The two main issues with which the woman with POF may be concerned are fertility and long-term health considerations. Women with POF have a high risk for osteoporosis and cardiovascular disease, with two thirds of women with POF having a bone mineral density one standard deviation below that of women their age. This translates to a 2.6 fold increased risk of hip fracture. 47% have significantly reduced bone density within 1.5 years of the diagnosis. In one survey of 19,000 women, the risk of death from heart disease and cancer was not significantly increased, but there was an increased risk of death from stroke and "all other causes".
Because the long-term health risks are felt to be secondary to hypoestrogenemia, it is appropriate to start hormone replacement therapy as soon as the diagnosis is confirmed. The usual postmenopausal regimens are appropriate. Keeping in mind that ovulation and pregnancy may still occur, oral contraceptives are appropriate for the sexually active woman who does not desire pregnancy.
There is no known therapy for autoimmune ovarian failure. There have been anecdotal reports of ovarian function returning after glucocorticoid treatment, but no controlled studies have been published. Because of the major risks of aggressive immunosuppression, empiric glucocorticoid therapy is not indicated and should be restricted to participants in clinical trials.
Women with POF may still have a 5% to 10% chance of conception, with about 80% of those pregnancies resulting in a live birth. No therapy other than oocyte donation has been shown to increase these numbers. Treatment with estrogen or high dose gonadotropin has been followed by sporadic pregnancies, but with no greater frequency than would be expected without treatment. The chance of successful pregnancy following oocyte donation is directly related to the age of the oocyte donor rather than to the age of the recipient or the status of her ovarian function.
In the case of iatrogenic POF, the woman may chose to undergo oocyte retrieval and embryo cryopreservation prior to chemotherapy or radiation therapy. At this time, the results of IVF using cryopreserved oocytes are dismal, requiring that the oocytes be fertilized after retrieval, and the embryos cryopreserved. Investigators are now studying techniques for cryopreservation and grafting of human ovarian tissue. This has exciting implications for women planning chemotherapy or radiation therapy as well as those women with familial POF.
Suggested Reading
