PREMATURE OVARIAN INSUFFICIENCY

Evidence-based recommendation for premature ovarian insufficiency (IGHG a)

This page is part of the PanCare follow-up recommendations for surveillance of late effects. Click here, for more information on these recommendations.

On this page you can find:

Click here, to read this recommendation in PLAIN language.

Who is at risk for premature ovarian insufficiency?

CAYA cancer survivors treated with

  • alkylating agents
  • radiotherapy to a volume exposing the ovaries, including TBI

What problems might occur?

  • Impaired fertility

  • Amenorrhea
  • Premature menopause

What surveillance modality should be used and at what frequency should it be performed?

All survivors at risk:

  • Counselling regarding the risk of premature ovarian insufficiency and its implications for future fertility at least every 5 years

For pre- and peri-pubertal survivors at risk:

  • Monitoring of growth (height) and pubertal development and progression (Tanner stage) at least every year, with increasing frequency as clinically indicated based on growth and pubertal progression
  • Measurement of FSH and oestradiol for girls who fail to initiate or progress through puberty at least for girls ≥ 11 years of age, and for girls with primary amenorrhoea (age 16) b

For post-pubertal survivors at risk:

  • History and physical examination with specific attention to premature ovarian insufficiency symptoms (amenorrhoea and irregular cycles), every 5 years
  • Measurement of FSH and oestradiol in females who present with menstrual cycle dysfunction suggesting premature ovarian insufficiency or who desire assessment about potential for future fertility b, c,d
  • Not recommended: measurement of AMH as the primary surveillance modality

What should be done if abnormalities are identified?

For pre- and peri-pubertal survivors:

  • Refer to paediatric endocrinology or gynaecology for any survivor who has no signs of puberty by 13 years of age, primary amenorrhoea by 16 years of age, or failure of pubertal progression e
  • Consider sex steroid replacement therapy by referral to paediatric endocrinology or gynaecology

For post-pubertal survivors:

  • Referral to gynaecology, reproductive medicine or endocrinology in females who present with menstrual cycle dysfunction suggesting premature ovarian insufficiency or who desire assessment about potential for future fertility
  • Consider sex steroid replacement therapy by referral to endocrinology or gynaecology a This recommendation reflects the content of the IGHG Premature Ovarian Insufficiency guideline

Disclaimer

While PanCare strives to provide accurate and complete information that is up-to-date as of the date of publication, we acknowledge that the sequence of referral and diagnostic tests might vary according to the local and national healthcare system logistics.

It is recognised that survivors and their healthcare professionals have the final responsibility for making decisions concerning their long-term follow-up care. As such, they may choose to either adopt these recommendations or not to do so after individual informed discussion. It is good practice to document this decision.

In addition to regular surveillance, real-time awareness and prompt reporting of new symptoms and signs is essential to the early detection and timely treatment of late effects.

No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information.

The PanCare materials are free to use for anyone aiming to inform about late effects and long-term survivorship care. However, no financial advantage may be achieved. All communication should reference PanCare and link to the PanCare website.

a This recommendation reflects the content of the IGHG Premature Ovarian Insufficiency guideline (Recommendations for Premature Ovarian Insufficiency Surveillance for Female Survivors of Childhood, Adolescent, and Young Adult Cancer: A Report From the International Late Effects of Childhood Cancer Guideline Harmonization Group in Collaboration With the PanCareSurFup Consortium, Journal of Clinical Oncology, 2016; accessible through http://www.ighg.org/guidelines/topics/premature-ovarian-insufficiency/)

b If amenorrhoea, measure FSH and oestradiol randomly; if oligomenorrhoea, measure during early follicular phase (day 2-5).

c Hormone replacement therapy should be discontinued prior to laboratory evaluation when applicable

d This assessment should be performed after ending oral contraceptive pill/sex steroid replacement therapy use, ideally after two months without oral contraceptive pills.

e The absence of initiation of puberty (Tanner stage 2 breast development) in girls 13 years or older or failure to progress in pubertal stage for ≥12 months.