Answers to Commonly Asked Questions ( 10 - 19 )

Answers for 1-9 | Answers for 10-19 | Answers for 20-29 | Answers for 30-39 | Answers for 40-45

10. Back to FSH. Is there a problem with the FSH stimulating the follicles?

The problem is a lack of follicles. In Premature Ovarian Failure there are either fewer than normal follicles or there is a dysfunction in the ovaries. Remember that the FSH stimulates the development of a follicle and that as the follicles ripen they release estrogen. The estrogen in turn sends a signal back to the brain that it can turn the FSH off. If a follicle isn't stimulated, there isn't enough estrogen to go back to the brain to say "turn off." So in a vicious cycle, instead of being able to turn off the FSH, the pituitary is driven to send out even more FSH to try to get a follicle to develop. And in turn the FSH level rises.

If there is a dysfunction of the ovaries, it is thought that women produce antibodies to their own FSH or to their own ovarian substances.

11. What has happened to the eggs?

Women with POF have one of the following:

• a low number of follicles to start with
• the eggs are lost more quickly than normal or
• a dysfunction of the follicles.

12. Why does this happen?

There are several different causes. Unfortunately, for most women a cause for their Premature Ovarian Failure is never identified. About 25 to 35 percent of women with Premature Ovarian Failure have an associated autoimmune disorder. After autoimmunity, the most frequent known cause is genetics. There are other reasons such as an end result of treatment for cancers with radiation or chemotherapy; or hysterectomy with removal of the ovaries. In addition, infections have been associated with Premature Ovarian Failure. A family history of Premature Ovarian Failure is found in about 4% of the women.

Causes of Premature Ovarian Failure
Unknown (Idiopathic) - for most women a cause is never found
Autoimmune disease (these are some of the autoimmune diseases associated with POF)
Thyroid dysfunction
Polyglandular failure I and II
Hypoparathyroidism
Rheumatoid arthritis
Idiopathic thrombocytopenia purpura (ITP)
Diabetes
Pernicious anemia
Chromosomal/genetic
Turner syndrome
Enzyme defects/Metabolic
Galactosemia
Chemotherapy/radiation therapy related
Other
Viral infection
Surgical
Inadequate gonadotropin (this is FSH and LH) secretion or action

13. Someone told me that I brought this on myself because I smoke.

Many women tell me that they blame themselves for their POF. They say they should have gotten married young and had children as teenagers or in their early 20's, they shouldn't have used BCP or that they are being punished by God because they had an abortion. It isn't unusual for us to try to find a reason for something when we don't know the cause. You did not bring this on yourself.
Back to smoking - it is true that smoking cigarettes is associated with an earlier age of menopause, but only by 2 - 3 years. That would mean a smoker's menopause would start around age 47.

14. Is it true POF can develop before you even started menstruation?

Yes, this can happen. Approximately 10 to 15 percent of females with POF have never had a spontaneous period. This is called primary amenorrhea. When primary amenorrhea happens along with delays in puberty (such as budding of the breasts and hair under the arms), about half of the girls have a chromosomal problem. Chromosomes contain the genes that determine each person's characteristics.

If there isn't a chromosomal problem, girls generally have normal puberty growth and development.

15. What are some of the physical changes I might notice? I've been having what I would call "hot flashes" but I'm too young and my doctor thinks I'm a hypochrondriac!

You may see changes in your period - the flow may be different or the length of the bleeding may change. Periods may stop altogether. Or, you may continue with a regular menstrual cycle and have other symptoms! You really may be experiencing hot flashes. In addition, some of the other symptoms you may experience include: night sweats, irritability (because the night sweats disturb your sleep), poor concentration, decreased sex drive, painful sex, and thinning and drying of the vagina. Some women discover the problem when they go for fertility testing and discover that they have an elevated FSH. They may not have had any symptoms.

If your doctor isn't knowledgeable about Premature Ovarian Failure or isn't compassionate about it's effects on you, it is time to educate (take this information to him or her) and work together OR find a new doctor!

16. When I see my doctor what medical information should s/he ask me about?

Your doctor should ask you about the following. Your visit will be more productive if you've thought about the following and are prepared with as much information as possible:

• Menstrual cycle changes
• Menopausal symptoms (see above)
• Surgery you've had on your reproductive system, particularly ovarian surgery
• Chemotherapy
• Radiation therapy
• Recent infections (an example is PID - Pelvic Inflammatory Disease)
• Family history of Premature Ovarian Failure
• A history of autoimmune disorders in yourself or in your family such as:
  Hypothyroidism
  Addison's disease
  Diabetes
  Graves' disease
  Vitiligo
  Lupus
  Rheumatoid arthritis
  Sjogren's syndrome
  Inflammatory bowel syndrome (IBS)
• Deafness in yourself or a family member
• Because symptoms of some diseases can start very subtly (such as Addison's disease) your doctor will ask you about loss of appetite, nausea, weight loss, vague abdominal pain, weakness, tiring easily, salt craving or increased skin pigmentation.

17. What should I expect my doctor to do during an examination?

The Physical Examination might include:

• Physical inspection to see if you have the physical characteristics of Turner syndrome (includes nails that are soft and turn up at the ends and short pinkie fingers)
• Physical inspection to look for physical characteristics of autoimmune disorders associated with Premature Ovarian Failure such as:
  • Changes in pigmentation. They include: premature graying of the hair (associated with Hashimoto's thyroiditis); vitiligo; increased pigmentation of the gums or the skin folds of the hands (associated with Addison's disease)
  • Loss of axillary or pubic hair (associated with Addison's disease)
  • Butterfly rash on face (associated with Lupus)
  • Thyroid enlargement (associated with Hashimoto's thyroiditis or Graves' disease).
• A pelvic examination (this includes a bimanual exam)

Blood tests generally include:

• FSH - generally this is done at least two times and at least 1 month apart. There is debate about the time of the month the FSH is done (such as Day 2 or 3 of the menstrual cycle). However, in general the timing during the month isn't found to be that important. It is important that more than 1 test be performed. And, obviously, if you're not menstruating how would you know when Day 2 or 3 was?
• Estradiol
• Karyotype - some doctors will say that this does not need to be done if you've had children or if your POF occurred after the age of 35. However, neither age nor having children rules out a chromosomal abnormality. Some insurance companies may not pay for this test.
• Screening for associated autoimmune disorders might include:
  • Thyroid-stimulating hormone (TSH) - Ultrasensitive
  • Antithyroid antibodies
  • Antinuclear antibody titer
  • Fasting glucose
  • Electrolytes
  • Corticotropin stimulation test - for women with signs and symptoms of adrenal insufficiency. Do not have a random plasma corticol level done instead. They are not helpful because they can be in the normal range even with impaired adrenal reserve.
  • CBC (Complete Blood Count)
  • Urinalysis
  • In addition, these may be obtained if clinically indicated:
    • Sedimentation rate
    • Rheumatoid factor
    • Quantitative serum IgA - for women with a history of recurrent respiratory tract infections
      infections.

Radiology:

• A bone-density study can be useful. The best available test is a dual energy x-ray absorptiometry (DEXA) of the lumbar spine and hip. Before starting HRT a baseline study can document any bone loss and future studies can be compared to it.
  This is important to remember: there is no way to predict a person's risk of having a future fracture by having a regular x-ray taken.
  

18. Are there any tests that I don't need to have done?

• Progesterone challenge test - this test is often done but it's not necessary. For this test women are given 10 mg of progesterone (pills) for approximately 10 days and at the end of the 10 days we ask the woman if she's had any vaginal bleed. However, women with POF intermittently have estrogen levels high enough for endometrial growth and withdrawal bleeding in response to the progesterone. A positive withdrawal test suggests there's some estrogen secretion. Unfortunately, it is not enough to reach the threshold required to allow ovulation. If withdrawal bleeding occurs in response to a Progesterone challenge test women may be falsely reassured that ovarian failure is not a possibility. This can delay the timing of the diagnosis.
  
  
• Antiovarian antibody testing - one readily available test is positive in nearly 1/3 of the general population of women.
  
  
• Pelvic ultrasound - this detects structures that look like ovarian follicles in 30 - 40% of women with POF. But showing follicles on ultrasound doesn't change how it's treated so it's not routinely recommended.
  
  
• Ovarian biopsy - it is invasive, provides little information and is generally considered a research tool.
  

19. Do women have normal fertility before developing POF?

Yes. In general, women with secondary amenorrhea have normal fertility before developing POF.

Answers for 1-9 | Answers for 10-19 | Answers for 20-29 | Answers for 30-39 | Answers for 40-45