The silent grief: psychosocial aspects of premature ovarian failure

A qualitative study of work and early menopause: 'On-the job' experiences and career trajectories

OBJECTIVES

Early menopause or premature ovarian insufficiency (POI), menopause occurring before age 45 and 40 years respectively, occur at the age when most women are establishing or consolidating their careers. Studies of older postmenopausal women indicate an adverse bidirectional relationship between menopause and work. However, data are lacking regarding the work experiences of women with early menopause or POI. We explored the experiences of women with early menopause or POI in relation to work.

STUDY DESIGN

Using maximum variation sampling, 30 women (median age 44 years and 38 years at menopause diagnosis) of diverse backgrounds and menopause causes (16/30 iatrogenic) participated in qualitative interviews to explore experiences of early menopause/POI in the context of their overall lives, work and career. Dual thematic (themes identified across interviews) and thematic narrative (themes identified within individual interviews) analysis was done using NVivo 12 software.

MAIN OUTCOME MEASURES

Themes related to work experiences and influencing factors.

RESULTS

Two major themes were identified: 'on-the-job' experiences (work performance, bodily presentation and disclosure) and career trajectories (intact and altered). Factors impacting the interaction between work and early menopause/POI included: career (type of work, environment, working conditions), personal (age, socio-economic background, family arrangements, migration history) and menopause experience (spontaneous versus iatrogenic, treatment complexity).

CONCLUSIONS

Early menopause/POI has multiple impacts on women's work experiences and career trajectories. As with older postmenopausal women, career and personal factors influence younger women's work experience. However, this research highlights differences associated with menopause occurring at an earlier, often unexpected age compared with menopause at the usual age.

Optimising health after early menopause

The typical age at menopause is 50-51 years in high-income countries. However, early menopause is common, with around 8% of women in high-income countries and 12% of women globally experiencing menopause between the ages of 40 years and 44 years. Menopause before age 40 years (premature ovarian insufficiency) affects an additional 2-4% of women. Both early menopause and premature ovarian insufficiency can herald an increased risk of chronic disease, including osteoporosis and cardiovascular disease. People who enter menopause at younger ages might also experience distress and feel less supported than those who reach menopause at the average age. Clinical practice guidelines are available for the diagnosis and management of premature ovarian insufficiency, but there is a gap in clinical guidance for early menopause. We argue that instead of distinct age thresholds being applied, early menopause should be seen on a spectrum between premature ovarian insufficiency and menopause at the average age. This Series paper presents evidence for the short-term and long-term consequences of early menopause. We offer a practical framework for clinicians to guide diagnosis and management of early menopause, which considers the nature and severity of symptoms, age and medical history, and the individual's wishes and priorities to optimise their quality of life and short-term and long-term health. We conclude with recommendations for future research to address key gaps in the current evidence.

The impact of premature ovarian insufficiency on sexual function; which domain is mostly disrupted?

This study aimed to compare the sexual function (SF) and its domains between women with idiopathic premature ovarian insufficiency (POI) and healthy control. A cross-sectional study was conducted on 63 married women with idiopathic POI, referred to the reproductive endocrinology research center (Tehran, Iran), and 784 married women with regular menstrual cycles who visited for routine annual gynecological exams in 2021-2022. The Female Sexual Function Index (FSFI) questionnaire was used to assess the SF of participants. Linear regression and factor analysis were used to analyze the data. Characteristics were similar in both study groups except for body mass index, hip circumference, job status, and number of deliveries. The mean score (standard deviation) of FSFI in women with POI and control were 21.70 (9.0) and 24.30 (5.0), respectively (P < 0.001). All domains' scores of FSFI were significantly lower in POI women than in the control group (P < 0.05). After adjusting for potential confounders, these findings remained unchanged. Factor analysis demonstrated the arousal and lubrication domains as the most influential factors SF among POI women, while the desire domain played the lowest role. In addition to various health conditions threatening POI women's future lives, sexual disturbances must be addressed in their routine care.

Ovarian Insufficiency and Fertility Preservation During and After Childhood Cancer Treatment

Premature ovarian insufficiency (POI) is one of many potential long-term consequences of childhood cancer treatment in females. Causes of POI in this patient population can include chemotherapy, especially alkylating agents, and radiation therapy. Rarely, ovarian tumors lead to ovarian dysfunction. POI can manifest as delayed pubertal development, irregular menses or amenorrhea, and infertility. This diagnosis often negatively impacts emotional health due to the implications of impaired ovarian function after already enduring treatment for a primary malignancy. The emerging adult may be challenged by the impact on energy level, quality of life, and fertility potential. POI can also lead to low bone density and compromised skeletal strength. This review discusses the health consequences of POI in childhood cancer survivors (CCS). We also explore the role of fertility preservation for CCS, including ovarian tissue cryopreservation and other available options. Lastly, knowledge gaps are identified that will drive a future research agenda.

A Systematic Review of Autoimmune Oophoritis Therapies

Autoimmune primary ovarian insufficiency (POI) is a devastating disease with limited clinical guidance. The objective of this systematic review was to identify treatments for autoimmune POI and analyze their efficacy. A comprehensive search of CINAHL, Cochrane, Embase, PubMed, Scopus, and Web of Science was performed from inception to April 2022. English language publications that evaluated women with autoimmune POI after a documented intervention were included. Animal models of autoimmune POI were also included. Risk of bias was assessed with the SYRCLE's risk of bias tool for animal studies or the NIH Quality Assessment Tool for Case Series as appropriate. Twenty-eight studies were included in this review, with 11 RCTs, 15 case reports, and 2 case series. Seventeen studies were in humans, and 11 were in animal models. No completed RCTs, cohort studies, or case-control studies were identified in humans. In observational human studies, corticosteroids were effective in select patients. In many case reports, adequate treatment of comorbid autoimmune conditions resulted in return of menses, hormonal normalization, or spontaneous pregnancy. In terms of assisted reproductive technologies, there was case report evidence for both in vitro fertilization (IVF) and in vitro maturation (IVM) in women wishing to conceive with their own oocytes. Ovulation induction, IVF, and IVM resulted in a total of 15 pregnancies and 14 live births. In animal models, there was additional evidence for stem cell therapies and treatments used in traditional Chinese medicine, although this research may not be generalizable to humans. Furthermore, litter size was not evaluated in any of the animal studies. Additional research is needed to establish the efficacy of current treatments for autoimmune POI with a controlled experimental design and larger sample size. Additionally, there is a critical need to develop novel therapies for this condition, as understanding of its pathophysiology and  available tools to modulate the immune response have progressed.

Primary ovarian insufficiency: a toolkit for the busy clinician

Primary ovarian insufficiency (sometimes known as premature ovarian insufficiency) is a result of loss of ovarian follicular activity before the age of 40 years. It is an endocrine deficiency state in women, characterized by premature estrogen deprivation. In the absence of estrogen replacement, women experience bothersome menopause symptoms and a predisposition to accelerated aging and multimorbidity accumulation. Unless a true contraindication exists, estrogen therapy is recommended at least until the age of natural menopause. This Practice Pearl summarizes the clinical manifestations, diagnostic evaluation, and management of primary ovarian insufficiency.

Premature Ovarian Insufficiency

Natural menopause typically occurs between the ages of 46 to 55 years. Premature ovarian insufficiency or premature menopause refers to compromised ovarian follicular activity, occurring spontaneously or because of medical interventions, prior to the age of 40 years. The premature loss of estrogen leads to bothersome menopause symptoms and predisposes the women to multiple long-term health risks including a higher mortality risk. Hormone replacement therapy used until the natural age of menopause can help manage the symptoms effectively and can mitigate the long-term risk of estrogen deprivation to some extent. However, hormone replacement therapy is underutilized in this population due to the inappropriate extrapolation of potential risks that have been demonstrated with hormone therapy use in women after natural menopause. There is a large unmet need for educating patients and providers regarding the impact of premature ovarian insufficiency and the compelling need for its appropriate management.

Quality of life among female childhood cancer survivors with and without premature ovarian insufficiency

PURPOSE

Due to an increase in survival, a growing population of childhood cancer survivors (CCS) is present. However, female CCS are at risk of developing premature ovarian insufficiency (POI) after cancer treatment. POI involves a decreased chance of conceiving and the increased infertility state has a large impact on affected individuals' health and mental life. The objective of this study was to investigate health state and well-being among female CCS with and without POI and healthy controls (HC).

METHODS

Female CCS treated in southern Sweden between 1964 and 2008 were included. Each patient was matched with a HC. The final study population included 167 female CCS and 164 HC that were examined between October 2010 and January 2015 at the Reproductive Medicine Centre at Skåne University Hospital in Malmö, Sweden. All participants, except for two HCs, answered an EQ-5D-3L questionnaire for measuring health state including a visual analogue scale (VAS) for estimating well-being.

RESULTS

There were 22 CCS with POI, none of the HC had POI. The mean health state differed among groups (unadjusted: P = 0.002; adjusted: P = 0.007). A difference in mean experienced well-being among groups was noted (unadjusted: P = 0.003; adjusted: P = 0.012). Lowest well-being was found in the CCS group with POI (P = 0.024).

CONCLUSIONS

Female CCS have a significantly decreased health state and well-being. Female CCS with POI additionally have the lowest self-estimated well-being.

IMPLICATIONS FOR CANCER SURVIVORS

Female CCS with POI should be identified early in order to give them adequate information and support.

The diagnostic experience of women with fragile X-associated primary ovarian insufficiency (FXPOI)

PURPOSE

The fragile X premutation occurs when there are 55-200 CGG repeats in the 5' UTR of the FMR1 gene. An estimated 1 in 148 women carry a premutation, with 20-30% of these individuals at risk for fragile X-associated primary ovarian insufficiency (FXPOI). Diagnostic experiences of FXPOI have not previously been included in the literature, limiting insight on experiences surrounding the diagnosis. This study identifies barriers and facilitators to receiving a FXPOI diagnosis and follow-up care, which can inform care and possibly improve quality of life.

METHODS

We conducted qualitative interviews with 24 women with FXPOI exploring how FMR1 screening, physician education, and supportive care impacted their experience. Three subgroups were compared: women diagnosed through family history who have biological children, women diagnosed through family history who do not have biological children, and women diagnosed through symptoms of POI.

RESULTS

Themes from interviews included hopes for broader clinician awareness of FXPOI, clear guidelines for clinical treatment, and proper fertility workups to expand reproductive options prior to POI onset. Participants also spoke of difficulty finding centralized sources of care.

CONCLUSIONS

Our results indicate a lack of optimal care of women with a premutation particularly with respect to FMR1 screening for molecular diagnosis, short- and long-term centralized treatment, and clinical and emotional support. The creation of a "FXPOI health navigator" could serve as a centralized resource for the premutation patient population, assisting in connection to optimal treatment and appropriate referrals, including genetic counseling, mental health resources, advocacy organizations, and better-informed physicians.

Primary ovarian insufficiency quality of life scale (POIQOLS): development and psychometric properties

Background

Primary ovarian insufficiency is menopause before the age of 40. It can affect the quality of life of afflicted women. Because there is no instrument available for measuring the quality of life of these women, the present study was carried out to develop and assess the psychometric properties of the quality of life scale for women with primary ovarian insufficiency.

Methods

This exploratory sequential mixed method study was performed in two phases. In the qualitative phase (item generation), semi-structured in-depth interviews were conducted with 16 women having primary ovarian insufficiency, and a literature review was performed to generate initial items pool. In the quantitative phase (psychometric evaluation), the face, content, and construct validity (exploratory factor analysis), as well as reliability (internal consistency and test–retest methods), were evaluated. Besides, the responsiveness and interpretability were investigated.

Results

During the first phase of the study, the initial item pool was generated with 132 items. After the face and content validity, the number of items was reduced to 40. The results of exploratory factor analysis yielded a 28 item scale with six factors. These factors explained 58.55% of the total variance. The Cronbach’s alpha for each factor was more than 0.7. Furthermore, the intraclass correlation coefficient for the entire scale was 0.95.

Conclusions

The primary ovarian insufficiency quality of life scale (POIQOLS) is a valid and reliable tool for accessing the quality of life of women with primary ovarian insufficiency.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

Stem Cell Therapies for Human Infertility: Advantages and Challenges

Physical and mental health and hormonal imbalance are associated with the problems related to infertility and reproductive disorders. The rate of infertility has increased globally over the years, due to various reasons. Given the psychosocial implications of infertility and its effects on the life of the affected people, there has been an increased focus on its treatment over the last several years. Assisted reproductive technology can only solve about 50% of the cases. Moreover, it contains significant risks and does not solve the fundamental problem of infertility. As pluripotent stem cells have the potential to differentiate into almost any type of cell, they have been widely regarded as a promising option in the development of stem cell-based fertility treatments, which could even correct genetic diseases in offspring. These advancements in reproductive biotechnology present both challenges and possibilities for solving infertility problems caused by various unexplainable factors. This review briefly presents the different types of infertility disorders and the potential applications of stem cells in the treatment of these reproductive diseases.

Diagnosis and management of premature ovarian insufficiency

Premature ovarian insufficiency (POI) is a complex clinical syndrome with life-changing physiological and psychological consequence in young women of reproductive age. However, the understanding of the etiology, diagnosis and optimal intervention strategies for this condition remains poorly understood. In recent years advances in epidemiologic and genetic research has improved our knowledge and awareness of POI. Further prospective randomised trials are required to improve the psychological and sexual health, fertility treatment options and long-term management of the impact on bone, cardiovascular and cognitive impact in women with POI. In this paper we aim to provide an overview on the diagnosis and management of POI, discuss the current understanding of the condition and future directions.

Position statement on the diagnosis and management of premature/primary ovarian insufficiency (except Turner Syndrome)

Premature ovarian insufficiency (POI) is a rare pathology affecting 1-2% of under-40 year-old women, 1 in 1000 under-30 year-olds and 1 in 10,000 under-20 year-olds. There are multiple etiologies, which can be classified as primary (chromosomal, genetic, auto-immune) and secondary or iatrogenic (surgical, or secondary to chemotherapy and/or radiotherapy). Despite important progress in genetics, more than 60% of cases of primary POI still have no identifiable etiology; these cases are known as idiopathic POI. POI is defined by the association of 1 clinical and 1 biological criterion: primary or secondary amenorrhea or spaniomenorrhea of>4 months with onset before 40 year of age, and elevated follicle-stimulating hormone (FSH)>25IU/L on 2 assays at>4 weeks' interval. Estradiol level is low, and anti-Müllerian hormone (AMH) levels have usually collapsed. Initial etiological work-up comprises auto-immune assessment, karyotype, FMR1 premutation screening and gene-panel study. If all of these are normal, the patient and parents may be offered genome-wide analysis under the "France Génomique" project. The term ovarian insufficiency suggests that the dysfunction is not necessarily definitive. In some cases, ovarian function may fluctuate, and spontaneous pregnancy is possible in around 6% of cases. In confirmed POI, hormone replacement therapy is to be recommended at least up to the physiological menopause age of 51 years. Management in a rare diseases center may be proposed.

New insights into the diagnosis and management of bone health in premature ovarian insufficiency

Premature ovarian insufficiency (POI), defined as a loss of ovarian function before the age of 40 years, is a life-changing diagnosis that has numerous long-term consequences. Musculoskeletal complications, including osteoporosis and fractures, are a key concern for women with POI. The risk of bone loss is influenced by the underlying etiology of POI, and the degree and duration of estrogen deficiency. A decline in muscle mass as a result of estrogen and androgen deficiency may contribute to skeletal fragility, but has not been examined in women with POI. This article aims to review musculoskeletal health in POI; summarize the traditional and novel modalities available to screen for skeletal fragility and muscle dysfunction; and provide updated evidence for available management strategies.

Perceptions and experiences of women with premature ovarian insufficiency about sexual health and reproductive health

Background

Premature ovarian insufficiency (POI) is a condition with impaired ovarian function that occurred in women before the age of 40. Considering that women with POI are in reproductive age and their fertility and sexual life are afflicted by this disorder directly, the present study aimed to investigate perception and experience of women with POI of sexual and reproductive health (SRH).

Methods

This is a qualitative that was implemented based on the conventional content analysis approach. The data were collected using semi-structured in-depth interviews with 16 women having POI, based on purposeful sampling and continued until data saturation. The participants were women with POI that referred to the three infertility center in Tehran, Iran. The audio recorded data were transcribed verbatim and then analyzed using conventional content analysis based on the method proposed by Zhang and Wildmouth.

Results

After content analysis of the interviews with a focus on the perception and experience of women with POI of SRH, four main categories emerged i.e. endangerment of women's health, psychological agitation, disruption of social life and disturbance in sexual life.

Conclusion

POI affects different aspects of women SRH (women physical, psychological, social and sexual heath). Therefore, knowledge of patients' concerns by health professionals is helpful to improve service delivery and increasing the effectiveness of treatment interventions by a comprehensive health care attitude.

Menopausal symptoms in women with premature ovarian insufficiency: prevalence, severity, and associated factors

OBJECTIVE

To comprehensively investigate and evaluate the prevalence, severity, and associated factors of menopausal symptoms in women with premature ovarian insufficiency (POI). In this study, the specific symptomatology experienced by women with POI and women with natural menopause was also compared.

METHODS

In this cross-sectional study, 293 Chinese women with POI from an outpatient clinic were recruited between June 2014 and January 2019. The prevalence and severity of menopausal symptoms were assessed with modified Kupperman Menopausal Index. Participants completed a structured questionnaire, including medical history, menstrual characteristics, and sociodemographic data. Serum levels of reproductive hormones were measured.

RESULTS

Among 293 women with POI (33.76 ± 5.47 y), the most prevalent symptoms were mood swings (73.4%), insomnia (58.7%), sexual problems (58.7%), and fatigue (57.3%). Moderate-to-severe mood swings were most frequently reported (23.9%), followed by formication (17.4%) and hot flashes/sweating (17.1%). Compared with women with natural menopause, women with POI exhibited significantly higher risks for fatigue (odds ratio  = 1.42; 95% confidence interval, 1.04-1.94), melancholia (3.12; 1.94-5.01), mood swings (3.57; 2.33-5.45), insomnia (1.41; 1.02-1.96), and significantly lower risks for moderate-to-severe sexual problems (0.40; 0.23-0.69), any and moderate-to-severe muscle/joint pain (0.41; 0.27-0.62 and 0.45; 0.25-0.78, respectively). Living in urban areas and higher gravidity were independently associated with menopausal symptoms in women with POI.

CONCLUSIONS

Women with POI experienced a high prevalence of menopausal symptoms, particularly related to psychological and sexual domains. Furthermore, women with POI tended to have more distressing menopausal symptoms compared with women with natural menopause.

Premature ovarian insufficiency: an International Menopause Society White Paper

The aim of this International Menopause Society White Paper on premature ovarian insufficiency (POI) is to provide the latest information regarding this distressing condition. The impact of POI has far-reaching consequences due to its impact on general, psychological, and sexual quality of life, fertility prospects, and long-term bone, cardiovascular, and cognitive health. Progress in fully understanding the etiology, diagnosis, and optimal management options has been slow thus far due to the complexity of the condition and fragmented research. Recent advances in epidemiological and genetic research have improved our understanding of this condition and randomized prospective trials are being planned to determine the intervention strategies, which will optimize quality of life and long-term well-being. The International Menopause Society has commissioned a number of experts at the forefront of their specialty to define the state of the art in the understanding of this condition, to advise on practical management strategies, and to propose future research strategies. It is hoped that a global task force will subsequently be convened in order to formulate a consensus statement across key societies, to accelerate date collection and analysis of a global POI registry, and to facilitate progress in the key defined areas of research.

An exploration of factors affecting the quality of life of women with primary ovarian insufficiency: a qualitative study

Background

Menopause before the age of 40 years is known as primary ovarian insufficiency (POI). Besides physical effects, being diagnosed with this disorder adversely affects the psychological health and quality of life (QOL). The present study aimed at shedding light on the factors affecting the QOL of women with POI.

Methods

The present study is a qualitative one. The data were collected using semi-structured in-depth interviews with 16 women having POI, selected purposively. Data rigor was ensured using Lincoln and Guba’s criteria. The recorded data were transcribed verbatim and then analyzed constantly at the same time as gathering the data using conventional content analysis.

Results

Three themes emerged regarding the QOL of women with POI, i.e. disease effect (physical and psychological effects), distorted self-concept (threatened identity and disease stigma), and hormone replacement therapy effect (positive and negative physical/psychological effects).

Conclusions

Due to the profound effects of the disease on different aspects of the biopsychosocial health of women with POI, a multifaceted health care approach is recommended to improve their QOL.

Women with premature ovarian failure using hormone therapy do not experience increased levels of depression, anxiety and stress compared to controls

OBJECTIVE

To evaluate anxiety, depression and stress of POI women using hormone therapy.

METHODS

A quantitative cross-sectional study included 61 women diagnosed with POI receiving HT, and 61 women with preserved ovarian function, matched 1:1 for age (control group). Instruments used to evaluate depression, anxiety and stress were Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Lipp's Stress Symptom Inventory (LSSI). The chi-square or Fisher's exact tests, Mann-Whitney test, Spearman's correlation coefficient or logistic regression analysis with stepwise criteria were used for analysis.

RESULTS

The mean age of POI women and control group was 35.03±7.68 and 34.49±7.55 years old (p = 0.63). POI group and control group had a mean of 0.44±0.92 and 1.28±1.38 children (p = 0,001); the total BDI, BAI and LSSI scores were 15.72±11.68 and 13.66±8.44 (p = 0.64); 17.54±13.16 and 17.25±11.05 (p = 0.90), 19.39±12.08 and 18.93±11.21 (p = 0.945). The majority of women did not have depression or presented mild depression, but approximately one-third had moderate-severe undiagnosed depressive or anxiety symptoms. In POI group, depression was positively correlated with the number of children and anxiety. Anxiety and stress were also positively correlated. It was observed that for each point in the BDI, the risk of stress above 20 increased 19.6%, while for each point in the BAI, the risk of greater stress increased 32.4%.

LIMITATIONS

This is a cross-sectional study, which made it impossible to draw cause and effect conclusions CONCLUSION: Women with POI receiving HT have indexes of depression, anxiety and stress similar to the population of women with preserved ovarian function.

Predicting acute ovarian failure in female survivors of childhood cancer: a cohort study in the Childhood Cancer Survivor Study (CCSS) and the St Jude Lifetime Cohort (SJLIFE)

BACKGROUND

Cancer treatment can cause gonadal impairment. Acute ovarian failure is defined as the permanent loss of ovarian function within 5 years of cancer diagnosis. We aimed to develop and validate risk prediction tools to provide accurate clinical guidance for paediatric patients with cancer.

METHODS

In this cohort study, prediction models of acute ovarian failure risk were developed using eligible female US and Canadian participants in the Childhood Cancer Survivor Study (CCSS) cohort and validated in the St Jude Lifetime Cohort (SJLIFE) Study. 5-year survivors from the CCSS cohort were included if they were at least 18 years old at their most recent follow-up and had complete treatment exposure and adequate menstrual history (including age at menarche, current menstrual status, age at last menstruation, and menopausal aetiology) information available. Participants in the SJLIFE cohort were at least 10-year survivors. Participants were excluded from the prediction analysis if they had an ovarian hormone deficiency, had missing exposure information, or had indeterminate ovarian status. The outcome of acute ovarian failure was defined as permanent loss of ovarian function within 5 years of cancer diagnosis or no menarche after cancer treatment by the age of 18 years. Logistic regression, random forest, and support vector machines were used as candidate methods to develop the risk prediction models in the CCSS cohort. Prediction performance was evaluated internally (in the CCSS cohort) and externally (in the SJLIFE cohort) using the areas under the receiver operating characteristic curve (AUC) and the precision-recall curve (average precision [AP; average positive predictive value]).

FINDINGS

Data from the CCSS cohort were collected for participants followed up between Nov 3, 1992, and Nov 25, 2016, and from the SJLIFE cohort for participants followed up between Oct 17, 2007, and April 16, 2012. Of 11 336 female CCSS participants, 5886 (51·9%) met all inclusion criteria for analysis. 1644 participants were identified from the SJLIFE cohort, of whom 875 (53·2%) were eligible for analysis. 353 (6·0%) of analysed CCSS participants and 50 (5·7%) of analysed SJLIFE participants had acute ovarian failure. The overall median follow-up for the CCSS cohort was 23·9 years (IQR 20·4-27·9), and for SJLIFE it was 23·9 years (19·0-30·0). The three candidate methods (logistic regression, random forest, and support vector machines) yielded similar results, and a prescribed dose model with abdominal and pelvic radiation doses and an ovarian dose model with ovarian radiation dosimetry using logistic regression were selected. Common predictors in both models were history of haematopoietic stem-cell transplantation, cumulative alkylating drug dose, and an interaction between age at cancer diagnosis and haematopoietic stem-cell transplant. External validation of the model in the SJLIFE cohort produced an estimated AUC of 0·94 (95% CI 0·90-0·98) and AP of 0·68 (95% CI 0·53-0·81) for the ovarian dose model, and AUC of 0·96 (0·94-0·97) and AP of 0·46 (0·34-0·61) for the prescribed dose model. Based on these models, an online risk calculator has been developed for clinical use.

INTERPRETATION

Both acute ovarian failure risk prediction models performed well. The ovarian dose model is preferred if ovarian radiation dosimetry is available. The models, along with the online risk calculator, could help clinical discussions regarding the need for fertility preservation interventions in girls and young women newly diagnosed with cancer.

FUNDING

Canadian Institutes of Health Research, Women and Children's Health Research Institute, National Cancer Institute, and American Lebanese Syrian Associated Charities.

Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations

There is a new appreciation of the perimenopause - defined as the early and late menopause transition stages as well as the early postmenopause - as a window of vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects of hormone therapy; and 5) efficacy of other therapies (eg, psychotherapy, exercise, and natural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women, particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

Health-related quality-of-life among patients with premature ovarian insufficiency: a systematic review and meta-analysis

PURPOSE

To systematically review studies investigating health-related quality-of-life (HrQoL) in patients with premature ovarian insufficiency (POI), to examine questionnaires used and to conduct a meta-analysis of control studies with normal ovarian function.

METHODS

Data sources: PubMed, Embase, Web of science, CNKI, and CQVIP, searched from inception until June 2018. The search strategy was a combination of medical (e.g. POI), subjective (e.g. well-being) and methodological (e.g. questionnaires) keywords. PRISMA guidelines were used to assess outcome data quality/validity by one reviewer, verified by a second reviewer. Risk of bias within studies was evaluated. A meta-analysis compared HrQoL in patients and non-patients. Due to measurement differences in the studies, the effect size was calculated as standard mean difference.

RESULTS

We identified 6869 HrQoL studies. Nineteen geographically diverse studies met inclusion criteria, dated from 2006, using 23 questionnaires. The meta-analysis included six studies with 645 POI participants (age 33.3 ± 5.47) and 492 normal-ovarian control subjects (age 32.87 ± 5.61). Medium effect sizes were found for lower overall HrQoL (pooled SMD = - 0.73, 95% CI - 0.94, - 0.51; I² = 54%) and physical function (pooled SMD = - 0.54, 95% CI - 0.69, - 0.39; I² = 55%). Heterogeneity was investigated. Effect sizes varied for sexual function depending on the measure (SMD = - 0.27 to - 0.74), overall HrQoL (SF-36) had the largest effect size (- 0.93) in one study. The effect sizes for psychological and social HrQoL were small.

CONCLUSION

POI is associated with low-to-medium effect size on HrQoL compared to normal ovarian controls. The greatest effects are found in general HrQoL and most sexual function areas. Condition-specific questionnaires and RCTs are recommended for further investigation.

Identifying and addressing osteoporosis knowledge gaps in women with premature ovarian insufficiency and early menopause: A mixed-methods study

OBJECTIVE

Osteoporosis associated with premature ovarian insufficiency (POI) and early menopause (EM) is a major concern for women. We aimed to (a) identify information and knowledge gaps and behaviours regarding bone health in women with POI/EM and (b) co-design an osteoporosis fact sheet.

DESIGN

Mixed-methods study: survey of women and online resource appraisals to develop and refine, using semi-structured interviews, an osteoporosis fact sheet.

PATIENTS

Women with POI/EM (menopause before ages 40 and 45 years respectively).

MEASUREMENTS

Demographics, comorbidities, information needs, calcium intake, exercise, osteoporosis knowledge (OKAT), beliefs and self-efficacy, DISCERN appraisal (validated scales).

ANALYSIS

descriptive statistics, logistic regression and thematic analysis of interviews.

RESULTS

Median age of survey respondents (n = 316) was 54(IQR47-63) years, median age of menopause was 40(IQR38-43) years, and osteoporosis diagnosis was reported in 19%. Most reported inadequate dietary calcium intake (99%) and exercise (65%). Median OKAT score 8 [IQR6-10]/19 indicated knowledge gaps regarding risk factors and treatment options. Adjusting for age and education, OKAT predicted calcium intake (OR 1.126 [CI 1.035-1.225]; P = 0.006) and screening (OR 1.186 [CI 1.077-1.305]; P = 0.001); beliefs predicted screening (OR 1.027 [CI 1.004-1.050]; P = 0.019); and self-efficacy predicted calcium intake (OR1.040 (CI 1.013-1.069); P = 0.003] and exercise (OR 1.117 [CI 1.077-1.160]; P < 0.001). Current online resources have deficiencies. Five themes identified from two interview rounds (n = 10/ round) were as follows: content, emotional response, design, perceived usefulness and clinical considerations. The final fact sheet was considered acceptable and useful in addressing knowledge gaps, promoting information-seeking, impacting behaviours and facilitating healthcare discussions.

CONCLUSION

A co-designed fact sheet is acceptable and addresses identified osteoporosis knowledge gaps in women with POI/EM.

Young women's opinions on the use of a blood test to predict the possibility of premature ovarian failure: a qualitative study

The anti-Müllerian hormone (AMH) test is increasingly being used to predict the age when women will enter menopause, signalling the end of their reproductive life. However, the accuracy of the AMH test varies widely. In this qualitative study, we asked young women of three differing education levels about the possibility of predicting premature ovarian failure (POF), defined as menopause that occurs before the age of 40. A total of 15 face-to-face semi-structured interviews were conducted. The overarching theme was 'considering the possibility of predicting POF', and the three interpretive themes were (i) limited fertility knowledge, (ii) preconditions for pregnancy and (iii) desire to have children. The interview was their first awareness of the concept of POF. All the women who participated in this study wished to have children at some point later in life and tended to think more about fulfilling preconditions before getting pregnant than about their actual fertility. Most participants (n = 8) were interested in the AMH test regardless of their education level. Five participants wanted to take the test in the future. This research provides some insight into young women's current thoughts about the possibility of predicting POF with an AMH test.

Is the age at menopause a cause of sexual dysfunction? A Brazilian population-based study

OBJECTIVES

The aim of the study was to evaluate the association between age at menopause and sexual dysfunction and the components of sexual function in postmenopausal women.

METHODS

In this cross-sectional population-based study, data of 540 women aged 45 to 60 years regarding the age they were when they achieved menopause and its association with sexual dysfunction (evaluated using the Short Personal Experiences Questionnaire) were obtained through interviews. We assessed the data for associations between age at menopause and sexual dysfunction and demographic, behavioral, and clinical characteristics.

RESULTS

Age at menopause was not associated with sexual dysfunction. Arousal (dysfunction) was the only component of sexual function that was associated with premature ovarian insufficiency (POI) and early menopause (P = 0.01). It was reported by 64.2% of women with POI (women <40 y), compared with sexual dysfunction rates of 50% and 45.6% of women aged 40 to 45 and >45 years, respectively (P = 0.04). In women with POI or early menopause, Poisson regression analysis showed that having a partner with sexual problems (prevalence ratio [PR] = 6.6; 95% CI: 3.3-13,2; P < 0.001) and dyspareunia (PR = 3.9; 95% CI: 1.8-8.2; P = 0.0005) were factors associated with arousal dysfunction. Satisfaction with the partner as a lover (PR = 0.4; 95% CI: 0.2-0.7; P = 0.002) was protective against arousal dysfunction.

CONCLUSIONS

Arousal dysfunction was associated with early ovarian failure and POI. The major factors affecting this association were having a partner with sexual problems, dyspareunia, and no satisfaction with the partner as a lover. These findings highlight the importance of evaluating partner problems and improving lubrication in these groups of women.

Committee Opinion No. 698: Hormone Therapy in Primary Ovarian Insufficiency

Primary ovarian insufficiency describes a spectrum of declining ovarian function and reduced fecundity due to a premature decrease in initial follicle number, an increase in follicle destruction, or poor follicular response to gonadotropins. The sequelae of primary ovarian insufficiency include vasomotor symptoms, urogenital atrophy, osteoporosis and fracture, cardiovascular disease, and increased all-cause mortality. In women with primary ovarian insufficiency, systemic hormone therapy (HT) is an effective approach to treat the symptoms of hypoestrogenism and mitigate long-term health risks if there are no contraindications to treatment. Hormone therapy is indicated to reduce the risk of osteoporosis, cardiovascular disease, and urogenital atrophy and to improve the quality of life of women with primary ovarian insufficiency. Although exogenous estrogen replacement is recommended for women with primary ovarian insufficiency, data comparing various hormonal regimens for disease prevention, symptom amelioration, and safety are lacking in this population. As a first-line approach, HT (either orally or transdermally) that achieves replacement levels of estrogen is recommended. Combined hormonal contraceptives prevent ovulation and pregnancy more reliably than HT; despite only modest odds of spontaneous pregnancy in women with primary ovarian insufficiency, this is a critical consideration for those who deem pregnancy prevention a priority. Treatment for all women with primary ovarian insufficiency should continue until the average age of natural menopause is reached (age 50-51 years). Finally, considering the challenges that adolescents and young women may face in coping with the physical, reproductive, and social effects of primary ovarian insufficiency, comprehensive longitudinal management of this condition is essential.

Improving Health Education for Women Who Carry an FMR1 Premutation

Women who carry an FMR1 (i.e., fragile X) premutation have specific health risks over their lifetime. However, little is known about their experience understanding these risks and navigating their health needs. The aim of this study was to use qualitative analysis to uncover both barriers and facilitators to personal healthcare using a framework of the Health Belief Model. Five focus groups were conducted with a total of 20 women who carry the FMR1 premutation using a semi-structured discussion guide. All sessions were transcribed verbatim and independently coded by two researchers. The coders used a deductive - inductive approach to determine the prominent themes related to the participants' experiences seeking healthcare for premutation-related conditions. Salient barriers to personal healthcare included difficult clinical translation of research findings, lack of knowledge among healthcare providers and among the women themselves, different priorities, and shortage of premutation-specific support and targeted educational materials. Facilitators included family members, national and community support organizations, research studies, compassionate physicians, and other premutation carriers. Addressing barriers to personal healthcare through up-to-date educational materials can help diminish misperceptions regarding health risks. Targeted educational materials will aid in information sharing and awareness for women who carry the FMR1 premutation and their physicians.

Current Concepts in Premature Ovarian Insufficiency

Premature ovarian insufficiency (POI) is a life-changing diagnosis, with profound physical and psychological consequences. Unfortunately, there are many deficiencies in our understanding of the condition as the underlying etiology and optimum management strategies are poorly understood. Improved awareness of POI and its long-term implications has led to increased research interest in recent years. Current research has allowed a greater understanding of the changing epidemiology in POI, genetic factors in its etiology and randomized controlled trials of hormone therapy are underway to provide evidence for treatment. This article reviews the latest literature on POI to summarize current understanding and future directions.

A cross-sectional national questionnaire survey assessing the clinical attitudes of members of the British Menopause Society to the management of women with premature ovarian insufficiency

OBJECTIVE

To explore the current clinical attitudes of members of the British Menopause Society to the management of premature ovarian insufficiency.

DESIGN

An electronic cross-sectional questionnaire survey.

SETTING

Members of the British Menopause Society.

POPULATION

All members of the British Menopause Society with a valid email address.

METHOD

Completion of an electronic survey.

MAIN OUTCOME MEASURES

Investigations and treatment options and preferences for the management of women with premature ovarian insufficiency.

RESULTS

A total of 130 questionnaires were returned and analysed. The majority of responses were from Hospital Consultants (n = 55/130; 42.3%). A total of 53/124 (42.7%) clinicians routinely performed a bone density scan. A total of 73/130 (56.2%) clinicians would prescribe hormone replacement therapy in preference to combined ethinyl estradiol and progesterone (COC; 27/130, 20.8%). A total of 44/108 (40.7%) routinely prescribed oral estradiol in preference to transdermal administration (62/108, 57.4%). A total of 26/128 (20.3%) prescribed oral micronised progesterone, 31/128 (24.2%) oral progestogens, while 42/128 (32.8%) preferred the intra-uterine system. Fertility concerns remain an important aspect of care, with 33.9% (n = 39/115) of clinicians indicating that more than 50% of their patients had a concern regarding their fertility.

CONCLUSION

The majority of clinicians indicated a preference for hormone replacement therapy instead of the COC as their choice of hormone replacement in women with premature ovarian insufficiency. However, there was a significant variation in practices. This information can be useful in counselling women and in guiding clinical practitioners. The results highlight the need for further research to determine the optimal regimens for the management of women with premature ovarian insufficiency.

Symptoms, health behavior and understanding of menopause therapy in women with premature menopause

OBJECTIVE

To explore symptoms, understanding of menopausal therapies, medication use and health-related behavior in women with and without premature menopause.

METHODS

Cross-sectional, questionnaire-based study involving a community-based sample of 77 women in Australia: 23 premenopausal, 25 with premature ovarian failure (POF) and 29 with medically induced premature menopause (MIPM).

RESULTS

The median (interquartile range) age of each group was: premenopausal = 29 (13) years, POF = 36 (8.0) years and MIPM = 38 (4.0) years (p < 0.001). The reported frequency of menopausal symptoms differed across the groups for difficulty sleeping (premenopausal = 26%, POF = 44%, MIPM = 69%, p = 0.01), some depression symptoms (premenopausal = 4.4-22%, POF = 20-25%, MIPM = 38-59%, p < 0.05), hot flushes (premenopausal = 4.4%, POF = 28%, MIPM = 59%, p < 0.001), sweating at night (premenopausal = 4.4%, POF = 20%, MIPM = 52%, p < 0.001) and loss of interest in sex (premenopausal = 17%, POF = 52%, MIPM = 54%, p = 0.02). More women with premature menopause than premenopausal women reported taking prescription medication (premenopausal = 52%, POF = 92%, MIPM = 86%, p = 0.002), perceived that hormone therapy (HT) was associated with increased breast cancer risk (premenopausal = 43%, POF = 56%, MIPM = 79%, p = 0.03) and that HT prevented fractures (premenopausal = 13%, POF = 56%, MIPM = 39%, p = 0.01). Most women reported not knowing risks/benefits of bioidentical hormone therapy (premenopausal = 86%, POF = 56%, MIPM = 75%, p = 0.06). Regarding health-related behavior around prevention and screening, varying rates of bone densitometry (premenopausal = 4.4%, POF = 64%, MIPM = 59%, p < 0.001), blood glucose testing (premenopausal = 39%, POF = 67%, MIPM = 57%, p = 0.16) and cholesterol testing (premenopausal = 22%, POF = 71%, MIPM = 54%, p = 0.003) were reported.

CONCLUSIONS

Differences in understanding of menopausal therapies and health-related behavior exist among women with premature menopause of differing etiology and premenopausal women. While perceived understanding of HT was greater than other therapies, targeted education is needed regarding specific risks/benefits of menopausal therapies and regarding preventive health screening after premature menopause.