Ovarian insufficiency is a dysfunction of the ovaries (ovary) that can be attributed to various causes and manifests itself in different degrees. If left untreated, ovarian dysfunction often results in sterility (infertility) in the affected woman and an unfulfilled desire to have children.
What is ovarian insufficiency?
Ovarian insufficiency is the term used to describe ovarian dysfunction resulting from hormonal dysregulation of follicular maturation or premature depletion of the follicular supply in the ovaries. In its milder form, ovarian insufficiency is manifested by corpus luteum insufficiency, in which ovulation occurs but progesterone synthesis is impaired. Premenstrual spotting, breast tenderness and/or edema (water retention) are signs of this mild form. More severe ovarian insufficiency is characterized by anovulation (lack of ovulation) and results in a complete absence of progesterone production. The female organism is exposed to an excess of estrogens, which in the long term can lead to changes in the endometrium (lining of the uterus), continuous bleeding and endometrial carcinoma. In the most severe variant of ovarian insufficiency, there is amenorrhea (absence of menstruation) with a complete lack of follicular maturation, causing estrogen synthesis to decrease to such an extent that there is a deficiency of the sex hormone, which can cause osteoporosis, cardiovascular disease, and menopausal symptoms (including sleep disturbances and hot flashes).
Causes
Ovarian insufficiency is divided into different forms depending on the underlying cause. In primary ovarian insufficiency, there is either a genetic dysfunction (Turner syndrome, gonadal dysgeneses, Swyer syndrome) or a prematurely depleted follicle supply as a result of chemotherapy or radiation therapy, nicotine use, severe infectious or autoimmune diseases in the ovaries themselves. The secondary forms of ovarian insufficiency are due to impairment of pituitary or hypothalamic function. Thus, in pituitary ovarian failure, there is an increased prolactin concentration due to pituitary dysfunction, which may be caused by prolactinomas (benign pituitary tumors), hypothyroidism, or stress, among other factors. Hyperandrogenemic ovarian insufficiency is characterized by elevated testosterone levels resulting in impaired follicle maturation and is caused by PCO (polycystic ovaries), hyperthecosis ovarii, or adrenogenital syndrome. The hypothalamic variant is usually caused by eating disorders (bulimia, anorexia), competitive sports, psychological stress, or genetically by the so-called Kallmann syndrome and is associated with dysregulated gonadoliberin release from the hypothalamus, resulting in impaired synthesis of gonadotropins (including FSH).
Symptoms, complaints, and signs
Typical symptoms of ovarian insufficiency include spotting, a feeling of tightness in the breasts, and water retention in the tissues (edema). In mild forms of ovarian insufficiency, menstruation may occur despite the absence of ovulation, but the desire to have a child remains unfulfilled. If the function of the ovaries is very severely weakened, menstruation is completely absent (amenorrhea). If menstruation does not occur until the age of 15, primary ovarian insufficiency must also be considered. Affected women often suffer from the characteristic symptoms of menopause, such as hot flashes, sleep disturbances, night sweats and chronic fatigue. In many cases, depressive moods, anxiety and severe mood swings occur, and vaginal dryness and a declining libido can severely affect sexual life. Involuntary urination is common, and a decrease in bone density due to estrogen deficiency can manifest itself in an increased tendency to fractures. Turner syndrome is characterized by low pubic hair growth, reduced body growth, wing-shaped skin folds on the neck (pterygium colli), widely spaced nipples, and a shield-shaped chest. In Swyer syndrome, the secondary sexual characteristics do not form during puberty.Secondary ovarian failure may be manifested by increased hair growth, skin blemishes, a decrease in vocal frequency, and increased muscle formation (hyperandrogenic ovarian failure); disturbances in the menstrual cycle occur in both hypothalamic and hyperprolactinemic ovarian failure.
Diagnosis and course
Suspicion of ovarian insufficiency is derived in most cases from an irregular menstrual cycle. To determine the specific form present, hormone levels in the serum are determined, among other tests. Thus, LH and FSH levels are elevated in serum in primary ovarian insufficiency, prolactin in pituitary, and testosterone and DHEAS in hyperandrogenemic. In addition, polycystic ovaries can often be detected on sonogram (ultrasound image) in the latter. In hypothalamic ovarian insufficiency, on the other hand, all hormone concentrations (LH, FSH, progesterone, estradiol) are decreased or in the normal range. Other decreased hormone levels (gonadotropins, insulin, prolactin) indicate Kallmann syndrome. The prognosis and course of ovarian insufficiency depend largely on the underlying cause. Whereas no promising therapeutic measures exist for the primary form to date and a desire to have children often remains unfulfilled, the success of therapy for the secondary forms of ovarian insufficiency depends mostly on the cooperation of the affected person as well as causal therapy.
Complications
Complications of ovarian failure usually occur when the condition is left untreated. In this case, the woman may become completely infertile, so that a desire to have children can no longer be fulfilled by conventional means. This can further lead to various psychological complaints and possibly also to depression. The patient’s quality of life is significantly reduced by ovarian insufficiency. Likewise, the affected women suffer from spotting and also from cycle disturbances. As a result, mood swings or water retention often occur in different parts of the body. Due to infertility, there may possibly also be complications or tension with one’s partner. Usually, ovarian insufficiency cannot be treated causally. Unfortunately, if the woman is already infertile, this complaint cannot be treated either. Furthermore, this insufficiency can be treated with hormones. Complications do not occur in this case. The desire to have children can also be pursued with the help of suitable treatment. The life expectancy of those affected is not affected by ovarian insufficiency. However, if ovarian insufficiency occurs due to another underlying disease or due to an eating disorder, this disease must first be diagnosed and treated.
When should you see a doctor?
If sexually mature women have an unfulfilled desire to have children, they should see a doctor for a checkup together with their partner. Although the condition may not occur in the partner, overall the couple’s fertility should be examined and evaluated so that an overall assessment can be made. Consultation with a physician is recommended if pregnancy has not occurred over several cycles, although sexual activity has occurred during the ovulation phase. If the woman experiences changes in libido, changes in personality, or if a woman with an unfulfilled desire for a child experiences severe emotional problems, it is advisable to see a doctor. Spotting, swelling of the breasts or water retention on the body should be presented to a doctor. Disturbances of menstruation or absence of menstruation are signs of health problems. A visit to the doctor is necessary so that an investigation of the cause and subsequent treatment can be initiated. Complaints such as vaginal dryness, involuntary urination or night sweats should be investigated by a doctor. Exhaustion, general malaise, listlessness or a reduced zest for life are also symptoms that should be clarified by a doctor. A depressive appearance or mood swings are further signs of a health irregularity. If they persist for several weeks or months, a doctor is needed.
Treatment and therapy
Therapeutic measures for ovarian insufficiencies depend on the specific form present.Primary ovarian insufficiency is usually irreversible and cannot be treated if the woman wishes to have children. Affected women under 40 years of age are recommended hormonal substitution therapy to compensate for the estrogen deficiency. Therapy of pituitary ovarian insufficiency is aimed at normalizing prolactin levels by drugs that inhibit prolactin synthesis and thus restore the menstrual cycle. If the malfunction is due to a prolactinoma, this is treated with dopamine agonists. Surgical intervention is indicated only if adjacent structures are affected by it. The hyperandrogenemic variant can be treated hormonally by an antiandrogenic pill. If there is a desire to have children, additional ovarian stimulation therapy is indicated by default. The therapy of hypothalamic ovarian insufficiency aims at the causal treatment of the individual underlying cause. Concomitantly, in the absence of a desire to have children, affected women are recommended hormone replacement therapy to prevent osteoporosis and cardiovascular disease. If there is a desire to have children, the disturbed gonadoliberin secretion can be simulated by a small micropump worn on the body to induce the onset of pregnancy. If ovarian insufficiency is due to eating disorders or psychological stress, affected women should receive additional psychological or psychiatric care.
Outlook and prognosis
The outlook for ovarian failure varies widely and depends on the presenting form and the cause of the disease. In most cases, primary ovarian failure cannot be successfully treated. Patients are usually unable to carry their own children to term. However, some affected women have given birth to healthy children after receiving egg donation. However, this method is legally and morally controversial. After surgical removal of the ovaries, pregnancy is completely impossible. However, in about ten percent of affected women, spontaneous recovery occurs without treatment. These patients can become pregnant naturally. The prognosis is different in the secondary form of ovarian insufficiency. This can be treated well in most cases. Once hormone levels return to normal, women often have a normal menstrual cycle again. In most cases, those affected can become pregnant naturally. In some cases, artificial conception (IVF) or intracytoplasmic sperm injection (ICSI) is necessary. Rarely, affected women remain infertile. In any case, ovarian insufficiency does not affect the course of pregnancy. It only affects the fertility of affected women.
Prevention
Ovarian insufficiency can be prevented only to a limited extent. Abstaining from nicotine use, avoiding being underweight or overweight, learning stress management techniques, and consistent therapy for conditions that can affect hormonal balance minimize the risk of ovarian dysfunction.
Follow-up
There are usually few and usually limited aftercare measures available to the affected person with ovarian insufficiency. For this reason, early diagnosis is very important in this condition to prevent the onset of other symptoms and complications. Ovarian insufficiency usually cannot be cured on its own, so that those affected are always dependent on a visit to a doctor. The disease can be treated relatively well with the help of various medications. Care must always be taken to ensure that the correct dosage is given and that the medication is taken as prescribed. If there is any uncertainty or if there are any questions or side effects, a doctor should always be consulted first. Likewise, most patients with ovarian insufficiency are dependent on the help and support of their partner. This can also prevent the development of depression. Further measures of aftercare are usually not available to the patient. The disease itself does not reduce the life expectancy of the affected person. However, no general prediction can be made about the further course.
What you can do yourself
When primary ovarian insufficiency is diagnosed, it is usually a traumatic experience for the women affected.In order to come to terms with the diagnosis, discussions with the partner, with other affected persons and with the gynecologist help. Accompanying medical treatment, which focuses on alleviating the causes, affected women must receive psychological care. In the case of hypothalamic ovarian insufficiency, causal therapy is possible, provided that the patient implements the necessary accompanying measures. These include rest and sparing, a change in diet and observation of symptoms. If any unusual symptoms appear, the physician must be informed. After surgery, the patient must take it easy for at least three to four weeks. In addition, it is important to make use of the regular follow-up examinations. Pregnancy is often no longer possible after ovarian insufficiency, which is why women with the disease should consider alternative options if they wish to have children. Especially in younger women, primary ovarian insufficiency can cause major psychological problems that need to be treated both therapeutically and with medication. Women older than 40 years should take advantage of screening to rule out complications.