Long-term follow-up of bone density in women with primary ovarian insufficiency

Impact of hormone therapy on the bone density of women with premature ovarian insufficiency: A systematic review

INTRODUCTION

Women with premature ovarian insufficiency (POI) are exposed to a long period of estrogenic deficiency, which potentially brings higher health risks, especially regarding bone health. We performed a systematic review of the literature to evaluate the effect of hormone therapy (HT) on bone mineral density (BMD) in women with POI.

MATERIALS AND METHODS

A systematic search was performed of the MEDLINE and EMBASE databases up to September 2021. We included studies that analyzed women with idiopathic (spontaneous) POI treated with HT, and those who had BMD evaluated. Analysis of risk of bias of studies selected was performed.

RESULTS

We found 335 articles and selected 16 studies according to the inclusion criteria. Most of the studies revealed lower bone density in both the femoral neck and lumbar spine of women with POI compared with healthy women. Bone mass had the tendency to remain stable in women treated with estrogen + progestin therapy. However, in women already with bone mass loss, the therapy - in the doses most frequently used - was not able to revert the loss. Higher doses of estrogen seem to have a positive impact on BMD, as did combined oral contraceptives used continuously. Also, the interruption of HT for longer than one year was linked to significant bone loss.

CONCLUSION

Although HT brings clear benefits, further studies are needed to establish its long-term effects, as well as doses and formulations with better protective effects on the bone mass of these women.

The association of bisphenol A exposure with premature ovarian insufficiency: a case-control study

BACKGROUND

A few epidemiological investigations and animal studies have demonstrated that bisphenol A (BPA) may affect female reproductive health. However, no epidemiologic study has investigated the relationship between BPA exposure and the risk of premature ovarian insufficiency (POI).

METHODS

In this case-control study, urinary concentrations of BPA and serum levels of reproductive hormone were measured. Associations between BPA concentrations and the risk of POI and POI-related hormone levels were estimated.

RESULTS

Among BPA quartiles, no obvious association was found between BPA levels and the risk of POI (p = 0.603). Although the adjusted odds ratio (OR) of POI was slightly increased for participants in the highest BPA concentration quartile, the association was not statistically significant (OR = 1.282, 95% confidence interval [CI] 0.615-2.049 for the highest vs. lowest quartile, p = 0.508). Although follicle stimulating hormone (FSH) and anti-Mullerian hormone (AMH) levels showed no tendency of an association with BPA (p = 0.941 and p = 0.876 for FSH and AMH, respectively), the highest quartile of luteinizing hormone was significantly positively associated with BPA levels (OR = 1.333, 95% CI 0.986-1.803, p = 0.042).

CONCLUSIONS

The urinary concentrations of BPA determined in this study were consistent with the range of exposure currently observed in Chinese women. However, BPA exposure at a relatively low level is not associated with POI in Chinese women. Further epidemiological studies are needed to confirm our findings.

Estrogen-based hormone therapy in women with primary ovarian insufficiency: a systematic review

PURPOSE

Sex hormones play a role in bone density, cardiovascular health, and wellbeing throughout reproductive lifespan. Women with primary ovarian insufficiency (POI) have lower estrogen levels requiring hormone therapy (HT) to manage symptoms and to protect against adverse long-term health outcomes. Yet, the effectiveness of HT in preventing adverse outcomes has not been systematically assessed. We summarize the evidence regarding effects of HT on bone and cardiovascular health in women with POI.

METHODS

A comprehensive search of the electronic databases MEDLINE, EMBASE, and Scopus was conducted by a medical reference librarian from database inception to January 2016. Randomized trials and observational cohort studies with an estrogen-based HT intervention in women with POI under the age of 40 were included. Reviewers worked independently and in duplicate to assess eligibility and risk of bias, and extract data of interest from each study.

RESULTS

The search identified 1670 articles; 12 met inclusion criteria. Four randomized clinical trials and eight cohort studies at high risk of bias enrolled 806 women with POI. The most common HT formulations were transdermal estradiol and oral conjugated equine estrogen combined with medroxyprogesterone acetate. Bone mineral density was the most frequent outcome, with three out of eight studies showing HT associated increase benefits. Only one study reported effects on fractures or vasomotor symptoms and none on cardiovascular mortality. Results regarding lipid profiles were inconsistent.

CONCLUSIONS

Evidence supporting bone and cardiovascular benefits of HT in women with POI is limited by high risk of bias, reliance on surrogate outcomes, and heterogeneity of trials regarding the formulation, dose, route of administration, and regimen of HT. Further research addressing patient important outcomes such as fractures, stroke, and cardiovascular mortality are crucial to optimize benefits of this therapy.

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

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

Primary ovarian insufficiency: different approaches in three cases and a review of literature

Primary ovarian insufficiency (POI) is the condition of intermittent or permanent gonadal insufficiency that occurs in women before the age of 40. We describe three cases of POI referred to the outpatient endocrinology clinic of a university hospital. The three patients met diagnostic criteria for POI and were managed by specific approaches tailored to individualized goals. In the first case, the main concern was fertility and the reproductive prognosis. The second patient was a carrier of a common genetic cause of POI: premutation of the FMR1 gene. The third case was a patient diagnosed with a POI and established osteoporosis, a common complication of estrogen deprivation. This study reports the treatment and follow-up of these cases, with an emphasis on relevant aspects of individualized management, alongside a brief literature review.