Sunday, February 21, 2010

Premature Ovarian Failure in 38 Year Old - What Are Her Options?



Question:

Dear Dr. Ramirez, I am a 38 year old from Birmingham, UK. After experiencing irregular periods and sometimes having 3 to 4 month absences, my hormone levels were tested and showed my level as 20. I was told that either I was experiencing premature ovarian failure (POF) or an early menopause. The course of action I was given at that time to determine which I had was to take a months supply of hormone replacement therapy. Obviously the bleed at the end would not have accounted for anything but the idea was to see if my periods came back after that. My gyno told me was that sometimes the ovaries can shut down for whatever reason and because of this the pituitary gland is desperately sending out more and more fsh to try and spur the ovaries into action and they are not responding hence the high FSH.

I was told that by taking a month of HRT it will switch off the pituitary gland and give the ovaries a rest from this constant hammering and that sometimes after this rest the ovaries start working again on their own. They did come back for about 3 months and a day 21 progesterone test showed my level as 20 suggesting some kind of ovarian activity.

I was told if I was in POF or menopause the ovaries would not respond to this but because I did get my periods back after the hrt for about 3 months it showed that I had POF, not menopause. I was also told that if I didn't get my periods back then they would be able to confirm menopause with a laparoscopy. My gyno said that because the HRT brought back my periods it showed that I have eggs so I am not in menopause.

Does this make any more sense to you at all? I have now been advised to stay off HRT for 2 months and then just go and get my hormone levels tested again and if my levels show menopausal then go on hrt permanently. I sort of feel as though I was given false hope. Can I still get pregnant?

Answer:

Hello,

The elevated FSH level is definitely concerning. It needs to be confirmed and should have been done on cycle day #2 or 3 of the first available menstrual cycle. If you are not having periods any more, then a random FSH can be done (done at any time in the cycle). If that level is greater than 20, then your ovaries have shut down and you are menopausal. The only difference between that and premature ovarian failure, is POF occurs in women under the age of 40 (as in your case). Otherwise, the net effect is the same. The ovaries have shut down. In that case, you cannot conceive naturally. Having a period is not a sign of the lack of menopause. You can have breakthrough bleeding or dysfunctional bleeding, which are caused by a lack of hormones, not the result of ovulation.

The exact cause of POF is unknown. Most think that it is an autoimmune problem, whereby somehow the body is shutting down the ovary. However, pregnancies have occurred in POF patients from random spontaneous ovulation. The problem is that the ovary is not picking up the FSH so the levels are increased. Fertility medications work by "bombarding" the ovary with increased FSH. The pituitary does not do that. The pituitary sends FSH to the ovary to stimulate ovulation. If the ovary does not pick up the hormone from the blood stream, the level is increased. I tell my patients to think of the ovary as a ball with lots of holes in it. If the holes are plugged up, the FSH can't get into the ovary and hence the FSH levels in the blood stream are elevated. POF is NOT due to the lack of eggs. It is due to the lack of ovarian stimulation/function. In addition, laparoscopy CANNOT diagnose menopause. It is a purely clinical and hormonal diagnosis.

In order to have a period on HRT, you need to be cycled i.e. take estrogen and then progesterone. In a young woman, the best method for HRT and cycling is the birth control pill. DO NOT USE menopausal hormone replacement drugs. It is too low for a young woman and you won't get adequate estrogen replacement. If you are indeed in premature ovarian failure, then you need to take estrogen and progesterone because your ovaries are not making them. The lack of these hormones will have long term detrimental effects. Since you want to get pregnant, then you need to see a reproductive specialist as soon as possible. Sometimes, in the early evolution of POF, the ovary can still be stimulated with HIGH dose FSH, which can lead to pregnancy. You want to be doing the optimal treatment method for pregnancy to ensue if either of these occur. That optimal treatment method is IVF because it performs 7 of the 9 steps required to get pregnant and has the highest chances of pregnancy.

For that reason, I would definitely recommend that you proceed to IVF as soon as possible. As long as your ovaries stimulate and eggs can be obtained (you only need one or two good quality embryos), you would have a 50-70% chance of pregnancy per IVF cycle. There are some IVF programs that will not allow a patient to try with her own ovaries if the FSH level is above 12. I do not have that policy. I don't make decisions for my patients, I only counsel them thoroughly and let them decide what they want to do. In your case, I would encourage you to try with your own eggs as long as the ovaries can be stimulated.

I counsel patients who are POF to also consider freezing some of thier eggs. Egg freezing techniques have greatly improved over the years and can be an alternative method of extending your fertility. It takes approximately four to six weeks to complete the egg freezing cycle, which follows the same protocol as IVF. Two to four weeks of self-administered hormone injections along with birth control pills to temporarily turn off natural hormones. This is followed by ten to fourteen days of hormone injections to stimulate the ovaries and ripen multiple eggs. Once the eggs are retrieved they can be frozen using a slow-freeze method or the flash-freeze method known as vitrification. They then can be thawed, ICSI'd, and the resulting embryos transferred into the uterus. The egg freezing process should be carefully considered, as it is still classified as an experimental technique by the American Society for Reproductive Medicine (ASRM). We have begun to offer this as a service at our clinic.

If the ovaries don't stimulate well, that means your ovaries have shut down or are shutting down. Then your next alternative would be donor eggs, but I would recommend you give it the best try that you can right away. Make sure you choose an IVF clinic that has good pregnancy rates. You don't want to waste your eggs! Good Luck!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

30 comments:

  1. Hi Dr. Ramirez, I just turned 28 years old six months ago and was told I had high fsh. My level came back at 27, however, it was done on day 4 and only a month after doing Clomid.

    My question is, do you think IVF or IUI is the way to go?? I just went through an IUI w/ injectables cycle. My AFC on day 3 was 8.

    Please let me know your opinion and advice. We've been trying to conceive for 18 months.

    Thank you

    ReplyDelete
  2. An FSH level of 27 is very high. In fact, it indicates ovarian failure (premature ovarian failure) if it is correct. You mentioned that you had Clomid one month prior. Was the month preceding this test a natural cycle or a Clomid cycle? The CD#2/3 FSH levels should be checked after a natural cycle, not Clomid or birth control pill cycle.

    I think that if a repeat FSH level is above 7, then I would strongly consider IVF rather than IUI, in order to maximize your chances of pregnancy. My worry is that the FSH level will continue to rise and you will lose the opportunity to get pregnant with a genetic child. Once the FSH level reaches 15, most fertility centers will recommend Donor eggs.

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  3. Basically I did Clomid in May 2009, July 2009, and August 2009. The high fsh reading was taken in September 2009.

    Again, it was also done on day 4 of my cycle and only tested once. Deep down I know this result is inaccurate. This was my first visit with RE #1. He never checked AFC or anything, just said "Sorry, adoption or donor eggs."

    I was under the impression and through research that in order to confirm such a diagnosis as POF, there had to be more than one blood test done to show the high fsh levels.

    As for treatment, we actually just went through an IUI cycle with injectables. On day 3, u/s showed 8 follicles and day before IUI we had two follicles (19mm & 17mm)

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  4. If you did a Clomid cycle in August, then a September FSH would not be valid. It should be done after a normal and unmedicated cycle. Also, if you have done injectables with a stimulatory response (had follicles that grew), then you are definitely NOT in premature ovarian failure. POF is when the ovaries STOP working, which yours have not. You may be a decreased ovarian reserve (DOR) patient, which means that the ovaries do not stimulate well, and so the yield is less i.e. less eggs are retrieved. I presume you had a low stimulation for your IUI, because we don't want many with a natural treatment like IUI, so with a high protocol, you should do well, and with your age, I would expect your eggs to be of good quality so your chances of success are high.

    I think, that you should go directly to IVF, although because of your age, I understand why you attempted an IUI cycle. Again, my worry would be time more than anything else. I'd hate to see you lose the opportunity to have a genetic child.

    ReplyDelete
  5. I am 20 years having AMH <0.3 and with high FSH and LH.I was on OCPs since LAST 6 Months and these FSH AND lh tests were done then only.I have some 5 years gap in my marriage,how can i help myself for concieving 5 years later??

    ReplyDelete
  6. Hello Akriti,

    The AMH should not be affected by taking OCP's and is, in general, a measure of the number of follicles available in the ovaries. A low number is not good, especially at your age. However, a recent study just came out that showed that this does not mean you can't get pregnant. It may just mean that you don't have as many fertility years as the average woman.

    The FSH and LH are important because that indicates how your ovaries are functionng. If the levels are over 20, that may be an indication that you have "Premature Ovarian Failure" also known as premature menopause. This is a disorder that occurs in young women where the ovaries go through menopause and stop working. In that case, the ovaries don't work so pregnancy is not possible. However, FSH and LH can be influenced by being on OCP's so the tests should be done after a natural cycle (if you have them)on the second or third day of your period.

    In terms of planning for a pregnancy 5 years in the future, the only recommendation I can make is to try to live a healthy lifestyle.

    Good Luck.

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  7. Hi Edward, I've just turned 27. An internal ultrasound showed that my ovaries are approximately 2.2mls each. The ultrasound showed 2 follicles in one ovary and 1 in the other. The biggest being 6mm. The ultrasound was done at approximately day 10 of my cycle. Do these results point to POR? Will I be able to have my own children?

    ReplyDelete
    Replies
    1. Hello,

      These results do not give any indication of anything to be concerned about. The diagnosis of premature ovarian failure is made by hormonal blood testing, not ultrasound.

      Delete
  8. Good Afternoon Dr Ramirez,
    I was diagnosed with Premature Ovarian Failure last year aged 25 based on FSH Levels being at 93 and 64, having no periods for over a year, hot flushes etc...
    I went in for a scan yesterday to see if anything had changed and the specialist saw 1 follicle in my left ovary that wasnt there in the scan I got last year. He has advised me to take 150mg of Clomid for 5 days and go back and see if any eggs have formed.
    I would just like to know if finding a follicle was a positive thing and how likely I would be to create an egg from this??
    He has told me that if an egg is there, he will give me an injection to release the egg.
    What are the chances?
    Thank You

    ReplyDelete
    Replies
    1. Hello,

      I'm afraid I can't answer your questions specifically. You are asking about information that is unknown. It is known, however, that POF patients have been known to have spontaneous ovulation once in a while and achieve pregnancy. It is also known that they can sometimes reverse the failure for short periods of time. This is not in all cases but there have been case reports. So, if there is any chance that your ovaries are occassionally functioning, then there is a chance of becoming pregnant. I'm not sure that Clomid is going to do anything because all it does is increase FSH output, but it won't hurt to try.

      Good Luck

      Delete
  9. Good evening, Dr. Ramirez,

    I am 38 years old and just confirmed premature ovarian failure. As I am not trying to get pregnant and have no desire to have more children, my doctor recommended doing nothing right now. After speaking to him and reading more about it, I'm concerned with other health issues that it could lead to as well as the possibility that this condition could be passed on to my daughter. Is this hereditary?

    Thank you

    ReplyDelete
    Replies
    1. Very little is known about premature ovarian failure, but it does not seem to be a heritable disease, so I don't think your daughter necessarily is at risk.

      Your health is at issue and your doctor is completely WRONG! If the diagnosis is correct, you are in premature menopause, which means that your ovaries are no longer functioning. You need to have your hormones replaced otherwise you WILL suffer some long term consequences such as osteoporosis, aging of the skin, increased heart disease risk, mental/emotional changes, vaginal shrinkage and dryness, pain with intercourse, etc. You are too young not to have adequate hormones in your body. The easiest way to replace the hormones is to use the birth control pill since it is made up of estrogen and progesterone. The estrogen is the main hormone that you need.

      Delete
  10. Hi i am 34 years old. I have done an IVF 2 years ago but it wasn't successful because my husband also has some issues with his sperms. I was perfectly fine, normal FSH, normal LH, good anti mullarian hormone levels. 6 months ago my anti mullarian hormon became 1.48 which was little low at my age....and then 3 months ago it was 1.22. Last week my Dr said that he wants to test me again for that because im planning for another IVF and i was shocked because it has dropped to 0.48????? can it happen that in just 3 months it is has dropped from 1.22 to 0.48,,,, can AMH drop too fast? can u tell me where im heading? i shall be thankful to u...

    ReplyDelete
    Replies
    1. Hello,

      I can't explain why your doctor keeps checking you. Once is usually enough. The AMH has been shown to change from cycle to cycle and it has NO SIGNIFICANCE except to give a ptient an idea of ovarian reserve (the ability to be stimulated by fertility drugs). It does NOT predict fertility or pregnancy potential, that is why repeating is of no use. If you are already doing IVF, then that is the best/maximum that you can do so why check? IVF is still the treatment of choice.

      Good Luck

      Delete
  11. Dear Edward,

    I have just turned 36 and been given the shocking news that I am post menopausal. Within 1 year, my FSH has increased from 8.6 to 43.6. In January 2013, my hormones were fairly normal, except that my testosterone was very low <0.1 and I was hypothyroid (Free T4 was 10,8). My Gynae referred me to an endocrinologist, who explained that I still had plenty of eggs, and that my thyroid would resolve once I put on a bit of weight. Now, my thyroid is normal/borderline hypothyroid and my testosterone level has slightly increased to 0.3. But my progesterone is only 0.9, and estrogen is less than 18. Is it possible that such changes could happen so quickly? I have been told to go off a monophasal pill (Meliane) for a month to see if I get a period to do another hormone test. I think that I have to face the fact that I can only get pregnant with a donor egg now, but besides that, I am extremely worried about my health. Very rapidly my skin has changed, loss of muscle tone with weight (fat) gain, sex is painful and I am aging rapidly. Also my bones appear to be getting lighter if my nifty scale is correct. What type of OCP would be the best for me to take that will increase/maintain hormone levels for my age. I am scared at the speed of changes in my body and I have not found a doctor who is knowledgeable enough of my condition, or taking me seriously. Last year, I asked for a prescription of testosterone and estrogen cream and was laughed off for not needing it at my age. I would really appreciate your input. Thank you so much.

    ReplyDelete
    Replies
    1. Menopausal changes don't occur that quickly, so I am not sure about all the physical changes you describe. If in fact you are in premature ovarian failure (not premature menopause exactly), then hormones can easily be replaced by using any birth control pill. There is not one that is better than another. This should restore your hormonal balance and resolve the issues.

      Delete
  12. Hi Dr.Ramirez,

    I am 38 years old and had POF 2 years ago but still have my period. I have two children, but now I have symptoms such as hot flash, heart problem and my period is not coming yet, last one is Feb 26th, so my doctor suggest me to take HRT (a patch and progesterone), I did not take yet, I saw you mentioned that birth control pills is better then HRT, so for my case, what's your suggestions? Thanks

    ReplyDelete
    Replies
    1. I believe that normal HRT is insufficient estrogen for a young person. I don't have any studies to base this on but it is based on the fact that younger persons have a higher metabolism than older persons and thus their hormone requirement is probably higher. HRT medications are testing in women averaging 50 years old, NOT 38 years old. Because BCP's are low risk in your age group (and until 50) I think they are easier to use and give a better/higher estrogen for the younger body. I use them until my patient reaches 55 then change to HRT dosage medication.

      Delete
  13. Last year (November), I was due for my depo shot. I had been on it for a year and a half and decided based off of health and lack of sexual activity, that I would discontinue the shot. As expected I began to spot (as I had done plenty of times off and on throughout my use of the Depo shot) but soon this developed into a full blown period in January that lasted about a week and I was happy! I had been worried that my body would take longer to get back to normal. Now, it's March and I have not had a period since then. However, I have noticed that for the past couple of weeks that my breasts are sore and that I've been having cramps and although they are minor, they are noticeable. Should I be worried? I am not sexually active and haven't been in over 6 months. I know that it's been said that it takes 1-3 months for your periods to start back up again after the Depo, but why did I go from having a full blown period for one week in January, maybe a month and a half later after discontinuing, to now nothing? Please help, any insight is much appreciated!

    ReplyDelete
    Replies
    1. Hi. I can't specifically answer your question without running some tests, but you need to be examined and probably have an ultrasound done. An ovarian cyst can cause the type of symptoms that you are having or some other type of ovulatory dysfunction.

      Delete
    2. Ok. I have noticed some spotting from yesterday for the first time in a while and it is still continuing. It's not much, but it's something! If this continues to be abnormal then I will take your advice and go see a doctor. Thank you so much!!!:)

      Delete
  14. Thank you! I have just noticed some spotting yesterday and it is still continuing today. It's not much, but it's something! If it stops, then I will take your advice and have an ultrasound. Thanks so much!

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  15. i was on the shot for about 4 yrs my mom found out i was sexually active @ ages 12 /13 and immediately placed me on birth control ive been off this shot for almost a yr may will be a yr and i have not seen a period .i have no dryness but should i be worried .

    ReplyDelete
    Replies
    1. Hello Cynthia. It is not normal for you to not have a period 1 year out from stopping the Depo. That shows that your ovaries are not working for some reason. The problem with this, although it may be great not having a period, is that there is a hormone imbalance within that can lead to long term irreversible side effects like facial hair, obesity, male pattern baldness, diabetes, osteoporosis, vaginal dryness and wilting, to mention a few. You need to see a competent gynecologist about this to replace the hormones that you may not be producing.

      Delete
  16. thank you i really appreciate this

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  17. i also have another short question .i have horrible cramps from time to time is that a sign of anything?

    ReplyDelete
    Replies
    1. Sorry. The symptoms are too non-specific for me to answer that question.

      Delete
  18. I was dx with POF at 38. I finally went on Necon 1/35 and felt great for 2 years. At 41 I had to change doctors and she moved me to the .1 Climara and Prometrium. It's been awful. The prometrium practically puts me in a coma and the Climara patch feels ok the first day, but I feel like I run out of estrogen after a few days. but my doctor feels that because I'm technically "post" menopausal (FSH in the 80's) I should be on HRT due to the health risks of bcp. She even prefers the patch over the pill form of Estridol. I've never had a blood clot, I don't smoke, I weigh about 135 pounds....is the BCP safe for me? She has me a little worried now....but I feel so much better on the pill. Thank you.

    ReplyDelete
    Replies
    1. Your current doctor is not understanding POF now the metabolism of younger women. Current HRT formulations are made for women who are naturally menopausal and the studies were done in women 60 years old or older. They have a decreased metabolic rate (as the metabolic rate decreases with age). As such, their hormone requirement will be lower. You should mention this to your doctor. Because you are younger, your metabolic rate is naturally higher and so your hormone usage will be greater. If you use HRT formulations, you will not be getting adequate estrogen. For this reason, I recommend the usage of birth control pills, which have a higher estrogen amount, for hormone replacement in young women with POF. There is not standard HRT formulation currently made that fits younger women so OCP's are the only option. I would recommend a low dose pill.

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