Current Concepts in Premature Ovarian Insufficiency

Premature ovarian insufficiency: knowledge, attitudes, and quality of care offered by gynecologists

OBJECTIVE

Premature ovarian insufficiency (POI) affects up to 3% of the global female population, influencing metabolic, cardiovascular, and reproductive health. Medical expertise in diagnosis, effects, and treatment strategies, particularly for gynecologists, is crucial for ensuring improved healthcare for women. The objective of this study is to assess the state of medical knowledge regarding the diagnosis, treatment, and follow-up of POI among Brazilian gynecologists.

METHODS

A cross-sectional study was conducted using online questionnaires administered to 16,000 members of the Brazilian Federation of Gynecology and Obstetrics.

RESULTS

In total, 460 questionnaires were received from gynecologists who had an average age of 44.49 ± 12.57 years and 19.37 ± 12.95 years of professional experience. Fifty-three percent of gynecologists diagnosed POI correctly, and 49% requested karyotype analysis, while fewer than 10% identified all POI etiologies. Over 90% of gynecologists understood the long-term consequences of POI for bone and cardiovascular health. Despite being a consequence of hypoestrogenism, hormone therapy was recommended only by 20% of doctors, with no more than 50% of them prescribing appropriate doses for young women. Regarding self-perception, 60% of gynecologists declared deficient knowledge regarding how to offer care and guidance to women, with hormone therapy being reported as the most important reason (47%).

CONCLUSIONS

Current concepts and guidelines for POI are not adequately understood or applied in Brazilian clinical practice, leading to suboptimal care.

Female-specific risk factors for cardiovascular disease: an update

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. While it was previously believed that men have greater susceptibility to CVD, recent research suggests that women face an increased risk of CVD after the onset of menopause, primarily due to the loss of the protective effects of estrogens. Premature ovarian insufficiency (POI), polycystic ovarian syndrome (PCOS), and gestational factors, such as gestational diabetes mellitus (GDM), recurrent pregnancy loss, preterm delivery, and preeclampsia, are specific reproductive disorders that may contribute to an elevated risk of CVD at earlier ages, i.e., before the onset of menopause. This suggests that women with these conditions should be closely monitored for CVD risk factors even before reaching menopause. Such early intervention may help reduce the incidence of CVD and improve overall cardiovascular health in this population. The precise pathophysiological mechanism underlying the development of CVD in women with menopause, premature POI, PCOS, and gestational factors remains elusive. This review article seeks to elucidate the latest research on the relationship between these conditions and CVD in women, aiming to explore the underlying pathogenic mechanisms contributing to this association.

Sexual function in women with premature ovarian insufficiency (POI): Systematic review and meta-analysis

Premature ovarian insufficiency (POI) is a rare condition characterized by loss of ovarian function before the age of 40. POI seems associated with mood disorders and sexual dysfunction. However, there is a lack of high-quality evidence relating to the impact of POI on sexual function. Therefore, we conducted a systematic review and meta-analysis to evaluate sexual function in women with POI compared to women without the condition. The following online databases were systematically searched up to January 2023: EMBASE, Medline (Ovid), Web of Science, Cochrane, PsychInfo, and Google Scholar. Random effects models were used for analyses, with data reported as Hedges' g and 95 % confidence interval, and the risk of heterogeneity was evaluated. The protocol of this study was registered with PROSPERO (CRD42023437203). A total of 10 studies were included in the systematic review and 5 studies involving 352 women with POI were included in the meta-analysis. Eight of the ten studies concluded that women with POI have reduced sexual function. An overall medium Hedges' g effect size of -0.72 was found (ranging between -0.20 and -1.29) in favor of control women, with moderate heterogeneity (I2 = 64 %). Stratified studies of women on systemic hormone replacement therapy (HRT) showed an even higher Hedges' g effect size, of -0.82 (95 % CI -1.18, -0.47). In conclusion, sexual function in women with POI is reduced compared with control women. Sexual function should be discussed with women with POI and they should be offered psychosexual counseling.

Ovarian Insufficiency and Fertility Preservation During and After Childhood Cancer Treatment

Premature ovarian insufficiency (POI) is one of many potential long-term consequences of childhood cancer treatment in females. Causes of POI in this patient population can include chemotherapy, especially alkylating agents, and radiation therapy. Rarely, ovarian tumors lead to ovarian dysfunction. POI can manifest as delayed pubertal development, irregular menses or amenorrhea, and infertility. This diagnosis often negatively impacts emotional health due to the implications of impaired ovarian function after already enduring treatment for a primary malignancy. The emerging adult may be challenged by the impact on energy level, quality of life, and fertility potential. POI can also lead to low bone density and compromised skeletal strength. This review discusses the health consequences of POI in childhood cancer survivors (CCS). We also explore the role of fertility preservation for CCS, including ovarian tissue cryopreservation and other available options. Lastly, knowledge gaps are identified that will drive a future research agenda.

Premature ovarian insufficiency: a review on the role of tobacco smoke, its clinical harm, and treatment

Premature ovarian insufficiency (POI) is a condition in which the quantity of follicles and the quality of oocytes gradually decrease. This results in an estrogen secretion disorder and abnormal follicle development, which can lead to related diseases, early onset of menopause, sexual dysfunction, and an increased risk of cardiovascular issues, osteoporosis, and depression, among others. This disease significantly impacts the physical and mental health and overall quality of life of affected women. Factors such as genetic abnormalities, oophorectomy, radiotherapy for malignancy, idiopathic conditions, and an unhealthy lifestyle, including smoking, can accelerate the depletion of the follicular pool and the onset of menopause. Extensive research has been conducted on the detrimental effects of tobacco smoke on the ovaries. This article aims to review the advancements in understanding the impact of tobacco smoke on POI, both in vivo and in vitro. Furthermore, we explore the potential adverse effects of common toxicants found in tobacco smoke, such as polycyclic aromatic hydrocarbons (PAHs), heavy metals like cadmium, alkaloids like nicotine and its major metabolite cotinine, benzo[a]pyrene, and aromatic amines. In addition to discussing the toxicants, this article also reviews the complications associated with POI and the current state of research and application of treatment methods. These findings will contribute to the development of more precise treatments for POI, offering theoretical support for enhancing the long-term quality of life for women affected by this condition.

Acupuncture and moxibustion for diminished ovarian reserve: A scoping review

OBJECTIVE

Diminished ovarian reserve (DOR) refers to the decreased number and quality of oocytes in the ovary. Acupuncture and moxibustion has a certain effect on DOR; however, the number of studies and reports of research evidence are limited. This study aimed to conduct a scoping review of the clinical research status of acupuncture and moxibustion for treating patients with DOR.

METHOD

PubMed, Cochrane Library, Excerpta Medica database, Allied and Complementary Medicine Database, Chinese Biological Medicine, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, and Wanfang database were searched from January 2010 to May 2022 using keywords and medical subject heading terms. After applying the inclusion and exclusion criteria, relevant studies were selected. Structured tables and descriptive charts were made to visually express research features by using Excel, Original, IBM SPSS Model 18.0, Adobe Illustrator and other software packages. Report quality was evaluated for Cochrane bias using Review Manager 5.3.

RESULTS

Overall, 851 studies were identified; of these, 90 met the inclusion criteria. The results extracted from these studies were classified into four categories: research characteristics, study type, acupuncture and moxibustion prescriptions, and efficacy observation.

CONCLUSIONS

The quality assessment of acupuncture and moxibustion for DOR is not ideal. Therefore, standardisation and normalisation should be strengthened, and high-quality evidence is needed to further demonstrate the effectiveness of this approach. Due to heterogeneity in DOR diagnosis, the observation index should be updated with reference to the latest research to improve efficacy evaluation.

MicroRNA profiling reveals effects of Erzhi Tiangui granules on kidney deficiency diminished ovarian reserve: A randomized trial

BACKGROUND

Diminished ovarian reserve (DOR) is a danger signal of reduced fertility. The clinical incidence is increasing yearly, exhibiting a gradual low-age trend. Traditional Chinese medicine theory suggests that kidney deficiency is the basic pathogenesis. Erzhi Tiangui granules (ETG), a kidney-tonifying prescription, have been clinically shown to improve ovarian reserve function. The purpose of this study was to investigate the microRNA (miRNA) markers of kidney deficiency DOR and the potential mechanism of ETG on in vitro fertilization outcomes in DOR patients.

METHODS

Experiment 1: Granulosa cells from 5 normal ovarian reserves and 5 kidney deficiency DOR patients were subjected to miRNA sequencing. Experiment 2: Eighty DOR patients were randomly divided into treatment and control groups (40 subjects each), then treated with ETG and placebo, respectively. granulosa cells were collected and subjected to quantitative polymerase chain reaction for analyzing the expression of specific miRNA found in experiment 1. We also compared fertilization rates, high-quality embryos, and clinical pregnancy rates between the 2 groups.

RESULTS

miRNA sequencing revealed differential expression of 81 miRNAs, of which 39 were downregulated, specially miR-214-3p and miR-193a-5p, whereas 42 were upregulated, specially let-7e-5p and miR-140-3p. In the second experiment, we found that miR-214-3p was significantly upregulated whereas let-7e-5p and miR-140-3p were significantly downregulated in the treatment group, relative to the control group (P < .05). Patients in the ETG treatment group exhibited a significantly higher fertilization rate than those in the control group (P < .05).

CONCLUSION

ETG significantly increased fertilization rates in DOR patients with kidney deficiency syndrome and affected the expression of miR-214-3p, let-7e-5p, and miR-140-3p, the potential biomarkers.

The management of infertility for primary care physicians

To conduct this review of primary care, we looked for related papers in PubMed from the last 15 years. WHO's initial concept of Health defined a condition of physical, mental, and social well-being, nowadays extended to quality of life. Infertility or not being able to form a family fits perfectly into the definition. Primary care is responsible for mandatory discussions about fertility as part of a broader aspect regarding reproductive health issues. Having children is a decision taken by heterosexual couples, same sex couples, or single individuals. Understanding factors associated with infertility help guiding propedeutic. Although woman's age is one of the main factors to influence treatment success rates, multifactorial male factor may contribute to 50 percent. Infertility consultations should include partners, alleviating the accompanying stress and anxiety. Anamnesis must focus on duration of infertility, primary or secondary, sexual activity, and lifestyle habits such as smoking, alcohol consumption, diet, physical activity, use of licit and/or illicit drugs, and occupational risks. Previous treatments should be accessed. Management of infertility by primary care is mandatory, and patients requiring specialized treatments must not have their journey protracted. Strategies and couple-based interventions are essential to continuity of care and close follow-up should follow these patients.

The Trends and Hotspots in Premature Ovarian Insufficiency Therapy from 2000 to 2022

This study aims to map the knowledge structure and themes trends of primary ovarian insufficiency (POI) therapy to help researchers rapidly master the hotspots and prospects of POI therapy from the increasing number of publications. The literature search and bibliometric analyses were performed by using Web of Science Core Collection and VOSviewer. Annual publications from 2000 to 2022 continued to increase with some fluctuations. The most productive country, organization, and journal were the USA, Shanghai Jiao Tong University, and Human Reproduction, respectively. Harvard University was the organization with the highest citation. Fertility and Sterility and Nelson, L.M. were the most influential journal and author, respectively. Seven clusters separated by keywords association showed the extensive scope of POI therapy. The hotspots of POI therapy were hormone replacement therapy and fertility preservation, and the innovative treatment strategies including in vitro activation and mesenchymal stem cells had development potential. In addition, our result showed that the high-cited articles were published in journals with high impact factors. The paper provides a comprehensive overview of the development and hotspots of POI therapy, allowing researchers to recognize the current status and future directions of POI therapy.

HGF Secreted by Mesenchymal Stromal Cells Promotes Primordial Follicle Activation by Increasing the Activity of the PI3K-AKT Signaling Pathway

Primordial follicle activation is fundamental for folliculogenesis and for the maintenance of fertility. An effective therapeutic strategy for patients with premature ovarian insufficiency (POI) is to promote the activation of residual primordial follicles. The secretome of human umbilical cord mesenchymal stromal cells (hUC-MSC-sec) contains several components that might promote the activation of primordial follicles. In the present study, we revealed that treatment with the hUC-MSC-sec significantly increased the proportion of activated primordial follicles in mouse ovaries both in vitro and in vivo. The activating effects of hUC-MSC-sec on primordial follicles were attributed to the activation of the PI3K-AKT signaling pathway by hepatocyte growth factor (HGF). While the effect of the hUC-MSC-sec was attenuated by the neutralizing antibodies against HGF, application of exogenous HGF alone also promoted the activation of primordial follicles. Furthermore, we demonstrated that HGF promoted the expression of KITL in granulosa cells by binding with the HGF receptor c-Met, thereby increasing the activity of the PI3K-AKT signaling pathway to activate primordial follicles. Taken together, our findings demonstrate that hUC-MSC-sec promotes primordial follicle activation through the functional component HGF to increase the PI3K-AKT signaling activity, highlighting the application of the hUC-MSC-sec or HGF for the treatment of POI patients.

Diagnosis and management of premature ovarian insufficiency

Premature ovarian insufficiency (POI) is a complex clinical syndrome with life-changing physiological and psychological consequence in young women of reproductive age. However, the understanding of the etiology, diagnosis and optimal intervention strategies for this condition remains poorly understood. In recent years advances in epidemiologic and genetic research has improved our knowledge and awareness of POI. Further prospective randomised trials are required to improve the psychological and sexual health, fertility treatment options and long-term management of the impact on bone, cardiovascular and cognitive impact in women with POI. In this paper we aim to provide an overview on the diagnosis and management of POI, discuss the current understanding of the condition and future directions.

Age at menopause among rural and urban women in the state of Campeche, Mexico

OBJECTIVE

The purpose of this study was to examine age at natural menopause among women of Maya and non-Maya ancestry living in urban and rural communities in the state of Campeche, Mexico.

METHODS

Women ages 40 to 60 (n = 543) participated in semi-structured interviews and anthropometric measures. The last names, languages spoken, and the birthplace of the woman, her parents, and her grandparents were used to determine Maya or non-Maya ethnicity. Recalled age at natural menopause was compared across four communities; analysis of variance was used to compare means and Kaplan-Meier analyses were used to compare medians. Probit analysis was also used to estimate median ages at menopause. Cox regression analyses were applied to identify variables associated with age at menopause.

RESULTS

Mean recalled age at natural menopause across all sites was 46.7 years, ranging from 47.8 years in the city of Campeche to 43.9 years in the rural Maya communities in the municipality of Hopelchén. Median ages at menopause across all sites were 50.55 years by probit analysis and 50.5 years by Kaplan-Meier. Variables associated with a later age at menopause included higher socioeconomic status, higher parity, and a later age at menarche.

CONCLUSIONS

The early mean recalled age at menopause in southern Hopelchén was consistent with previous studies in the Yucatán peninsula. As expected, probit and Kaplan-Meier analyses demonstrated later ages at menopause. Contrary to our expectations, Maya/non-Maya ethnicity was not associated with age at menopause. Demographic and reproductive factors were more important than ethnicity in explaining variation in age at menopause within the state of Campeche, Mexico.

Position statement on the diagnosis and management of premature/primary ovarian insufficiency (except Turner Syndrome)

Premature ovarian insufficiency (POI) is a rare pathology affecting 1-2% of under-40 year-old women, 1 in 1000 under-30 year-olds and 1 in 10,000 under-20 year-olds. There are multiple etiologies, which can be classified as primary (chromosomal, genetic, auto-immune) and secondary or iatrogenic (surgical, or secondary to chemotherapy and/or radiotherapy). Despite important progress in genetics, more than 60% of cases of primary POI still have no identifiable etiology; these cases are known as idiopathic POI. POI is defined by the association of 1 clinical and 1 biological criterion: primary or secondary amenorrhea or spaniomenorrhea of>4 months with onset before 40 year of age, and elevated follicle-stimulating hormone (FSH)>25IU/L on 2 assays at>4 weeks' interval. Estradiol level is low, and anti-Müllerian hormone (AMH) levels have usually collapsed. Initial etiological work-up comprises auto-immune assessment, karyotype, FMR1 premutation screening and gene-panel study. If all of these are normal, the patient and parents may be offered genome-wide analysis under the "France Génomique" project. The term ovarian insufficiency suggests that the dysfunction is not necessarily definitive. In some cases, ovarian function may fluctuate, and spontaneous pregnancy is possible in around 6% of cases. In confirmed POI, hormone replacement therapy is to be recommended at least up to the physiological menopause age of 51 years. Management in a rare diseases center may be proposed.

Investigation of the role of serum telomerase levels in patients with occult primary ovarian insufficiency: a prospective cross-sectional study

This study was designed to investigate serum telomerase levels of occult primary ovarian insufficiency (POI) and the relationship between in vitro fertilisation (IVF) results of these patients and serum telomerase levels. A cross-sectional case-control study was conducted between May and October 2017 including 78 patients at University of Health Science, Turkey. Occult POI was defined as women with a history of follicle-stimulating hormone (FSH) elevation between 12 and 25 IU/L and low ovarian reserve before initiation of IVF (n = 39). The control group were patients attending the hospital for contraception, with no history of infertility, having at least one healthy child (n = 39). Telomerase levels in serum samples were determined using enzyme-linked immunosorbent assay method. There was no statistically significant difference in serum telomerase levels in occult POI patients when compared with the control group.Impact statementWhat is already known on this subject? Clinical studies investigating the role of telomerase on reproductive function and in vitro fertilisation (IVF) outcomes in occult primary ovarian insufficiency (POI) patients are limited with no clear consensus and in all these studies polymerase chain reaction technique was used to evaluate telomere length. Regarding our knowledge, this is the first study in the literature investigating the role of serum telomerase levels in occult POI patients.What do the results of this study add? In contrast to the previous studies, in this study no statistically significant difference was found in serum telomerase levels in occult POI patients when compared with the fertile control patients.What are the implications of these findings for clinical practice and/or further research? The occult POI patients examined in this study are overlooked until they apply with infertility. Serum telomerase measurement is not useful to support the diagnosis of occult POI. Nevertheless, in order to confirm these findings, further studies in larger populations are needed.

Human Mesenchymal Stem Cell Therapy and Other Novel Treatment Approaches for Premature Ovarian Insufficiency

Premature ovarian insufficiency (POI) is a condition characterized by amenorrhea, hypergonadotropic hypogonadism, estrogen deficiency, and reduced follicle counts leading to infertility under the age of 40. POI occurs in approximately 1-3% of women in the general population. Evaluation is warranted when the diagnosis of POI is made to rule out underlying etiologies, which could be multifactorial. This review serves to cover the novel treatment approaches reported in the literature.

Danggui Buxue Tang Rescues Folliculogenesis and Ovarian Cell Apoptosis in Rats with Premature Ovarian Insufficiency

Premature ovarian insufficiency (POI) is a common female endocrine disease that is closely linked to ovarian function. Danggui Buxue Tang (DBT) is a classic prescription of traditional Chinese medicine that is helpful for rescuing ovarian function. However, the mechanism by which DBT rescues ovarian function remains unclear. This study explored the molecular mechanism of DBT with respect to apoptosis and related signals in ovarian cells. The quality control of DBT was performed by HPLC. After DBT intervention in the POI rat model, serum AMH/FSH/LH/E₂ levels were detected by ELISA, follicles at various developmental stages were observed by HE staining, apoptosis was detected by TUNEL, and the expression profiles of Bcl-2 family proteins and key proteins in the Jak2/Foxo3a signaling pathway were evaluated by western blot. The results demonstrated that DBT could encourage the development of primary/secondary/antral follicles and increase the secretion of AMH. Moreover, DBT might inhibit Foxo3a by upregulating Jak2, thereby mediating Bcl-2 family activities and inhibiting apoptosis in ovarian cells. In conclusion, DBT promotes follicular development and rescues ovarian function by regulating Bcl-2 family proteins to inhibit cell apoptosis, which could be related to the Jak2/Foxo3a signaling pathway.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

AIM

To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with hypoactive sexual desire disorder (HSDD).

METHODS

The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

OUTCOMES

A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

RESULTS

Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

CLINICAL IMPLICATIONS

This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

STRENGTHS AND LIMITATIONS

This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

CONCLUSION

Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

BACKGROUND

The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) recommended testosterone therapy for postmenopausal women with hypoactive sexual desire disorder (HSDD).

AIM

To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with HSDD.

METHODS

The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

OUTCOMES

A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

RESULTS

Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

CLINICAL IMPLICATIONS

This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

STRENGTHS & LIMITATIONS

This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

CONCLUSION

Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need. Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med 2021;18:849-867.

Assessment of premature menopause on the sexual function and quality of life in women

INTRODUCTION

Premature Ovarian Insufficiency (POI) is characterized by ending menstruation in women under 40 years of age. It has a significant effect on women's sexuality and mental health and quality of life. This study aimed to evaluate the sexual function and quality of life of premature menopausal women.

METHODS

This study was a case-control study on 132 people (66 women with a diagnosis of POF and 66 women of reproductive age with normal ovarian function) who were matched in terms of the age, presenting to Women's Clinic in Jahrom in 2019. The WHOQOL-BREF questionnaire and the Female Sexual Function Index (FSFI) questionnaire were used to collect data. p < .05 was considered statistically significant.

RESULTS

The mean score of sexual function in premature menopausal women was 21.35 ± 4.82 and in non-menopausal women was 25.4 ± 6.61 (OR = 0.11, 95% CI = 0.04-0.28). All areas of sexual function; desires disorder (OR = 0.21 95% CI = 0.07-0.56), Arousal disorder(OR = 0.28, 95% CI = 0.08-0.93), orgasm disorder (OR = 0.36 95% CI = 0.16-0.80), lubrication disorder (OR = 0.21 95% CI= 0.05-0.78), satisfaction disorder (OR = 0.11, 95% CI = 0.04-0.28) and quality of life domains: physical health (OR = 0.4 95%CI = 0.06-0.3), mental health (OR = 0.28 95% CI = 0.06-0.1), environmental health (OR = 0.22 95%CI = 0.04-0.6) and social health (OR = 0.28 95%CI = 0.01-0.2) saw a decrease in the premature menopausal women group compared to the control group.

CONCLUSION

The results demonstrated that premature menopausal women are found to be weaker than the control group in all areas of sexual function and quality of life. Among the areas of sexual function, such as libido, arousal, satisfaction, and pain have the most impact on quality of life. Therefore, based on the results from improving sexual function, this issue can improve the quality of life.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

Background: The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) recommended testosterone therapy for postmenopausal women with hypoactive sexual desire disorder (HSDD).

Aim: To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with HSDD.

Methods: The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

Outcomes: A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

Results: Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

Clinical Implications: This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

Strengths & Limitations: This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

Conclusion: Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.

Predictable increase in female reproductive window: A simple model connecting age of reproduction, menopause, and longevity

With the ever-increasing lifespan along with societal changes, women can marry and procreate later than in previous centuries. However, pathogenic genetic variants segregating in the population can lead to female subfertility or infertility well before the average age of normal menopause, leading to counter-selection of such deleterious alleles. In reviewing this field, we speculate that a logical consequence would be the later occurrence of menopause and the extension of women's reproductive lifespan. We illustrate this point with a simple model that applies to other variants that contribute to female infertility, including epigenetic variation. We also consider the effect of medical interventions and lifestyle.

Fragile X premutation and associated health conditions: A review

Fragile X syndrome (FXS) is the most common single gene disorder, which causes autism and intellectual disability. The fragile X mental retardation 1 (FMR1) gene is silenced when cytosine-guanine-guanine (CGG) triplet repeats exceed 200, which is the full mutation that causes FXS. Carriers of FXS have a CGG repeat between 55 and 200, which is defined as a premutation and transcription of the gene is overactive with high levels of the FMR1 mRNA. Most carriers of the premutation have normal levels of fragile X mental retardation protein (FMRP) and a normal intelligence, but in the upper range of the premutation (120-200) the FMRP level may be lower than normal. The clinical problems associated with the premutation are caused by the RNA toxicity associated with increased FMR1 mRNA levels, although for some mildly lowered FMRP can cause problems associated with FXS. The RNA toxicity causes various health problems in the carriers including but not limited to fragile X-associated tremor/ataxia syndrome, fragile X-associated primary ovarian insufficiency, and fragile X-associated neuropsychiatric disorders. Since some individuals with neuropsychiatric problems do not meet the severity for a diagnosis of a "disorder" then the condition can be labeled as fragile X premutation associated condition (FXPAC). Physicians must be able to recognize these health problems in the carriers and provide appropriate management.

Premature ovarian insufficiency: a toolkit for the primary care physician

Premature ovarian insufficiency (POI) refers to the loss of ovarian activity before the age of 40 years, which leads to hypoestrogenism and amenorrhea. The diagnosis of POI in a young woman has potentially life-changing physical and emotional consequences for both the patient and her family. Therefore, it is very important that the diagnosis is correct and that it is made in a timely manner. Unfortunately, the diagnosis and therefore the effective treatment of POI are often delayed, which underlines the need for education of the broad medical community on the issue. A panel of menopause experts reviewed and critically appraised the literature, and present: (1) the diagnostic approach to POI, (2) the investigation of the etiology of this condition, (3) the therapeutic strategy regarding both hormone replacement therapy and fertility, and (4) the long-term follow-up and management for ensuring quality of life, as well as urogenital, cardiovascular, bone and mental health. The ultimate goal of this article is to provide a complete toolkit for the primary care physician to have easy access to all the information needed for the optimal management of women with POI, in the context of evidence-based and personalized medicine.HIGHLIGHTSPremature ovarian insufficiency occurs in 1% of the female population of reproductive age, yet the diagnosis is often delayed, with severe physical and emotional consequences for the patient.Primary care physicians should be aware of the possibility of premature ovarian insufficiency in young women presenting with menstrual irregularity.Prompt initiation of hormone replacement therapy ensures quality of life and prevents osteoporosis and cardiovascular disease.Women seeking fertility should be referred to specialists to discuss assisted reproduction options.

Premature ovarian insufficiency: A toolkit for the primary care physician

Premature ovarian insufficiency (POI) refers to the loss of ovarian activity before the age of 40 years, which leads to hypoestrogenism and amenorrhoea. The diagnosis of POI in a young woman has potentially life-changing physical and emotional consequences for both the patient and her family. Therefore, it is very important that the diagnosis is correct and that it is made in a timely manner. Unfortunately, the diagnosis and therefore the effective treatment of POI are often delayed, which underlines the need for education of the broad medical community on the issue. A panel of menopause experts reviewed and critically appraised the literature, and present: 1) the diagnostic approach to POI, 2) the investigation of the etiology of this condition, 3) the therapeutic strategy regarding both hormone replacement therapy (HRT) and fertility and 4) the long-term follow-up and management for ensuring quality of life, as well as urogenital, cardiovascular, bone and mental health. The ultimate goal is to provide a complete toolkit for the primary care physician to have easy access to all the information needed for the optimal management of women with POI, in the context of evidence-based and personalized medicine.

After cyclophosphamide exposure, granulosa cells recover their anti-müllerian hormone-producing ability but not their numbers

Anti‐müllerian hormone (AMH) produced by granulosa cells (GCs), reserves the ovarian follicle pool for future recruitment and ovulation. However, women who have undergone cyclophosphamide (Cy) treatment have decreased AMH levels due to damaged GCs. This study establishes flow cytometry protocols for identification of GCs and investigates the cause of the Cy‐induced AMH decrease by analyzing the number of GCs and their AMH production at the single cell level. Over 2 weeks, C57BL/6 mice were intraperitoneally injected 6 times with 100 mg/kg Cy and sacrificed either immediately or 4 weeks after Cy treatment. Twenty‐four hours post‐Cy exposure, a decrease in serum AMH levels was seen due to a reduction in the number of follicle‐stimulating hormone receptor (FSHR)⁺AMH⁺ GCs and their ability to produce AMH. However, 4 weeks after Cy treatment, serum AMH levels were still decreased due to the decreased number of FSHR⁺AMH⁺ GCs, however, their AMH‐producing ability was unaltered. Consistently, in vitro, Cy‐induced low AMH production in FSHR⁺AMH⁺ hGL5 cells (immortalized human GCs) was restored 24 h after Cy treatment, although their numbers remained decreased. Thus, the surviving GCs after Cy exposure had intact AMH‐producing ability. In future, an effort to minimize GC death by Cy treatment is required, while maintaining its therapeutic effects.

Anti-Müllerian hormone (Amh/amh) plays dual roles in maintaining gonadal homeostasis and gametogenesis in zebrafish

Anti-Müllerian hormone (AMH/Amh) plays a role in gonadal differentiation and function across vertebrates. In zebrafish we demonstrated that Amh deficiency caused severe gonadal dysgenesis and dysfunction. The mutant gonads showed extreme hypertrophy with accumulation of early germ cells in both sexes, namely spermatogonia in the testis and primary growth oocytes in the ovary. In amh mutant females, the folliculogenesis was normal in young fish but receded progressively in adults, which was accompanied by progressive decrease in follicle-stimulating hormone (fshb) expression. Interestingly the expression of fshb increased in the pituitary of juvenile amh mutant males but decreased in adults. The upregulation of fshb in mutant male juveniles was likely one of the mechanisms for triggering gonadal hypergrowth, whereas the downregulation of fshb in adults might involve a negative feedback by gonadal inhibin. Further analysis using mutants of fshb and growth differentiation factor 9 (gdf9) provided evidence for a role of FSH in triggering ovarian hypertrophy in young female amh mutant as well. In summary, the present study provided comprehensive genetic evidence for dual roles of Amh in controlling zebrafish gonadal homeostasis and gametogenesis in both sexes. Amh suppresses proliferation or accumulation of early germ cells (spermatogonia in testis and primary growth oocytes in ovary) while promoting their exit to advanced stages, and its action may involve both endocrine and paracrine pathways.

Premature ovarian insufficiency: an International Menopause Society White Paper

The aim of this International Menopause Society White Paper on premature ovarian insufficiency (POI) is to provide the latest information regarding this distressing condition. The impact of POI has far-reaching consequences due to its impact on general, psychological, and sexual quality of life, fertility prospects, and long-term bone, cardiovascular, and cognitive health. Progress in fully understanding the etiology, diagnosis, and optimal management options has been slow thus far due to the complexity of the condition and fragmented research. Recent advances in epidemiological and genetic research have improved our understanding of this condition and randomized prospective trials are being planned to determine the intervention strategies, which will optimize quality of life and long-term well-being. The International Menopause Society has commissioned a number of experts at the forefront of their specialty to define the state of the art in the understanding of this condition, to advise on practical management strategies, and to propose future research strategies. It is hoped that a global task force will subsequently be convened in order to formulate a consensus statement across key societies, to accelerate date collection and analysis of a global POI registry, and to facilitate progress in the key defined areas of research.

Endothelial cell-specific-molecule-1 (endocan) levels in women with premature ovarian insufficiency: a prospective comparative study

There is an increased risk of cardiovascular disease in women with premature ovarian insufficiency (POI). A relationship between cardiovascular disease and endocan levels has been shown. Endocan is a marker that is prominent in many diseases caused by endothelial dysfunction and can be measured in the blood. POI is also associated with endothelial dysfunction. The causes of POI include chromosomal and genetic defects, autoimmune processes, chemotherapy, radiation, infections and surgery, but many are unidentified (idiopathic). This study aimed to evaluate serum endocan levels in women with idiopathic POI. The blood for analysis was obtained at the early follicular phase of the menstrual cycle and endocan levels were measured using a commercially available enzyme-linked immunosorbent assay kit. There were 38 patients with idiopathic POI in the study group and 39 healthy subjects in the control group. The median ages of the women were not significantly different between the groups 34 [7] years vs. 34 [7] years, respectively (p = .862). The median endocan level was not different in the POI and control group 769 [727] vs. 1077 [403] pg/mL, respectively (p = .603). Endocan is not associated with the cardiovascular diseases risk linked with endothelial dysfunction in idiopathic POI. Clinical trial number: NCT03932877 (Clinicaltrials.gov)IMPACT STATEMENTWhat is already known on this subject? There is an increased risk of cardiovascular disease in premature ovarian insufficiency (POI) due to the decreased level of oestrogen, which is linked with endothelial dysfunction.What do the results of this study add? This study showed that endocan is not associated with the cardiovascular disease risk linked with endothelial dysfunction in idiopathic POI.What are the implications of these findings for clinical practice and/or further research? A marker to be used to predict the risk of cardiovascular disease in patients with POI could facilitate in improving the quality of life of these patients. Moreover, advantageous and easy-to-measure markers are needed in larger sample studies to better understand the cardiovascular diseases risk in POI.

Demographic, clinical and hormonal characteristics of patients with premature ovarian insufficiency and those of early menopause: data from two tertiary premature ovarian insufficiency centers in Greece

The aim of the study was to compare demographic, hormonal and clinical parameters in patients with premature ovarian insufficiency (POI) and women with early menopause in Greece. One hundred thirty-nine women of Greek origin, aged 14-45 years, referring for oligomenorrhea and having elevated FSH concentrations were divided into three groups regarding the age of menstrual disturbances onset [POI₁: </=30 years (n = 42); POI₂: 31-39 years (n = 36); early menopause: 40-45 years (n = 61)]. The mean age of menstrual disturbances onset and that of diagnosis in all POI and early menopause patients were 28.7 years (28.7 ± 7.7) versus 42.1 years (42.1 ± 1.5) and 33.8 years (33.8 ± 7.2) versus 43.3 years (43.3 ± 1.4), respectively. POI patients and women with early menopause were diagnosed, respectively, five years and approximately four to six months later than the age of menstrual disturbances onset. Moreover, FSH₂ (second confirmatory FSH measurement at 4-to-6-weeks interval) was greater in all POI patients than in early menopause women (55.4 ± 33.9 vs. 32.4 ± 19.4; p < .05) whereas mean age of menarche was greater in early menopause women than in POI patients (13 ± 1.3 vs. 12 ± 2.2; p < .05). Furthermore, FSH₂ was increased in all POI and decreased in early menopause patients.

Hormonal replacement therapy in adolescents and young women with chemo- or radio-induced premature ovarian insufficiency: Practical recommendations

In women with premature ovarian insufficiency (POI), hormonal therapy (HT) is indicated to decrease the risk of morbidity and to treat symptoms related to prolonged hypoestrogenism. While general recommendations for the management of HT in adults with POI have been published, no systematic suggestions focused on girls, adolescents and young women with POI following gonadotoxic treatments (chemotherapy, radiotherapy, stem cell transplantation) administered for pediatric cancer are available. In order to highlight the challenging issues specifically involving this cohort of patients and to provide clinicians with the proposal of practical therapeutic protocol, we revised the available literature in the light of the shared experience of a multidisciplinary team of pediatric oncologists, gynecologists and endocrinologists. We hereby present the proposals of a practical scheme to induce puberty in prepubertal girls and a decisional algorithm that should guide the clinician in approaching HT in post-pubertal adolescents and young women with iatrogenic POI.

Interferential current: a new option for the treatment of sexual complaints in women with premature ovarian insufficiency using systemic hormone therapy: a randomized clinical trial

OBJECTIVE

The aim of the study was to evaluate the efficacy of interferential current (IC) in the sexual function of women with premature ovarian insufficiency (POI) using systemic hormone therapy (HT), compared to topical estriol.

METHODS

A randomized clinical trial with 40 women with POI using systemic HT, who were sexually active and referred for dyspareunia and reduction of lubrication. The women were divided into two treatment groups for 4 weeks: IC group (eight electrotherapy sessions twice a week); or E group (estriol vaginal cream, daily application, 0.5 mg/d). The Female Sexual Function Index was used to evaluate pre-/posttreatment sexual function.

RESULTS

Mean age was 37.13 ± 7.27 years and mean treatment time with HT was 8.20 ± 8.73 years, similar data for both groups. There was an improvement in global sexual function, lubrication, and pain domains for both treatments. The differences between the pre-/posttreatment lubrication scores were respectively 0.75 ± 3.31 (P = 0.014) for IC and 1.16 ± 1.22 (P < 0.001) for estriol, whereas for dyspareunia the differences were 1.00 ± 1.47 (P = 0.005) for IC, and 0.68 ± 1.30 (P = 0.006) for estriol. There was no pre-/posttreatment difference for the desire and arousal domains. Only in the IC group did orgasm (difference 0.90 ± 1.42, P = 0.010) and satisfaction improve (difference 0.70 ± 1.28, P = 0.021).

CONCLUSION

The use of perineal IC seems to be a new option for women with POI using systemic HT and presenting with sexual complaints, leading to an improvement in pain, lubrication, satisfaction, and orgasm.

A case of premature ovarian insufficiency in Nijmegen breakage syndrome patient and review of literature. From gene mutation to clinical management

Background: Nijmegen breakage syndrome (NBS) is an autosomal recessive disorder leading to chromosomal instability and an array of symptoms, including characteristic facial features (bird-like face), predisposition to malignancies, as well as hypergonadotropic hypogonadism. This case report discusses the diagnostic process and management of a 23-year-old Polish female patient who was admitted to hospital with symptoms of secondary amenorrhea and clinical features corresponding to NBS. Methods: Clinical examination, per-rectal ultrasound, laboratory diagnostics (including serum concentrations of FSH, LH, estradiol, testosterone, and TSH), as well as SSCP analysis and classic karyotyping were performed. Results: During hormonal evaluation elevated serum concentration of FSH and LH and decreased serum concentration of estradiol were measured. The genetic testing revealed translocation 7;14 (t(7;14)) and inversion 7 in 22% of examined cells which confirmed the initial hypothesis of NBS. The diagnosis was finally verified by identifying a Slavic founder mutation, c.657_661del5, on both allels of the NBN gene. Furthermore, hormonal serum evaluation conducted after four weeks allowed the patient to be diagnosed with premature ovarian insufficiency (POI) suspected earlier on the grounds of preliminary examinations (ultrasound imaging and laboratory tests). Conclusions: Chromosomal instability resulting from a mutation present in Nijmegen breakage syndrome patients might be a causative factor of premature ovarian insufficiency. Therefore, females diagnosed with NBS should undergo additional diagnostic procedures in order to determine further management and treatment.

Health-related quality-of-life among patients with premature ovarian insufficiency: a systematic review and meta-analysis

PURPOSE

To systematically review studies investigating health-related quality-of-life (HrQoL) in patients with premature ovarian insufficiency (POI), to examine questionnaires used and to conduct a meta-analysis of control studies with normal ovarian function.

METHODS

Data sources: PubMed, Embase, Web of science, CNKI, and CQVIP, searched from inception until June 2018. The search strategy was a combination of medical (e.g. POI), subjective (e.g. well-being) and methodological (e.g. questionnaires) keywords. PRISMA guidelines were used to assess outcome data quality/validity by one reviewer, verified by a second reviewer. Risk of bias within studies was evaluated. A meta-analysis compared HrQoL in patients and non-patients. Due to measurement differences in the studies, the effect size was calculated as standard mean difference.

RESULTS

We identified 6869 HrQoL studies. Nineteen geographically diverse studies met inclusion criteria, dated from 2006, using 23 questionnaires. The meta-analysis included six studies with 645 POI participants (age 33.3 ± 5.47) and 492 normal-ovarian control subjects (age 32.87 ± 5.61). Medium effect sizes were found for lower overall HrQoL (pooled SMD = - 0.73, 95% CI - 0.94, - 0.51; I² = 54%) and physical function (pooled SMD = - 0.54, 95% CI - 0.69, - 0.39; I² = 55%). Heterogeneity was investigated. Effect sizes varied for sexual function depending on the measure (SMD = - 0.27 to - 0.74), overall HrQoL (SF-36) had the largest effect size (- 0.93) in one study. The effect sizes for psychological and social HrQoL were small.

CONCLUSION

POI is associated with low-to-medium effect size on HrQoL compared to normal ovarian controls. The greatest effects are found in general HrQoL and most sexual function areas. Condition-specific questionnaires and RCTs are recommended for further investigation.

Risk-Reducing Bilateral Salpingo-Oophorectomy for BRCA Mutation Carriers and Hormonal Replacement Therapy: If It Should Rain, Better a Drizzle than a Storm

Women carrying a BRCA mutation have an increased risk of developing breast and ovarian cancer. The most effective strategy to reduce this risk is the bilateral salpingo-oophorectomy, with or without additional risk-reducing mastectomy. Risk-reducing bilateral salpingo-oophorectomy (RRBSO) is recommended between age 35 and 40 and between age 40 and 45 years for women carriers of BRCA1 and BRCA2 mutations, respectively. Consequently, most BRCA mutation carriers undergo this procedure prior to a natural menopause and develop an anticipated lack of hormones. This condition has a detrimental impact on various systems, affecting both the quality of life and longevity; in particular, women carrying BRCA1 mutation, who are likely to have surgery earlier as compared to BRCA2. Hormonal replacement therapy (HRT) is the only effective strategy able to significantly compensate the hormonal deprivation and counteract menopausal symptoms, both in spontaneous and surgical menopause. Although recent evidence suggests that HRT does not diminish the protective effect of RRBSO in BRCA mutation carriers, concerns regarding the safety of estrogen and progesterone intake reduce the use in this setting. Furthermore, there is strong data demonstrating that the use of estrogen alone after RRBSO does not increase the risk of breast cancer among women with a BRCA1 mutation. The additional progesterone intake, mandatory for the protection of the endometrium during HRT, warrants further studies. However, when hysterectomy is performed at the time of RRBSO, the indication of progesterone addition decays and consequently its potential effect on breast cancer risk. Similarly, in patients conserving the uterus but undergoing risk-reducing mastectomy, the addition of progesterone should not raise significant concerns for breast cancer risk anymore. Therefore, BRCA mutation carriers require careful counselling about the scenarios following their RRBSO, menopausal symptoms or the fear associated with HRT use.

Hypogonadism in Children with a Previous History of Cancer: Endocrine Management and Follow-Up

Hypogonadism after treatment for childhood cancer is a recognized complication and its cause may be subdivided into primary gonadal failure and central hypogonadism. Here, we provide an overview of the risk factors for the development of hypogonadism, assessment and potential interventions and give a summary of the current recommendations for management and follow-up of hypogonadism in childhood cancer survivors.

BMS consensus statement for primary prevention of coronary heart disease in women

The British Menopause Society Council is committed to provide up to date authoritative reviews to aid health professionals to inform and advise women about key issues in postreproductive health. Coronary heart disease is a leading cause of death in women. Observational studies have consistently shown estrogen to help prevent coronary heart disease in postmenopausal women. The large randomized controlled Women’s Health Initiative trial initially did not confirm these observational findings. However, further analyses of the Women’s Health Initiative study as well as meta-analyses of randomized clinical trials of hormone replacement therapy and of the observational Nurses’ Health Study have now found that the timing of onset of hormone replacement therapy use is important and that estrogen may have an important protective role in coronary heart disease, particularly in women initiating treatment below age 60 years. This consensus statement will examine the evidence regarding hormone replacement therapy and non-estrogen therapies (lipid-lowering agents, aspirin, antihypertensives, anti-diabetic medications, selective estrogen receptor modulators) as well as diet, lifestyle and smoking cessation in the primary prevention of coronary heart disease in women.

Age-specific values of Access anti-Müllerian hormone immunoassay carried out on Japanese patients with infertility: a retrospective large-scale study

BACKGROUND

The ovarian reserve in women is known to correlate with anti-Müllerian hormone (AMH) levels, and currently the latest, third-generation, fully-automated AMH immunoassays, such as Access and Cobas, are beginning to be used for measuring AMH levels. However, the age-specific reference values obtained for AMH levels have been based on samples from an American population, measured using first-generation immunoassays. In this study, we attempted to determine the age-specific AMH reference values based on a large set of samples taken from Japanese infertile women measured by Access so that they could be used by infertility centers treating Japanese and those with similar racial and life-style characteristics.

METHODS

The study included 5483 Japanese patients who enrolled in infertility treatment programs at two in-vitro fertilization centers, Shimbashi YUME Clinic and Natural ART Clinic Nihombashi in Tokyo, and who had their serum AMH levels measured between December 2015 and November 2017 by Access. Each patient was represented only once in the study. The mean, median, and standard deviation values were obtained from the measured values for single-year intervals from 28 through 48 years of age (21 age groups in total). The 3D-fitted curve of age-specific mean and median values measured by Access was obtained by regression analysis.

RESULTS

The mean and median values decreased with advancing age (mean: R² = 0.9864; median: R² = 0.9926). In all age groups, the mean values were higher than the median values; however, the differences between these values decreased with increasing age.

CONCLUSIONS

The age-specific AMH reference values measured by Access in this study may serve as a useful diagnostic marker in infertility centers, especially those treating Japanese patients or patients with similar characteristics.

PGRMC1/2 promotes luteal vascularization and maintains the primordial follicles of mice

To determine whether conditional depletion of progesterone receptor membrane component (PGRMC) 1 and PGRMC2 affected ovarian follicle development, follicle distribution was assessed in ovaries of young (≈3-month-old) and middle-aged (≈6-month-old) control (Pgrmc1/2fl/fl) and double conditional PGRMC1/2-knockout (Pgrmc1/2d/d) mice. This study revealed that the distribution of primary, preantral and antral follicles was not altered in Pgrmc1/2d/d mice, regardless of the age. Although the number of primordial follicles was similar at ≈3 months of age, their numbers were reduced by ≈80% in 6-month-old Pgrmc1/2d/d mice compared to age-matched Pgrmc1/2fl/fl mice. The Pgrmc1/2d/d mice were generated using Pgr-cre mice, so ablation of Pgrmc1 and Pgrmc2 in the ovary was restricted to peri-ovulatory follicles and subsequent corpora lutea (CL). In addition, the vascularization of CL was attenuated in Pgrmc1/2d/d mice, although mRNA levels of vascular endothelial growth factor A (Vegfa) were elevated. Moreover, depletion of Pgrmc1 and Pgrmc2 altered the gene expression profile in the non-luteal component of the ovary such that Vegfa expression, a stimulator of primordial follicle growth, was elevated; Kit Ligand expression, another stimulator of primordial follicle growth, was suppressed and anti-Mullerian hormone, an inhibitor of primordial follicle growth, was enhanced compared to Pgrmc1/2fl/fl mice. These data reveal that luteal cell depletion of Pgrmc1 and 2 alters the expression of growth factors within the non-luteal component of the ovary, which could account for the premature demise of the adult population of primordial follicles. In summary, the survival of adult primordial follicles is dependent in part on progesterone receptor membrane component 1 and 2.

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

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

Consequences of premature ovarian insufficiency on women's sexual health

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