Managment of women with premature ovarian insufficiency: a multi-disciplinary review of practice

Abstract

Introduction: Premature ovarian insufficiency (POI) isassociated with numerous aetiologies and may thereforepresent before or after menarche. Women may complainof various symptoms and consequently be seen in a rangeof clinical settings. The management of POI is multifactorialand may potentially vary depending on the awareness andexpertise of the clinicians within each specialty/subspecialty. In 2015, the European Society for HumanReproduction and Embryology (ESHRE) published guidelines on the management of POI. These state that womenshould have the following investigations: chromosomalanalysis; screening for Fragile-X pre-mutation, thyroid peroxidase (TPO) and 21-hydroxylase antibodies; and measurement of bone mineral density (BMD). Treatment shouldincorporate: lifestyle advice; oestrogen replacement;contraception and/or fertility options; bone protection;and psychological support.Aims: To assess compliance with the ESHRE guidelines atthe Leeds Teaching Hospitals NHS Trust (LTHT) anddetermine whether this varies according to clinical settingof presentation.Methods: A retrospective review of all females with POIdiagnosed between 1 July 2016 and 30 June 2017 in one ofthe following clinics: reproductive medicine; menopause;general gynaecology; general endocrinology; paediatricendocrinology; and oncology follow-up. We reviewedwhether the necessary investigations had been performedand what treatments had been discussed.Results: We identified 103 women, who were distributedfairly evenly between the different clinics. Overall, 40.6%had a karyotype. Screening for the Fragile-X pre-mutation,TPO and 21-hydroxylase antibodies occurred in 7.4%,11.1% and 13.6%, respectively. Only 35.9% had theirBMD measured. There was significant variation in the performance of a karyotype (p < 0.001) and TPO antibodies(p < 0.01) between the different settings. Overall, lifestyleadvice was offered to 30.1%. Oestrogen replacement,contraception, fertility and bone protection were discussed with 76.0%, 38.4%, 59.0% and 75.0%, respectively.Psychological support was offered to 25.2%. There wassignificant variation for all apart from contraception.Conclusion: Management of women with POI at theLTHT is not compliant with the ESHRE guidelines andrequires improvement. Furthermore, there is significantvariation in practice amongst the different specialties/subspecialties. We suspect similar results will occur elsewhere. We have proposed remedial action and willreassess following implementation.