion in the FMR1 gene may be justified in women with POF and EM until the real role of the FMR1 premutation is determined.

Possibilities of sterility therapy in a patient with a premature menopause due to an X-chromosomal anomaly - a case report

Our report concerns a patient with a climacterium praecox and an X-chromosomal anomaly (86% 46, XX; 7% 47, XXX; 7% 45, X0) desiring to give birth. She conceived once after down-regulation of the gonadotrophins by means of a cyclical hormone replacement therapy followed by gonadotrophin stimulation, as well as a second time under down-regulation with a GnRH-analogue and gonadotrophin stimulation. On the basis of the case report and of the literature, a possible interval therapy in such a patient, especially one even with increasing ovarian insufficiency, will be portrayed and discussed.

Genetic contributions of the endothelial nitric oxide synthase gene to ovulation and menopause in a mouse model

OBJECTIVE

To investigate the influence of the endothelial nitric oxide synthase gene (Nos3) on ovulatory capacity and reproductive senescence.

DESIGN

Prospective, controlled study.

SETTING

Academic research institution.

SUBJECT(S)

Laboratory mice with targeted mutagenesis of Nos3.

INTERVENTION(S)

Hyperstimulation protocol, oocyte culture, and ovarian histology using wild-type (Nos3(+/+); n = 20), heterozygous (Nos3(+/m); n = 39), and homozygous deficient (Nos3(m/m); n = 11) female mice; observation of reproductive outcomes.

MAIN OUTCOME MEASURE(S)

Number and survival of oocytes; onset of menarche and menopause.

RESULT(S)

The mean number of superovulated oocytes (18 +/- 36 vs. 41 +/- 4) and the 48-hour overall survival rate of embryos (65% vs. 81%) were significantly reduced for Nos3(m/m) female mice compared with Nos3(+/+) female mice. Nos3(m/m) females showed a significantly reduced number and size of antral follicles and corpora lutea compared with wild-type controls. Compared with Nos3(+/m) x Nos3(+/m) breedings, Nos3(m/m) x Nos3(m/m) breedings showed a higher female age at first litter (76.2 +/- 10.3 vs. 107.8 +/- 26.6 days), fewer litters (10.5 +/- 3.6 vs. 7. 8 +/- 4.2), and a lower female age at reproductive senescence (400.2 +/- 64.5 vs. 332.1 +/- 27.4 days), respectively.

CONCLUSION(S)

Our data suggest that Nos3 deficiency is associated with reduced ovulatory capacity and impaired early embryonic viability and that it influences the onset of menarche and menopause.

Premature ovarian failure

Secondary amenorrhoea with elevated gonadotrophins occurring under the age of 40 (premature ovarian failure (POF)), and at the age between 41 and 44 years (early menopause (EM)), respectively, affects 1-2% and 5% of women in the general population. Objective of this study was to evaluate the prevalence of familial cases of POF and EM and to assess the clinical and genetic characteristics of these patients. One hundred and sixty women with idiopathic secondary amenorrhoea before the age of 45 and serum follicle-stimulating hormone (FSH) levels greater than or equal to 40 IU/l were included in the study. Tests performed on patients included complete medical history, pedigree's analysis, clinical pelvic examination, gonadotrophins and thyroid assessment, chromosomal analysis. The 160 patients included in the study showed idiopathic POF (n=130) or EM (n=30). Following pedigree assessment, we were able to identify an incidence of familial cases of 28.5% in the POF group (n=37) and of 50% in the EM group (n=15). POF and EM condition were often present in the same family. There were no differences between POF and EM patients and between familial and sporadic cases regarding age at menarche, personal history, gynaecological history, weight, height and diet habits. There was a statistically significant difference between sporadic and familial cases in age at POF onset: 32.0+/-7.3 years (12-40) compared to 35. 0+/-5.8 (18-40), respectively (P<0.05). The POF and EM families identified showed two or more affected females and transmission through either maternal or paternal relatives; in four families both maternal and paternal transmission was observed. This study suggests that idiopathic POF and EM conditions, differing only in age of menopause onset, may represent a variable expression of the same genetic disease. The different age of menopause onset in these patients may be explained by genetic heterogeneity and/or by different environmental factors. Our results indicate a high rate of familial transmission of the condition. Pedigree's analysis suggests an autosomal or an X-linked dominant sex-limited pattern of inheritance for POF and EM.