Big changes have been made to the guidelines for premature ovarian insufficiency, which were last published in 2015.
Attendees at the recent International Menopause Society event were given a sneak peek at the updated guidelines for the diagnosis and management of premature ovarian insufficiency.
As part of a symposium at the recent World Congress on Menopause, held earlier this month in Melbourne, Professor Richard Anderson introduced the soon-to-be updated guidelines for premature ovarian insufficiency.
“This is really a very substantial and extensive guideline,” the head of obstetrics and gynaecology at the University of Edinburgh told delegates.
“It hasn’t just been a little bit of a quick top-up here and there from the one 10 years ago. There’s been an awful lot of extensive rewriting of many of these chapters.”
The new guidelines, which were developed in response to 40 clinically relevant questions about the condition and resulted in 145 recommendations – 92 of which were backed by published data – builds on the previous version of the guidelines
“One of the things that we put into the last guideline was to try and change the terminology from primary to premature ovarian insufficiency to recognise that it’s the prematurity that is the issue for these young women, as all ovaries fail or become insufficient in due course,” Professor Anderson said.
The updated guidelines contain detailed recommendations on how to diagnose POI, with Professor Anderson discussing that only one elevated FSH reading (above 25 IU/L) was required alongside the patient having at least four months of disordered menses.
“It became clear in discussions among the group that we really thought, ‘well, if the FSH is 30 the first time you measure it, why are you doing it again? You’re just delaying the diagnosis [and] giving the opportunity for confusion if the second test comes back more borderline,” he said.
If a patient presents with these symptoms, the first think to consider is whether they have previously undergone chemotherapy, pelvic radiotherapy or pelvic or ovarian surgery, as more than 10% of POI cases are iatrogenic.
“Frankly, it’s still really quite distressing and upsetting, that the single most common cause is doctors taking out ovaries from young women – that’s the single commonest cause of POI in our young patients,” Professor Anderson said.
“And I’m sure many of us will be slightly horrified at that and think, ‘oh gosh, that’s what gynaecologists used to do back in the 80s’. But unfortunately, that is not the case [as it is still happening]. The good news, I guess, is that it is something we can continue to work on and change.”
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If there are not iatrogenic factors in play, genetic testing should be undertaken after the appropriate counselling and informed consent to determine if the diagnosis of a genetic cause of POI can be made. The updated guidelines contain a whole section about considering the potential knock-on effects for the female family of patients found to have a genetic case of POI.
Autoimmune conditions are the next cab off the rank that should be considered if no underlying genetic cause is found.
“I think we had some nice clarity in the updated guidelines, where we struggled a bit last time to really try and nail these things down,” Professor Anderson explained.
“The key test is to look for adrenal involvement with 21-hydroxylase antibody testing. [Most] testing labs don’t have good autoantibodies against ovarian antigens; they’re not terribly useful and we don’t recommend them. But we do recommend that testing thyroid function (TSH) is appropriate and should be part of screening [for] women presenting with POI.”
A diagnosis of idiopathic POI should only be made in patients where there are no iatrogenic, genetic or autoimmune factors that can be linked to the symptoms of POI.
Professor Anderson was joined by Associate Professor Amanda Vincent, lead endocrinologist in the menopause, early menopause and menopause oncology clinics at Monash Health, who discussed some of the long-term implications of POI.
“The consequences of POI can be quite overwhelming for the patient who is suddenly told, ‘yes, you have POI, and this is what could potentially occur’. [But] I think it’s important to realise that there is some variation [in long-term outcomes] depending on the cause of POI,” Professor Vincent told delegates.
One key addition to the new guidelines has been the impact of POI on the musculoskeletal system.
“This had not been previously looked at, and there seems to be evidence that there is decreased muscle mass, muscle function and muscle strength in women with POI which raises the question of sarcopenia as these women move into later life,” Professor Vincent highlighted.
The management algorithm for women with POI included in the new guidelines covers a broad range of areas to consider, including lifestyle management, psychological health, sexual functioning and genitourinary symptoms.
