The British Menopause Society consensus statement on the management of women with premature ovarian insufficiency
The guidance document by the British Menopause Society provides recommendations on the assessment and management of women with premature ovarian Insufficiency (POI).
Summary of recommendations
- Diagnosis of POI should be based on a combination of oligomenorrhoea / amenorrhoea of more than 4 months’ duration associated with elevated gonadotropins (FSH >40 iu/l) on at least two occasions measured 4-6 weeks apart in women under the age of 40. AMH should not be routinely used to diagnose POI, but may have a role when the diagnosis of POI is inconclusive.
- Advice should be given to women with POI regarding lifestyle modification and bone health. This should include information on a balanced diet, adequate calcium and vitamin D intake, exercise, smoking cessation as well as avoidance of excessive alcohol intake.
- Systemic sex steroid hormone replacement is effective for the management of menopausal symptoms in women with POI and topical estrogen preparations are eﬀective for the management of symptoms related to urogenital atrophy.
- Women with POI are at increased risk of cardiovascular disease, osteoporosis and cognitive impairment. Sex steroid hormone replacement is likely to lower the long-term risk of cardiovascular disease in women with POI, prevent osteoporosis and have a beneficial effect on cognitive function.
- Women with POI should be advised to take hormone replacement and continue to do so until the natural age of the menopause in the absence of a contra-indication to minimise this risk. The aim of hormone replacement in women with POI should be to achieve physiological levels of estradiol.
- There is limited evidence assessing the optimal regimen, dose or route of administration of hormone replacement in women with POI. HRT and the combined oral contraceptive pill containing ethinyl estradiol would both be suitable options for hormone replacement, although HRT may be more beneficial in improving bone health and cardiovascular markers compared to the combined oral contraceptive pill.
- Sex steroid hormone replacement should be considered the preferred choice of treatment for the prevention and management of osteoporosis in women with POI. Bisphosphonates should not be first line treatment for the management of osteoporosis in women with POI and should only be considered after discussion with an osteoporosis specialist.
- Assessment of bone mineral density should be considered at the time of diagnosis of POI. The frequency of repeat bone density assessment should be guided by the woman’s risk for developing osteoporosis and consideration should be given to repeat bone mineral density assessment in women with osteoporosis within 2-3 years of the diagnosis.
- Women with POI can have intermittent ovarian activity and have a chance of natural conception estimated to be in the region of 5-10%. Assisted reproduction techniques using the woman’s own eggs are unlikely to be successful and oocyte donation remains the most effective intervention in this context.
- Fertility preservation techniques including oocyte / embryo cryopreservation or ovarian tissue cryopreservation are unlikely to be successful in women with established POI. However, fertility preservation and in particular oocyte / embryo cryopreservation would be suitable options for women at risk of POI including those due to undergo chemotherapy or radiotherapy that may diminish their ovarian function or women with a strong family history of POI.
- Observational data have shown that women with POI have a lower risk of breast cancer compared with controls. HRT does not appear to increase the risk of breast cancer in younger menopausal women under the age of 50.
- There is limited evidence on the risk of VTE in women with POI or that associated with the use of sex steroid hormone replacement in this group of women. Data from large observational studies and meta-analyses has shown that transdermal administration of estradiol is unlikely to increase the risk of venous thromboembolism in naturally menopausal women. The transdermal route of estradiol administration should therefore be considered in women with POI who are at increased risk of venous thrombosis including those with raised body mass index.
- Further research is required to assess the optimal regimen, dose or route of administration of hormone replacement in women with POI. In addition, National and International databases as the POI Registry (https://poiregistry.net) are required to allow collection of data that may allow better understanding and management of the condition.