Premature ovarian insufficiency (POI)

Premature ovarian insufficiency, or POI, is when the ovaries stop working normally before 40, and periods become irregular or stop.

How common it is depends on whom you ask. The British Menopause Society and the Australasian Menopause Society put it at about 1 in 100 women. A 2024 international guideline from ESHRE, ASRM, CRE-WHiRL and the International Menopause Society puts it at 3.5 in 100, from newer studies. Both figures leave out POI caused by surgery or cancer treatment.

The name is chosen with care. The Pakistan Menopause Society prefers it to "premature ovarian failure" or "premature menopause" because the ovaries can still work on and off, and pregnancy occasionally happens. Insufficiency, not failure.

The NHS website uses premature menopause for menopause before 40, and early menopause for before 45.

In Urdu, Roshara keeps the English name a doctor will recognise and explains it: the ovaries stopping work before their time.

Writing about early and premature menopause together, the NHS website says the main sign is periods that are no longer regular, or that stop, before 45. Other symptoms can include hot flushes and night sweats, vaginal dryness, difficulty sleeping, low mood or anxiety, a lower sex drive, and problems with memory or concentration.

Then there is what no list covers. Being told it is stress, or weight, or nothing. Wondering what it means for the children you still want.

The NHS website says early or premature menopause is more likely if it runs in your family, if your periods started early, if you smoke or if you are underweight. It can also be caused by treatment for other conditions: radiotherapy or chemotherapy, certain hormone medicines, or surgery to remove the ovaries.

The WHO adds chromosomal conditions and autoimmune disorders as possible causes of menopause before 40, and says that sometimes the cause is unknown. The European Menopause and Andropause Society (EMAS) adds endometriosis, or its treatment, as a possible cause.

Diagnosis

NICE NG23 sets this out for women under 40. Doctors should take your medical, surgical and family history into account (1.7.1). Diagnosis rests on menopause symptoms, including no or infrequent periods, together with raised FSH on two blood samples taken weeks apart (1.7.2), never on one test alone (1.7.3). If there is doubt, NICE says to refer to a specialist in menopause or reproductive medicine (1.7.5).

The Pakistan Menopause Society lists symptoms before 40 that suggest POI among its red flags that need evaluation or referral (2.3). Its Table 3 asks doctors to confirm POI, assess fertility and long-term health, and seek specialist advice where needed.

Long-term health

The NHS website says replacing missing hormones matters if menopause starts before 45, because the chance of problems with bones and the heart is higher. The PMS recommendations list POI among the reasons to consider a bone density scan, where available (Table 4).

The BMS points out a particular risk for South Asian women: with families often complete by the mid-30s, POI may go unnoticed and untreated, with consequences for heart disease, dementia and osteoporosis later. EMAS also says that POI left untreated raises the risk of osteoporosis, heart disease and dementia.

NICE NG23 recommends offering hormone replacement, with a choice of HRT or a combined hormonal contraceptive, unless there is a reason not to, such as a hormone-sensitive cancer (1.7.6). The Pakistan Menopause Society says HRT is indicated and recommended in POI (5.1).

NICE asks doctors to explain several things (1.7.7). Treatment matters, and should continue until at least the age of natural menopause unless there is a reason to stop. The background risk of diseases such as breast cancer and heart disease is very low under 40. HRT may be better for blood pressure than the combined pill. Both protect bone. And HRT is not a contraceptive.

The Menopause Society adds that the results of the Women's Health Initiative, the large HRT trials in older women, do not apply to women with POI.

For women who cannot take hormones, such as after some cancers, NICE says to give advice on bone and heart health and on managing symptoms (1.7.8).

If you are under 40 and your periods have become irregular or stopped, see a doctor. Do not wait for it to sort itself out.

If you have been told it is stress and the changes carry on, it is fair to ask, by name, whether POI has been considered.

In families that expect more children, POI can land as a judgement on a woman rather than a medical condition. It is a condition with a name, a guideline and treatment.

The NHS website says POI can make it harder to get pregnant, and lists IVF with your own frozen eggs or donor eggs, surrogacy and adoption as options. Some of these raise faith questions, and many women ask them. A qualified scholar is the person to take them to, and a fertility specialist the person for the medical side.