Frequently Asked Questions (FAQs)

What is premature ovarian insufficiency (POI)?

Premature ovarian insufficiency (previously referred to as ‘premature menopause’ or ‘premature ovarian failure’) is a loss of ovarian function before the age of 40 years.

What are the symptoms of POI?

With POI, periods become infrequent or stop. There may be other symptoms such as hot flushes (sudden feeling of heat), night sweats, palpitations, decreased energy levels, lack of concentration, poor sleep, lack of interest in sex, vaginal dryness and painful sexual intercourse.

How does POI differ from natural menopause?

Natural menopause occurs at an average age of 51 in the UK. The natural menopause occurs when there are no more follicles (developing eggs) in the ovaries and it is irreversible. In unexplained POI, the function of the ovaries can return intermittently, and some women may even start to have periods or become pregnant many years later, although this is rare. Autoimmune POI can also fluctuate over time. Chemotherapy can cause either temporary or permanent ovarian damage, depending on the type of drugs, total dose received and duration of treatment. Younger women who receive short courses of chemotherapy tend to regain ovarian function sometime after the end of chemotherapy and may resume menstrual cycles and ovulation. They do however remain at risk of recurrence of POI or early menopause.

What effect will POI have on my long-term health?

The low oestrogen level in POI can cause osteoporosis (bone thinning), which can lead to fractures. You will be offered a painless X-ray bone density scan (known as a DEXA), which is a simple and painless test using a low dose of X-rays. This can be repeated every few years to monitor your bone strength. The risk of osteoporosis is also influenced by smoking, exercise, calcium and vitamin D levels. POI probably also causes an increase in cardiovascular risk (the risk of having a heart attack or stroke), which is also influenced by many other factors including smoking, diet, exercise and weight.

POI can be a very difficult diagnosis to come to terms with and many women have feelings of anxiety and low mood following the diagnosis. Some women feel inadequate and may feel they have ‘failed’ their partners or parents. Many feel embarrassed or left out when their friends are talking about periods and having babies. Getting information about the condition and meeting others who have it can help you come to terms with it and help develop a positive attitude to life with POI. It is important to seek help if you feel like this or feel that you are unable to cope. Talking to friends or family and having counselling can help.

Are there any treatments for POI?

Specialists recommend that women with POI take oestrogen replacement because lack of oestrogen can cause bone thinning, an increased risk of heart disease as well as the symptoms mentioned above. Women with POI are usually advised to have hormone replacement therapy until the average age of the natural menopause (50 years). Oestrogen replacement can be given as HRT (hormone replacement therapy) or the combined oral contraceptive pill. HRT is usually recommended as the first-line treatment for women with POI. It is up to you to decide whether you would like to take oestrogen replacement and if so, which pill or HRT you would like to take.

Some women prefer to use alternative medicine, dietary supplements, herbal and homeopathic remedies. It is important to remember that these treatments do not necessarily protect against heart disease and low bone density.

What should I expect at my first appointment?

At your first visit to the clinic, the doctor will obtain your medical history, discuss symptoms/health concerns and agree a treatment plan with you.

We will arrange any relevant blood tests or scans if you need them. If you require a referral for specialist treatments such as Mirena coil insertion, hysteroscopy or fertility treatment - we will organise this for you.

What is Hormone Replacement Therapy (HRT) and why do I need it?

HRT is medication aimed at relieving the symptoms that women experience during premature menopause. Common symptoms include hot flushes, night sweats, vaginal dryness, tiredness and irritability, and decrease in sex drive.

HRT works by replacing the hormone (oestrogen) your body stops producing when you go through premature menopause or when you have had surgery to remove your ovaries.

Used long-term, HRT may help to reduce the risk of osteoporosis (thinning of the bones), cardiovascular disease and bowel cancer. However, there are also known risks including an increased risk of blood clotting. These risks will be discussed with you in your clinic appointment.

When you start HRT, the doctor will discuss your age, symptoms and medical conditions before looking at the risks and benefits of HRT which are specific to you.

What are the different types of HRT?

There are two different types of HRT:

Oestrogen only (no progestogen) - when women have had a hysterectomy, they do not need progestogen to protect the lining of the womb.
Combined HRT (oestrogen and progestogen) - this is necessary if you still have your womb. This can be given in two ways:
- Continuous combined HRT - oestrogen and progesterone, taken together daily (one a day) for 28 days, this means that there will be no withdrawal bleeds.
- Sequential HRT - oestrogen only for the first 14 days then both hormones for the second 14 days. This usually results in monthly withdrawal bleeds.

The type of HRT you take will depend on where you are in the menopause and if your periods have stopped completely for a year.

How long does HRT take to work?

It usually takes a few weeks before you will feel the initial benefits of HRT and up to three months to feel the full effects. It may also take your body time to get used to HRT. When treatment begins you may experience side effects such as breast tenderness, nausea and leg cramps. Usually these side effects will disappear within six to eight weeks. If they do not, a change in the type or dose of HRT may be necessary and your own doctor will advise you on this. If after four to six months of HRT, you have not felt the benefits of the HRT it may help to try a different type.

How do I take the medicine?

This depends on the type of HRT you are taking (oestrogen only or combined) and does not always mean tablets. The different types, or ‘preparations’, of HRT are:

Patches

HRT patches can contain oestrogen, alone or with progestogen. They are applied once or twice a week to any area below the waist. They are effective in relieving both short-term symptoms and, if taken for longer, the long-term complications of the menopause.

HRT tablets

A wide range of tablets are available, and they are taken once a day. They can contain oestrogen or a combination of oestrogen and progesterone. They are effective in relieving both short-term symptoms and, if taken for longer, the long-term complications of the menopause.

HRT gel

Oestrogen is also available in the form of a gel. It is applied once a day to a clean, dry, unbroken area of skin, usually on the upper arm, shoulder or inner thigh. It is rubbed in and takes a few minutes to dry. The gel is clear and non-greasy.

Progesterone

If you have a womb then you will also need to have progesterone to protect the womb lining. This can be in the form of either tablets or Intra Uterine System (IUS) Mirena coil.

Implants

Oestrogen and testosterone can be administered via implants inserted beneath the skin.

Vaginal oestrogen (local HRT)

Vaginal creams, vaginal tablets, vaginal rings or vaginal pessaries contain a small amount of oestrogen and only work for specific symptoms where they are applied, such as vaginal dryness and urinary symptoms. Local HRT will not improve other symptoms such as hot flushes, or protect against the longer-term effects of the menopause such as osteoporosis. Local HRT does not have the same increased risks as other types of HRT so can be used by most women.

Tibolone (brand name ‘Livial’) is another type of hormone treatment, but it does not contain oestrogen or progesterone. It does not affect the lining of your womb. This means that, if you start taking it at least one year after your periods have stopped, you should not get any monthly periods. If you take tibolone, you are likely to have half as many hot flushes, less vaginal dryness, improved sexual satisfaction and more sexual arousal. Researchers have found that sex drive increases much more in women taking tibolone than in women taking combined hormonal HRT.

What should I do if I forget to take the medicine?

If you forget to take your HRT do not take the doses that you have forgotten, just take the next dose when you remember.

Is HRT contraceptive?

HRT is not a contraceptive. If you have been diagnosed with unexplained POI, you may occasionally ovulate and there is approximately 5–10% chance of having a pregnancy. You should therefore use contraception if you wish to avoid pregnancy. An oral contraceptive pill may be the best choice in this situation, as it can provide both contraception and oestrogen replacement.

Are there any side effects?

Many women experience side effects in the first few months of taking HRT. If problems persist after three months of treatment, then the type of HRT may be changed. Women react differently to HRT, so there is no one preparation that is better than any of the others. It is often a personal choice as to the type of preparation we try first.

Weight gain: it has been scientifically proven that women gain weight during the menopause, so any weight gain may not be a result of HRT. Your body’s fat distribution also changes, with an increase in fat around the waist and less around the hips and buttocks. You can also experience water retention when on HRT. If this happens then it may be worth trying a different preparation of HRT.

Blood pressure: there is no evidence that blood pressure increases with taking HRT in most women. Women are advised to have their blood pressure checked and treated in the usual way.

Bleeding: irregular bleeding in the first few months of taking any form of HRT is quite common and usually settles. Any bleeding after the first six months will need to be investigated with ultrasound scans and possibly a hysteroscopy (where we look inside the womb, through the vagina, using a small telescope at the end of a narrow tube).

Nausea: some women complain of nausea associated with HRT. This can be reduced by taking the HRT tablet at night with food instead of in the morning, or by changing from tablets to another type of HRT.

Skin irritation: this can happen with patches and occasionally gel. Sometimes the patches may fall off.

Other side effects that can occur and normally settle include: breast tenderness and enlargement, leg cramps, bloating, headache, pre-menstrual symptoms, lower abdominal pain, backache, depressed mood, acne/greasy skin.

What are the risks of HRT?

The information leaflets contained in the HRT packages can be misleading. For young women the risks associated with HRT are very small, but you will need to talk to your doctor to weigh up the risks and benefits for you as an individual. The information contained in the leaflets provided with HRT packages can be misleading as it mainly refers to women taking HRT after the age of the natural menopause (above 50 years). The biggest studies on risks of HRT (the Women's Health Initiative and Million Women studies) were undertaken in women aged over 50. Younger women who take HRT because of POI have higher benefits and fewer risks than older women.

1. Venous thromboembolism
HRT tablets increase the risk of venous thromboembolism (blood clots), pulmonary embolism (blood clot in lungs) and stroke (1-2 extra cases per 1000 HRT users). HRT patches have lower risk of blood clotting than tablets. Overall the risk of all types of HRT is lower than taking the contraceptive pill. If you've had blood clots before, you should let your doctor know as HRT may not be suitable for you. Your risk may also be higher if you are overweight or a smoker.

2. Stroke
The risk of stroke does not appear to be significantly increased in women under 50 years old.

3. Breast cancer
If you are under the age of 50 and taking HRT there is no increased risk of breast cancer, although you still have the same risk as the rest of the population (this is called background risk).

4. Endometrial (womb) cancer
Oestrogen is always given with progesterone, unless you have had a hysterectomy. This is because oestrogen on its own causes thickening of the womb lining, which can lead to heavy irregular bleeding, and over time this increases the risk of cancer in the womb lining (endometrial cancer). Adding progesterone for at least 10-12 days every month, or continuously, eliminates this risk.

5. Other risks
There is a chance that taking HRT for a year or more could increase your risk of gallbladder disease (gallstones).

How long should I take HRT for?

For women who have had premature menopause or surgical removal of the ovaries, HRT is recommended until they have reached the age of 50 (the average age at menopause). All discussions about stopping or decreasing the amount of HRT you take should be had with your doctor. Yearly review of benefits versus risks should be undertaken.

How do I get a repeat prescription?

You can get a repeat prescription from your GP or you can contact us .

What are the alternatives to HRT?

If you are unable to have conventional HRT, other medications or treatments may be prescribed to help control your menopausal symptoms. For vaginal dryness and painful sex – vaginal lubricants and moisturisers are often effective. For hot flushes and night sweats – antidepressants or selective serotonin reuptake inhibitors such as Venlafaxine and Clonidine (blood pressure lowering agent) are oral medications which are most commonly prescribed. Complementary therapies include homeopathy, phytoestrogens, yoga and acupuncture. It is important to remember that these treatments do not necessarily protect against heart disease and low bone density.

Is pregnancy possible with POI?

Infertility can be a devastating consequence of POI. Unlike women with regular periods, women with POI do not ovulate (release an egg) every month. However, studies have shown that women with unexplained POI do occasionally ovulate and approximately 5–10% will become pregnant. Unfortunately, there is no way of predicting which group of women this will happen to. You may read about ultrasound scans and blood tests being used to try to predict if there are any eggs left, but these are not proven and are currently only used in research settings. Women who resume menstruation and ovulation following recovery from chemotherapy are fertile and may be able to conceive naturally.

HRT does not affect your chances of becoming pregnant. However, the combined oral contraceptive pill is not a suitable treatment for you if you want to become pregnant because it prevents ovulation.

Women with POI can have fertility treatment using eggs donated by an egg donor and fertilised in a test tube (in vitro fertilisation [IVF]) with partner’s sperm. You will need to take HRT to prepare the womb and thicken the womb lining before an embryo is placed inside. HRT is continued for the first few weeks of pregnancy.
Many couples decide that remaining childless is a positive option. Adoption is a rewarding way of building a family, but it is not always easy. Adoption agencies would expect you to have ended any fertility treatment before you apply.

Where can I get more information?

Additional resources for information:

British Menopause Society

International Menopause Society

NHS Choices

The Daisy Network