Postprocedural ovarian failure - Clinicals, Diagnosis, and Management

General Gynecology

Clinicals - History

Fact Explanation
Absence of menstruation This could be primary (absence of menarche) or secondary (absence of menstruation before the age of 40 years) amennorrhoea. Absence of menstruation
This could be primary (absence of menarche) or secondary (absence of menstruation before the age of 40 years) amennorrhoea.
Absence of secondary sexual characteristics Occurs in severe form of ovarian failure, in early lose of follicular pool. Absence of secondary sexual characteristics
Occurs in severe form of ovarian failure, in early lose of follicular pool.
Infertility Due to depletion of ovarian follicles Infertility
Due to depletion of ovarian follicles
Hot flushes, heat intolerance, night sweats. These are common vasomotor symptoms associated with menopause which is seen ovarian failure. Hot flushes, heat intolerance, night sweats.
These are common vasomotor symptoms associated with menopause which is seen ovarian failure.
Depression, anxiety, irritability, fatigue, sleep disturbance These psychological symptoms equivalent to menopause occurs. Depression, anxiety, irritability, fatigue, sleep disturbance
These psychological symptoms equivalent to menopause occurs.
Pathological fractures Prolonged lack of oestrogen causes osteopenia which results in early onset osteoporosis resulting in frequent fractures even in minor trauma. Pathological fractures
Prolonged lack of oestrogen causes osteopenia which results in early onset osteoporosis resulting in frequent fractures even in minor trauma.
Decreased libido Sexual drive is reduced due to lack of sexual hormones, vaginal dryness may also be a contributing factor. Decreased libido
Sexual drive is reduced due to lack of sexual hormones, vaginal dryness may also be a contributing factor.
Forgetfulness, disorientation Increased risk of Alzheimer's disease due to lack of sex hormones. Forgetfulness, disorientation
Increased risk of Alzheimer's disease due to lack of sex hormones.
Chest pain/ tightness, reduced excercise tolerence, past myocardial infarctions Increased risk of hypercholesterolemia and ischemic disease due to lack of sex hormones. Chest pain/ tightness, reduced excercise tolerence, past myocardial infarctions
Increased risk of hypercholesterolemia and ischemic disease due to lack of sex hormones.
History of chemotherapy, radiotherapy, pelvic surgery These can result in postprocedural ovarian failure. Pelvic surgery such as that for endometriosis, ovarian cyst removal are known to cause postprocedural ovarian failure. History of chemotherapy, radiotherapy, pelvic surgery
These can result in postprocedural ovarian failure. Pelvic surgery such as that for endometriosis, ovarian cyst removal are known to cause postprocedural ovarian failure.

Clinicals - Examination

Fact Explanation
Lack of secondary sexual characteristics: Poor breast formation, lack of pubic hair This occurs is severe form of ovarian failure when early depletion of follicles occur and patients present with primary amenorrhoea. Lack of secondary sexual characteristics: Poor breast formation, lack of pubic hair
This occurs is severe form of ovarian failure when early depletion of follicles occur and patients present with primary amenorrhoea.
Short stature Due to poor growth spurt in severe form of ovarian failure patients do not achieve the normal height. Short stature
Due to poor growth spurt in severe form of ovarian failure patients do not achieve the normal height.
Hirsutism (excessive body and facial hair) Occurs due to unopposed action of androgen formed in adrenal glands Hirsutism (excessive body and facial hair)
Occurs due to unopposed action of androgen formed in adrenal glands
Abdominal examination May reveal past laparoscopy/ laparotomy scars Abdominal examination
May reveal past laparoscopy/ laparotomy scars
Vaginal examination Will show dry vagina and sparse pubic hair Vaginal examination
Will show dry vagina and sparse pubic hair

Investigations - Diagnosis

Fact Explanation
Estrogen levels These gonadal hormone levels will be low due to lack of ovarian follicles to synthesis them. Estrogen levels
These gonadal hormone levels will be low due to lack of ovarian follicles to synthesis them.
FSH and LH levels Synthesis of these gonadotropins from pituitary is controlled by negative feedback from the gonadal hormones. Since gonadal hormonal levels are low, there is no negative feedback thus gonadotropins level will be very high.
FSH levels are usually higher than LH levels (FSH >30 U/L)
FSH and LH levels
Synthesis of these gonadotropins from pituitary is controlled by negative feedback from the gonadal hormones. Since gonadal hormonal levels are low, there is no negative feedback thus gonadotropins level will be very high.
FSH levels are usually higher than LH levels (FSH >30 U/L)
Ultrasound scan of the pelvis This will show streaky ovaries without any growing follicles Ultrasound scan of the pelvis
This will show streaky ovaries without any growing follicles
inhibin B, anti-mullerian hormone (AMH) levels These are of ovarian origin and lack of inhibin B indicates low ovarian reserve even prior to FSH elevation. inhibin B, anti-mullerian hormone (AMH) levels
These are of ovarian origin and lack of inhibin B indicates low ovarian reserve even prior to FSH elevation.

Management - Supportive

Fact Explanation
Emotional support Postprocedural ovarian failure resulting in premature ovarian failure will cause symptoms of menopause and infertility and affected women should be provided with adequate emotional support at all times. Emotional support
Postprocedural ovarian failure resulting in premature ovarian failure will cause symptoms of menopause and infertility and affected women should be provided with adequate emotional support at all times.
Multi disciplinary management with councellor and psychologist Prior to procedure counseling regarding possible infertility/ oocyte preservation and early menopause should be given. Multi disciplinary management with councellor and psychologist
Prior to procedure counseling regarding possible infertility/ oocyte preservation and early menopause should be given.

Management - Specific

Fact Explanation
Hormone replacement therapy- oestrogen and progesterone supplements can be given in various routes ( oral, vaginal, transdermal) Exogenous oestrogen has proven of benefit for enhancing bone density and cardiovascular function. It increases high density lipoprotein and reduce total cholesterol and low density lipoprotein. It should be started as early as possible and should be continued till age of menopause and reviewed afterwards.
Transdermal estradiol and vaginal progesterone has been proven to have higher cardiovascular benefit than oral ethinylestradiol and norethisterone
Hormone replacement therapy- oestrogen and progesterone supplements can be given in various routes ( oral, vaginal, transdermal)
Exogenous oestrogen has proven of benefit for enhancing bone density and cardiovascular function. It increases high density lipoprotein and reduce total cholesterol and low density lipoprotein. It should be started as early as possible and should be continued till age of menopause and reviewed afterwards.
Transdermal estradiol and vaginal progesterone has been proven to have higher cardiovascular benefit than oral ethinylestradiol and norethisterone
Use of donated ovum to achieve fertility This is the only possible way of achieving fertility. Use of donated ovum to achieve fertility
This is the only possible way of achieving fertility.
Cryopreservation of oocyte, embryo or ovarian tissue They can be kept frozen and used later to achieve pregnancy, this method is widely used in expected cases of ovarian failure after high radiotherapy(>10 Gy) and after chemotherapy with alkylating agents and procarbazine Cryopreservation of oocyte, embryo or ovarian tissue
They can be kept frozen and used later to achieve pregnancy, this method is widely used in expected cases of ovarian failure after high radiotherapy(>10 Gy) and after chemotherapy with alkylating agents and procarbazine
Calcium-rich diet and vitamin D supplementation This enhances bone density. Patient should also be advised regarding increasing physical activity and reducing smoking and alcohol to achieve this. Calcium-rich diet and vitamin D supplementation
This enhances bone density. Patient should also be advised regarding increasing physical activity and reducing smoking and alcohol to achieve this.
Transplantation of ovarian cortex/ ovary This should be obtained from a monozygotic twin thus not available all the time, but pregnancy after transplantation have been reported. Transplantation of ovarian cortex/ ovary
This should be obtained from a monozygotic twin thus not available all the time, but pregnancy after transplantation have been reported.
Gonadal shielding, ovarian transposition These methods are used prior to radiation to save the ovaries from being irradiated. Gonadal shielding, ovarian transposition
These methods are used prior to radiation to save the ovaries from being irradiated.

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  1. ARORA PUNEET, POLSON DAVID W. Diagnosis and management of premature ovarian failure. [online] December, 13(2):67-72 [viewed 27 August 2014] Available from: doi:10.1576/toag.13.2.67.27648
  2. BECK-PECCOZ Paolo, PERSANI Luca, Premature ovarian failure Orphanet J Rare Dis [online] 2006 December [viewed 27 August 2014] Available from: doi:10.1186/1750-1172-1-9
  3. GREEN DM, SKLAR CA, BOICE JD JR, MULVIHILL JJ, WHITTON JA, STOVALL M, YASUI Y. Ovarian Failure and Reproductive Outcomes After Childhood Cancer Treatment: Results From the Childhood Cancer Survivor Study J Clin Oncol [online] 2009 May 10, 27(14):2374-2381 [viewed 27 August 2014] Available from: doi:10.1200/JCO.2008.21.1839
  4. JEWELEWICZ R, SCHWARTZ M. Premature ovarian failure. Bull N Y Acad Med [online] 1986 Apr, 62(3):219-236 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1629109