Some women show poor ovarian reserve, which is an entity named as early ovarian ageing. Early ovarian ageing is mostly genetically determined, but acquired modifiable factors like smoking, or ovarian surgery have some roles. Infertility and subfertility are the only clinical recognisable sequelae in the early ovarian ageing.
Screening of women with antimullerian hormone, antral follicle count and genetic analysis may be useful for recommendation at appropriate biological time regarding conception or fertility preservation.
Premature ovarian insufficiency (POI), defined as amenorrhoea due to the loss of ovarian function before 40 years of age, can occur spontaneously or be secondary to medical therapies. POI is associated with cardiovascular morbidity, osteoporosis and premature mortality. Women with POI present in primary care with menstrual disturbance, menopausal symptoms, infertility and, often, significant psychosocial issues. General practitioners play an important role in the evaluation and long-term management of women with POI.
Diagnosis of POI requires follicle-stimulating hormone (FSH) levels in the menopausal range on two occasions, at least four to six weeks apart in a woman aged <40 years, after more than four months of amenorrhoea or menstrual irregularity. The diagnosis is often distressing and women are likely to require psychological support. Hormone replacement therapy, unless contraindicated, is required and should be continued until the age of natural menopause.
Presentations of menstrual abnormalities are common in primary care, and POI is often an under-recognised cause. POI, defined as the ‘development of amenorrhea due to loss of ovarian function before the age of 40’, encompasses premature menopause (menopause before 40 years of age)and primary amenorrhoea (absence of spontaneous menarche).
POI can be associated with a fluctuating and unpredictable course, with a small possibility that ovarian function may spontaneously resume. The term POI is increasingly preferred to ‘primary/premature ovarian failure/menopause’ as it more accurately reflects the variability in the clinical picture, and removes the negative connotations associated with the word ‘failure’.
Depletion of ovarian follicles with POI leads to a decline in oestradiol, anti-Müllerian hormone and inhibin B levels, and a rise in pituitary gonadotrophins.Women with POI typically present in the primary care setting with primary or secondary amenorrhoea and infertility, and may have symptoms of oestrogen deficiency.
Early diagnosis is important, as women are at risk of morbidity, such as infertility, osteoporosis, accelerated cardiovascular disease (CVD) and neurocognitive disorders, and increased mortality. Delayed diagnosis also misses the opportunity for timely institution of oestrogen therapy.
GPs play a vital role in the evaluation and initial management of women with POI, and also in monitoring for long-term consequences.