MEDICAL TREATMENT :
No proven treatments restore normal ovarian function for women who have primary ovarian insufficiency. The goals are to inform them about their condition, counsel them regarding solutions for building a family, and provide ovarian hormone replacement therapy as clinically indicated.
For women with secondary ovarian insufficiency, the treatment required to restore ovarian function depends on the specific etiology.
Primary ovarian insufficiency
Patients should be informed that spontaneous remission could occur. Even women with stage 4 primary ovarian insufficiency have a 5-10% chance of becoming pregnant with no treatment. Sometimes, these spontaneous pregnancies occur many years after diagnosis. Unproven treatments to restore fertility should be avoided because they have the potential of interfering with the development of a spontaneous pregnancy.
Gonadotropin therapy carries a theoretical risk of exacerbating autoimmune premature ovarian failure.
The use of prednisone or dexamethasone in an attempt to restore ovarian function in suspected autoimmune ovarian failure is not clinically indicated. Use of these agents carries a risk of osteonecrosis. Their use in patients with premature ovarian failure should be confined to studies approved by an institutional review board.
Counseling patients who are infertile that waiting a period of time to permit a spontaneous remission to occur may be in order. A change in life plans or adoption may then be the best solution for some couples. After an appropriate amount of time has passed for the couple to develop the needed emotional reserve after learning of the diagnosis, ovum donation is another option for them to consider.
Patients with stage 3 and 4 primary ovarian insufficiency require ovarian hormone replacement.
Surgical Care: Ovarian biopsy is not clinically indicated in women with ovarian insufficiency, but surgical procedures should be performed in women with secondary ovarian insufficiency as indicated when hypothalamic or pituitary lesions are identified.
DRUG THERAPY : Patients with stage 3 or 4 primary ovarian insufficiency require ovarian hormone replacement. No proven medical therapy improves fertility for patients with primary ovarian insufficiency.
The required medical therapy for secondary ovarian insufficiency depends on the etiology of the condition.
Estrogens can be administered transdermally or orally. The appropriate dose for young women with ovarian failure has not been established in control studies. The authors recommend full replacement doses for young women. These generally are approximately twice as high as those normally recommended for hormone replacement therapy for postmenopausal women.
The authors prefer to administer estradiol by skin patch. This avoids the first-pass effect of oral estrogen on the liver. Generally, for young women who are estrogen deficient, the authors begin with the 100-mcg patch. However, some women do not tolerate the patch. In these women, the authors use conjugated equine estrogens (CEE) at 1.25 mg or oral micronized estradiol at 2 mg.
PROGESTINS - Should be given cyclically 12 days each month to prevent the endometrial hyperplasia that unopposed estrogen may cause. In young women, regular withdrawal bleedings are preferable because even young women with primary ovarian failure have a 5-10% chance of spontaneous pregnancy (unlike postmenopausal women). If expected withdrawal bleeding is missing, a pregnancy test should be performed and a timely diagnosis of pregnancy would not be missed. Other causes of amenorrhea also may remit spontaneously and result in an unexpected pregnancy.
- MEDROXYPROGESTERONE ACETATE : Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until maturity of positive feedback system is achieved.
Progestins stop endometrial cell proliferation, allowing organized sloughing of cells after withdrawal; typically does not stop acute bleeding episode but produces a normal bleeding episode following withdrawal. Provera tabs are 2.5 mg, 5 mg, and 10 mg.
- PROGESTERONE
2. ESTROGENS - Estrogens can be given continuously or cyclically (21 d on, 7 d off). Because no controlled studies are available to compare the efficacy and safety of one method over another, the choice of therapy should be determined after considering patient's preference and the physician's experience. Some patients cannot tolerate estradiol patches. CEEs can be used to achieve adequate estrogenization of vaginal epithelium in young women and to maintain bone density.
- TRANSDERMAL ESTRADIOL
- CONJUGATED ESTROGENS ( PREMARIN )