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CLINICAL FOCUS 29
Table 3 . Recommendations for management of premature ovarian insufficiency
Initial evaluation
History and examination : symptoms , sexual function , psychological health , comorbidities , CVD and osteoporosis risk factors , and related to cause of POI
Investigations : liver function , renal function , fasting lipids , diabetes screen , vitamin D , cancer screening as per national guidelines , bone densitometry , and related to cause of POI ( eg , Turner syndrome or autoimmune disease )
Menopausal hormone therapy Refer for induction of puberty if primary amenorrhoea Individualise according to comorbidities , needs and preferences Higher oestrogen doses required to optimise musculoskeletal health Continue until at least the usual age of menopause
Quality of life Use empathic communication skills and leave ample time to discuss the diagnosis Use shared decision-making to develop a personalised management plan Provide information and education on POI
Mental health
Screen for mood disorders regularly Antidepressants and psychotherapy are proven strategies for management of depression Oestrogen therapy may have positive effects on mood Sexual health Screen for sexual dysfunction regularly Treat vulvovaginal atrophy / genitourinary syndrome of menopause with systemic and / or local vaginal oestrogen therapy Androgen therapy is not routinely recommended Use a multidisciplinary approach to manage sexual dysfunction Cardiovascular health Healthy heart diet low in saturated fats and reduced salt intake Exercise ( weekly aerobic ) No smoking Maintain healthy weight range
Table 2 . Factors affecting risk of premature ovarian insufficiency or early menopause
Factor type
Genetic
Risk factor
Chromosomal abnormality Specific genetic variant Family history
Screen for and treat dyslipidaemia , diabetes mellitus or hypertension Assess CVD risk using calculator : consider referral to specialist in cases of high CVD risk Bone health Maintain healthy weight range Exercise ( weekly weight-bearing ) Adequate intake of calcium and vitamin D
Autoimmune disorders Early life
Reproductive
Lifestyle
History of associated autoimmune disorder
Child of multiple birth Breastfeeding protective for EM ( POI unknown ) Low birthweight , adverse childhood experience and lower socioeconomic status are associated with a lower age of natural menopause , but there are no specific data regarding POI / EM
Early menarche Nulliparity Menstrual cycle length < 25 days associated with EM
Smoking Underweight
No smoking Reduced alcohol consumption Monitor BMD via bone densitometry at diagnosis and then every 2-5 years Consider referral to endocrinologist when BMD declines despite optimal MHT or low-trauma fracture occurs Related to cause of POI Management of comorbidities associated with cause of POI ( eg , Turner syndrome , autoimmune disease or cancer ) Fertility Provide counselling and support — refer if needed
Social / environmental Lower Human Development Index countries , lower educational / occupational level and toxins are associated with lower age of natural menopause but there are no specific data regarding POI / EM
Iatrogenic
Chemotherapy : increased risk with greater cumulative dose and alkylating agents Radiotherapy : increased risk with greater cumulative dose Pelvic surgery
Provide advice regarding contraception if fertility not desired ( eg , levonorgestrel IUD + oestrogen therapy or continuous use of combined oral contraceptive ); MHT is not a contraceptive
Refer to fertility specialist if pregnancy desired
Cancer screening Cervical , breast and bowel cancer screening as per national guidelines
needs to be conveyed in a sensitive man- |
available ( see online resources ). Additional |
psychological health and comorbidities ; |
of the barriers , especially for those living |
ner with counselling and support offered . |
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investigations may be required depending |
and to determine appropriate menopausal |
outside metropolitan areas . |
Once diagnosis is made , comprehensive |
on initial history and examination ( eg , coe- |
hormone therapy ( MHT ) regimen and fer- |
Prompt initiation of systemic MHT |
evaluation and investigations should be |
liac antibodies ). Referral for genetic coun- |
tility needs . Management recommenda- |
is essential and should be continued |
performed to determine aetiology . These |
selling is suggested if abnormal karyotype |
tions are shown in table 3 ( see also online |
until at least the usual age of meno- |
include karyotype , fragile X premutation |
or fragile X premutation is detected . |
resources ). Women should be reviewed at |
pause to manage menopausal symptoms |
testing ( see How to Treat : Fragile X syndrome ), thyroid and adrenal autoantibody testing and pelvic imaging ( eg , ultrasound or pelvic MRI ). A diagnostic algorithm is |
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Management
Initial comprehensive evaluation is needed to assess and screen for symptoms ,
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least yearly . Multidisciplinary management is recommended , although may be difficult to achieve . 10 , 12 The increased use of telehealth may help to overcome some |
if present , improve quality of life and reduce the risk of cardiovascular disease , osteoporosis and neurocognitive disorders . 2 , 10-12
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