Primary Ovarian Insufficiency

Endocrinology is the branch of medicine that studies endocrine glands, specifically their structures, functions and disorders. Endocrine disorders or diseases include a malfunction (no secretion, hyposecretion or hypersecretion) of hormones involving an endocrine gland. The endocrine glands in our body include: hypothalamus, pituitary, thyroid, parathyroid, adrenals, pancreas, ovaries, testes and the pineal gland. Hormones are chemical substances that control and regulate actions of target cells or organs by methods of simple feedback (positive and negative feedback) or the nervous system.

Common hormones include: growth hormone, thyroid stimulating hormone, adrenocorticotropic hormone, follicle stimulating hormone (FSH), luteinizing hormone, antidiuretic hormone, oxytocin, thyroxine, triiodothyronine, calcitonin, glucocorticoids, mineralocorticoids, corticosteroids, cortisol, aldosterone, glucagon and insulin.

These hormones collectively play a role in the reproductive and central nervous system development of the fetus, stimulation of growth and development during childhood and adolescence, sexual reproduction, maintaining homeostasis and responding to emergency demands. The endocrine disorder that will be discussed is Primary Ovarian Insufficiency, also known as Premature Ovarian Failure.

Primary Ovarian Insufficiency (POI) involves the decrease in the normal functionality of a woman’s ovaries before the age of forty years old due to the depletion or dysfunction of ovarian follicles. This may include regular or irregular menses and reduced fertility prior to the age of forty. This occurs because the ovaries do not release eggs monthly as expected and therefore fail to produce normal amounts of estrogen and progesterone. This is the inherent cause of POI. It is found to be more common in women in their thirties and has been found to affect both women that have not had and those that have had children.

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Signs and symptoms include: irregular menses, hot flashes, night sweats, irritability, depression, anxiety, trouble sleeping, trouble with concentration and memory, decreased libido, painful intercourse, vaginal dryness, heart disease, infertility, hypothyroidism, osteoporosis, small breasts or decrease in breast size, and lack of normal vaginal discharge.

Research has proven that Primary Ovarian Insufficiency is related to malfunctions in the ovaries, specifically in the follicles. Follicles are known as small sacs within the ovaries where eggs are expected to grow and mature. Anything that causes a decrease in the production of eggs or ovarian hormone production can lead to POI. The depletion or dysfunction of follicles may be caused by: genetic disorders (Fragile X Syndrome and Turner Syndrome), endocrinopathies (hypoparathyroidism and hypoadrenalism), a low number of follicles, impairment of ovarian function due to pelvic surgery, autoimmune diseases (thyroiditis and Addison’s Disease), chemotherapy, radiation therapy, metabolic disorders and toxins (tobacco, chemicals and pesticides). Although the normal functionality of the ovaries has decreased, research has shown that five to ten percent of women have fertility restored and are able to get pregnant due to the spontaneous remission of POI.

Risks that have been associated with Primary Ovarian Insufficiency include: eating disorders, thyroid disease, age bracket of women between thirty-five to forty years old, hyposecretion or hypersecretion of follicle stimulating hormone and ovarian surgery. It can be caused by autoimmune diseases in women that make their antibodies attack her ovaries and viral infections that damage the ovaries (mumps). It can also be caused by chromosomal abnormalities including Turner Syndrome, Fragile X Syndrome and Galactosemia. POI can be caused by toxins that affect the ovaries including chemotherapy and radiation therapy.

Screening and diagnostic testing for Primary Ovarian Insufficiency include taking a medical history specifically looking for a possibility of inheritance with further genetic testing and menstrual and sexual history including menstrual cycle and any abnormalities noted. A physical exam may also be performed to rule out disorders that may be attributing to current symptoms as well as assessment of basal FSH and basal estradiol to rule out thyroid disease, pregnancy and hyperprolactinemia. Blood tests may be performed to assess hormone levels because low levels of estrogen may indicate POI and to analyze chromosomes for abnormalities that may have caused this disease. Other ways to determine the cause are assessment of adrenal autoantibodies to determine if the cause is due to autoimmunity and bone density testing because low estrogen production causes osteoporosis. A pelvic ultrasound may also be ordered to determine if the ovaries are enlarged or contain an adequate number of follicles.

Primary Ovarian Insufficiency has a genetic component as an unmodifiable risk. Research has shown that Fragile X Syndrome and Turner Syndrome have been the cause for up to twenty-eight percent of POI cases. Fragile X Syndrome is a genetic disorder with symptoms of developmental delays, learning disabilities and social and behavioral problems. It has been found that most women who have Turner Syndrome also develop POI. Turner Syndrome is a condition in which women have XO chromosomes, instead of XX resulting in short height, heart defects and failure of ovaries to develop. The risk for offspring is greatly increased if their mother or sister have been diagnosed with POI; research has proven about ten to twenty percent of people with POI have a hereditary origin.

At this time, there are no treatments to restore the structure and function of ovaries. However, treatment of Primary Ovarian Insufficiency is targeted at relieving the accompanying symptoms as well as preventing associated health risks and conditions. Treatments for POI include: hormone replacement therapy (HRT), calcium and vitamin D supplements, in vitro fertilization (IVF) and regular physical activity and a healthy body weight. HRT in the form of a pill or patch can be used to effectively restore the estrogen and progesterone the ovaries are not producing until a woman reaches menopause, it can decrease the chance of heart disease and osteoporosis and is found to be the most common treatment. Calcium and vitamin D supplements are recommended to be taken daily to treat osteoporosis which is frequently found in women with POI. IVF is performed if the client desires to become pregnant. Regular exercise and maintenance of weight can help decrease the chance of osteoporosis and heart disease. Clients diagnosed with this disease, especially adolescents, will need emotional and physical support. A referral to a psychologist or social worker should be implemented as well as assessment of their support group.

Treatment of disease or symptoms reap benefits that usually far outweigh the side effects. However, the side effects are worth mentioning to allow for patient education and to prevent possible complications. HRT treatment may cause breasts to enlarge and feel sore, initial menstruation, bloating, nausea, headaches, indigestion, cramps, and premenstrual syndrome (PMS) symptoms. In postmenopausal women, HRT is not recommended because it increases the chances of breast cancer, heart disease and stroke. Nursing interventions for HRT can include patient education of stopping HRT treatment after the age of fifty to prevent further risks of associated symptoms and encouraging frequent small meals to alleviate bloating and indigestion.

Daily calcium and vitamin D intake may cause arrythmias, nausea, constipation, fatigue, drowsiness, headache, dry mouth and muscle or bone pain. Nursing interventions for intake of calcium and vitamin D may include a β -blocker to regulate contractility of the heart, antiemetic medication to prevent nausea and emesis and a diet high in fiber to prevent constipation. The side effects commonly associated post IVF are mild cramping and bloating, constipation, high emotional stress, anxiety and breast tenderness. Nursing interventions for IVF include regular psychology sessions to help alleviate emotional stress and anxiety and heat packs or NSAIDS to treat and relieve mild stomach cramping and breast tenderness.