Michael J. Heard, M.D. Dr. Heard is a Reproductive Endocrinologist in private practice in Houston, Texas. Board certified in Obstetrics and Gynecology and a Fellow in the American College of Obstetricians and Gynecologists, Dr. Heard maintains a specialized focus on the evaluation and treatment of premature ovarian failure (POF). He is the medical director of the Houston POF Support Group, one of the largest POF support groups in the country. He also interacts with patients with POF all over the United States and around the world through his private practice and the internet. Dr. Heard is a member of the Houston chapter of RESOLVE, the National Fertility Association, and the American Society of Reproductive Medicine. Dr. Heard received his M.D. from Emory University School of Medicine in Atlanta, Georgia. He trained in obstetrics and gynecology at the University of Tennessee in Memphis and went on to serve four years on active duty as an officer in the United States Air Force. Dr. Heard completed a three-year Fellowship in Reproductive Endocrinology and Infertility at Baylor College of Medicine in Houston. He was recently appointed Assistant Clinical Professor at the University of Texas Health Science Center in Houston.

The Latest Facts About Premature Ovarian Failure

What is premature ovarian failure (POF)?

Premature ovarian failure (POF) is defined as the cessation of ovarian function prior to the age of 40. It is diagnosed in women under age 40 when ovarian function ceases, resulting in an end or pause in menstruation, the onset of menopausal symptoms, and a decline in the production of estrogen and eggs, resulting in infertility.

Is premature ovarian failure the same as early menopause?

No, not exactly. Although the symptoms are often similar and POF was once thought to be a form of premature menopause, there are many differences in the two conditions. Normal menopause occurs as a result of aging, which results in follicle depletion and the onset of menopause with related symptoms. With POF, up to 50% of patients may ovulate once in any given year and 5-10% may become pregnant, leading to a theory that there is a follicular dysfunction rather than complete ovarian failure. In addition, POF is often associated with autoimmune disease, the most common being thyroid dysfunction (i.e., Hashimoto's thyroiditis). These characteristics are not common to menopause with the cessation of ovarian function in the early fifties.

Who suffers from premature ovarian failure?

Although often considered a rare disorder, POF actually affects one percent of women by the age of 40. According to RESOLVE, the National Infertility Association, POF occurs in one in 1,000 women between the ages of 15 and 29, and one in 100 women between the ages of 30 and 39. The average age of onset of POF is 27 years. Withdrawal from hormonal contraception in order to pursue fertility is a common time to diagnose POF. Masking symptoms of POF with hormonal therapy may be contributing to an underestimation of the actual incidence of POF and leading to a delay in diagnosis and treatment.

Lawrence M. Nelson, M.D., MBA, in Spontaneous Premature Ovarian Failure: Young Women, Special Needs, [Menopause Management, July/August 2001] indicates that half of the women with POF in a National Institute of Health research program developed the condition before the age of 32, and it has been diagnosed in girls as young as 14.

What are the symptoms of premature ovarian failure?

The symptoms can vary considerably from patient to patient and the disorder may occur abruptly or spontaneously or it may develop gradually over several years. Women may experience infertility, hot flashes, the absence of menses, night sweats, irritability, moodiness, sleep disturbance, decreased libido, hair coarseness, and vaginal dryness.

POF also manifests as intermittent ovarian failure, where the patient may miss her menstrual periods several consecutive months, and then have her menstrual period return spontaneously.

Early indications of premature ovarian failure include menstrual cycles less than 21 days in length, very infrequent or light menstrual periods, and the absence or cessation of menstruation.

What causes a young woman to have premature ovarian failure?

Unfortunately, in the majority of cases, the causes of POF are idiopathic or unknown. Genetic, environmental, and autoimmune etiologies have been associated with POF and are currently the subjects of ongoing research.

It is estimated that up to 40% of POF can be attributed to genetic causes, as the disorder has a tendency to be familial. Known environmental causes include pelvic surgery, cancer therapy such as chemotherapy and radiation, and viral oophoritis, all which affect ovarian function and could contribute to POF. Autoimmunity has also been shown to play a role, with the most common cause thought to be Hashimoto's thyroiditis. Other secondary causes include disorders such as anorexia nervosa or chemotherapy treatments for various cancers.

Is POF easily recognizable and readily diagnosed?

No. Since the constellation of symptoms can vary considerably from patient to patient, the diagnosis is often delayed. A patient can be shuttled from physician to physician before a correct diagnosis is made. As many physicians do not always consider POF in their working differential diagnosis, it often takes an average of three different physicians over a span of months or years to evaluate the patient and offer a correct diagnosis. Women with symptoms of POF are best served by evaluation and treatment by a reproductive endocrinologist.

The cessation of menstrual periods is often incorrectly attributed to a variety of conditions, such as stress, without appropriate testing or consideration, delaying the diagnosis even further.

In addition, many women who affected by POF may have been incorrectly treated for irregular bleeding with oral contraceptives which may have masked symptoms. All too often, POF is not diagnosed until the woman becomes interested in fertility and the oral contraceptives are stopped when the patient wants to conceive.

How is POF diagnosed?

The diagnosis of POF is made with a through medical evaluation that begins with a complete history and physical examination along with a simple blood test off hormonal therapy measuring an FSH level, or follicle stimulating hormone. When this value is over 40 mIU/ml on at least two occasions over a four weeks period, the diagnosis can be made. Other diagnostic testing that may be used in the evaluation includes genetic karyotyping, assessment of other organ systems such as the thyroid or bones, and antibody testing to search for signs of autoimmune diseases that are often associated with POF.

How do patients handle the diagnosis of POF?

The diagnosis of POF can be devastating to patients, particularly to women who are looking forward to their childbearing years. I have heard heart-breaking stories where women are informed of their condition over the telephone or through voice mail messages. Emotional trauma of this kind can adversely affect mentalhealth and must be dealt more appropriately in today's healthcare system.

As with any diagnosis that will require long-term resolution, a patient should be informed of the condition and provided with the current resources that are available. Any diagnostic testing should be reviewed thoroughly and a course of action presented to each patient. I believe it is imperative to inform the patient that while POF is a serious disorder, there are therapeutic regimens available. Each POF patient is a unique individual with special needs. Besides endocrine and reproductive issues, emotional support is paramount in treating this condition. Treating physicians should recognize the emotional impact this diagnosis will have on a woman and counsel her to seek guidance with a private practitioner or a POF support group. The POF Support Group (www.pofsupport.org) is a growing national organization started through the internet to address the particular issues affecting women with POF and their families and provides numerous resources including updated research, provider referrals, and future meetings.

In addition to infertility, how can POF be harmful?

Chronic low levels of estrogen can lead to a weakening of the bony skeleton, which can subsequently lead to osteoporosis, making bones more fragile and prone to fracture.

Other medical disorders that affect the heart, eyes, and neurologic systems can put POF patients at a greater risk for serious health problems such as cardiovascular disease, glaucoma, Parkinson's disease, and Alzheimer's disease.

How is POF treated?

Treatment for POF is based on the needs of particular patient. The lack of estrogen in a young mentioned.

There are a variety of hormone replacement regimens available that can be used along with different routes of administration based on patient preference and the response to therapy. These formulations contain estrogen, progesterone, and sometimes androgens (i.e., the male hormone testosterone) in varied doses. Each patient should discuss the available options with their provider and be informed of all the risks, benefits, and alternatives prior to initiating therapy. Some patients may consider alternative or herbal therapies as a type of hormone replacement therapy (HRT). Available research data is not always available for these therapies and should be discussed closely and carefully between the patient and provider.

Other than HRT, a thorough diagnostic evaluation may reveal a medical condition that requires treatment. This includes autoimmune conditions that are often associated with POF. These problems should be addressed by providers that have expertise in their particular areas. A variety of conditions such as thyroid disease, diabetes, dermatologic and bleeding disorders may develop. It is important for all patients to pay close attention to any new symptoms after their initial diagnosis and be referred to the appropriate provider for evaluation.

Besides the need for endocrine evaluation and treatment, current technology utilizing egg donation through in-vitro fertilization enables POF women the opportunity to reproduce after ovarian failure with high success. It is also important to remember that 5-10% of POF patients become pregnant after the diagnosis, many times after initiating hormone replacement therapy. Other than egg donation, there is no proven method to increase the chance for ovulation and conception after the diagnosis of POF with a high FSH level. With this in mind, patients should be counseled about the need for contraception if they are sexually active and do not desire future fertility.

Finally, it is of primary importance that a woman diagnosed with POF finds a physician with whom she can develop a trusting relationship. The physician should understand all the ramifications of the disease and be willing and able to meet the endocrine, reproductive, and emotional needs of these patients. Subspecialists certified in reproductive endocrinology who have additional training in diagnosis and treatment of POF can be found through the American Society of Reproductive Medicine at www.asrm.org.

For more information about POF, click here.

Created by Dr. Michael Heard, 2/03.

Created: 3/7/2003  -  Michael J. Heard, M.D.